Virtual Library

Abstract
Chemotherapy is still standard treatment for the majority of patients with advanced NSCLC, who do not have specific molecular markers (i.e. EGF mutations, ALK translocations). Platinum based doublets remain standard treatment for most patients and the choice of regimen is based mainly on side effect profile. There is a preference for pemetrexed based therapies for patients with adenocarcinoma histologies, based on one randomized study. Benefit of chemotherapy can be extented by maintenance chemotherapy (pemetrexed), in terms of increased progression-free survival and overall survival. Maintenance with erlotinib has also been approved, although the largest effects are really seen in EGFR mutant patients. Very few chemotherapy doublet regimens have been improved by addition of a third agent, chemotherapy or biological. Bevacizumab was shown to increase response rate, progression-free survival as well as overall survival in one study where carboplatin-paclitaxel was the backbone. Bevacizumab is continued as maintenance. Cetuximab improved survival in addition to cisplatin-vinorelbine, and again cetuximab was continued after the end of chemotherapy. Unfortunately most of the other combinations of biologicals with chemotherapy have been disappointing. Novel agents with different mechanisms of action from the classical tyrosine kinase inhibitors might obtain better results (e.g. PD-1/PD-L1 antibodies). Results of randomzied studies are awaited. The HSP-90 inhibitor gatenespib, in combination with docetaxel gave promising results in a relatively large randomized phase II study, and a phase III study is now underway.

Abstract not provided

Abstract
Optimal adjuvant chemotherapy: selection of patients and agents Patients with early stage, resectable non-small cell lung cancer (NSCLC) have the best chance to be cured with 5 year survival rates ranging from 73% for patients with pathological stage IA disease to 24% for patients with pathological stage IIIA disease. However, the presence of micro-metastases will lead to the development of systemic relapse and death in the majority of patients. To improve survival of these patients adjuvant chemotherapy following complete tumor resection has been studied. Three phase III trials with cisplatin-based regimens and the LACE meta-analysis demonstrated increased cure rates by adjuvant chemotherapy and established adjuvant chemotherapy as the standard of care. Randomized Trials The first trial to demonstrate a survival advantage for adjuvant chemotherapy was the International Adjuvant Lung Cancer Trial Cooperative Group (IALT) study. This trial enrolled 1867 patients; 932 patients were randomized to receive chemotherapy (cisplatin plus etoposide, vinorelbine, vinblastine, or vindesine for 3-4 cycles) and 935 patients were randomized to observation. The 5 year overall survival rate significantly favored the chemotherapy arm (Hazard Ratio [HR] 0.86; 95% CI 0.76-0.98; P <0.03). Disease free survival (DFS) was also superior in the treated arm (HR 0.83; 95% CI 0.74-0.94; P=0.003). With longer follow up of 8 years, the HR for overall survival was not significant (HR 91; 95% CI 0.81-1.02; P=0.10) while the HR for DFS retained significance (HR 0.88; 95% CI 0.78-0.98; P=0.02). In 2005, the National Cancer Institute of Canada Cancer Treatment Group (NCIC CTG) reported the results of JBR10. Patients with completely resected stage IB or stage II NSCLC were randomized to receive cisplatin plus vinorelbine (242 patients) or observation (240 patients). An impressive overall survival benefit was observed for the treated group (HR 0.69; 95% CI 0.52-0.91; P=0.04) corresponding to an absolute survival improvement of 15%. In a subgroup analysis, the survival benefit was restricted to patients with Stage II disease. An update of this study, with > 9 years of follow up continued to show a survival benefit for the treated group with an absolute improvement in the 5 year overall survival (OS) rate of 11% (67% versus 56%, respectively) with a HR of .78; 95% CI 0.62-0.99; P=0.04 (11). Subsequently, the results from the ANITA trial (Adjuvant Navelbine International Trialist Association) solidify the role of adjuvant systemic treatment. A total of 840 patients with Stage IB, II, and IIIA NSCLC were randomized to cisplatin plus vinorelbine versus observation. The HR for death was significantly lower for the chemotherapy group (HR= 0.80, 95% CI 0.66-0.96; P=0.017). The 5 and 7 year overall survival was improved by 8.6% and 8.4% in the chemotherapy group, respectively. No benefit was seen in the subset of patients with Stage IB disease (HR 1.10; 95% CI 0.76-1.57; P=NS). To identify which patients might have the greatest benefit from adjuvant chemotherapy, the LACE (Lung Adjuvant Cisplatin Evaluation) meta-analysis was conducted. Individual patient data was collected and pooled from 4,584 patients in 5 trials (BLT, ALPI, IALT, JBR10 and ANITA). The HR of death was 0.89; 95% CI 0.82-0.96; P=0.005, which corresponded to a 5-year absolute survival benefit of 5.4% with chemotherapy. This benefit varied with stage of disease and was not seen for stage IA patients. A positive chemotherapy effect was seen in patients with performance status (PS) 0-1 whereas chemotherapy was potentially harmful for patients with a PS of 2. Other subgroups analyzed including age, sex, histology, type of surgical resection, planned radiation, dose of cisplatin or the second agent used did not affect overall or disease free survival. Elderly patients Since the majority of patients diagnosed with lung cancer are 70 years old or greater, an additional analysis of the LACE data set by age was conducted. Elderly patients (age > 70 years) accounted for 9% of the patients. Their HR of death was better with treatment at .90 (95% CI 0.74-1.16) and was similar to the HR of death for treated patients < 65 years old at .86 (95% CI 0.78-.94). Elderly patients achieved a survival benefit despite having received lower cisplatin doses and fewer number of chemotherapy cycles than their younger counterparts. Tumor size The Cancer and Leukemia Group B (CALGB) trial 9633 evaluated four cycles of adjuvant paclitaxel and carboplatin versus observation in stage IB patients. With mature follow up of 74 months, overall survival was not significantly different between the two groups (HR 0.83; 95% CI 0.64-1.08; P=0.12). No significant improvement in DFS was observed. In an unplanned subgroup analysis based on tumor size a survival advantage for paclitaxel and carboplatin was seen in patients who had tumors >4 cm (HR, 0.69; 95% CI 0.48-0.99; P = .043). In support of this finding, a retrospective analysis of patients with stage IB disease on JBR 10 was conducted according to tumor size of < or > 4 cms. Patients with smaller tumors did not benefit from adjuvant therapy while treated patients with tumors > 4 cm had a favorable 5 year OS rate of 79% compared to 59% for untreated patients (HR .66; 95% CI 0.39-1.14; P=0.13). It is important to remember that in the 7[th] TNM staging system, patients with tumors of > 4 cm could be Stage IB, IIA or IIB. Chemotherapy regimen In the clinical trials described above vinorelbine plus cisplatin was the most commonly used regimen. In a subgroup analysis of LACE, adjuvant cisplatin plus vinorelbine improved survival at 5 years by 8.9% in the vinorelbine cohort and this outcome was superior to the “other” cohort. Today more modern regimens are frequently used based on their activity in advanced disease including cisplatin and gemcitabine, cisplatin and docetaxel and cisplatin and pemetrexed. In summary, adjuvant cisplatin based chemotherapy is the standard of care for patients with resectable Stage II-III NSCLC with a good performance status and should be considered for patients with tumor size > 4 cm. Current strategies to improve outcome of adjuvant chemotherapy focuses on the integration of targeted therapies, tumor vaccines and the identification of prognostic and predictive biomarkers.

Abstract
At the beginning of 20th century only a few hundred cases of lung cancer were diagnosed annually, but the progressive huge spread of tobacco consumption caused a dramatic increase of the incidence of this disease among men and later on among female smokers. US data shows that the prevalence of smoking in American women peaked in 1965 at 33% and remained at that level throughout the 1970s, before beginning to slowly decrease in 1980. In contrast, more than half of American men smoked before 1965, but the prevalence dramatically decreased during the subsequent 20 years. Currently, 18% of American women smoke compared with 23% of men, reflecting the earlier and more marked decline in the prevalence of tobacco use in men. Nowadays, more women in United States die from lung cancer each year than from breast, ovarian and uterine cancer combined: lung cancer is the leading cause of cancer death with more than 110,000 new cases and more than 72,000 estimated deaths in 2013. In European countries there are more than 79,000 new cases of lung cancer in female sex per year and 82,000 is the estimated death number in 2013, that means 9,024 more than what was reported in 2009. Approximately 80% - 85% of lung cancers in women are caused by cigarette smoking. Wang et al. investigated the association of both active and passive smoking on lung cancer risk in a prospective cohort of more than 90,000 post-menopausal women: the results of the Women’s Health Initiative Observational Study (WHI-OS) have been presented at 2013 ASCO annual meeting and evidenced an higher lung cancer incidence, particularly small cell lung cancers and squamous lung cancers, in current smokers (Hazard Ratio, HR 13.44, 95%, CI 10.80-16.75) and former smokers (HR 4.20, 95% CI 3.48-5.08) compared to never smokers. In the same study, among never smoking women, passive exposure, as an adult at home for > 30 years, was associated with a trend of increased risk (HR 1.61, 95% CI 1.00-2.58) for lung cancer, confirming findings of previous prospective cohort studies. In recent times, an increased proportion of non-smoking female patients, with earlier age at diagnosis and a majority of adenocarcinoma has been observed, particularly in Asian countries. Prevalence of lung cancer in females without history of tobacco smoking is estimated to represent 19% compared with 9% of male lung carcinoma in the United States. Freedman et al. reported, on a cohort of nearly 500,000 individuals, aged from 50 to 71 years, a significant increase in the rate of lung cancer for women who did not smoke, compared with male non-smokers, whereas no increased risk was described in current and former female smokers compared with matched males. Hormonal status is one of the potential explanations for gender differences. Estrogens are involved in lung tumorigenesis and progesterone receptor expression has been described in non small cell lung cancers (NSCLC). Combination of estrogen and progesterone works synergistically in vitro to promote vascular endothelial growth factor secretion increasing tumor-associated angiogenesis. Chlebowski et al. examined estrogen plus progestin (E+P) association with lung cancer incidence and outcome evaluating more than 30,000 postmenopausal women. Results have been presented at 2013 ASCO annual meeting: in non users of E+P, lung cancer incidence and deaths from lung cancer were significantly and substantially greater in current smokers versus never smokers (p< 0.0001 for both comparisons). In current smokers, lung cancer incidence and deaths from lung cancer were significantly and substantially greater in E+P users versus non-users (p=0.0021 and 0.0005, respectively), nearly doubling a smoker’s already high risk of death from lung cancer. Conversely, the role of androgens remains unclear. Harlos et al. evaluated more than 3,000 men with lung cancer evidencing that exposure to androgen deprivation therapy (ADT) is associated with significantly better survival when compared with no exposure. Patients exposed to ADT after their diagnosis were found to have a significantly better survival than those not exposed (HR 0.36 p=0.0007). This effect was also seen in those who received ADT before and after diagnosis (HR 0.53 p<0.0001). With regard to specific gene alterations there are relevant differences in men and women. The most widely recognized is the epidermal growth factor receptor (EGFR) mutation, that is found at a much higher frequency in adenocarcinomas, women, Asians and never smokers. Mutations in HER2 gene, although much rarer, target the same subpopulations. Mutations in EGFR (and HER2) are mutually exclusive of K-ras mutations: these are primarily observed in smokers and historically associated with male sex, but there are also publications demonstrating an higher frequency in women of “non-classical” type of K-ras mutations even if these data need further validations. The echinoderm microtubule associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) translocation has been evidenced to occur more frequently in young patients, light or never smokers, while no major differences have been clearly stated between genders. B-Raf (V600) is described in 2% of patients with lung adenocarcinoma in western countries, related with worse prognosis and it is noted more frequently in women. An analysis of the p53 mutation databases indicated that the different spectra of p53 mutational patterns among smoker and never smoker cancers were almost entirely a result of differences between lung cancers in women, whereas male tumours did not show significant differences. Finally, recent studies investigated the role of telomere shortening in lung cancer. Kim et al. hypothesized that relative telomere length may be associated with recurrence in early stage NSCLC after curative resection. Longer telomeres were significantly associated with higher risk of developing recurrence in female (HR 2.25; 95% CI, 1.02-4.96, P= 0.044) and adenocarcinoma subgroups (HR 2.19; 95% CI, 1.05-4.55). All these findings provide multiple evidence for the specificities of lung cancer in women. The different expression of specific biomarkers, which could be targeted by therapy, will improve research towards personalized sex-based investigations, stimulating the development of further gender-based approaches in thoracic oncology.

Abstract not provided

Abstract not provided

Abstract not provided

Abstract not provided

Background
2nd-line therapy for advanced NSCLC patients (pts) after progression on platinum-based regimens typically employs CT or E. A test for optimizing choice of treatment in these pts is of clinical value. VeriStrat (VS) is a serum protein test that assigns "good" (VSG) or "poor" (VSP) classification and has demonstrated prognostic and predictive utility. PROSE is a multicenter prospective randomized biomarker validation trial, designed to evaluate the ability of VS to predict survival in 2nd- line NSCLC pts treated with E or CT. As reported at 2013 ASCO1, PROSE met its primary endpoint of demonstrating significant treatment*VS interaction with a p value of 0.031, with VSG pts deriving similar overall survival (OS) benefit from both treatments (hazard ratio (HR) for E=1.06; p=0.71) and VSP pts benefitting more from CT than E (HR for E=1.72; p=0.02). Previous studies in EGFR-TKI-treated pts have shown that at progression around 30% of pre-treatment VSG pts have changed classification to VSP2. The present report discusses the exploratory analysis of longitudinal VS classifications generated during the PROSE study.

Methods
Of the 263 pts in the PROSE primary analysis population, 89 provided serum samples during treatment and 108 at progression, with 47 pts providing both. VS testing was performed on these longitudinal samples blinded to all clinical and treatment outcomes and pts and physicians remained blinded to VS results.

Results
VSG or VSP classifications were obtained for 89 pts from treatment samples (67 VSG / 22 VSP) and 107 pts (one sample was classified as indeterminate) from progression samples (59 VSG / 48 VSP). In pts with matched baseline and progression samples, the percentage of VSG classifications was lower at progression (55%) than at baseline (77%) (p < 0.001 ). Twenty eight pts (34%) classified at baseline as VSG changed to VSP at progression, in line with previous studies2, and this did not show any significant dependence on treatment. When treated with E, pts whose classification changed from VSG at baseline to VSP during treatment (n=6) had inferior PFS to the 25 pts who remained VSG (p=0.001, median PFS: 3.6 and 7.7 months (mos), respectively). Patients whose classification changed from VSG at baseline to VSP at progression on E (n=18) had numerically inferior OS (median 10.0 mos) compared with the 31 pts who remained VSG at progression (median 14.6 mos) and significantly superior OS (median 5.0 mos) compared with the 10 pts who were VSP at both time points (p<0.001).

Conclusion
The observed changes in VS classification at progression demonstrate the importance of obtaining a VS result prior to each line of therapy for which erlotinib is considered as a therapeutic option. The proportion of patients who are good candidates for erlotinib therapy (VSG) decreases from 2[nd] to 3[rd] line and the possible impact of this on treatment sequencing and monitoring for 2[nd] and higher line advanced NSCLC pts merits further studies.

Background
Preclinical data have shown that the EGFR-T790M mutation confers resistance to reversible EGFR-TKIs (gefitinib, erlotinib) but not to irreversible EGFR-TKIs (afatinib). This study evaluated advanced NSCLC patients (pts) harboring an activated EGFR mutation (exon 18-21) to investigate the incidence of the T790M mutation in pretreatment tumor samples and the correlation between the T790M mutation and the clinical outcome, comparing patients positive for the T790M mutation treated with reversible TKIs, an irreversible TKI or chemotherapy to patients negative for the T790M mutation treated with the same agents.

Methods
We screened 317 advanced NSCLC pts for EGFR mutations using the PCR/Sanger sequencing (PSS) method. Tumor tissues from EGFR-mutated pts were analyzed for the EGFR-T790M mutation using a highly sensitive locked nucleic acid-PSS method (LNA-PSS) capable of detecting EGFR-T790M-mutated alleles at extremely low frequencies. The response rate (RR), progression-free survival (PFS) and overall survival (OS) were evaluated retrospectively in these pts.

Results
Using PSS, 17.3% (55/317) of pts had an activating mutation in the EGFR-TK domain; 56.3% (31/55) of pts had an in-frame deletion in exon 19, 32.7% (18/55) of pts had point mutation L858R in exon 21, 3.6% (2/55) of pts had an insertion in exon 20, and 7.2% (4/55) of pts had both the T790M mutation and either an exon 19 or 21 mutation. Forty-two pts with EGFR-activating mutations (82.3%) without the T790M mutation (by PSS) were successfully analyzed for the T790M mutation using LNA-PSS. The T790M mutation was detected in 17 (40.5%) pts, with a higher incidence in never smokers (47.7%), adenocarcinoma (76.2%) and females (71.4%). A treatment response evaluation was available in 39 pts, 18 of whom (46.1%) harbored the T790M mutation. Pts with T790M had a lower RR (22.2%) to TKIs than wild-type pts (35.3%); however, mutated pts had better PFS and OS (median PFS 9.2 vs 7 months, respectively; median OS 15.2 vs 11.1 months, respectively). Pts treated with afatinib and positive for T790M obtained longer PFS compared to pts negative for T790M (median PFS 4.7 vs 3.2 months, respectively), but their OS was shorter (median OS, 16.3 vs 18.2 months, respectively). Notably, pts with the T790M mutation had a greater response to chemotherapy (44.4%) compared to pts without the mutation (18.2%) and had a longer PFS (median PFS 8.2 vs 6.1 months, respectively) and OS (median OS 21.8 vs 12.4 months, respectively).

Conclusion
In this study, the high proportion of pretreatment tumor samples positive for the EGFR-T790M mutation indicates that its identification at diagnosis is more common than expected using a highly sensitive method. Consequently, in NSCLC pts with EGFR-activating mutations, detection of the T790M mutation at diagnosis can help customize therapy and identify a subset of patients with a relatively more favorable prognosis.

Background
Erlotinib is a standard treatment for NSCLC patients harboring EGFR mutations. Many tumors acquire resistance mutations during erlotinib treatment; consequently, confirmation of EGFR mutation status is important to select appropriate subsequent therapy after progression. Obtaining tumor samples is not easy, therefore, serum samples are more applicable for this purpose. This analysis measured serum EGFR mutations before and after administration of erlotinib in a phase II study in Japanese chemotherapy-naïve patients with advanced NSCLC harboring EGFR mutations (JO22903).

Methods
We analysed serum samples from patients in the JO22903 study by Scorpion-ARMS to confirm the presence of EGFR mutations before and after erlotinib administration (190 days post treatment initiation and at disease progression). The mutation results were evaluated in relation to clinical characteristics and effects of erlotinib.

Results
Of the 103 patients registered in JO22903, 95 consented to the examination of EGFR mutations in serum samples prior to and following administration of erlotinib. Of these 95 patients, 26 were positive for EGFR mutations (16 were exon 19 deletions, nine were exon 21 L858R mutations, one was an exon 20 S768I mutation). In the 26 patients classed as EGFR mutation-positive in serum samples, the concordance rate between tumor samples and serum samples was 96.2% (matching 25 cases except the S768I mutation case). The EGFR mutation detection rate in serum samples prior to erlotinib administration was 35.6% for exon 19 deletions (16/45) and 18.0% for L858R mutations (9/50). In six cases where exon 20 T790M or minor mutations were detected alongside major mutations in tumor samples, the major mutations were detected in corresponding serum samples of four patients but the T790M mutations or minor mutations were not detected in any serum samples. In the 65 cases in which serum samples were taken 190 days after erlotinib administration, five were positive for EGFR mutations (exon 19 deletions in four, and L858R in one). Four of these cases were consistent with the mutation type of the tumor samples taken before erlotinib administration; one case changed from L858R to exon 19 deletion. Serum samples at disease progression were taken for 72 patients. Of these, 16 were positive for EGFR mutations (three were exon 19 deletions, five were exon 19 deletions + T790M, six were L858R and two were L858R + T790M). EGFR mutation type had changed after administration of erlotinib in three cases; these cases also had multiple metastases. Characteristics of EGFR mutation-positive cases in the pre-treatment serum samples were large tumor size, and metastases to other organs (bone, brain, liver). Patients with baseline serum EGFR mutations had median PFS of 9.7 months and those without baseline serum EGFR mutations had median PFS of 15.2 months. Further efficacy results will be presented.

Conclusion
The sensitivity of these analyses was not enough to draw firm conclusions; however, results show the possibility that serum EGFR mutations correlate with disease activity and emergence of resistance mutations. Further study is recommended to measure serum EGFR mutations throughout the treatment course, to ascertain whether this can predict the risk of disease progression.

Background
A significantly greater proportion of females and adenocarcinoma patients is found in never-smoking NSCLC groups than in smoking NSCLC groups. Recent studies have demonstrated that estrogens may contribute to the carcinogenesis and development of lung carcinoma. In the present study, we investigate the correlation between the expression of aromatase (CYP19-1) and clinicopathologic factors and assess the prognostic significance of the aromatase expression in patients with primary lung adenocarcinoma.

Methods
The aromatase mRNA expression levels in the primary tumors and corresponding nonneoplastic lung specimens of 110 Japanese patients who underwent complete resection for primary lung adenocarcinoma were evaluated using quantitative RT-PCR. The relationships between the aromatase expression and clinicopathologic factors or survival were analyzed. To test the growth inhibitory effects of the aromatase inhibitor exemestane alone and in combination with the EGFR-TKI erlotinib in vitro, the cell proliferation of the lung adenocarcinoma cell lines HCC4006 and 11-18 was measured according to the WST-8 method.

Results
The mRNA expression level of aromatase in the carcinoma tissues was significantly higher than that in the corresponding normal lung tissues (P = 0.013). The aromatase expression in the lung adenocarcinoma tissues was not correlated with the clinicopathologic factors, including patient gender, age, smoking status, EGFR mutation status or pathologic stage. A high aromatase expression was associated with a poor prognosis in terms of both the recurrence-free survival (RFS) (P = 0.004) and overall survival (OS) (P = 0.003). A multivariate analysis showed that the aromatase expression was a significant prognostic factor, with a relative risk of 2.35 (P = 0.043) for RFS and 5.19 (P = 0.004) for OS. We further stratified the population according to gender, smoking status and EGFR mutation status. A high aromatase expression was related to a poor prognosis in femles (RFS; P = 0.008, OS; P < 0.001), never-smokers (RFS; P = 0.009, OS; P < 0.001) and patients with EGFR mutations (RFS; P = 0.005, OS; P = 0.003). A multivariate analysis showed that the aromatase expression was a significant prognostic factor, with a relative risk of 5.22 (P = 0.013) for RFS in the patients with EGFR mutations. HCC4006, harboring an EGFR mutation with a low aromatase mRNA expression, was not sensitive to exemestane alone or combination with erlotinib. In contrast, 11-18, harboring an EGFR mutation with a high aromatase mRNA expression, was sensitive to exemestane alone. In addition, cell growth was significantly inhibited by the combination of exemestane and erlotinib.

Conclusion
A high expression of aromatase is correlated with a poor outcome in patients with lung adenocarcinoma, especially those harboring EGFR mutations. Aromatase may be a therapeutic target in lung adenocarcinoma with a high aromatase expression and with an EGFR mutation.

Background
NSCLC patients with EGFR mutations initially respond to EGFR tyrosine kinase inhibitors (TKIs) but ultimately relapse. Sub-genomic molecular studies indicate that the EGFR T790M mutation and the activation of MET, PI3K, AXL, HER2 and MAPK can lead to acquired resistance to EGFR TKIs. To date, no integrated comprehensive genomic investigation of EGFR TKI resistance has been reported.

Methods
FFPE biopsies of erlotinib-sensitive and erlotinib-resistant tumors were obtained from 13 EGFR mutant NSCLC patients. The samples were analyzed by whole exome sequencing and whole transcriptome sequencing utilizing the Illumina HiSeq2500 platform. In addition, targeted gene sequencing was performed with the Illumina TruSeq Amplicon-Cancer Panel and run on the MiSeq system.

Results
Erlotinib resistant NSCLC specimens harbored known resistance drivers, including EGFR T790M mutations (9/13; 69%), MET amplification (3/13; 23%), HER2 amplification (3/13; 23%), and AXL upregulation (3/13; 23%). Differential expression analysis between resistant and pre-treatment states revealed enrichment in the pre-treatment tumors of immune signaling pathways, and in the resistant tumors upregulation of ERBB2, mTOR, PI3 kinase and ribosomal signaling pathways. PI3K/AKT pathway upregulation also occurred through somatic mutations in AKT and LKB1 in the resistant tumors. Copy number analysis demonstrated both large scale and focal amplifications and deletions in the resistant tumors, including the focal loss of EGFR and gain of c-Myc and NKX2-1. There was strong correlation between the copy number changes observed and the expression mRNA levels of the involved cancer-associated genes. Of note, each resistant tumor exhibited greater copy number similarity to the corresponding matched pre-treatment sample compared to other tumors within the resistance cohort.

Conclusion
We conducted the first ever comprehensive integrated genomic analysis of EGFR TKI resistant NSCLC patients, and identified both known and potentially novel drivers of EGFR TKI resistance. This study demonstrated the feasibility and utility of comprehensive genomic analysis in the clinical management of NSCLC receiving targeted therapy. Together, our data provide unprecedented insight into the molecular pathogenesis of escape from EGFR oncogene inhibition in NSCLC. We are now conducting a prospective observational study in additional NSCLC patients on targeted therapy.

Abstract not provided

Background
EGFR TKI sensitizing mutations in plasma DNA isolated prior to treatment were shown to be a potent predictor for survival outcome of advanced NSCLC (T. Mok, ASCO 2013). Levels of EGFR mutations (pEGFRmut) in plasma during treatment, including sensitizing and resistance mutations, may offer an opportunity to monitor patient’s response to therapy and disease progression. In this study, we measured the levels of pEGFRmut at every 4 weeks during erlotinib treatment and investigated the emergence of the T790M mutation in relationship to disease progression.

Methods
Retrospective EGFR mutation testing of plasma samples from an unselected cohort of 227 patients with adenocarcinoma with an allele-specific PCR assay, cobas® EGFR_blood test (in development at Roche Molecular Systems, Inc.). The test is designed to detect 42 mutations in exon 18-21 of the EGFR gene including TKI sensitizing mutations (Exon 19 deletions, L858R, G719X and L861Q), resistance mutation (T790M) and atypical mutations (S768I and Exon 20 Insertions). 2 ml plasma of each patient was used for EGFR_blood PCR test. The genomic equivalent copy number of plasma DNA was determined by comparing to a standard curve of genomic DNA.

Results
25 (11%) of 227 unselected patients with adenocarcinoma had a sensitizing EGFR mutation in their plasma prior to the erlotinib treatment. Sequential plasma samples were retrieved for 23 of the 25 pEGFRmut+ patients. 22 (96%) of the 23 pEGFRmut+ patients had lower TKI sensitizing mutations after the first cycle (4 weeks) of erlotinib treatment. The mutated DNA was reduced below the limit of detection for 13 (57%) of the 23 pEGFRmut+ patients during the course of erlotinib treatment. At the time of progression, 6/23 had the same EGFR sensitizing mutations, 9/23 developed T790M mutation with the original mutation and 6/23 patients had no detectable mutation. T790M mutation was not detected in 227 plasma samples taken prior to erlotinib treatment. The figure shows the time course of two representative patients where a T790M resistance mutation emerges. In the 9 patients with T790M mutation, it can be detected in the blood between 15 and 344 days (mean of 98 days) before progression is clinically evident.Figure 1

Conclusion
The amounts of EGFR TKI sensitizing mutant DNA in plasma change during the erlotinib treatment. T790M mutation was not detected prior to erlotinib treatment and is detected between 15 and 344 days before disease progression is evident.

Background
EGFR TKI sensitizing mutations from plasma prior to treatment were shown to be a potent predictor for survival outcome of advanced NSCLC (T. Mok, ASCO 2013). In this study, we tested EGFR mutations in the archived plasma from 199 advanced adenocarcinoma. The plasma samples were taken when they progressed on their chemotherapy and before their 2nd erlotinib treatment a mean of 10.5 months after the diagnostic biopsy was obtained. EGFR mutations detected in plasma after chemotherapy and in the tumor DNA from their original diagnostic biopsies were also compared.

Methods
Plasma DNA and tumor DNA were tested with two allele-specific PCR assays, cobas® EGFR_ FFPET tissue test and cobas® EGFR_blood test (in development at Roche Molecular Systems, Inc.). Both allele-specific PCR assays detect 41 mutations in exon 18-21 of the EGFR gene including TKI sensitizing mutations (Exon 19 deletions, L858R and G719X), resistance mutation (T790M) and atypical mutations (S768I and Exon 20 Insertions). cobas® EGFR_blood test also detects L861Q. Plasma samples of all 199 adenocarcinoma were collected immediately (less than 2 days) prior to the patient’s erlotinib treatment and stored at -80°C. From 197 (99%) of 199 of the patients tumor DNA was extracted from the diagnostic biopsy.

Results
Among 199 advanced adenocarcinoma patients, 24/199 (12%) were EGFR mutation positive in plasma. 28/196 (14%) were EGFR mutation positive in tumor DNA. The comparison of EGFR mutation in plasma and tumor DNA is shown in the table 1. The overall concordance of EGFR mutation status in plasma and tumor biopsy was 91% (179/196). 17/196 (9%) patients had the same EGFR mutations in plasma as in their original diagnosis biopsy and 162/196 (82%) patients were mutation negative in both samples. In this study, different EGFR mutation status in plasma and original biopsy was observed in 17 of 196 (9%) patients. 6 of 17 were EGFR mutation positive in plasma only and 11 of 17 were EGFR positive in tumor DNA only. These differences could reflect alterations in the tumor cells between sampling of biopsy and blood (average of 10.5 months) where the patients are treated with chemotherapy. Another possibility is limitations of assay technology with circulating cell-free DNA in plasma or heterogeneity of tumor.

Conclusion
Tumor mutations in the patient’s original diagnostic biopsy can be detected in their plasma when they progress on chemotherapy which may provide another opportunity for mutation testing. Table 1. Comparison of EGFR mutations detected in plasma and diagnostic biopsy. MND=Mutation-Not-Detected.Figure 1

Background
Resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in advanced non-small cell lung cancer patients (NSCLC) is attributed to the T790M mutation of EGFR. Here, we evaluated T790M mutation using dynamic, quantitative and non-invasive method and explored its role predicting outcomes of EGFR-TKI treatment.

Methods
We enrolled 135 EGFR-TKI-resistant NSCLC patients in the study. Pre- and post-EGFR-TKI treatment (pre-TKI and post-TKI, respectively) plasma samples were obtained for analysis. T790M mutation was measured qualitatively and quantitatively by the amplification refractory mutation system (ARMS) and digital polymerase chain reaction (D-PCR).

Results
D-PCR was more sensitive than ARMS in detecting the T790M mutation (pre-TKI: 29.4% (32/109) vs 5.5% (6/109), P<0.001; post-TKI: 43.0% (58/135) vs 25.2% (34/135), P=0.001). Patients with a pre-TKI T790M mutation (N=32) showed shorter progression free survival (PFS) and overall survival (OS) than patients without a T790M mutation (N=77) (9.2 vs 12.7 months, P=0.004; and 19.3 vs 31.9 months, P=0.001, respectively). No differences were observed in post-TKIPFS or OS (12.5 vs 12.2 months, P=0.744; and 27.0 vs 29.7 months, P=0.636, respectively). Post-treatment patients were divided into high-frequency (>4.375%) and low-frequency (≤4.375%) groups, according to the mutant T790M-to-wild-type gene ratio calculated from D-PCR results. Patients in the high-frequency group showed a significantly shorter OS than the low-frequency group (20.67 vs 29.13 months, P=0.009).

Conclusion
D-PCR is more sensitive than ARMS in detecting the T790M mutation. The presence of a pre-TKI T790M mutation and a high frequency of post-TKI T790M mutation predicted poor outcomes of EGFR-TKI treatment.

Background
Background: We explored the minimally-invasive detection of EGFR mutations in circulating free DNA from plasma and studied the concordance of EGFR mutation status between matched plasma and tumor tissue in a cohort of newly diagnosed or relapsed patients with advanced NSCLC. CO-1686 is an oral, potent, small-molecule irreversible tyrosine kinase inhibitor that selectively targets mutant forms of EGFR, including T790M and the common initial activating mutations, while sparing wild-type EGFR. Promising clinical activity has recently been reported from an on-going Phase I/II trial.

Methods
Methods: Matched tumor tissue and blood from 80 Stage IIIB/IV NSCLC patients, 41 treated with CO-1686, were tested using two allele-specific PCR assays, the cobas® EGFR FFPET and cobas® EGFR blood tests. Each test detects 41 mutations in EGFR, including the T790M resistance mutation, exon 19 deletions and L858R. We also used BEAMing, a highly quantitative and sensitive technology based on digital PCR, to assess a subset of 18 patients treated with CO-1686. BEAMing was compared to cobas analysis at baseline, and also used to serially monitor plasma EGFR mutation levels in response to CO-1686.

Results
Results: Using tissue as reference, the positive percent agreement between tissue and plasma was 76% (44/58) for activating mutations and 63% (17/27) for T790M. The cobas® EGFR blood test identified two patients with T790M mutations in plasma that were not detected in the corresponding tumor biopsy—likely because of tumor heterogeneity. The M1a/M1b status was known for 63 EGFR mutation-positive patients. Of the 44 with extrathoracic metastatic disease (M1b), 38 were found to have an activating mutation in plasma (86%). Conversely, only 53% (10/19) of EGFR mutation-positive patients with intrathoracic metastatic disease (M1a) had detectable activating mutations in plasma (p = 0.0081). For the 18 patients profiled by BEAMing, the overall percent agreement between BEAMing and the cobas® EGFR blood test was 94% (17/18) for T790M and 83% (15/18) for activating mutations. Nine of the 18 patients had detectable baseline plasma T790M levels, and several patients treated with CO-1686 had an initial decrease in plasma T790M by BEAMing.

Conclusion
Conclusions: Using the cobas® EGFR blood test, a high proportion of EGFR mutations identified in tissue were also detected in plasma. Mutations were more readily detectable in the plasma of patients with M1b rather than M1a disease. These findings suggest that the cobas® EGFR blood test and BEAMing can be useful tools for the non-invasive assessment and monitoring of EGFR mutations in NSCLC patients.

EGFR mutation	Evaluable patients	Patients with tissue mutations*	Patients with plasma mutations**	Patients with same mutation detected in tissue and plasma	Positive Percent Agreement***
L858R, del19, S768I, G719X, or ex20ins	80	58	44	44	76%
T790M	80	27	19	17	63%
* identified by the cobas® EGFR tissue test
** identified by the cobas® EGFR blood test
***agreement of blood and tissue mutation-positive results with tissue as reference; although tissue is reference, some mutations may be missed due to tumor heterogeneity

Abstract not provided

Background
The first generation EGFR TKIs gefitinib and erlotinib provide significant clinical benefit in patients with advanced EGFR mutant NSCLC but many patients ultimately develop disease progression due to acquired resistance. The EGFR T790M mutation is the most common mechanism of acquired drug resistance, detected in more than 50% of gefitinib/erlotinib resistant patients. Current therapeutic strategies are limited for NSCLC patients with EGFR T790M.

Methods
AZD9291 is an oral, irreversible, third generation inhibitor of both EGFR activating (EGFRm+) and resistance mutations (T790M). The mechanistic and functional activity of AZD9291 was characterised in vitro across a number of cell lines harbouring various EGFR-mutations or wild type EGFR. Efficacy of AZD9291 was further evaluated across a number of different EGFR-mutant xenograft and transgenic models in vivo. One open label, dose escalation phase I study of AZD9291 (NCT01802632) is ongoing to determine the safety and tolerability [primary measure], pharmacokinetics and preliminary efficacy profiles of AZD9291, in patients with advanced NSCLC who have progressed following EGFR TKI. Sequential cohorts of 3-6 patients with advanced NSCLC who have had at least one prior regimen containing an EGFR TKI agent (with confirmed EGFRm+ status or Jackman criteria), were treated with AZD9291 once daily. Other key inclusion criteria were PS 0-1, measurable disease, and no prior history of ILD. RECIST assessments were scheduled 6 weekly. Dose escalation can occur after ≥ 3 patients complete both single dose and the first 21-day cycle of AZD9291 multiple dosing with no DLT.

Results
AZD9291 potently inhibits EGFR phosphorylation in EGFRm+ (PC9; 14nM) and EGFRm+/T790M (H1975; 13nM) cell lines in vitro, whilst demonstrating much less activity against wild-type EGFR lines (LoVo; 400nM). Consistently, AZD9291 showed significantly more potent inhibition of proliferation in mutant EGFR cell lines compared to wild-type in vitro. In addition, AZD9291 treatment caused profound growth regression across multiple EGFRm+ (PC9; 250% growth inhibition) and EGFRm+/T790M (H1975; 132% growth inhibition) tumour models in vivo, at doses as low as 5mg/kg after 14 days. Tumour growth inhibition was associated with profound inhibition of EGFR activity and key downstream signaling pathways. Chronic long-term treatment of in vivo PC9 and H1975 xenograft tumours with AZD9291 led to a complete and sustained macroscopic response. In the phase I study, clinical activity with RECIST responses have already been observed at the starting dose level of 20mg once daily, with good tolerability, no reported events of EGFR wild-type rash, and only grade 1 diarrhoea (based on preliminary data, unvalidated and subject to change).

Conclusion
Preclinical data demonstrates that AZD9291 is a potent and effective inhibitor of both EGFR activating (EGFRm+) and resistance mutations (T790M) whilst sparing wild-type EGFR and, early clinical data have been promising. Taken together, these data support the further clinical investigation of AZD9291 in advanced EGFR mutant NSCLC.

Abstract not provided

Abstract
Tumors evade immune system attack through various different mechanisms. One such mechanism is through coopting inhibitory immune checkpoints.(1) These inhibitory checkpoints cause compromised T cell activation and effector function. The two immune checkpoints best known are CTLA-4 and PD-1.(2) CTLA-4 is the receptor that is expressed earlier on in T cell activation and whose ligands are B7.1 and B7.2. Tumor cells have not been known to express the CTLA-4 ligands which are only known to be expressed on antigen presenting cells (APC). CTLA-4 deficient mice die early on of massive lymphoproliferative disorders.(3) Alternatively, the PD-1 receptor is expressed later on in T cell activation in the periphery and binds to two ligands, PD-L1(B7-H1) and PD-L2 (B7-DC). Both ligands are known to be expressed in peripheral tissues on APCs as well as tumor cells. Both ligands are upregulated by type 1 and 2 interferons, particularly gamma interferon.(4) PD-1 deficient mice develop strain specific autoimmune diseases later on in life.(5) Antibodies developed to block the binding between co-inhibitory receptor and its ligands cause T cell activation. While CTLA-4 blockade via the antibody, ipilimumab, has yielded an improvement in survival in patients with melanoma, PD-1 blockade is earlier on its development.(6,7) Several antibodies are in various stages of development. Of the antibodies designed to bind to the PD-1 receptor, Nivolumab (BMS-936558) is furthest along in development. In the first in human, single dose study of nivolumab, no maximum tolerated dose was found.(8) The pharmacokinetics of the antibody revealed a 14 day half-life, but the antibody was found to occupy T cell receptors for up to 3 months after treatment leading to prolonged pharmacodynamic effects. The toxicities were relatively mild and consistent with the immune mechanism of action. Early signs of clinical activity were seen in patients with melanoma, colon cancer, non-small cell lung cancer (NSCLC), and renal cell cancer (RCC).(9) Two patients remain in a complete response even up to almost 5 years after their last treatment. One patient’s response was maintained up to 18 months after stopping treatment and when the cancer progressed, the patient was retreated with nivolumab resulting again in a response. More recently, a multidose phase I study of Nivolumab was performed.(10) Again, no maximum tolerated dose was found up to 10 mg/kg every two weeks. Toxicities again tended to be manageable and consistent with the immune mechanism of action. Because of initial signs of significant clinical activity, expansion cohorts in NSCCLC, RCC, and melanoma were enrolled. Exciting responses in NSCLC (17%) were seen. These responses were durable with a median duration of response of 17 months. Based on these results, two phase III trials have been initiated in the second line treatment setting comparing nivolumab to docetaxel in both squamous cell and non-squamous cell carcinomas. Another anti-PD-1 antibody, MK-3475, recently reported similar toxicities consistent with the immune mechanism of action as well as initial clinical activity in melanoma (47% response rate).(11) Further expansion cohorts were enrolled in NSCLC and information is forthcoming. Antibodies blocking the ligand, PD-L1, have also been developed. Theoretically there may be differences in activity and toxicities between the two groups of antibodies. By blocking the PD-L1, the interaction between PD-1 and PD-L2 remains intact. It remains to be seen if this is meaningful, clinically. The first in human study of once every two week dosing of BMS-936559 reported initial tumor activity in several tumor types including NSCLC (10%) as well as a tolerable safety profile.(12) Another PD-L1 antibody, MPDL3280A, initial phase I trial was reported at ASCO in 2013. Toxicities were mild, no MTD was reached, and initial clinical activity was seen in multiple tumor type including NSCLC (22%).(13) These trials demonstrate that the PD-1 pathway is important in tumor immune evasion, and by blocking this pathway, immune activation occurs which in turn can cause durable tumor control. References 1. Zou W: Immunosuppressive networks in the tumour environment and their therapeutic relevance. Nat Rev Cancer 5:263-74, 2005 2. Chen L: Co-inhibitory molecules of the B7-CD28 family in the control of T-cell immunity. Nat Rev Immunol 4:336-47, 2004 3. Waterhouse P, Penninger JM, Timms E, et al: Lymphoproliferative disorders with early lethality in mice deficient in Ctla-4. Science 270:985-8, 1995 4. Keir ME, Butte MJ, Freeman GJ, et al: PD-1 and its ligands in tolerance and immunity. Annu Rev Immunol 26:677-704, 2008 5. Nishimura H, Nose M, Hiai H, et al: Development of lupus-like autoimmune diseases by disruption of the PD-1 gene encoding an ITIM motif-carrying immunoreceptor. Immunity 11:141-51, 1999 6. Hodi FS, O'Day SJ, McDermott DF, et al: Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 363:711-23, 2010 7. Robert C, Thomas L, Bondarenko I, et al: Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med 364:2517-26, 2011 8. Brahmer JR, Drake CG, Wollner I, et al: Phase I study of single-agent anti-programmed death-1 (MDX-1106) in refractory solid tumors: safety, clinical activity, pharmacodynamics, and immunologic correlates. J Clin Oncol 28:3167-75, 2010 9. Lipson EJ, Sharfman WH, Drake CG, et al: Durable cancer regression off-treatment and effective reinduction therapy with an anti-PD-1 antibody. Clin Cancer Res 19:462-8, 2013 10. Topalian SL, Hodi FS, Brahmer JR, et al: Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med 366:2443-54, 2012 11. Iannone R, Gergick K, Cong C, et al: Efficacy and safety of MK-3475 in patients with advanced melanoma, 9th International Congress of the Society for Melanoma Research. Los Angeles. California, 2012 12. Brahmer JR, Tykodi SS, Chow LQ, et al: Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med 366:2455-65, 2012 13. Herbst R, Gordon M, Fine J, et al: A study of MPDL3280A, an engineered PD-L1 antibody in patients with locally advanced or metastatic tumors, ASCO Annual Meeting 2013. Chicago, I.L., 2013

Abstract not provided

Abstract
Surgical resection is the standard therapy for early stage NSCLC, but about half of the patients still develop a relapse and die of their cancer. In case of unresectable locally advanced disease, the combination of chemo- and radiotherapy may cure some patients, but the majority will relapse. Targeted agents have brought progress for patients with advanced NSCLC selected based on molecular factors such as EGFR or ALK mutation, but other novel approaches are needed. One is therapeutic cancer vaccination (TCV), which may become an important part in our future treatment armamentarium, especially for patients with local or locally advanced NSCLC. Cancer immunotherapy in a broad sense is any interaction with the immune system to treat cancer. A first approach is non-antigen-specific modulation of the immune system. Historical experience (BCG, C. parvum, interferon, interleukins, thymosin, etc.) was disappointing. Promising response rates in heavily pre-treated NSCLC patients were reported in recent phase I trials with agents acting on the interaction between antigen presenting cells, T-lymphocytes and tumor cells. Examples are antibodies against Cytotoxic T-lymphocyte Antigen 4 (CTLA-4) or against Programmed Death 1 receptor or its ligands. Antigen-specific immunotherapy aims at specific priming of immune system to recognize the tumor as foreign, thereby generating specific antibodies and/or cytotoxic T cells. This is “therapeutic cancer vaccination”. Conditions for optimal TCV are: 1/ specificity (well-defined target antigen in the tumor, not in other tissues); 2/ selectivity (use in the population expressing the target); 3/ immunogenicity (interaction with antigen leads to effective humoral and/or cellular response); 4/ tumor sensitive to immune kill in order to obtain improvement in patients’ outcome. Although the historical results of TCV for NSCLC were disappointing, knowledge from the last decades about the molecular pathology of tumors, of the immune system in general, and of tumor immunity in particular, has led to the introduction of several modern and more sophisticated TCVs. These vaccine formulations have shown encouraging data in phase II randomized clinical trials, and are now being studies in large phase III studies. Important examples are the MAGE-A3 vaccine in resected early stage NSCLC, the BLP-25 vaccine in locally advanced NSCLC after chemoradiotherapy, and e.g. belagenpumatucel-L and the TG4010 vaccine in advanced stage NSCLC. The MAGE-A3 protein is totally tumor-specific and present in about 35% of early stage NSCLC. In the hypothesis generating double-blind, randomized, placebo-controlled phase II study, 182 patients with completely resected MAGE-A3-positive stage IB-II NSCLC received recombinant MAGE-A3 protein combined with an immunostimulant (13 doses over 27 months) or placebo [1]. No significant toxicity was observed. There was a 24% - non-significant - improvement in disease-free survival (HR 0.76; 95% CI 0.48 to 1.21). Moreover, a predictive gene signature, initially described in advanced melanoma patients could be confirmed in early stage NSCLC [2].A large phase III study (n=2270) with MAGE-A3 vaccine is recruited and awaiting results (MAGRIT, NCT00480025). Mucins like the MUC1 protein are present in many epithelia, but MUC1 expression is altered (mainly by aberrant glycosylation) in many cancer types, including NSCLC. The tandem repeat MUC1-peptide liposomal vaccine BLP-25 has been studied in patients with stage IIIB-IV NSCLC [3]. Patients in disease control after conventional treatment with chemo(-radio)therapy were randomly assigned to BLP25 (8 weekly s.c. immunizations, followed by administration at 6-week intervals) plus BSC or BSC alone. While overall survival (OS) was not significantly different in the total group, a challenging effect was observed in stage IIIB patients (HR 0.524; 95%CI 0.261-1.052). No significant toxicity was observed. At the 2013 ASCO meeting, the double-blind, randomized, placebo-controlled phase III study was presented (START, NCT00409188) [4]. Patients not progressing after primary chemoradiotherapy for unresectable stage III NSCLC were randomized to BLP25 or placebo. In the primary analysis population (n=1239), OS was better with the vaccine (HR 0.88, 95%CI 0.75-1.03). In the predefined subgroup analysis in patients after concurrent chemoradiotherapy (n=806) there was a median OS difference of 10.2 months (HR 0.78, 95%CI 0.64-0.95). While the most obvious role for TCV is for patients with small residual disease after treatment, several compound are in phase III testing in advanced NSCLC as well. Belagenpumatucel-L is a vaccine based on a mixture of allogeneic tumor cells with TGF-β2 antisense blockade as adjuvant. In a phase II open trial, survival was related to the dose administered [5]. A phase III trial in patients with stage III-IV NSCLC in disease control after first-line therapy is now fully recruited (STOP, NCT00676507). TG4010 is a vaccine based on a recombinant viral vector (attenuated strain of vaccinia virus) expressing both the tumor-associated antigen MUC1 and interleukin-2. In a phase II randomized study, 148 patients with advanced NSCLC expressing MUC1 by immunohistochemistry received either up to 6 cycles of cisplatin-gemcitabine plus TG4010, or the same chemotherapy alone [6]. The primary endpoint, a 6-month progression-free survival more than 40% in the experimental arm was met. A confirmatory phase IIB-III trial is ongoing (TIME, NCT01383148). 1. Vansteenkiste J, Zielinski M, Linder A, et al. Adjuvant MAGE-A3 immunotherapy in resected non-small cell lung cancer: Phase II randomized study results. J Clin Oncol 2013; 31: 2396-2403. 2. Ulloa-Montoya F, Louahed J, Dizier B, et al. Predictive gene signature in MAGEA3 antigen-specific cancer immunotherapy. J Clin Oncol 2013; 31: 2388-2395. 3. Butts C, Murray N, Maksymiuk A, et al. Randomized phase IIB trial of BLP25 liposome vaccine in stage IIIB and IV non-small cell lung cancer. J Clin Oncol 2005; 23: 6674-6681. 4. Butts CA, Socinski MA, Mitchell P et al. START: A phase III study of L-BLP25 cancer immunotherapy for unresectable stage III non-small cell lung cancer. J Clin Oncol 31 Suppl, abstract 7500. 2013. 5. Nemunaitis J, Dillman RO, Schwarzenberger PO, et al. Phase II study of belagenpumatucel-L, a transforming growth factor beta-2 antisense gene-modified allogeneic tumor cell vaccine in non-small cell lung cancer. J Clin Oncol 2006; 24: 4721-4730. 6. Quoix E, Ramlau R, Westeel V, et al. Therapeutic vaccination with TG4010 and first-line chemotherapy in advanced non-small cell lung cancer: a controlled phase 2B trial. Lancet Oncol 2011; 12: 1125-1133.

Abstract not provided

Abstract
The radiology report forms an essential component of any radiological examination, and an accurate radiology report requires two key components: the detection of abnormalities (if any), and subsequently their interpretation. However, for radiology reports to be useful to the clinician and patient, a third crucial factor is successful communication. In the setting of lung cancer reporting, radiologists rely on their perceptive ability to detect nodules or masses, while interpretation requires knowledge and experience of the appearances, staging and behaviour of lung carcinomas. Improvements in both of the factors have been achieved by developments such as the use of computer aided detection software or maximum intensity projections (MIPs), for example, to detect lung cancer; and the use of internationally recognized documents such as the IASLC lung cancer staging classification which aids radiological interpretation. By comparison, the communication of the radiology report has changed little over the years, and it could be argued that efforts to improve lung cancer detection and staging are diminished without satisfactory communication. Standardized reporting (SR) has been advocated as a tool that can improve the communication of radiology reports, and which may also have benefits in the detection and interpretation of radiological abnormalities. This presentation will review the definitions of SR, and examine its purported benefits and disadvantages. Studies investigating the impact of SR will be reviewed. In particular, its relevance to lung cancer imaging will be highlighted. There is no single definition of what a standardized report should look like, but a key principle is that standardized reports (SRs) follow a pre-defined format. At the most basic level this includes the use of brief headings within a report, such as “clinical information” or “impression”, each of which contains free-text. At the other extreme is the mandatory use of a check-list of itemised headings, and the selection from a list of only pre-defined terms (using standardized language) within these headings, rather than free-text. Itemised headings in a CT structured report of a patient with lung cancer might include tumour morphology, tumour location, tri-dimensional measurements, presence or absence of invasion of structures such as pleura or chest wall, the presence or absence of enlarged lymph nodes recorded for all of the nodal stations, and the presence or absence of metastatic disease in each of the body organs. The hypothesized advantages of SR is that it produces: i) reports that are more accurate, ii) reports that are easier to read and understand, and iii) reports from which it is straightforward to retrieve data for research purposes. It has also been suggested that SRs allow radiologists to better convey uncertainties and likelihoods to clinicians. This is standard practice in mammographic reporting, where abnormalities are given a score between 1(negative) and 5 (highly suggestive of malignancy) and could in theory be extrapolated to the description of lung nodules in a clinical or lung cancer screening setting. The main disadvantages of SR that are put forward include its negative impact on workflow and the interpretation process. Additionally, it is suggested that, in fact, free text can better capture the uncertainties within a radiological examination, as often findings cannot be simply categorized into negative or positive. Unlike standardized reporting, the subject of standardized protocols in lung cancer imaging is perhaps less controversial, but no less important. The protocols used for the imaging of lung cancer can have a significant impact on the accurate staging and treatment planning of lung cancer. Furthermore, the successful implementation of future lung cancer screening programmes will require consistent adherence to low-dose CT acquisition protocols. In the staging of patients with lung cancer, protocols such as the routine reconstruction of multi-planar reformats to better identify tumour invasion are becoming widely adopted. Less agreement exists on imaging pathways. For example, the role of routine brain MRI in lung cancer staging or the possible use of contrast-enhanced PET/CT as a “one-stop shop”.

Abstract not provided

Abstract not provided

Background
The purpose of this study was to explore the effect of screening with spiral CT on lung cancer mortality in comparison with no screening in a high-risk population. Secondary endpoints were incidence, stage and resectability.

Methods
Male subjects, aged 60-75, smokers of 20+ pack-years were randomized to screening with low-dose spiral CT or control. Prospective participants were pre-assessed for eligibility and randomized during a telephone interview, while formal enrolment took place at a later date. All enrolled participants underwent a structured medical interview and physical examination, a baseline, once-only chest X-ray (CXR) and sputum cytology examination. Screening-arm subjects had a LDCT upon accrual, which was repeated every year for four additional years (5 rounds), while controls had a yearly clinical review only, with further testing only if needed.

Results
Between March 2001 and February 2006, 2811 subjects were pre-assessed and randomized (CT arm: 1403, control arm:1408). 20 cases of double registration and two test records have been identified in the database, and 2540 subjects actually appeared for assessment (1229 CTR arm, 1299 CT arm), of whom 2450 (1264 CT arm and 1186 Controls) were eligible and enrolled. The two study groups are comparable for age, smoking exposure, and comorbid conditions. As per inclusion criteria, all subjects are males and 99.8 % are 60 or older. As of December 2012, median follow-up was 73.1 months in the control arm and 75.5 months in the screening arm. Altogether, 152 patients were detected during active follow-up with 161 lung cancers: 92 CT-arm subjects (7.27%) versus 60 controls (5.05%), p< 0,0237. 82% of CT-arm lung cancers were detected at scheduled CT examinations, and 55% were stage I disease at the time of diagnosis compared with 27% in the Control arm. The absolute number of lung cancer cases with stage II-IV disease was virtually the same as in the control arm. Resectability rate was similar in the two groups. After linkage with population registries, vital status information is now available for 2528 subjects (99.5%). Overall, 370 subjects have died, for 104 of whom we are currently investigating mortality causes.

Conclusion
While the number of participants is relatively small, smoking exposure and average age of participants are higher than in similar trials. A comparatively high number of events has been observed. To date, 28% of such events cannot yet be attributed to a specific cause. Health registry data necessary to complete mortality comparisons is expected to become available in the next few weeks. Merging of all European trials may yield robust data about this strategy in the future.

Background
The National Lung Screening Trial reported a 20% reduction in lung cancer mortality achieved through low dose computed tomography (CT) screening of the at risk population, compared to screening with chest x-ray. Challenges with clinical implementation of CT screening for lung cancer include the high number of lesions detected that require further follow-up, approximately 97% of which are ultimately diagnosed as benign. A computer-aided diagnosis (CAD) tool can be designed to determine the probability of malignancy of a lung nodule based on objective measurements. While current CAD tools examine the pulmonary nodule’s shape, density, and border, analyzing the lung parenchyma surrounding the nodule is an area that has been minimally explored. By quantifying characteristics, or features, of the surrounding tissue, this study explores the hypothesis that textural differences in both the nodule and surrounding parenchyma exist between malignant and benign cases, which can be utilized to improve CAD performance.

Methods
From CT data, several novel feature extraction techniques were developed, including a three-dimensional application of Laws’ Texture Energy Measures to quantify the textures of the parenchyma as well as the nodule. In addition, the densities of the nodule and parenchyma were summarized through metrics such as mean, variance, and entropy of the intensities. The margins of the nodule were characterized following ray casting and rubber-band straightening to analyze mean and variance of border irregularity. Basic demographics and risk factor data were also included. The large feature set was reduced by statistical testing and stepwise forward selection to a few independent features that best summarize the dataset. A neural network was used to classify the cases in a leave-one-out method.

Results
To illustrate proof of concept, the CAD tool was applied to 27 lung nodule cases: 10 malignant and 17 benign. These data were diverse with regards to data acquisition protocol, reconstruction kernel and slice thickness – all of which can pose challenges to CAD. Through statistical testing, 36 features were found to be significant predictors of malignancy (p < 0.05), including many textural and parenchymal features. Two of these significant features, selected through stepwise forward selection, were utilized to classify the data: nodule variance (p = 0.0003) and parenchyma median intensity (p = 0.0028). CAD performance achieved a sensitivity of 90%, specificity of 100%, and an accuracy of 96.3%.

Conclusion
Preliminary findings indicate features from both the nodule and the surrounding parenchyma have value in distinguishing benign and malignant lesions. This is particularly valuable in the analysis of early detected, small pulmonary lesions (<10mm). In these small lesions, standard CAD approaches are hindered by few CT data voxels contained within the lesion. By incorporating local, surrounding and global features, more information is included and augmented CAD performance may be achieved. Finally, many significant features were identified despite diversity in the CT data acquisition parameters which indicates the suitability of the approach to broad clinical application. We are currently working on applying the CAD tool to a larger dataset.

Background
LDCT has recently been recommended as a screening tool for lung cancer in a high risk population, provided a 20% reduction in lung-cancer specific mortality. Nevertheless, LDCT has some limitations with respect to its high false positive rate, accumulated radiation exposure and relatively high cost. Digital tomosynthesis (DT) is a multisection imaging technique which can improve detection ability of small lung nodules and renders much lower radiation dosage and operation costs.

Methods
Thai heavy smokers (>30 pack-years) were enrolled in a prospective study starting from July 2012 to April 2013 (n=580). LDCT, DT and CR were utilized as a screening tool for lung cancer screening. All participants underwent imaging studies on the same day and the results were independently reviewed within a 1-week interval. Abnormal findings were categorized into 3 groups: negative, indeterminate (maximum diameter of pulmonary nodule >5- 9.9 mm), and suspicious for malignancy (maximum diameter of pulmonary nodule > 10 mm, consolidation, obstructive atelectasis, pleural effusion or mediastinal lymphadenopathy).

Results
At baseline, LDCT and DT classified 16/580 cases as suspicious for primary lung cancer while CR detected 15/580 cases. Seven cases with positive LDCT and DT findings were tissue-proven primary lung cancer including 3 - stage I cancers, 1 - stage III cancer and 3 - stage IV cancers. CR detected only 3 proven cases of primary lung cancer and all of them were stage IV cancer. The lung cancer detection rate for pulmonary nodule > 10 mm and other suspicious findings was 1.2%, 1.2%, and 0.5% by LDCT, DT, and CR, respectively. LDCT classified 67 cases as indeterminate while DT and CR classified 21 and 11 as such cases, respectively. Two additional primary lung cancer cases were detected at a 3-month follow-up LDCT of the indeterminate group by LDCT (2 cases), DT (1 case) and CR (0 case), respectively. The lung cancer detection rate for pulmonary nodule > 5 mm and other suspicious findings was 1.6%, 1.4%, and 0.5% by LDCT, DT, and CR, respectively. The positive predictive value (PPV) for pulmonary nodule >10 mm and other suspicious findings by LDCT, DT and CR was 43.8%, 43.8%, and 20.0%, respectively, while the PPV for pulmonary nodules of> 5 mm and other suspicious for malignancy findings by LDCT, DT and CR were 10.8%, 21.6%, and 11.5%, respectively. The sensitivity and specificity was 100% and 87%, respectively, for LDCT, and 88.9% and 94.9%, respectively, for DT, and 33.3% and 96%, respectively, for CR.

Conclusion
DT is a lung cancer screening modality that is comparable to LDCT, particularly for pulmonary lesions that are larger than 10 mm. and other suspicious for malignancy findings while CR was far inferior to DT and LDCT.

Abstract not provided

Background
Randomized data support annual screening for lung cancer among smokers using low-dose CT scans. To compare the resource implications of annual versus biennial screening, a cost-effectiveness analysis was undertaken using the Cancer Risk Management Model (CRMM version 2.0.1) in the context of the Canadian publicly funded healthcare system.

Methods
The CRMM performs simulations at an individual level and incorporates demographic data, cancer risk factors, cancer registry data, diagnostic and treatment algorithms and health utilities. Outputs are aggregated and costs (in 2008 Cdn dollars) and life-years are discounted at 3% annually. Simulations were performed with a cohort 55-74 years and a ≥30 pack-year (p-y) smoking history recruited from 2012-2032. CT scan sensitivity (Sens) and specificity (Spec) and cohort outcomes were based on NLST and Canadian data. It was assumed 60% of the eligible population participates by 10 years, 70% adhere to the screening regimen, and smoking cessation rates are unchanged. Sensitivity analysis was undertaken.

Results
An annual screening program incurs net costs of $2.97 billion and saves 55,000 quality-adjusted life-years (QALYs) at an incremental cost-effectiveness ratio (ICER) of $53,700 per QALY. Under default biennial screening assumptions (Table 1, scenario 3), biennial screening costs are $1.81 billion, saving 32,000 QALYs and producing an ICER of $56,200. In the least favourable stage shift scenario (1) tested, the ICER is $275,000, whereas the most favourable shift (4) results in $49,300. Using Sens/Spec 0.90/0.73 for all scans in scenario 3 produces an ICER of $61,400, whereas changing all incidence scan Sens/Spec to 0.87/0.73 gives an ICER of $60,900. Increasing age of eligibility to 55-79 cost $2.25 billion at an ICER of $58,700 per QALY while requiring a 40 p-y smoking history reduced cost to $1.3 billion at an ICER of $49,800 per QALY. Table 1.

Year			Stage Shift Scenario			Sens/ Spec
	1	2	3	4	5
0	T0	T0	T0	T0	T0	0.9/0.73
1	CD	PS	PS	PS	CD	-
2	T0	T0	T0/T1	T1	T1	0.89/0.84
3*	CD	PS	PS	PS	CD	-
4**	T0	T0	T0/T1	T1	T1	0.89/0.84
ICER	$275,000	$65,000	$56,200	$49,300	$104,00

T0, T1 refer to the NLST stage shift at specified time, where T0 equals shift at time zero screen, T1 shift at 12 month screen. T0/T1 indicates an average. CD: the unscreened Canadian stage distribution. PS: NLST post-screening stage shift. *Represents 3[rd] year and all future odd years. **Represents 4[th] year and all future even years. Hyphens indicate years without screening.

Conclusion
Compared to annual lung cancer screening, biennial screening reduces net cost but may have a similar ICER. Stage shift assumptions have a significant impact on ICER values. Minor adjustments in Sens/Spec modestly change the ICER. Widening the age range increases but increasing the p-y requirement reduces system costs.

Background
In September 2008 the Pan-Canadian early lung detection of lung cancer study recruited 2537 current or former smokers who were determined to have a high risk of developing lung cancer. An economic analysis was conducted to estimate the potential costs and benefits of screening with the aim of knowledge translation and decision aid for provincial screening programs. An analysis of prospectively collected resource utilization and cost data is presented.

Methods
Screening costs have been determined, accounting for the cost of all resources utilized to confirm true negative and false positive screen tests as well as early stage treatment costs for resources applied to obtain diagnostic confirmation of true positive and false negative results for screened individuals, treat the primary disease and any subsequent lung cancer within three years. All costs have been calculated from the Canadian public payer’s perspective. The average CT-screening cost over a fixed period of 18 months for the pan-Canadian study participants who did not have cancer was determined and compared with the phase specific costs of true positive and false negative lung cancer screening participants who had a lung cancer diagnosis proven prior to Dec. 31, 2012. The costs for early-detected lung cancer were determined and presented by diagnosis, treatment and surveillance phases of care.

Results
The average cost per screened individuals who did not end up having cancer in the first two years of the study was $456 (95%CI: $385-$570) per-person. The average rate of non-invasive investigations to pursue suspicious CT findings was 49% (CI: 45%-54%); depending significantly on the follow-up protocol observed in different participating sites. The rate of invasive investigations for individuals who had true negative or false positive results was low (<0.4%) as was the rate of complication (<0.004%). 85 individuals had lung cancer detected and diagnosed prior to December 31, 2012. The average cost of screening and the subsequent diagnostic workup for the most common detected lung cancer (stage IA and IB non-small cell lung cancer) was $4,233 (95%CI: $3,643-$4,822) per person. Per-person treatment and surveillance costs are presented by stage and mode of treatment for 84 lung cancers found in the early detection study.

Conclusion
This information indicates that screening costs are low on average, as are the rates of complications in the screened individuals that do not receive a cancer diagnosis in the first two years of screening. These numbers arrive while Canadian and other national healthcare systems must manage the impacts of several private, opportunistic, lung-screening clinics that are already operational. This study is sponsored by the Terry Fox Research Institute and the Canadian Partnership against Cancer

Background
Based on a 20% reduction in lung cancer deaths in the CT screening arm of the National Lung Screening Trial (NLST), yearly CT screening for lung cancer is now widely recommended. Eligibility for the NLST was based on age and smoking history only. However, we and others propose that multivariate risk models of lung cancer that incorporate variables for chronic obstructive pulmonary disease (COPD), improve risk prediction for lung cancer. The aim of this study was to examine recently published CT screening studies for lung cancer and the effect of having COPD on outcome.

Methods
We searched the literature for CT screening studies of lung cancer where spirometry had been done at baseline to assess the effects of spirometry-defined COPD on outcomes. We identified six studies where there was published data reporting spirometry results in lung cancer screening studies. Using this data we objectively measured outcomes stratified or pre-selected on spirometry-defined COPD.

Results
By comparing outcomes in these single arm and randomized studies we found the following lung cancer detection rates were between 1.5 to 6 fold higher in current and former smokers eligible for screening with spirometry-defined COPD compared to those with no airflow limitation or normal lungs (Table 1). Only 15% of those screened had advanced stage COPD (GOLD 3-4) The proportion of eligible current or former smokers with COPD had less indolent lung cancers with long doubling times (Table 2), and Survival after surgical resection of early stage CT-detected lung cancers was no different between those with or without COPD at baseline screening. Figure 1 Figure 2

Conclusion
We conclude that a COPD-centric approach to lung cancer screening offers a more efficient means of identifying lung cancer (higher lung cancer detection rate), with less over-diagnosis and comparable outcomes to screening those without COPD.

Abstract not provided

Background
Tumor-derived autophagosomes, referred to as DRibbles, are novel cancer vaccines that have been shown to be effective against 5 preclinical models of established tumors. We hypothesize that DRibbles’ efficacy stems from their ability to present stabilized tumor-derived short-lived proteins (SLiPs) and defective ribosomal products (DRiPs) that are, due to their short-lived nature, normally not processed and presented by professional antigen presenting cells. These SLiPs and DRiPs represent a potential pool of tumor antigens against which the host is not tolerant. A pilot clinical trial of an autologous DRibble vaccine demonstrated feasibility and suggested immune effects in 4 patients with advanced NSCLC (WCLC 2013, submitted). In order to expand the DRibble strategy to patients without an autologous tumor source, we have produced an allogeneic DRibble vaccine (DPV-001) from two NSCLC cell lines and developed a panel of 13 NSCLC cell lines expressing relevant antigenic targets that will be used to monitor induction of tumor-specific immunity.

Methods
The two NSCLC cell lines used to produce the DPV-001 vaccine (UbiLT3 and 6) were cultured with bortezomib and ammonium chloride to block the proteasome and prevent lysosomal degradation of SLiPs and DRiPs. Gene expression profiles were performed for each lot produced (Human Gene 1.0 ST arrays). Stability of indicator tumor antigens was assessed by Western blots. Toll-like receptor (TLR) agonist activity was assessed using HEK blue cells transfected with specific TLRs. After informed consent, a panel of NSCLC cell lines was established from 13 patients (tumor tissue or pleural fluid). These cell lines were HLA-typed for use in immunologic monitoring studies. cDNA was synthesized in triplicate from total RNA extracted from each cell line in log phase growth. Samples were then analyzed using human microarrays containing approximately 17,000 oligonucleotides (CBER array). Data files were uploaded into the mAdb database and analyzed by software provided by the Center for Information Technology (CIT), NIH. Group t-test was used to compare gene expression differences between NSCLC and normal lung tissues and between cell lines.

Results
Analyses confirm reproducible gene expression profiles from both cell lines during DPV-001 manufacture, and stability studies demonstrate that the vaccine remains stable for 23 months. The vaccine contains at least nine NCI-prioritized cancer antigens and agonists for 5 TLRs. Gene expression profiles of the 13 NSCLC cell lines identified 46 commonly overexpressed genes, all of which are expressed in the DPV-001 vaccine.

Conclusion
The DPV-001 vaccine provides a source of broad-spectrum relevant NSCLC antigens. We are conducting a multicenter, randomized, phase II trial of adjuvant DPV-001 vaccine in patients with definitively treated stage IIIA/B NSCLC. T-cell immune responses will be monitored using HLA matched cell lines from the indicator panel of 13 NSCLC cell lines. NIH grants R21 CA123864 (WJU) and R43/44 CA121612 (SA, TH), Kuni Foundation (WJU), Murdoch Trust, Robert Franz, Wes and Nancy Lematta, Lyn and Jack Loacker, and the Chiles Foundation. Clinicaltrials.gov study identifier pending

Background
Successful translation of adoptive T-cell therapy for solid cancers is predicated on the ability to generate a potent antitumor immune response and establish T-cell persistence. Thoracic malignancies typically lack expression of costimulatory ligands but do express negative regulators of T- cell function—factors that may impede T-cell therapy. We hypothesized that cancer antigen–targeted T cells engineered with activating CD28 costimulatory signaling would eradicate tumor and establish long-term functional persistence.

Methods
Mesothelin-specific chimeric antigen receptors (CARs) were engineered without (Mz) or with (M28z) a CD28 costimulatory domain. CAR-transduced human T cells were evaluated in vitro for cytotoxicity ([51]Cr-release assay), cytokine release (Luminex cytokine-release assay), and proliferation (cell-counting assay). In vivo assessment included monitoring of tumor progression by bioluminescence imaging (BLI), flow cytometric analysis of splenic/peripheral blood T-cell phenotypes, and Kaplan-Meier analysis of median survival, in NOD-scid IL-2Rγ-null mice bearing orthotopically implanted mesothelin-expressing mesothelioma cells (MSTO-211H: CD80/86-, TGF-β+, PD-L1+) and treated with human T cells transduced to express either Mz, M28z, or a control vector.

Results
In vitro, M28z CAR–transduced T cells exhibited equivalent cytotoxicity but enhanced Th1 cytokine secretion and antigen-specific proliferation, compared with Mz transduced T cells. In vivo, mice treated with a single low dose of M28z CAR–transduced T cells achieved tumor eradication and prolonged survival (median survival not reached; p=0.01), compared with mice treated with an equal dose of Mz-transduced (median survival, 63 days; tumor eradication in 20% of mice) or control CAR–transduced (median survival, 36 days) T cells (Figure 1A, 1B). Furthermore, CD28 costimulation enhanced CD62L[-]CD45RA[-] effector memory T-cell persistence (Figure 1C), leading to a robust T-cell proliferative response and superior control of tumor burden on tumor rechallenge 87 days after T-cell administration (Figure 1D, 1E). Figure 1

Conclusion
CD28 costimulation plays an important role in achieving long-term antitumor efficacy and functional persistence in mesothelin-targeted T-cell therapy. These data provide the scientific rationale for our upcoming clinical trial for pleural malignancies.

Background
Noninvasive T-cell imaging technology allows monitoring of adoptive T-cell responses without the need for invasive biopsies. Herein, we report dynamic imaging of tumor-targeted T cells in preclinical models by use of luminescent-enhanced firefly luciferase vector, and we further demonstrate the successful use of a clinical-grade herpes simplex virus type 1 thymidine kinase (HSV1-tk)–incorporated vector for monitoring of T-cell trafficking, antigen-specific proliferation, and biodistribution.

Methods
T cells transduced with mesothelin-targeted chimeric antigen receptors (M28z) were either cotransduced with an enhanced firefly luciferase vector (effLuc-M28z) or singly transduced with HSV1-tk-M28z (TK-M28z). To simultaneously visualize tumor during T-cell PET imaging, cancer-cell imaging was performed using MSTO-GFP/ffLuc+ (MSTO-211H cells transduced to express mesothelin and the green fluorescent protein/firefly luciferase fusion protein). In vitro, uptake of [18]F-FEAU radiotracer by T cells was measured by [3]H channel counting. In vivo studies used either SCID-beige or NSG mice bearing pleural or flank tumors. Bioluminescence imaging (BLI) quantification was determined by the mean number of photons per second in the region of interest. PET imaging with [18]F-FEAU was performed in a 3-dimensional microPET scanner. T-cell imaging results were validated by flow cytometric and immunohistochemical analysis of harvested tissue.

Results
Quantification studies showed a linear relationship between photon emission and T-cell number both in vitro and in vivo. In vivo, evaluation of T-cell biodistribution kinetics, by intravenous administration of effLuc-M28z T cells into mice bearing flank tumors, demonstrated initial accumulation of T cells in the lungs, liver, and spleen and progressive accumulation in the tumor (Figure 1A). Pleurally administered effLuc-M28z+ T cells displayed an increasing BLI signal (5-fold; p<0.01) in response to antigen 72 hours after administration, compared with pleurally administered effLuc+ T cells alone (control) (Figure 1B). T-cell accumulation in pleural tumor and extrathoracic sites (spleen) was confirmed by flow cytometric analysis of tissues harvested at serial time points (Figure 1C). These results were reproduced with clinical-grade vector TK-M28z+ T cells administered intrapleurally in mice bearing pleural tumor. Serial [18]F-FEAU PET imaging showed antigen-specific T-cell accumulation with decreasing tumor burden, as seen by corresponding tumor BLI (Figure 1D). Figure 1

Conclusion
We provide an optimized method for monitoring of T-cell trafficking, localization and proliferation in thoracic malignancies. Our findings—derived using a clinical-grade imaging construct and substrate—provide convincing evidence for the use of noninvasive T-cell monitoring in our upcoming adoptive T-cell therapy clinical trial.

Abstract not provided

Background
Activation of anaplastic lymphoma kinase (ALK) via the EML4 translocation occurs in a proportion of non-small cell lung cancers (NSCLC). Whilst inhibitors of ALK such as crizotinib have been successful in the clinic, most patients ultimately relapse due to resistance via a number of different mechanisms. EML4-ALK and many critical components of signalling pathways involved in resistance are clients for the chaperone HSP90. This offers an alternative approach for targeting both ALK inhibitor-sensitive and -resistant disease through inhibition of HSP90 alone or in combination with an ALK inhibitor. AT13387 is a potent second-generation HSP90 inhibitor currently being clinically tested in a number of indications, including ALK-positive NSCLC as single-agent and in combination with the ALK inhibitor, crizotinib. Here we describe its activity in preclinical models of ALK-positive NSCLC and investigate its potential in combination with crizotinib.

Methods
The activity of AT13387 was investigated in vitro in the EML4-ALK translocated H2228 cell line. Protein levels were determined by western blotting. In vivo, AT13387 was evaluated in an H2228 tumor xenograft and an EML4-ALK translocated patient-derived xenograft model by measuring inhibition of tumor growth.

Results
AT13387 potently inhibited the proliferation of the crizotinib-sensitive EML4-ALK NSCLC cell line, H2228, in vitro with an IC~50~ value of 69 nM. The HSP90 client proteins, EML4-ALK and AKT, along with their phospho-forms, were depleted on treatment of these cells with AT13387. A simultaneous reduction in levels of phospho-ERK, phospho-AKT and phospho-S6 indicated that ALK signalling was inhibited, whilst induction of HSP70 confirmed HSP90 inhibition. In vivo, AT13387 demonstrated activity in ALK-dependent xenograft models, including an ALK-dependent patient-derived xenograft model. When mice bearing H2228 tumor xenografts were treated with AT13387 (70 mg/kg or 55 mg/kg ip once weekly), significant inhibition of tumor growth was observed. As expected, treatment with crizotinib (50 mg/kg po daily) caused partial tumor regression in this model (75% regression after 8 weeks of treatment). However, when AT13387 (55mg/kg weekly) was combined with the crizotinib treatment, a further enhancement of the inhibition of tumor growth over either of the monotherapies (88 % regression after 8 weeks) was observed, with 5 out of 7 tumors achieving complete regression, suggesting that the upfront addition of AT13387 to crizotinib treatment could lead to an improved response and potentially delay the emergence of resistance. In addition, this combination was well-tolerated.

Conclusion
AT13387 was shown to be effective in models of ALK-positive NSCLC as monotherapy or in combination with crizotinib, supporting the ongoing Phase II trial of AT13387 in ALK-positive NSCLC as single agent and in combination with crizotinib. These data suggest that treatment with an HSP90 inhibitor such as AT13387, alone or in combination with crizotinib, has therapeutic potential in ALK-positive NSCLC and that, furthermore, upfront combination of the two agents could extend the duration of response.

Background
Non-small cell lung cancer (NSCLC) patients with tumors bearing “driver” mutations in the epidermal growth factor receptor (EGFR) tyrosine kinase (TK) domain have very high response rates to small molecule EGFR TK inhibitors (TKIs). However, all patients eventually develop resistance to the TKIs, and more recent reports have shown that patients who have stopped TKI therapy may be sensitive again upon re-treatment. While several genetic mechanisms of resistance have been documented, including the gate keeper T790M mutation and Met amplification, cell line studies in vitro have also implicated alternate epigenetic mechanisms that may explain the clinical progression observed in patients with EGFR mutations treated by TKIs. Studies in vivo using patient-derived primary lung tumor xenograft models have not been reported.

Methods
Patient-derived primary tumor xenografts were established from surgically resected early stage NSCLC implanted subcutaneously in non-obese diabetic severe combined immune deficient (NOD-SCID) mice. Tumors were passaged after reaching the humane endpoint 1.5 cm maximum diameter. EGFR TKI therapy was initiated when tumors reached ~6 mm diameter. Treatment included daily oral gavage for erlotinib (50 mg/Kg) and dacomitinib (3 mg/Kg). Cetuximab was administered weekly intraperitoneally (50 mg/Kg).

Results
Among 33 tumors with EGFR mutations engrafted into the mice, only 6 (18.2 %) formed tumors that could be propagated beyond first passage. Three models have been studied for their responses to EGFR TKIs. Model 148 with L858R mutation showed intrinsic pan-resistance to erlotinib and dacomitinib, as well as to cetuximab. This model was derived from a patient who received pre-operative erlotinib in a window of opportunity trial and did not respond. The patient relapsed after surgery and did not receive additional TKI therapy. Model 137 with exon19 E746-A750 deletion mutation demonstrated complete response to both erlotinib and dacomitinib. However, microscopic examination of tissue from the implantation site revealed viable tumor cells, consistent with the inability of TKI to completely eradicate tumor cells even when complete response is observed clinically. The patient subsequently developed disease recurrence and responded to third line gefitinib treatment. Model 164 has double exon19 L747-T751 deletion/T790M mutations. As anticipated, the xenograft failed to respond to erlotinib but responded dramatically to cetuximab alone. Importantly, model 164 xenograft showed transient stabilization of the tumor growth when treated by dacomitinib, but eventually developed progressive growth after 2 weeks of treatment. Resistance was reversible each time the dacomitinib-resistant tumor was propagated, without drug in new mice. The reversibility of resistance observed upon re-initiation of dacomitinib treatment suggests an epigenetic mechanism for TKI resistance. This patient developed recurrence after surgery and failed to respond to second line erlotinib treatment.

Conclusion
Patient-derived primary lung cancer xenografts may provide important patient-like models to study mechanisms of resistance to targeted therapies, and to test novel treatment strategies that may improve further treatment efficacy.

Abstract not provided

Background
The current treatment paradigm for metastatic non-small cell lung cancer (NSCLC) includes systemic therapy, radiotherapy or both. A “watch and wait” approach (WW) is commonly used in clinical practice. Whether this approach would have any effect on survival outcomes has not previously been evaluated.

Methods
The British Columbia Cancer Agency (BCCA) provides comprehensive cancer care to a population of 4.5 million across 944735 sq kms. A retrospective review was conducted of all referred patients diagnosed with stage IIIb/IV NSCLC from January to December 2009 in BC who saw a medical oncologist (MO). Patient characteristics, treatment recommendations, and outcomes were abstracted. WW-treated is defined as initial observation with chemotherapy > 8 weeks from MO consult. WW-missed are patients who were on a WW strategy that did not receive chemo. Kaplan-Meier survival analysis was compared using log rank test. Cox proportional hazards modeling was used to evaluate prognostic factors and control for potential confounders.

Results
710 patients were seen by a MO. Median age 66 years (29-90), ECOG 0-1 51%, male 52%, non squamous/squamous/NOS 40%/19%/41%, rural/urban 19%/81%. 327 received upfront chemo, 171 WW and 209 deemed chemo ineligible due to poor ECOG, and comorbidities. Of the 171 patients on a WW approach 44% missed an opportunity for chemotherapy (Figure 1). Reasons for WW-missed included poor ECOG (50%), death (47%), asymptomatic (1%), and illness (1%). Median OS was highest in the WW-treated 16.5 months (CI 12.7-20.3), followed by 13.9 months (CI 12.0-15.8) in the upfront chemo and lowest in the WW-missed 5.9 months (CI 4.4-7.4), p<0.0001. On multivariate analysis, factors predicting a poorer OS included ECOG >2, squamous histology, and a shorter the time from diagnosis to referral and referral to MO consult. When controlled for confounding factors (age, sex, ECOG) OS was similar between the upfront chemo and WW-treated (HR 1.16, CI 0.849-1.58, p=0.353), while those who were in the WW-missed had a significantly lower OS (HR 5.54, CI 3.00-10.24, P<0.0001). Figure 1

Conclusion
Our study demonstrates that a “watch and wait” strategy is potentially detrimental to patients because a significant proportion never receives chemotherapy. A decline in ECOG status accounts for 50% of the “missed” chemotherapy. Frequent follow up should be employed for patients who are on a WW approach to ensure the window of opportunity for chemotherapy is not lost.

Background
RAP80, a component of the BRCA1 complex, influenced outcome both in p with low BRCA1 expression treated with cisplatin (cis)/gemcitabine (gem) and in p with intermediate/high BRCA1 levels treated with cis/docetaxel (doc) or with doc alone in the SLCG phase II customized chemotherapy trial (NCT00883480). Based on these findings, the SLCG and the French Lung Cancer Group performed a prospective, randomized phase III trial in metastatic NSCLC patients to compare non-customized cis/doc with customized therapy customized according to BRCA1 and RAP80 mRNA expression levels.

Methods
From 2008 to 2013, patients with wild-type EGFR were randomized 1:1 to the control or experimental arm. Planned accrual was 391 patients. Treatment in the control arm was cis/doc, while patients in the experimental arm received treatment according to their BRCA1 and RAP80 levels: 1) those with low RAP80, regardless of BRCA1 levels, received cis/gem; 2) those with intermediate/high RAP80 and low/intermediate BRCA1 received cis/doc; and 3) those with intermediate/high RAP80 and high BRCA1 received doc alone. The primary endpoint was progression-free survival (PFS).

Results
At 15 October 2012, 279 patients had been included and the planned interim analysis was performed. PFS was 5.49 months (m) in the control and 4.38 m in the experimental arm (P=0.07). Overall survival (OS) was 12.66 m in the control and 8.52 m in the experimental arm (P=0.006). Response rate (RR) was 37.3% in the control and 27% in the experimental arm (P=0.07). In the multivariate analysis including PS, treatment arm, BRCA1, RAP80, histology, smoking status and metastatic site, only extrathoracic metastases were associated with an increased risk of progression (HR, 1.78; P=0.02). In a post hoc analysis restricted to patients with ECOG PS 0, PFS was 3.91 m in the control and 7.47 m in the experimental arm (P=0.01) for those with low RAP80 levels (experimental group 1). PFS for patients in experimental groups 1, 2 and 3 was 7.47, 7.01 and 3.22 m, respectively (P=0.02). OS for patients in experimental groups 1, 2 and 3 was 28.88, 15.86 and 11.81 m, respectively (P=0.04).

Conclusion
Based on the negative results for PFS at the interim analysis, accrual was closed on this study. The negative results may be due to the poor predictive capacity of RAP80 and/or to the inclusion of doc alone as a treatment in the experimental arm. In addition, doc/cis may not have been the ideal combination for the control arm. Customized chemotherapy could be further encouraged in oncogene-driven pan-negative patients with PS 0.

Background
Incidence of advanced NSCLC in the elderly is increasing. The use of a CGA is recommended to detect the patient’s vulnerability but its integration in treatment decision making has never been prospectively evaluated. The main objective of this study was to show that, compared to a standard strategy based on PS and age, the use of a CGA can improve the management of NSCLC in first line.

Methods
Randomized, multicentric, prospective phase III study in patients ≥70 y, PS 0-2 with stage IV NSCLC. We compared in arm A a standard algorithm of chemotherapy allocation based on PS and age: carboplatin based doublet in PS≤1 and age ≤75y, mono-therapy in PS =2 or age >75y with in arm B an experimental strategy of treatment allocation based on CGA: carboplatin based doublet for fit patients, mono-therapy for vulnerable patients and BSC for frail patients. Carboplatin (AUC5,d1), was associated to pemetrexed (500 mg/m2,d1) in non-squamous tumors and to gemcitabine (1000 mg/m2, d1-8) in squamous tumors, monotherapy was docetaxel 38 mg/m2 (d1-8). Four cycles of chemotherapy were to be given every three weeks. The main endpoint was time to failure treatment (TTF=duration between the date of randomization and the date the patient was withdrawn from treatment for any reason (progression, toxicity, death), secondary endpoints were Overall Response Rate (ORR), overall survival (OS), toxicity and quality of life (QoL), survival adjusted on QoL .

Results
493 patients were randomized from 01/2010 to 01/2013 by 45 centers. Patients characteristics were: male: 74%, median age: 77 (70-91) years, non-squamous histology: 71.8%, PS 0-1: 81.4%, ADL<6:13.9%, IADL<4:27.5%, Charlson’s index ≥2: 23%, score GDS 5≥3:2.5%. The 2 arms were well-balanced for patients characteristics except for ADL<6 (17.4% in arm A vs 10.3% in arm B). Respectively in arms A and B, 34.4% and 47% patients received a carboplatin based doublet, 65.6% and 31.5% received docetaxel and in arm B 21.5% received BSC. There was no significant difference in terms of TTF, respectively for arm A and arm B: median TTF was 99 days (d), 95%CI:[89; 126] vs. 98 d, 95%CI:[81;135], p=0.7149 and in terms of mOS: 196 d in arm A, 95%CI [171;231] vs. 185 d in arm B ,95%CI [148;235], p=0.7784. All grades toxicities were significantly less frequent in arm B than in arm A (93% vs.86.2%, p=0.016), but there was no difference in terms of grade 3-4 toxicities. All the secondary endpoints data will be updated at time of the meeting.

Conclusion
this large phase III study failed to show a superiority of a CGA based strategy of treatment allocation in terms of TTF. In experimental arm, 21.5% of frail patients according to Balducci’s criteria were enrolled and received an exclusive BSC management. Carboplatin-based doublets with pemetrexed and gemcitabine according to histology are feasible with a good profile of tolerance in selected elderly patients. This study will help to precise the most relevant geriatric tools and their cut-off in order to improve the management of the elderly with advanced NSCLC.

Abstract not provided

Background
Docetaxel plus cisplatin (DP) is the only third-generation regimen that has demonstrated statistically significant improvements in overall survival and QOL by head-to-head comparison with a second-generation regimen (vindesine plus cisplatin) in patients with advanced non-small cell lung cancer (NSCLC). S-1 plus cisplatin (SP) has shown activity and good tolerability in phase II settings. Molecularly targeted agents including bevacizumab (BEV) have shown activity and safety in non-squamous (non-Sq) NSCLC.

Methods
Patients with previously untreated stage IIIB or IV NSCLC, an ECOG PS of 0-1 and adequate organ functions were randomly assigned to receive either oral S-1 80 mg/m[2]/day (40 mg/m[2] b.i.d.) on days 1 to 21 plus cisplatin 60 mg/m[2] on day 8 every 5 weeks or docetaxel 60 mg/m[2 ]on day 1 plus cisplatin 80 mg/m[2] on day 1 every 3 weeks, both up to 6 cycles. The primary endpoint was overall survival (OS). A non-inferiority study design was employed; the upper confidence interval (CI) limit of the hazard ratio (HR) was <1.322. Secondary endpoints included progression-free survival (PFS), response, safety, and QOL. Subgroup analysis by histology (non-Sq vs Sq) was conducted.

Results
From April 2007 through December 2008, 608 patients were randomly assigned to SP (n=303) or DP (n=305) at 66 sites in Japan. Patient demographics were well balanced between the two groups. Non-Sq and Sq patients in SP/DP arm was 251/247 and 50/48 respectively. Two interim analyses were preplanned. At the final analysis, a total of 480 deaths had occurred. The primary endpoint was met. OS in the SP arm was non-inferior to that in the DP arm (median survival, 16.1 vs. 17.1 months, respectively; HR=1.013; 96.4% confidence interval, 0.837-1.227). PFS was 4.9 months in the SP arm and 5.2 months in the DP arm. The rates of febrile neutropenia (7.4% vs. 1.0%), grade 3/4 neutropenia (73.4% vs. 22.9%), grade 3/4 infection (14.5% vs. 5.3%), and grade 1/2 alopecia (59.3% vs. 12.3%) were significantly lower in the SP arm than in the DP arm. In terms of physical functioning and global functioning on the EORTC QLQ-C30 and lung cancer module (LC-13), QOL was better in the SP arm (repeated measures ANOVA: p<0.01). Subgroup analysis by histology revealed that the median OS of non-Sq and Sq patients in SP/DP group was 17.4/19.1 months and 12.3/11.7 months respectively, of which hazard ratio was 0.973 (95% CI, 0.797-1.187) and 1.239 (95% CI, 0.819-1.874). Interaction P value was 0.3004.

Conclusion
S-1 plus cisplatin is a standard first-line chemotherapeutic regimen for advanced NSCLC both non-Sq and Sq histology. Favorable toxicity profile of the SP regimen and encouraging outcome in patients with non-Sq prompted us to conduct a prospective study of SP plus BEV and maintenance S-1 BEV for non-SQ currently underway.

Background
Iniparib is an agent originally thought to function as an inhibitor of the DNA repair enzyme PARP-1, which is overexpressed in squamous lung cancers. Promising phase II activity and safety were reported with iniparib in combination with GC in pts with metastatic triple-negative breast cancer (O’Shaughnessy, NEJM 2011); however, subsequent phase III data were negative. Further study of iniparib’s mechanism of action suggests that this agent induces DNA damage, cell cycle arrest in the G2/M phase, and potentiates DNA-damaging chemotherapies not through PARP inhibition. Herein we report the final results from an international Phase III trial (NCT01082549) of first-line chemotherapy and iniparib in pts with advanced squamous lung cancer.

Methods
Pts were randomized 1:1 to GC or GCI. All pts received G 1000 mg/m[2] IV days (D) 1 and 8, and C AUC=5 IV D1 of each 21-D cycle. Iniparib was dosed 5.6 mg/kg IV D 1, 4, 8, and 11. All pts were assessed for response per RECIST 1.1 every 6 weeks. Pts without evidence of progressive disease (PD) or other reason for discontinuation could remain on treatment beyond 6 cycles. Accrual of 780 pts provides 89% power to detect an improvement in survival from 8 months (mos) anticipated with GC to 10.7 mos with GCI (HR of 0.75). Eligibility: Pts with newly diagnosed stage IV (M1a and M1b) squamous lung cancer, ECOG PS 0-1. Exclusion criteria included: history of recent cardiac disease, untreated brain metastases, and treatment for early-stage lung cancer within 12 months of study entry. The primary endpoint was overall survival (OS). Interim analyses for safety and futility were performed by an independent data safety monitoring board.

Results
780 pts were enrolled and randomized (GC, 390), (GCI, 390) from March 2010 to May 2012. Baseline characteristics were well balanced between groups (GC/GCI): median age 66 years (21-86); 74%/73% male; 30%/33% ECOG 0; 28%/33% current smokers; 66%/62% past smokers. The median number of cycles for GC/GCI were 4 (1-26)/5 (1-32). Dose reductions, dose intensity, and discontinuations due to tumor progression or adverse events were similar in both arms. The median OS for GC/GCI was 8.9 v. 8.9 months, HR 1.08 (0.92-1.28), p=.348. 1-year OS was 41 v. 40%. The median progression-free survival (PFS) for GC vs GCI was 4.9 v. 4.8 months, HR 0.99 (0.83-1.19), p=.92. The objective response rate (ORR) for GC v GCI was 34 v. 32%, p=.648. The safety profile was similar in both arms; anemia (28/26%), neutropenia (31/35%), thrombocytopenia (27/28%), and fatigue (6/9%).

Conclusion
The addition of iniparib did not improve the efficacy of GC in the treatment of pts with advanced squamous lung cancer. Further development of iniparib in squamous lung cancer is not recommended.

Background
Both Pemetrexed and gefitinib are standard second-line treatments for advanced non-squamous NSCLC in East Asia. The CTONG 0806, a multi-center, randomized, controlled, open-label phase II trial was designed to explore the efficacy of pemetrexed versus gefitinib as second-line treatment in advanced non-squamous NSCLC with wild-type EGFR.

Methods
Patients with locally advanced or metastatic non-squamous NSCLC previously treated with platinum-based chemotherapy and with wild-type EGFR detected by direct sequencing were randomized to receive gefitinib orally 250 mg/day (G arm) or pemetrexed 500 mg/m[2] iv day 1 every 21 days (P arm) until disease progression or unacceptable toxicity. Primary endpoint was progression-free survival (PFS). Secondary endpoints included 4-month and 6-month PFS rate, overall survival (OS), objective response rate (ORR), disease control rate (DCR), quality of life and safety. Independent Review Committee (IRC) evaluated all pictorial data.

Results
From Feb. 2009 to Aug. 2012, 161 patients were enrolled and 157 were evaluable (81 in G arm and 76 in P arm). Baseline characteristics were balanced between arms. The primary endpoint of median PFS was met with 4.8 months in P arm versus 1.6 months in G arm（HR 0.54, 95% CI 0.40~0.75, P<0.001), which was confirmed by IRC evaluation (5.6 vs. 1.7 months, HR 0.53, 95% CI 0.38~0.75, P<0.001). Significant difference between two arms was also seen in terms of 4-month PFS rate, 6-month PFS rate and DCR (Table 1). Median OS showed the trend of superiority in P arm (12.4 vs. 9.6 months, HR 0.72, 95% CI 0.49 ~ 1.04, P=0.077). In 108 patients having enough tumor tissue, EGFR mutation status was tested again by Scorpion amplification refractory mutation system (ARMS) and 32 were found to be positive. In 76 patients with wild-type EGFR confirmed by ARMS (35 in P arm and 41 in G arm), median PFS was 4.0 vs. 1.3 months (HR 0.42, 95% CI 0.26~0.67, P<0.001). More skin rash and diarrhea were seen in G arm while more fatigue and ALT increase were in P arm. CTCAE grade 3 or 4 adverse events was 12.3% in G arm and 32.9% in P arm (P=0.002). The detailed survival analysis and biomarkers analysis will be presented on the ground.

Table1. Efficacy of pemetrexed and gefitinib evaluated by investigators and IRC

	Evaluated by Investigators			Evaluated by IRC
	Pemetrexed arm	Gefitinib arm	P	Pemetrexed	Gefitinib arm	P
PFS	4.8months	1.6months	<0.001	5.6months	1.7months	<0.001
	HR 0.54，95% CI 0.40 ~ 0.75			HR 0.53, 95% CI 0.38 ~ 0.75
4-month PFS rate	59.0%	33.0%	<0.001	62.0%	37.0%	<0.001
6-month PFS rate	43.0%	23.0%	<0.001	48.0%	27.0%	<0.001
ORR	13.2%	13.6%	0.938	14.5%	12.3%	0.695
DCR	60.5%	29.6%	<0.001	61.9%	30.8%	<0.001
OS	12.4months	9.6months	0.077
	HR 0.72，95% CI 0.49 ~ 1.04

Conclusion
CTONG0806 is the first trial to show significant improvement in PFS, DCR and a trend of improving OS with pemetrexed compared with gefitinib in second-line setting for EGFR wild-type advanced non-squamous NSCLC.

Abstract not provided