Virtual Library

Abstract not provided

Abstract:
Major advances in the understanding of molecular pathways that regulate tumor growth have led to development and FDA approval of new anticancer agents leading to improved survival in patients with certain cancer types. A common cancer like Non Small Cell Lung Cancer (NSCLC) is now subdivided in a number of molecularly defined subsets. Large randomized trials are not feasible anymore. This challenge to accrue to small subsets with availability of multiple drugs for each has led to novel trial design strategies like “Master Protocols” with multiple arms that are biomarker driven. Master Protocols are ideal if multiple molecular targets are known to drive tumor growth, if there is pre-clinical/clinical evidence that these targets can be pharmacologically inhibited and if the drugs to be tested are available. These protocols provide consistency of drug development approach regardless of intended target, utilize resources (including patient resources) in an efficient manner and have potential of bringing safe and effective drugs to patients faster. On the other hand these trials are time and resource intense, and some trials with public/private partnership have added need of a high level coordination. Part of NCI precision medicine initiative has led to “Master Protocols” like Lung-MAP, ALCHEMIST and NCI-MATCH. The Lung-MAP trial is evaluating patients with squamous cell lung cancer who have progressed beyond at least one line of therapy. The study divides patients into multiple treatment arms based on the molecular profiles of their cancers testing efficacy of targeted drugs. Promising results in any arm can lead to testing the drugs in that treatment arm in more patients, with the goal of more rapid drug approvals in these small subsets of squamous cell lung cancer patients. ALCHEMIST is testing the benefits of molecularly targeted adjuvant (post-surgical) treatment of patients with early-stage lung adenocarcinomas whose tumors have either an EGFR gene mutation or an anaplastic lymphoma kinase (ALK) gene rearrangement. Depending on the genetic abnormality in a tumor, the patient will be randomized to receive the EGFR protein kinase inhibitor erlotinib or the ALK protein kinase inhibitor, crizotinib against a placebo. The Food and Drug Administration (FDA) has approved these molecularly targeted therapies for advanced lung adenocarcinoma in patients with the relevant genetic changes. It is expected that most patients with early lung adenocarcinoma who are screened will not be eligible for the therapeutic portion of this trial because their tumors will not have the necessary mutations. However, the tumor samples from these patients will be saved, and, if they relapse while on standard treatment, their tumors will be biopsied again and analyzed for insight into the progression of their disease and for potential therapeutic approaches suggested by this analysis. The NCI-MATCH trial will test a large number of agents in virtually any tumor type in which appropriate abnormalities are identified. This umbrella protocol will examine between 20 and 25 drugs, including those that have been FDA-approved for the treatment of cancer at another tumor site or experimental agents that have shown activity against a known target at one or more tumor sites. If the response rate to a particular agent is high, the number of patients evaluated with that treatment would be expanded to further explore whether the targeted treatment represents a substantial advance over standard chemotherapy. If a tumor becomes resistant to the first test drug, it will be re-biopsied to see if another targeted therapy might be effective and to understand the basis for resistance to the initial treatment. By studying multiple agents at the same time, a higher proportion of patients will be eligible for the trial, and efficient progress can be made in the assessment of clinical benefit.

Abstract not provided

Abstract:
Over the past decade, there have been rapid advances in cancer drug discovery and development. Much of this progress has resulted from a better understanding of the genetic changes in cancer and the development of agents that target the underlying biology of disease. In addition, an improved understanding of the immune system and cancer has resulted in the development of immune checkpoint inhibitors that have profound clinical activity in many tumors. Finally, the role of the tumor microenvironment in the regulation of tumor growth, metastatic spread, and modulation of the immune system is an area of intense investigation[1]. This enhanced understanding of the complex biology of cancer, and novel drugs against these new targets, have ushered in an exciting era in drug development leading to important new drug approvals[2]. An increasingly important aspect in both clinical development and drug approval is the incorporation of biomarkers and companion diagnostics to select patients more likely to benefit from specific therapies[3]. In lung cancer, the utilization of companion diagnostics has been key in the clinical development of TKIs directed at a variety of EGFR mutations and ALK alterations[4,5,6]. Other biomarker tests have been used to identify genes such as BRAF and ROS1 in order to develop clinical trials to test approved targeted agents with activity in patients with these molecular alterations[7]. Ongoing clinical studies exemplified by the Lung Master Protocol and NCI Match Protocol are utilizing biomarker panel strategies, including next generation sequencing (NGS), to identify patients with specific mutations in lung and other cancers respectively[4]. The use of NGS to characterize molecular alterations is also becoming more common to characterize patients’ tumors in both the academic and community settings. Immunohistochemistry assays continue to be a mainstay for understanding tumor biology and are also being utilized to quantitate markers such as PDL-1 expression in tumor immune cells in order to identify patients who are more likely to respond to immune checkpoint inhibitors[8]. In addition, analysis of biomarkers in liquid biopsies (e.g. plasma, spinal fluid) are being analyzed to provide supplemental information and/or to obviate the need for ongoing tumor biopsies during therapy[9]. Clinical development based on patient subset will increasingly be the norm, rather than the exception, in oncology. Rather than exclusively utilizing histology to screen patients for clinical trials, the use of basket trials to identify and treat patients of various histologies with agents targeted to similar molecular alterations is an approach which is increasingly being utilized[10]. In addition, retrospective analyses are being conducted to understand underlying molecular abnormalities of patients with exceptional responses to existing therapies and to use the information to design future clinical trials. One of the major challenges in clinical development is tumor heterogeneity and drug resistance. To prevent or overcome the development of drug resistance, combination therapies to target specific pathways are being explored. One such example is the use of BRAF and MEK inhibitors in the treatment of metastatic melanoma[11]. Many clinical studies in lung cancer are now incorporating mandatory tumor biopsies during the course of EGFR and ALK inhibitor therapy to identify evolving genetic changes in tumors during therapy in order to incorporate second and third generation TKIs. New mechanisms to facilitate the drug review and approval processes are underway[12]. One such mechanism is the Breakthrough Therapy (BT) Program. Breakthrough Therapy is intended to expedite the development and review of drugs for serious or life threatening conditions. Designation of a drug as a BT is based on preliminary clinical evidence that demonstrates that a new drug may have substantial improvement over available therapy and facilitates ongoing communication between the sponsor and the FDA to streamline the drug development process. Accelerated approval has been developed by the FDA for speeding the development and approval of promising therapies to treat serious disease that provides a meaningful therapeutic benefit over available therapy. Accelerated approval is based on an improvement in patient benefit utilizing surrogates of survival that are reasonably able to predict clinical benefit. The accelerated approval mechanism has been essential in facilitating new drug approvals of promising therapies. In addition, fast track designation is an FDA program intended to facilitate the development and expedite the review of drugs to treat serious medical conditions. This program allows sponsors to facilitate the review process for drug approval by having ongoing FDA interactions and utilizing a rolling review of submissions. Given the importance of biomarker-directed therapy, an additional critical component of the regulatory landscape is the review and approval of companion diagnostics at the same time as specific drug approvals. The drug-diagnostic co-development model is becoming increasingly common in oncology as biomarker-driven patient selection is required for many of the new targeted and immune therapies. Thus, an evolution in both the clinical development paradigm and the regulatory landscape is occurring based on the discovery and development of more effective, biomarker-directed targeted agents and novel immune checkpoint inhibitors.REFERENCES 1. Hanahan, D. and Weinberg, RA. Cell 2011; 144: 646-674. 2. Wolford, JE. and Tewari, KS. Future Onc. 2015; 11: 1931-1945. 3. Shen, T., Hans Pajaro-Van de Stradt, S., Yeat, NC., et al. Front in Genet. 2015; 6:215 in press. 4. Morgensztern, D., Campo, MJ., Dahlberg, S., et al. J. Thor. Onc. 2015; 10: S1-S63. 5. Somasundarsm, A., Socinski, MA., and Burns, TF. Informa 2014; 15: 2693-2707. 6. Kwak EL, Bang Y-J, Camidge DR, et al. N Engl J Med. 2010; 18: 1693-1703. 7. Camidge, DR., Pao, W., and Sequist, LV. Nature Rev. Clin. Onc. 2014; 11: 473-481. 8. Carbognin, L., Pilotto, S., Milella, M., et al. PLOS ONE 2015; 10:1371 in press. 9. Francis, G. and Stein, S. Int. J. Mol. Sci. 2015; 16: 14122-14142. 10. Catenacci, DVT. Mol. Onc. 2015; 9: 967-996. 11. Long, GV., Stroyakovskiy, D., Gogas, H., et al. NEJM 2014; 371: 1877-1888. 12. Kesselheim, AS. and Darrow, JJ. Clin. Pharm. & Ther. 2015; 97: 29-36.

Abstract:
Background Brain metastases are an important clinical problem in patients with small cell lung cancer (SCLC), with 20% of patients having them at diagnosis and about 80% at autopsy. In patients with LS-SCLC, prophylactic cranial irradiation (PCI) significantly reduces the risk of brain metastases, and it improves survival [1]. A meta-analysis showed a survival benefit of almost 6% at 3 years with PCI (21 vs 15%). A subsequent international multi-center study comparing higher and lower dose PCI found no improvement in outcomes with higher doses [2]. Consequently, a dose of 25 Gy in 10 fractions remains the standard dose for PCI. Since the risk of brain metastases is even higher in patients with ES-SCLC, PCI has also been investigated in these patients.A randomized EORTC study showed that PCI both reduced the risk of brain metastases and improved overall survival [3]. Survival at 1 year was 27% for the patients who received PCI compared to 13% for the controls. Interestingly, patients who received PCI were more likely to receive 2[nd] or 3[rd] line chemotherapy with subsequent disease progression (68 vs45%), presumably because they remained fitter without brain metastases. PCI was well tolerated in the effect on quality of life was small and transient [4]. The beneficial effect of of PCI was underscored in the recent CREST trial, where the risk of brain metastases was less than 5% [5]. Controversies surrounding the use of PCI Firstly, PCI can have a negative effect on cognition [6], with important risk factors being advanced age, pre-existing cerebrovascular problems, diabetes and the use of anti-epileptics. It should however be appreciated that brain metastases by themselves also have an important negative effect on cognition and quality of life. Moreover, SCLC patients may have impaired cognitive functioning in comparison with healthy controls, independent of the use of chemotherapy or radiotherapy. Another point to consider is that metastases in SCLC, often are multiple with limited options for high dose (stereotactic) radiotherapy, in contrast to NSCLC. Use of radiotherapy techniques that reduce doses to the hippocampus [7], as well as the use of Alzheimer drugs drugs such as memantine and donezepil [8] may further mitigate the effect of PCI. The effectiveness and safety of these approaches remains to be be evaluated in prospective clinical trials. Second, it has been questioned whether PCI will continue to show a beneficial effect if a brain MRI is repeated after completion of chemotherapy, in order to eliminate some subclinical metastases. This is discussion intensified after the presentation of a Japanese study in 2014 [9]. In the study, MRI brain was not only performed after chemotherapy, but also at regular intervals during the follow-up. Any brain metastases detected were treated with radiotherapy or radiosurgery. The study was designed as a superiority study for PCI, with overall survival as primary endpoint, but closed early due to futility. The likelihood of finding a survival benefit of PCI was less than 0,1%, but the discussion was fueled by the incorrect and misleading title using the word ‘detrimental’. Due to slow accrual, the Japanese study enrolled 160 patients entered from 40 centers in 4 years, thereby suggesting that patient selection may have played a roll. The publication of this analysis is awaited with interest. In order to address this topic from another angle, we have re-analyzed the effect of PCI on brain metastases and survival in a previous EORTC PCI study, after excluding patients who either died or developed brain metastases in the first 8 weeks after randomization, as such patients may have had asymptomatic brain metastases, visible if an MRI would have been performed. Even after exclusion of these patients, the EORTC PCI trial found a significant effect on brain metastases (HR 0.40; p<0.001) and overall survival (HR0.74; p=0.035) [unpublished data]. Conclusion In conclusion, PCI should remain standard of care in SCLC patients who have responded to chemotherapy. The pros and cons of PCI should be individually weighted and discussed with the patient. Some promising new techniques undergoing evaluation now may reduce the side-effects of PCI. References 1. Aupérin A, Arriagada R, Pignon JP, et al.. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med. 1999 Aug 12;341(7):476-84. 2. Le Péchoux C, Dunant A, Senan S, et al. Standard-dose versus higher-dose prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer in complete remission after chemotherapy and thoracic radiotherapy (PCI 99-01, EORTC 22003-08004, RTOG 0212, and IFCT 99-01): a randomised clinical trial. Lancet Oncol. 2009 May;10(5):467-74. 3. Slotman B, Faivre-Finn C, Kramer G, et al. Prophylactic cranial irradiation in extensive small-cell lung cancer. N Engl J Med. 2007 Aug 16;357(7):664-72. 4. Slotman BJ, Mauer ME, Bottomley A, et al. Prophylactic cranial irradiation in extensive disease small-cell lung cancer: short-term health-related quality of life and patient reported symptoms: results of an international Phase III randomized controlled trial by the EORTC Radiation Oncology and Lung Cancer Groups. J Clin Oncol. 2009 Jan 1;27(1):78-84. 5. Slotman BJ, van Tinteren H, Praag JO, et al. Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 2015 Jan 3;385(9962):36-42. 6. Gondi V, Paulus R, Bruner DW, et al. Decline in tested and self-reported cognitive functioning after prophylactic cranial irradiation for lung cancer: pooled secondary analysis of Radiation Therapy Oncology Group randomized trials 0212 and 0214. Int J Radiat Oncol Biol Phys. 2013 Jul 15;86(4):656-64. 7. Kundapur V, Ellchuk T, Ahmed S, Gondi V. Risk of hippocampal metastases in small cell lung cancer patients at presentation and after cranial irradiation: a safety profile study for hippocampal sparing during prophylactic or therapeutic cranial irradiation. Int J Radiat Oncol Biol Phys. 2015 Mar 15;91(4):781-6 8. Day J, Zienius K, Gehring K, et al. Interventions for preventing and ameliorating cognitive deficits in adults treated with cranial irradiation. Cochrane Database Syst Rev. 2014 Dec 18;12:CD011335. 9. Seto T, Takahashi T, Yamanaka T, et al. Prophylactic cranial irradiation (PCI) has a detrimental effect on the overall survival (OS) of patients (pts) with extensive disease small cell lung cancer (ED-SCLC): Results of a Japanese randomized phase III trial. J Clin Oncol 32 (Suppl) Jun 11, 2014, abstract 7503

Abstract not provided

Abstract:
Fewer than 20% of all lung cancers are small cell lung carcinomas (SCLCs). As SCLC is an aggressive tumor because of its high and early risk of dissemination, most patients (60-70%) have metastatic disease at diagnosis. Given the high propensity of SCLC for early metastatic dissemination, chemotherapy has been and still is the cornerstone of treatment based on etoposide and platinum, but SCLC is also very sensitive to radiotherapy. Median survival for patients with non-metastatic disease for whom the standard treatment is combined chemotherapy and thoracic radiotherapy, as well as prophylactic cranial irradiation (PCI), is currently 15–20 months, with 20–40% surviving to 2 years, and 25% surviving at 5 years in the best series. For metastatic patients, median survival is 8–13 months and 2 year survival is around 5%. Recent advances in SCLC management derive mostly from a better integration of chemotherapy and radiotherapy. So patients with a limited number of metastases in number and location may have an intermediate outcome; and local treatment of both the primary tumor as well as oligometastatic disease could be discussed. Such an approach is supported by the fact that many patients in early studies that established the role of thoracic radiation therapy in limited disease would now be considered as having metastatic disease. The percentage of such metastatic patients seems to have increased partly because of stage migration with the more frequent use of PET scan and brain MRI. Thus there is a category of patients with oligometastatic disease for whom local treatment may be envisaged. The oligometastatic status was first described by Hellman and Weichselbaum as an intermediate clinical state between locoregionally confined and widespread cancer in 1995. There has been strong interest lately in this subgroup of non-small cell lung cancer oligometastatic patients, with the development of stereotactic ablative radiotherapy. Until recently, there were few data supporting the role of radiation therapy in metastatic small cell lung cancer, except PCI. As there are few therapeutic options in second line, local treatment approaches have been evaluated in extensive disease. Prophylactic cranial irradiation is now part of the standard treatment in responders and more recently a phase III trial has shown that consolidation thoracic radiotherapy could improve outcome. The 2-year survival rate was 13% in the investigational arm versus 3% in the control arm where patients had 4-6 cycles of chemotherapy and PCI [Auperin, 1999; Slotman 2007; Slotman, 2015]. A randomized phase II trial (RTOG 0937) went further in the local approach of metastatic disease after systemic chemotherapy and really addressed the issue of oligometastatic disease [Gore, RTOG 0937]. It compared PCI to PCI and consolidative radiation therapy not only to the primary intrathoracic disease but also to residual extracranial metastatic lesions (1-4 extracranial metastases who achieve a CR/PR following chemotherapy). The trial has included 96 patients and has closed recently after a planned protocol interim analysis. Results are eagerly awaited. Even if there are studies supporting the role of radiotherapy in metastatic SCLC, new strategies are needed for this category of patients. There are promising preclinical data showing a strong synergy between radiotherapy and immune treatments. Such approaches are starting to be explored in SCLC in prospective studies.

Abstract not provided

Background:
Plasma cell-free DNA (cfDNA) contains genetic information from primary and metastatic cancer foci. We utilized multiplex deep sequencing technology to investigate the clinical significance of cfDNA concentration and mutational burden in advanced non-small-cell lung cancer patients treated with EGFR tyrosine kinase inhibitors (TKIs).

Methods:
Between January 2012 and February 2014, seventy-one eligible patients from Sun Yat-sen University Cancer Center were enrolled. All the patients provided written informed consent and donated 2 ml plasma before taking EGFR-TKIs. Plasma DNA was isolated and purified using QIAamp Circulating Nucleic Acid Kit. CfDNA concentration was determined by Qubit Fluorometer. A set of 234 primer pairs were designed to amplify sequences covering hotspots of 35 genes. The amplicon libraries were prepared and entered into deep sequencing on Ion Torrent PGM chip. Variants were called by established bioinformatics methods. Circulating DNA mutational burden was defined as the number of somatic variants other than EGFR mutations. Objective response rate (ORR) and disease control rate (DCR) between different groups were compared using Fisher’s exact test while progression-free survival (PFS) and overall survival (OS) between different groups were compared by Kaplan-Meier curves and log-rank tests. Multivariate stepwise Cox regression analyses were performed to identify independent prognostic factors.

Results:
Forty-nine out of 71 patients were observed to harbor at least one variant and at most 7 variants, involving 10 genes (totally 124 variants). Higher cfDNA concentration was associated with impaired DCR (18.6% vs 81.4%; p=0.008), PFS (median PFS, 3.5 vs 15.2 months; HR=3.03; p=0.001) and OS (median OS, 27.3 vs not-reached; HR=2.38; p=0.042) compared with low cfDNA concentration group. Higher mutational burden was associated with unfavorable ORR (31.6% vs 73.7%; p=0.004) and PFS (median PFS; 8.6 vs 17.8 months; HR=1.61; p=0.050) compared with low mutational burden group. EGFR mutation conferred better ORR, DCR and PFS compared with EGFR wild-type (Figure 1). Multivariate analyses revealed that apart from EGFR mutation status, cfDNA concentration and mutational burden were also associated with the efficacy and/or the prognosis of EGFR-TKIs.Figure 1



Conclusion:
We for the first time showed that cfDNA concentration and mutational burden might influence the efficacy and prognosis of patients receiving EGFR-TKIs. These findings call for the need for the multiplex genetic analysis of patients’ cfDNA to tailor their treatment.

Background:
To detect the consistency of the c-MET gene amplification in peripheral blood and tumor tissue of patients with non small cell lung cancer and discuss the clinical application value of c-MET gene amplification in peripheral blood.

Methods:
Real-time fluorescent quantitative PCR was used to test the tissues in 257 patients of non small cell lung cancers and the peripheral blood samples in 318 patients of non small cell lung cancer, of which 185 cases of peripheral blood specimens could match the tissue samples, and detected the c-MET gene amplification in them by comparison of amplifications consistency in blood and tissue samples, and analysed the correlation between c-MET gene amplification and clinical characteristics of patients.

Results:
The c-MET gene amplification rate was 9.75% in peripheral blood of 31 patients with non small cell lung cancer，and was 8.95% in 23 cancer tissues, the amplification consistency was 81.25% in peripheral blood-tumor tissue matched samples. The difference was statistically significant (P<0.05).

Conclusion:
The consistency of the c-MET gene amplification in peripheral blood and tissue is high. c-MET gene amplification of peripheral blood could be used for clinical diagnosis and treatment in cases when tissue specimen is hard to get．

Abstract not provided

Background:
Ipilimumab (Ipi) is a humanized CTLA-4 antibody that blocks binding of CTLA-4 with its cognate ligands, permitting T cell activation through CD28 binding. There is evidence that phased in Ipi added to chemotherapy (C) may enhance efficacy in non-small cell lung cancer NSCLC. This trial was undertaken to gain a better understanding of the changes that occur in T cells, regulatory T cells (Tregs), and myeloid-derived suppressor (MDSC) in both the blood and tumor micro-environment with CTLA-4 blockade.

Methods:
Patients with stage T > 4 cm and/or N1, N2 NSCLC were offered neoadjuvant carboplatin AUC6 plus paclitaxel 200 mg/m[2] every 21 days 3 cycles with ipilimumab 10 mg/kg day 1 cycles 2 and 3. Blood for immune profiling of circulating T cells was collected prior to cycle 1, after cycle 1 chemotherapy alone, and after cycle 3 chemotherapy plus Ipi. If patients underwent tumor resection and excess tumor was available, viable tumor infiltrating lymphocytes (TILS) were disaggregated and stored for later analysis. Phenotypic and functional polychromatic flow cytometry (PFC) analyses were performed on peripheral blood mononuclear cells (PBMC).

Results:
Blood was successfully collected at all 3 time points for the first 17/18 patients who initiated trial therapy. Excess tumor (0.96-5 gms) was collected on 5 patients and ample viable CD45+ TIL cells (9.4-26x10[6]) were isolated and viably cryopreserved. Phenotypic analyses revealed that both CD4+ and CD8+ cells from all 17 patients were highly activated following two cycles of ipilimumab (cycle 3) as evidenced by greatly increased frequencies of CD28, HLA-DR, PD-1, and intracellular CTLA-4 expressing cells. The frequencies of Tregs, defined by CD4+CD25+FoxP3+ expression, were highly variable among the 17 participants, with 8 showing increased Tregs, 7 showing decreased frequencies, and 2 remaining unchanged over the course of therapy. Seven of the 17 participants had levels of MDSC cells at or above 5%, with two patients achieving MDSC levels of 13% and 26.7%. Tumor associated antigen (TAA)-specific CD4+ or CD8+ cells were detected at baseline on 4 patients (24%), but their relative frequencies were unaltered by Ipi therapy. The most commonly recognized TAA was Survivin, followed by MAGEA3 and PRAME. No patients developed detectable de novo TAA reactivities while on Ipi therapy. We will report the phenotypic and functional parameters of TILs isolated from 5 tumors of the patients enrolled on the current trial at the time of presentation.

Conclusion:
TAA-specific CD4+ or CD8+ cells were unexpectedly detected in the blood at baseline in a subset of patients. We were able to determine what common NSCLC antigens the circulating CD4+ or CD8+ T cells were activated against, and this has the potential to be a blood based biomarker for trials studying immunotherapy such as vaccines. Neoadjuvant ipilimumab therapy neither facilitated the development of anti-TAA reactivities nor enhanced the frequencies of existing TAA-reactive T cells in PBMC. Neoadjuvant ipilimumab therapy effectively enhanced the frequencies of highly activated T cells, but had no consistent effect of the frequencies of Tregs.

Background:
During the past decade, circulating tumor cells (CTCs) have been accepted as new prognostic and predictive factors for some type of cancers. In non small lung cancer cells (NSCLC) their detection and characterization is especially important to identify treatment resistances that some patients develop. Here, we report the value of characterization of CTCs and established cytological criteria to assess a good response for EGFR- tyrosine-Kinase inhibitors

Methods:
From Feb 2012 to October 2014, 39 patients (median age 63 years) with metastatic lung cancer were included in this study. NSCL (26 Adenocarcinomas and 13 Squamous cell carcinoma) EGFR wild-type patients were being treated with second or higher lines therapies with erlotinib. 10 ml of blood were collected from each patient into a CellSave TM Preservatives Tubes (Veridex, LLC, Johnson & Johnson Company) blood collection tube, maintained at room temperature and processed within a maximum of 72 hr after collection according to the protocol established by our group .For CTCs enrichment from PBMCs we used “Carcinoma Cell Enrichment and Detection kit: MACS technology (Miltenyi Biotechnology), using magnetic beads labeled with a multi-CK-specific. After isolation of CTCs, samples containing CTCs CK+ were stained for EGFR in double immunofluorescence (IF) experiments, following our standard protocol.The assessment of treatment was evaluated by histological criteria (CyCaR: Cytological Criteria of assessment Response).This way, as favorable response was defined when the number of CTCS was reduced more than 50% at 6 or 12 weeks of starting erlotinib treatment

Results:
Before treatment 18/39 patients (46%) were identified as positive for CTC[CK+ ]with an average number of 3.5 cell (range 1-11); 9 of which were presented persistence of CTCs after treatment. 7/ 18 patients positive for the presence of CTC[CK + ]were positive to presence EGFR marker (CTC[CK+ /EGFR +).]. More important was, that we found A positive correlation between CTCs and survival: patients with CTC(CK+ /EGFR-) presented a shorter OS (34 vs 53 weeks) and PFS (13 vs 17 weeks) compared with those patients with CTC(CK+ /EGFR +) which responded favorably to erlotinib. Patients without cytological response criteria had a worse survival OS (28 vs 53 weeks, p=0.057) and PFS (11,5 vs 21,3 weeks, p=0.06).

Conclusion:
Our study suggests that the characterization of CTC based in the EGFR expression might be useful as a marker for the therapeutic selection and monitoring of lung cancer patients sensitive to treatment with inhibitors of tyrosin-kinase.

Background:
Precision therapy with tyrosine kinase inhibitor (TKI) crizotinib and ceritinib against EML4-ALK (ALK+) non-small cell lung cancer (NSCLC) has advanced rapidly in recent years as a new paradigm in personalized cancer therapy. However, acquired drug resistance despite initial response still remains the rule, necessitating further investigations into mechanisms of resistance and novel therapies to overcome progressive resistant disease. Liquid-biopsy using peripheral blood circulating tumor cells (CTCs) as a minimally-invasive tool to determine patient’s disease status, tumor cells molecular-genomic make-up and evolution during therapies, is highly desirable. There is still an unmet need to develop affordable and robust technology platforms to empower such liquid-biopsy assay of CTC. There are relative advantages and pitfalls with various CTC platforms and a method to capture CTC in an unbiased fashion without pre-definition would be beneficial.

Methods:
We conducted pilot studies with adoption of two different CTC detection and enrichment platforms. First, we used the CellSearch[®] “positive-selection” platform through EpCAM immunomagnetic separation to profile 11 pts with ALK(+) NSCLC who were treated with crizotinib prospectively. Blood samples were collected (i) pretreatment, (ii) on TKI with CR/PR/SD, and (iii) at disease progression. Second, we evaluated a novel “negative-selection” CTCs capture-isolation platform, based on unbiased immunomagnetic removal of pan-leukocyte marker CD45+ cells coupled with RBC lysis, to enable CTC isolation without predefined CTC criteria. Pilot studies utilizing ALK+ H3122 cell line and ALK+ patients’ blood samples were performed for assay optimization and comparison. Whole genome sequencing using Illumina HiSeq x TEN was performed after whole genome amplification of the CTC tumor gDNA with paired-normal germline DNA for genomic interrogation.

Results:
Using ALK+ NSCLC patients’ peripheral blood samples, we demonstrated the presence of the EML4-ALK fusion (variant 1) in QPCR assay from the enriched CTC isolated using the CellSearch® platform. Also, CellSearch[®] enumeration in our pilot ALK+ cohort revealed a trend of correlation between the CTC numbers and disease status. The spike-in experiment in “negative selection” CTC platform enriched the spiked H3122 cells by 10,000 fold from the nucleated blood cells. Applying our “negative-selection” CTC assay to a patient with known EML4-ALK variant 1 (EML4-ex13/ALK-ex20) fusion lung cancer during disease progression on crizotinib, we detected the specific EML4-ALK variant 1 fusion in QPCR assay from the CTC enriched “eluate” fraction, but not in the “feed” fraction, whether the CellSearch® platform revealed any CTCs or not. In our index case of ALK-rearrangement NSCLC, we successfully performed whole genome sequencing analysis on the pretreatment negative-selection CTCs in comparison with the germline DNA and pretreatment lymph node tumor biopsied tissue tumor DNA. Our preliminary WGS results revealed similar genomic landscapes between the CTC and the biopsied tumor tissues.

Conclusion:
Taken together, our pilot CTC study results support the high sensitivity of the unbiased “negative selection” enrichment platform and its potential to empower molecular and genomic determinations in lung cancer. We also demonstrated the feasibility of the negative-selection CTC liquid-biopsy platform to achieve whole genome sequencing analysis of the captured CTCs.

Background:
The addition of bevacizumab, a monoclonal antibody against vascular endothelial growth factor, to a standard, first-line platin-based, two-agent chemotherapy regimen conferred a significant improvement in overall survival, progression-free survival, and response rate in patients with advanced non-squamous NSCLC (ns-NSCLC). The feasibility of the combination of bevacizumab and chemotherapy as the second-line or more therapy for ns-NSCLC is currently explored as well. However, no effective biomarker is validated to predict the response or clinical benefit of bevacizumab. This study aims to investigate the correlation between biomarkers and overall response to bevacizumab plus chemotherapy for patients with advanced ns-NSCLC.

Methods:
Patients with locally advanced or metastatic ns-NSCLC who were assigned to 7.5mg/kg 3-weekly doses of bevacizumab plus chemotherapy were eligible. Aaccording to investigators’ decision, chemotherapy regimens were pemetrexed (500mg/m[2]) with or without platinum (75mg/m[2]). Peripheral blood samples were collected at baseline and after 2[nd] cycle of therapy for the analysis of granulocyte colony-stimulating factor（G-CSF）, vascular endothelial growth factor A（VEGF-A） and VEGF receptor-2 (VEGFR-2). Plasma samples concomitantly with the radiological evaluation of disease progression were collected as possible. Correlation between biomarkers and overall response rate (ORR) were assessed by using a logistic regression model.

Results:
Baseline blood samples were available from 45 patients (100%, 19 patients were therapy naive, 26 patients failed of prior therapies), while samples after 2[nd] cycle were obtained from 37 patients (82.22%). For the primary analysis, there was no significant association between baseline plasma biomarkers and best overall response to the treatment. But, patients with low baseline plasma G-CSF level showed a trend toward improving ORR versus patients with high G-CSF level (odds ratio [OR], 3.846; 95%CI, 0.868 to 17.044，p＝0.076). Patients with high baseline plasma VEGF-A level showed a trend toward higher ORR versus patients with low VEGF-A levels (OR, 3.477; 95%CI, 0.857 to 14.113，p＝0.081). No significant correlations were observed between plasma biomarkers and progression-free survival (PFS). In comparison to baseline, plasma VEGF-A level increased significantly at 2[nd] cycle or radiological disease progression (p＜0.001). However, the magnitude of the difference did not correlate with ORR or PFS.

Conclusion:
Baseline or dynamic changes in plasma G-CSF, VEGF-A and VEGFR-2 did not correlate significantly with response of bevacizumab plus chemotherapy treatment for ns-NSCLC patients, while low baseline plasma G-CSF and high VEGF-A are possible candidate biomarkers for predicting response of bevacizumab plus chemotherapy for ns-NSCLC.

Background:
Circulating tumor cells (CTCs) and plasma circulating-free DNA (cfDNA) are promising candidates as non-invasive prognostic markers in malignant diseases. 18-fluorodeoxyglucose positron emission tomography integrated with computed tomography (18FDG-PET/TC) has a well-recognized diagnostic and prognostic value in non-small cell lung cancer (NSCLC). Very little is known about the mutual relationship between circulating biomarkers (CTCs and cfDNA) and 18FDG-PET/CT indicators in NSCLC.

Methods:
Peripheral blood samples from 28 patients affected by advanced/metastatic NSCLC were collected before starting first-line chemotherapy. CTCs were isolated by size using a filtration-based device (ScreenCell) and then identified and enumerated; cfDNA was isolated from plasma (QIAamp DNA Blood Mini Kit, Qiagen) and quantified by qPCR method using human telomerase reverse transcriptase (hTERT). All patients underwent 18FDG-PET/TC (Biograph 16 Siemens) at baseline. Maximum diameter (dmax) of the primary lesion (T), dmax of the greater lymph nodal (N), and metastatic (M) lesions were measured. Similarly, maximum and mean standardized uptake value (SUVmax, SUVmean) and size-incorporated SUVmax (SIMaxSUV) were computed for T, N and M, respectively; SIMaxSUV was calculated with the following formula for T, N, and M: SIMaxSUV= SUVMax*dmax. Presence (B+) and absence (B-) of metabolically active bone lesions (bone mets) were recorded. The association among CTCs, cfDNA and 18FDG-PET/CT-derived parameters was evaluated through multivariate analysis. T-test was performed to evaluate the difference in CTCs and cfDNA in B+ and B- groups, respectively.

Results:
Twenty-eight patients were evaluated; median age was 66 years (range: 51-80); male/female ratio was 18/10; 15 patients were current smokers, while 11 were former-smokers and 2 were never-smokers. Histo-types were grouped as it follows: adenocarcinoma= 22; squamous cell carcinoma= 5; not otherwise specified NSCLC= 1. Nine patients out of 28 had metabolically active bone lesions. Median CTC count was 7 CTCs/3ml (range: 0-47 CTCs/3ml), while median HTERT copy number was 109.0 (range: 16.7-1405-5).

	18FDG-PET/CT PARAMETERS	MEAN	STANDARD DEVIATION	P
T	Size	44.93	20.25	0.175
	SUV max	10.16	4.48	0.036
	SUV mean	10.6	3.4	0.994
	SIMaxSuv	487.7	333.5	0.472
N	Size	22.2	10.9	0.313
	SUV max	7.4	4.0	0.318
	SUV mean	5.8	3.0	0.294
	SIMaxSuv	172.8	158.1	0.231
M	Size	23.9	15.0	0.083
	SUV max	7.5	4.1	0.318
	SUV mean	7.4	1.2	0.307
	SIMaxSuv	216.4	206.5	0.463

At multivariate analysis, SUVmax of T was the only variable independently associated with cfDNA (p=0.036). No correlations were highlighted between CTCs and all PET-derived parameters. A trend towards significance between high HTERT and the presence of metabolically active bone lesions was observed (p=0.058).

Conclusion:
Our data demonstrate that the expression of cfDNA is correlated with the metabolic activity of the primary tumor lesion. Since SIMaxSUV was not correlated with HTERT, it appears that the expression of cfDNA depends from tumor metabolism rather than its burden. Further analyses on 18FDG-PET/TC-derived metabolic tumor volume are ongoing.

Abstract not provided

Background:
Detection of epidermal growth factor receptor (EGFR) mutation in non-small cell lung cancer (NSCLC) patients is mainly based on tissue biopsy, which is invasive and time consuming. Furthermore, there is still a need for serial monitoring of EGFR mutations and detection of EGFR tyrosine kinase inhibitors (TKIs) resistance. We hypothesized that plasma-based EGFR mutation analysis may be feasible for monitoring response to EGFR TKIs and could be used to predict the resistance.

Methods:
From January 2012 to October 2014, 200 EGFR mutant NSCLC patients were enrolled and treated with EGFR TKIs (141 patients for gefitinib, 46 patients for erlotinib, and 13 patients for afatinib). Plasma samples were prospectively obtained every 2 months from baseline until disease progression. The longitudinally collected plasma samples (n = 368) from 81 patients who progressed were analyzed using droplet digital PCR (ddPCR). We identified an association between serial EGFR mutant titers in plasma cell-free DNA (cfDNA) samples and the patient’s clinical response to EGFR TKIs.

Results:
Of a total 58 baseline cfDNA samples available for ddPCR, 43 (74%) samples demonstrated same mutation in the matched tumors (i.e. sensitivity: 70.8% (17/24) for L858R vs 76.5% (26/34) for exon 19 deletions). The concordance rate of plasma with tissue results of EGFR mutation was 88% for L858R and 86% for exon 19 deletion, respectively. Of the 54 patients with both before and after treatment plasma samples, 40 patients showed a dramatic decrease of mutant copies (greater than 50%) in blood in the first 2 months after treatment. We also found the secondary mutation (T790M) emerged in 28 patients around 3~13 months after treatment and in 4 patients before the treatment. Elevated circulating mutations (L858R/ex19/T790M) can be detected in 5 patients before disease progression as determined by CT scan.

Conclusion:
These results suggest that ddPCR is an appropriate method for determining plasma-based EGFR mutation status and may aid in monitoring response to EGFR TKIs and early detection of EGFR TKIs resistance.

Background:
Analysis of circulating tumor DNA (ctDNA) in plasma offers an opportunity to noninvasively monitor tumor burden and identify alternative drivers of disease progression in real-time. However, cancer progression during targeted therapy, such as EGFR-targeted therapies in non-small cell lung cancer (NSCLC), is driven by clonal evolution, and how this impacts the levels of targeted mutations in circulating tumor DNA (ctDNA) for monitoring disease burden is unclear.

Methods:
We collected serial plasma samples from 47 NSCLC patients receiving EGFR-targeted therapy (gefitinib) and hydroxychloroquine, and analysed mutations in EGFR, TP53, PTEN and PIK3CA in plasma by digital PCR and tagged-amplicon deep sequencing (TAm-Seq) of ctDNA.

Results:
We identified the same EGFR mutations in tumor and plasma samples in over 97% of patients, and found that patients with high pre-treatment levels of ctDNA are associated with worse progression-free survival and overall survival. Serial plasma analysis of 32 patients reveals clonal dynamics in ctDNA in response to treatment. In >72% of patients (23/32), EGFR mutations levels increased preceding clinical progression, with the resistant mutation T790M detected in around 50% of these patients (13/23) a median of 6 months before progression became clinically evident. In the remaining 9 of the 32 patients, EGFR-mutant ctDNA levels became uninformative during treatment, and in two patients we identified alternative driver mutations in ctDNA that correlated with progression. In one patient we also showed that the analysis of relative representations of resistant and sensitizing mutations may provide insight to the response to sequential treatment.

Conclusion:
Our results demonstrate the potential of ctDNA for noninvasive stratification and monitoring disease progression in NSCLC patients, and highlight that targeted therapy may drive the selection of alterative mutations. This may impact the representation of the targeted mutations in plasma for assessing disease burden. We therefore propose that effective ctDNA-based monitoring of targeted therapies in oncogene-addicted cancers requires tracking of multiple mutations beyond the targeted genes.

Background:
Plasma circulating tumor DNA (ctDNA) has been widely accepted as a form of liquid biopsy to detect EGFR mutations in NSCLC for its high concordance rate with tumor tissues. There are some retrospective studies about the ctDNA quantitative changes of EGFR mutations in EGFR-TKI treatment, but there is no report about serial ctDNA assessment of response and resistance to EGFR-TKI by detecting the dynamic changes of EGFR mutations during the whole course of EGFR-TKI treatment based on prospective clinical trial.

Methods:
Based on a randomized trial initiated to compare erlotinib with gefitinib in advanced NSCLC harboring EGFR exon 21 L858R mutation in tumor tissues (CTONG0901, NCT01024413), we prospectively collected serial plasma samples as preplanned schedule (baseline, one week after treatment, one month after treatment and then every 8 weeks until disease progression) and quantitatively detected EGFR L858R mutation in ctDNA by using fluorescence quantitative polymerase chain reaction. We made a serial ctDNA assessment of response and resistance to EGFR-TKI and its correlation with survival outcomes. Four patients’ serial plasma samples were selected to undergo next generation sequencing (NGS).

Results:
From 108 patients enrolled in the trial, serial plasma of 80 patients were collected as schedule and tested the quantity of L858R. As a whole, the quantity of L858R decreased to the lowest level when patients achieved best response to EGFR-TKI and increased to the highest level when disease progressed. Further analysis by Ward's Hierarchical Clustering Method showed that the dynamic changes of quantity of L858R could be categorized into two groups, Ascend Group and Stable Group (Figure 1A). Median progression-free survival (PFS) was 11.1 months (95%CI=6.6-15.6) and 7.5 months (95%CI=1.4-13.6) in two groups, respectively (HR=0.57, 95%CI=0.34-0.97, P=0.035) (Figure 1B). Median overall survival was 20.1 months (95%CI=15.7~24.5) vs. 16.4 months (95%CI=13.3~19.6) (HR=0.73, 95% CI =0.38~1.38, P=0.322). In multivariate Cox proportional hazards regression analysis, changing group was independent predictive factor for PFS. In plasma samples of 4 patients underwent NGS, similar dynamic changing characteristics were confirmed and more genetic mutations were found. Detailed data will be presented on site.Figure 1



Conclusion:
This is the first report about serial ctDNA assessment of response and resistance to EGFR-TKI by detecting the dynamic changes of EGFR mutation based on a prospective clinical trial. The quantity of plasma L858R has different changing patterns during EGFR-TKI treatment and higher L858R mutation abundance on EGFR-TKI resistance is correlated with longer PFS.

Background:
EGFR-T790M mutation, which is the valuable target for the next generation of EGFR-TKI, accounts for about half of the acquired resistance to current EGFR-TKI therapy in the EGFR sensitive mutation positive NSCLC patients. Due to clinical challenge in obtaining re-biopsy tumor tissues, noninvasive detection of EGFR-T790M in plasma circulating free DNA (cfDNA) has been proved to be feasible. Yet a highly sensitive assay needs to be developed to avoid false-negative detection. We here explored whether droplet digital PCR (ddPCR) of cfDNA can an alternative assay to identify the EGFR-TKI resistance mediated by EGFR-T790M in the clinical practice.

Methods:
The digital PCR method was recently developed for EGFR sensitive mutations, and its high sensitivity and specificity were validated in plasma cfDNA from EGFR-TKI-naïve NSCLC patients. In this study, we applied this method to detect EGFR-T790M in plasma cfDNA from metastatic NSCLC patients who initially responded but acquired resistance to current EGFR-TKI treatment. For the concordance analysis, the paired re-biopsy or pleural effusion cytology samples after failed EGFR-TKI were also collected for EGFR-T790M testing.

Results:
25 consecutive NSCLC patients were enrolled and analyzed in this study according to these criteria: 1. Metastatic NSCLC patients with acquired EGFR-TKI resistance. 2. The re-biopsy tissue or cytology samples and paired plasma samples were available after disease progression on EGFR-TKI. Among these 25 patients, 13 were positive and 9 were negative for EGFR-T790M mutation in both tumor tissue and plasma samples. 3 patients positive for EGFR-T790M mutation in tumor tissue were detected negative in their plasma. The overall concordance rate between plasma and tumor tissue testing was 88.00% (22/25) (Kappa=0.757, 95%CI: 0.4996-1.0). The sensitivity and specificity for plasma testing of EGFR-T790M mutation by ddPCR were 81.25% (13/16) (95%CI: 54.35%-96.00%) and 100.00% (9/9) (95%CI: 66.37%-100%), respectively. Figure 1



Conclusion:
Detection of EGFR-T790M in plasma cfDNA by ddPCR is highly sensitive and specific when compared to the pairedre-biopsy tissue or cytology samples. This noninvasive method could complement current invasive biopsy approach or provide an alternative method to identify specific mutation mediated resistance in clinic.

Abstract not provided

Background:
Small cell lung cancer (SCLC) is an aggressive malignancy with an average of 20,000 new cases per year and 16,000 deaths per year. SCLC accounts for about 10-15% of newly diagnosed lung cancers. Even in the face of extensive research, the standard of care- platinum-based combination chemotherapy- has not changed in decades. Yet even with modern chemotherapy formulations, the two year survival rate for advanced disease stages is less than 5%. Complicating treatment is that often at the time of diagnosis, SCLC as already metastasized to the patient’s surrounding lymph nodes. Therefore, a novel therapeutic strategy will have address three disease aspects: (1) reduce primary tumor growth and eliminate metastatic spread; (2) avoid resistance mechanisms used by SCLC to escape radio- and chemotherapies; (3) synergize with or supersede current therapeutic strategies. Chimeric antigen receptor T cells, little explored in SCLC, is well suited to address these aspects.

Methods:
Human SCLC cell lines were analyzed using a 90 gene signature to establish immunological targets. Western blot analysis confirmed the expression of CD56 and other targets on SCLC cell lines. For CAR T cell generation, PBMC were electroporated with the Sleeping Beauty transposase and a transposon containing a CD56R chimeric antigen receptor. CD56R-CAR transduced T cells were cultured for 4 weeks in the presence of K562 cells expressing CD56 and the cytokines IL-2/IL-21 to expand CD56R-CAR T cells. CAR T cells were tested in vitro for killing ability in the presence of three SCLC cell lines using a chromium release assay. CAR T cells were also analysed via FACS to assess CAR expression, T cell phenotype, and memory status.

Results:
An analysis of immune markers in SCLC cell lines revealed that, compared to NSCLC lines, there is a reduction in the expression of suppressive ligands and co-stimulatory ligands, antigen presentation, and natural killer ligands. SCLC cell lines, however, express high levels of CD56. When two CD56-positive and one CD56-negative cell line was tested, CD56-CAR T cells could kill efficiency CD56 expressing cell lines, however there was little killing of the CD56-negative cell line. An analysis of PBMCs cultured after electroporation revealed that a large percentage of CD3+ T cells expressed the CD56 CAR and even after 4 weeks in culture, the CAR T cells displayed a memory phenotype.

Conclusion:
An interrogation of SCLC cell lines versus NSCLC cell lines revealed that SCLC cell lines had reduced expression of checkpoint ligands, NK cell killing ligands, antigen presentation, but consistent with their origin, high expression of CD56. Our conclusion from this analysis is that expansion of SCLC-specific immune responses in vivo or elicitation of de novo responses in vivo will be hindered. Therefore, immunotherapies centered around adoptive transfer of T cell that can kill in an HLA-independent manner maybe better suited for SCLC. In that vein, CD56R-CAR T cells effectively targeted CD56-positive SCLC in vitro, but was unable to kill CD56-negative cells- which indicates a possible escape variant. Our lab is now moving toward testing CD56R-CAR T cell in vivo in both xenograph models and spontaneous ones.

Background:
Small cell lung cancer (SCLC) is an extremely aggressive and lethal disease for which there is a desperate need for novel and more effective treatments. A recently discovered oncolytic picornavirus, Seneca Valley Virus (SVV), infects tumors with neuroendocrine features, including SCLC with high selectivity. SVV is highly effective in the eradication of solid tumors in multiple in vivo models; however the mechanism of selective tropism for SVV is unknown. Because of the strong selectivity of the virus for SCLC, we hypothesize the host determinants of SVV permissivity could constitute future druggable targets for the treatment of SCLC.

Methods:
A retroviral gene trap mutagenesis screen was utilized in HAP1, a haploid human cell line permissive to SVV, HAP1. Once mutagenized, resistant cells, or cells with retroviral insertion in a gene essential to the viral life cycle, were selected for by incubation of the pool with SVV at a high multiplicity of infection (MOI). Hits from this screen were deconvoluted using an insertion mapping approach. Illumina sequencing provided quantitative counts of each insertion site in each gene. Hits from the screen were validated using various mechanistic approaches.

Results:
Our screen identified multiple unique insertion sites in the gene RPS25 on Chromosome 11. The RPS25 protein is a ribosomal protein that is a component of the 40S subunit of the ribosome. RPS25 has been previously shown to be important for IRES-dependent translation of multiple viral genomes as well as cellular mRNAs containing IRES elements. Using the CRISPR-Cas9 approach, we knocked out the RPS25 gene in the SVV-permissive SCLC cell line, NCI-H446. Upon total knock-down of RPS25, H446 cells become completely resistant to cell killing by SVV at high MOI. Surprisingly, these cells also show a severely marked decrease in doubling time and robustness in culture. In contrast, RPS25 CRISPR knock-down in HEK293T cells has been previously shown to have no distinguishable phenotype other than defects in IRES-dependent translation. Further studies to fully characterize the interaction of RPS25 with the SVV genome as well as the importance of RPS25 in other SCLC cell lines are ongoing.

Conclusion:
We have identified a host protein that is essential for SVV replication and infection using a genome wide mutagenesis screen. SCLC cells completely defective in RPS25 are resistant to SVV-dependent cell killing. RPS25 appears to not only be important for the life cycle of SVV but may be important in proliferative capacity in SCLC. As SVV is highly selective for SCLC, we hypothesize that the host determinants of SVV tropism may be very specific to SCLC cells. Proteins important in the SVV life cycle may be novel “druggable” targets for the treatment of SCLC.

Background:
Small cell lung carcinoma (SCLC) represents 15% of lung cancers and is treated using chemotherapy +/- radiation but despite initial responses most recur within a few months and become resistant to therapy. Novel immune checkpoint inhibition of programmed death-1 (PD1) targeted therapy has shown promise in other solid tumors including non-small-cell lung cancer (NSCLC) and malignant melanoma. In some tumor types correlation with response and significant expression of programmed death- ligand 1 (PD-L1), the lead candidate biomarker of anti-PD-1 therapy, has been described but no data is available regarding expression levels in SCLC. Here we report the rate of PD-L1 expression in SCLC and in associated tumor infiltrating immune cells lymphocytes and macrophages.

Methods:
Immunohistochemistry (IHC) for PD-L1 using two monoclonal antibodies (clone 5H1 and clone SP142) and for CD3 (clone PS1) was performed on standard formalin fixed paraffin embedded tissue sections of 21 resected SCLC specimens (median age: 67) and three additional tumors with pre- and post-therapy biopsies. Since there is no generally accepted scoring system for PD-L1 expression we chose to evaluate staining in tumor cells and immune cells infiltrating the tumor nests and in adjacent stroma using a 4 tier semi quantitative scoring system (score 0 -no or <1%, 1+ 1-<5%, 2+ 5-25% and 3+ >25% of cells staining). Both cytoplasmic and membranous staining was accepted as positive. The number of tumor infiltrating lymphocytes (TIL) were estimated utilizing a CD3 stain while macrophages were identified on corresponding H&E stains.

Results:
PD-L1 staining of tumor cells and Immune Cells (TIL & Macrophage) are shown in the table below. Membranous PD-L1 staining was only seen in two tumors and in variable number of immune cells with 2+ or 3+ PD-L1 scores. The majority of positive staining was cytoplasmic with both antibodies. The staining intensity was stroger with the 5H1 antibody. The paired pre- and post-therapy samples were all negative for PD-L1.

Clone/score	PD-L1 staining in
5H1	Tumor	IC in tumor	IC in stroma
0 (<1%)	19/21 (90%)	7/21 (33%)	5/21 (24%)
1+ (1-<5%)	1/21 (5%)*	11/21 (53%)	6/21 (29%)
2+ (5-25%)	1/21 (5%)*	3/21 (14%)	7/21 (33%)
3+ (>25%)			3/21 (14%)
SP142	Tumor	IC in tumor	IC in stroma
0 (<1%)	20/21 (95%)	8/21 (38%)	10/21 (48%)
1+ (1-<5%)	1/21 (5%)*	11/21 (52%)	7/21 (33%)
2+ (5-25%)		2/21 (10%)	4/21 (19%)
3+ (>25%)

* Tumors with membranous staining; IC: immune cells

Conclusion:
Most SCLC are tumor membrane PD-L1 negative by IHC. A subset of SCLC contain PD-L1 positive TILs and/or macrophages in the tumor and the stroma. No up regulation of PD-L1 expression was seen in a small pilot sample of matched pre- and post-therapy biopsies. It is unclear whether PD-L1 expression assessed by IHC will be a predictive marker for PD-1 targeted therapy in SCLC. Preliminary data indicates single agent and combined checkpoint inhibitors (PD1 plus CTLA-4 inhibitors) are active in previously treated SCLC indicating additional research is required to understand their mechanism of action in a tumor type that has seen no therapeutic advances in the last two decades.

Background:
Blocking the interaction between the programmed cell death (PD)-1 protein and one of its ligands, PD-L1, has been reported to have impressive antitumor responses. PD-L1 interaction is a major pathway often hijacked by tumors to suppress immune control. Studies on the roles of PD-L1 in non-small cell lung cancer (NSCLC) are controversial, but its roles in small cell lung cancer (SCLC) are rare and unclear. Moreover, MET/HGF axis seems to be the other one of the most aberrant signaling pathways in SCLC. The aim of our study was to investigate the expression and prognostic roles of PD-L1 and cellular-mesenchymal to epithelial transition factor(c-MET) in SCLC.

Methods:
The expression of PD-L1 and c-MET were evaluated by immunohistochemical analysis in 83 specimens of SCLC, including 47 limited disease (LD) and 36 extensive disease(ED). Tumors with PD-L1 staining in over 5% of tumor cells were scored as positive for PD-L1 expression. Tumors with c-MET strong staining in at least 10% or weak to moderate staining in at least 40% of tumor cells were scored as positive for c-MET expression. Survival analysis was performed using the Kaplan-Meier method.

Results:
The positive rate of PD-L1 and c-MET in SCLC specimens were 51.8% and 25.3% respectively. The higher expression level of PD-L1 in tumor specimens was significantly correlated with a limited disease (LD) stage (p=0.004), a normal serum LDH level (p=0.031), and a normal NSE level (p=0.005). No association was found between the expression level of c-MET and PD-L1 , or c-MET expression with the other clinical characteristics of SCLC patients. SCLC patients with PD-L1-positive tumors showed significantly longer overall survival (OS) than those with PD-L1-negative (median OS, 17.0 vs 9.0, p=0.018). SCLC patients with positive c-MET expression showed a trend of shorter overall survival (12.0 vs 15.0, p=0.186). But sub-analysis of Limited disease (LD)-stage patients showed that the c-MET negative group had a longer OS (25.0 vs 14.0; p=0.011). Multivariate analyses revealed that LD stage, good performance status but except for PD-L1 or c-MET immunoreactivity were independently predictive of better OS.

Conclusion:
In patients with SCLC, expression of PD-L1 was positively correlated with a LD stage and better OS, but was not an independently predictive factor of outcome. High expression level of c-MET revealed a trend of worse outcome. It was associated with poor prognosis especially in LD-Stage patients.

Abstract not provided

Background:
As a subtype of lung cancer, small cell lung cancer (SCLC) remains a severe threat to human health. Although it is initially a chemosensitive disease, development of acquired resistance is a major problem. Studies in recent years revealed that cancer stem cell (CSC) could play a role in this process. However, the CSC specific marker and the detailed signal pathway associated with acquired resistance in SCLC is unknown yet. It was recently reported that the voltage-dependent calcium channel α2δ1 subunit positive cells is a CSC marker in hepatic cell cancer and that 1B50-1 is the specific monoclonal antibody of the α2δ1 subunit. In present study, we attempted to disclose that α2δ1 could play a role in acquired resistance of SCLC. Also we investigated possible molecular mechanism of α2δ1 mediated resistance in SCLC and finally provided the potential strategies overcoming the resistance.

Methods:
We screened for positive expression of 1B50-1and CD133 in SCLC cell lines and in patient-derived xenograft (PDX) models, and we used flow cytometry to verify the properties of CSCs. We recorded the expression of 1B50-1 before and after chemotherapy in PDXs in chemosensitive and resistant models to determine if α2δ1 subunit-positive cells were related to acquired resistance. We used exome and transcriptome sequencing to explore the expression of genes related to stem cell properties and drug resistance. We used Western blotting to verify the key molecules and pathways in the process of drug resistance. On the basis of these results, we explored the mechanisms of acquired drug resistance that are mediated by the α2δ1 subunit.

Results:
We observed a difference in the positive expression levels of 1B50-1 and CD133 in SCLC cell lines (H1048, H69, and H209) and PDX models. Both 1B50-1-positive and CD133-positive cells exhibited stem cell-like properties such as the capacity to self-renew in vitro, tumorigenesis in vivo, the potential for differentiation, and high expression levels of genes related to CSCs and drug resistance. Chemotherapy could induce the enrichment of 1B50-1-positive cells but not CD133-positive cells in PDXs. Also, high rates of 1B50-1-positive cells corresponded to high levels of resistance. Together, these findings indicated that the expression of 1B50-1 is related to chemoresistance. Exome and transcriptome sequencing revealed that the expressions of multiple pathway related genes in pathways, including MAPK, CAMs, TGFβ, and Notch, were increased in 1B50-1-positive H1048 cells. Western blotting revealed the activation of the Erk protein in the MAPK pathway and the over-expression of the Erk protein in 1B50-1-positive H1048 cells. The specific α2δ1 antibody 1B50-1 improved response to chemotherapy and delayed relapse when combined with chemotherapy or used y as maintenance therapy.

Conclusion:
The α2δ1 subunit positive SCLC cells (1B50-1+) displayed CSC properties, and were associated with acquired resistance. The Erk protein in the MAPK pathway was highly expressed in the 1B50-1-positive H1048 cell line, and might be the key molecule involved in resistance mediated by the α2δ1 subunit. The α2δ1 subunit-specific antibody 1B50-1 could improve response to chemotherapy and delay relapse when combined with chemotherapy or when used as sequential therapy.

Background:
Small cell lung cancer (SCLC) is an extremely aggressive cancer with limited treatment options and poor outcome. The majority of SCLC patients respond to frontline chemotherapy, but experience rapid recurrence with metastasis, that may be attributed to the prevalence of cancer stem cells (CSCs). We previously demonstrated that PI3K/mTOR signaling is key for CSCs in cell culture and solid tumor models. As shown with a dual PI3K/mTOR inhibitor, VS-5584, inhibition of multiple PI3K isoforms and mTOR is necessary to achieve preferential targeting of CSCs.

Methods:
Antitumor activity of VS-5584 was assessed by in vitro proliferation assay as well as in multiple xenograft models in vivo, including patient-derived xenograft models. Anti-CSC activity was measured by the side-population CSC assay in vitro and in limiting dilution tumor initiation assay in vivo.

Results:
VS-5584 inhibited SCLC growth in vitro at sub-µM IC50, and was synergistic with cisplatin and etoposide in reducing the viability of SCLC cells. In vivo, single agent VS-5584 (20 mg/kg, 3 days per week dosing, MWF) demonstrated robust anti-CSC activity in the NCI-H841 SCLC model by reducing tumor initiating potential 70-fold (p=5x10[-6]). In tandem, VS-5584 partially reduced tumor growth of the NCI-H841 xenograft tumors. Furthermore, a VS-5584 dose dependency was evident, both for tumor initiating potential and tumor growth reduction. When VS-5584 was combined with cisplatin and etoposide, the standard of care agents for SCLC, an increased tumor growth inhibition was observed whether VS-5584 was concurrently administered or added sequentially following the dual chemotherapy. In the SCLC PDX model, combination treatment also suppressed the regrowth of the tumor following cessation of chemotherapy for extended duration. VS-5584 was found to preferentially induce apoptosis in CSCs in multiple cell lines, indicating that these cells are eliminated through cell death-related mechanism. Importantly, we demonstrated that for eradication of CSCs it is necessary to inhibit simultaneously multiple PI3K isoforms and mTOR pathways.

Conclusion:
The VS-5584 pre-clinical findings support the preferential targeting of CSCs in SCLC models and provide an important rationale for advancing clinical development of the compound. A phase 1 dose finding clinical trial is on-going to establish a Phase 2 dose of VS-5584 and explore target inhibition. VS-5584 alone or in combination with standard of care chemotherapy may lengthen the time to relapse and improve outcome for patients with small cell lung cancer.

Background:
NOTCH expression is associated with cancer cell survival via effects on cancer stem/progenitor cells. Targeting NOTCH2 and 3 decreases growth and survival of SCLC patient-derived human tumor xenografts (PDX). Phase1b/2 trials testing Tarextumab (TRXT) anti-NOTCH2/3 therapy are underway (NCT01647828 and NCT01859741) and show promising anti-tumor activity. Here, we studied NOTCH3 protein expression using immunohistochemistry (IHC) in SCLC human tissues and correlated with survival. Also, we studied NOTCH3 gene expression in phase 1b patients (pts) treated with TRXT.

Methods:
For NOTCH IHC staining, murine monoclonal antibodies were generated by immunizing mice with a NOTCH3 extracellular domain (ECD) protein, then creating hybridomas. Clones were screened by FACS and western blots for specificity to NOTCH3.ECD. A lead clone was selected for NOTCH3 protein measurement in 47 SCLC samples represented in a tissue microarray from Yale Pathology Tissue Services (YPTS). NOTCH3 signal was determined in tumors using H-scores generated by Leica Aperio Scanscope IHC membrane image analysis. For survival analysis, NOTCH3 signal was binarized with cutoffs defined by X-tile software. For the phase 1b clinical trial, a standard 3+3 dose escalation design was employed with cohorts of 3 to 6 pts treated at each dose level. TRXT was given IV on Day 1 of each 21 day cycle with etoposide 100 mg/m[2] (Days 1-3) and cisplatin 80 mg/m[2 ]or carboplatin at AUC 5 (Day 1) for 6 cycles, followed by TRXT alone every 21 days until progression of disease or unacceptable toxicities. Then, the MTD TRXT plus etoposide and carboplatin was confirmed in a cohort of 6 subjects. All pts are required to submit tissues for Notch 3 gene expression and IHC staining.

Results:
A single hybridoma clone demonstrating specific reproducible membranous staining with a dynamic range for NOTCH3.ECD in control and PDX tissues was chosen for IHC analysis in SCLC human FFPE tissues (n=47). Forty cases (85.1%) demonstrated NOTCH3 signal, with eighteen (38.3%) having none to very low signal. Of the 31 cases with adequate follow-up, there was a strong trend with worse outcome and high NOTCH3 expression in the extensive stage (p=0.063), but not in limited stage (p=0.857). The level of significance was a function of the experimental cut-point and can only be considered exploratory. Finally, 27 pts were treated with TRXT in the phase 1b trial, with an overall response rate of 84%. The median duration of treatment was 128 days (6 cycles) with mPFS and mOS of 124 and 228 days, respectively. The median follow-up for PFS and OS was 86 and 107 days, respectively. Twenty-five pts have tissues evaluable for NOTCH3 gene expression and the analysis is underway.

Conclusion:
NOTCH3 IHC staining showed expression in most SCLC cases, with high NOTCH3 trending towards worse survival in extensive stage. This supports the rationale of targeting NOTCH3 by TXRT in SCLC pts. Further evaluation of the prognostic and predictive value of TRXT for anti-Notch therapies in SCLC is underway in an ongoing Phase 2 clinical trial.

Background:
Pulmonary neuroendocrine tumors such as small cell lung cancer (SCLC) and large cell neuroendocrine cancer (LCNEC) remain among the most deadly malignancies and are increasing in incidence. Patient-derived xenograft (PDX) tumors provide excellent models to study tumor biology and discover tumor-initiating cell (TIC) populations. Novel therapies that target and eradicate TIC represent a promising strategy to improve survival. An effectively targeted antibody-drug conjugate (ADC) carrying a cell-cycle independent toxin should result in significant anti-tumor activity and eliminate TIC.

Methods:
Whole transcriptome sequencing was performed using TIC isolated by fluorescence-activated cell sorting from SCLC and LCNEC PDX tumors. Quantitative RT-PCR, microarray analysis of PDX tumors and cell lines, and mining of publically available transcriptome and proteome datasets were executed to validate that prospective targets, such as Delta-like protein 3 (DLL3), were highly expressed in neuroendocrine tumors, but limited in their expression in normal tissues. DLL3-specific monoclonal antibodies were generated and used to determine protein expression by immunohistochemistry, flow cytometry and ELISA. Select DLL3-specific antibodies were conjugated to a cell-cycle independent pyrrolobenzodiazepine (PBD) dimer toxin and evaluated for their ability to internalize and mediate cell killing. Finally, established SCLC and LCNEC PDX tumors were treated in vivo with a lead anti-DLL3 ADC (i.e. SC16LD6.5). Limiting dilution assay (LDA) serial transplantation experiments were executed to assess the impact of SC16LD6.5 on TIC.

Results:
Elevated expression of DLL3 mRNA was discovered in TIC of SCLC and LCNEC PDX tumors and confirmed in additional distinct primary SCLC and LCNEC tumor samples and PDX tumors. In contrast, little to no mRNA expression was detected in vital organs and other normal tissues outside of the brain. DLL3-specific antibodies confirmed protein expression on the cell surface in both primary SCLC and LCNEC tumors and in PDX tumors initiated from patients with these diseases, whereas protein was scarce in normal tissues. SC16LD6.5 rapidly internalizes and localizes to late endosomes, and treatment of 10 SCLC and 2 LCNEC PDX tumor models resulted in significant and durable tumor regression with a median time to progression benefit of 75 days versus 16 days with standard-of-care (SOC: SCLC, cisplatin/etoposide; LCNEC, cisplatin). During the course of these in vivo studies, many mice were cured as tumors often did not recur despite being followed for 120+ days post-randomization and treatment. LDA experiments executed using tumors actively responding to SC16LD6.5 provided further functional evidence that the common lack of tumor recurrence following treatment resulted from effective targeting of DLL3-expressing TIC. In vivo efficacy strongly correlated with DLL3 protein expression, and responses were observed in PDX tumor models initiated from patients with both limited and extensive stage disease and independent of their sensitivity to SOC.

Conclusion:
The DLL3-targeted ADC, SC16LD6.5, effectively targets and eradicates TIC in SCLC and LCNEC PDX tumors. SC16LD6.5 (i.e. rovalpituzumab teserine) is currently concluding Phase 1b trials and is a promising first-in-class therapeutic for the treatment of high grade pulmonary neuroendocrine tumors.

Abstract not provided

Background:
Although most patients with SCLC are current or former smokers, this disease has been reported in never-smokers. In our prospective genomic profiling of SCLC patients, we have identified four never-smokers. Here, we report next generation sequencing (NGS) results for these four SCLC patients and describe how they differ from those of smokers.

Methods:
We are evaluating pathologically confirmed SCLC tumors in patients undergoing treatment. Formalin-fixed, paraffin-embedded surgical resections, core biopsies, and fine needle aspirates are being evaluated using a targeted, hybrid capture-based, NGS assay, MSK-IMPACT, which identifies single nucleotide variants, indels, and copy number alterations in 341 cancer-associated genes. We determined never-smoking status prospectively: all smoked <100 cigarettes in their lifetime. Clinical data on stage [extensive (ES), limited (LS)], treatment, and response were collected.

Results:
Four never-smokers have been identified within the 50 patient samples that have undergone NGS evaluation thus far. The median age at diagnosis of the four never-smokers is 58 (range, 47-75); 50% are male; and one presented with LS-SCLC. None of these four patients developed SCLC as acquired resistance to EGFR tyrosine kinase inhibitors after treatment for EGFR-mutant lung cancers. The tumors from the four never-smokers displayed a median of 3 non-synonymous somatic mutations, while those from moderate (<20 pack years) and heavy (20+ pack years) smokers contained 4.5 and 8 mutations, respectively (P<0.05). None of the four never-smoker samples contained smoking associated G-to-T transversions (see Table). Inactivation of RB1 and TP53 occurred in 75% and 50% of the samples, respectively. Only patient 4 had platinum-refractory disease. The median survival of these patients was 20.7 months (range, 17 to 25).

Sample	Gene altered	Alteration Present	Protein Alteration	Base Pair Alteration
Patient 1	PHOX2B	Missense Mutation	P82L	G-to-A
	NOTCH1	Frame-Shift Insertion	P2485fs
	RB1	Splice Site	R500_splice	G-to-A
	TP53	Frame-Shift Deletion	V218fs
	TP53	Frame-Shift Deletion	V73fs
	TERT	Amplification
Patient 2	CBL	Missense Mutation	C401S	G-to-C
	GNAS	Missense Mutation	M102V	A-to-G
	MYCL	Amplification
Patient 3	TP53	Nonsense Mutation	R342	G-to-A
	RB1	Frame-Shift Insertion	T197fs
	CDKN2C	Amplification
	MYCL	Amplification
Patient 4	RB1	Nonsense Mutation	C666
	ETV1	Amplification

Conclusion:
Using a targeted NGS assay, we have shown that the molecular characteristics differ between never-smokers and smokers, while the majority of the tumors demonstrate RB loss. Whole exome sequencing of the tumors from these never-smokers is underway. Ongoing comprehensive, multiplexed genotyping is needed to fully characterize the molecular diversity of SCLC in this unique population.

Background:
SCLC is an aggressive malignancy that shows dramatic clinical responses in 70% of cases to platinum-based chemotherapy in the first line setting, while the remainder have de novo treatment resistance. Of initial treatment responders, almost all will relapse with drug-resistant disease within months of initial therapy. From a clinical perspective, the emergence of drug resistance remains one of the most important barriers to improving SCLC patient outcomes. Better models of in vitro and in vivo drug resistance are therefore required. Cell surface markers are proteins expressed on the outer surface of cells that can identify specific cell types and biologic states. Surface markers represent an attractive class of biomarkers in SCLC: 1) they are independent of cellular transport mechanisms that are known to play a role in SCLC drug resistance; and 2) they can be readily accessed for diagnostic and therapeutic purposes using commercial antibodies.

Methods:
NCI-H69 is a classic SCLC cell line derived from a patient prior to systemic treatment, and is chemotherapy sensitive. H69AR is an anthracycline-resistant derivative cell line generated through serial culture of NCI-H69 in increasing concentrations of Adriamycin. H69AR is also cross-resistant to other cytotoxic drugs commonly used to treat SCLC. We performed a pilot screen in both cell lines in duplicate using a human cell surface marker panel containing Alexa Fluor 647-conjugated antibodies against 242 unique cell surface proteins. High-throughput multiplexed flow-cytometry was performed to generate cell surface expression profiles for each antibody in each cell line.

Results:
A total of 53 markers were expressed in at least 20% of cells in either cell line, with 22 positive markers shared by both cell lines including CD44. NCI-H69 was uniquely positive for 24 markers including CD56, a neural progenitor marker used commonly to diagnose SCLC. Seven markers were uniquely positive in H69AR including CD9 and some of its known interactors. The percentage H69AR cells positive for each of the 7 markers ranged from 25% to 88%. CD9 is a member of the transmembrane 4 superfamily involved in many cellular processes including differentiation, adhesion, and signal transduction. Eighty-eight percent of H69AR cells were positive for CD9 compared to only 5.4% of H69 cells. CD9 has previously been implicated in a cell adhesion-mediated drug resistance mechanism in unrelated SCLC chemotherapy-resistant cell lines (S. Kohmo et al. Cancer Research 2010).

Conclusion:
Our pilot data provides a proof-of-concept for our surface biomarker screen-based approach to further understand mechanisms of chemotherapy-resistance in SCLC. We have expanded this screen to additional drug-sensitive and drug-resistant SCLC cell line pairs. Results of the expanded screen will be presented at the meeting.

Background:
Most cases of small-cell lung cancer (SCLC) are detected at extensive stage, where current guidelines recommend 4-6 cycles of chemotherapy. Although upfront progression to doublet platinum based chemotherapy in SCLC is <20%, current clinical practice often includes treatment monitoring with imaging, mainly with computed tomography, every two cycles. Since the purpose of imaging during treatment is identification of progression (to avoid further exposure to an ineffective but still potentially toxic regimen), we sought to evaluate whether monitoring SCLC patients during treatment with a blood-based biomarker (ProGRP) would correlate with response.

Methods:
Patients with SCLC treated with mainly standard chemotherapy at six centers worldwide (Europe and China) were included. ProGRP levels from serum or plasma were measured with a fully automated ProGRP assay in a prospective fashion prior to treatment start and repeatedly during treatment. Imaging was done and interpreted according to local guidelines at each institution. Percent change of ProGRP from baseline to the time of maximum response (‘best response’) was correlated with imaging findings, and patients were divided into two groups: Responders (= stable disease [SD] or better) vs. Non-Responders (= progression on scan). The ability of ProGRP to discriminate between Responders and Non-Responders was assessed by sensitivity and specificity.

Results:
215 patients with available CT result were included, of whom 145 had received first-line treatment (131 received platinum+VP-16 doublet). Clinical characteristics were as follows: 60.5% male, median age was 62 years, 72.1% were (ex)smokers, 93.5% with Stage IIIB or IV SCLC, and the majority of patients were either Caucasian (59.6%) or Asian (32.6%). Across all lines of treatment, 186/215 (86.5%) had SD or better as best response to treatment. There was a positive trend for higher ProGRP levels with clinical stage at presentation, and in general higher pre-treatment levels in 1[st] line compared to later lines of treatment. A decline in ProGRP levels was strongly correlated with response, whereby higher baseline levels were associated with subsequent higher relative declines of ProGRP during treatment. Using different cut-off levels for ProGRP decline during treatment (-50%, -70%, or -90%), we detected patients with no response to treatment based on ProGRP levels alone, with a sensitivity of 82.8%, 89.7% and 96.6%, and a specificity of 65.6%, 55.4%, and 39.8%, respectively. Specificity was increased by approximately 10% when only patients with baseline ProGRP levels exceeding 100 pg/ml were included.

Conclusion:
To our knowledge, this is the largest SCLC cohort to date with available ProGRP data for therapy monitoring. The data showed that ProGRP levels at baseline were positively correlated with advanced disease stage, and decline in ProGRP levels during treatment was associated with tumor control in SCLC. The ProGRP assay used in this study is currently not cleared or approved for use in the USA.

Background:
Aurora kinase expression has been associated with a poor prognosis in non-small cell lung cancer (NSCLC) and aurora kinase inhibitors have activity in preclinical lung models. Aurora kinases are required for mitosis and cell division. Small cell lung cancer cells have rapid proliferation and higher rates of MYC family amplification, which makes aurora kinase inhibition a natural target.

Methods:
23-SCLC lines with known MYC family amplification and MYC family gene expression were exposed to varying concentrations of the specific aurora kinase B inhibitor AZD1152-HQPA. The percentage growth inhibition compared to control was determined in MTS assays at 120 hours. Cell lines were classified as “sensitive” if the GI50 concentration was < 50 nM and with ≥ 80% growth inhibition at 100 nM. Fisher’s exact test was used to determine the correlation between amplification of MYC family members and sensitivity of the cell lines to growth inhibition by AZD1152-HQPA. A two-group t-test (gene expression as a continuous variable) and an odds ratio estimate (dichotomized gene expression level) were used to determine a correlation between MYC family gene expression and growth inhibition by AZD1152-HQPA. To determine whether growth inhibition correlated with the published MYC-signature gene expression, we used Fisher’s exact test. In vivo growth inhibition by AZD1152 (prodrug) was evaluated on SCLC xenografts in nude mice.

Results:
Nine (39%) of the 23 cell lines were sensitive to AZD1152-HQPA with IC50 values < 50 nM. There was a significant association between sensitivity to growth inhibition by AZD1152-HQPA and cMYC amplification (p = 0.018). The odds of being sensitive is 16 (95% CI, 1.4, 183) times higher for cMYC amplified compared to non-cMYC amplified cell lines. By a two-group t-test, the mean cMYC gene expression of 10.9 (std 4) in sensitive lines compared to 7.2 (std 3.3) in resistant lines was also significant (p = 0.026). Cell lines were separated into two groups based on cMYC gene expression > 12.9 vs < 12.9. The odds of being sensitive is 11 (95% CI, 1.2, 103) time higher for cell lines with cMYC gene expression > 12.9 compared to cell lines with cMYC gene expression < 12.9. Sensitive cell lines were enriched in a published MYC-signature of gene expression (p = 0.042). AZD1152 (prodrug) caused significant growth delay in vivo in two of these lines. The doses of AZD1152-HQPA used in this study are within the range reported to be clinically achievable.

Conclusion:
Aurora kinase inhibitors have promise in SCLC therapy. Questions that currently need answering in translating aurora kinase inhibitors in the clinical setting are: (1) the dosing schedule to avoid myelosupression, (2) should aurora kinase inhibitors be used in maintenance therapy and (3) should the aurora kinase inhibitors be evaluating in combination with chemotherapy.

Abstract not provided

Background:
Physical activity (PA) has been shown to improve fatigue and quality of life (QOL) in a range of cancer populations. Little research has been done in the advanced lung cancer setting. This RCT evaluated a 2-month PA intervention in patients with unresectable lung cancer.

Methods:
Participants were stratified (disease stage, performance status [PS] 0-1 vs 2, centre) and randomized (1:1) to usual care (UC) (general nutrition and PA education materials) or UC plus 2-month program of supervised weekly PA and behaviour change sessions and home-based PA. Assessments were completed at baseline, 2, 4 and 6 months. The primary endpoint was fatigue (FACT-F subscale) at 2-months. Secondary endpoints included: QOL, functional abilities, physical fitness, activity (accelerometers), mood, dyspnea, survival and blood results. Intention-to-treat analysis using linear mixed models was done.

Results:
111 patients were randomized: male 55%, median age 62 (35-80); 95% NSCLC, 5% SCLC; 95% Stage IV. At baseline 77% were on active treatment. Baseline characteristics, including PA levels, comorbidities and Glasgow Prognostic Score (GPS) were well balanced between groups. Attrition was 22, 36 and 50% at 2, 4 and 6 months respectively; no difference between groups. Adherence to intervention sessions: behavioral 77%, PA 69%. There were no significant differences in fatigue, QOL, symptoms, mood, distress, sleep, dyspnea, activities of daily living, GPS between the groups at 2, 4 or 6 months. Patients over report PA levels compared to accelerometer data. Using accelerometer data, PA only increased in the PA group from 0 – 2 months, but the difference in PA between groups was not significant. Median survival (months): PA 13.7 vs UC 12.6 (p= 0.76): 38 participants remain alive.

	PA n=55	UC n=56	p-value
FACT-F Fatigue: 0 2 4 6	38.4 37.5 39.6 36.6	36.3 36.3 35.4 34.5	0.61 0.10 0.44
EORTC Global QOL 0 2 4 6	63.8 63.2 64.2 60.8	58.9 64.3 60.2 54.2	0.81 0.45 0.26
Performance Status 0 2 4 6	0.8 0.8 0.8 0.7	0.9 1.0 1.0 1.2	0.30 0.16 0.01

Conclusion:
Adherence to the 8-week intervention was good but did not increase PA levels compared to education materials alone. No difference was seen in fatigue, QOL, symptom control or functional status.

Background:
Lung cancer is the leading cause of cancer death in the United States and is also a significant source of morbidity. Patient-reported outcomes (PROs) are prognostic for survival. Herein we report our analysis of emerging patterns of longitudinal PROs collected in the development of survivorship care plans (SCPs) using an anonymous web-based program.

Methods:
OncoLife and the LIVESTRONG Care Plan are web-based programs that generate unique SCPs and are accessed via OncoLink (www.oncolink.org), the world’s first cancer website. We selected all consecutive patients identifying as primary lung cancer survivors creating SCPs. Patient-reported demographics, treatment and toxicity were examined. For toxicity data, questions with > 10 “yes” responses were included, and were categorized into: cardiovascular; genitourinary; neurocognitive; endocrine; speaking, breathing, swallowing (SBS); thoracic; and musculoskeletal/dermatologic symptoms. Research was conducted under an IRB-approved protocol.

Results:
Overall, 689 plans were created for users self-identifying as primary lung cancer survivors. Average time from diagnosis to reporting was 1.68 years (0-24). Most were Caucasian (85.9%), well-educated (67.3% > “some college”), and lived in a suburban area (45.6%) and the United States (91%). Table 1 shows treatment modalities . Neurocognitive symptoms (e.g. fatigue and cognitive changes) were most common (48.8%), followed by musculoskeletal/dermatologic (14.1%), and thoracic (13.5%). Figure 1 shows symptoms analyzed by treatment. Only 11.2% were initially offered a SCP, and of those, 54.5% were offered by their healthcare provider, most often at a non-university-based cancer center (66.2%).

TREATMENT	N (689 total)	%
Any Surgery	375	54.4
Any Chemotherapy	522	75.8
Any Radiation	377	54.7
Surgery Alone	98	14.2
Surgery + Chemotherapy	119	17.3
Surgery + Radiation	15	2.2
Surgery + Chemotherapy + Radiation	143	20.8
Chemotherapy Alone	70	10.2
Chemotherapy + Radiation	190	27.9
Radiation Alone	29	4.2
Not Specified	25	3.6

Figure 1



Conclusion:
For lung cancer patients worldwide, it is feasible to obtain PROs and create SCPs through a web-based program. As lung cancer survivors live longer, further attention should be paid to PROs, and our data indicates that, surprisingly, the most common symptoms to address are neurocognitive. As very few patients were offered SCPs, increased effort should be made to provide SCPs, particularly in urban and university cancer center settings. This study was funded in part by the LIVESTRONG Foundation.

Background:
Survivorship care has emerged as an important topic in lung cancer due to advances in screening and treatment that have led to prolonged survival. These survivors may have pre-existing comorbidities or health impairments from their treatments that impact quality of life. A better understanding of the healthcare needs of lung cancer survivors will assist in the development of patient-centered, comprehensive survivorship care. We used a population dataset to assess the most common reasons for hospital admission and causes of death among long term (5-year) survivors of lung cancer.

Methods:
Using linked data from the California Cancer Registry and Office of Statewide Health Planning and Development database, we identified all in-state lung cancer patients diagnosed from 2000-2009. Patients of all stages were included. We used ICD-9 codes to identify causes of death and primary admission diagnoses in survivors after 5 years of lung cancer diagnosis. Annual proportional distribution of reasons for admission and causes of death for survivors were calculated over time.

Results:
Among 157,236 lung cancer patients, 80.6% (n=126,775) died within 5 years of diagnosis. Although lung cancer accounted for the majority of hospital admissions in the initial years post-diagnosis, nonmalignant pulmonary disease, (n=7,102, 23.3%) replaced lung cancer progression (n=2,047, 6.7%) as the most common principal diagnosis in 30,461 admissions among 9,166 survivors who were admitted after 5 years from initial lung cancer diagnosis (Figure 1A). Cardiovascular (n=5,712, 18.8%), gastrointestinal (n=2,901, 9.5%), and infectious diseases (n=2,819, 9.3%) also surpassed lung cancer progression as reasons for admission after 5 years of survival. However, lung cancer progression remained the leading cause of death in long-term lung cancer survivors (Figure 1B). Among 5-year survivors, 46.2% (n= 2,855) eventually died from lung cancer progression. The next most common causes of death were cardiovascular disease (n=947, 15.3%), nonmalignant pulmonary disease (n=776, 12.6%), and secondary malignancy (n=605, 9.8%). Figure 1



Conclusion:
Most lung cancer patients died within 5 years of diagnosis. Among remaining survivors, cardiovascular, pulmonary, and gastrointestinal diseases rather than lung cancer were the primary reasons for hospital admission 5 years after diagnosis. However, lung cancer progression remained the dominant cause of patient death even beyond 5 years of survival. Cardiopulmonary disease and other malignancies were secondary competitors for mortality. Active control of chronic cardiopulmonary disease in addition to lung cancer surveillance should be priorities in long-term lung cancer survivors.

Abstract not provided

Background:
Anxiety and depression are present in significant number of patients with lung cancer. Aims of this trial were to examine the frequency of depression and anxiety in lung cancer (LC) patients and to investigate relations between clinico-pathological characteristics (CPC) and depression and anxiety disorders.

Methods:
This prospective observational trial was conducted at Institute for Pulmonary Diseases of Vojvodina, Serbia. Two hundred and eight LC patients at various stages of disease and treatment rated themselves on the Hospital Anxiety and Depression Scale (HADS). Investigated CPC among other were Eastern Cooperative Oncology Group Performance Status (ECOG PS), tumor type and tobacco abuse. In order to correlate the data univariate and multivariate analysis was performed.

Results:
Of total 208 enrolled patients 76% (158) were males and 24% (50) females. Majority of patients were with ECOG PS 1 75% (156), smokers (58.7%), in stage III and IV (42.3% each) LC. Most frequent LC type was adenocarcinoma 46.6% (97) while squamous, small-cell and other types were confirmed in 38% (79), 13.5% (28) and 1.9% (4) respectively. Patients with brain metastasis and known depression and/or anxiety disorder before LC diagnosis were excluded from the trial. HADS-defined depression and/or anxiety were identified in 39.5% (82) patients. Frequency of anxiety was 22.6% (47) and of depression 36.1% (75). Both depression and anxiety severity were ranged from mild to severe. Combined depression with anxiety was identified in 19.2% (40) patients. We identified significant relation (p=0.003) between ECOG PS and anxiety. There is positive correlation between depression and ECOG PS (p=0.007). When depression and anxiety are present as combined disorders severity of each anxiety and depression are significantly higher (p<0.0001).

		MALE	FEMALE
N (%)		158(76%)	50(24%)
ECOG PS	0	32(20.3%)	7(14%)
	1	115(72.8%)	41(82%)
	2	10(6.3%)	1(2%)
	3	1(0.6%)	1(2%)
SMOKING	Never	16(10.1%)	11(22%)
	Ex smoker	46(29.1%)	13(26%)
	Smoker	96(60.8%)	26(52%)
PCKY	Ex smoker	50,7	37,7
(mean)	Smoker	40,9	37,2
TUMOR TYPE	Adenocarcinoma	68(43%)	29(58%)
	Squamouse carcinoma	65(41.1%)	14(28%)
	Small-cell carcinoma	22(13.9%)	6(12%)
	Other	3(1.9%)	1(2%)
STAGE	I	14(8.9%)	2(4%)
	II	14(8.9)	2(4%)
	III	63(39.9%)	25(50%)
	IV	67(42.4%)	21(42%)
DEPRESSION		59(37.3%)	16(32%)
ANXIETY		37(23.4%)	10(20%)
SEVERITY OF DEPRESSION	Mild	34(21.5%)	8(16%)
	Moderate	20(12.7%)	8(16%)
	Severe	5(3.2%)	-
SEVERITY OF ANXIETY	Mild	22(13.9%)	5(10%)
	Moderate	10(6.3%)	3(6%)
	Severe	5(3.2%)	2(4%)

Conclusion:
Anxiety and depression are diagnosed in significant number of lung cancer patients. Presence of these disorders can significantly influence quality of life of lung cancer patients. The results of this trial suggest that screening on depression and anxiety should be performed at any stage of disease course. Early recognition, detection and therapy can help in better control of depression and anxiety with aim to increase patients quality of life.

Background:
South West Sydney (SWS) is a region of greater ethnic diversity and poorer socioeconomic status than the Australian average. Over half of all patients with Non-Small Cell Lung Cancer (NSCLC) in SWS present with metastatic disease. The primary goals of management are palliation of symptoms and maintenance of quality of life. Patients need adequate access to specialist palliative care (PC) and psychosocial care (PSC) in order to achieve these goals. The aims of this study were to evaluate referrals to PC and PSC services in SWS residents with Stage IV NSCLC and identify factors associated with utilisation of these services.

Methods:
SWS residents diagnosed with Stage IV NSCLC between January 2006 and December 2012 were identified from the SWS Local Health District Clinical Cancer Registry. Supplementary information was sourced from oncology and hospital electronic medical records and palliative care databases. Modified Poisson regression was used to analyse significant factors associated with referrals to PC and PSC. Cox regression was used for multivariate survival analysis.

Results:
A total of 923 patients were identified. The median age was 69 years, 63% were male and 54% were born overseas. Active treatment was received by 65% of patients with 34% receiving chemotherapy and 65% receiving radiotherapy. Eighty-three percent of patients were referred to PC, with 67% occurring within 8 weeks of diagnosis. Eighty-two percent of patients were referred to PSC, with referrals to social workers being most frequent (76%) followed by specialist nursing (26%) and psychology/psychiatry (16%). On multivariate analysis, radiotherapy treatment, M1b disease and residential location were associated with PC referrals, and radiotherapy treatment, PC referral and residential location were associated with PSC referrals. Age, language spoken, country of birth, socioeconomic status, year of diagnosis and multidisciplinary team discussion were not significant factors in referral to either service. The median overall survival was 4.3 months and one year survival was 19%. On multivariate analysis, factors associated with improved survival were active treatment, chemotherapy and multidisciplinary team discussion.

Conclusion:
Rates of referral to PC and PSC services were high in this cohort suggesting good access to care. Greater referrals were particularly associated with patients undergoing radiotherapy. There were no sociodemographic barriers to referral. Some geographic differences were noted in referrals to both services. Further investigation into referral gaps will guide service delivery to improve quality of life and care for future patients.

Background:
Palliative care is focused on supporting the best possible quality of life (QOL) for patients and family caregivers (FCGs) coping with serious and complex illnesses such as lung cancer. Although the accepted definition of palliative care encompasses the entire trajectory of the cancer continuum from diagnosis to the end of life, the majority of published palliative care trials focused primarily on patients with metastatic disease. The purpose of this National Cancer Institute-supported Program Project (P01) was to test the effect of a concurrent, interdisciplinary palliative care intervention in patients with Stage I-IV non-small cell lung cancer (NSCLC) and FCGs in an ambulatory care setting, comparing the usual care and intervention groups.

Methods:
Patients undergoing treatments for NSCLC and their FCGs were enrolled in a prospective, sequential design whereby the usual care group was accrued first followed by the intervention group. Patients and FCGs in the intervention group completed a comprehensive QOL assessment at baseline, and were presented by nurses at weekly interdisciplinary care meetings. They also received four educational sessions that addressed physical, psychological, social, and spiritual well-being needs. Patients and FCGs in the usual care group received disease-focused therapies and procedures and were referred by their treating oncologist to palliative care services as needed per standard of care. Patients’ QOL, symptoms, and psychological distress were assessed at baseline and 12 weeks using validated measures which included the FACT-L, FACIT-Sp-12, LCS, and the Distress Thermometer. FCG outcomes included QOL, psychological distress, perceived burden, and caregiving preparedness, with validated measures that included the COH-QOL-FCG, Distress Thermometer, Caregiver Burden Scale, and Caregiver Skills Preparedness Tool. Outcomes were tested using factorial ANOVAs controlling for baseline scores, with disease stage as a blocking variable and group (usual care versus intervention) as the factor.

Results:
A total of 491 patients (219 = usual care; 272 = intervention) and 354 FCGs (157 = usual care; 197 = intervention) who completed baseline assessments were included in the primary analysis. Patients who received the intervention had significantly better scores for QOL (109.1 vs. 101.4; p<.001), symptoms (25.8 vs. 23.9; p<.001) spiritual well-being (38.1 vs. 36.2; p=.001), lower psychological distress (2.2 vs. 3.3; p<.001), and more advance care planning (44% versus 9%; p<.001) at 12 weeks compared to patients in the usual care group. FCGs in the intervention group had significantly better scores for social well-being (5.84 vs. 6.86; p<.001) and lower psychological distress (4.61 vs. 4.20; p=.010) at 12 weeks compared to FCGs in the usual care group. Survival analysis for stage IV patients using the Kaplan-Meier approach did not achieve statistical significance but showed a 6 month difference in favor of the intervention group. t included the COH-QOL-FCG, Distress Thermometer, Caregiver Burden Scale, and Caregiver Skills Preparedness Tool. Outcomes were tested using factorial ANOVAs controlling for baseline scores, with disease stage as a blocking variable and group (usual care versus intervention) as the factor.

Conclusion:
Interdisciplinary palliative care in the ambulatory care setting resulted in significant improvements in QOL, symptoms, and psychological distress for NSCLC patients and FCGs.

Abstract not provided

Background:
Brain metastases affect up to 40% of patients with non-small cell lung cancer (NSCLC), and for patients not suitable for surgical resection or stereotactic radiosurgery, whole brain radiotherapy (WBRT) and dexamethasone is standard treatment. However there are no randomised clinical trials showing whether WBRT improves either quality of life (QoL) or survival.

Methods:
A phase III randomised non-inferiority trial with a primary outcome measure of quality adjusted life years (QALYs). Patients with brain metastases from NSCLC who were not suitable for resection or stereotactic radiotherapy, irrespective of any other clinical characteristics, were randomly allocated to either optimal supportive care, including dexamethasone, plus WBRT 20 Gy/5f (OSC+WBRT) or OSC alone. QALYs were generated from overall survival and patients’ weekly completion of the EQ-5D questionnaire. OSC alone was considered non-inferior if not greater than 7 QALY days worse than OSC+WBRT (80% power and a one sided significance level of 5% requiring 534 patients). Secondary outcome measures include sub-group analyses to identify/validate predictive classifications.

Results:
From 2007-2014 538 patients were recruited from 69 UK and 3 Australian centres. Summary trial information is presented in table 1, with baseline characteristics well balanced between trial arms. Median survival was 65 days (OSC+WBRT) vs 57 days (OSC), hazard ratio 1.05 (95% CI 0.89 – 1.26). The mean QALY was 43.3 days (OSC+WBRT) vs 41.4 days (OSC), difference -1.9 days (90% CI -9.1 – +6.6). More OSC patients received additional anti-cancer treatment (39% vs 25%, p-value=0.0004), particularly radiotherapy (22% vs 13%, p-value=0.0067), with palliative thoracic irradiation in the two weeks following randomisation accounting for most of the difference. At 4 weeks post-randomisation, 36% of patients in each arm were alive with maintained or improved QoL compared to baseline. This fell to 17% in each arm at 8 weeks. The most commonly reported problems at 4 weeks concerned mobility (73% WBRT vs 79% OSC) and the ability to perform usual activities (68% vs 67%). Table 1. Summary of main trial data

		OSC+WBRT (N=269)	OSC (N=269)
Sex	Male	157 (58%)	157 (58%)
Age	Median	66	67
	IQR	60 – 72	62 – 72
	Range	38 – 84	45 – 85
KPS	<70	101 (38%)	102 (38%)
	≥70	168 (62%)	167 (62%)
Extra-cranial mets	No	122 (45%)	124 (46%)
Number of brain mets	Solitary	80 (30%)	82 (30%)
Time since brain mets diagnosis	<= 4 weeks	165 (61%)	153 (57%)
	> 4 weeks	104 (39%)	116 (43%)
	Median (days)	23	26
	Range (days)	2 – 235	0 – 196
Survival (weeks)	Deaths	260	262
	One-year (95% CI)	2.6% (1.1%, 5.1%)	2.7% (1.2%, 5.3%)

Conclusion:
This is the only large randomised trial evaluating the utility of WBRT in this disease. Although the results include the pre-specified non-inferiority margin, the estimate of the difference in QALYs suggests WBRT provides no additional clinically significant benefit for this group of patients. Additionally there were no significant differences in overall survival or quality of life. .

Background:
Interstitial lung diseases (ILDs) are sometimes seen in patients with primary lung cancer. Therapeutic interventions for lung cancer patients with ILDs occasionally induce acute exacerbation (AE), which is a potentially fatal complication. However, no prophylactic treatments have been established. Although the etiology of ILD-related AE is unknown, management of the ILD disease process, including fibrotic changes and inflammatory reactions, is thought to lead to the prophylaxis of AE. C-type natriuretic peptide (CNP) is a member of the natriuretic peptide family, which includes atrial and brain natriuretic peptides. CNP has cardioprotective effects, such as anti-fibrotic and anti-inflammatory effects, in animal models of myocarditis and myocardial infarction. The objective of the present study was to investigate the anti-fibrotic and anti-inflammatory effects of CNP on bleomycin (BLM)-induced lung injury.

Methods:
C57BL/6 mice were divided into two groups, vehicle- and CNP-treated groups, for evaluation of pulmonary fibrosis and inflammation induced by BLM. CNP (2.5 µg/kg/min) or vehicle were subcutaneously infused using an osmotic mini-pump from 24 h before BLM administration until the mice were euthanized. On 14 days after intratracheal administration of BLM (1 mg/kg), histological changes, collagen content, and mRNA expression of inflammatory cytokines in lungs and bronchoalveolar lavage fluid (BALF) were assessed.

Results:
Continuous infusion of CNP attenuated BLM-induced fibrotic changes. Quantitative histological analysis showed that BLM-induced fibrotic lesions were significantly smaller in CNP treated mice compared to vehicle mice. The collagen content, determined with the hydroxyproline assay, increased in BLM-administered lung and CNP treatment reduced BLM-induced collagen production. CNP treatment tended to improve body weight loss after BLM administration. In BALF, BLM administration augmented the number of inflammatory cells in the vehicle group, which was significantly lower in CNP treated mice. The expression of IL-1β, IL-6, and bFGF mRNA were significantly elevated by BLM administration, and CNP treatment significantly attenuated these increases. Figure 1



Conclusion:
These results indicate that CNP attenuates fibrotic changes, namely the accumulation of inflammatory cells, and the increased expression of inflammatory cytokines in BLM-induced pulmonary fibrosis. CNP may have therapeutic potential in patients with ILD and lead to prophylaxis for AE.

Background:
Dyspnoea is a common symptom of lung cancer. Morphine is widely used to control dyspnoea.

Methods:
We randomised 173 patients with advanced non-small cell lung cancer or mesothelioma with a dyspnoea score ≥ 4 on visual analogue scale (VAS) to one of three arms (acupuncture [A], morphine [M] or combination [AM]). A was delivered to upper sternal, paravertebral, hand and trapezius trigger points. Patients on arm A were given rescue morphine if needed. We recorded VAS dyspnoea and relaxation, lung function tests, respiratory rate, and EORTC QLQ-30/ QLQ-LC13 questionnaires at baseline, 30mins, 90mins, 4 hours, day 2, 7 and 14. Primary endpoint was proportion of patients achieving ≥1.5 improvement in VAS dyspnoea at 4 hours.

Results:
The median age of the study population was 73. 53% were performance status 2-3. The baseline median VAS dyspnoea score was 6.5. All patients scored >7 on HAD depression score. 44.3% scored >10 on HAD anxiety. Dyspnoea improved by ≥1.5 points on the VAS in 74% of patients in arm A, 60% in arm M and 66% in arm AM (A versus M p-value 0.12, AM versus M p-value 0.50). On VAS scales there was improved anxiety, relaxation and tiredness of A over M. Analysis of EORTC questionnaire data showed a mean change from baseline global health % score for arm A of 7.08 compared to -2.08 for arm M (p-value = 0.009). There was a mean change from baseline in dyspnoea % score for arm A of -7.89 compared to -1.05 for arm M (p=0.029, not significant at 1% level). There was no improvement in lung function or respiratory rate. 21% of patients in arm A, 87% in arm M and 87% in arm AM took one of more doses of morphine (p<0.001). 123 patients had toxicity data. All toxicities were CTCAE grade 1/2 and in line with morphine’s toxicity profile, with 8% of patients in arm A, 35% in arm M and 39% of patients in arm AM reporting toxicities. Two patients stopped morphine because of side effects. There were two cases of skin irritation attributable to acupuncture site dressings. Score Changes from Baseline

	A	M	AM
Mean VAS relaxation (SD)	-1.06 (±2.60)	0.19 (±2.43)	-1.48 (±2.05)	p<0.001
Day 7 median LAR relaxation (range)	-1 (-6.7–4.5)	0 (-3.5–4.4)	-0.9 (-5.6–4)	p=0.006
Day 7 median LAR anxiety (range)	1.5 (-2.5–8)	0 (-4–6.2)	1.2 (-5.4–6.3)	p=0.003
Mean LAR tiredness (SD)	-0.82 (±2.61)	0.02 (±2.20)	-0.94 (±2.37)	p=0.002
Mean EORTC global health % (SD)	7.08 (±25.54)	-2.08 (±17.70)	2.72 (±16.96)	p=0.009
Mean EORTC dyspnoea % (SD)	-7.89 (±17.382)	-1.05 (±17.704)	-6.37 (±17.797)	p=0.029
Median dose morphine (range)	32mg (1-60)	53mg (13-163)	40.63mg (3-154)	p=0.007

Conclusion:
This study population was of poor performance status. A is as effective as M in the treatment of dyspnoea and has additive value for anxiety, relaxation and global health. Acupuncture is morphine sparing. Acupuncture should be a treatment available to lung cancer patients with dyspnoea and as a morphine adjunct.

Background:
The incidence of hyponatremia in non-small cell lung cancer (NSCLC) varies from 1% to 50%. Early recognition and a prompt treatment of this electrolytic imbalance could prevent clinical complications and improve survival. Hyponatraemia has recently been reported with targeted therapies in cancer patients. Aim of the study was to perform an up-to-date meta-analysis in order to determine the incidence and relative risk (RR) in cancer patients treated with these agents.

Methods:
The published scientific literature regarding hyponatremia in peer-review journals was extensively reviewed using the MEDLINE and Pubmed databases till January 2015. Eligible studies were selected according to PRISMA statement. Summary incidence, RR, and 95% Confidence Intervals were calculated using random-effects or fixed-effects models based on the heterogeneity of selected studies.

Results:
A total of 4803 potentially relevant trials were identified: of them, 13 randomized phase III studies were included in this meta-analysis. A total number of 6670 patients treated with 8 distinct targeted agents were available for this analysis: 648 patients had NSCLC and were treated with afatinib or gefitinib (vs. placebo) and vorinostat + chemotherapy (vs. placebo + chemotherapy). The highest incidences of all-grade hyponatraemia were observed with the combination of brivanib and cetuximab (63.4) and pazopanib (31.7), while the lowest incidence was reported by afatinib (1.7). The highest incidence of high-grade hyponatraemia was reported by cetuximab (34.8), whilst the lowest incidences were reported by gefitinib (1.0). Summary RR of developing all-grade and high-grade hyponatraemia with targeted agents was 1.36 and 1.52, respectively. The highest RRs of all-grade and high-grade hyponatraemia were associated with brivanib (6.5 and 5.2, respectively). Grouping by drug category, the RR of high-grade hyponatraemia with angiogenesis inhibitors was 2.69 compared to anti-Epidermal Growth Factor Receptors Tirosine Kinase Inhibitors or monoclonal Antibodies (1.12).

Conclusion:
Treatment with biological therapy in cancer patients is associated with a significant increased risk of hyponatraemia, therefore frequent clinical monitoring should be emphasized when managing these and newer targeted agents.

Abstract not provided

Background:
Clinical trials of immune checkpoints modulators, including both programmed cell death-1 (PD-1) and programmed cell death-ligand 1 (PD-L1) inhibitors, have recently shown promising activity and tolerable toxicity in pre-treated NSCLC patients. However the predictive role of PD-L1 expression is still controversial. This pooled analysis aims to clarify the association of clinical objective responses to anti PD-1/PD-L1 monoclonal antibodies (MoAbs) and PD-L1 expression in pre-treated NSCLC patients.

Methods:
Data from all published studies, that evaluated efficacy and safety of PD-1/PD-L1 inhibitors in pre-treated NSCLC patients, stratified by tumor PD-L1 expression status (immunohistochemistry, cut-off point 1%), were collected by searching in PubMed, Cochrane Library, American Society of Clinical Oncology, and World Conference of Lung Cancer, meeting proceedings. Pooled Odds ratio (OR) and 95% confidence intervals (95% CIs) were calculated for the Overall Response Rate (ORR) (as evaluated by Response Evaluation Criteria in Solid Tumors, version 1.1), according to PD-L1 expression status.

Results:
A total of six studies, with 776 patients, were eligible. Pooled analysis showed that patients with PD-L1 positive tumors (PD-L1 tumor cell staining ≥1%), had a significantly higher ORR, compared to patients with PD-L1 negative tumors (OR: 2.53; 95% CIs: 1.65-3.87). Figure 1Figure 2





Conclusion:
PD-L1 tumor expression seems to be associated with clinical activity of anti PD-1/PD-L1 MoAbs, in pre-treated, NSCLC patients, suggesting a potential role of PD-L1 expression, IHC cut-off point 1%, as predictive biomarker for the selection of patients who may benefit more from these therapies. Further analysis from ongoing phase II/III clinical trials will provide more information about this observation.

Background:
Pembrolizumab is a humanized monoclonal antibody against PD-1 that has demonstrated robust antitumor activity and a manageable safety profile in patients with advanced malignancies, including NSCLC. Similar to other immune checkpoint inhibitors, immune-mediated toxicities have been observed with pembrolizumab. We characterized the incidence of potentially immune-mediated adverse events (AEs) and the use of systemic corticosteroids for their management in patients with NSCLC treated with pembrolizumab in the phase 1 KEYNOTE-001 trial (ClinicalTrials.gov, NCT01295827).

Methods:
550 patients with advanced NSCLC received pembrolizumab 2 or 10 mg/kg every 3 weeks (Q3W) or 10 mg/kg every 2 weeks (Q2W). Potentially immune-mediated AEs were derived from a prespecified list and considered regardless of attribution to study treatment by the investigator. High-dose corticosteroid use was defined as an initial dose of ≥40 mg/day prednisone or equivalent. Low-dose corticosteroid use was defined as an initial dose of <40 mg/day prednisone or equivalent.

Results:
71 (12.9%) patients experienced ≥1 immune-mediated AE, including 17 (3.1%) who experienced grade 3-4 events, 1 (0.2) who died because of an immune-mediated AE (pneumonitis), and 14 (2.5%) who discontinued pembrolizumab because of immune-mediated AEs. The median time to onset of the first immune-mediated AE was 104 days (range, 2-393 days). Immune-related AE incidence was similar in patients treated with pembrolizumab 10 mg/kg Q2W and Q3W. The most common immune-mediated AEs were hypothyroidism, pneumonitis, and infusion-related reactions (Table). Pneumonitis was the most common grade 3-4 toxicity. Excluding hypothyroidism, 74.2% of immune-mediated AEs had resolved at the time of data cutoff. Of the 71 patients who experienced immune-mediated AEs, 30 (42.2%) received corticosteroids: 20 received high dose, 10 low dose. The highest incidence of corticosteroid use was for pneumonitis (84.2%) and colitis (80.0%) (Table). The duration of initial steroid use ranged from 1 to 129 days. Analyses related to the impact of steroid use on pembrolizumab efficacy are ongoing and will be available for presentation. Figure 1



Conclusion:
Potentially immune-mediated AEs, particularly those of grade 3-5 severity, are relatively infrequent in patients with advanced NSCLC treated with pembrolizumab. As evidenced by the low rate of pembrolizumab discontinuation, most immune-mediated events were managed by temporary pembrolizumab interruption and corticosteroid use.

Background:
The CheckMate 017 (NCT01642004) randomized, open-label, global phase 3 study evaluated efficacy and safety of second-line nivolumab vs docetaxel in patients with advanced squamous (SQ) non-small cell lung cancer (NSCLC). Overall survival was significantly superior and duration of treatment longer for nivolumab vs docetaxel. The study also evaluated disease-related symptoms using the Lung Cancer Symptom Scale (LCSS).

Methods:
The LCSS includes 100 mm visual analog scales for 6 major lung cancer symptoms plus three global items evaluating the impact of symptoms; 0 represents the least severity and 100 the greatest severity. Assessment was performed every 4 weeks for nivolumab and every 3 weeks for docetaxel for the first 6 months on treatment, followed by every 6 weeks for the remainder of the treatment period for both study arms. Following treatment discontinuation, the LCSS also was assessed at two follow-up visits. The LCSS average symptom burden index (ASBI) was computed from the 6 individual symptom scores. Mean baseline and mean change from baseline of the LCSS ASBI at each assessment were summarized by treatment group. A study secondary endpoint was to estimate the proportion of patients whose LCSS ASBI showed a clinically meaningful improvement by week 12 (10 point or greater decrease, the minimally important difference [MID]), which was based on all randomized patients.

Results:
Patient baseline characteristics were generally balanced across treatment groups. LCSS completion rates for baseline and at least one subsequent assessment were 68.9% and 62.8% for nivolumab and docetaxel, respectively. Completion rates remained relatively consistent throughout assessments and by treatment arm. Baseline LCSS ASBI values were similar for nivolumab (29.6; standard deviation [SD] 16.4) and docetaxel (29.6; SD 14.7). By week 12, 20.0% (27/135; 95% CI: 13.6, 27.7) of nivolumab patients demonstrated clinically meaningful symptom improvement compared to 21.9% (30/137; 95% CI: 15.3, 29.8) of docetaxel patients. Examining mean changes from baseline in patients’ LCSS ASBIs at each assessment, the nivolumab group demonstrated statistically significant improvements from baseline at each assessment from week 12 through week 54, after which sample sizes dropped to fewer than 10 patients; from week 40 through 54, the mean improvements exceeded the MID. In contrast, docetaxel patients remaining on treatment had no statistically significant changes in LCSS ASBI through week 18, after which the sample dropped to fewer than 10 patients. In the two follow-up visits after treatment discontinuation, the mean of the LCSS ASBI for both nivolumab and docetaxel patients indicated similar worsening of symptoms relative to baseline (range, 5.5–9.5); for docetaxel patients, the differences from baseline were statistically significant.

Conclusion:
By week 12, the proportion of patients showing meaningful symptom improvement was similar for both the nivolumab and docetaxel groups. However, the overall average symptom burden while on nivolumab improved from baseline over most of the year of available follow up, while average symptom burden for docetaxel patients remained stable relative to baseline during their shorter time on treatment. These results show statistically and clinically significant reductions from baseline in lung cancer symptoms for patients with squamous NSCLC treated with second-line nivolumab.

Abstract not provided

Background:
Responses to PD-1 blockade have been induced in approximately 20% of advanced non-small cell lung cancer (NSCLC) patients with progressive disease after standard therapy [Garon, NEJM 2015]. One challenge is to understand how the immune response was initiated in responding patients. Tumor mutational burden has been associated with response to PD-1 checkpoint inhibitors in NSCLC [Rizvi, Science, 2015]. In addition, studies in melanoma patient-derived tumor specimens revealed that responses to PD-1/L1 blockade rely on pre-therapy tumor infiltration of activated T effector cells [Tumeh, Nature, 2014]. We hypothesize that clonal T cell infiltration is correlated with tumor mutational load and clinical response with PD-1 blockade.

Methods:
We studied tumor specimens in NSCLC patients treated with pembrolizumab at UCLA on the KEYNOTE -001 clinical trial. All patients signed informed consent for the trial as well as separate specimen acquisition protocols. Responses were classified by the investigators according to irRC. DNA was extracted and whole exome sequencing was performed at the UCLA Immunogenetics Core. DNA from the same patient’s PBMC or other non-cancerous tissue was sequenced for baseline comparison. Immunohistochemistry (IHC) was done for CD8 (Clone C8/144B, Dako), CD4 (Clone SP35, Cell Marque) and PD-L1 (Clone SP142, Spring Bioscience).

Results:
We report results from 27 patients (14 responders, and 13 nonresponders). Significantly higher density of pre-dosing CD8+ cells (percentage of CD8+ nucleated cells) in the tumors of the responding patients was observed (mean of 17.7% in responders vs 5.6% in non-responders, p=0.02 by unpaired t test) suggestive of a pre-existing immune response. Mutational load in 5 patients (3 responders and 2 nonresponders) showed a trend towards correlation with response (mean of 19 nonsynonymous somatic mutations per MB in responders vs 6 in nonresponders, p=0.33). Interestingly, a strikingly significant correlation between mutational load and CD8 expression was observed (R[2]=0.96, p=0.003). In addition, pre-dosing tumor PD-L1 expression demonstrated a trend towards correlation with response (mean of 72.1% in responders vs 51.5% in nonresponders, p=0.07) but not with CD8 tumor infiltration (R[2]=0.05, p=0.28). No significant association of CD4+ T cell tumor infiltration with response (mean of 37.4% CD4 + cells in responders vs 27.0% in nonresponders, p=0.32) was observed.

Conclusion:
We observed strong correlation of pre-dosing intratumoral T cell infiltration with response and mutational load in NSCLC patients treated with pembrolizumab. Our results have direct implications for the design and interpretation of ongoing and planned immunotherapy studies for NSCLC and evaluation of potential predictive biomarkers to select patients most likely to benefit.

Background:
New therapeutic modalities in metastatic squamous non-small cell lung cancer (SQ NSCLC) focus on targeting pathways (programmed cell death 1 [PD-1]) involved in inhibiting anti-tumor T cell responses leading to tumor evasion. Nivolumab, an anti-PD-1 monoclonal antibody, blocks T cell inhibitory signal pathways by preventing engagement of PD-1. On March 4, 2015, FDA approved nivolumab for the treatment of patients with metastatic SQ NSCLC with progression on or after platinum-based doublet chemotherapy. The approval was based on a randomized study (CA209017) demonstrating a large magnitude of improvement in overall survival (OS) and was supported by single arm study (CA209063) demonstrating a 15% objective response rate (ORR), which appeared to be durable. We conducted a retrospective exploratory responder analysis to evaluate the association between response and OS in study CA209063. Figure 1



Methods:
CA209063 was a multicenter, multinational, single-arm, open-label study in patients with SQ NSCLC who previously received at least two lines of systemic therapies. Patients (n=117) received nivolumab 3 mg/kg as an intravenous (IV) infusion every 2 weeks until progressive disease (PD) or toxicity; treatment past PD was allowed if certain “clinical benefit” criteria were met. Response was defined as a partial response (PR) or complete response (CR) as determined by a blinded independent review committee (IRC) utilizing the Response Evaluation Criteria In Solid Tumors (RECIST) criteria (98 of 117 were evaluable). Responders were categorized into the following groups: A CR or PR, stable disease (SD), PD with continuation of treatment, and PD with discontinuation of treatment. A sensitivity landmark-based analysis was performed to exclude timing of response evaluation bias (Anderson et al, 1983).

Results:
The exploratory responder analysis showed that patients who achieved a best response of CR or PR had the longest survival with anti-PD1 therapy, followed by patients who either achieved a best response of SD or PD with continuation of treatment beyond RECIST progression. Patients whose best response was PD and no treatment beyond progression had poor survival (figure 1). The Landmark time-based sensitivity analysis at 3.5 months (median time to response) also suggested that responders had longer survival than non-responders.

Conclusion:
Our analysis suggests that patients with NSCLC who respond are likely to derive the most clinical benefit from anti-PD1 therapy. However, given the exploratory retrospective nature of this analysis, results should be interpreted cautiously. Further development of predictive biomarkers to identify patients most likely to respond is necessary.

Background:
Patients with advanced non-small cell lung cancer (NSCLC) often develop brain metastases (BrMs), and standard therapy such as surgery or radiation can cause toxicity and delay systemic treatment. Pembrolizumab is a PD-1 inhibitor with promising clinical activity and a favorable toxicity profile in patients with advanced NSCLC, however the efficacy of pembrolizumab in the central nervous system (CNS) is unknown. This trial aims to determine the safety and activity of pembrolizumab in patients with advanced NSCLC and untreated brain metastases.

Methods:
Eligibility for patients with NSCLC in this Phase II trial includes the presence of at least 1 BrM between 5 and 20 mm that is asymptomatic, untreated or progressing after prior local therapy, and not requiring urgent local therapy. PD-L1 expression in tumor obtained since the most recent systemic therapy is required. Patients are treated with pembrolizumab 10mg/kg every 2 weeks. Systemic response is determined by RECIST 1.1, and BrM response is determined by modified RECIST (mRECIST) in which brain lesions ≥ 5mm are considered measurable and up to 5 target lesions are allowed. The primary endpoint of this trial is BrM response rate.

Results:
Fifteen patients with NSCLC and untreated BrMs were treated with pembrolizumab, none of whom had a drug-related Grade ≥ 3 adverse event (AE) or any grade AE attributed to BrMs. Of the 10 patients evaluable for response, 5 (50% with 95% CI: 0.24-0.76) had a BrM response (4 partial and 1 complete) and 5 had a systemic response. Only one patient who responded in the body had progressive disease in the brain; all other patients who had a systemic response also had a CNS response. The duration of response in the brain was at least 12 weeks for 4 of the 5 responders, and all responses are ongoing at the time of data analysis.

Conclusion:
To our knowledge this is the first study to demonstrate that the PD-1 inhibitor pembrolizumab has activity in the CNS in patients with NSCLC and untreated brain metastases. To date there have been no drug-related neurologic or significant toxicity identified. Patient enrollment and biomarker analysis are ongoing.

Abstract not provided

Background:
Overexpression of EGFR and other ErbB receptors, and/or dysregulation of their downstream pathways are implicated in the pathogenesis of squamous cell carcinoma (SCC) of the lung, generating interest in exploring EGFR/ErbB-targeted agents in this setting. Recent analyses from the global LUX-Lung 8 trial (n=795) in patients with SCC of the lung demonstrated that second-line afatinib (an irreversible ErbB family blocker) conferred overall survival (OS; median 7.9 vs 6.8 months; HR [95% CI] 0.81 [0.69‒0.95]; p=0.008) and progression-free survival (PFS; median 2.6 vs 1.9 months; HR [95% CI] 0.81 [0.69‒0.96]; p=0.010) benefit over erlotinib (a reversible EGFR inhibitor). To assess biomarkers for efficacy for these agents in SCC we conducted an exploratory analysis using archival tumor tissue collected at time of study entry.

Methods:
Among all randomized patients, samples were retrospectively enriched for those from patients with PFS >2 months and appropriate controls (PFS ≤2 months; Figure 1) and were selected for analysis using the Foundation Medicine (FM) FoundationOne™ next-generation sequencing (NGS) platform (n=433); 300 cancer-related genes were analyzed for copy number alterations (CNAs), rearrangements and single nucleotide variants (SVs). Preliminary results from the 238 samples analyzable so far (~30% of the randomized patients), focusing on genomic alterations of EGFR and their potential association to survival endpoints PFS and OS, are presented.

Results:
Fourteen EGFR SVs (5.8%) were detected of which 10 were novel with unknown clinical significance (Figure 1). Figure 1 Four had been previously reported; 2 (E114K [afatinib arm], Q1021* [erlotinib arm]) occurred in the non-kinase domains and 2 (L861Q [afatinib arm], L858R [erlotinib arm]) in the kinase domain. The frequency of EGFR CNAs (n=15 [6.3%]; afatinib: 9; erlotinib: 6) was also low. At the time of these ongoing analyses, these low frequencies of EGFR mutations/amplifications were deemed not to be associated with the observed improvements in PFS and OS. Genomic alterations aggregated across two key gene groups (ErbB and FGF families) and their association with survival outcomes will be presented.



Conclusion:
The frequency of EGFR genomic aberrations in the samples tested was low. Based on this analysis of a subgroup of patients, PFS and OS improvements conferred by afatinib in LUX-Lung 8 were not driven by the presence of activating EGFR mutations or amplifications and may be related to afatinib’s ability to inactivate multiple aberrant signaling cascades associated with, and downstream of, ErbB receptors.

Background:
The overwhelming majority of advanced NSCLC p worldwide is wild-type (WT) EGFR. The results reported so far are difficult to interpret due to the heterogeneous nature of this large group of p. There is a variation in terms of efficacy considering known prognostic factors; however, other characteristics, as yet undefined, might further explain this variability. In the clinical setting, prolonged second-line treatment with Erlotinib (E) has been identified in a small group of p with WT EGFR leading to a long-term survival. The role of E in this special subset needs to be further determined in order to identify who might be most likely to benefit.

Methods:
WILT is a multicentre, open-label, observational study. WT EGFR (if rarely unknown, both squamous tumour and current/former smoking status as mandatory criteria) advanced NSCLC p treated with second-line E (150mg/d, until unacceptable toxicity/progressive disease) were included. Using a prognostic index model, the aim of this study is to identify subgroups of p with specific clinical and laboratory parameters that are likely to derive clinically meaningful and statistically significant benefit from E. Here we present the results of patients’ subgroups with long-term E treatment in second-line setting (PFS≥6 months and PFS≥9 months).

Results:
355 p were included in the study and preliminary reported data showed an overall median PFS of 2.3 months, finding 40% of p with a median PFS>2.5 months. Baseline subgroups characteristics of 52 p (14.6%) with a PFS≥6 months and 30 p (8.5%) with a PFS≥9 months are shown in Table 1. Efficacy data in PFS≥6 months subgroup: Median PFS of 10.8 months (95% CI: 9.2-12.3). Objective Response Rate of 21.6% and Disease Control Rate of 82.4%. Main related grade≥3 toxicities were rash (1.9%) and diarrhoea (3.8%). Efficacy data in PFS≥9 months subgroup: Median PFS of 13.5 months (95% CI: 12-15). Objective Response Rate of 17.2% and Disease Control Rate of 82.8%. Main related grade≥3 toxicities were rash (3.3%) and diarrhoea (6.7%). Table1: Patient characteristics

	SLP ≥6 months (N=52)	SLP ≥9 months (N=30)
Median age ( years)	65	67
Male/Female (%)	69/31	67/33
ECOG 0/1/2 (%)	21/62/17	23/64/13
Histology (%) Adenocarcinoma/Squamous	48/39	43/50
Stage (%) IV	75	67
EGFR status (%) WT Unknown*	85 15	80 20
Smoking status (%) Current/Never/Former	19/17/64	17/16/67
Metastases (%) Yes Lung/Bone/CNS/Pleura/Liver	83 44/21/14/12/9	77 39/22/9/13/13
Prior platinum-based doublet (%) Yes	94	93
Prior Maintenance Treatment (%) Yes	27	17
Best response to first-line (%) CR+PR/SD	48/31	40/37
Weight loss during first-line (%) Yes	22	23
Anaemia (%) Yes	69	63

*Unknown: Squamous and current/former smokers

Conclusion:
Global efficacy results of E, in terms of PFS, match with previously reported data for second-line setting. A long-term survivors group has been identified, whom the administration of E resulted in an extraordinary prolonged response. Highlighting the heterogeneity of this subgroup, it was not possible the identification of standardized prognostic factors. Potentially molecular variables for long-term survival with E in WT EGFR NSCLC could play a role in the determination of different evolutions.

Background:
The SQUIRE study demonstrated that the addition of necitumumab (N) to gemcitabine-cisplatin (GC) improved survival in patients with stage IV sq-NSCLC. This retrospective analysis compares efficacy and safety outcomes for patients who received single-agent N as continuation therapy after completion of chemotherapy treatment (CT) in GC+N arm to the continuation therapy-eligible population of the GC arm.

Methods:
Patients were randomized 1:1 to GC (G=1250 mg/m² iv, days 1 and 8; C=75 mg/m² iv, day 1) plus N (800 mg iv, days 1 and 8), or GC alone every 21 days up to 6 cycles. Patients in GC+N with no progression continued on N alone until progressive disease. In this analysis, we consider patients in GC+N arm who were alive and progression-free before the start of N single-agent therapy (GC+N arm continuation therapy patients) and patients in GC arm who were alive, progression-free after completion of CT and did not discontinue treatment due to adverse event (AE) (GC arm non-progressor patients). This analysis included patients in both arms who received ≥4 cycles of CT. Overall survival (OS) and progression-free survival (PFS) were measured from the date of randomization, with parameters estimated using the Kaplan-Meier method. Hazard ratios and 95% CIs between subgroups were estimated from stratified Cox proportional hazards models. OS and PFS for post-induction period were measured from the completion of CT + 21 days. Selected treatment-emergent AEs (TEAEs) for patients in each arm are presented in the table.

Results:
261 patients were progression-free, received ≥4 cycles of CT, and received ≥1 dose of N alone in GC+N arm. 215 pts in GC arm completed ≥4 cycles of CT, were progression-free, and did not discontinue due to AE. Patient baseline characteristics and exposure to CT were well balanced between GC+N and GC arms. Median OS from randomization in GC+N vs GC was 15.9 vs 15.0 months; HR 0.85 (95% CI, 0.69, 1.05). Median OS for post-induction period in GC+N vs GC was 11.5 vs 10.9 months; HR 0.84 (95% CI, 0.68; 1.04). Median PFS from randomization in GC+N vs GC was 7.4 vs 6.9 months; HR 0.86 (95% CI, 0.70, 1.06). Median PFS from post-induction period in GC+N vs GC was 3.2 vs 2.3 months; HR 0.85 (95% CI, 0.70, 1.04). Selected TEAEs (Overall):

	GC+N Continuation PatientsN = 261, %		GC Non-ProgressorsN = 215, %
Category	Any Grade	Grade ≥3	Any Grade	Grade ≥3
Neutropenia	55.9	34.1	57.7	33.0
Anemia	46.7	10.0	49.3	8.8
Thrombocytopenia	26.1	9.6	29.3	12.6
Hypomagnesemia	42.1	14.9	18.6	0.9
Conjunctivitis	11.9	0.8	3.3	0
Rash	87.4	8.8	10.2	0.5
Arterial thromboembolic event	5.7	3.1	0.5	0
Venous thromboembolic event	9.2	3.8	4.2	0.9

Conclusion:
There was a consistent treatment effect in favor of GC+N continuation patients as compared to GC non-progressors with no unexpected increases in AEs.

Abstract not provided

Background:
SQUIRE, a randomized phase III study, demonstrated that the addition of necitumumab (N) (a second-generation, recombinant, human immunoglobulin G1 EGFR antibody) to gemcitabine-cisplatin (GC) improved overall survival (OS) in patients with stage IV squamous non-small cell lung cancer (NSCLC). Analyses of the relationship between efficacy and epidermal growth factor receptor (EGFR) protein expression using the immunohistochemistry (IHC) H-score=200 cut-point were previously reported (Thatcher et al. Lancet Onc, 2015; doi: 10.1016/S1470-2045(15)00021-2). Here we report additional exploratory analyses of the relationship with EGFR protein, as well as analyses of EGFR gene copy number.

Methods:
SQUIRE included mandatory tissue collection from archived tumor. EGFR protein expression was assessed by IHC in a central lab, using the Dako EGFR PharmDx kit. Analyses of the relationships between efficacy outcomes with EGFR across the range of protein levels were performed, using methodologies including subpopulation treatment effect pattern plot (STEPP) with a sliding window target size of 200 patients. An exploratory assessment of EGFR gene copy number gain was performed in tissue sections using fluorescence in situ hybridization (FISH) (J Clin Pathol; 2009;62(11):970-7). Efficacy outcomes were estimated using the Kaplan-Meier method and hazard ratios estimated using an un-stratified Cox model. .

Results:
A total of 982 patients (89.8% of the ITT) had evaluable IHC assay results. The large majority of these patients (95.2%) had tumor samples expressing EGFR protein; only 4.8% had tumors without detectable EGFR protein (H-score=0). The STEPP analyses showed no consistent trend or obvious cut-point for the relationship between either OS or PFS with EGFR protein across the range of IHC values when comparing treatment arms. Archived tumor tissue with evaluable results for exploratory EGFR FISH analysis was available for 51.0% of patients (557 of 1093 ITT patients). Of these patients, 208 patients (37.3%) had increased EGFR gene copy number (FISH positive). A trend for greater necitumumab benefit was observed in EGFR FISH positive patients. Treatment HR (95% CI) for FISH positive and negative patients were 0.70 (0.52, 0.96) and 1.02 (0.80, 1.29) for OS, and 0.71 (0.52, 0.97) and 1.04 (0.82, 1.33) for PFS. However, the interaction of EGFR gene copy number gain with treatment was not statistically significant for either OS or PFS (p=0.066 and 0.057, respectively).

Conclusion:
The analysis of EGFR protein expression did not identify consistent trends related to efficacy outcomes across the range of IHC values. EGFR gene copy number gain showed a trend for a more favorable HR, but did not appear to be strongly predictive. However, both markers showed some evidence of potential trends that will be investigated further in future trials.

Background:
This study investigated whether intercalating and maintenance use of gefitinib with chemotherapy improves clinical outcomes versus chemotherapy alone in selected, chemotherapy-naive patients with advanced non-small cell lung cancer (NSCLC) after receiving two cycles of gemcitabine plus carboplatin with stable disease.

Methods:
We undertook an open-label, randomized, phase III trial at 14 centres in China. Non-smoking patients with previously untreated stage IIIB/IV lung adenocarcinoma with EGFR mutation status unknown (tissue not available) firstly received two cycles of gemcitabine (1,250 mg/m2 days 1 and 8) plus carboplatin (AUC=5, day 1). The patients with stable disease and Eastern Cooperative Oncology Group performance status of 0 or 1 were randomly assigned (1:1) to receive either gefitinib (250mg/d) on days 15 to 25 with a 4-week cycle of gemcitabine and carboplatin or a 4-week cycle of gemcitabine and carboplatin alone. A maximum of four cycles of chemotherapy was allowed in both arms after which time patients continued to receive gefitinib or observation until disease progression or unacceptable toxicity. The primary endpoint was progression-free survival (PFS). Secondary endpoints included overall survival (OS) and safety. The trial is registered at ClinicalTrials.gov, number NCT01404260, and has completed enrolment; patients are still in follow-up.

Results:
From June 2011 to August 2014, 219 patients with stable disease were randomized to intercalating and maintenance use of gefitinib with chemotherapy (n=109) or chemotherapy alone (n=110). The number of PFS events is 84 cases for the gefitinib plus chemotherapy group and 93 cases for the chemotherapy alone group. PFS was significantly longer in the patients receiving gefitinib and chemotherapy than in those receiving chemotherapy alone (median 10.0 vs 4.4 months, respectively; hazard ratio 0.475, 95% CI 0.349-0.646; p<0.0001). The median follow-up duration for OS is 24.5 months; OS of maturity 34.7% was not statistically different between these two arms (32.2 vs 32.5 months, respectively; hazard ratio 1.01, 95% CI 0.64-1.58; p=0.97). The addition of gefitinib to chemotherapy was well tolerated, with no increase in haematologic toxicity and no treatment-related interstitial lung disease.

Conclusion:
Intercalating and maintenance use of gefitinib with gemcitabine/carboplatin led to a significant improvement in PFS versus gemcitabine/carboplatin alone for Chinese nonsmoking patients with advanced pulmonary adenocarcinoma (EGFR mutation status unknown) who had previously achieved stable disease after receiving two cycles of gemcitabine/carboplatin; immature OS was not statistically different.

Background:
While concurrent administration of EGFR-TKI and chemotherapy failed to improve the survival outcome, preclinical and clinical data suggested that sequential administration of EGFR-TKI within a chemotherapy cycle might improve the clinical outcome by avoiding the putative antagonism of TKI-induced G1 arrest of the cell cycle phase-dependent activity of chemotherapy. This study was designed to evaluate this idea with gefitinib and Pemetrexed/Cisplatin (Pem/Cis), the best known regimen for lung adenocarcinoma (ADC), in never-smokers with chemo-naive ADC of the lung.

Methods:
Eligible patients (pts) were never-smokers with chemo-naive stage IIIB/IV ADC, performance status of 0-2 and adequate organ functions, who were randomized after stratification by the EGFR mutation status (positive vs. negative/unknown) to receive either gefitinib (G) 250 mg/day or placebo (P) on days 5-18 of a 3-weekly cycle of chemotherapy, which consisted of Pem 500 mg/m[2] and cisplatin(Cis) 75mg/m[2] given iv on day 1, every 3 weeks for a maximum of 9 cycles. Responding patients continued to receive either G or P every day until PD or unacceptable toxicity. After documentation of PD, pts who had been on P arm were crossed over to receive G. The primary endpoint was progression-free survival (PFS).

Results:
Between 06/2012 and 12/2014, 76 pts (M/F: 9/67) with median age of 58.0 years (range 32-75) were enrolled; 72 pts had stage IV and 4 had IIIB tumors. EGFR mutation was (+) in 29, (-) in 43, and unknown in 4. As of 03/17/2015, while randomization code is not broken yet, 53 pts are off treatment (48 due to PD, 2 deaths, 2 patient’s refusal, and 1 due to intercurrent brain tumor) and 19 pts are known dead (17 due to PD and 2 due to other causes). Overall, more pts with EGFR mt(+) tumor received 6 cycles of therapy than those with EGFR mt(-) tumor [28/29 (97%) vs. 32/43 (73%)] and completed 9 cycles of therapy as planned [19/29 (66%) vs. 14/43 (33%)]. The treatment was well tolerated with less G-associated skin toxicities, due to intermittent administration schedule of G per protocol. The most common G3/4 adverse events were: anemia (17.1%), neutropenia (15.8%), vomiting (5.3%), thrombocytopenia (3.9%), and peripheral neuropathy (3.9%). There was no unexpected safety issue except for more Cis-associated peripheral neuropathy which became more noticeable as the treatment continued beyond 6 cycles of therapy. Median PFS was 8.2 months (mos) for the entire group, and 10.6 mos and 6.6 mos for EGFR mt(+) and mt(-) groups, respectively. Overall median survival has not been reached yet with an estimated 2-year survival rate of 56.3%.

Conclusion:
First-line sequential administration of G with Pem/Cis chemotherapy was well tolerated with no undue side effects or any compromise in efficacy parameters. Detailed data will be presented to see whether this strategy warrants further investigation in a certain subset of pts with advanced NSCLC.

Abstract not provided

Background:
Phase III trials have demonstrated the superiority of the ALK tyrosine kinase inhibitor (ALK-TKI) crizotinib compared to standard chemotherapy in advanced ALK positive non-small cell lung cancers (ALK+ NSCLC) in first line and second line setting. Objective response rate (ORR) with crizotinib ranged from 65 to 75% and median progression free survival (PFS) from 7.7 to 10.9 months. However a resistance to crizotinib always occurs. The French Cooperative Thoracic Intergroup (IFCT)-1302 CLINALK study aimed to describe clinical outcome and post-progression management in a large cohort of French patients with ALK+ NSCLC treated with crizotinib.

Methods:
IFCT-1302 CLINALK is a multicentric observational retrospective study. Patients with ALK+ NSCLC from centers of the IFCT network were included according to the main following criteria: advanced stage III or stage IV NSCLC, ALK immunochemistry (IHC) and/or ALK FISH positivity, crizotinib treatment in the setting of the French expanded access cohort program or as approved drug. Epidemiological and clinical data, crizotinib efficacy (objective response based on RECIST, PFS, overall survival (OS)), duration of treatment with crizotinib after disease progression and post progression outcome were collected on a case report form. The study inclusion period was from November 18 2011 to December 31 2013. The data cut-off was December 31 2014.

Results:
318 patients were included (median age 58.3, female 49.4%, caucasian 98.6%, non-smoker 55.1%, performance status 0/1 78.7%, adenocarcinoma 91.7%, stage III 14.5%, stage IV 85.5%, brain metastasis 35.9%). IHC was positive in 151/173 patients and FISH in 279/283 patients. Before crizotinib treatment, patients received platinum-based chemotherapy in 89% of cases and pemetrexed-based chemotherapy in 76.1%. Crizotinib was prescribed as first-line treatment in 17 patients (5.3%), second-line in 168 patients (52.8%), third-line in 58 patients (18.2%) and more than third-line in 75 patients (23.7%). Objective response was complete response in 1 patient (0.3%), partial response in 126 patients (40.0%), stable disease in 62 patients (19.7%) and progression in 58 patients (18.4%). ORR was 40.3 % (95%CI, 34.9-45.7). 262/318 patients presented progressive disease (82.4%) at time of analysis. Median PFS was 6.9 months (95%CI, 5.7-8.6). Median OS with crizotinib was 18.7 months (95%CI, 15.2-22.5). Median duration of treatment with crizotinib after disease progression was 56 days (29-203). Among 143 patients with subsequent treatments, crizotinib was rechallenged in 32 patients (22.4%). 58/143 patients (40.6%) were treated after crizotinib failure with another ALK-TKI, either alectinib (19/58, 32.8%) or ceritinib (40/58, 69.0%). The ALK-TKI sequence was crizotinib-alectinib in 18 patients, crizotinib-ceritinib in 39 patients and crizotinib-alectinib-ceritinib in 1 patient.

Conclusion:
This retrospective study of 318 patients with ALK+ NSCLC showed a remarkable efficacy of crizotinib, with a 18.7 months median OS, a 40.3% ORR and a 6.9 months median PFS. However, ORR and mPFS were lower than those reported in phase III trials, which may be due to less stringent selection criteria. Analysis of predictive factors of response and survival including post-progression strategies will be presented.

Background:
There is strong interest in evaluating the outcomes of patients who have progressed after failing targeted agents. With different agents, the post-progression survival (PPS) may be either improved or shortened when a longer duration of time-to-progression (TTP) has been observed. This study evaluated the association between TTP and the duration of PPS among adult patients who received ceritinib for the treatment of advanced anaplastic lymphoma kinase-positive (ALK+) NSCLC.

Methods:
Patients experiencing disease progression during two single-arm, open-label, Phase I and II trials of ceritinib (ASCEND-1 [ClinicalTrials.gov Identifier: NCT01283516] and ASCEND-2 [ClinicalTrials.gov Identifier: NCT01685060]) were included in this analysis. For uniformity, all patients analyzed had received crizotinib prior to ceritinib. TTP after the initiation of ceritinib was studied as a predictor for the length of subsequent PPS using Cox proportional hazards models. Adjustments were made for patients’ baseline characteristics, including age, body mass index, gender, race, Eastern Cooperative Oncology Group (ECOG) performance score, number of prior regimens, tumor histology, and presence of brain metastases. A Kaplan-Meier analysis for PPS was performed stratified by shorter (< 6 months) versus longer TTP (≥ 6 months). As a secondary descriptive analysis, associations were quantified between the duration of TTP and the duration of survival (OS) measured as the sum of TTP and PPS.

Results:
Of 181 patients who experienced disease progression during study follow-up, 94% received at least one chemotherapy prior to baseline, 75% had an ECOG performance score greater than zero at screening, and 79 died during subsequent follow-up. In an unadjusted model, each 3 months of longer TTP was associated with a 24% lower hazard of death following progression (hazard ratio [HR]: 0.76, 95% confidence interval [CI]: 0.60-0.96). Results were similar after adjusting for baseline characteristics (HR: 0.77, 95% CI: 0.61-0.97). Patients with TTP ≥ 6 months experienced significantly longer PPS compared to those with TTP < 6 months (median: 9.8 vs. 6.5 months, log-rank p-value < 0.01). This positive relationship between TTP and PPS translated into the duration of OS: each 3 months of longer TTP was associated with a 58% lower hazard of death after adjusting for baseline characteristics (HR: 0.42, 95% CI: 0.32-0.54). Median OS was not reached for patients with TTP ≥ 6 months and was 10.3 months for patients with TTP < 6 months.

Conclusion:
A longer duration of TTP after treatment with ceritinib was significantly associated with both longer duration of PPS and longer OS.

Background:
ALK gene rearrangements occur in approximately 3–6% of patients with non-small-cell lung cancer (NSCLC). Crizotinib has demonstrated efficacy in ALK+ NSCLC, however many patients experience systemic and/or central nervous system (CNS) disease progression within one year of treatment. Alectinib, a CNS-penetrant and highly selective ALK inhibitor, has shown preclinical activity in the CNS (Ou, et al. JTO 2013) and clinical efficacy in crizotinib-naïve (Ohe, et al. ASCO 2015) and pre-treated (Ou, et al. ASCO 2015; Gandhi, et al. ASCO 2015) ALK+ NSCLC patients. We will present updated efficacy and safety outcomes from the phase II NP28761 study (NCT01871805).

Methods:
North American patients ≥18 years of age with ALK+ NSCLC (by FDA-approved FISH test), disease progression following first-line crizotinib, and ECOG PS ≤2 were enrolled. Patients received oral alectinib (600mg) twice daily until progression, death or withdrawal. The primary endpoint was overall response rate (ORR) by independent review committee (IRC) using RECIST v1.1. Secondary endpoints included investigator-assessed ORR; progression-free survival (PFS); quality of life (QoL); CNS response rate; disease control rate (DCR); and safety.

Results:
At data cut-off (24 October 2014), 87 patients were enrolled in the intent-to-treat population. Median age was 54 years; 74% had received prior chemotherapy; 60% of patients had baseline CNS metastases, of whom 65% (34/52) had prior brain radiation therapy. Median follow-up was 20.7 weeks. ORR by IRC was 48% (95% CI 36–60); median PFS was 6.3 months (Table 1). In patients with measurable CNS lesions at baseline (n=16), IRC CNS ORR was 69% (95% CI 41–89) and CNS DCR was 100% (complete response, 13%; partial response, 56%; stable disease, 31%). In patients with measurable or non-measurable CNS disease (n=52), IRC CNS ORR was 39% (95% CI 25–53) and 11 patients (21%) had complete CNS responses. The most common grade ≥3 AEs were elevated levels of blood creatine phosphokinase (8%), alanine aminotransferase (6%) and aspartate aminotransferase (5%); no GI toxicities leading to treatment withdrawal were reported. Clinically meaningful improvements were seen in EORTC QLQ-C30 items, including Global Health Status. Figure 1



Conclusion:
Alectinib (600mg twice daily) was well tolerated and demonstrated clinical efficacy in patients with ALK+ NSCLC disease who had progressed on prior crizotinib. A clinical benefit with alectinib was also observed in patients with CNS lesions at baseline. These data are preliminary; updated efficacy and safety data from a cut-off date of 27 April 2015 will be presented.

Abstract not provided

Background:
The central nervous system (CNS) is a frequent site of progression in ALK+ NSCLC patients treated with crizotinib, thus good CNS efficacy is of crucial importance for new ALK inhibitors. Two recent phase II studies examined the efficacy and safety of alectinib in patients with ALK+ NSCLC who progressed after crizotinib; data from both studies were pooled to further examine the efficacy of alectinib in the CNS.

Methods:
Both phase II, single-arm, multicenter studies enrolled ALK+ NSCLC patients previously treated with crizotinib. One study was conducted in North America only (NP28761; NCT01871805), the other was global (NP28673; NCT01801111). All patients received 600mg oral alectinib twice daily. A primary endpoint of both studies was objective response rate (ORR) by independent review committee (IRC) and key secondary endpoints included CNS ORR by IRC and CNS duration of response (DOR). Response was determined according to RECIST v1.1. All patients underwent imaging at baseline to assess CNS metastases.

Results:
The pooled analysis population comprised 225 patients (n=87 from NP28761 and n=138 from NP28673); baseline characteristics were similar to each study population, with most patients being non-smokers, <65 years old with ECOG performance status 0/1. Median follow-up was 27.7 weeks. Fifty patients had measurable CNS disease at baseline (MD) while a further 85 had non-measurable disease (NMD) at baseline; both groups together (M+NMD) comprised 135 patients, 60% of the overall study population. In the MD group, 34 patients (68%) had received prior radiotherapy, but 24 of them had completed that radiotherapy >6 months prior to starting alectinib. For the M+NMD group, 94 patients (70%) had received prior radiotherapy, with 55 completing this >6 months prior to starting alectinib. In the MD group, 30/50 patients had a CNS response (60.0%; 95% CI 45.2–73.6%), with 7 complete responses (CR; 14.0%) and a CNS DCR of 90.0% (78.2–96.7%). In the M+NMD group, 22 additional patients had a CR (29/135; 21.5%), giving a CNS ORR of 38.5% (30.3–47.3%), with a CNS DCR of 85.2% (78.1–90.7%). Complete responses were seen in patients with and without prior radiotherapy. Median CNS DOR after only 17% of events in both groups was 7.6 months (5.8–7.6) in the MD group (n=30) and 7.6 months (5.8–10.3) in the M+NMD group (n=52), which is similar to the systemic DOR reported in both studies (Ou et al, ASCO 2015; Gandhi et al, ASCO 2015). Tolerability was also similar to the overall study population.

Conclusion:
Alectinib showed promising efficacy in the CNS in ALK+ NSCLC patients previously treated with crizotinib, achieving a complete response rate of 22% and a DCR of 85%, irrespective of prior radiotherapy. The CNS response was sustained for an equivalent duration to the systemic response, suggesting that alectinib could provide an effective treatment for patients with ALK+ NSCLC while actively targeting CNS metastases. The ongoing phase III clinical studies will assess the systemic and CNS efficacy of alectinib versus crizotinib as front-line therapy for ALK+ NSCLC patients.

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.

Background:
Overcoming acquired resistance in ALK+ and ROS1+ non-small-cell lung cancer (NSCLC) patients (pts) is key to optimizing therapy. PF-06463922 is a selective, brain-penetrant tyrosine kinase inhibitor (TKI) with demonstrated clinical activity against de novo fusions as well as resistance mutations, including ALK G1202R, that arise during treatment with other TKIs.

Methods:
In this ongoing phase I study, eligible pts had ALK+ or ROS1+ NSCLC, with or without brain metastases, and were treatment naïve or had disease progression after at least 1 prior TKIs. Pts with central nervous system (CNS) metastases, including untreated asymptomatic metastases, were eligible. Tumor tissue (archival sample or de novo biopsy) was required for enrollment. A modified continual reassessment method was used to estimate the maximum tolerated dose (MTD) and select a recommended phase II dose (RP2D). Once- (QD) or twice-daily (BID) dosing in 21-day cycles was explored. Secondary objectives included efficacy, safety, tolerability, pharmacokinetics (PK), effect on cognitive function, patient-reported outcomes, potential to induce/inhibit CYP3A4, biomarkers of drug response and resistance, and intracranial antitumor activity.

Results:
25 ALK+ pts (20 with CNS metastases, 23 previously treated with at least 1 ALK TKIs) and 5 ROS1+ pts (3 with CNS metastases, 3 previously treated with crizotinib) have been enrolled across 7 QD dose levels and 2 BID dose levels. Of 21 patients evaluable for intracranial response, 16 had stable disease or confirmed complete/partial response. The most common treatment-related adverse events (AEs) were hypercholesterolemia, peripheral neuropathy, and peripheral edema, occurring in 47%, 27% and 23% of pts, respectively. Peripheral neuropathy was reversible following treatment delay or dose reduction. The most common grade 3 and higher treatment-related AE was hypercholesterolemia, occurring in 10% of pts, which was well managed with statins. One DLT was reported for a pt at 200 mg QD, who received less than 16 of the 21 planned doses of study drug due to grade 2 CNS effects. To date, 20 pts remain on treatment. Preliminary PK analyses suggest that exposure increased linearly from 10 to 75 mg QD, with a terminal half-life of 20-28 hrs. At doses beyond 75 mg QD, the increase in exposure appeared to be non-proportional. PF-06463922 is considered a moderate inducer of CYP3A4.

Conclusion:
PF-06463922 is a potent ALK/ROS1 TKI that has demonstrated clinical activity in ALK+ and ROS1+ NSCLC pts, most of whom had CNS metastases and had received at least 1 prior TKI. The RP2D has not yet been established.

Abstract not provided

Background:
In patients operated on for non-small cell lung cancer, several guidelines recommend a follow-up based on regular clinic visits and chest CT-scans. However, evidence to support these recommendations is poor, in the absence of randomized data. The IFCT-0302 trial is a randomized multicenter trial which compared 2 follow-up programs after complete resection for a clinical stage I, II, IIIA and T4 (pulmonary nodules in the same lobe) N0-2 NSCLC (TNM 6[th] edition). We present the results of compliance with the follow-up programs for the first 2 years after randomization.

Methods:
In the CXR arm, follow-up consisted of clinic visit and chest X-rays. In the CCT arm, patients underwent clinic visit, chest X-rays, thoraco-abdominal CT scan plus fiberoptic bronchoscopy (only mandatory for squamous cell and large cell carcinomas). In both arms, procedures were repeated every 6 months after randomization during the first 2 years, and yearly until 5 years, in the absence of recurrence or second primary cancer. Supplementary procedures were allowed in case of symptoms. Primary endpoint was overall survival.

Results:
Between January 2005 and November 2012, 1775 patients were randomized (CXR: 888; CCT: 887). Patient characteristics were well balanced between the two arms : males 76.3%, median age 62 years (range: 33-87), adenocarcinomas 56.7%, stage I-II 82.1%, lobectomy or bilobectomy 86,8%, pre- and/or post-operative radiotherapy 8.7%, and pre- and/or post-operative chemotherapy 45%. Surveillance was performed in 97% of patients at 6 months, in 94% at 12 months, in 90% at 18 months and in 84% at 24 months, and did not differ between the 2 arms. Intervals between randomization and visits were respected with no difference between arms (mean +/-SD in months from randomization: 5.93 +/- 0.84; 11.95 +/- 0.98; 18.05 +/- 0.99; 24.18 +/-1.30, respectively). In the 757 patients of the CXR arm, who had a follow-up visit at 6 months and no recurrence, 754 (99.6%) had a clinic visit and 730 (96.4%) a chest X-ray. In the 706 patients of the CCT arm who had a follow-up visit at 6 months and no recurrence, 702 (99.4%) had a clinic visit, 478 (67.7%) a chest X-ray, 678 (96%) a chest CT-scan, and 342 (48.4%) a bronchoscopy. Comparable compliance results were observed at 12, 18 and 24 months. In the CXR arm, supplementary thoracic CT-scans were done in 119 patients (15.7 %) at 6 months, in 96 (14.4 %) at 12 months, in 78 (13.2%) at 18 months and in 58 (11.4%) at 24 months. Other supplementary procedures were more frequent in the CCT arm than in the CXR arm, consisting mostly of brain imaging (at 6 months, in 93 (13.2%) and 39 (5.2%) patients, respectively, p<.001).

Conclusion:
Compliance with the follow-up programs was excellent in terms of timing. Chest X-ray was often omitted in the CCT arm. In the CXR arm, supplementary CT-scans that did not lead to a diagnosis of recurrence or second primary cancer were performed in 10 to 15% of patients. In the CCT arm, the most frequently performed supplementary procedure was brain imaging.

Background:
The NCCN surgical resection guidelines for non-small cell lung cancer (NSCLC) recommend lobectomy or greater extent of resection, negative margins, and examination of lymph nodes from the hilum, and 3 or more mediastinal stations. We sought to determine the impact of these guidelines on patients’ long-term survival.

Methods:
We conducted a retrospective review of patient-level data from all curative-intent NSCLC resections at 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi, and Western Tennessee from 2004 to 2013. Following a descriptive analysis of the cohort, we used a Cox proportional hazard model to assess the overall survival impact of attaining the NCCN guidelines. All models were adjusted for patient age and pathologic stage.

Results:
Of the 2,410 eligible resections, 314 (13.1%) were sub-lobar, 86.9% were lobectomy or greater; 90.2% had negative margins, 5.8% had positive margins, 4% unknown margin status; 73.2% had hilar nodes sampled; but only 25.9% of surgeries had three or more mediastinal nodal stations sampled. Overall, although only 18% of surgeries met all four criteria, there was a significant increasing trend from 4% in 2004 and 12% in 2009, to 39% in 2013 (p<0.001). Patients whose surgery met all four criteria had a 23% survival benefit compared with those who did not (Hazard Ratio [HR]: 0.77, 95%CI: 0.64-0.94, p=0.009). Patients with negative margins had 15% survival benefit compared to those with positive margins (HR: 0.85, 95%CI: 0.66-1.08, p=0.18); those with lobectomy or greater resection had a 14% survival benefit over those with sub-lobar resection (HR: 0.86, 95%CI: 0.70-1.04, p=0.12); those with hilar node sampling had a 3% survival benefit (HR: 0.97, 95%CI: 0.83-1.13, p=0.68); and those with three or more mediastinal stations examined had a 17% survival benefit over those without (HR: 0.84, 95%CI: 0.71-0.98, p=0.03). Figure 1



Conclusion:
Although only 18% of NSCLC resections in this cohort from a high lung cancer mortality region of the US met all four NCCN good-quality surgical resection criteria, the rate of quality attainment has significantly increased during the past decade. Patients whose resections met NCCN quality criteria had a substantially survival benefit, which is particularly driven by the recommendation for sampling of ≥3 mediastinal nodal stations. Intraoperative mediastinal lymph node retrieval should be a focus of quality improvement for NSCLC resections.

Background:
The MAGRIT study was a worldwide, multicenter, phase-3 double-blind, randomized trial evaluating efficacy of the MAGE-A3 Cancer Immunotherapeutic in resected non-small cell lung cancer (NSCLC) (www.clinicaltrials.gov NCT00480025). We examined baseline patient and disease characteristics associated with overall survival (OS) and disease-free survival (DFS) among patients assigned to placebo.

Methods:
Study participants were ≥18 years, with histologically proven, MAGE-A3-positive stage IB, II or IIIA NSCLC (AJCC 6.0). Participants had undergone complete anatomical resection of the tumor (lobectomy or pneumectomy) with mediastinal lymph node (LN) dissection or sampling according to standard of care. Up to four cycles of platinum-based adjuvant chemotherapy were allowed. Cox regression models were used to explore characteristics that could predict DFS and OS. Factors statistically significant in univariate analysis (p<0.05) were included in multivariate models using a stepwise approach (p<0.05 to enter/remain in the model).

Results:
There were 757 placebo patients in the total treated population; median age 63 years, 76% male, 53% with squamous cell carcinoma (SCC), 34% with adenocarcinoma, 98% with performance status 0-1, 52% had received adjuvant chemotherapy.In univariate analyses, SCC, lower N-category and earlier disease stage were associated with improved DFS. Lower N-category, earlier stage and smaller tumor size were associated with improved OS. In multivariate analysis, N-category (HR 1.34, 95%CI [1.16-1.55]) and histological type (HR for SCC vs non-SCC 0.64, 95%CI [0.51-0.81]) remained significant for DFS. N-category (HR 1.47, 95%CI [1.21-1.79]) and tumor size (HR by unit increase 1.08, 95%CI [1.01-1.15]) did so for OS. No association was found between DFS or OS and age, gender, race, region, baseline performance status, quantitative MAGE-A3 expression, chemotherapy administration or type of chemotherapy, smoking status or type of LN sampling (minimal/systematic). Among patients with SCC, univariate analysis identified increased number of chemotherapy cycles and operative technique (pneumectomy) as associated with improved DFS (p<0.05). Only operative technique remained in the multivariate model. When including N-category (p<0.10 in univariate analysis) in the multivariate model, N-category and number of chemotherapy cycles were also selected. Lower N-category and smaller tumor size were significantly associated with improved OS, in univariate and multivariate analyses. Among patients with non-SCC, univariate analysis identified younger age, being female, lower N-category and earlier disease stage with improved DFS, and lower N-category, earlier disease stage and region (East Asia) with improved OS. N-category and gender, and N-category and region remained significant in the multivariate analysis for DFS and OS, respectively.

Conclusion:
This is the first prognostic factor analysis in resected NSCLC performed on data from a large, prospective randomized study. It highlighted that in terms of DFS, SCC patients have a better prognosis than non-SCC patients. N-category plays a major role in determining prognosis. Operative technique (pneumectomy), number of chemotherapy cycles (SCC) and gender (non-SCC) are also associated with outcome. Variables predictive for OS are N-category and tumor size (all) and region (non-SCC). These results confirm retrospective studies done within the context of TNM classification, but add that histopathology subtype is a strong determinant for DFS in resected NSCLC.

Abstract not provided

Background:
Variation in the thoroughness and accuracy of pathologic lymph node (LN) staging may contribute to within-stage variation in survival after curative-intent resection of non-small-cell lung cancer. Accurate staging mandates effective collaboration between surgeons and pathologists. ACOSOG Z0030 tightly controlled surgeon practice, but not pathology practice. We tested the impact of the thoroughness of pathologic examination (using the number of examined LNs as a surrogate) on detection of LN metastasis and survival.

Methods:
We reanalyzed the mediastinal LN dissection arm of ACOSOG Z0030, using linear regression to examine the clinical and demographic factors associated with LN count, Cox proportional hazards models to determine the association between the number of LNs examined and survival of patients with pN0 and pN1 disease, and logistic regression to determine association of number of LN examined and the discovery of unexpected N2 LN metastasis. Overall (OS) and recurrence-free survival (RFS), were analyzed without and with adjustment for T-category.

Results:
The 524 patients, had a mean age of 66.8 years, and were 52% male. Forty-four percent had adenocarcinoma, 27% squamous, 4% large cell, and 25% ‘other’ histology; 96% had T1/2 disease. Four hundred and thirty-nine (84%) were pN0, 63 (12%) pN1, and 21 (4%) pN2. In patients with pN0, pN1, and pN2 respectively, the mean number of mediastinal LNs examined was 13.5, 12.9, and 17.4; station 10 LNs were 2.4, 2.7, and 2.5; station 11-14 LNs were 4.6, 6.2, and 6.2; total LNs (from all stations) were 19.7, 21.3, 25. Tumor histology and pN-category were the only factors associated with the number of LNs examined: patients with squamous histology tended to have the most number of non-hilar N1 LNs examined (p<0.001); patients with pN1/N2 had more non-hilar N1 nodes than those with pN0 (p=0.005); those with pN2 had more N2 nodes examined than those with pN0 or pN1 (p=0.085). There was a consistent association between the number of LNs examined and survival. Patients with pN0 had better OS (HR 0.96; p=0.12) and RFS (HR 0.97; p=0.2) with examination of more non-hilar nodes; patients with pN1, had better OS and RFS with increased examination of LNs from N2 (OS HR=0.96, p=0.059; RFS HR=0.95, p=0.03) and all stations (OS HR=0.97, p=0.048; RFS HR=0.96, p==0.012). Adjustment for T-category strengthened these relationships between the number of LNs, pN-stage and survival. The likelihood of discovering N2 disease was associated with increased examination of LNs from mediastinal (odds ratio=1.04; p=0.035) and all stations (OR=1.03; p=0.035).

Conclusion:
Despite uniformly thorough surgical hilar/mediastinal LN harvesting, the number of LNs examined was associated with the likelihood of detecting nodal metastasis, and survival. Patients with more LNs examined were more likely to have LN metastasis, examination of more LNs was associated with better survival in patients within the same pN-category. This may indicate an effect of variable thoroughness in pathologic examination processes on the accuracy and prognostic value of the pathology nodal staging system. Heterogeneity in the cancer immune response may be an alternative hypothesis to explain these findings.

Background:
The 60,000 patients who annually undergo curative-intent resection for lung cancer in the US constitute the vast majority of long-term NSCLC survivors. However, >50% of patients die within 5 years after curative-intent resection. We sought to directly measure the effect of variability in surgeon practice on patients’ survival.

Methods:
We collected patient-level data from all NSCLC resections performed in 8 mid-south hospitals from 2009 to 2013. Recipients of preoperative adjuvant therapy were ineligible. We grouped surgeons by their resection proportions for pneumonectomy and wedge resection, resections with positive margins, and resections without mediastinal lymph nodes. We assigned scores of 1 = <5%, 2 = 5-15%, and 3 = ≥ 15% for pneumonectomy and wedge resection rates; 1 = <5%, 2 = 5-10%, and 3 = ≥ 10% for resections with positive margins; 1 = < 10%, 2 = 10-50%, and 3 = ≥ 50% for resections without mediastinal lymph node examination. The individual scores were then combined for an aggregate surgeon score. Surgeons were then grouped into three tiers: 1 =≤6, 2 = 7-8, and 3 = ≥9. A survival analysis was conducted for patients aggregated by surgeon score tier, adjusted for patient race, gender, and age at surgery, pathologic stage, and surgeon’s case-volume.

Results:
1,339 resections were performed by 39 surgeons: 17 surgeons (43.6%) in tier 1(aggregate score ≤ 6) operated on 623 patients (44.5%); 14 surgeons (35.9%) in tier 2 operated on 669 patients (47.8%); and 8 surgeons (25.5%) in tier 3 operated on 107 patients (7.65%). Figure 1 plots the Kaplan – Meier survival curve for patients in each surgeon tier. Tiers 2 and 3 patients had significantly higher hazard rates than tier 1 patients, with Hazard Ratio (HR)=1.76, 95%CI: 1.17, 2.64, p=.007 and HR=1.39, 95%CI: 1.11, 1.75, p=.004, respectively. Hazard rates between patients in surgeon tiers 3 and 2 were not significantly different, HR=1.26, 95%CI: 0.87, 1.82, p=.221. Figure 1



Conclusion:
We have developed a simple method of measuring the effect of variability in surgeon practice on patient outcomes. Patients who had resection by surgeons with lower rates of pneumonectomy and wedge resections, positive margins, and non-examination of mediastinal lymph nodes show improved survival over patients operated by surgeons with higher rates. Deficiency in attaining these quality parameters can be corrected at the individual surgeon level. Surgeon-level corrective interventions are warranted.

Background:
The survival impact of incomplete resection of NSCLC has never been systematically quantified, nor has the value of postoperative adjuvant therapy in this situation. Current clinical practice guidelines are based on single-institutional retrospective studies with few patients. The studies have contradictory findings about the survival impact of non-R0 resection and the benefit of adjuvant therapy.

Methods:
We analyzed pathologic stage I-IIIA NSCLC resections in the National Cancer Data Base from 2004 to 2011 to determine clinical, socio-demographic and institutional factors associated with margin involvement using multivariate logistic regression models. We compared the survival of patients with and without positive margins and evaluated the impact of postoperative adjuvant therapy, using proportional hazards models.

Results:
Of 112,998 resections over 8 years, 5335 (4.72%) had positive margins. This population represents >4-fold the sum of all previous English-language publications on margin-positive resections. The annual incomplete resection rate was stable over the 8-year time-span, ranging between 4.38% and 5.23% (trend-test p=0.07). Patient demographic and clinical factors associated with increased adjusted odds ratio (aOR) of incomplete resection included black race (p=0.006), age-based Medicare insurance (p=0.006), urban residence (p=0.01), squamous histology, high tumor grade, tumor overlapping more than 1 lobe, tumor location in the main bronchus, and advanced pathologic stage (p < .001 for all clinical factors). Surgery performed at Community Cancer Programs (p=0.002), institutions with high proportions of underinsured patients (p=0.01), and institutions with lower cancer resection volumes (p=0.006), also had increased aOR. The crude 5-year survival rate of patients with complete v incomplete resection was 58.5% v 33.8% (p < 0.001). The survival difference persisted when patients were stratified by tumor size, T-category and aggregate American Joint Committee on Cancer stage. The survival curve of patients with margin-positive stage I disease overlapped that of patients with completely resected stage II. Patients with incompletely resected stage II disease had worse survival than those with completely resected stage III disease. The survival detriment was consistent at 1, 3, and 5 years. After incomplete resection, adjuvant chemotherapy was associated with improved 5-year survival across all stages (p<0.01); radiotherapy was associated with worse survival in stage I patients (p<0.001), and had no significant impact in patients with stage II and III disease; chemo-radiation therapy had no significant impact in patients with stage I, but was associated with improved survival in patients with stage II and III disease (p<0.001).

Conclusion:
Margin involvement significantly impaired survival after NSCLC resection, irrespective of stage. Causative institutional and provider practices should be identified, to minimize this adverse outcome. Postoperative adjuvant chemotherapy mitigated the mortality risk independently of stage, whilst postoperative radiotherapy exacerbated the risk in patients with stage I disease, and chemoradiation therapy was associated with improved survival in patients with stage II and III disease. These findings need validation in prospective clinical trials.

Abstract not provided

Background:
Surgical resection is the standard treatment for early stage Non-Small Cell Lung Cancer (NSCLC). Anatomical resection with lymphadenectomy is recommended in surgically treated patients with Stage I-IIIA NSCLC. Whether mediastinal lymph node dissection (MLND) or mediastinal lymph node sampling (MLNS) should be performed remains controversial, and there is currently no consensus within the literature. We describe surgical approaches and patterns of disease recurrence in patients enrolled in MAGRIT: a large global randomized study of the MAGE-A3 Cancer Immunotherapeutic versus placebo after complete tumor resection (Phase III trial, MAGRIT, NCT00480025).

Methods:
Study participants were aged ≥18 years, with histologically-proven, MAGE-A3-positive Stage IB, II or IIIA NSCLC (AJCC 6.0) who had undergone R0 anatomic resection of their tumor (lobectomy or pneumonectomy) with mediastinal lymphadenectomy. Patients were randomized to MAGE-A3 or placebo in a 2:1 ratio. A total of 2,272 patients were treated at 556 centers in 34 countries. Because MAGRIT did not demonstrate efficacy overall, and because the number of recurrences in the placebo arm was small (n=271), recurrence patterns by surgical technique are presented in the overall population. An analysis of the placebo population was also conducted as the overall population results are subject to potential bias (a limited treatment effect in small sub-groups cannot be excluded). Cox regression models were used to explore whether lymphadenectomy procedure could be prognostic for disease-free survival (DFS) or overall survival (OS).

Results:
In the total treated population, 76% were men, 52% had squamous cell carcinoma, and 52% received adjuvant chemotherapy. More than half (57%) of patients were enrolled in Europe, with 23% in East Asia, 16% in North America and 4% in other countries. 47% of patients had Stage IB, 6.5% IIA, 30% IIB, and 17% IIIA disease. Lobectomy (including bi- and sleeve-lobectomy) was performed in 85% of patients, and 14% required pneumonectomy. MLNS was performed in 53% and MLND in 47% of patients. MLNS and MLND patients had a similar disease stage distribution. By region, the percentage of patients who underwent MLNS was: 36% in Europe, 65% in East Asia, 94% in North America and 59% in other countries. Among patients who had undergone MLNS or MLND, 37% (n=447/1202) and 36% (379/1067) developed recurrent disease, respectively. Loco-regional recurrence was observed in 40% (177/447) of patients after MLNS and 31% (118/379) after MLND, with distant recurrence observed in 55% (244/447) and 64% (244/379), respectively. There was no difference in the pattern of distant metastases between patients who had MLNS or MLND. Cox modeling showed no impact of the extent of lymphadenectomy on either DFS or OS. A separate analysis of patients in the placebo arm demonstrated similar trends to those of the total study population.

Conclusion:
Lobectomy (including bi- and sleeve-lobectomy) was the most frequently used treatment for patients who participated in the MAGRIT study. Important regional differences in lymphadenectomy were observed. Although the patterns of recurrence varied to some extent with the type of lymphadenectomy, our study did not demonstrate any prognostic impact related to the type of lymphadenectomy performed.

Background:
A previous study of the Society of Thoracic Surgeons database showed that non­-anatomic resection had lower perioperative morbidity than segmentectomy for non­-small cell lung cancer (NSCLC); however the study lacked long­ term outcomes. We tested the hypothesis that segmentectomy for stage T1a N0 NSCLC had better long-­term survival than wedge resection using the U.S. National Cancer Data Base (NCDB).

Methods:
Perioperative outcomes and overall survival (OS) of patients with clinical T1a N0 NSCLC who underwent wedge resection or segmentectomy in the NCDB from 2003-­2011 were assessed using propensity­-score-­matched analysis. Groups were matched for common prognostic co­variates (year of diagnosis, race, sex, age, education, income, insurance status, facility type, distance from facility, Charlson/Deyo co­morbidity score, tumor size and location). Additional propensity-­matched analyses were performed on patients with tumors ≤ 1 cm, patients with no comorbidities, and patients with pathologic T1a pN0 disease.

Results:
Of 40,058 clinical stage T1a N0 NSCLC patients, wedge resection and segmentectomy were performed in 7,517 (19%) and 1,268 (3%) patients, respectively. After matching, all baseline covariates, including comorbidity scores, were balanced between the wedge (n=1,231) and segmentectomy (n=1,231) groups. There were no significant differences between wedge and segmentectomy regarding 30-day mortality (1.6% [n=20] vs 1.5% [n=18], p=0.94). However, wedge was associated with significantly lower long-term survival than segmentectomy (Figure 1); this finding remained consistent even in a propensity-matched analysis of patients with tumors ≤ 1 cm (5 year OS: 56.8% [wedge] vs 78.2% [segmentectomy], log-rank p<0.01). To minimize treatment selection bias due to comorbidities, a propensity-matched analysis was also performed between wedge (n=509) and segmentectomy (n=509) for patients without comorbidities; wedge resection was associated with worse survival when compared with segmentectomy (5 year OS: 65.5% vs 69.5%, log-rank p<0.01). An additional propensity-matched analyses demonstrated that wedge (n=1,099) was associated with worse survival when compared with segmentectomy (n=1,099) for patients with pathologic T1a pN0 disease (5 year OS: 56.8% vs 65.5%, log-rank p<0.01).Figure 1



Conclusion:
In an analysis of a population-­based dataset, a large proportion of patients was found to have received wedge resection for stage T1a N0 NSCLC. Segmentectomy for T1a N0 NSCLC had similar 30­-day mortality but improved long-­term survival when compared to wedge resection, even for patients with very small tumors ≤ 1 cm, for patients with no comorbidities and for patients with pathologic T1a pN0 disease.

Background:
Stereotactic ablative radiotherapy (SABR) is a guideline-recommended therapy for unfit patients with early stage non-small cell lung cancer (NSCLC), and for pulmonary metastases. Experience with SABR for potentially operable patients is also increasing, and salvage surgery may have a role in patients who subsequently develop a local tumor recurrence. However, prior high-dose SABR could theoretically increase local adhesions and compromise wound healing. As the published literature is limited, we describe our experience with salvage surgery in 17 patients who developed a local recurrence after SABR.

Methods:
Patients who underwent surgical salvage for a local recurrence following SABR for pulmonary malignancies were identified from two Dutch institutional databases, as well as cases provided by other Dutch surgeons. Complications were scored using the Dindo-Clavien-classification.

Results:
Seventeen patients who underwent surgery for a local recurrence were identified. Patients were treated with SABR for either primary non-small cell lung cancers (N=9) or solitary metastasis (N=8). Four patients with solitary metastasis underwent surgery twice each for separate recurrences. Median time to local recurrence was 15.6 months. Recurrences were diagnosed with CT- and/or [18]FDG-PET-imaging, with 5 patients also having a pre-surgical pathological diagnosis. Extensive adhesions were observed during 5 resections, requiring conversion from a thoracoscopic procedure to thoracotomy in 3 procedures. Four patients experienced complications post-surgery; grade 2 (N=2) and grade 3a (N=2), respectively. All resected specimens confirmed the presence of viable tumor cells. Median length of hospital stay was 7 days (range 4-15 days) and 30-day mortality was 0%. Lymph node dissection revealed mediastinal metastases in 3 patients, all of whom received adjuvant therapy. Median follow-up after surgery was 41 months and median overall survival was 38 months.

Conclusion:
Experience with 21 surgical procedures for local recurrences post-SABR revealed only two grade IIIa complications, and a 30-day mortality of 0%. Median overall survival after surgery was 38 months. These results suggest that salvage surgery may be safely performed in selected patients following SABR.

Abstract not provided

Background:
Comparison of long-term survival of patients with clinical Stage I non-small-cell lung cancer (NSCLC) with and without mediastinal lymph node resection (MLNR) in the International Early Lung Cancer Action Program, a large prospective cohort in a low-dose CT screening program.

Methods:
All instances of thoracic surgery for first solitary primary non-small-cell lung cancer prompted by low-dose CT screening, performed under an IRB approved common protocol at each of the participating institutions since 1992 to 2014, are included. Follow-up time was calculated from diagnosis to death from lung cancer, last contact, or December 31, 2014, whichever came first. Univariate logistic regression analysis of the demographic, CT, and surgical findings for those with and without MLNR was performed. Kaplan-Meier (K-M) survival rates and Cox regression analysis was performed using all significant univariate variables.

Results:
The 10-year Kaplan-Meier (K-M) NSCLC-specific survival rate for the 225 patients manifesting as a subsolid nodule was 100%, regardless of whether they had MLNR (N = 169) or not (N = 56). For the 373 NSCLC patients manifesting as a solid nodule, for those who had MLNR (N = 285) and those who did not (N = 88), the K-M NSCLC-survival rate was not significantly different (86 % vs. 93%, P = 0.23). The rate was 95% vs. 96% (P = 0.86) for those whose pathologic tumor diameter was <= 10 mm; 83% vs. 94% (P = 0.19) for 11-20 mm, and 79% vs. 86% (P = 0.67) for 21-20 mm. Cox regression analysis comparing MLNR with no MLNR showed that survival rates were not significantly different (P = 0.33), but significantly survival decreased when the tumor diameter was above 20 mm (HR= 5.1, 95% CI: 1.6-15.7).

Conclusion:
Lymph node evaluation is not necessary for resection of subsolid nodules in patients with screen-detected lung cancer.

Background:
Precise preoperative diagnosis of the in-situ or minimally invasive carcinomas may identify patients that can be treated by limited resection. Though some clinical trials of limited resection for lung cancer have started, it will take much time to get results. We have reported a large scale data of limited resection at the previous WCLC meeting. We report here the data of subclass analysis according to the differences of pathology.

Methods:
Data from multiple institutions was collected on 1,737 patients who had undergone limited resection (segmentectomy or wedge resection) for cT1N0M0 non-small cell carcinoma. As 11 patients without pathological diagnosis were excluded, 1726 patients were analyzed to determine the indication of limited resection in pathological differences. Disease free survival (DFS) and recurrence free proportion (RFP) were analyzed.

Results:
Median age was 63 years. Mean maximal diameter of the tumors was 1.4 ± 0.5 cm. DFS and RFP at 5 years were 91.0 % and 93.6 %, respectively. DFSs and RFPs at 5years in pathology were 92.2% and 94.7% in adenocarcinoma (n=1575), 76.3% and 82.4 % in squamous cell carcinoma (SqCC) (n=100), 100% and 100% in carcinoid (n=16), and 73.6% and 75.9 % in others (n=35). Adenocarcinomas were classified using 2 factors, the ratio of consolidation and tumor diameter (C/T) and tumor diameter into 4 groups, group A (C/T ≤ 0.25 and tumor diameter ≤ 2.0 cm), group B (C/T ≤ 0.25 and tumor diameter > 2.0 cm), group C (C/T > 0.25 and tumor diameter ≤ 2.0 cm), and group D (C/T > 0.25 and tumor diameter > 2.0 cm). DFSs and RFPs at 5 years were 96.7% and 98.8% in group A, 100% and 100% in group B, 89.2% and 92.3% in group C, and 76.7% and 77.8% in group D. In all groups of adenocarcinoma, the prognosis in patients who underwent segmentectomy was not superior to wedge resection.The prognosis in both groups A and B was good. These groups seemed to be good candidates of limited resection. The prognosis of group D were not good. Group D seemed not to be a good candidate of limited resection. Prognosis of group C was not bad, however, we could not conclude indication in group C because group C included both part solid tumors and solid tumors. In SqCC, tumor diameter was not prognostic factor and only segmentectomy was favorable prognostic factor (DFSs and RFPs in segmentectomy vs wedge resection: 78.2% and 85.5% vs 65.5% and 65.5%, respectively). In SqCC, there seemed to be indication of limited resection with segmentectomy. In carcinoid, all tumors except one were resected by segmentectomy. Segmentectomy for cT1 carcinoid seemed to be allowed. As prognosis in other pathologies was worse in limited resection, there seemed to be no indication of limited resection.

Conclusion:
Pathological diagnosis was important to determine the indication of limited resection. Measurement of tumor diameter and C/T was useful to determine the indication of limited resection for adenocarcinoma.

Background:
General anesthesia with intubated ventilation is the standard in thoracic surgery. However, intubated anesthesia is often associated with postoperative discomfort and related complications. Recently, non-intubated anesthesia has emerged as a new option, but has only been assessed by several small-size reports. This study is to evaluate the feasibility and safety of non-incubated video-assissted thoracic surgery (VATS) for NSCLC under combined intravenous anesthesia (spontaneous respiratory status) and to compare it with the endotracheal intubated anesthesia.

Methods:
We retrospectively collected all NSCLC cases who underwent complete VATS lobectomy or segmental resection in our center under either non-intubated or intubated anesthesia. In this study, all non-intubated anesthesia cases were performed under combined intravenous anaesthetics plus analgesics while the intubated anesthesia cases were performed using double lumen endotracheal anesthesia. All procedures were conducted by the same group of surgeons and anesthesiologists from Dec 2011 to Dec 2014. Intra-operative and post-operative outcomes were compared between the two groups.

Results:
A total of 156 non-intubated and 188 intubated cases were included for analyses (Table 1). All non-intubated segment resections and the majority of non-intubated lobectomies were well exposed and were successfully completed; only 9 non-intubated cases planned for lobectomy (9/115, 7.2%) switched to intubated anesthesia. As shown in Table 2, both non-incubated lobectomy and segmentectomy had comparable outcomes with intubated anesthesia, regarding surgical duration, intraoperative blood loss, etc., as well as post-operative complications. Potential advantages were observed when comparing post-operative feeding time, volume of postoperative pleural drainage, and duration of post-operative hospital stay. Table1. Patient Demographics and Baseline Characteristics

		Segmentectomy			Lobectomy
	Intubated	Non-intubated	P- value	Intubated	Non-intubated	P- value
Age (years)	56.5±12.3	51.2±11.8	0.115	58.9±11.7	56.5±10.3	0.179
Sex(male,%)	11(44%)	12(35.3%)	0.087	97（58.4%）	64（55.2%）	0.215
Smoking	5(25)	7（20.6%）	0.161	21（12.7%）	15（13.0%）	0.679
BMI(kg/m2)	22.7±3.1	22.1±2.2	0.412	23.0±3.5	22.6±2.5	0.316
Tumor size	1.2±0.6	1.0±0.4	0.255	2.9±1.5	2.4±1.4	0.207
stage
Ⅰ	25	32		108	87
Ⅱ	0	0	29	8
Ⅲ	0	0	26	20

Table2. Operative results

		Segmentectomy			Lobectomy
	Intubated	Non-intubated	P- value	Intubated	Non-intubated	P- value
Surgical duration(min)	149.8±38.7	157.4±40.5	0.483	186.5±57.5	186.1±56.6	0.730
Intraoperative blood loss (mL)	83.6±64.1	73.9±56.5	0.076	154.7±258.3	130.8±185.7	0.165
Conversion to intubation		0			9
Postoperative feeding time (h)	13.9±4.6	7.6±3.2	<0.001	12.9±2.2	7.2±2.5	<0.001
Volume of pleural drainage (mL)	694.8±768.2	486.9±313.8	0.038	817.7±727.2	647.7±402.0	0.023
Chest-tube dwell time (days)	4.0±6.5	2.9±2.5	0.148	3.6±2.5	3.1±1.7	0.321
Duration of postoperative hospital stay (days)	9.5±7.4	7.1±3.5	0.041	8.8±4.1	7.6±2.4	0.044
Number of dissected lymph nodes	6.6±4.7	9.5±6.2	0.408	16.5±9.4	17.1±9.0	0.574
Stations of dissected lymph nodes	2.7±3.5	3.5±1.0	0.526	4.5±1.1	4.6±1.0	0.619

Conclusion:
This large comparative study demonstrated that complete VATS for resection of NSCLC under non-intubated anesthesia is feasible and safe. Non-intubated anesthesia is comparable to intubated approaches, and might have advanteages in terms of post-operative rehabilitation. However, the comparison regarding the long-term outcome is warranted.

Abstract not provided