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D.C. Lam

Moderator of

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    CALC - Chinese Alliance Against Lung Cancer Session (ID 79)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Other Topics
    • Presentations: 15
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      Morning Tea and Chinese Poster Review (ID 3870)

      • Abstract

      Abstract not provided

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      CALC.01 - Welcome (ID 3865)

      Y. Wu, C. Bai

      • Abstract
      • Slides

      Abstract

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      CALC.02 - Keynote: Epidemiology and Burden of Smoking Related Diseases in China (ID 3866)

      C. Bai

      • Abstract
      • Slides

      Abstract
      Epidemiology and Burden of Smoking Related Diseases in China Prevalence of Smoking in China Being the largest producer and consumer of tobacco across the globe, China produces one-third (2.66 million tons/year) of the global tobacco leaves [1] and consumes 30% of the world’s cigarettes [2]. According to the Global Adult Tobacco Survey (GATS) Collaborative Group, China had the highest number of tobacco users (300.8 million) and a low quit ratio compared to 16 countries [3]. The International Collaborative Study of Cardiovascular Disease in Asia showed that 147,358,000 Chinese male and 15,895,000 Chinese female aged 35–74 years had been current cigarette smokers [4]. Regardless of gender difference, such prevalence was higher in the rural population compared to the urban population (male 61.6% vs 54.5% P <0.001; female 7.8% vs. 3.4% P<0.001) [4]. A growing prevalence of smoking was also observed in women [5], adolescents and young adults [2,6-8]. Even among non-smokers, the threat of tobacco smoke remained because airborne nicotine had been detected in 91% of the 273 public locations sampled in rural and urban China [9]. Specifically, an estimated 50-72% of Chinese non-smokers had been exposed to secondhand tobacco smoke [10,11]. Considering active and passive smoking altogether, 72% of the Chinese population were tobacco exposed [12]. Such common exposure has aggravated tobacco-related morbidity and mortality which create a direct economic burden accounting for 42.31 billion yuan [13]. By increasing mortality from cancer, respiratory disease and cardiovascular disease [14-18], smoking currently costs over 1 million Chinese lives per year. If the trend continues, a predicted sum of 2 million Chinese may die of tobacco-related diseases in 2025 [19]. COPD and Smoking Chronic obstructive pulmonary disease (COPD) had an estimated prevalence of 8.2% (>43 million) in the Chinese population > 40 years old [20] and was ranked the fourth/third leading cause of death in urban/rural area respectively [21]. Prompted by the causative roles of active [22-24] and passive smoking [25], a yet increasing prevalence of COPD would be expected in the Chinese population. In the meantime, the expensive treatments and compromised productivity of COPD patients had already created an enormous economic burden equaling to 110% and 34% of the annual incomes in rural areas and urban areas respectively [26]. Even so, the situation might have been undermined due to premature mortality and impaired working capabilities within affected families. Anti-smoking measures could be the best solution since the absolute risks of COPD would fall by 56% in Chinese male and 63% in Chinese female 5 years after smoking cessation [27]. Lung Cancer and Smoking Smoking is the main risk factor for lung cancer regardless of smoking experience (ever, current and ex smoking), tobacco product variety (pipes, cigars and cigarettes) and histological subtypes [28].\\Lee et al. demonstrated the dose-response relationship between smoking and lung cancer pathogenesis [28]. Specifically, risk of lung cancer decreased with duration of smoking cessation but increased with an earlier age of smoking and elevations in (i) the amount and fraction of smoking; (ii) duration of smoking; and (iii) tar level. Analyzing data from10 cancer registries, the crude incidence rate of lung cancer in China was estimated to be 49.35 per 100,000 population (63.7 per 100,000 men and 35.0 per 100,000 women) in 2005 [29]. Compared to lifelong non-smokers, the mortality rate of lung cancer was found to be approximately 23 times and 13 times higher in current male smokers and current female smokers respectively [30]. As prevalence of smoking rose during the past 3 decades, lung cancer mortality also increased by 464.84% [31]. Since 2008, lung cancer has surpassed other malignant tumors to become the most common cause of death in Chinese cancer patients [32]. At present, the mortality rate of lung cancer is 600,000 per year [33]. If the current trend continues, it may reach 1 million by 2025 [33]. With an increased prevalence of lung cancer and more advanced technology, the total number of lung cancer inpatients increased from 174,066 to 364,484 while medical costs increased from 2.16 billion yuan to 6.33 billion yuan between 1999 to 2005 as illustrated in the China Statistical Yearbook. Nonetheless, such dedication did not effectively prove its worth since the 5-year survival rate of lung cancer remained relatively low (10% - 14%) [34]. To relieve the socioeconomic burden, measures should be taken to reduce the incidence of lung cancer and relevant medical costs. CAD and Smoking Smoking has been associated with increased risk of coronary artery disease (CAD). In China, the reported crude odd ratio varied between 1.37 - 5.19 in former and current smokers [35-38]. In a study about risk ratio for CAD mortality, former smokers and current smokers had a risk ratio of 0.68 and 1.81 respectively when compared to never smokers [37]. Nonetheless, such figures bore no significant difference if stratified by co-morbidity of diabetes. Perhaps not surprisingly, passive smoking was verified to independently increase the risk of cardiovascular heart disease (CHD) by 25% - 30% [39,40]. While the prevalence of coronary artery disease (CAD) have fallen in developed countries through control of preventable risk factors, China witnessed an opposite trend as CAD climbed from the fifth most common heart disease in 1948-1957 to the most common in 1980-1989 [41]. As reported, CAD caused 51.4% and 32.8% of mortality related to cardiovascular disease (CVD) in urban and rural areas respectively. Projected from 1990, 72.7 million Chinese male and 72.1 million Chinese female will have been diagnosed with CAD in 2020 [42]. Smoking, one of the modifiable risk factors of CAD, should be tightly controlled in China if the socioeconomic burden has to be alleviated. Conclusion COPD, lung cancer and CAD are common smoking related chronic diseases which occupy a large share of medical resources yet cost a massive number of lives in China. In order to improve the current situation, smoking cessation should be reinforced in China through introduction of effective measures supported by favorable policy. Reference 1. Wang H. Tobacco control in China: the dilemma between economic development and health improvement. Salud Publica Mex. 2006; 48(Suppl. 1): S140–7.

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      CALC.03 - Pathogenesis and Pathology of Never Smoking Lung Cancer (ID 3867)

      A.F. Gazdar, C. Zhou

      • Abstract
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      Abstract
      Lung cancer (LC) is the leading cause of cancer deaths in the world. While smoking is universally accepted as the major cause of lung cancer in tobacco users, lung cancer in lifetime never smokers (LCNS) is among the 10 major causes of cancer deaths. LCNS is a very different disease than LC arising in ever smokers (LCES), and these differences are discussed in this Abstract. Because LCNS is highly influenced by gender and ethnicity, we put special emphasis on LCNS arising in East Asians. The reader is referred to several recent review articles on this subject [1-5] Etiology: Unlike LCES, the etiology of LCNS is not fully elucidated. The suspected factors include exposure to environmental tobacco smoke (ETS), exposure to industrial or domestic carcinogens including coal smoke and volatile cooking oils, radon exposure, viruses including HPV, and genetic factors. While these factors may individually or in combination contribute to the pathogenesis of LCNS, none of them is likely to be the major causative factor. Further investigation of causation is required. Clinico-patholgoical differences. While adenocarcinoma is the predominant form of NSCLC, the vast majority of LCNS are of adenocarcinoma histology, or large cell carcinomas (which may represent poorly differentiated adenocarcinomas). Squamous cell histology is rare and small cell carcinomas almost never occur. A retrospective study from Singapore identified significantly better performance status, younger age at diagnosis, and higher proportion of females (68.5% vs. 12-13%) and more advanced stage at diagnosis in never smokers compared with current and former smokers [6]. The disease stage variation at diagnosis might be explained by late presentation of symptoms and delayed diagnosis by physicians. The survival outcome of never smokers was significantly better than smokers, with the 5-year overall survival rate of LCES, respectively [6]. The differences in the treatment response and survival outcome between never smokers and smokers with lung cancer may be attributed to the differences in molecular pathogenesis and tumor biology (see below). Genetics: While lung cancer prone families have been well described, the risk of affected subjects is greatly increased after smoke exposure. Recently the interest has focused on single nucleotide polymorphisms (SNPs). Genome wide association studies (GWAS) identified a locus in chromosome region 15q25 that was strongly associated with lung cancer. The association region contains several genes, including three that encode nicotinic acetylcholine receptor subunits [7]. Such subunits are expressed in neurons and other tissues, including alveolar epithelial cells, pulmonary neuroendocrine cells and lung cancer cell lines, and they bind to potential lung carcinogens. Thus variants in this region undoubtedly code for increased susceptibility to smoke and are unlikely to be associated with LCNS. Not unexpectedly, GWAS studies indicate different patterns of susceptibility for Asians and never smokers and possibly related to gender [8, 9]. Molecular differences: The molecular differences between LCES and LCNS show marked differences and characteristic patterns. While TP53 mutations are common to all types of lung cancer, the mutational spectra are very different [10]. KRAS mutations are largely limited to LCES, and, along with TP53, show the typical smoking associated characteristic G to T transversions. In addition, the total numbers of non-synonymous and synonymous mutations in LCES tumors are much higher than that in LCNS, indicating that tobacco exposure results in in widespread genomic instability. Paradoxically, some of the most responsive currently available or potential molecular targets for precision medicine are more frequent in never smokers, including EGFR, BRAF and HER2 mutations and ALK translocations. Therapeutic options and precision medicine: While the overall treatment strategy is the same for LCES and LCNS, the differences in molecular profiles dictate differences in precision medicine and, response to targeted agents and overall survival. These factors are also influenced by gender and ethnicity. For instance, one study found that the frequency of driver mutations (EGFR, HER2, ALK, KRAS, or BRAF) in lung adenocarcinoma from female never-smokers in China was over 87% [11]. Summary: The differences between LCES and LCNS are major, and cover etiologic factors, clinic-pathological changes, genetic susceptibility genes, mutational and molecular changes and precision medicine. These differences are vast enough so that we can regard lung cancers arising in ever and never smokers as two different diseases. References: 1. Rudin CM, Avila-Tang E, Harris CC, et al. Lung cancer in never smokers: molecular profiles and therapeutic implications. Clin Cancer Res 2009;15(18):5646-61. 2. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers - a different disease. Nat Rev Cancer 2007;7(10):778-90. 3. StatBite lung adenocarcinoma in smoker vs. never smokers. J Natl Cancer Inst 2010;102(10):674. 4. Lee YJ, Kim JH, Kim SK, et al. Lung cancer in never smokers: change of a mindset in the molecular era. Lung Cancer 2011;72(1):9-15. 5. Subramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol 2007;25(5):561-70. 6. Toh CK, Gao F, Lim WT, et al. Never-smokers with lung cancer: epidemiologic evidence of a distinct disease entity. J Clin Oncol 2006;24(15):2245-51. 7. Hung RJ, McKay JD, Gaborieau V, et al. A susceptibility locus for lung cancer maps to nicotinic acetylcholine receptor subunit genes on 15q25. Nature 2008;452(7187):633-7. 8. Shiraishi K, Kunitoh H, Daigo Y, et al. A genome-wide association study identifies two new susceptibility loci for lung adenocarcinoma in the Japanese population. Nat Genet 2012;44(8):900-3. 9. Lan Q, Hsiung CA, Matsuo K, et al. Genome-wide association analysis identifies new lung cancer susceptibility loci in never-smoking women in Asia. Nat Genet 2012;44(12):1330-5. 10. Pfeifer GP, Besaratinia A. Mutational spectra of human cancer. Hum Genet 2009;125(5-6):493-506. 11. Zhang Y, Sun Y, Pan Y, et al. Frequency of driver mutations in lung adenocarcinoma from female never-smokers varies with histologic subtypes and age at diagnosis. Clin Cancer Res 2012;18(7):1947-53

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      CALC.04 - SBRT for Lung Cancer (ID 3868)

      D. Liu, M. Fan

      • Abstract
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      Abstract
      Approximately 20% of patients with NSCLC present with early stage diseases. While with the advances in imaging and the success in low-dose CT screening in high risk patients, the proportion of patients diagnosed of stage I disease may increase. Radical surgery has been well established as the primary treatment for localized disease. However, a substantial number are ineligible for resection because of comorbidities that are associated inoperable medical condition or advanced age. Conventional fractionated therapy has had disappointing outcomes for stage I NSCLC, with reported local failure rates as high as 60–70% in some series, likely due of inadequate doses. Prior dose escalation study suggested that 70 Gy in 2 Gy fractionation would predict a local-progression free survival of only 24% at 30 months, while dose of 80 to 90 Gy were needed to achieve a recurrence-free survival rate of 50%. Utilizing the advances in radiotherapy planning and tumor targeting techniques, stereotactic body radiation therapy (SBRT) using ablative-range daily doses of 7.5–30 Gy (1-8 fractions), has achieved a biologically effective dose above 100 Gy. This biological unique treatment is associated with notable increases in tumoricidal effect. Reported local control rates have been repeatedly around 90% at 3 years. There is some uncertainty equating SBRT doses and fractionations. In a recent systemic review involving 1076 patients with stage I NSCLC with a follow up of at least 30 months (15 studies), no positive dose–response relationship for tumor control was revealed within different schemes. Current dose to eradicate stage I disease might thus be overestimated. Treating central lesions with hypo-fractionated radiotherapy or SBRT at lower biologically effective doses may be justified. Survival after SBRT is, in general, worse than that after surgery in indirect comparisons, probably because of the frail nature of the patients who receive SBRT. In a population-based study, SEER data showed that even though lobectomy were associated with the best long term outcomes in fit patients with early-stage NSCLC, the survival after SBRT was similar to that after lobectomy in the propensity-score matched analysis, suggesting comparable efficacy with in select populations. Further, the introduction of SBRT reduced the proportion of stage I NSCLC patients who received no local therapy. In north Netherlands population, the application of SBRT corresponded to a 16% absolute increase in the proportion of patients receiving radiotherapy, and this shift was associated with a 6-month median survival improvement SBRT is characterized by both high conformality of the ablative dose delivered to the target, and a sharp dose gradient at the edge of the target volume. This enables possibility for the physician to minimize treatment toxicity. Rate of symptomatic pneumonitis is usually less than 20%. Common, self-limited toxicities were revealed in approximately up to 40% of patients including fatigue, cough, dyspnea and chest pain. Hemoptysis and rib fracture can occur, whereas life-threatening complications are rare. Dose constraints have been investigated for SBRT, though the basic data are now being accrued. Nevertheless, clinical factors like gender, smoking history, and larger gross PTV may equally important or even overweight dosimetric metrics. Further research is required to better understand the tolerance of normal tissues and the long term quality of life after SBRT.

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      CALC.05 - COPD and Lung Cancer (ID 3869)

      I.A. Yang

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      Abstract
      Lung cancer and COPD frequently occur together in smokers, and COPD increases the risk of developing lung cancer in at-risk individuals. Exposure to cigarette smoke is clearly the most important causative factor. Other biological mechanisms for susceptibility to both lung cancer and COPD may involve inflammation, abnormal repair, oxidative stress, cellular proliferation, and epithelial-mesenchymal transition. In addition, genomic and epigenomic changes - such as single nucleotide polymorphisms, copy number variation, promoter hypermethylation and microRNAs - could alter biological pathways and enhance susceptibility to lung cancer and COPD. Approaches of studying genomics, epigenomics and gene-environment interaction will yield greater insight into the shared pathogenesis of lung cancer and COPD, leading to new diagnostic and therapeutic modalities. In addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, in order to develop new methods of prevention, diagnosis and treatment of lung cancer and COPD.

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      CALC.06 - Diagnosis of Lung Nodules by CT-Guided Lung Biopsy (ID 3873)

      Y. Song

      • Abstract
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      Abstract
      CT-guided percutaneous needle biopsy(CT-guided PTNB) of the lung, with its high sensitivity, specificity, and accuracy, is an important diagnostic tool in the evaluation of pulmonary lesion, especially in malignant disease . And it’s specificity can reach 95 percent to 100 percent in malignant disease. Although PTNB of the lung is a mature technique, careful case selection is necessary to increase diagnostic yield and avoid unnecessary complications. It is indicated for indeterminate pulmonary nodules or masses, particularly those that will likely require chemotherapy or radiation rather than surgery. Pneumothorax and pulmonary hemorrhage are the most common complications of PTNB, whereas air embolism and tumor seeding are extremely rare. Attention to biopsy planning and technique and postprocedural care help to prevent or minimize most potential complications. A retrospective investigation of patients with CT-guided PTNB in Jinling Hospital between January 2000 to October 2010 was performed. The risk factors for complications were determined by multivariate analysis of variables related to patients’ demographics, lung lesions, biopsy procedures, and individual radiological features.1014 biopsy prcedures were enrolled. The total complication rate was 18.5 percent with pneumothorax 12.9 percent (131/1014), hemoptysis 5.6 percent (57/1014), and with no mortality. The diagnosis was cofirmed by PTNB in 961 patients (94.8 percent) with 639 patients as malignant disease (63 percent) and 322 patients as benign diease (31.8 percent). Taken into all the evidence, CT-guided percutaneous needle biopsy is a safe and effective means in the diagnosis of pulmonary occupying lesions.

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      CALC.07 - Molecular Signatures for the Accurate Classification of NSCLC and Neuroendocrine Tumors and Cell Lines (ID 3874)

      A.F. Gazdar, L. Girard

      • Abstract
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      Abstract
      Until recently the oncologist was only interested to know whether a lung cancer was SCLC or NSCLC. However, recent changes, particularly during this century, require more precise classification of lung cancer, and, in some cases, for subclassification [1]. The different classes of lung cancer respond differently to conventional therapy and to precision medicine. The patterns of driver mutations are highly tumor type dependent, with very little overlap between classes. Thus mutation testing depends of accurate classification. Other reasons for accurate classification include: 1) Adenocarcinoma histology is a strong predictor of response to pemetrexed therapy in patients with advanced disease; and 2) Serious hemorrhagic complications after bevacizumab therapy have been reported in patients with squamous histologies. With the development and application of newer agents for precision medicine, the need for accurate classification will only increase. Complicating the increased need for accurate classification is the fact that currently 70% of lung cancers are diagnosed from small biopsies or cytological samples. Thus more accurate diagnoses are demanded from smaller amounts of materials [1, 2]. A further complication is that large international clinical trials often require that tumor materials be reserved for entry requirements or various tests. In routine pathology practice, immunostains are often used to classify poorly differentiated lung carcinomas. While many immunostains have been proposed, a simple algorithm utilizing TTF1 and Napsin A for adenocarcinoma and p63 (or its isoform p40) and high molecular weight keratins have is effective [3]. However, even with excellent pathology practices, over 10% of cases will be incorrectly classified or be unclassified (undifferentiated large cell carcinoma or NSCLC-not other wise specified (NSCLC-NOS). Pathology practices and quality may vary from institution to institution or country to country. The SEER data on cancer incidence indicates that over 20% of lung cancer cases in the USA are not further classified. For these reasons we developed highly specific and sensitive RNA expression signatures as an adjunct test for routine pathological classification. The signatures not only classify the smaples, but provide a numeric scor ranging from 0-1.0, indicating the degree of differentiation. We utilized expression arrays from multiple public and private sources including The Tumor Cell Genome Atlas (TCGA), which used several platforms including Illumina, Affymetrix and RNA-Seq. For complete identification, four signatures had to be developed and validated and can be utilized independently or in combination. These signatures are: 1) Adenocarcinoma-squamous cell carcinoma discrimination, 2) lung specific neuroendocrine (NE)-non neuroendocrine lung cancer discrimination, 3) Non-malignant lung- lung carcinoma discrimination and 4) lung respiratory cell-lung carcinoma cell discrimination. The adenocarcinoma signature includesTTF1, the squamous cell carcinoma signature includes p63 and several high molecular weight keratins, and the NE cell signature includes chromgranin A, synaptophysin and dopa decarboxyase, adding credence to the signatures. These signatures have <10% discrepancy rates with expert pathology review and have helped n the correct classification of NSCLC, large cell and NSCLC-NOS carcinomas, NE lung tumors and lung cancer cell lines. John Minna and Alex Augustyn, in collaboration with us, have utilized their modification of the NE cell signature, and have identified two potential major clinical applications. These include identification of the full NE expression signature in a subset (5-10%) of NSCLC. While some of these may represent misclassified large cell neuroendocrine carcinomas, others appear to be typical adenocarcinomas. In addition, they have identified that BCL2 is one of the downstream targets of ASCL1, the driving force for NE differentiation in the lung, and that inhibition of BCL2 results in apoptosis of SCLC and NSCLC-NE tumors. Practical application of our signatures requires modification to a more practical platform such as Nanostring technology, and application to formalin fixed paraffin embedded small biopsies. These are currently in development. We are grateful to Drs. William Travis and Natasha Rehktman, members of the TCGA pathology panel and Ignacio Wistuba, John Minna and Alex Augustyn for their invaluable assistance. References 1. Gazdar AF. The evolving role of the pathologist in the management of lung cancer. Lung Cancer Management 2012;1(4):1-9. 2. Travis WD, Brambilla E, Noguchi M, et al. Diagnosis of Lung Cancer in Small Biopsies and Cytology: Implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification. Arch Pathol Lab Med 2012. 3. Travis WD, Rekhtman N. Pathological diagnosis and classification of lung cancer in small biopsies and cytology: strategic management of tissue for molecular testing. Semin Respir Crit Care Med 2011;32(1):22-31.

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      CALC.08 - Targeted Therapies for Adenocarcinoma, Now and Future (ID 3875)

      C. Zhou

      • Abstract
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      Abstract
      Lung cancer remains as the most fatal disease world-wide.Non-small cell lung cancer (NSCLC) accounts for about 80% of all lung cancers. Incidence of pulmonary adenocarcinoma has been increasing in most countries and becomes a major histology. We had, up to the recent past, treated patients with chemotherapy without any clinical or biological selection. Unfortunately, the improvement in overall survival (OS) with platinum-based doublets is modest, although statistically significant when compared to best supportive care. We now, however, understand that adenocarcinoma could be divided into several subsets according to oncogenic drivers and each subset of adenocarcinoma has a different biology. So, targeted therapies against these drivers have been extensively studied and will play more and more important roles in treatment of advanced adenocaricnoma of the lung. Oncogenic drivers Adenocarcinoma is different in oncogenic drivers between East Asian and Caucasian patients. East Asian patients have more frequent epidermal growth factor receptor (EGFR) mutation but less frequent KRAS mutation. Incidence of EGFR mutation is about 50% - 78.8% but of KRAS mutation about 1.9% to 12%. Other oncogenic drivers include ALK or ROS1 rearrangement, BRAF mutation, HER2 amplification or mutation, c-MET amplification, etc, and arecomparable in their incidencesbetween Asian and Caucasian patients. These oncogenic drivers are mutually exclusive in majority cases. EGFR TKI Several phase II/III studies have investigated the efficacy of EGFR tyrosine kinase inhibitors (TKI) as front-line therapy of patients with advanced NSCLC. EGFR TKI is not appropriate for front-line therapy in unselected populations, in those without EGFR mutation, or those with unknown EGFR mutation status. Improvement in PFS with EGFR TKI is confined to those with EGFR mutation. In fact, first-line EGFR TKI seems to have a detrimental effect in those without an EGFR mutation. Clinical characteristics alone are not sufficient to correctly predict benefit from EGFR TKIs. Treatment with EGFR TKI in EGFR mutant NSCLC patients has also been found to be associated with improvement of progression-free survival (PFS) and quality of life and less toxicity profile. Both first-generation and second-generation EGFR TKIs are effective. Treatment of patients with acquired resistance to EGFR-TKI is wildly being studied. Switching to standard chemotherapy, continuation of an EGFR TKI beyond disease progression and/or plus local therapy, afatinib plus cetuximab are some options of treatment. ALK inhibitors Crizotinib proves effective in adenocarcinoma with ALKorRos1 rearrangement. Several studies (Profile 1001, 1005 and 1007) investigated crizotinib in advanced NSCLC with ALK rearrangement. Tumor response is about 51-61% and PFS 41.9-48.1 weeks. Second-line crizotinib was found more effective than chemotherapy in terms of tumor response rate and PFS. The compound was also found to be effective in those with ROS1 rearrangement. Among 35 patients, its tumor response rate was 60% and PFS was not reached. LDK 387 is a second-generation ALK inhibitor. Phase I study showed its promising efficacy in the patients with ALK rearrangement. It could overcome acquired resistance of NSCLC to crizotinib. Antiangiogenicagents Bevacizumab is approved to be combined with doublet chemotherapy as 1[st] line treatment of non-squamous NSCLC. The combination significantly improves tumor response, PFS and OS. But up to now, there is no biomarker for selection of non-squamous NSCLC patients to receive bevacizumab therapy. Many small molecular anti-angiogenicinhibitors plus standard chemotherapy have been investigated but failed in improvement of OS. Recently, LUME-Lung 1 trials suggested ninetedanib plus docetaxelsignificantly improved PFS and OS of patients with advanced adenocarcinoma of the lung in second line setting compared with docetaxel + placebo. KRAS inhibitors Some compounds are being investigated in those with KRAS mutation. Selumetinib, MKE1/2 inhibitor, combined with docetaxel significantly improved tumor response (37% vs 0%) and PFS (5.2 months vs 2.1 months, HR 0.58), compared with docetaxel alone.Trametinib plus second line chemotherapy produced about 12 to 28% of tumor response rate and 2.9 to 4.1 months of PFS. BRAF inhibitor Dabrafenib has been approved for treatment of melanoma harboringBRAF V600E mutation. Incidence of BRAF V600E mutation is about 1% in NSCLC. A phase II study investigated dabrafenib in adenocarcinoma of the lung withBRAF V600E mutation. Preliminary results in 20 patients showed 40% of tumor response rate and 60% of disease control rate with the compound. c-MET inhibitors c-METamplification is one of major mechanisms for acquire resistance of NSCLC to EGFR TKI. Several small molecular inhibitors of cMET and monoclonal antibodies against cMET are under clinical development. METmab plus erlotinib significantly improved PFS than erlotinib in those with MET high patients in the phase II trial. Crizotinib led to tumor shrinkage in a patient with MET amplification. HER2 inhibitors HER2 mutation and amplification are not frequently observed in adenocarcinoma of the lung. Mazieres and the colleagues reported that HER2-targeted therapies in additional lines of treatment produced 50% of overall response rate, 82% of disease control rate and 5.1 months of PFS. The disease control rate was 96% with trastuzumab-based therapies and 100% with afatinib monotherapy. The relative efficacy of these compounds deserves prospective evaluation in larger international clinical trials. Inhibitors of other oncogenic drivers Many inhibitors of other drivers including PDGFR, FGFR, RET rearrangement, PI3K, mTOR, MEK, AKT, STAT3, etc are under clinical development. We are just waiting for their results of clinical trials. In summary, EGFR TKI and ALK inhibitors are important agents for EGFR mutant and ALK or ROS1 rearranged adenocarcinoma of the lung, respectively. They become standard 1[st] line therapy for these patients. Bevacizumab plus doublet chemotherapy could be 1[st] line therapy for those with advanced adenocarcinoma harboring no oncogenic drivers. Many inhibitors of other oncogenic drivers are under clinical development and will become standard therapy for these patients in near future.

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      CALC.09 - Targeted Therapies for SCC, Now and Future (ID 3876)

      T. Mok

      • Abstract
      • Slides

      Abstract not provided

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      CALC.10 - Second Line Treatment of NSCLC: Needed to Detect Driven Gene Mutation Status (ID 3877)

      B. Han

      • Abstract
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      Abstract
      Despite progressive advances in biomarker-driven personalised therapeutic approaches to non-small cell lung cancer (NSCLC) in recent years, the efficacy of first-line treatment remains suboptimal. Most chemotherapy-treated patients experience disease progression within 3–6 months[1,2] and even those who initially benefit from tyrosine kinase inhibitor (TKI) therapy inevitably progress after 10–14 months.[3–6] However, 40–50% of patients have a good performance status at progression and are suitable for subsequent therapy.[7,8] Thus, improving second-line treatment has the potential to significantly impact patient outcomes. The success of several molecularly targeted therapies in the first-line setting in clinical trials has stimulated research interest in similar applications in the second-line setting. Data from the DELTA[9] and CTONG0806[10] studies presented at ASCO 2013 corroborate findings from the TAILOR[11] study which suggest that chemotherapy may be a marginally better option than epidermal growth factor receptor (EGFR)-TKI for EGFR wild-type patients beyond the first-line setting. It is now clear that treatment response varies widely between patients with different biomarker profiles and this underscores the increasing importance of biomarker testing prior to second-line therapy. For patients with unknown mutation status in the first-line setting, biomarker analysis upon progression is essential to guide second-line treatment decisions to optimise treatment response, both for targeted therapies and chemotherapy. In the pivotal BR.21 trial of erlotinib versus placebo in the second-line setting, response to erlotinib increased from 8.9% in the unselected population to 27.0% in the EGFR mutation-positive sub-population. Similarly, overall survival (OS) increased from 6.7 months to 10.9 months when the EGFR genotype was known.[12,13] In patients with anaplastic lymphoma kinase (ALK)-positive tumours, crizotinib has demonstrated superiority to chemotherapy in the second-line setting with improved progression-free survival (PFS; 7.7 vs. 3.0 months; p<0.001) and quality of life, an important second-line outcome.[14] Although improvements in chemotherapy efficacy seem to have reached a plateau, the use of molecular testing to identify patients who will benefit most from chemotherapy is being actively investigated. A recent study exploring the predictive role of BRCA1 and ERRC1 genes in patients receiving second-line platinum-based chemotherapy showed that low mRNA levels of both genes correlated with increased OS (16.0 vs. 5.4 months; p<0.001) and PFS (4.1 vs. 2.0 months; p=0.002) compared with high levels.[15] Although clinically validated biomarkers have not been identified for most therapies, they remain a critical focus of research and currently available information offers clinicians new insights into second-line management. For patients with known mutation status who experience disease progression following first-line therapy, biomarker testing prior to therapy allows identification of mechanisms of acquired resistance to enable clinicians to tailor subsequent treatment strategies. The most common mechanism of acquired resistance to EGFR-TKIs is the T790M mutation, which has been reported in up to 60% of patients with acquired EGFR-TKI resistance.[16–19] Oxnard et al. demonstrated favourable prognosis and more indolent disease progression in patients with T790M-mediated acquired resistance compared with other mechanisms of acquired resistance, and customised subsequent treatment based on these findings. Over 80% of T790M-positive patients were maintained on TKI therapy, along with chemotherapy, to help maintain the indolent characteristics of T790M-associated progression.[17] A re-response phenomenon has also been described in T790M-positive patients in whom TKI-sensitive cells repopulate upon cessation of TKI therapy, allowing the tumour to regain sensitivity to EGFR-TKI. Thus, re-treatment with EGFR-TKI and chemotherapy may be well suited to target both sensitive and resistant cell populations.[20] Other mechanisms of acquired EGFR-TKI resistance include secondary c-MET overexpression/amplification via HER3/erbB3 or KRAS activation (5–19%), AXL upregulation (20–25%) and phosphatidylinositol-3-kinase mutations (5%).[21,22] Similarly, secondary genetic alterations have been demonstrated in crizotinib-resistant ALK-positive tumours.[23,24] For patients with known mutation status who are still on first-line treatment, biomarker testing provides real-time information to monitor for the development of mutations and to uncover additional targetable tumour characteristics that may impact treatment response and warrant a change in therapy. Tumour characteristics may evolve following first-line treatment as tumour heterogeneity may exist at both genomic and morphological levels. Bai et al. investigated the impact of chemotherapy on EGFR mutation in advanced NSCLC patients who received first-line chemotherapy and patients with stage IIb–IIIb disease who received neoadjuvant chemotherapy, and found that mutation-positive rates were lower post-chemotherapy in both cohorts (p<0.01 and p=0.13, respectively). Importantly, patients who lost EGFR mutation positivity post-chemotherapy had a better partial response than patients with a reverse change (p=0.037).[25] Morphological tumour heterogeneity following first-line therapy has been increasingly reported in the literature. EGFR mutation-positive adenocarcinomas have been reported to transform to small cell histology with maintained EGFR mutation following progression.[16,18] In a study by Sequist et al., these observations allowed investigators to switch patients to small cell lung cancer chemotherapy regimens, with 75% responding to treatment.[18] Epithelial-mesenchymal transitions have also been reported.[18,26] Biomarker testing in the second-line setting is important to detect any changes in tumour characteristics before significant clinical deterioration when alterations to regimens might be most effective. The growing number of biomarker-targeted treatment options may create a need for biopsy or re‑biopsy during treatment. Recent guidelines by the College of American Pathologists, the International Association for the Study of Lung Cancer and the Association for Molecular Pathology recommends re-biopsies for EGFR and ALK mutation analysis to guide treatment decisions beyond the first-line setting.[27] Although re-biopsy may be challenging due to patients’ and/or clinicians’ reluctance, it has shown to be feasible and provides sufficient material for mutation analysis in most patients. High-sensitivity sequencing methods can detect T790M mutation in up to 68% of re-biopsy samples from patients with acquired resistance.[16,17,28,29] Nevertheless, promising surrogates for tumour tissue DNA, such as circulating blood biomarkers, are being investigated and may represent a less invasive approach. The BATTLE-1 trial, which employed real-time biopsies to match patients to targeted therapies, proved that a biomarker-driven treatment approach is feasible.[30] BATTLE-2, which involves more drug combinations, and real-time selection and validation of predictive biomarkers, is currently ongoing;[31] the highly anticipated results hold promise for revolutionising NSCLC treatment.

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      CALC.11 - MicroRNA Biomarkers in Lung Cancer (ID 3878)

      S. Lu, W. Huang, D. Yang, J. Hu, C. Bai, Y. Wu, H. Zhu

      • Abstract
      • Slides

      Abstract
      ABSTRACT Rationale: Effective treatment for lung cancer requires accuracy in sub-classification of carcinoma subtypes. Objectives: To identify microRNAs in bronchial brushing specimens for discriminating small cell lung cancer (SCLC) from non-small cell lung cancer (NSCLC) and for further differentiating squamous cell carcinoma (SQ) from adenocarcinoma (AC). Methods: Microarrays were used to screen 723 microRNAs in laser-captured, microdissected cancer cells from 82 snap-frozen surgical lung tissues. Quantitative reverse-transcriptase PCR was performed on 153 macrodissected formalin-fixed, paraffin-embedded (FFPE) surgical lung tissues to evaluate 7 microRNA candidates discovered from microarrays. Two microRNA panels were constructed based on a training cohort (n = 85) and validated using an independent cohort (n = 68). The microRNA panels were applied as differentiators of SCLC from NSCLC and SQ from AC in 207 bronchial brushing specimens. Measurements and Main Results: Two microRNA panels yielded high diagnostic accuracy in discriminating SCLC from NSCLC (miR-29a and miR-375, AUC 0.991 and 0.982 for training and validation dataset, respectively) and in differentiating SQ from AC (miR-205 and miR-34a, AUC 0.977 and 0.982 for training and validation dataset, respectively) in FFPE surgical lung tissues. Moreover, the microRNA panels accurately differentiated SCLC from NSCLC (AUC 0.947) and SQ from AC (AUC 0.962) in bronchial brushing specimens. Conclusion: We found 2 microRNA panels that accurately discriminated between the 3 subtypes of lung carcinoma in bronchial brushing specimens. The microRNA panels could have considerable clinical value in differential diagnosis and play an important role in determining optimal treatment strategies based on the lung carcinoma subtype.

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      CALC.12 - IPF Caused by EGFR-TKIs in Asia (ID 3879)

      Q. Hong

      • Abstract
      • Slides

      Abstract
      Drug-associated interstitial lung disease (ILD) is not uncommon, but it may developed to fatal acute respiratory distress syndrome, so an accurate diagnosis based on clinical, radiological and histological manifestations is important. As an EGFR-TKI, Gefitinib or Erlotinib has been widely used in advanced NSCLC, although it may prolong the patient’s survival, the possibility of ILD associated with EGFR-TKI remains a big problem that we need to confront especially in Asian NSCLC patient. Diagnosis For the assignation of ILD, patient usually need to accord with the following requirements: (1) progressive dyspnea with or without cough or fever, (2) radiographic findings(HRCT recommended) show bilateral, diffuse, or patchy interstitial and/or alveolar opacifications, (3) lack of evidence of infection and progression of underlying lung cancer, (4) consistent pathologic findings if available. Establishing a diagnosis on EGFR-TKI associated ILD is often difficult, and is particularly challenging in a patient having been given chemotherapy and/or radiotherapy, chemotherapy and radiotherapy, either alone or in combination, have been associated with the development of ILD. In addition, infections, and other environmental exposures can also mimic ILD. The characteristic images of EGFR-TKI associated ILD were of patchy diffuse ground-glass shadows; several other characteristic HRCT patterns can also been observed. In acute forms of ILD, ground-glass attenuation is usually seen bilaterally in the lung fields. In chronic forms of the disease, “honeycombing” is seen that results from extensive pulmonary fibrosis and loss of acinar architecture of the lungs. Although ILD can occur during the first 3 months of treatment, the median time to onset was actually 24 to 42 days, and ILD developed in most patients within the first 4 weeks of treatment, with possibly rapid progression.On the other hand, ILD can develop in patients who are retreated with EGFR-TKI after a period of interruption. Therefore, all patients receiving EGFR-TKI who present with an acute onset of dyspnea, regardless of the presence of cough or low-grade fever, should be promptly evaluated, especially during the first month of treatment. Epidemiology There are more frequent reports of EGFR TKI-associated ILD in Japan than elsewhere in the world. The causes for this worldwide differences are unknown and require further scientific investigation. Several reasons have been suggested for this difference, including differences in follow-up period, the clinical characteristics of the study population, and the applied diagnostic criteria for ILD. Pre-existing ILD, including usual interstitial pneumonia, has been found in the reported EGFR-TKI induced ILD patients,the presence of IPF seems to be an important risk factor. Alternatively, there may be a specific increased genetic susceptibility to ILD among the Japanese population. However, this ethnic difference in reporting rates does not extend to other Asian countries, where the frequency of ILD is comparable with the rest of the world Mechanism of ILD The molecular mechanisms leading to ILD are also unclear. The distribution of EGF and EGFR in normal adult human lung has been demonstrated by immunohistochemistry, with expression observed in the basal cell layer of the bronchial epithelium . EGF signaling probably represents an important mechanism that helps coordinate the process of recovery from lung injury by stimulating epithelial repopulation and restoration of barrier integrity. Some investigator have suggested that EGFR-TKI therapy may augment any underlying pulmonary fibrosis via a decrease in EGFR phosphorylation with a coincident decrease in regenerative epithelial proliferation. Therefore, it is possible that EGFR inhibition will at least in part reduce the ability of pneumocytes to respond to lung injury. Compared with other EGFR inhibitors, the largest amount of information regarding the association with ILD is available for gefitinib, as this agent has been given to more patients than any other EGFR-TKIs. Treatment Treatment of EGFR TKI–induced ILD include supplemental oxygen, empirical antibiotics, and mechanical ventilation depending on the severity of the situation. Immediate discontinuation of the TKI drug is recommended . Acute pneumonitis commonly resolves on discontinuation of therapy, although in severe cases patients , systemic corticosteroids are usually prescribed, Prognosis with treatment is good if the diagnosis is made early; however, once fibrosis has occurred, the damage may be permanent with irreversible loss of lung function.

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      CALC.13 - Novel Lung Cancer Plasma Immunoinflammatory Complexes (ID 3880)

      J. Hu

      • Abstract
      • Slides

      Abstract
      The plasma protein complexes level was measured by electrophoresis analyses in 31 patients with advanced NSCLC treated with 125 or 150 mg/day icotinib hydrochloride until disease progression or unacceptable toxic effects or the patient refused further treatment. Eligibility criteria include performance status≤2, age≥18 years, and stage ⅢB-Ⅳ disease. Herein we found more than 87 % of the change in plasma IIRPCs appears at earlier time than histopathology occurs during the treatment with icotinib hydrochloride: (1) having a crest; (2) having a trough. The increasing or discreasing point always appears at earlier time in the treatment before histopathology occurs. There are no significant differences of the median PFS among the other clinical information groups, including: ages, gender, smoking history and EGFR mutation. Therefore, we showed that measurement of plasma protein complexes level during the treatment in patients with NSCLC may be a new surrogate marker for monitoring the therapeutic efficacy of icotinib and predicting the progression of the disease.

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      CALC.14 - Summary and Close, Thanks to CALC, Speakers and Sponsors (ID 3881)

      D.C. Lam, C. Bai

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    MO04 - Lung Cancer Biology I (ID 86)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Biology
    • Presentations: 12
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      MO04.01 - Molecular mechanisms of cigarette smoke induced hyper-proliferation of human lung cells and its prevention. (ID 2636)

      N. Dey, D. Chattopadhyay, I.B. Chatterjee

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer is the leading cause of cancer-deaths throughout the World. Cigarette smoke (CS) is the strongest risk factor of lung cancer. Cigarette smoking and exposure to environmental tobacco smoke account for 90% of lung cancer cases, and smokers have a 20-fold increased risk of death from lung cancer compared to non-smokers. Unregulated cell proliferation together with suppressed apoptosis is a contributory factor for lung-carcinogenesis. However, the carcinogenic mechanism of cigarette smoking is not well understood. This is particularly because CS is a complex mixture of about 4000 compounds. We consider that identifying the risk factor(s) in CS and its prevention might be a novel way to prevent lung cancer.

      Methods
      Cytotoxicity was evaluated by the MTT assay. Cell cycle analysis was performed by propidium iodide (PI) staining followed by flow-cytometry. Apoptosis was assessed by AnnexinV- PI staining followed by flow-cytometry, phosphorylation of p53 and activation (cleavage) of caspase 3. Reactive Oxygen Species (ROS) production was detected by 2’, 7’-dichlorodihydrofluorescein diacetate (H~2~DCFDA) using confocal microscope. Cell proliferation was assessed using “In Situ Cell Proliferation Kit, FLUOS” (Roche Applied Science, Germany). DNA double-strand break was detected using “OxiSelect DNA Double Strand Break (DSB) Staining Kit” (CELL BIOLABS, INC.).

      Results
      We have identified p-benzoquinone (p-BQ) as a major risk factor that is derived from CS. p-BQ has a biphasic-nature as evidenced by MTT assay, AnnexinV-PI staining, cell cycle analysis and BrdU-incorporation assay. Low concentrations of p-BQ mimicked CS-induced proliferation of cultured lung adenocarcinoma cells (A549) as well as normal human primary small airway cells (ATCC[®] PCS-301-010[™]). On the contrary, high concentrations of CS/p-BQ resulted in cell death caused by oxidative stress and apoptosis. No such cell death was observed with low concentrations of CS/p-BQ. Coimmunoprecipitation and immunoblot experiments indicated that p-BQ-induced proliferation was mediated via aberrant phosphorylation of EGFR that lacked c-Cbl mediated ubiquitination and degradation. This resulted in prolonged EGFR signaling leading to persistent activation of Ras (a potent oncoprotein), the downstream survival and proliferative signaling molecules Akt and ERK1/2, as well as the transcription factors c-Myc and c-Fos. It is known that patients with lung cancer generally have a smoking history of more than 30-40 years. We therefore exposed A549 cells repeatedly to CS/p-BQ for 2 months. Repeated exposure of AECS/p-BQ generated high levels of DNA double-strand breaks in A549 cells that might lead to genomic instability as well as mutation of different proto-oncogenes and tumor suppressor genes – the hallmark events in cancer. In addition, CS/p-BQ altered the acetylation pattern of different histone epigenetic marks, thereby regulating the transcription of several candidate genes responsible for proliferation and apoptosis. Both anti-p-BQ antibody and vitamin C (a strong reductant of p-BQ) prevented CS/p-BQ-induced proliferation of lung cells.

      Conclusion
      Despite major advances in the treatment and management of lung cancer, most patients eventually die. Consequently, newer approaches such as chemoprevention(s) are necessary. We consider that prevention of CS-induced proliferation of lung cells by vitamin C and/or anti-p-BQ antibody may provide a novel intervention for preventing initiation of CS-induced lung cancer.

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      MO04.02 - Paclitaxel resistance is associated with drug accumulation in intracellular compartments and paclitaxel-binding proteins in human lung cancer cell lines (ID 75)

      M. Shimomura, T. Yaoi, D. Kato, J. Shimada, S. Fushiki

      • Abstract
      • Presentation
      • Slides

      Background
      Several mechanisms have been suggested for paclitaxel resistance in cancer cells, including overexpression of the multidrug transporter gene, ATP-binding cassette, sub-family B, member 1 (ABCB1), and the presence of a point mutation in the β-tubulin gene at the paclitaxel-binding site. However, the mechanisms underlying resistance to this agent have not yet been completely elucidated.

      Methods
      Three human lung cancer cell lines, II18, A549, and RERF-LC-KJ, were analyzed; their 50% inhibitory concentrations of paclitaxel were -8.33, -7.69, and -4.51 logM, respectively. The cell lines did not have any β-tubulin mutation. We evaluated the expression levels of ABCB1, intracellular accumulation of paclitaxel, paclitaxel-induced stabilization of microtubules, and intracellular localization of Oregon Green[®] 488-conjugated paclitaxel in these cell lines. Moreover, we prepared paclitaxel conjugated ferriteglycidyl metacrylate (FG) beads to purify paclitaxel-binding proteins from whole cell lysates of these cells.

      Results
      The ABCB1 expression level was strongly correlated to intracellular [[3]H]-paclitaxel accumulation (r[2] = -0.804) but was not related with paclitaxel resistance. The changes in the quantities of polymerized tubulin and acetylated tubulin after paclitaxel exposure were not related to paclitaxel resistance. Differences were observed between the intracellular localization of paclitaxel in RERF-LC-KJ, the most resistant cell line, and in the other 2 cell lines. The use of Oregon Green[®] 488-conjugated paclitaxel enabled visualization of not only the normal microtubule formation in the partial cells but also the aggregated vesicle formation in RERF-LC-KJ cells; aggregated vesicle formation was not remarkable in the other cell lines. Affinity purification by paclitaxel immobilized beads revealed several specific bands in RERF-LC-KJ; these bands were not revealed in the other cell lines.

      Conclusion
      We propose that paclitaxel resistance is associated with intracellular compartments in which paclitaxel accumulates and paclitaxel-binding proteins expressed specifically in resistant cell line.

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      MO04.03 - Chromosomal and mutational analysis of the cisplatin resistant phenotype in NSCLC cells (ID 3313)

      M.P. Barr, L.C. Alcock, R.L. Stallings, S. Toomey, A. Carr, B.T. Hennessy, D. Richard, K. O'Byrne

      • Abstract
      • Presentation
      • Slides

      Background
      Primary and acquired resistance to platinum agents such as cisplatin have become a major obstacle in the management of lung cancer patients, in particular non-small cell lung cancer (NSCLC). The availability of comprehensive genomic data on DNA copy number changes in cisplatin resistant NSCLC is limited, and little is known about the genes driving this chemoresistant phenotype. Detailed molecular portraits through high density genomic DNA arrays and genome wide mutation profiles will aid in understanding the molecular basis of individual responses to new molecular therapies.

      Methods
      A panel of cisplatin resistant (CisR) NSCLC cell lines were recently generated and characterised in our laboratory. In this study, high resolution array-based comparative genome hybridization (aCGH) was performed on a panel of five CisR NSCLC cell lines to examine DNA copy number gains, losses and amplifications. Cellular DNA (500ng) and control DNA was differentially labelled with Cy3 and Cy5, respectively. Labelled test (4µg) and reference DNA were hybridised to a 12-plex 135,000 probe array (Roche NimbleGen) for 18 hours in a MAUI hybridisation station (BioMicro Systems) at 42°C. Fluorescent intensities were extracted and log 2 ratios calculated and normalized using NimbleScan Software (version 2.4). Chromosomal aberrations were identified using the CGH-segMNT algorithm (NimbleScan 2.4). A significance log 2 ratio threshold of <−0.25 for loss and >0.25 for gain was used to identify DNA copy number imbalances. For mutational analysis, Sequenom®, a mass-spectrometry-based SNP genotyping technology, was used to identify mutations in our panel of resistant cell lines. Using a literature search and the Catalogue of Somatic Mutations in Cancer (COSMIC) database, a mutation panel was identified for the detection of 547 frequently occurring and potentially clinically relevant mutations in 49 cancer-related genes. Some of these include KRAS, NRAS, BRAF, PIK3CA, MET, CTNNB1, STK11, AKT, and EGFR. Matrix chips were analysed on a Sequenom® MassArray MALDI-TOF system. Visual inspection and Sequenom® typer software were used to perform genotyping based on mass spectra.

      Results
      Using aCGH arrays, a number of gains, losses and amplifications of various chromosomes were found across a panel of CisR cell lines, relative to corresponding PT cells. The most frequently occurring of these chromosomal imbalances included gains, losses and homozygous deletions on chromosome 3 (MOR, A549, H1299), deletions and amplifications on chromosome 7 (H460, A549, H1299) and deletions and gains on chromosome 15 (MOR, A549, H1299) and chromosome X (MOR, H460, SKMES-1). Deletions on chromosomes 4, 6, 11, 12, 14, and amplification of chromosome 5, were also identified among the different CisR cell lines. The collation and analysis of data arising from mutation analysis of CisR cells using the Sequenom® platform are currently being completed.

      Conclusion
      High-resolution mapping of chromosomal imbalances may offer potential in the identification of genes, including oncogenes and tumour suppressor genes, affected by these imbalances. These findings may further contribute to the delineation of the genomic profile of cisplatin resistant lung cancer, and offer perspectives for the identification of genes contributing to this disease phenotype and in assessing the response to new molecular treatments.

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      MO04.04 - Aerosol Azacitidine Reduces Methylation Levels of Tumor Suppressor Genes and Prolongs Survival in the Orthotopic Lung Cancer Models in Mice. (ID 1621)

      X. Qiu, Y. Liang, B. Piperdi, R. Perez-Soler, Y. Zou

      • Abstract
      • Presentation
      • Slides

      Background
      Promoter hypermethylation plays an important role in lung cancer carcinogenesis by silencing key tumor suppressor genes (TSG). Reversing the hypermethylation of TSG by direct aerosolized administration of a demethylating agent may have a potential to inhibit lung cancer growth and development. This study examines the therapeutic potential of aerosolized azacytidine (Aza) in the orthotopic mice model of human NSCLC.

      Methods
      Vidaza® (the clinical grade Aza formulation for IV administration) was dissolved into sterile water for injection and aerosolized in a clinical standard aerosol system. The aerodynamic size, the lung deposition, and the Aza level in the lung and circulation of mice were measured by previously described methods. The demethylation and gene reactivation functions of aerosolized Aza were detected by qPCR methylation array and western blotting assay in the human non-small cell lung cancer (NSCLC) tumor tissues from the orthotopic intratracheally inoculated xenograft models in nude mice. The therapeutic efficacy and toxicity of the aerosolized Aza were also evaluated in mice. Mice treated with an intravenously administered Aza with clinically equivalent dose and schedules were used as a comparison.

      Results
      The aerosolized Aza is an appropriate pharmaceutical inhalation formulation with size distribution of about 80% of droplets from 0.1 to 5 micron. This dynamic size range ensures the aerosol droplets depositing in the lower airway as indicated by the recovery of approximately 80% Aza from the lung tissue 20 min after the aerosol administration. In efficacy and toxicity studies, aerosol administration of Aza significantly prolonged the survival of nude mice with intratracheally inoculated human NSCLC tumors. The %-increased in life span was 5- to 10-fold higher than that of a systemic treatment of Aza at a clinically equivalent dose. The aerosolized Aza, at a potentially therapeutic dose, did not cause any detectable lung toxicity or systemic toxicity (myelosuppression). After the aerosolized Aza treatment, the lung tumors were resected and the methylation levels of the 24 promoters driving the lung cancer related tumor suppressor genes (TSGs) in the lung tumors were examined by qPCR methylation array. The aerosolized Aza significantly reduced the methylation level in 9 of the 24 promoters examined. This demethylating effect also resulted in the gene reactivation at the protein level in several tested genes.

      Conclusion
      In our orthotopic NSCLC model, aerosolized Aza was well tolerated with good drug delivery to bronchial epithelium at non-cytotoxic doses. The pharmacodynamic effect of the TSG demethylation and reactivation was observed. Interesting therapeutic efficacy of prolonging survival was observed in our model from aerosolized 5-Aza over intravenous administration in mice. The phase I clinical trial of aerosolized Aza with pharmacodynamic endpoints will be conducted. Acknowledgement: Supported by a NIH (NCI) grant 5R01CA154755-02

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      MO04.05 - Tracheal basal cells in the lung squamous dysplasia: moving proximal. (ID 1700)

      M. Ghosh, L.D. Nield, J. Kwon, R.L. Keith, D.T. Merrick

      • Abstract
      • Presentation
      • Slides

      Background
      Squamous cell carcinoma (SCC) is the second most common form of lung cancer, a disease primarily observed in smokers. Studies have shown that preneoplastic dysplasias are the precursors for SCC. However, only a subset of these lesions progress to invasive carcinoma and predicting the fate of individual lesions is difficult. Understanding the processes associated with the development of dysplasia would therefore have significant impact on preventative therapy for high-risk lesions. To this goal we have studied N-nitroso-tris chloroethyl urea (NTCU) model of premalignant murine squamous dysplasia. Bi-weekly topical application of NTCU for 32-weeks caused endobronchial dysplasias that were pathologically similar to dysplasias encountered in human smokers. In the current study we used NTCU model to identify the events that precede dysplastic changes in murine airways.

      Methods
      Immunofluorescence analysis of NTCU treated airways showed abundant expression of keratin 5 positive (K5+) basal cells. In normal mouse respiratory epithelium K5+ cells are confined only in the trachea and are absent in the bronchial epithelium. Ectopic expressions of K5+ cells in the mouse bronchial epithelium therefore suggested a role for tracheal basal cells in the pathogenesis of NTCU-induced dysplasia. To explore this possibility we analyzed tracheal and bronchial histology after vehicle and 20mM NTCU treatment at 4, 8, 12, 16, 25 and 32 weeks.

      Results
      Low-grade dysplasia of the tracheal epithelium was observed as early as 4 weeks of NTCU exposure. On the contrary, squamous metaplasia or low-grade dysplasia of the bronchial epithelium was not seen until 25 weeks. Morphometric analysis of immunostained tracheal tissue showed a time-dependent increase in the numbers of K5+ cells and a concomitant loss of cells expressing Clara cell secretory protein (CCSP) and ciliated cells. We have shown previously that injury to the trachea upregulates expression of keratin 14 (K14) in basal cells. Consistent with this phenomenon, NTCU exposure showed a time-dependent increase in the number of K5/K14 dual-positive basal cells. To understand the mechanism by which NTCU treatment mediates ectopic expression of basal cells in the lung, we used flow-cytometry to analyze cell-surface markers expressed by tracheal basal cells. These studies revealed a time-dependent decrease in the level of integrin a6b4 (CD49f). CD49f is a hemidesmosomal protein that facilitates attachment of basal cells to the basement membrane. These findings suggested that NTCU treatment might promote migration of tracheal basal cells by destabilizing their adherence to the basement membrane.

      Conclusion
      Collectively, our results showed an early involvement of tracheal basal cells in the generation of dysplastic lung lesions in a murine model of SCC. By moving the focus proximal, we have discovered a realm of biological developments in the trachea that had not been previously examined. Further research of these processes will aid in the elucidation of dysplastic development in SCC.

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      MO04.06 - DISCUSSANT (ID 3894)

      G.R. Simon

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MO04.07 - Chronic lung injury by constitutive expression of AID leads to focal alveolar regeneration and cancer (ID 116)

      J. Kitamura, K. Kinoshita, M. Uemura, M. Sonobe, H. Hiai, H. Date

      • Abstract
      • Presentation
      • Slides

      Background
      Activation-induced cytidine deaminase, AID, is an enzyme required for somatic hypermutation and class-switch recombination which diversify immunoglobulin genes and causes DNA mutations and strand breaks. Uncontrolled expression of AID is cytotoxic. AID transgenic mice invariably develop lung lesions morphologically similar to human atypical adenomatous hyperplasia (AAH), which can be a precursor of bronchioloalveolar carcinoma. About 10 % of these mice develop visible lung tumor including adenocarcinoma. However, the relationship between this mouse AAH-like lesion (MALL) and lung cancer is unclear. In the present study, we examined MALLs to elucidate their characteristics and involvement in lung cancer.

      Methods
      p53, KRAS, and EGFR mutation status in each laser-microdissected MALL were analyzed. The expression of airway epithelial cell markers and lung alveolar regeneration markers in MALLs were investigated by immunohistochemistry. Apoptosis assay were performed in murine lungs. For cell proliferation assay, AID Tg mice were received a daily intraperitoneal injection of 1 mg 5-ethynyl-2’-deoxyuridine (EdU) for 7 days. Then, mice were studied 1 day (day 1) or 3 weeks (day 20) after the last injection.

      Results
      We found mutations of p53 in 10.5% of MALLs (4/38), but no mutations of KRAS and EGFR. In immunohistochemistry, MALLs were partially positive for SP-C (lung alveolar type II cell-specific marker), but negative for CC-10 (clara cell-specific marker) and podoplanin (lung alveolar type I cell-specific marker). Frequency of apoptotic cells among lung alveolar wall cells was significantly higher in AID transgenic mice than in wild type mice. Moreover, frequency of Edu-positive MALL decreased significantly at day 20 compared to that at day 1. The expressions of p63, cytokeratin 5/14, and E-cadherin/Lgr6, the recently described markers of lung alveolar regeneration, were observed in MALLs.

      Conclusion
      Based on these observations, we speculate that MALL is a regenerating tissue compensating for alveolar epithelial cell loss caused by AID-induced genotoxic stress. AID expression in such regenerating tissue should predispose cells to malignant transformation by its mutagenic activity. AID transgenic mice could be a mouse model that may provide the link between lung regeneration after injury and the development of lung cancer.

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      MO04.08 - Activation of liver X receptor induces interferon-gamma production and inhibits tumor growth (ID 705)

      Q. Wang, X. Ma, Y. Duan

      • Abstract
      • Presentation
      • Slides

      Background
      Interferon-γ (IFN-γ) has been well documented to have multiple functions including anti-tumorigenesis. Liver X receptors α and β (LXR) are members of ligand- activated nuclear receptor superfamily. LXR can be ac- tivated by natural ligands of some oxysterols and by numerous synthetic ligands (e.g. T317).The LXR-induced ABCA1 expression promotes free cholesterol efflux from macrophages thereby inhibiting the development of atherosclerosis. LXR has also been demonstrated the important functions in immune system . Here we tested the hypothesis that IFN-γ is a target for LXR activation, and the induction of IFN-γ expression by LXR can lead to inhibition of tumor growth.

      Methods
      C57 wild type or IFN-γ-/- mice (same background) in two groups were s.c. injected with2×10 5 LLC1 cells (ATCC) in the right flank to establish a carcinoma tumor model. For carcinogen-induced tumor: at the first week, C57 mice were i.p. injected with MCA (15 mg/kg body); from the second week, the mice were i.p. weekly injected with BHT for 6 weeks. The doses of BHT were: 1st injection, 150 mg/kg body weight; 2nd to 6th injections, 200 mg/kg.

      Results
      In this study, we observed that LXR ligand (T317) induced IFN-γ protein expression which was associated with increased mRNA and secreted protein levels in culture medium. In vivo,T317 increased wild type mouse serum IFN-γ levels and IFN-γexpression in tissues. T317 inhibited the inoculated LLC1 tumor growth in wild type mice but not in IFN-γ knockout (IFN-γ-/-) mice. In addition, T317 displayed inhibitory and therapeutic effects on 3-methylcholanthrene/butylated hydroxytoluene (MCA/BHT)-induced pulmonary carcinomas. T317 inhibits the growth of inoculated LLC1 tumor in wild type mice but not in IFN-γ-/- mice Wild type or IFN-γ-/- mice. Figure 1 T1317 inhibits MCA/BHT-induced pulmonary tumors Figure 2

      Conclusion
      Our study demonstrates IFN-γ is a target gene of LXR activation. LXR-induced IFN-γ expression can be attributed, at least in part, to the anti-tumorigenic properties of LXR.

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      MO04.09 - Exercise Induced Lung Cancer Tumor Growth Suppression via Activation of p53: Mechanistic Findings from a Mouse Model (ID 182)

      K.A. Higgins, D. Park, W.J. Curran, X. Deng

      • Abstract
      • Presentation
      • Slides

      Background
      Regular exercise has been shown to improve the quality of life in patients undergoing treatment for lung cancer and has been associated with reductions in cancer-specific mortality in patients with colon and breast cancer. The direct effects of cardiovascular exercise on lung cancer tumor biology, however, remain unknown. This study evaluated cardiovascular exercise in a mouse model of lung adenocarcinoma, including clinically relevant endpoints such as lung tumor growth and distant metastasis. Furthermore, biologic mechanisms of action underlying clinical findings were also explored.

      Methods
      Luciferase-tagged A549 lung adenocarcinoma cells were injected through the tail vein of nude male mice. Mice underwent weekly bioluminescent imaging until lung tumors were clearly identified. After lung tumors were identified, mice were randomized to daily wheel-running versus no wheel-running. Mice were imaged weekly. After 4 weeks, all mice were euthanized and lung tumors were harvested. Western blots and immunohistochemistry (IHC) studies were undertaken on tumor tissue to identify potential differences in protein expression levels in exercise versus sedentary mice.

      Results
      Exercising mice tumors grew significantly more slowly relative to sedentary mice (figure 1). There was no change in development of metastatic lesions between the two groups. Protein analysis by Western blot or IHC demonstrated increased p53 protein levels in exercising mice relative to sedentary mice, as well as increased mediators of apoptosis including Bax, Bak and active caspase 3 in tumor tissues (figure 2 and data not shown). No normal tissue toxicity in other organs was observed in the two groups of mice. Figure 1. Figure 1 Figure 2. Figure 2

      Conclusion
      Daily cardiovascular exercise appears to mitigate growth of lung adenocarcinoma tumors by activation of p53 tumor suppressor function and increased apoptosis.

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      MO04.10 - Identification of biological properties of intralymphatic tumor related to the development of lymph node metastasis in lung adenocarcinoma (ID 1724)

      K. Kirita, G. Ishii, R. Matsuwaki, Y. Matsumura, S. Umemura, S. Matsumoto, K. Yoh, S. Niho, K. Goto, H. Ohmatsu, Y. Ohe, K. Nagai, A. Ochiai

      • Abstract
      • Presentation
      • Slides

      Background
      Intralymphatic tumors in the extratumoral area are considered to represent the preceding phase of lymph node (LN) metastasis. The aim of this study was to clarify the biological properties of intralymphatic tumors susceptible to the development of LN metastasis, with special reference to the expression of cancer initiating/stem cell (CIC/CSC) markers in cancer cells and the number of infiltrating stromal cells.

      Methods
      A total of 2087 consecutive adenocarcinoma patients underwent complete resections and systematic LN dissections between May 1998 and December 2012 were identified. Among these cases, we selected those that had been diagnosed as having lymphatic permeation in the extratumoral area (n = 107). We examined the expression levels of CIC/CSC related markers including ALDH1, OCT4, NANOG, SOX2 and Caveolin-1 in the intralymphatic and primary tumor cells to evaluate their relationship to LN metastasis. The number of infiltrating stromal cells expressing CD34, α-smooth muscle actin, and CD204 were also evaluated. Moreover, we measured E-cadherin expression to identify a correlation between CIC/CSC related molecules and epithelial - mesenchymal transition (EMT) process.

      Results
      Intrathoracic LN metastases were detected in specimens from 86 patients (80%). Among the intralymphatic tissues, low ALDH1 expression in cancer cells, high SOX2 expression in cancer cells, and a high number of CD204(+) macrophages were independent predictive factors for LN metastasis (odds ratio [95%CI] = 3.25 [1.11 – 9.82], P = 0.031 for ALDH1; 4.09 [1.38 – 13.4], P = 0.011 for SOX2; and 3.45 [1.16 – 11.4], P = 0.026 for CD204(+) macrophages). However, in the primary tumors, only a high SOX2 expression level in the cancer cells within the primary tumor was significantly correlated with LN metastasis (p=0.008); ALDH1 expression in the cancer cells and the number of CD204(+) macrophages were not correlated with LN metastasis (P = 0.230 and P = 0.088, respectively). Among these factors, only low ALDH1 expression in intralymphatic cancer cells was significantly correlated with the farther spreading of LN metastasis (mediastinal LN, pN2) (P = 0.046) and higher metastatic LN ratio (metastatic/resected) (P = 0.028). Intralymphatic cancer cells expressing low ALDH1 levels exhibited lower E-cadherin expression levels than cancer cells with high levels of ALDH1 expression (P = 0.015). The expressions of other CIC/CSC related markers, including OCT4, NANOG, SOX2, and Caveolin-1, were not correlated with the E-cadherin expression.

      Conclusion
      Intralymphatic cancer cells expressing low levels of ALDH1 and infiltrating macrophages expressing CD204 have a critical impact on LN metastasis. Especially, intralymphatic cancer cells expressing low levels of ALDH1 might acquire a metastatic aggressiveness by the EMT process. Our study highlighted the significance of evaluating the biological properties of intralymphatic tumors for tumor metastasis and suggested the possibility of usefulness as a new molecular target, especially as an adjuvant therapy.

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      MO04.11 - The tumor microenvironment expression of the Inhibitor of Differentiation-1 (Id1) is determinant of the development of liver metastasis from lung cancer through gene regulation of tumor cells (ID 2429)

      I. Gil-Bazo, E. Castañón, I. López, M. Ponz-Sarvisé, J.M. López-Picazo, M. Collantes, M. Ecay, I. Gil-Aldea, A. Calvo

      • Abstract
      • Presentation
      • Slides

      Background
      Liver metastases appear in about 30% of non-small cell lung cancer (NSCLC) patients during the disease course with a dramatic impact on clinical outcome and quality of life. TME gene expression might be crucial for allowing tumor cells to migrate and spread to the liver. However, no candidate genes have ever been proposed as responsible for this process. Id1, a member of the gene signature that facilitates breast cancer cells to disseminate to the lungs, might be determinant for NSCLC LM development.

      Methods
      For the first time, a mouse model of LM from lung cancer was developed. Two cohorts of mice were compared; C57BL/6 females vs. Id1-knockout (KO) females (gently provided by Dr. Benezra, MSKCC, New York). Lewis lung carcinoma cells (500,000) were selected for intrasplenic injection. Five minutes after tumor cells injection all mice were splenectomized to avoid bulky flank tumor formation. Mice were closely followed after tumor cells inoculation. Weekly FDG-micro-positron emission tomography (PET) scans were performed to study liver metastasis formation in both groups of mice. Animals were sacrificed at the time of LM development. Liver metastatic lesions were obtained for RNA extraction (Qiagen kit). A microarray gene expression analysis (Affymetrix) with the support of Ingenuity Pathways Analysis (IPA) was performed to evaluate the potential impact of Id1 genotype on the regulation of genes mediating proliferation, invasion, migration, angiogenesis and metastasis in LM.

      Results
      The first week after tumor cells intrasplenic injection, FDG-PET scans showed no liver metabolic uptake in any of the mice. By week 2 however, 70% of C57BL/6 mice and 10% of Id1-KO mice showed clear LM by FDG-PET (p=0.02). Three weeks after intrasplenic tumor cells injection, 100% of C57BL/6 animals showed LM compared to 30% of Id1-KO mice (p=0.03). In addition, 50% of Id1-KO mice remained LM-free 4 weeks after tumor cells injection. No other metastatic sites were indentified at the time of necropsy. In the mircroarray gene expression analysis, only a set of 50 out of nearly 900 genes appeared upregulated in the LM of Id1-KO mice compared to C57BL/6 animals whereas the rest of the genes were downregulated. Interestingly, amphiregulin, caveolin-1, aurora kinase B, MMP3, Hsp90aa1, Cdk1, Hif1a, Cyclin D2 were among the significantly downregulated genes in the Id1-KO LM.

      Conclusion
      A novel mouse model for liver metastasis from lung cancer has been developed allowing the study of this complex and unexplored process. Id1 gene expression seems to be a key mediator of the development of liver metastasis from lung cancer in this in vivo model. The absence of Id1 expression in the tumor microenvironment of Id1-KO mice was sufficient to significantly delay and impair the metastatic process of lung cancer tumor cells to the liver. Id1 might be able to modulate LM through a direct downregulation of genes involved in proliferation, invasion, migration, angiogenesis and metastasis. This study has been partially funded by "UTE project CIMA" and an ISCIII-FIS grant 2011.

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      MO04.12 - DISCUSSANT (ID 3895)

      N. Watkins

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    MO21 - Prognostic and Predictive Biomarkers V - EGFR (ID 98)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Medical Oncology
    • Presentations: 12
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      MO21.01 - Randomized Proteomic Stratified Phase III Study of Second Line Erlotinib (E) versus Chemotherapy (CT) in Patients with Inoperable Non-Small Cell Lung Cancer (PROSE): VeriStrat analysis of longitudinal samples (ID 3122)

      A. Bulotta, C. Lazzari, S. Foti, M. Viganò, D. Ghio, S. Novello, S. Barni, M. Aieta, F. Grossi, T. De Pas, F. De Marinis, M. Mencoboni, A. Bearz, J. Roder, H. Roder, J. Grigorieva, I. Floriani, V. Torri, V. Gregorc

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.02 - Pretreatment evaluation of the T790M mutation and its correlation with the response to tyrosine kinase inhibitors (TKIs) or chemotherapy in advanced non-small cell lung cancer (NSCLC) patients with activated EGFR mutations (ID 2455)

      F. Grossi, M.G. Dal Bello, E. Rijavec, C. Sini, C. Genova, G. Barletta, C. Defferrari, S. Coco, A. Truini, A. Alama, S. Zupo, M. Dono

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.03 - Variability of epidermal growth factor receptor (EGFR) mutations in serum during erlotinib therapy and its clinical implications: exploratory analysis of a phase II study of erlotinib in patients with advanced non-small-cell lung cancer (NSCLC) harboring EGFR mutations (ID 2719)

      M. Maemondo, M. Nishio, N. Yamamoto, K. Chikamori, N. Katakami, T. Hida, T. Seto, H. Yoshioka, T. Kozuki, N. Ohishi, T. Tamura

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.04 - Prognostic and Therapeutic Implications of the Aromatase Expression in Lung Adenocarcinoma Harboring EGFR Mutation (ID 2242)

      M. Kohno, T. Okamoto, K. Suda, Y. Suzuki, T. Fujishita, S. Shimamatsu, H. Kitahara, T. Yoshida, Y. Morodomi, D. Kawano, T. Yano, Y. Maehara

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.05 - Integrated genomic analysis by whole exome and transcriptome sequencing of tumor samples from EGFR-mutant non-small-cell lung cancer (NSCLC) patients with acquired resistance to erlotinib. (ID 1426)

      T. Bivona, P. Gianikopoulos, C. Costa, N. Karachaliou, J. St. John, M. Wilkerson, A.F. Cauhlin, O. Westesson, N. Boley, N. Hahner, U. Parikh, M.D. Lozano, S. Viteri, J.L. Perez-Gracia, A. Curioni, E. Jantus-Lewintre, C. Camps, A. Vergnenegre, R. Gervais, A. Wellde, J. Barry, G.W. Wellde Jr., A.F. Cardona, R. Stahel, W.R. Polkinghorn, R. Rosell, J. Weissman

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.06 - DISCUSSANT (ID 3917)

      J.C. Yang

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MO21.07 - Monitoring of EGFR TKI sensitizing and resistance mutations in plasma DNA of advanced adenocarcinoma of NSCLC during erlotinib treatment. (ID 2168)

      B. Sorensen, L. Wu, W. Wen, J. Tsai, B. Weber, E. Nexo, P. Meldgaard

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.08 - Detection of EGFR mutations in plasma and diagnosis biopsies from non-small cell lung cancer patients using allele-specific PCR assays. (ID 2248)

      B. Weber, P. Meldgaard, H. Hager, L. Wu, J. Tsai, W. Wen, A.A. Khalil, E. Nexo, B. Sorensen

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.09 - Dynamic, quantitative, and non-invasive analysis ofT790M mutation in matched plasma DNA from pre-and post-EGFR-TKI treatment for advanced non-small cell lung cancer (ID 2568)

      R. Chen, H. Bai, S. Wang, Y. Wang, J. Duan, J. Wang, T. An, M. Zhuo, M. Wu

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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      MO21.10 - Serial monitoring of plasma EGFR T790M levels and evaluation of EGFR mutational status in matched tissue and plasma from NSCLC patients treated with CO-1686 (ID 2498)

      H.A. Wakelee, C.A. Karlovich, W. Wen, J. Sun, S. Chien, E. Mann, P. O'Donnell, P. Angenendt, R. Dziadziusko, L. Horn, D. Spigel, L.V. Sequist, B. Solomon, J. Soria, D..R. Camidge, J. Goldman, S. Gadgeel, M. Raponi, L. Wu, K. Park

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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

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      MO21.11 - DISCUSSANT (ID 3918)

      G.R. Oxnard

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      MO21.12 - AZD9291: an irreversible, potent and selective tyrosine kinase inhibitor (TKI) of activating (EGFRm+) and resistance (T790M) mutations in advanced NSCLC (ID 2289)

      M. Ranson, W. Pao, D. Kim, S. Kim, Y. Ohe, E. Felip, D. Planchard, S. Ghiorghiu, M. Cantarini, D. Cross, P.A. Jänne

      • Abstract
      • Presentation
      • Slides

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

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

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

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

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    CALC - Chinese Alliance Against Lung Cancer Session (ID 79)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Other Topics
    • Presentations: 1
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      CALC.14 - Summary and Close, Thanks to CALC, Speakers and Sponsors (ID 3881)

      D.C. Lam

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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