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A. Siggillino



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    ORAL 16 - Clinical Care of Lung Cancer and Advanced Biopsies (ID 115)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Treatment of Advanced Diseases - NSCLC
    • Presentations: 1
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      ORAL16.01 - Tyrosine Kinase Inhibitors (TKIs) for the Treatment of Brain Metastases (BMs) from Advanced Lung Cancer : A Large Retrospective Cohort Study (ID 2824)

      10:45 - 12:15  |  Author(s): A. Siggillino

      • Abstract
      • Presentation
      • Slides

      Background:
      BMs are found in up to 30% of patients (pts) with advanced non small cell lung cancer (NSCLC), and are associated with a poor prognosis despite radiotherapy treatment, with a median survival of 6 months (mo). Several data are suggesting the potential brain activity of tyrosin kinase inhibitors (TKIs) alone in NSCLC pts with activating mutations. We retrospectively identified EGFR mutated and ALK rearranged NSCLCs with BMs, to evaluate the efficacy of TKIs and their role in the upfront setting.

      Methods:
      Out of a cohort of 270 never smoker (NS) NSCLC patients (pts) treated at our Institution from 2/2006 to 2/2015, 89 (32.9%) NSCLCs BMs were identified, synchronous in 27 pts (30.3%). 38 pts (42.7%) harboured an EGFR mutation, 33 pts (37.1%) were ALK rearranged, 18 pts (20.2%) negative for both, were used as a control cohort. Among the EGFR mutated, an in-frame deletion in exon 19 (mostly E746-A750) was found in 26 (68.4%) patients, while a point mutation in exon 21 (L858R) was detected in 10 (26.4%), 1 (2.6%) exon 18 mutation and 1 (2.6%) exon 20 insertion were identified. The majority of EGFR and ALK positive (+) pts with BMs were female (53.9%), median age 52, adenocarcinoma histology, and a good performance status.

      Results:
      Out of the 71 NSCLCs with BMs EGFR/ALK+, 58 pts (81.7%) received at least one line of chemotherapy, while 13 pts (18.3%) were only treated with TKIs. Of the entire series, 40 pts (56.3%) were treated with standard radiotherapy (WBRT or radiosurgery) prior to TKIs treatment, while 31 (43.7%) received a TKI upfront, distributed as follows: 13 pts (37.9%) were treated with an EGFR inhibitor (gefitinib/erlotinib/afatinib), while 18 pts (62.1%) with an ALK TKI (crizotinib/ceritinib/alectinib). All the pts in the molecular negative cohort, received WBRT and, at least, one line of chemotherapy. Within the entire series, Overall Intracranial Response Rate (OIRR: complete response CR + partial response PR) was evaluated: EGFR+ 31 pts (81.5%), ALK+ 28 pts (84.8%), control cohort 6 pts (33.3%) (p,0.003). Median [95% CI] overall survival (OS) for EGFR mutans, ALK + and EGFR/ALK negative was: 52 months (mo) (32.6-74.4),74 mo (not reached), 25 mo (9.4-40.03) (p,0.003). In the subgroup who received a TKI upfront, all EGFR+ achieved a PR, while all ALK+ obtained an objective response: 4 (22.2%) a CR and 14 (77.8%) a PR. No significant difference in OS between EGFR/ALK+ BMs treated with a TKI upfront versus further line.

      Conclusion:
      This retrospective study confirms that TKIs are strongly active in patients with BMs from NSCLCs harbouring a sensitive mutation. Brain disease control was achieved in an impressive 81.5% of the EGFR+ pts and 84.8% of the ALK+ subset. Of particular note, is the highest response rate in the TKI upfront arm, with 22.2% attaining a complete remission. We conclude that the use of TKIs in first line setting for BMs treatment may be a reasonable option for asymptomatic subgroup of patients with a long survival expectation, for whom WBRT may be postponed at a later disease stage.

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    P1.04 - Poster Session/ Biology, Pathology, and Molecular Testing (ID 233)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Biology, Pathology, and Molecular Testing
    • Presentations: 1
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      P1.04-002 - Protein Signaling Analysis of KRAS Mutant Lung Adenocarcionomas Reveals Variable MAPK and mTOR Pathway Activation (ID 2280)

      09:30 - 17:00  |  Author(s): A. Siggillino

      • Abstract

      Background:
      Despite the numerous efforts made to target KRAS directly, this protein is still undruggable. A number of therapeutics that target linked KRAS pathway members have been tested, but their efficacy in KRAS mutant lung adenocarcinoma is still controversial. Understanding the biochemically linked protein signaling network associated with a KRAS mutation may lead to the identification of therapeutic targets to identify patients that may benefit from a therapeutic agent targeting KRAS downstream substrates.

      Methods:
      Thirty-four archived samples from surgically-treated KRAS mutant adenocarcinomas were included in this study. Samples were collected at the H.Lee Moffitt Cancer Center & Research Institute (Tampa, FL) and at the Santa Maria della Misericordia Hospital (Perugia, Italy). Pure cancer epithelial cell subpopulations were isolated using Laser Capture Microdissection. The expression/activation level of 155 proteins was then measured by Reverse Phase Protein Microarray, a high-throughput semi-quantitative platform.

      Results:
      The protein activation level of ERK (as measured by phosphorylation of T202/Y204), a direct downstream substrate of KRAS activity, was highly variable across KRAS mutant samples. While a subgroup of patients showed, as expected, high activation of ERK, approximately 2/3 of the patients had a comparable ERK activation level to the wild-type counterpart previously analyzed. The activation level of the remaining protein signaling analytes was then compared between samples with high and low ERK activation. Tumors with high levels of ERK activation showed a significant increase in the signaling network of: 1) the MAPK proliferative pathway including Ras-GRF1 S916, Mek 1/2 S217/221, MSK1 S360, p38MAPKinase T180/Y182 (p=0.03, p<0.01, p=0.04, p<0.01 respectively), 2) the AKT-mTOR pathway including Akt S473, AMPKα1 S485, ATP Citrate Lyase S454, LKB1 S428, mTOR S2448, p70S6K T389, p70S6K T412, 4E-BP1 S65 (p<0.01, p<0.01, p<0.01, p<0.01, p<0.01, p<0.01, p=0.02, p=0.03 respectively).

      Conclusion:
      This analysis suggests that the signaling network of KRAS mutant lung adenocarcinomas, while manifesting expected ERK activation as a group, is highly variable. In fact a majority of KRAS mutant tumors had the same range of MEK-ERK activation as KRAS WT tumors. Analysis of high and low ERK activation in the KRAS mutant tumors revealed druggable protein signaling activation of a number of important targets. If validated in a larger study set, these data may have important clinical implication for the allocation of patients toward more effective and specific targeted treatments.