Assessment of EGFR mutations in circulating tumor cell preparations from NSCLC patients by next generation sequencing: toward a real-time liquid biopsy for treatment.

INTRODUCTION: Assessment of EGFR mutation in non-small cell lung cancer (NSCLC) patients is mandatory for optimization of pharmacologic treatment. In this respect, mutation analysis of circulating tumor cells (CTCs) may be desirable since they may provide real-time information on patient's disease status. EXPERIMENTAL DESIGN: Blood samples were collected from 37 patients enrolled in the TRIGGER study, a prospective phase II multi-center trial of erlotinib treatment in advanced NSCLC patients with activating EGFR mutations in tumor tissue. 10 CTC preparations from breast cancer patients without EGFR mutations in their primary tumors and 12 blood samples from healthy subjects were analyzed as negative controls. CTC preparations, obtained by the Veridex CellSearch System, were subjected to ultra-deep next generation sequencing (NGS) on the Roche 454 GS junior platform. RESULTS: CTCs fulfilling all Veridex criteria were present in 41% of the patients examined, ranging in number between 1 and 29. In addition to validated CTCs, potential neoplastic elements were seen in 33 cases. These included cells not fulfilling all Veridex criteria (also known as "suspicious objects") found in 5 (13%) of 37 cases, and isolated or clustered large naked nuclei with irregular shape observed in 33 (89%) cases. EGFR mutations were identified by NGS in CTC preparations of 31 (84%) patients, corresponding to those present in matching tumor tissue. Twenty-five (96%) of 26 deletions at exon 19 and 6 (55%) of 11 mutations at exon 21 were detectable (P = 0.005). In 4 (13%) cases, multiple EGFR mutations, suggesting CTC heterogeneity, were documented. No mutations were found in control samples. CONCLUSIONS: We report for the first time that the CellSearch System coupled with NGS is a very sensitive and specific diagnostic tool for EGFR mutation analysis in CTC preparations with potential clinical impact.

Medical treatment choices for patients affected by advanced NSCLC in routine clinical practice: results from the Italian observational "SUN" (Survey on the lUng cancer maNagement) study.

Lung cancer is the most common cancer in the world today, in terms of both incidence and mortality. Non-small cell lung cancer (NSCLC) accounts for about 85% of all lung cancers, and the majority of people diagnosed with NSCLC have locally advanced or metastatic disease. Treatment algorithms have rapidly changed in the last 10 years because of the introduction of new chemotherapeutic and targeted agents in clinical practice. SUN is a 1-year longitudinal observational multicenter study that has consecutively enrolled patients affected by stage IIIB or IV NSCLC with the aim to describe the pattern of care and evolving approaches in the treatment of advanced NSCLC. 987 consecutive NSCLC patients were enrolled between January 2007 and March 2008 at the 74 participating centers throughout Italy and a 12-month follow-up was performed. Cyto-histological diagnosis was performed mainly by broncoscopy with only 24% by CT-scan guided fine-needle aspiration biopsy. 91.4% of the patients received a first-line medical treatment and 8.6% supportive care only. Median age of patients receiving first-line treatment was 66 years. First-line chemotherapy consisted of a single agent in 20% of patients and combination chemotherapy in 80%. The most frequently used chemotherapy regimens were cisplatin plus gemcitabine and carboplatin plus gemcitabine. Median survival of patients receiving first-line chemotherapy was 9.1 months. 32% percent of patients received a second-line treatment that consisted of chemotherapy in 71% of cases and erlotinib in 29%. Overall third-line treatment was given to 7.3% of patients. These results showed a pattern of care for advanced NSCLC that reflects the current clinical practice in Italy at the study time with a high adherence to the International guidelines by the Italian Oncologists.

Treatment, rationale, and study design of TALISMAN study: a randomized phase II open-label study of second-line erlotinib versus intermittent erlotinib dosing with docetaxel in the treatment of former-smoker men affected by recurrent squamous non-small-cell lung cancer.

We present the treatment rationale and study design of the TALISMAN (TArceva and docetaxeL In former-Smokers MAle patients with recurrent Non-small-cell lung cancer) study, an open-label, randomized phase II trial of erlotinib (arm A) or intermittent erlotinib and docetaxel (arm B) in male former smokers affected by recurrent squamous non-small-cell lung cancer (NSCLC). In arm A, treatment consists of erlotinib 150 mg daily orally until progression or inacceptable toxicity; in arm B, treatment consists of docetaxel 75 mg/m² on day 1 and erlotinib 150 mg orally on days 2-16, recycled every 3 weeks up to 4 cycles followed, in patients not progressed, by erlotinib 150 mg daily orally until disease progression or inacceptable toxicity. The primary endpoint of this study is the rate of patients without progression at 6 months, and secondary objectives include median progression-free survival, median overall survival, activity, and toxicity. In addition, translational research evaluating EGFR and KRAS mutational status will be investigated for both arms.

An expanded access program of erlotinib (Tarceva) in patients with advanced non-small cell lung cancer (NSCLC): data report from Italy.

BACKGROUND: Erlotinib demonstrated significantly prolonged survival versus placebo in patients with advanced NSCLC who had progressed after standard chemotherapy. TRUST is a phase IV trial initiated to provide erlotinib access to patients with advanced NSCLC. We report the interim analysis for patients enrolled in the TRUST trial in Italy. PATIENTS AND METHODS: Eligible patients had stage IIIB/IV NSCLC and had failed or were unsuitable for chemotherapy. Erlotinib (150 mg/day orally) was given until disease progression or unacceptable toxicity. Patients were monitored monthly. RESULTS: At time of this analysis, data from 651 patients were available. Patient characteristics were: median age 66 years (range 30-87), male 69%, former or current smoker 71%, ECOG PS 0-1 81%, adenocarcinoma histology 52% and stage IV 82%. Erlotinib was administered as first-, second-, third- or other-line in 12, 45, 43 and <1% of patients, respectively. Response rate was 9%, with a disease-control rate of 63%. Median progression-free survival was 15 weeks and was longer in females (p<0.001), patients with adenocarcinoma (p=0.008), those with no smoking history (p<0.001) and patients who experienced skin toxicity (p<0.001). Safety data were available for 609 patients, 35% of whom had at least one adverse event (AE), but only 4% of patients discontinued treatment due to erlotinib-related AEs. CONCLUSION: This analysis of the Italian TRUST results confirms the activity and favourable safety profile of erlotinib in unselected patients with advanced NSCLC.

Dose finding study of erlotinib combined to capecitabine and irinotecan in pretreated advanced colorectal cancer patients.

PURPOSE: This study evaluated the maximum tolerated dose (MTD) and the dose limiting toxicity (DLT) of erlotinib when combined to irinotecan and capecitabine in pre-treated metastatic colorectal cancer patients. METHODS: Five dose level combinations with irinotecan (from 180 to 240 mg/m(2), day 1, q21), capecitabine (1,500-2,000 mg/m(2) per day, days 2-15, q21) and erlotinib (50-150 mg per day, continuously) were planned. Patients were enrolled in cohorts of three, and evaluated for first cycle acute toxicity. RESULTS: Twenty-one patients were treated. In the first cohort, no DLT was reported, in the second: one DLT (G4 neutropenic fever associated with G3 cutaneous rash and mucositis); in the third dose level: two DLT (G3 diarrhea and G4 neutropenic fever). To confirm these results, other six patients were additionally included and no DLT was observed. CONCLUSIONS: The results documented that erlotinib at the dose of 100 mg per day, irinotecan 180 mg/m(2) and capecitabine 1,500 mg/m(2) per day for 14 days has an acceptable safety profile and appears suitable for further phase II studies.

Ceftriaxone versus Other Antibiotics for Surgical Prophylaxis : A Meta-Analysis.

OBJECTIVE: To investigate possible differences in prophylaxis with ceftriaxone compared with other antimicrobial agents for surgical-site infections and remote infections such as respiratory tract infections (RTIs) and urinary tract infections (UTIs). METHODS: The efficacy of ceftriaxone was compared with that of other antibiotics in the perioperative prophylaxis of local (surgical wound) and remote (RTIs and UTIs) infections in a meta-analysis of randomised controlled trials published between 1984 and 2003. The analysis was based on a 2 x 2 contingency table with classification by treatment and number of infections obtained from individual studies. RESULTS: Evaluations were performed on 48 studies, for a total of 17 565 patients. Overall, 406 patients (4.8%) in the ceftriaxone group and 525 (6.3%) in the comparator group developed a surgical-site infection (log odds ratio [OR] -0.30 [CI -0.50 to -0.13]; p < 0.0001). RTIs were observed in 292 (6.01%) patients in the ceftriaxone group and in 369 (7.6%) patients in the comparator group, (log OR -0.30 [CI -0.55 to -0.09]; p = 0.0013). UTIs were reported for 2.2% of the ceftriaxone prophylaxis patients compared with 3.74% of the comparator group patients (log OR -0.54 [CI -1.18 to -0.16]; p < 0.0001). Overall, in clean surgery 195 (5.1%) and 234 (6.2%) patients developed a surgical site infection in the ceftriaxone and comparator groups, respectively (log OR -0.22 [CI -0.51 to 0.01]; p = 0.0476). RTIs were prevented for all but 1.57% of patients in the ceftriaxone group and 2.62% of patients in the comparator group (p = 0.01) in clean surgery, and for 9.54% of the ceftriaxone group versus 11.6% of the comparator group (p = 0.01) in clean-contaminated surgery. While results observed in clean surgery did not show statistically significant superiority of ceftriaxone in preventing UTI insurgence (log OR -0.21 [CI 0.0-0.65]; p = 0.7702), this was clearly shown in the clean-contaminated surgery. In fact, 4.47% of patients in the ceftriaxone group versus 7.52% of patients in the comparator group developed a UTI (log OR -0.56 [CI -1.25 to -0.16]; p < 0.0001). Adverse events were observed in a similar proportion in the ceftriaxone prophylaxis and the comparator groups (0.35% and 0.23%, respectively). Duration of prophylaxis did not influence outcome of infection. CONCLUSIONS: The meta-analysis showed that ceftriaxone is statistically superior to other antibiotics in preventing both local and remote postoperative infections.