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G. Castro Jr.



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    Best of Posters - IASLC Selection - Part 2 (ID 263)

    • Event: WCLC 2013
    • Type: Exhibit Showcase Session
    • Track:
    • Presentations: 1
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      P1.11-018 - An Open-Label, Multicenter, Randomized, Phase II Study of Cisplatin and Pemetrexed With or Without Cixutumumab (IMC-A12) as First-Line Therapy in Patients With Advanced Nonsquamous Non-Small Cell Lung Cancer (ID 1449)

      09:55 - 10:25  |  Author(s): G. Castro Jr.

      • Abstract
      • Slides

      Background
      Pemetrexed combined with cisplatin is an approved first-line treatment regimen for patients with advanced/metastatic nonsquamous non-small cell lung cancer (NSCLC). New targets are needed to further improve first-line therapy outcomes. Cixutumumab, a fully human IgG1 monoclonal antibody, specifically blocks the insulin-like growth factor-type 1 receptor, inhibiting its activation and signal transduction. Early studies have reported clinical efficacy and safety with cixutumumab. However, the clinical benefit of adding cixutumumab to conventional chemotherapy is yet to be established. This study assessed whether pemetrexed and cisplatin combined with cixutumumab was superior to pemetrexed and cisplatin as first-line therapy.

      Methods
      This open-label, multicenter, randomized, phase II study (N=172) enrolled patients ≥18 years of age with stage IV nonsquamous NSCLC and ECOG performance status 0–1. Patients were randomized (1:1) to receive cixutumumab 20 mg/kg combined with pemetrexed 500 mg/m[2] and cisplatin 75 mg/m[2] (cixutumumab arm; n=87) or pemetrexed and cisplatin (control arm; n=85) every 21 days up to 6 cycles of induction therapy. Patients eligible for maintenance therapy received pemetrexed and cixutumumab (cixutumumab arm) or pemetrexed (control arm). The primary endpoint was progression-free survival (PFS) based on radiographic assessments. To test for superiority (1-sided significance level 20%; study power 80%), a median PFS of 7.16 months in the cixutumumab arm (HR cixutumumab/control=0.74) was expected. Secondary endpoints included objective response rate (ORR), duration of response, and overall survival (OS). Adverse events (AEs) were assessed using CTCAE version 4.0. Between-arm comparisons of unstratified data are presented.

      Results
      Baseline patient and disease characteristics were similar between arms in the intent-to-treat population. The mean age of the population was 59 years (range, 32 to 83). Dose intensity for all treatments was ≥90% during both study phases. Median PFS was 5.45 months (95% CI, 3.88–6.05) vs. 5.22 months (95% CI, 4.24–6.74) in the cixutumumab and control arms, respectively (HR 1.15, 95% CI, 0.81–1.61; P=0.440). ORR did not significantly differ between treatments (37.9% cixutumumab vs. 30.6% control; P=0.338); however, the median duration of response was numerically greater in the cixutumumab arm (4.9 months; 95% CI, 4.17–6.28) than in the control arm (3.91 months; 95% CI, 2.92–6.41), although differences were not significant (HR 0.74, 95% CI, 0.40–1.38; P=0.340). Median OS was 10.68 months (95% CI, 8.74–not evaluable) in cixutumumab vs. 10.38 months (95% CI, 7.43–14.39) in control patients (HR 0.85, 95% CI, 0.56–1.30; P=0.450). Common AEs reported in ≥10% of patients were nausea, hyperglycemia, fatigue, vomiting, and anemia. A greater proportion of patients in the cixutumumab arm (74.1%) had grade 3/4 AEs than patients in the control arm (61.7%). Grade 3/4 hyperglycemia occurred at a higher rate in the cixutumumab arm than the control arm (11.8% vs. 1.2%). One possibly cixutumumab-related death occurred during the study.

      Conclusion
      Superior PFS was not achieved in nonsquamous NSCLC patients when cixutumumab was added to the pemetrexed and cisplatin treatment regimen, and no significant improvement for any other endpoint was observed. Pemetrexed combined with cisplatin and cixutumumab was tolerable, with no new safety concerns reported.

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    O03 - NSCLC - Targeted Therapies I (ID 113)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Medical Oncology
    • Presentations: 1
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      O03.02 - Randomized Phase-3 trial (INSPIRE) of Necitumumab plus Cisplatin-Pemetrexed versus Cisplatin-Pemetrexed Alone as First-Line Therapy in Stage IV Non-Squamous NSCLC (ID 2337)

      10:30 - 12:00  |  Author(s): G. Castro Jr.

      • Abstract
      • Presentation
      • Slides

      Background
      Necitumumab is a human IgG1 anti-EGFR1 monoclonal antibody that competes for the binding of natural ligands to this receptor and prevents receptor activation. EGFR1 is detectable in approximately 85% of advanced NSCLC tumors. This phase 3 study investigated necitumumab in combination with first-line chemotherapy in advanced non-squamous NSCLC.

      Methods
      Patients with histologically or cytologically proven stage IV non-squamous NSCLC were randomized 1:1 to either Arm A: cisplatin 75mg/m[2] i.v.-pemetrexed 500mg/m[2] i.v. (Cis + PEM) on Day 1+ necitumumab 800mg i.v. on Days 1 and 8 of a 21-day cycle or Arm B: Cis+PEM alone. Patients received these regimens for up to six cycles. For patients in Arm A with at least stable disease, necitumumab continued until PD or intolerable toxicity. The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), objective response rate (ORR), safety, and EGFR protein expression level by immunohistochemistry (H-score) utilizing archived tumor tissue based on a mandatory tissue collection. The planned sample size of this study was 947 patients (assuming a hazard ratio [HR] of 0.8 would allow 85% power at 2-sided alpha level of 0.05). After 633 patients, enrollment was stopped (after Feb 2011) following an Independent Data Monitoring Committee (IDMC) recommendation.

      Results
      Between Nov 2009 and Feb 2011 633 patients were randomized (315 Arm A; 318 Arm B). Baseline characteristics were balanced between the arms; 67.0% were male and 33.0% female; ECOG-PS 0/1 94.2 % and PS 2 5.7 %. No difference between treatment arms was observed for OS (median 11.3 vs 11.5 months; HR 1.01 95%-CI [0.84, 1.21]), PFS (median 5.6 vs 5.6 months, HR 0.96 95%-CI [0.80, 1.16]) and ORR (31.1 vs 32.1%; Odds ratio 0.96 95%-CI [0.68, 1.34]). The exploratory analysis in 490 patients assessable for H-score revealed no association between H-score and differences in efficacy between treatment arms (H-score < 200: mOS 8.97 vs 9.72 months, HR 1.07, mPFS 4.90 vs 4.76 months, HR 0.95, ORR 27.1 vs 26.0%; H-score ≥ 200: mOS 15.01 vs 13.34 months, HR 1.03, mPFS 5.59 vs 5.62 months, HR 0.94, ORR 39.6 vs 39.4%). Grade ≥ 3 treatment-emergent adverse events (AEs) occurring more frequently in Arm A included skin or subcutaneous disorders (14.1 vs 0.3%), thromboembolic events (9.5 vs 6.4%), hypomagnesaemia (7.6 vs 2.2%), asthenia (6.9 vs 1.9%), vomiting (6.6 vs 3.2%), dyspnea (5.3 vs 2.6%) and diarrhea (4.3 vs 2.2%). The frequency of study drug related deaths was 4.9% and 2.9% in Arms A and B, respectively.

      Conclusion
      In this study, the addition of necitumumab did not improve the efficacy outcome over cisplatin plus pemetrexed alone in advanced non-squamous-NSCLC. The EGFR H-score did not seem to predict the efficacy outcomes of necitumumab in combination with cisplatin plus pemetrexed. The addition of necitumumab resulted in a higher frequency of grade ≥ 3 AE (skin reaction, GI, asthenia and other) and an imbalance of grade ≥ 3 thromboembolic events. Further biomarker studies are ongoing.

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    P2.06 - Poster Session 2 - Prognostic and Predictive Biomarkers (ID 165)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Biology
    • Presentations: 1
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      P2.06-008 - Polymorphisms in the exon 20 of EGFR gene in metastatic lung adenocarcinoma: prognostic relevance and sensitivity to erlotinib. (ID 1027)

      09:30 - 16:30  |  Author(s): G. Castro Jr.

      • Abstract

      Background
      EGFR-activating mutations are predictive of high response rates and overall survival gains in patients (pts) with pulmonary adenocarcinoma, treated with EGFR- tyrosine-kinase inhibitors (EGFR-TKIs), as erlotinib. Mutations in the EGFR gene, especially in the exon 20 (T790M), are related to resistance to EGFR-TKIs. We investigated if a polymorphic DNA sequence in exon 20 (Q787Q, NCBI database 162093G>A, SNP ID: rs1050171) was associated with clinical outcomes in pulmonary adenocarcinomas, treated with erlotinib.

      Methods
      It is a prospective, observational study on all consecutively pts whose tumors were genotyped for EGFR-activating mutations. Tumor samples were formalin-fixed and paraffin-embedded. Tumor areas were selected and macrodissected, followed by whole DNA extraction and amplification by PCR. EGFR genotyping was performed through DNA sequencing (exons 18, 19, 20 and 21) by Sanger´s methodology. Pts with adenocarcinomas harbouring EGFR-activating mutations were treated with erlotinib.

      Results
      191 pts had tumor samples genotyped between Aug/2011 and Apr/2013. Median age was 64 y (17-90), 106 (56%) female. According to ethnicity, 154 pts were Caucasian (81%), 26 African-American (14%) and 11 Asian (6%). Seventy pts were classified as never-smokers (37%), 23 (12%) as light-smokers (≤ 10 p.y.) and 95 as current smokers (51%). EGFR activating mutations could be identified in 54 out of 191 samples (28%): 35 were exon 19 deletions (65%), 15 were L858R mutation in exon 21 (30%), and three were rare mutations (G719S and G719A in exon 18, and V774M in exon 20). Polymorphism Q787Q in EGFR gene (exon 20) was detected in 108 samples (56.5%). The polymorphic status did not correlate with gender (p=0.324), smoking status (p=0.810) or EGFR mutational status (p=0.238), but it was more frequently detected in Caucasian pts (p=0.0002). Considering all 191 studied pts, no difference in median overall survival was detected according to polymorphic status (19.6 mo. vs. 24.3 mo., HR 0.86; 95% CI 0.54-1.38, p=0.541). There was no difference in response rate to erlotinib according to the polymorphic status (p=0.248). In addition, no difference in median overall survival was detected according to polymorphic status among the 38 pts treated with erlotinib and presenting EGFR-activating mutations (not reached in both groups, HR 2.44; 95% CI 0.31-16.01, p=0.425).

      Conclusion
      Polymorphism Q787Q in EGFR gene (exon 20) was commonly detected in pulmonary adenocarcinomas (56.5%), being more frequent in Caucasian pts. The presence of polymorphic status was neither related to sensitivity to erlotinib, nor to survival outcomes in our pts.

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    P2.11 - Poster Session 2 - NSCLC Novel Therapies (ID 209)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P2.11-009 - Erlotinib in metastatic pulmonary adenocarcinomas harbouring EGFR activating mutations, in Sao Paulo - Brazil. (ID 1025)

      09:30 - 16:30  |  Author(s): G. Castro Jr.

      • Abstract

      Background
      Background: EGFR-activating mutations are predictive of high response rates and overall survival gains in patients (pts) with pulmonary adenocarcinomas, treated with EGFR- tyrosine-kinase inhibitors (EGFR-TKIs), as erlotinib. Our objectives in this study were to analyze the efficacy and safety of erlotinib as first-line therapy or later in pts with adenocarcinomas harbouring EGFR-activating mutations.

      Methods
      Methods: It is a prospective, observational study on all consecutively pts whose tumors were genotyped for EGFR-activating mutations. All studied pts were treated in a single institution (ICESP) with erlotinib 150 mg PO daily. Tumor samples were formalin-fixed and paraffin-embedded. Tumor areas were selected and macrodissected, followed by whole DNA extraction and amplification by PCR. EGFR genotyping was performed through DNA sequencing (exons 18, 19, 20 and 21) by Sanger´s methodology.

      Results
      Results: 49 pts were treated with erlotinib from Nov/2010 to May/2013, as first-line (11 pts, 22%), second-line (31 pts, 63%) or third-line therapy (7 pts, 14%). Erlotinib was administered during a median time of 4 mo. (0.2-23.6 mo.). Among these 49 pts, 38 (78%) were diagnosed with adenocarcinomas harbouring EGFR-activating mutations: 26 with exon 19 deletions, 10 with L858R mutation in exon 21 and one presented a rare mutation in exon 18 (G719S). As expected, erlotinib was well tolerated, and acneiform rash and diarrhea were the most commonly observed toxicities. No treatment-related deaths were seen. Tumor response assessment was done in 42 pts: progressive disease was observed in 15 pts (36%) and 27 pts (64%) presented either partial response or disease stabilization. In a mean follow-up of 14 mo., 13 pts were dead. Median overall survival was not reached for the 38 pts with EGFR-mutated adenocarcinomas, and 1-year overall survival rate was 94% in these pts. In those pts with wild-type EGFR tumors, median overall survival was 15.6 mo (HR 0.17; 95% CI 0.02-0.33, p=0.0004). No difference in overall survival was observed between pts with EGFR-mutated adenocarcinomas if treated with erlotinib either as first-line therapy or later (HR 1.11; 95% CI 0.20-6.15, p=0.895). No difference in overall survival was observed between pts with EGFR-mutated adenocarcinomas according to the type of mutations (exon 19 deletions or others, p=0.147).

      Conclusion
      Conclusions: High rate of disease control (64%) and an impressive 1-year overall survival rate (94%) were observed among pts with metastatic pulmonary adenocarcinomas harbouring EGFR-activating mutations, as expected, with a favorable toxicity profile. These results do reinforce the importance of the correct identification of this subgroup of pts with EGFR-activating mutations and their treatment with an EGFR-TKI as a targeted therapy.

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    P3.22 - Poster Session 3 - Epidemiology, Etiology (ID 168)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Prevention & Epidemiology
    • Presentations: 1
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      P3.22-003 - EGFR genotyping and epidemiology, clinical and pathological features in 191 patients with metastatic pulmonary adenocarcinoma in Sao Paulo - Brazil. (ID 1026)

      09:30 - 16:30  |  Author(s): G. Castro Jr.

      • Abstract

      Background
      EGFR activating mutations in pulmonary adenocarcinoma does confer better prognosis and are also predictive of higher response rates to both chemotherapy and EGFR-tyrosine kinase inhibitors. Therefore, EGFR genotyping in these patients (pts) is a very helpful biomarker for treatment selection. Here we aimed to report the results of consecutive EGFR genotyping in our Institution in Sao Paulo - Brazil.

      Methods
      It is a prospective, observational study on all consecutively tested samples from pts diagnosed with pulmonary adenocarcinoma and treated at ICESP. All samples were formalin-fixed and paraffin-embedded. Tumor areas were selected and macrodissected, followed by whole DNA extraction and amplification by PCR. EGFR genotyping was performed through DNA sequencing (exons 18, 19, 20 and 21) by Sanger´s methodology.

      Results
      191 pts had tumor samples genotyped between Aug/2011 and Apr/2013. Median age was 64 y (17-90), 106 (56%) female. According to ethnicity, 154 pts were Caucasian (81%), 26 African-American (14%) and 11 Asian (6%). Seventy pts were classified as never-smokers (37%), 23 (12%) as light-smokers (≤ 10 p.y.) and 95 as current smokers (51%). EGFR activating mutations could be identified in 54 out of 191 samples (28%): 35 were exon 19 deletions (65%), 15 were L858R mutation in exon 21 (30%), and three were rare mutations (G719S and G719A in exon 18, and V774M in exon 20). These mutations were found to be more frequent in females than in males (56% vs. 45%, p=0.035), and in never-smokers and light-smokers than in current smokers (77% vs. 20%, p<0.0001). It is noteworthy to mention that 11 mutations were detected in current smokers. All tumors harboring EGFR activating mutations presented TTF-1 expression by immunohistochemistry, and among those seven TTF-1-negative adenocarcinomas, no mutation was detected (p=0.0969). In a mean follow-up of 12 months, 77 pts were dead. Median overall survival was not reached in those pts whose tumors harboring EGFR-activating mutations, versus 19 months in pts with wild-type EGFR tumors (HR 0.40; 95%CI 0.29-0.78, p=0.003).

      Conclusion
      In this group of pts, the frequency of EGFR activating mutations was 28%, being more frequent in females, and never-smokers or light smokers, as previously described. Indeed, the presence of EGFR activating mutations was a favorable prognostic factor. The data here presented does reinforce the importance of testing EGFR activating mutations in all pts with TTF-1-positive, pulmonary adenocarcinoma.

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    P3.24 - Poster Session 3 - Supportive Care (ID 160)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P3.24-051 - Primary Thoracic Angiosarcoma: Treatment and outcomes of 5 patients (ID 3280)

      09:30 - 16:30  |  Author(s): G. Castro Jr.

      • Abstract

      Background
      Angiosarcomas (AS) are rare aggressive tumors that represent about 1-2% of all soft-tissue sarcomas; 9.5% of them arise in the thorax. We describe five patients diagnosed with thoracic AS who were treated at ICESP.

      Methods
      It is a case series descriptive study with review of the medical files from five consecutively registered patients with AS confirmed by immunohistochemistry at our institution between June 2010 and March 2013.

      Results
      Case 1: A 49-year-old woman was admitted with pulmonary AS presenting progressive dyspnea and a recent hemoptysis. Pneumonectomy was performed in April 2011 and she was treated with adjuvant doxorubicin (every 3 weeks, 4 cycles) and paclitaxel (12 weeks). After 7 months, she developed progressive disease (PD) in liver, bones and lymph nodes. Weekly paclitaxel was restarted, but she had hepatic PD. Since May 2013 she has been treated with liposomal doxorubicin. She is alive after 26 months of diagnosis. Case 2: A 62-year-old woman was diagnosed with metastatic paracardiac AS after cardiac tamponade. She was treated with weekly paclitaxel and developed PD in liver and lungs. She died 3 months after diagnosis. Case 3: A 32-year-old man, was diagnosed with a primary AS in the right ventricle, metastatic to lungs, was admitted with recurrent pericardial effusion for 6 months. The tumor was considered unresectable and he was treated with doxorubicin and ifosfamide (only one cycle), temporarily interrupted due to febrile neutropenia grade 4, but with a partial response. He is alive after 3 months of diagnosis. Case 4: A 31-year-old man was diagnosed with unresectable AS in the right atrium after developing a superior vena cava syndrome. Weekly paclitaxel was started, with initial clinical improvement, but PD was detected after 6 cycles (24 weeks). As a second-line treatment, doxorubicin and ifosfamide were administered, with PD in lungs after 5 cycles. He died 13 months after the beginning of chemotherapy. Case 5: A 58-year-old woman was diagnosed with a right infraclavicular unresectable AS with local pain and edema in the upper right arm for one year. No response was seen after two cycles of doxorubicin and ifosfamide. Palliative radiotherapy followed by weekly paclitaxel was attempted as a second-line therapy with no response. Best supportive care was started and she is alive 6 months after diagnosis.

      Conclusion
      We concluded that thoracic AS presents a very dismal prognosis, due to the primary location and the high incidence of metastatic disease. For those patients with resectable disease and curative intent, surgery must always be considered. Weekly paclitaxel and the combination of doxorubicin and ifosfamide are both active in thoracic AS, but responses usually were not long-lasting. Oral tyrosine kinase inhibitors with antiangiogenic properties may be an option to be better explored.