Analysis of angiogenesis biomarkers for ramucirumab efficacy in patients with metastatic colorectal cancer from RAISE, a global, randomized, double-blind, phase III study

Background: The phase III RAISE trial (NCT01183780) demonstrated that the vascular endothelial growth factor (VEGF) receptor (VEGFR)-2 binding monoclonal antibody ramucirumab plus 5-fluororuracil, leucovorin, and irinotecan (FOLFIRI) significantly improved overall survival (OS) and progression-free survival (PFS) compared with placebo + FOLFIRI as second-line metastatic colorectal cancer (mCRC) treatment. To identify patients who benefit the most from VEGFR-2 blockade, the RAISE trial design included a prospective and comprehensive biomarker program that assessed the association of biomarkers with ramucirumab efficacy outcomes. Patients and methods: Plasma and tumor tissue collection was mandatory. Overall, 1072 patients were randomized 1 : 1 to the addition of ramucirumab or placebo to FOLFIRI chemotherapy. Patients were then randomized 1 : 2, for the biomarker program, to marker exploratory (ME) and marker confirmatory (MC) groups. Analyses were carried out using exploratory assays to assess the correlations of baseline marker levels [VEGF-C, VEGF-D, sVEGFR-1, sVEGFR-2, sVEGFR-3 (plasma), and VEGFR-2 (tumor tissue)] with clinical outcomes. Cox regression analyses were carried out for each candidate biomarker with stratification factor adjustment. Results: Biomarker results were available from >80% (n = 894) of patients. Analysis of the ME subset determined a VEGF-D level of 115 pg/ml was appropriate for high/low subgroup analyses. Evaluation of the combined ME + MC populations found that the median OS in the ramucirumab + FOLFIRI arm compared with placebo + FOLFIRI showed an improvement of 2.4 months in the high VEGF-D subgroup [13.9 months (95% CI 12.5-15.6) versus 11.5 months (95% CI 10.1-12.4), respectively], and a decrease of 0.5 month in the low VEGF-D subgroup [12.6 months (95% CI 10.7-14.0) versus 13.1 months (95% CI 11.8-17.0), respectively]. PFS results were consistent with OS. No trends were evident with the other antiangiogenic candidate biomarkers. Conclusions: The RAISE biomarker program identified VEGF-D as a potential predictive biomarker for ramucirumab efficacy in second-line mCRC. Development of an assay appropriate for testing in clinical practice is currently ongoing

Phase 2 study results of murlentamab, a monoclonal antibody targeting the Anti-Mullerian-Hormone-Receptor II (AMHRII), acting through Tumor-Associated Macrophage engagement in advanced/metastatic colorectal cancers

Introduction: Membranous expression of AMHRII is present in about 80% of colorectal adenocarcinomas. Murlentamab is a glycoengineered mAb binding with high affinity both AMHRII on the tumor cell membrane and CD16 via its low-fucose Fc on macrophages, inducing phagocytosis. Murlentamab reprograms TAMs, restoring their antitumoral functions, also resulting in cytotoxic T lymphocyte activation. Methods: Patients with pretreated advanced/metastatic colorectal adenocarcinoma, measurable disease, performance status ≤1, adequate organ function, baseline tumor biopsy, and agreeing to a subsequent biopsy under treatment, received murlentamab single agent (SA) or in combination with trifluridine/tipiracil (FTD/TPI) in two parallel non-randomized cohorts. Antitumor activity (objective response by RECIST 1.1, Tumor Growth Rate (TGR), progression-free survival (PFS), overall survival), pharmacodynamics (circulating immune cells and tumor microenvironment) and safety were to be assessed in 30 patients (15 in each cohort) evaluable for efficacy (having completed at least two 28-day cycles of treatment and with at least one tumor assessment under treatment). Results: Thirty-nine heavily pretreated patients were enrolled and received murlentamab, SA or in combination with FTD/TPI. Fourteen patients in SA and 15 patients in combination with FTD/TPI (after a median of 4 and 2 prior therapy lines, respectively) were evaluable for efficacy. No objective responses were observed. A 1.7-fold and 3.6-fold TGR decrease was observed with murlentamab SA and murlentamab combined with FTD/TPI, respectively. In the murlentamab SA cohort, 21% (3/14) of patients were progression-free at 2 months. In combination with FTD/TPI, 53% (8/15), 40% (6/15) and 31% (4/13) of patients were progression-free at 2, 4 and 6 months, respectively. Among patients with more than 20% AMHRII-positive tumor cells, 5/6 and 3/4 patients were stabilized at 4 and 6 months, respectively. In contrast, the 7 patients progressing at their first tumor evaluation (2 months) had less than 20% of AMHRII-positive tumor cells. In the 7 paired biopsies analyzed, tumor microenvironment immune activation (staining positive area increase) under murlentamab was observed: CD16 in 6/7 tumors reflecting macrophage activation; granzymeB/CD16 co-localisation in 5/7 tumors reflecting phagocytosis. In the paired biopsies from 2 patients stabilized at 4 months in combination with FTD/TPI, CD86 on antigen presenting cells and CD8 on T cell increased, reflecting activation. In the peripheral blood (samples from 20 patients analyzed), a significant activation of monocytes (CD69+) and neutrophils (CD64+) was observed under murlentamab SA and in combination with FTD/TPI. No serious adverse events related to murlentamab were reported. All 36 reported murlentamab toxicities experienced by 10 patients in combination with FTD/TPI cohort were G1-2, the most common being: decreased appetite (9 events), vomiting, nausea, constipation and asthenia (3 events each). No overlapping toxicities were observed when combining murlentamab with FTD/TPI. Conclusion: This pilot study suggests longer than expected PFS for murlentamab and FTD/TPI in advanced mCRC, especially in patients with high AMHRII expression. Immune activation of the macrophage / cytotoxic T cell cascade was observed in tumor microenvironment as well as in peripheral blood. These results together with murlentamab’s innovative immunological mode of action support its further development in combination with standard chemotherapies and/or immunological agents in colorectal cancers

Biomarker analysis beyond angiogenesis: RAS/RAF mutation status, tumour sidedness, and second-line ramucirumab efficacy in patients with metastatic colorectal carcinoma from RAISE-a global phase III study

Background: : Second-line treatment with ramucirumab+FOLFIRI improved overall survival (OS) versus placebo+FOLFIRI for patients with metastatic colorectal carcinoma (CRC) [hazard ratio (HR)=0.84, 95% CI 0.73-0.98, P = 0.022]. Post hoc analyses of RAISE patient data examined the association of RAS/RAF mutation status and the anatomical location of the primary CRC tumour (left versus right) with efficacy parameters. Patients and methods: Patient tumour tissue was classified as BRAF mutant, KRAS/NRAS (RAS) mutant, or RAS/BRAF wild-type. Left-CRC was defined as the splenic flexure, descending and sigmoid colon, and rectum; right-CRC included transverse, ascending colon, and cecum. Results: RAS/RAF mutation status was available for 85% of patients (912/1072) and primary tumour location was known for 94.4% of patients (1012/1072). A favourable and comparable ramucirumab treatment effect was observed for patients with RAS mutations (OS HR = 0.86, 95% CI 0.71-1.04) and patients with RAS/BRAF wild-type tumours (OS HR = 0.86, 95% CI 0.64-1.14). Among the 41 patients with BRAF-mutated tumours, the ramucirumab benefit was more notable (OS HR = 0.54, 95% CI 0.25-1.13), although, as with the other genetic sub-group analyses, differences were not statistically significant. Progression-free survival (PFS) data followed the same trend. Treatment-by-mutation status interaction tests (OS P = 0.523, PFS P = 0.655) indicated that the ramucirumab benefit was not statistically different among the mutation sub-groups, although the small sample size of the BRAF group limited the analysis. Addition of ramucirumab to FOLFIRI improved left-CRC median OS by 2.5 month over placebo (HR = 0.81, 95% CI 0.68-0.97); median OS for ramucirumab-treated patients with right-CRC was 1.1 month over placebo (HR = 0.97, 95% CI 0.75-1.26). The treatment-by-sub-group interaction was not statistically significant for tumour sidedness (P = 0.276). Conclusions: In the RAISE study, the addition of ramucirumab to FOLFIRI improved patient outcomes, regardless of RAS/RAF mutation status, and tumour sidedness. Ramucirumab treatment provided a numerically substantial benefit in BRAF-mutated tumours, although the P-values were not statistically significant. ClinicalTrials.gov number: NCT01183780.status: publishe

Dendrochronological data from twelve countries proved definite growth response of black alder (Alnus glutinosa [L.] Gaertn.) to climate courses across its distribution range

Black alder (Alnusglutinosa [L.] Gaertn.) is an important component of riparian and wetland ecosystems in Europe. However, data on the growth of this significant broadleaved tree species is very limited. Presently, black alder currently suffers from the pathogen Phytophthora and is particularly threatened by climate change. The objective of this study was to focus on the impact of climatic variables (precipitation, temperature, extreme climatic events) on the radial growth of alder across its geographic range during the period 1975-2015. The study of alder stands aged 46-108 years was conducted on 24 research plots in a wide altitude range (85-1015 m) in 12 countries of Europe and Asia. The most significant months affecting alder radial growth were February and March, where air temperatures are more significant than precipitation. Heavy frost and extreme weather fluctuations in the first quarter of the year were the main limiting factors for diameter increment. Within the geographical setting, latitude had a higher effect on radial growth compared to longitude. However, the most important variable concerning growth parameters was altitude. The temperature's effect on the increment was negative in the lowlands and yet turned to positive with increasing altitude. Moreover, growth sensitivity to precipitation significantly decreased with the increasing age of alder stands. In conclusion, the growth variability of alder and the number of negative pointer years increased with time, which was caused by the ongoing climate change and also a possible drop in the groundwater level. Riparian alder stands well supplied with water are better adapted to climatic extremes compared to plateau and marshy sites

A randomized, placebo-controlled phase 2 study of paclitaxel in combination with reparixin compared to paclitaxel alone as front-line therapy for metastatic triple-negative breast cancer (fRida)

Purpose: CXCR1, one of the receptors for CXCL8, has been identified as a druggable target on breast cancer cancer stem cells (CSC). Reparixin (R), an investigational oral inhibitor of CXCR1, was safely administered to metastatic breast cancer patients in combination with paclitaxel (P) and appeared to reduce CSC in a window-of-opportunity trial in operable breast cancer. The fRida trial (NCT02370238) evaluated the addition of R to weekly as first-line therapy for metastatic (m) TNBC. Subjects and Methods: Subjects with untreated mTNBC were randomized 1:1 to R or placebo days 1–21 in combination with weekly P 80 mg/m2 on days 1, 8, 15 of 28-day cycles. The primary endpoint was PFS by central review. Results: 123 subjects were randomized (62 to R + P and 61 to placebo + P). PFS was not different between the 2 groups (median 5.5 and 5.6 months for R + P and placebo + P, respectively; HR 1.13, p = 0.5996). ALDH+ and CD24−/CD44+ CSC centrally evaluated by IHC were found in 16 and 34 of the 54 subjects who provided a metastatic tissue biopsy at study entry. Serious adverse events (21.3 and 20% of subjects) and grade ≥ 3 adverse reactions (ADR) (9.1 and 6.3% of all ADRs) occurred at similar frequency in both groups. Conclusion: fRida is the first randomized, double-blind clinical trial of a CSC-targeting agent in combination with chemotherapy in breast cancer. The primary endpoint of prolonged PFS was not met. Clinical Trial Registration/Date of Registration: NCT01861054/February 24, 2015