Effect of trastuzumab (herceptin) administration on circulating CK-19 mRNA positive tumor cells, in peripheral blood and bone marrow, of breast cancer patients

Many investigators have shown that by using either monoclonal antibodies against molecules expressed on epithelial but not on mesenchymal cells, or molecular biology techniques, occult tumor cells can be detected in the bone marrow and/or the peripheral blood of patients with early and metastatic breast cancer. Moreover, prospective studies in patients with early stage breast cancer have shown that the detection of disseminated occult tumor cells in the bone marrow or the peripheral blood is an independent adverse prognostic factor associated with decreased disease-free survival (DFS) and overall survival (OS). In many patients (>50%), DTCs/CTCs are not killed by the administration of chemotherapeutic agents. Furthermore, the detection of micrometastatic cells after the administration of chemotherapy is associated with an increased risk of relapse and reduced survival. Although the HER2 receptor is overexpressed in 25-30% of the primary breast carcinomas, the overexpression of the receptor in CTCs/DTCs is >60% independently of HER2 expression on the primary tumor. The expression of HER2 on CTCs/DTCs is an independent prognostic factor associated with increased risk of relapse and reduced survival. Therefore, HER2 receptor could represent a suitable target for micrometastatic cells' elimination. In the first part of this study, we investigated the effectiveness of the anti-HER2 monoclonal antibody trastuzumab (Herceptin) to target the chemo resistant occult tumor cells in the peripheral blood and bone marrow of patients with breast cancer. For the detection of these cells, we used a nested RT-PCR and a real-time RT-PCR assay specific for cytokeratin-19 (CK-19) messenger RNA (mRNA). After trastuzumab infusions, overall 28 of 30 (93%) patients became CK19mRNA negative by nested RT-PCR and 20 of 30 (67%) by real-time RT-PCR. Since trastuzumab's administration effectively eliminates chemo-resistant CTCs, in the second part of this study we investigated the effect of trastuzumab on patients' clinical outcome. 75 patients with early HER2-negative breast cancer and detectable CK19mRNA-positive CTCs before and after adjuvant chemotherapy were randomized to receive either trastuzumab or observation. CK19 mRNA-positive CTCs were detected by RT-PCR and double-stained CK positive/HER2-positive cells by immunofluorescence. The primary end point was the 3-year disease-free survival (DFS) rate. After trastuzumab administration, 72% of the women in the trastuzumab arm became CK19mRNA-negative compared with 26% in the observation arm (P = 0.001). After a median follow-up time of 67.2 months, 4 (11%) and 15 (38%) relapses were observed in the trastuzumab and observation arm, respectively (P = 0.008). The median DFS was also significantly higher for the trastuzumab-treated patients (P = 0.008). Our results demonstrate that treatment with secondary adjuvant trastuzumab resulted in a significantly reduced probability of disease relapse and increased disease-free interval compared with patients receiving only standard treatment. A larger, multicenter, prospective randomized clinical trial is required to confirmthese findings.Η ανίχνευση κυκλοφορούντων στο περιφερικό αίμα (Circulating Tumor Cells-CTCs) ή διεσπαρμένων στο μυελό των οστών (Disseminated Tumor Cells-DTCs) καρκινικών κυττάρων ορίζεται ως μικρομεταστατική νόσος και σχετίζεται με χειρότερη πρόγνωση, αυξημένο κίνδυνο υποτροπής και μικρότερη επιβίωση, σε ασθενείς με πρώιμο ή μεταστατικό καρκίνο του μαστού. Η ανίχνευση της μικρομεταστατικής νόσου βασίζεται στη χρήση μονοκλωνικών αντισωμάτων κατά μορίων, όπως οι κυτταροκερατίνες, τα οποία εκφράζονται στα επιθηλιακά αλλά όχι στα μεσεγχυματικά αιμοποιητικά κύτταρα. Μεγαλύτερη ευαισθησία έχει η κυτταροκερατίνη 19 (CK-19) με ανοσοκυτταροχημεία. Εναλλακτικά μπορούν να χρησιμοποιηθούν μοριακές τεχνικές (PCR, RT-PCR). Τα κυτταροτοξικά φάρμακα εξαλείφουν τα μικρομεταστατικά κύτταρα σε 60%) αυτής του πρωτοπαθούς όγκου (20-25%). Η ανίχνευση HER2-θετικώνCTCs/DTCs σχετίζεται με μειωμένη ελεύθερη νόσου (DFS) και συνολική επιβίωση (OS). Στοχεύσαμε τα χημειο-ανθεκτικά μικρομεταστατικά κύτταρα με το αντι-HER2 μονοκλωνικό αντίσωμα Trastuzumab (Herceptin) με σκοπό να δείξουμε αν συμβάλλει στην εξάλειψη τους, και εφόσον αυτό συμβαίνει ποια επίπτωση έχει στην κλινική έκβαση ασθενών με πρώιμο καρκίνο του μαστού. Στο πρώτο σκέλος της μελέτης, ένα βραχύ σχήμα χορήγησης του trastuzumab πέτυχε να εξαλείψει τα μικρομεταστατικά κύτταρα στο 93% 30 προθεραπευμένων ασθενών με πρώιμο ή μεταστατικό καρκίνο του μαστού. Η ανίχνευση του CK19mRNA έγινε με nested RT-PCR (ποιοτικά) και σε 16 ασθενείς που υπήρχαν διαθέσιμα δείγματα έγινε και ποσοτικός προσδιορισμός του CK19mRNA με realtime RT-PCR. Στο δεύτερο σκέλος, 75 ασθενείς με πρώιμο HER2-αpvητικó καρκίνο μαστού και ανιχνεύσιμα CTCs πριν και μετά τη συμπληρωματική ΧΜΘ, τυχαιοποιήθηκαν σε trastuzumab έναντι παρακολούθησης, με πρωτεύοντα στόχο το DFS στα 3 έτη και δευτερεύοντα το ποσοστό εξάλειψης των CTCs. 72% των ασθενών στο σκέλος του trastuzumab έναντι μόνο 26% στο σκέλος της παρακολούθησης αρνητικοποίησαν το CK19mRNA. CK+/HER2+ CTCs ανιχνεύθηκαν σε ποσοστό 90% των ασθενών, με ανοσοφθορισμό. Η στόχευση των ανθεκτικών CTCs με το αντίσωμα επιτυγχάνει σημαντική μείωση του κινδύνου υποτροπής και παράταση της ελεύθερης νόσου επιβίωσης (DFS). Το όφελος του trastuzumab φαίνεται να οφείλεται στην εξάλειψη των CK+/HER2+ CTCs και άρα η χρήση του θα μπορούσε πιθανά να ωφελήσει και ασθενείς με HER2-αpvητικoύςπρωτοπαθείς όγκους. Τα αποτελέσματα είναι ενδεικτικά της κλινικής σημασίας που μπορεί να έχει η στόχευση των χημειο-ανθεκτικών CTCs με τη «συμπληρωματική» χορήγηση του trastuzumab. Επιβεβαίωση τους απαιτείται με μεγαλύτερη, πολυκεντρική, τυχαιοποιημένη κλινική μελέτη

Real-world experience of everolimus as second-line treatment in metastatic renal cell cancer after failure of pazopanib.

We aimed to provide real-life data on the outcomes of metastatic renal cell carcinoma (mRCC) patients treated with everolimus as second-line treatment after failure of first-line pazopanib. Data from the medical charts of mRCC patients from 8 centers in Greece and Spain were reviewed. All patients had received or were continuing to receive second-line everolimus treatment after failure of first-line treatment with pazopanib. No other previous therapies were allowed. The primary end point was the determination of progression-free survival (PFS). In total, 31 patients were enrolled. Of these, 26% had performance status (PS) >0, 88% were of intermediate/poor Memorial Sloan-Kettering Cancer Center (MSKCC) risk group, and only 61% had undergone prior nephrectomy. Median PFS was 3.48 months (95% CI: 2.37-5.06 months). Median overall survival (OS) from everolimus initiation was 8.9 months (95% CI: 6.47-13.14 months). Median OS from pazopanib initiation was 14.78 months (95% CI: 10.54-19.08 months). Furthermore, 32% of patients temporarily discontinued everolimus due to adverse events (AEs), and 22% of patients discontinued everolimus permanently due to toxicity. Most common toxicities were anemia (29%), stomatitis (26%), pneumonitis (19%), and fatigue (10%). Moreover, 14 AEs (27%) were graded as 3 or 4 and were reported by 13 patients (42%). This study provides data exclusively on the sequence pazopanib-everolimus in mRCC. Everolimus has a favorable safety profile and is active. The short PFS and OS could be attributed to the fact that the pazopanib-everolimus sequence was mainly offered to patients with adverse prognostic features, resulting in a modest increase in the combined OS of our population

Salvage treatment in metastatic breast cancer with weekly paclitaxel and bevacizumab

Weekly paclitaxel (P) in combination with bevacizumab (B) is an effective regimen as initial treatment of metastatic breast cancer (MBC). We investigated in a phase II study the activity of the same regimen as salvage therapy in MBC. Pretreated women with MBC received weekly P (90 mg/m(2) days 1, 8, 15) and B (10 mg/kg days 1, 15) every 28 days. B could continue after discontinuing P until disease progression. This was second-line chemotherapy for 30% and third-line or more for 70% of patients. A total of 40 patients were enrolled. Median age: 61 (range 32-80) years; postmenopausal: 80%; baseline ECOG performance status < 2 in 80% of patients. Two patients (5%) achieved complete response, 10 (25%) partial response (overall response rate 30%; 95% CI 15.8-44.2), and 10 (25%) stable disease. The response rate was 28% for the patients who had previously received taxanes. After a median follow-up of 20.6 months, the median time to progression was 4.8 months (95% CI 1.7-7.8), median survival 13.0 months (95% CI 10.3-15.7), and the probability of 1-year survival 55.5%. Main grade 3-4 toxicities were neutropenia 42.5%, febrile neutropenia 5%, and asthenia 10%. There was one toxic death due to sepsis. The PB regimen is well tolerated and active as salvage therapy in pretreated women with MBC. It could be an effective option even for patients exposed to taxanes during prior treatments