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R. Rosell
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MINI 09 - Drug Resistance (ID 107)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
- Moderators:L. Villaruz, J. Minna
- Coordinates: 9/07/2015, 16:45 - 18:15, 205+207
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MINI09.02 - Transcriptome-Metabolome Reprogramming of EGFR-Mutant NSCLC Contributes to Early Adaptive Drug-Escape via BCL-xL Mitochondrial Priming (ID 3085)
16:50 - 16:55 | Author(s): R. Rosell
- Abstract
Background:
Precision therapy using EGFR small molecular inhibitors is the current standard-of-care in treatment of advanced non-small cell lung cancer (NSCLC) patients (pts) with EGFR mutations. Nonetheless, emergence of acquired resistance to therapy invariably occurs despite effective initial response. Classical rebiopsy studies of EGFR-mutant pts at clinical tumor progression based on RECIST criteria have identified diverse resistance mechanisms involving T790M-EGFR, MET amplification or activation and AXL upregulation. Tumor cells within minimal or microscopic residual disease during drug response may constitute founder cells for future disease relapse. The mechanisms of molecular changes intrinsic to these early therapeutic survivors are not yet well-understood. Our studies focus on tumor cells adaptation early during therapy to map the initial course of molecular drug resistance emergence and evolution.
Methods:
Drug-sensitive model studies of EGFR-mutant lung cancer were performed using HCC827 and PC-9 cells (exon 19 deletions EGFR) under erlotinib, and H1975 (T790M/L858R-EGFR) cells under CL-387,785 inhibition. Affymetrix microarray profiling was performed in triplicate at 0h, 8h, 9d and 9d tyrosine kinase inhibitor (TKI) followed by 7d drug-washout. Both in vitro and in vivo xenograft analyses, immunofluorescence, immunohistochemistry, time-lapse video microscopy analysis were conducted. Mass-spectrometry based global metabolomics profiling was also conducted under similar conditions as in gene expression profiling.
Results:
We identified an early adaptive and reversible drug-escape within EGFR-mutant cells that could emerge as early as 9 days during course of effective therapy with molecular drug resistance. Principal component analysis (PCA) of gene expression profiling data identified distinct transcriptome signatures in each cell state. Of note, the prosurvival cell state was independent of MET pathway activation, and had a TKI cytotoxicity escape at 100x higher IC50. The drug resistant cell state was associated with reversible cellular quiescence, suppressed Ki-67 expression, and profoundly inhibited cellular motility and migration. Transcriptome gene expression profiling revealed a remarkable adaptive genome-wide signature reprogramming, centered on the autocrine TGFβ2 cascade that involved pathways of cell adhesion, cell cycle regulation, cell division, glycolysis, and gluconeogenesis. Global metabolomic profiling of cellular metabolites in HCC827 cells under erlotinib inhibition also revealed a concurrent adaptive reprogramming of cellular metabolism during the early drug-resistant cell state, with suppression of glycolysis, TCA cycle, amino acids metabolism, and lipid bioenergetics. Our studies identified a direct link of TGFβ2 within the drug escaping cells, with the metabolic-bioenergetics quiescence, reverse Warburg metabolism and mitochondrial BCL-2/BCL-xL priming. Furthermore, this adaptive drug-resistant cell state also displayed an increased EMT and cancer stem cell signaling as adaptation to the drug treatment and that could be overcome by broad BCL-2/BCL-xL BH3 mimetic ABT-263, but not BCL-2 only mimetic ABT-199.
Conclusion:
We identified and characterized the emergence of early adaptive drug-escape within EGFR-mutant NSCLC cells amid an overall precision therapy excellent response, through a MET-independent mechanism. The profoundly drug-resisting prosurvival cell state undertook remarkable cellular transcriptome-metabolome adaptive reprogramming coorindated through autocrine TGFβ2 signaling augmentation. Our study results have important implications in lung cancer drug-resistant minimal/microscopic disease and future therapeutic remedies in precision therapy.
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MINI 22 - New Technology (ID 134)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
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MINI22.01 - Detecting ALK, ROS1 and RET Fusion Genes in Advanced Non-Small Cell Lung Cancer (NSCLC) Using a Novel Multiplexed NCounter-Based Assay (ID 2254)
16:45 - 16:50 | Author(s): R. Rosell
- Abstract
- Presentation
Background:
Gene fusions of anaplastic lymphoma kinase (ALK), ROS1, and RET are targetable oncogenes present in approximately 9% of advanced NSCLC. Current assays for detecting gene fusions are based on FISH (FDA-approved companion diagnostic test for ALK), immunohistochemistry (IHQ) and qRT-PCR. These tests, however, are complex and have disadvantages in terms of turnaround, sensitivity, cost and throughput. The nCounter platform allows joint detection, in a single tube, without any enzymatic reaction and in 72 hours, of multiple fusion genes by transcript-based method from formalin-fixed paraffin-embedded (FFPE) samples.
Methods:
A custom set consisting of 5´and 3´ probes and/or fusion-specific probes to detect ALK, ROS1 and RET fusion transcripts was evaluated. A panel of ALK-ROS-RET positive cell lines (H2228, H3122 [EML4-ALK], SU-DHL-1 [NPM-ALK], HCC78 [SLC34A2-ROS], BaF3 pBABE [CD74-ROS], LC2/ad [RET]) and control fusion negative cell lines (PC9, H1975 [EGFR mut], H460, H23 [KRAS mut]) were used for nCounter validation. To determine the minimum of tumor surface area for detection, ALK translocated cell line H2228 was tested in FFPE at increasing cell numbers (2500, 5000, 10.000, 25000, 50000) corresponding to a surface area of 0.27, 0.55, 1.1, 2.75 and 5.5 mm2, respectively, in the FFPE block. A total of 38 FFPE samples positive by FISH, IHC and/or qRT-PCR for ALK (n=30), ROS (n=7) and RET (n=1) were also analyzed. Total RNA was isolated from cell lines and FFPE and < 225 ng were used for hybridization. Raw counts were normalized using positive controls, negative controls and 4 house-keeping genes (GAPDH, GUSB, OAZ1 and POLR2A) as described in Lira et al. J Mol Diagn 2013. Positive and negative ALK fusion translocation was defined by a 3’/5’ ratio score of > 2.0 and ≤ 2.0 respectively. Response to crizotinib by RECIST criteria was retrospectively collected in patients with ALK-positive NSCLC.
Results:
nCounter sensitivity to predict fusion transcripts ALK, ROS and RET in cell lines by using both methods (3’/5’ and direct reporter probes) was 100%. Results indicate that samples containing as few as 10% positive tumor cells and a 2.75 mm2 tumor surface area were sufficient for adequate gene fusion detection. The accuracy of prediction (AUC) of ALK 3’-5’ ratio score in 45 independent samples was 82.6% (95% CI 69.3-95.6) with a kappa coefficient score of 0.637. Among 28 samples ALK-FISH-positive, ALK 3’-5’ scoring was positive in 27 samples (96%). One sample was non-evaluable by ALK 3’-5’ scoring. Among the 17 samples ALK-FISH-negative, ALK 3’-5’ score was negative and positive in 10 (59%) and 7 (41%) samples, respectively. All patients with ALK-FISH-negative samples but ALK 3’-5’ score positive (n=7) were positive for ALK IHC and 5 of them were treated with crizotinib. Response assessment was available in 3 of these patients and response rate was 100%. One patient non-evaluable by FISH but positive 3’-5’ scoring also responded to crizotinib.
Conclusion:
The ALK/ROS1/RET nCounter-based assay is a highly sensitive screening modality that might identify FISH-negative/non-evaluable NSCLC patients who could benefit from ALK inhibitors.
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MS 12 - NSCLC Stems Cells: Are They a Real Target? (ID 30)
- Event: WCLC 2015
- Type: Mini Symposium
- Track: Treatment of Advanced Diseases - NSCLC
- Presentations: 1
- Moderators:C. Dive, K. Nakagawa
- Coordinates: 9/08/2015, 14:15 - 15:45, Mile High Ballroom 2c-3c
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MS12.03 - Where to Go from Here? (ID 1902)
15:00 - 15:20 | Author(s): R. Rosell
- Abstract
Abstract:
Lung cancer is a dismal disease, however, anticipated selective responses are observed in a subgroup of non-small cell lung cancer (NSCLC) patients where the disease is driven by epidermal growth factor receptor (EGFR) mutations. EGFR mutations occur in 15 – 40% of lung adenocarcinomas, according to gender, smoking history and geographical region. Two types of EGFR mutations account for 90% of all lung adenocarcinoma-associated EGFR mutations and are related to sensitivity to treatment with oral tyrosine kinase inhibitors (TKIs), such as gefitinib, afatinib or AZD9291: (i) small in-frame deletions in exon 19 that lead to elimination of an LREA motif in the protein (DEL) and (ii) a point mutation in exon 21 that substitutes an arginine for a leucine at position 858 in the protein (L858R). Lung cancer patients bearing EGFR mutations show radiographic responses to TKIs in 60 – 70% of cases. Although the majority of patients achieve a significant therapeutic benefit, almost all invariably progress in less than 1 year. Therefore there is an unmet medical need for novel therapies in order to avoid resistance to treatment. We have employed a wide array of approaches (MTT, western blot analysis, PCR, Aldefluor assay and mouse models) to demonstrate that the combination of gefitinib, afatinib or AZD9291 with compounds targeting signal transducer and activator of transcription 3 (STAT3) can suppress the mechanisms of early adaptive resistance. STAT3 is a member of a family of proteins responsible for transmission of peptide hormone signals from the extracellular surface of the cells to the nucleus. STAT3 is a master regulator of several key hallmarks and enablers of cancer cells, including cell proliferation, resistance to apoptosis, metastasis, immune evasion, tumor angiogenesis, epithelial-mesenchymal transition, response to DNA damage and the Warburg effect. In addition STAT3 promotes an increase in the cell renewal of tumor-initiating cells or cancer stem cell subpopulation, mainly aldehyde dehydrogenase (ALDH). EGFR mutations cause receptor oligomerization and activation of intrinsic or receptor-associated tyrosine kinases, respectively. These activated kinases phosphorylate receptor tyrosine residues creating docking sites for recruitment of cytoplasmic STAT3. STAT3 docks to receptor phosphotyrosyl (pY) peptide sites through its Src-homology (SH2) domain which leads to its phosphorylation on Y705 followed by STAT3 tail-to-tail homodimerization (SH2 domain of each monomer binds to the pY peptide domain of each partner). STAT3 homodimers accommodate in the nucleus, where they bind to specific STAT3 response elements in the promotor of target genes and regulate their transcription. EGFR mutations and tyrosine kinase-associated receptor interleukin-6 (IL-6) lead to the activation of STAT3 that is not obliterated by EGFR TKIs. Even more, 2 hours after starting gefitinib treatment there is an increase in STAT3 activation in EGFR mutant cell lines (P. Ma, Cancer Research, 2011). Moreover, following erlotinib treatment there is an enrichment of ALDH+ stem-like cells through EGFR-dependent activation of Notch3. We have tested several small molecules that target STAT3. The combination inhibits cell viability in several human EGFR mutant cells and blocks STAT3 activation. However, neither the combination of EGFR TKIs with TPCA1 (repurposed as a STAT3 inhibitor), nor the combination of gefitinib with AZD0530 (a Src inhibitor) prevent the increment in the ALDH + cancer stem cell subpopulation. Therefore, we are exploring more in depth the crosstalk between EGFR and IL-6. As a whole, human EGFR mutant cell lines have increased levels of IL-6 which leads to STAT3 hyper-activation. Nevertheless, recent evidence indicates that IL-6-Src can induce YAP activation and NOTCH signaling. The downstream effectors of YAP and NOTCH ligands CTGF and HES1, respectively, are being examined in clinical tumor samples. We have examined the combination of Src, YAP and NOTCH inhibitors in addition to the use of STAT3 inhibitors. The triple combination of gefitinib plus TPCA1 plus AZD0530 had great synergism with a very low combination index and also eliminated the ALDH+ population (Figure). Furthermore, the overexpression of ALDH1A1 was decreased with the triple combination, however with only gefitinib plus TPCA1 or gefitinib plus AZD0530, ALDH1A1 mRNA was substantially increased in comparison with gefitinib alone (Figure). The western blot for the triple combination shows the inhibition of STAT3 Y705 phosphorylation as well as the phosphorylation of YAP (Ser397) and also from BMI1. We plan to confirm some of the data in clinical tumor samples to understand the contribution of IL6 and well established effectors-the SHP2-ERK, PI(3)K-Akt-mTORC1 and JAK-STAT3 modules and the interaction with YAP. Figure 1
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ORAL 04 - Adjuvant Therapy for Early Stage Lung Cancer (ID 99)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:E. Vallieres, Y. Ohe
- Coordinates: 9/07/2015, 10:45 - 12:15, 205+207
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ORAL04.05 - Results Ph III Trial Customized Adjuvant CT after Resection of NSCLC with Lymph Node Metastases SCAT: A Spanish Lung Cancer Group Trial (ID 2983)
11:28 - 11:39 | Author(s): R. Rosell
- Abstract
- Presentation
Background:
Postop platinum-based CT improves outcomes in completely resected NSCLC with nodal involvement (St II-IIIA) but compliance and outcomes remain limited. Analysis of expression of genes involved in DNA repair could be used to individualize optimal CT. BRCA1 is primarily involved in the repair of double strand DNA breaks and functions as a differential regulator of response to cisplatin (Cis) and antimicrotubule agents. BRCA1 defficiency can enhance Cis resistance. Loss of BRCA1 function is associated to sensitivity to DNA-damaging CT and may also be associated with resistance to spindle poisons
Methods:
Randomized phase III multicenter trial. After surgery patients (p) with St II and III NCSLC were random 1:3 to control arm (3 cycles Cis-Docetaxel) or to experimental arm with treatment assigned according BRCA1 expression levels (low levels: Cis-Gemcitabine; intermediate levels: Cis-Doc; high levels: Docetaxel alone). Stratifification factors: N1 vs N2; age < or > 65 y; non-Squamous vs Squamous (Sq) histology; lobectomy vs pneumonectomy). Planned PORT in N2. Primary end-point OS. Secondary end-points DFS, toxicity profile (CTCAE v 3.0) /compliance, recurrence pattern. Statistical hypothesis: increase 20% 5y survival rate control group (45%)
Results:
From June/2007 to May/2013, a total of 591 p were screened and 500 of them were randomized in the study, 108 in control arm, 392 in experimental arm. In experimental arm 110 p received Cis-Gem, 127 Cis-Doc and 110 Doc alone. There were no significant differences between arm for known prognostic factors: Median age 64 y; 79% males, 21% females; 43% Sq, 49% Adenoca, 8% others; 57% former smokers, 32% current smokers, 11% never smokers; pneumonectomy 26%; N1 58%, N2 48%. Median tumor size 4.4 cm (0.8-15.5 cm). Median mRNA BRCA1 levels 15.78 (0.73-132). Mean BRCA1 levels 6.95 in Adenoca vs 20.29 in Sq (p<0.001). P with Sq histology showed a longer DFS (HR 0.73; p=0.05) but without differences in OR (HR 1) Median follow-up 28 months (0-79 m), with a cut-off of March 15[th] 2015, median survival has not reached both arms and no significant differences have been seen for OS with hazard ratio (HR) 0.866 (p=0.45) or DFS with HR 1. In experimental group HR for OS was 0.842 (NS) comparing low with high-BRCA1 levels. In p with high-BRCA1 levels control treatment (Cis-Doc) was superior to experimental (Doc) with HR 1.24 (NS).In non-Sq histology experimental treatment was superior to control with HR 0.75. For p receiving all planned treatment HR is 0.63 with p = 0.043 compared with p not able to complete treatment.
Conclusion:
Overall survival data are still immature because median survival is not reached with a median f-u 28 m for this N+ population. At this time analysis BRCA1 based adjuvant CT does not improve overall OS. In p with high BRCA1 levels Doc alone is inferior to Cis-Doc. BRCA-1 levels are higher in Sq and in non-Sq histology a trend to better survival in experimental arm was found. Full dose of planned treatment confers a survival advantage, however, longer follow-up is still warranted.
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ORAL 33 - ALK (ID 145)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Advanced Diseases - NSCLC
- Presentations: 1
- Moderators:S. Gadgeel
- Coordinates: 9/09/2015, 16:45 - 18:15, Mile High Ballroom 1a-1f
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ORAL33.06 - Brigatinib (AP26113) Efficacy and Safety in ALK+ NSCLC: Phase 1/2 Trial Results (ID 2125)
17:39 - 17:50 | Author(s): R. Rosell
- Abstract
- Presentation
Background:
Brigatinib (AP26113), an investigational oral tyrosine kinase inhibitor with FDA breakthrough therapy designation for the treatment of patients with crizotinib-resistant advanced ALK+ NSCLC, has preclinical activity against both rearranged ALK and clinically identified crizotinib-resistant mutant ALK.
Methods:
This is an ongoing phase 1/2, single-arm, open-label, multicenter study in patients with advanced malignancies (N=137; NCT01449461). Patients received escalating total daily doses of brigatinib from 30–300 mg during phase 1. Daily regimens of 90 mg, 180 mg, or 90 mg for 7 days followed by 180 mg were evaluated in phase 2. Safety is reported for all treated patients; antitumor efficacy (ORR and PFS per RECIST v1.1) is reported for ALK+ NSCLC patients.
Results:
Seventy-nine (58%) patients had ALK+ NSCLC. Median age was 54 (29–83) years, 49% were female, 90% had prior crizotinib, and 47% had ≥2 prior chemotherapy regimens. As of February 17, 2015, 45/79 (57%) ALK+ NSCLC patients remained on study, with median time on treatment of 12.6 months (1 day to 35.5 months; n=79); ORR/PFS for evaluable ALK+ NSCLC patients was 74%/13.4 months (additional data shown in Table). In a post hoc independent radiological review of patients with brain metastases at baseline (as of January 19, 2015), 8/15 (53%) patients with measurable brain lesions ≥10 mm had an intracranial response (≥30% decrease in sum of longest diameters of target lesions) and 9/30 (30%) patients with only nonmeasurable lesions had disappearance of all lesions. Treatment-emergent AEs in ≥30% of total patients, generally grade 1/2, included nausea (52%), fatigue (42%), diarrhea (40%), headache (33%), and cough (32%). Early-onset pulmonary events, which occurred ≤7 days after treatment initiation and included dyspnea, hypoxia, and new pulmonary opacities on chest CT consistent with pneumonia or pneumonitis, were reported in 13/137 (9%) patients overall (6/44 [14%] at 180 mg qd; 2/50 [4%] at 90 mg qd [maintained or escalated to 180 mg qd after 7 days]).Response and PFS With Brigatinib All Evaluable ALK+ NSCLC Patients n=78 Prior Crizotinib n=70 No Prior Crizotinib n=8 Response, n(%) OR (CR+PR) 58(74) 50(71) 8(100) [95% CI] [63–84] [59–82] [63–100] CR 7(9) 4(6) 3(38) PR 51(65) 46(66) 5(63) SD 11(14)[a] 11(16)[a] 0 PD 6(8) 6(9) 0 Termination before scan 3(4) 3(4) 0 Median duration of response,[b] mo 11.2[c] 9.9[d] Not reached[e] Median PFS,[b] mo 13.4 13.4 Not reached [a]Includes non-CR/non-PD for 4 patients with no measurable disease at baseline [b]Kaplan-Meier estimate [c]n=55 evaluable [d]n=48 evaluable [e]n=7 evaluable
Conclusion:
Brigatinib has promising antitumor activity in ALK+ NSCLC patients with (71% ORR; PFS 13.4 months) or without (100% ORR) prior crizotinib, including patients with brain metastases (53% ORR in patients with measurable brain lesions). Early-onset pulmonary events were less frequent when starting at 90 vs 180 mg qd. A pivotal global phase 2 trial (ALTA) of brigatinib 90 mg qd vs 90 mg qd for 7 days followed by 180 mg qd in crizotinib-resistant ALK+ NSCLC is ongoing.
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ORAL 42 - Drug Resistance (ID 160)
- Event: WCLC 2015
- Type: Oral Session
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
- Moderators:R.C. Doebele, J.V. DeGregori
- Coordinates: 9/09/2015, 18:30 - 20:00, Mile High Ballroom 4a-4f
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ORAL42.05 - <em>SMARCA4</em>/BRG1 Is a Biomarker for Predicting Efficacy of Cisplatin-Based Chemotherapy in Non-Small Cell Lung Cancer (NSCLC) (ID 849)
19:13 - 19:24 | Author(s): R. Rosell
- Abstract
Background:
Adjuvant platinum-based chemotherapy remains a primary treatment of non-small-cell lung cancer (NSCLC); however, identification of predictive biomarkers is critically needed to improve the selection of patients who derive the most benefit. In this study, we hypothesized that decreased expression of SMARCA4/BRG1, a known regulator of transcription and DNA repair, is a predictive biomarker of increased sensitivity to platinum-based therapies in NSCLC. Moreover, this study also sought to confirm the prognostic role of SMARCA4/BRG1 in NSCLC.
Methods:
The prognostic value of SMARCA4 expression levels was tested using a microarray dataset from the Director’s Challenge Lung Study (n=440). Its predictive significance was determined using a gene expression microarray dataset (n=133) from the JBR.10 trial, and RT-PCR data from 69 patients enrolled on the MADe-IT trial and 33 platinum-treated patients from an institutional cohort.
Results:
In the Director's challenge study, low expression of SMARCA4 was found to be associated with poor overall survival compared to high and intermediate expression (P = 0.006). Upon multivariate analysis, compared to high, low SMARCA4 expression predicted an increased risk of death and confirmed its prognostic significance (HR=1.75; P=0.002). In the JBR.10 trial, improved five-year disease-specific survival was noted only in patients with low SMARCA4 expression when treated with adjuvant cisplatin/vinorelbine (HR 0.1, P= 0.001 (low); HR 1.1 , P= 0.762 (high)). An interaction test showed significance (P=0.007). In addition, a trend toward improved progression-free survival was noted only in patients with low SMARCA4 receiving a carboplatin- versus a non-carboplatin-based regimen in the MADe-IT trial. Figure 1 Fig1. Low SMARCA4 correlates with improved disease-specific survival with adjuvant cisplatin-based chemotherapy in the JBR.10 trial.
Conclusion:
Although decreased expression of SMARCA4/BRG1 is significantly associated with worse prognosis, it is a novel significant predictive biomarker for increased sensitivity to platinum-based chemotherapy in NSCLC patients.
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P1.01 - Poster Session/ Treatment of Advanced Diseases – NSCLC (ID 206)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Advanced Diseases - NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.01-057 - Gemcitabine plus Platinum versus Other Platinum Doublets in Squamous NSCLC (ID 149)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Squamous cell carcinoma is the second most common histologic subtype of non-small-cell lung cancer (NSCLC). Platinum-based doublet chemotherapy regimens remain the basis of front-line systemic treatment. Most studies in NSCLC included all histologic subtypes. Here we present a pooled analysis of gemcitabine in combination with cisplatin or carboplatin, specifically focusing on patients with squamous NSCLC, from three studies for which individual patient data are available. The objective of this analysis was to evaluate the efficacy of first-line gemcitabine plus platinum (GP) compared with other regimens plus platinum (OP).
Methods:
This analysis included squamous NSCLC patients from three randomized, open-label, phase III studies of gemcitabine: 1) gemcitabine plus cisplatin versus etoposide plus cisplatin (n=61), 2) gemcitabine plus carboplatin versus paclitaxel plus carboplatin (n=128), and 3) gemcitabine plus cisplatin versus pemetrexed plus cisplatin (n=473). Patients were grouped into the GP subgroup (n=324) or the OP subgroup (n=338). Efficacy measures included overall response rate (ORR), overall survival (OS), and time to disease progression (TTP). Stratified (by study) Cox proportional hazard regression models were used to analyze OS and TTP by random assignment factors to identify potential prognostic factors and explore their predictive value.
Results:
Baseline characteristics were similar between the GP and OP groups. Median OS was 9.72 months for GP versus 9.33 months for OP (HR=0.898, p=0.223) (Figure 1). There was a significant difference in median TTP (5.52 months for GP versus 4.73 months for OP; HR=0.792, p=0.008) (Figure 2). ORR was 31.5% for GP, and 27.2% for OP (p=0.229). Cox regression model identified three prognostic factors for OS: Eastern Cooperative Oncology Group performance status, prior radiotherapy, and body mass index. Figure 1. Kaplan–Meier estimates of overall survival Figure 1 Figure 2. Kaplan–Meier estimates of time to disease progressionFigure 2
Conclusion:
This pooled analysis further confirmed the efficacy of gemcitabine plus platinum as first-line treatment of squamous NSCLC.
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P1.08 - Poster Session/ Thymoma, Mesothelioma and Other Thoracic Malignancies (ID 224)
- Event: WCLC 2015
- Type: Poster
- Track: Thymoma, Mesothelioma and Other Thoracic Malignancies
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.08-008 - Efficacy of Palliative Chemotherapy in Malignant Pleural Mesothelioma from Spanish BEMME Database. The Spanish Lung Cancer Group (SLCG) (ID 2356)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Palliative chemotherapy with cisplatin and antifolate (pemetrexed or raltitrexed) conferred a median overall survival of 12 months with a response rate of 24% to 43% in malignant pleural mesothelioma (MPM) patients. BEMME (Base Epidemiológica Mesotelioma Maligno en España) is an observational and retrospective study sponsored by the Spanish Lung Cancer Group that aimed to characterize the patient’s and tumor’s features as well as the treatment modalities outcomes of patients diagnosed with mesothelioma in Spain.
Methods:
Clinical records of patients with malignant pleural mesothelioma were retrospectively reviewed to collect epidemiological and survival data into an electronic and anonymous database. Thirty-five Spanish hospitals participated in the project and 538 MPM patients were included in the BEMME database. Here we present a descriptive analysis of MPM patients (stage III and IV) treated with palliative chemotherapy.
Results:
From January 2008 to December 2013, 297 of 538 patients (p) (55%) with MPM were treated with palliative chemotherapy. Most patients were males (79%), aged between 60-70y (40%), and 60% had a performance status 1 at diagnosis. No exposure to asbestos was reported in 54% of patients. Epithelioid was the most frequent histological subtype (66%), followed by sarcomatoide (12%), biphasic (9%) and not specified (14%). In stage IV, the most frequent metastatic site was lung (35%). Among patients who received chemotherapy, 55% were treated with palliative intent and reached a disease control rate (CR+PR+SD) of 62%. Platinum plus pemetrexed was the most common schedule used as a palliative treatment, without differences in ORR according to platinum-based agent used (Cisplatin: 36% vs. Carboplatin: 32%). A total of 61 of the 297p (21%) received maintenance treatment with an ORR of 10% and stable disease in 50% of p. The median overall survival (OS) for all patients was 12.6 months (95% CI 10.8 – 14.3). There were statistically significant differences in OS according histological subtype. The median OS for epithelioid was significantly longer (15 months, 95% CI 13.8-18) as compared with non-epithelioid (7 months 95% CI 4.3-9, p<0.001). There were no statistically significant differences in OS according to gender, asbestos exposure or type of platinum chemotherapy (Cisplatin 15.2 months 95% CI: 13.7-18.75; vs. Carboplatin 18 months 95% 12-25.3, p=0.32).
Conclusion:
In Spain, OS of MPM patients treated with platinum palliative chemotherapy exceeded the median OS reported in phase III trials.
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P2.03 - Poster Session/ Treatment of Locoregional Disease – NSCLC (ID 213)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.03-005 - Surgical Resection after Definitive Chemoradiotherapy (ID 782)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Approximately, 30% of non-small-cell lung cancer (NSCLC) patients are diagnosed with locally advanced disease (IIIA-B). Treatment of these patients is controversial, with recommendations including definitive chemoradiotherapy, induction chemotherapy followed by surgery or induction chemoradiotherapy followed by surgical resection. Salvage surgery is defined as resection after high doses of radiation (>50Gy), planned as a primary curative intent, and usually more than 12 weeks after radiotherapy. Lung resection after high-dose radiotherapy has traditionally been avoided due to high rates of morbidity and mortality.
Methods:
The aim of this review is to analyze the outcome of patients referred to our institution for surgical resection after definitive chemoradiation. We reviewed 23 NSCLC patients who underwent surgical treatment after definitive chemoradiation between 2003 and 2014.
Results:
There were 15 men and eight women with a median age of 54.64 years (range 33-69 years). Fifteen patients were diagnosed with adenocarcinoma (65.2%), and the most frequent cTNM stage was T3N2M0 (34.8%) followed by T2N2M0 and T4N2M0. The type of surgical resection included five lobectomies, six bilobectomies and 12 pneumonectomies (seven right and five left pneumonectomies). Four patients showed a complete pathological response after treatment (pT0N0M0 17.4%). There was only one postoperative death due to a bronchopleural fistula. All patients received platinum-based chemotherapy and definitive radiotherapy, with a median dose of 65Gy (range 45-70Gy). Median time from radiotherapy to surgical resection was 8.28 months (0.9-35.47 months). Six patients suffered recurrence after surgery, three to a distant site and three local recurrences. Median disease free survival for the group of patients who relapsed after surgery was 7.7 months (3.9-17.5 months). Figure 1 Median overall survival was 88.3 months (CI 95% 57.6–118.9), with 1, 3 and 5 year survival rates of 87%, 74.5% and 66.3% respectively. Figure 2
Conclusion:
Salvage surgery after definitive chemoradiotherapy is feasible, with low postoperative complication rates and encouraging survival.
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P2.04 - Poster Session/ Biology, Pathology, and Molecular Testing (ID 234)
- Event: WCLC 2015
- Type: Poster
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 3
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.04-028 - BIM Deletion Polymorphisms in Hispanic Patients with Non-Small Cell Lung Cancer Who Carriers EGFR Mutations (CLICaP) (ID 2597)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Germline alterations in the proapoptotic protein Bcl-2-like 11 (BIM) can have a crucial role in diverse tumors. To determine the clinical utility of detecting BIM deletion polymorphisms (par4226 bp/ par363 bp) in EGFR positive non-small-cell lung cancer (NSCLC), we examined outcomes of patients (pts) with and without BIM alterations
Methods:
We studied 89 NSCLC pts with EGFR mutation who were treated with erlotinib between January 2009 and November 2014. BIM deletion was analyzed by PCR in formalin-fixed paraffin-embedded (FFPE) tissues of tumor biopsies. We retrospectively analyzed clinical characteristics, response rate, toxicity, and outcomes among patients with and without BIM deletion (del)
Results:
BIM deletion was present in 14 pts (15.7%). There were no significant differences between pts with and without BIM del in clinical characteristics or type of EGFR mutation; however, pts with BIM del had a worse overall response rate to erlotinib (42.9% vs. 73.3% for pts without BIM del; p=0.024) as well as a significantly shorter progression-free survival (PFS) (10.8 del+ vs. 21.7 months for pts without BIM del; p=0.029) and overall survival (OS) (15.5 del+ vs. 34.0 months for pts without BIM del; p=0.035). Multivariate Cox regression analysis showed that BIM deletion was an independent indicator of shorter PFS (HR 3.0; 95%CI 1.2-7.6; p=0.01) and OS (HR 3.4; 95%CI 1.4-8.3; p=0.006)
Conclusion:
The incidence of BIM del found in pts from Colombia is similar to that previously described in Asia; this alteration is associated with a poor clinical response to erlotinib and represents an independent prognostic factor for pts who had NSCLC with EGFR mutations
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P2.04-048 - Analysis of Gene Expression in the Re-Replication Pathway and Selective Blockade with Checkpoint Inhibitors as a Therapeutic Option in NSCLC (ID 2594)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Targeted lung cancer therapy has undoubtedly made a difference to the treatment of EGFR mutation and ALK translocation carriers. However, targeted therapies for other subgroups like squamous cell carcinoma are still scarce. Re-replication of the genome could initiate gene amplification and cause chromosomal translocation and loss, contributing to tumor progression. It has been shown that cell cycle checkpoints and DNA damage response are activated when re-replication is induced. Cell cycle checkpoints, mediated by CHK1 and 2, are essential to prevent re-replication and maintain genomic integrity. Specific CHK1 inhibitors such as LY2603618 have been shown to delay tumor growth when given in combination with pemetrexed in NSCLC xenograft models.
Methods:
We selected a panel of NSCLC adenocarcinoma and squamous cell carcinoma cell lines representing different genetic backgrounds with TP53, KRAS and EGFR mutations. In addition, six PC9-derived, TKI resistant cell lines were included (PC9-ER, PC9-GR1 to GR5). Expression of genes involved in the re-replication pathway (MDC1, ATR, ATM, CHEK2, Rap80, Cdc1, Cdc6, MYC, SLX4, CHEK1, BRCA1, BRCA2, p53, ORC4, ORC5, ORC6 and GMNN) was analyzed by RT-PCR. All cell lines were treated with CHK1 and a CHK1/2 inhibitors, and the IC50 was determined by the MTT assay
Results:
We observed different expression levels of key genes involved in the re-replication pathway. Interestingly, a p53 mutated squamous cell line (SK MES1), which has high expression levels of CHK1 and CHK2 (22.31 and 18.66, respectively), showed the lowest IC50 in our study (IC50= 0.024 mM) with a CHK1 selective inhibitor (LY2603618). Also, two EGFR-resistant cell lines, one harbouring the T790M mutation, were highly sensitive to CHK1 inhibition (IC50 of 0.19µM for PC-GR5; 0.40 µM for PC9-GR4). Interestingly, when using a dual CHK1-CHK2, the IC50 is significantly higher in the SK MES1 cell line (84.62 µM vs 0.024 µM) when compared to single CHK1 inhibitonHalf maximal inhibitory concentrations (IC50s) of CHK1 and CHK1-2 inhibitors
Cell line CHK1 (IC50 µM, mean) CHK1-2 (IC50 µM, mean) SK-MES1 0.027 84.62 A549 0.8 15 HCC78 1.2 33.4 H2228 2 0.5 H3255 8.1 12.6 H1975 22.6 9.6
Conclusion:
A great advance has been made in targeted therapy for NSCLC during the last 10 years. Nevertheless, few specific therapeutic options exist for squamous cell carcinoma of the lung nowadays. Different expression of genes involved in the re-replication pathway, and the sensitivity of some NSCLC cell lines (such as SK-MES1, a squamous carcinoma cell line) to selective CHK-1 and dual CHK1-CHK2 inhibitors identify this pathway as a possible therapeutic target worthy of further investigation.
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P2.04-077 - PDL1 Expression in Metastatic Non-Small Cell Lung Cancer Patients from Colombia (CLICaP) (ID 2839)
09:30 - 09:30 | Author(s): R. Rosell
- Abstract
Background:
Programmed cell death-1-ligand 1 (PD-L1) is involved in the ability of tumor cells to escape the host’s immune system. PD-L1 is selectively expressed in a number of tumors. The blockade of interactions between PD-1 and PD-L1 enhances the immune function in vitro and mediates antitumor activity in preclinical models. Recent studies have suggested that antibody-mediated blockade of PD-L1 induced durable tumor regression and prolonged stabilization of the disease in certain cancers including NSCLC. A recent study demonstrated that immunohistochemical (IHC) analysis detected no objective response in PD-L1-negative patients. However, 36% of the patients with PD-L1-positive tumors had a positive response.
Methods:
PD-L1 was assessed by IHC (Dako MAb) in 115 NSCLC patients, considering as positive a staining intensity ≥ 2 in more than 5% of cells. The driver mutation epidermal growth factor receptor (EGFR) was examined by direct sequencing and allele specific PCR. ALK FISH was performed using the Vysis ALK Break-Apart Probe. The correlations of PD-L1 expression with major clinicopathologic parameters and outcomes were analyzed.
Results:
Mean age was 64.3 years (SD+/-10.7), 66% were females, 83% had adenocarcinoma and 58% were former/current smokers. Fourteen patients (18%) had mutations in the EGFR and 19 (25%) were PD-L1+. PD-L1 was positive in fifty-nine patients (51%) and this condition was more frequent in the light or never smokers (p=0.05). In the same way PD-L1 positivity was significantly associated with presence of EGFR mutations (p=0.03), in tumors with a higher grade of differentiation (p=0.023) and in presence of vascular invasion (p=0.038). Patients with positive PD-L1 expresion had a longer progression free survival (PFS) (6.4 months vs. 3.0 months, p= 0.001) and overall survival (OS) (28.2 vs. 12.4 months; p=0.001).
Conclusion:
Although the study sample is small, PD-L1 positivity correlates with PFS and OS. This results supports that PD-L1 might be a critical factor in the use of NSCLC immunotherapy.
