Standard Cisplatin-based Chemotherapy Research Articles

Prognostic factors and survival in men with testicular germ cell tumors (GCT).

e17018 Background: The International Germ Cell Cancer Collaborative Group (IGCCCG) has recently discovered new factors for GCT in 2021. We have estimated previously known and new prognostic factors in patients with nonseminomatous germ cell tumors (NSGCT) and seminoma treated at N.N. Petrov NMRC of Oncology. Methods: From 2011 to 2021, the study included 273 adult patients receiving standard cisplatin-based chemotherapy. Primary endpoints were progression-free survival (PFS) and overall survival (OS). Survival was estimated using the Kaplan-Meier and Cox methods. Results: 5-year OS rates were 94%, 85% and 70% in the good, intermediate, and poor prognosis groups, respectively for NSGCT and 95% and 86% in good and intermediate prognosis groups for seminoma (p<0.05). 5-year PFS rates were 74%, 51%, and 41% for NSGCT and 76% and 62% for seminoma of the above-mentioned prognostic groups, respectively (p<0,05). Presence of pulmonary metastases (mts) (HR 0.177; 95% CI: 0.051-0.612; p=0.006), non-pulmonary visceral mts (HR 4.636; 95% CI: 1.710-12.570; p= 0.003), elevated LDH of ≥ 2.5 limit of normal (≥ 2.5 × ULN) (HR 4.107; 95% CI: 1.614-10.451; p= 0.003), treatment in high-experienced clinic (HR 0.37; 95% CI: 0.147-0.919; p=0.0032), and non-compliance with guidelines (HR 3.731; 95% CI: 1.456-9.564; p= 0.006) was significantly associated with OS in NSGCT. The presence of pulmonary mts (HR 0.15; 95% CI: 0.024-0.877; p=0.035) and elevated LDH ≥ 2.5 × ULN (HR 0.109; 95% CI: 0.015-0.775; p=0.027) were the only factors associated with poor OS in seminoma. The presence of pulmonary mts (HR 0.446; 95% CI: 0.247-0,804; p=0.007), non-pulmonary visceral mts (HR 2.668; 95% CI: 1.390-5,120; p=0.003) and treatment in high-experienced clinic (HR 1.852; 95% CI: 1.059-3.238; p=0.031), were significantly associated with inferior PFS in NSGCT. Pulmonary mts were the only significant (HR 0.301; 95% CI: 0.100-0.910; p=0.033) factor in the multivariate OS analysis for all testicular GCT. The absence of non-pulmonary visceral mts (HR 0.522: 95% CI: 0.265-0.963; p=0.019) and compliance with guidelines (HR 0.565; 95% CI: 0.309-0.910; p=0.038) were significant factors in the multivariate PFS model for all patients with testicular GCT. Conclusions: The original IGCCCG classification remains the reference for treatment decisions for testicular GCT in daily practice. Non-compliance with guidelines and treatment in high-experienced clinic could become additional poor prognostic factors.

Comparing survival in trial- versus routine-care advanced urothelial cancer patients on immune checkpoint blockade.

Although recent trials involving first-line immune checkpoint inhibitors have expanded treatment options for patients with advanced urothelial carcinoma (aUC) who are ineligible for standard cisplatin-based chemotherapy, there exists limited evidence for whether trial efficacy translates into real-world effectiveness for patients seen in routine care. This retrospective cohort study compares differences in overall survival (OS) between KEYNOTE-052 trial participants and routine-care patients receiving first-line pembrolizumab monotherapy. A routine-care patient cohort was constructed from the Flatiron Health database using trial eligibility criteria and was weighted to balance EHR and trial patient characteristics using matching-adjusted indirect comparisons. The routine-care cohort was older, more likely to be female, and more often cisplatin-ineligible due to renal dysfunction. ECOG performance status was comparable between the cohorts. Median OS was 9 months (95% CI 7-16) in the weighted routine-care cohort and 11.3 months (9.7-13.1) in the trial cohort. No significant differences between the Kaplan-Meier OS curves were detected (p = 0.76). Survival probabilities were similar between the weighted routine-care and trial cohorts at 12-, 24-, and 36- months (0.45 vs. 0.47, 0.31 vs. 0.31, 0.26 vs. 0.23, respectively). Notably, routine care patients had modestly lower survival at 3 months compared to trial participants (0.69 vs. 0.83, respectively). Our results provide reassurance that cisplatin-ineligible aUC patients receiving first-line immunotherapy in routine care experience similar benefits to those observed in trial patients.

Abstract 4561: Mechanism of histone H3K27me3 demethylase therapy for restoring cisplatin sensitivity in refractory testicular cancer

Abstract Testicular germ cell tumors (TGCTs) can be cured at a high rate with standard cisplatin-based chemotherapy, but 15% of metastatic patients are cisplatin resistant/refractory and die from progressive disease. In prior work, we used de novo pharmacogenetic approaches leveraging a series of unique cisplatin resistant cell models that uncovered an important role for polycomb and histone H3K27me3 methylation in mediating TGCT sensitivity and resistance to cisplatin. Importantly, we demonstrated that pharmacological inhibition of H3K27 methylation with the EZH2 inhibitor GSK-126 conferred cisplatin resistance to parental cells while induction of H3K27 methylation with the histone lysine demethylase inhibitor GSK-J4 resulted in a high degree of cisplatin sensitization of TGCT tumors including cisplatin resistant TGCT cells. In order to elucidate mechanisms that account for the remarkable cisplatin sensitization effects of GSKJ4 in TGCTs, we used two distinct cisplatin resistant TGCT cell lines 2102EP-C1 and NT2D1-A4. Cells were pretreated for three days with either vehicle control or 1µM GSK-J4 to modulate H3K27me3 followed by treatment with vehicle control or 0.5µM cisplatin for 6 hours. RNA was extracted from cells after 24 hours of cisplatin removal. This treatment protocol was designed to capture “early” transcriptional responses to GSKJ4 sensitization before the onset of cell death. RNA-seq transcriptomic profiling and differential gene expression analysis revealed as expected a severely attenuated transcriptional response to cisplatin in cisplatin refractory cells that was restored with GSKJ4 pretreatment. Interestingly GSKJ4 alone resulted in a robust transcriptional response with a large overlap with gene changed with cisplatin alone, despite the fact that GSKJ4 alone did not affect cell proliferation or survival. However, GSKJ4 uniquely regulated a subset of genes and uniquely restored cisplatin response to a subset of genes which are candidates for driving the remarkable cisplatin sensitizing effects of GSKJ4 in TGCTs. Further enrichment and biological classification analysis of these distinct gene subsets are ongoing and will be presented. In summary, our data suggests mechanisms to account for why directly targeting H3K27 methylation with GSKJ4 appear highly effective in treating cisplatin resistant/refractory TGCTs and may provide biomarkers for future clinical investigation of this strategy. Citation Format: Doha Naguib Ahmed Mohamed Shokry, Ratnakar Singh, Mehwish Khan, Zeeshan Fazal, Raya Boyd, Christine Powell, Sarah J. Freemantle, Michael J. Spinella. Mechanism of histone H3K27me3 demethylase therapy for restoring cisplatin sensitivity in refractory testicular cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4561.

Abstract 2856: Multi-omics approaches for biomarker discovery and target therapy in pediatric germ cell tumors

Abstract Pediatric germ cell tumors (GCT) are rare and heterogeneous, presenting various histologies. There are no specific markers for diagnosing GCT, and 30% of patients are resistant to standard cisplatin-based chemotherapy, which can be related to epithelial-mesenchymal transition (EMT). Therefore, this study aims to elucidate markers for classifying GCTs, evaluate the molecular mechanisms related to drug resistance, and search for new therapeutic approaches. The expression of miRNAs was assessed for 42 GCT-pediatric patients through miRNA Panel - Nanostring technology. Whole Exome Sequencing (WES) was performed for 16 GCT-pediatric patients to assess somatic mutations. In silico analysis of epithelial-mesenchymal transition (EMT) markers was performed using the cBioPortal database. The expression of EMT markers was evaluated in vitro in parental and cisplatin-resistant models (NTERA-2R). Xenograft model-derived NTERA-2R was established and EMT markers were also assessed. We identified specific miRNA expression signatures for each histology, including 34 miRNAs for dysgerminomas, 13 for embryonal carcinomas, 25 for yolk sac tumors, and one for immature teratoma. We identified 26 miRNAs that were commonly expressed in malignant tumors, with six miRNAs (miR-302a-3p, miR-302b-3p, miR-371a-5p, miR-372-3p, miR-373-3p, miR-367-3p) showing significant overexpression. MiR-302b-3p had a significant association with all the evaluated clinical features. WES analysis showed that Single Base Substitution signature 39 was observed in 68.75% of samples and SBS22 in 12.5%. Copy number alterations were identified in 4, 7, 8, 10, 12, 21, and 22 chromosomes, with amplification of CDKN1B, KRAS, CCND2, ETV6, and KDM5A genes and deletions of KIT and PTEN genes. Somatic mutations in NYAP2, RHBDF2, MTOR, KIT, ATM, KRAS, and PIK3CA were frequent among the samples. KIT (Asp816Val, Ala829Pro) and KRAS (Gln61Leu) mutations were classified with potential clinical significance and were validated. In silico analysis showed that different histologies had distinct expression profiles for EMT markers. Patients with SNAILlowSLUGlow expression had higher PFS than those with SNAILhighSLUGhigh (p=0.006). The median PFS of patients with SLUGlow was 46.4 months, while SLUGhigh was 28.0 months (p=0.022). In vitro analysis using NTERA-2R showed overexpression of EMT markers. The same result was obtained in the xenograft model derived from NTERA-2R. Our study offers vital insights into pediatric GCTs' molecular landscape, using in silico, in vitro, in vivo analyses, and genetic assessments, highlighting three points: 1) The miRNA signatures for each histology may have robust diagnostic and prognostic potential, besides clinical implications as biomarkers. 2) KIT and KRAS genes are possible therapeutic targets of pediatric GCTs. 3) EMT is related to cisplatin resistance and SLUG is a potential molecular target. Citation Format: Ana Flavia Souza Peres, Ingridy Izabella Vieira Cardoso, Janaina Mello Soares Galvao, Ana Glenda Santarosa Vieira, Marcela Nunes Rosa, Isabela Cristiane Tosi, Daniel Antunes Moreno, Ana Carolina Laus, Andre van Helvoort Lengert, Silvia Aparecida Teixeira, Adriane Feijo Evangelista, Rui Manuel Reis, Luiz Fernando Lopes, Mariana Tomazini Pinto. Multi-omics approaches for biomarker discovery and target therapy in pediatric germ cell tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2856.

Comprehensive genomic profiling (CGP) of clinical T2-4N0M0 muscle-invasive bladder cancer (MIBC) treated with neoadjuvant pembrolizumab or cisplatin-based chemotherapy before radical cystectomy (RC).

653 Background: The identification of tumor biomarkers associated with pathological complete response (CR: ypT0N0) to neoadjuvant therapies is a primary goal of the ongoing clinical research in MIBC. Furthermore, evaluating the shifting spectrum of genomic alterations (GA) in matched pre-post therapy samples could orient novel therapeutic sequences. Methods: We retrospectively evaluated the clinical and genomic findings of patients (pts) with cT2-4N0M0 MIBC who received neoadjuvant pembrolizumab in the PURE-01 study, or standard cisplatin-based neoadjuvant chemotherapy (NACT), preceding RC at our center. We focused the analyses on the DNA GA via CGP assays, performed on tumor samples, to identify GA in 324 cancer-associated genes and genomic signatures, including TMB, using a hybrid capture-based comprehensive genomic profiling assay. TMB was categorized as low (<10 mutations [mut]/Mb), high (10-19), or very high (≥20). Germline status of GA was predicted using a validated somatic-germline computational method. Genomic signatures were analyzed via the principal Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways distribution according to the pathological response. The primary endpoint was to compare differences between ypT0N0 responders and nonresponders (NR: ypT≥2 and/or ypN1-3). All p-values were two-sided, and multiple hypothesis testing correction was performed using the Benjamini–Hochberg procedure to calculate the false discovery rate (FDR). Results: We identified TURBT samples from 129 pts included in PURE-01 and 27 patients treated with NAC, from 2017 to 2022. Mean GA/tumor of CR from PURE-01 was 28.8 vs 17.3 from NAC. No germline GA were found. In PURE-01, higher mean GA/tumor and higher mean TMB were the only GA associated with CR vs NR (p<0.001), whereas no differences were found at single gene and gene pathways level. In NAC cohort, no GA nor signatures were found to be significantly associated with CR. Despite the mean TMB of CR pts were similar between PURE-01 and NAC cohorts (16.4 vs 19.6 mut/Mb), mean TMB of NR in PURE-01 cohort was lower than that of NR from NAC cohort (9.3 vs 18.6 mut/Mb). In PURE-01 we analyzed 37 matched TURBT-RC samples: there were no significant differences in GA or pathways, with a nonsignificant decrease in mean TMB values in RC vs TURBT samples (6.73 vs 8.86 mut/Mb, p=0.16). Conclusions: In our study, no genomic biomarkers linked to NAC activity emerged at the CGP. Conversely, in PURE-01 TMB confirmed to be to most reliable DNA biomarker to separate CR vs NR. Interestingly, TMB values could also help predicting the lack of benefit from neoadjuvant pembrolizumab use, confirming the reliability of the 10 mut/Mb cutoff to allow the exclusion of predicted nonresponders from neoadjuvant pembrolizumab trials.

Perioperative Immune Checkpoint Blockade for Muscle-Invasive and Metastatic Bladder Cancer.

Checkpoint inhibitors offer promise in treating muscle-invasive and metastatic bladder cancer, but the optimal timing of their administration-neoadjuvant or adjuvant-remains unclear. To determine the efficacy of combining checkpoint inhibition with standard cisplatin-based chemotherapy, we conducted a phase II trial of neoadjuvant anti-PD-1 (αPD-1) and anti-CTLA-4 (αCTLA-4), in combination with cisplatin-gemcitabine, for patients with muscle-invasive bladder cancer prior to radical cystectomy. In addition, a novel murine model of spontaneous metastatic bladder cancer was used to compare the efficacy of neoadjuvant versus adjuvant anti-PD-L1 (αPD-L1) treatment. The clinical trial was closed prematurely due to the industry's withdrawal of drug provision. Adverse events were observed in all patients; however, serious adverse events were not observed in any patient. A complete pathologic response was observed in 50% of the 4 patients enrolled. Response to treatment was significantly associated with elevated urinary T cells including CD8+ and IFNγ+ CD4+ T cells, suggesting potential reinforcement of immune responses by neoadjuvant αPD-1 and αCTLA-4 against bladder tumor cells. These findings suggest that combining chemotherapy and immunotherapy in the neoadjuvant setting could be safe. However, the complete response rate of this four-drug regimen was modest and emphasizes the need for randomized controlled trials to properly assess immunotherapy efficacy in the neoadjuvant setting. In corresponding murine studies, the MB49-met model consistently displayed widespread metastasis, including tumor growth in the lungs, liver, and bowel mesentery, within 20 days of subcutaneous transplantation. Mice receiving surgery plus neoadjuvant αPD-L1 or adjuvant αPD-L1 exhibited improved survival compared to those receiving only αPD-L1. However, no significant difference in survival was observed between the neoadjuvant and adjuvant αPD-L1 cohorts. Furthermore, the timing of neoadjuvant therapy administration (early vs. late) did not significantly impact survival. This study highlights the potential of perioperative immunotherapy in the treatment of locally advanced and metastatic bladder cancer.

Safety and efficacy of preoperative chemotherapy for muscle-invasive bladder cancer in elderly patients.

This study aimed at describing the feasibility and oncological outcomes of standard cisplatin-based neoadjuvant chemotherapy (C-NAC) for muscle-invasive bladder cancer (MIBC) in patients aged ≥ 75 and assess the impact of baseline geriatric parameters. This retrospective study included patients with stage cT2-4NanyM0 MIBC aged 75 and older treated with ≥ 1 cycle of C-NAC from 2011 to 2021 at a high-volume academic center. Primary outcome was overall survival (OS). Secondary outcomes were chemotherapy feasibility (administration of ≥ 4 cycles), safety, and pathological downstaging. Fifty-six patients were included. Median age was 79 (range 75-90). C-NAC regimen was ddMVAC in 41 patients and GC in 15. Seventy-three percent of patients received ≥ 4 cycles of C-NAC. Grade ≥ 3 toxicity was observed in 55% of patients. The febrile neutropenia rate was 7%. Thirty patients underwent cystectomy, and 13 underwent chemoradiotherapy. Three-year OS was 63%. Geriatric parameters polypharmacy, undernutrition, and age-adjusted Charlson comorbidity index ≥ 8 predicted worse OS. Standard-of-care C-NAC and local treatments are feasible in selected elderly MIBC patients, with efficacy and safety findings similar to that observed in pivotal trials with younger patients. The prognostic impact of geriatric parameters underlines the need for specialized evaluation before treatment initiation.

Carboplatin Induction Chemotherapy in Clinically Lymph Node–positive Bladder Cancer

BackgroundThere are currently no guideline recommendations regarding the treatment of cisplatin-ineligible, clinically lymph node–positive (cN+) bladder cancer (BCa). ObjectiveTo investigate the oncological efficacy of gemcitabine/carboplatin induction chemotherapy (IC) in comparison to cisplatin-based regimens in cN+ BCa. Design, setting, and participantsThis was an observational study of 369 patients with cT2–4 N1–3 M0 BCa. InterventionIC followed by consolidative radical cystectomy (RC). Outcome measurements and statistical analysisThe primary endpoints were the pathological objective response (pOR; ypT0/Ta/Tis/T1 N0) rate and the pathological complete response (pCR; ypT0N0) rate. We applied 3:1 propensity score matching (PSM) to reduce selection bias. Overall survival (OS) and cancer-specific survival (CSS) were compared across groups using the Kaplan-Meier method. Associations between the treatment regimen and survival endpoints were tested in multivariable Cox regression analyses. Results and limitationsAfter PSM, a cohort of 216 patients was available for analysis, of whom 162 received cisplatin-based IC and 54 gemcitabine/carboplatin IC. At RC, 54 patients (25%) had a pOR and 36 (17%) had a pCR. The 2-yr CSS was 59.8% (95% confidence interval [CI] 51.9–69%) for patients who received cisplatin-based IC versus 38.8% (95% CI 26–57.9%) for those who received gemcitabine/carboplatin. For the pOR (p = 0.8), ypN0 status at RC (p = 0.5), and cN1 BCa subgroups (p = 0.7), there was no difference in CSS between cisplatin-based IC and gemcitabine/carboplatin. In the cN1 subgroup, treatment with gemcitabine/carboplatin was not associated with shorter OS (p = 0.2) or CSS (p = 0.1) on multivariable Cox regression analysis. ConclusionsCisplatin-based IC seems to be superior to gemcitabine/carboplatin and should be the standard for cisplatin-eligible patients with cN+ BCa. Gemcitabine/carboplatin may be an alternative treatment for selected cisplatin-ineligible patients with cN+ BCa. In particular, selected cisplatin-ineligible patients with cN1 disease may benefit from gemcitabine/carboplatin IC. Patient summaryIn this multicenter study, we found that selected patients with bladder cancer and clinical evidence of lymph node metastasis who cannot receive standard cisplatin-based chemotherapy before surgery to remove their bladder may benefit from chemotherapy with gemcitabine/carboplatin. Patients with a single lymph node metastasis may benefit the most.

Neoadjuvant Chemotherapy with Accelerated Methotrexate, Vinblastine, Doxorubicin, and Cisplatin in Patients with Muscle-invasive Bladder Cancer: A Retrospective Age-stratified Analysis on Safety and Efficacy

BackgroundThe standard of care (SOC) for muscle-invasive bladder cancer (MIBC) includes cisplatin-based combination chemotherapy in the neoadjuvant setting followed by radical cystectomy. Older patients often do not receive SOC due to perceived toxicity concerns despite guideline-directed recommendations. ObjectiveTo characterize the safety and efficacy of neoadjuvant accelerated methotrexate, vinblastine, adriamycin, and cisplatin (aMVAC) in MIBC patients as a function of age. Design, setting, and participantsA retrospective analysis was conducted in 186 MIBC patients treated at Fox Chase Cancer Center between January 1, 2002 and December 31, 2018. Adults with histologically proven muscle-invasive urothelial cancer were eligible. The exclusion criteria included nonurothelial histology, lack of muscularis propria invasion, and primary upper tract or metastatic disease. InterventionNeoadjuvant chemotherapy with aMVAC. Outcome measurements and statistical analysisPatients were stratified by age (<65, 65–74, and >75 yr old). Renal function was assessed at baseline and at time points after treatment. Clinicopathologic variables were compared between age groups to determine efficacy. Results and limitationsThere were no statistically significant differences in dose reductions, treatment interruptions, time to surgery, or adverse events when patients were stratified by age in univariate and multivariate analyses. Full safety data were not available due to the retrospective nature of the study. Baseline renal function was significantly worse among older patients, and the percent decline in creatinine clearance was greater with older age. We found comparable efficacy of aMVAC regardless of age. ConclusionsAccelerated MVAC was safe and demonstrated efficacy in MIBC irrespective of age in this single-center, retrospective study. Careful selection based on clinical variables, and not age, should identify patients able to receive neoadjuvant chemotherapy. Patient summaryWe examined the feasibility of the standard cisplatin-based chemotherapy regimen given prior to surgery in patients with muscle-invasive bladder cancer. Elderly patients experienced a greater decline in kidney function with treatment but not more complications than younger patients and tolerated therapy with minimal dose changes, resulting in benefit regardless of age.

Abstract 2096: Genome wide remodeling of DNA methylation and CpG hypermethylation is tightly linked to acquired resistance in testicular cancer

Abstract Acquired resistance to chemotherapy is perhaps the major barrier to cure of advanced cancers. Testicular germ cell tumors (TGCTs) are the most common cancers of young males. TGCTs are one of the few solid tumors that are cured at a high rate with standard cisplatin-based chemotherapy. However, TGCTs become resistance to cisplatin resulting in poor outcomes. While the mechanisms accounting for cisplatin hypersensitivity in TGCT remain elusive, it has been suggested that DNA hypermethylation may play a role. However, there is little direct experimental evidence to support this claim. In the present study, we have leveraged unique isogenic cell models to provide strong evidence for net DNA hypermethylation as a key mechanism leading to acquired cisplatin resistance in TGCT cells. Genome-wide DNA methylation analysis revealed that hypomethylated CpG loci were enriched for SUZ12 and EZH2 binding and H3K27me3 sites. In contrast hypermethylated CpG loci were significantly enriched for CTCF and RAD21 domains as well as repressive DNA segments indicating the global remodeling of nuclear chromatin structure in resistant cells. Integrative computational analysis of RNA-seq and EPIC DNA methylation array data revealed a strong inverse correlation between gene expression and CpG gene promoter methylation. This analysis also revealed a strong bidirectional shift between gene promoter and gene body DNA methylation that correlated closely with upregulated expression of PRC2 target genes and down regulation of tumor suppression genes in resistant cells. Hence the data further suggests a functional interplay between DNA methylation and the PRC2 pathway that modulates cisplatin sensitivity of TGCTs. Further studies including H3K27me3 ChIP-seq are ongoing to further elucidate this relationship. In conclusion, our finding supports the hypothesis that genome wide remodeling of DNA methylation is associated with cisplatin hypersensitivity and resistance of TGCTs and further supports the use of hypomethylation therapy for relapsed TGCT patients. Citation Format: Zeeshan Fazal, Ratnakar Singh, Megan Tomlin, Doha Shokry, Aleyah Hattab, Sarah Spinella, Michael Spinella. Genome wide remodeling of DNA methylation and CpG hypermethylation is tightly linked to acquired resistance in testicular cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2096.

Inability to Complete the Second of Planned Tandem Autologous Stem Cell Transplantations for Metastatic Germ Cell Tumors: Reasons, Toxicity and Impact on Outcomes

IntroductionHigh-dose chemotherapy with autologous stem cell transplantation (HDCT/ASCT) is a potentially curative treatment for men with metastatic germ cell tumors (GCT) in relapse after standard cisplatin-based chemotherapy. It is usually performed as tandem or triple transplantations and results in 2-year progression-free and overall survival rates of ~60%. However, a tandem ASCT is not always possible and outcomes for men treated with a single ASCT are poorly described. We reviewed our institutional experience of the use of HDCT/ASCT for men with relapsed GCT, aiming to ascertain reasons behind why a tandem transplant could not be completed, and the impact of a single ASCT on clinical outcomes and toxicity.MethodsAll men with metastatic GCT who underwent HDCT/ASCT at our institution between January 2000 and December 2016 were included in the study. After obtaining IRB approval, clinical data was abstracted from the medial record. Peripheral blood stem cells (PBSCs) were mobilized with G-CSF, with or without plerixafor; bone marrow harvests were reserved for men with failure to mobilize PBSCs. Conditioning was performed with carboplatin 700mg/m2 and etoposide 700mg/m2 (CE) or carboplatin 600mg/m2, etoposide 600mg/m2 and cyclophosphamide 50mg/kg/day (CEC) on days -5, -4 and -3; the regime chosen was at the discretion of the transplant physician. Progression-free (PFS) and overall survival (OS) were calculated as the duration from the first day of HDCT to date of relapse or death, or censored at last follow-up.Results31 men underwent HDCT/ASCT for metastatic GCT between 2000-2016; median age was 30yrs (range 22-53) and median follow-up was 3.5yrs (95% CI 1.8-5.3). Clinical characteristics of patients before the start of HDCT, stratified by single (n=11) or tandem ASCT (n=20), are shown in Table 1. The two cohorts were well-matched with the exception that median LDH prior to HDCT was higher amongst patients who had a single ASCT (300 vs. 185, p=0.024), while a greater proportion of men who underwent a single ASCT were conditioned with CEC (82% vs. 25%, p=0.007).(i) Single ASCT cohortIn the 11 men in whom a single ASCT was performed, a tandem had been originally planned in 8 (73%). 3 men, in the pre-plerixafor era, were unable to mobilize sufficient stem cells to permit a tandem ASCT, with 2 of these having to undergo a bone marrow harvest due to insufficient peripheral CD34 counts to permit apheresis (both had previously received 2 lines of platinum-based chemotherapy); the third patient had severe pain with G-CSF and was only able to collect sufficient cells (3.3x106/kg) for a single ASCT. Other reasons why men were unable to proceed to the second ASCT included disease progression with rising tumor markers after the first ASCT (n=3), poor performance status (n=1), and lack of insurance approval (n=1).(ii) ToxicityAny Grade 3 or higher non-hematologic toxicity occurred in all but one patient overall (n=30, 97%). Toxicity was similar between single and tandem ASCT, and did not lead to significant delays in proceeding with a tandem ASCT. Febrile neutropenia was very common, occurring in 82% and 85% of men who had a single or tandem ASCT respectively. There was notable ototoxicity, afflicting 27% of single and 25% of tandem ASCTs. There was no treatment-related mortality or leukemia.(iii) OutcomesA total of 12 men (39%) have died, all from progressive disease, 7 of whom had a single and 5 of whom had a tandem ASCT. Figure 1 shows PFS and OS stratified by single or tandem ASCT. Differences in median OS [3.0yrs (0.2-5.9) vs. not reached, p=0.133] or PFS [0.5 (0.3-0.7) vs. 3.0 (0.1-5.8), p=0.142] were not significant between single or tandem ASCT; 2-year PFS was 27% and 49%, and 2-year OS was 61% and 72% respectively. 10 of the 20 men (50%) who had a tandem ASCT are alive and disease-free after a median of 3.0yrs compared to 2 men (18%) who had a single ASCT.ConclusionsA significant proportion of men undergoing HDCT/ASCT for metastatic GCT were unable to complete a planned second ASCT due to poor mobilization of PBSCs (mostly in the pre-plerixafor era) or rapid disease progression after the first ASCT. Toxicity was similar for men undergoing single or tandem ASCT and had minimal impact on ability to complete a second ASCT. There was a trend towards inferior survival among those who were unable to complete the second of planned tandem ASCT. [Display omitted] DisclosuresAnsell:Affimed: Research Funding; Bristol-Myers Squibb: Research Funding; Celldex: Research Funding; Seattle Genetics: Research Funding; Merck: Research Funding.

The combination of an innovative dry powder for inhalation and a standard cisplatin-based chemotherapy in view of therapeutic intensification against lung tumours

Cisplatin is one of the most commonly used chemotherapy in lung cancer despite its high nephrotoxicity leading to an administration only every 3–4 weeks. This study is the first report of a preclinical investigation of therapeutic intensification combining a cisplatin dry powder for inhalation (CIS-DPI) with an intravenous (iv) cisplatin-based treatment. CIS-DPI with 50% cisplatin content (CIS-DPI-50) was developed using lipid excipients through scalable processes (high-speed and high-pressure homogenization and spray-drying). CIS-DPI-50 showed good aerodynamic performance (fine particle fraction of ~ 55% and a mass median aerodynamic particle size of ~ 2 µm) and a seven-fold increase and decrease in Cmax in the lungs and in plasma, respectively, in comparison with an iv cisplatin solution (CIS-iv) in healthy mice. Finally, the addition of CIS-DPI-50 to the standard cisplatin/paclitaxel iv doublet increased the response rate (67% vs 50%), decreased the tumour growth and prolonged the median survival (31 vs 21 days), compared to the iv doublet in the M109 lung carcinoma model tending to demonstrate a therapeutic intensification of cisplatin.

Immune Checkpoint Inhibitors in the Management of Urothelial Carcinoma.

Urothelial carcinoma is one of the most common cancers in the United States, yet outcomes are historically suboptimal. Since 2016, the approval of five programmed cell death 1 and programmed death-ligand 1 immune checkpoint inhibitors for locally advanced and metastatic urothelial carcinoma has led to improved oncologic outcomes for many patients in the second-line setting. Two checkpoint inhibitors, pembrolizumab and atezolizumab subsequently earned approval for first-fine therapy with restricted indications. More recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive high-risk non-muscle invasive bladder cancer, opening the door for other immune checkpoint inhibitors to be integrated into treatment in earlier disease stages. Recent bacillus Calmette-Guérin shortages have highlighted the need for alternative treatment options for patients with non-muscle invasive bladder cancer. Currently, there are no FDA-approved checkpoint inhibitors for non-metastatic muscle-invasive bladder cancer. Furthermore, many patients are ineligible for standard cisplatin-based chemotherapy regimens. Numerous ongoing clinical trials are employing immune checkpoint inhibitors for muscle-invasive bladder cancer patients in the neoadjuvant, adjuvant, perioperative, and bladder-sparing setting. Although up to 10% of urothelial carcinoma tumors arise in the upper urinary tract, few studies are designed for this population. We highlight the need for more trials designed for patients with upper tract disease. Overall, there are numerous clinical trials investigating the safety and efficacy of immune checkpoint inhibitors in all stages of disease as single-agents and combined with dual-immune checkpoint inhibition, chemotherapy, radiotherapy, and other pharmacologic agents. As the field continues to evolve rapidly, we aim to provide an overview of recent and ongoing immunotherapy clinical trials in urothelial carcinoma.

DUTRENEO Trial: A randomized phase II trial of DUrvalumab and TREmelimumab versus chemotherapy as a NEOadjuvant approach to muscle-invasive urothelial bladder cancer (MIBC) patients (pts) prospectively selected by an interferon (INF)-gamma immune signature.

5012 Background: Cisplatin-based neoadjuvant chemotherapy (CT) followed by radical cystectomy (RC) is a standard treatment for MIBC. PD-1/L1 inhibitors as single agent induce pathological complete responses (pCR) in this setting. Predictors of response are still ill defined. DUTRENEO trial aimed to prospectively explore the activity of anti-PDL1 + anti-CTLA4 vs CT in pts selected according to a tumor pro-inflammatory IFN-gamma signature (tumor immune score, TIS). Methods: Cisplatin-eligible pts with urothelial MIBC (cT2-T4a, N≤1, M0) candidates to RC were classified as “hot” or “cold” according to a tumor TIS determined by Nanostring technology. Patients with "hot" tumors were randomized to DU 1500 mg + TRE 75 mg every 4 weeks x 3 cycles or standard cisplatin-based CT (GEMCIS or MVACdd). Pts in the “cold” arm received standard CT. Primary endpoint was to achieve ≥8 pCR in the DU+TRE arm. PDL1 expression was assessed using immunohistochemistry. Results: 61 pts were recruited in 10 sites between oct-2018 and dec-2019. Pts randomized in the “hot” arms received standard CT (n = 22) or DU+TRE (n = 23) and had a pCR rate of 8/22 pts (36.4%) vs 8/23 pts (34.8%), respectively [OR = 0.923 (0.26 – 3.24)]. In the “cold” arm, 16 pts received CT obtaining a pCR rate of 68.8% (11/16 pts). There were more PDL1 low tumors in the "cold" TIS arm (10/12, 83.3%). pCR rate by PDL1 status is shown in the table. One pt in the DU+TRE arm refused RC. Full treatment was delivered to 81.3% of CT "cold" vs 59.1% of CT "hot" vs 73.9% in the DU+TRE arm pts. Grade 3-4 toxicities were more frequent in the CT arms. Conclusions: The combination of DU+TRE is safe and active in MIBC patients in the neoadjuvant setting. Nevertheless prospective stratification by a pro-inflammatory IFN-gamma signature failed to select patients more likely to benefit from IO vs CT in this context. Further studies are required to guide treatment selection. Clinical trial information: NCT03472274 . [Table: see text]

High aurora kinase expression identifies patients with muscle-invasive bladder cancer who have poor survival after neoadjuvant chemotherapy

ObjectivesOverexpression of aurora kinase A (AURKA) confers a poor prognosis in patients with urothelial carcinoma of the bladder. The prognostic value of high aurora kinase B (AURKB) expression in local bladder cancer is not well defined, and whether the prognostic value of either AURKA or AURKB is affected by the use of chemotherapy is unknown. We sought to characterize the impact of high AURKA and AURKB expression on clinical outcome in patients with muscle-invasive bladder cancer (MIBC) who received neoadjuvant chemotherapy (NAC). Materials and methodsImmunohistochemistry for AURKA and AURKB was performed on pretreatment diagnostic transurethral resection of bladder tumor (TURBT) and matched cystectomy specimens in 50 subjects with MIBC who received NAC. Receiver operator characteristic curves (ROC) were calculated to assess the impact of AURKA and AURKB expression on pathologic response rate. Kaplan-Meier techniques and Cox proportional hazards models were used to assess the association with relapse-free survival (RFS) and overall survival (OS). ResultsTwenty-two of 50 [44%] patients had residual muscle-invasive (ypT2-4) urothelial carcinoma after NAC. Neither baseline tumor expression of AURKA (ROC = 0.57, P = 0.46) nor AURKB (ROC = 0.56, P = 0.87) predicted for ypT2-4 status. However, baseline expression of AURKA above the 75th percentile for this cohort was associated with an inferior RFS, (HR = 3.88, P = 0.008) and OS, (HR = 6.10, P < 0.001). Similar trends for worse survival outcomes were also observed for high AURKB levels (RFS, [HR = 2.2, P = 0.13] and OS, (HR = 2.25, P = 0.09). ConclusionsHigh baseline tumor AURKA and AURKB expression identified MIBC patients with inferior RFS and OS despite the use of NAC and may identify patients who should be prioritized for clinical trial enrollment rather than standard cisplatin-based chemotherapy.

Epigenetic treatment combinations to effectively target cisplatin-resistant germ cell tumors: past, present, and future considerations.

Type II germ cell tumors represent the most common solid malignancy in men aged 15-45years. Despite high cure rates of >90% over all stages, 10-15% of advanced patients develop treatment resistance and potentially succumb to their disease. Treatment of refractory germ cell tumors remains unsatisfactory, and new approaches are needed to further improve outcomes. With this narrative review, we highlight epigenetic mechanisms related to resistance to standard systemic treatment, which may act as promising targets for novel combined epigenetic treatment approaches. A comprehensive literature search of PubMed and MEDLINE was conducted to identify original and review articles on resistance mechanisms and/or epigenetic treatment of germ cell tumors invitro and invivo. Review articles were hand-searched to identify additional articles. Distinct epigenetic phenomena have been linked to chemotherapy resistance in germ cell tumors, among which DNA hypermethylation, histone acetylation, and bromodomain proteins appear as promising targets for therapeutic exploitation. Inhibitors of key regulators, for example DNA methyltransferases (e.g. decitabine, guadecitabine), histone deacetylases (e.g. romidepsin), and bromodomain proteins (e.g. JQ1) decreased cell viability, triggered apoptosis, and growth arrest. Additionally, these epigenetic drugs induced differentiation and led to loss of pluripotency and re-sensitization towards cisplatin in cell lines and animal models. Epigenetic treatments hold promise to (i) reduce the treatment burden of and (ii) overcome resistance to standard cisplatin-based chemotherapy. Combined approaches may enhance activity, while the ideal target and treatment combination of epigenetic drugs, either with another epigenetic agent or conventional cytotoxic agents need to be defined. Epigenetic (combination) treatment for germ cell tumors should be further explored in pre-clinical and clinical research for its potential to further improve germ cell tumor treatment.

PD-1 Inhibition Minimally Affects Cisplatin-Induced Toxicities in a Murine Model.

Immune checkpoint inhibition used in combination with standard cisplatin-based chemotherapy regimens is currently under evaluation in clinical trials for head and neck squamous cell carcinoma (HNSCC). The impact of anti-PD-1 therapy on cisplatin-induced ototoxicity and nephrotoxicity has not been established. Here we use a murine model of cisplatin-induced hearing loss to investigate the impact of anti-PD-1 immunotherapy on auditory brainstem responses (ABRs), distortion product otoacoustic emissions (DPOAEs), serum creatinine, and hair cell and renal histology. We demonstrate only mild worsening of DPOAEs at 14.4 and 16 kHz as well as a mild increase in serum creatinine. Renal and hair cell histology as well as ABR measures were unchanged by PD-1 inhibition. Thus, our data suggest that the use of PD-1 inhibition in conjunction with cisplatin results in toxicities that are similar to those of cisplatin alone.

Prognostic role of programmed-death ligand 1 (PD-L1) expressing tumor infiltrating lymphocytes in testicular germ cell tumors.

PurposeTesticular germ cell tumors (TGCTs) are nearly universally curable malignancies. Nevertheless, standard cisplatin-based chemotherapy is not curative in a small subgroup of patients. Previously, we showed that PD-L1 overexpression is associated with worse prognosis in TGCTs, while tumor infiltrating lymphocytes (TILs) are prognostic in different types of cancer. This study aimed to evaluate the prognostic value of PD-1 and PD-L1 expressing TILs in TGCTs.ResultsPD-L1 positive TILs were found significantly more often in seminomas (95.9% of patients) and embryonal carcinomas (91.0%) compared to yolk sac tumors (60.0%), choriocarcinomas (54.5%) or teratomas (35.7%) (All p < 0.05). TGCTs patients with high infiltration of PD-L1 positive TILs (HS ≥ 160) had significantly better progression-free survival (HR = 0.17, 95% CI 0.09 – 0.31, p = 0.0006) and overall survival (HR = 0.08, 95% CI 0.04 – 0.16, p = 0.001) opposite to patients with lower expression of PD-L1 (HS < 150). PD-1 expressing TILs were not prognostic in TGCTs.Materials and MethodsSurgical specimens from 240 patients with primary TGCTs were included into this translational study. The PD-1 and PD-L1 expression on tumor and TILs were detected by immunohistochemistry using anti-PD-1 and anti-PD-L1 monoclonal antibody. Scoring was performed semiquantitatively by weighted histoscore (HS) method.ConclusionsThe prognostic value of PD-L1 expressing TILs in TGCTs was demonstrated for the first time.

Front-line Treatment with Gemcitabine, Paclitaxel, and Doxorubicin for Patients With Unresectable or Metastatic Urothelial Cancer and Poor Renal Function: Final Results from a Phase II Study

To estimate the response rate of gemcitabine, paclitaxel, and doxorubicin in patients with advanced urothelial carcinoma, we conducted a phase II clinical trial. Patients with renal insufficiency cannot receive standard cisplatin-based chemotherapy for urothelial carcinoma, and carboplatin-based regimens have proved unsatisfactory. Secondary end points for this study included overall survival, safety of the regimen, and safety of same-day pegfilgrastim dosing. A two-stage design was chosen with target response rate of 40%. Key inclusion criteria were metastatic or unresectable urothelial carcinoma, no prior chemotherapy, glomerular filtration rate <60 mL/min, and no dialysis. Gemcitabine (900 mg/m(2)), paclitaxel (135 mg/m(2)), and doxorubicin (40 mg/m(2)) were administered on day 1 of each 14-day cycle. Pegfilgrastim was given with every cycle on either day 1 or optionally day 2. Forty patients were enrolled and 39 were treated. Median age was 72 years (range 51-89). There were 7 complete and 15 partial responses, for a response rate of 56.4% (95% confidence interval, 39.6-72.2). Most cycles (82.8%) were given with same-day pegfilgrastim. Notable grade 3 and 4 nonhematologic toxicities were fatigue and mucositis (10.3% each). There were 4 episodes of neutropenic fever (4 of 198 cycles [2%]; 4 of 39 patients [10.3%]) and no treatment-related deaths. Median overall survival was 14.4 months. The combination of gemcitabine, paclitaxel, and doxorubicin is effective first-line chemotherapy for patients with advanced urothelial carcinoma and renal insufficiency. Neutropenic prophylaxis was acceptable whether pegfilgrastim was given immediately or 24 hours after chemotherapy.

The efficacy of irinotecan, paclitaxel, and oxaliplatin (IPO) in relapsed germ cell tumours with high-dose chemotherapy as consolidation: a non-cisplatin-based induction approach.

To determine the outcome of an expanded cohort of patients with relapsed germ cell tumours (GCTs) treated with a salvage chemotherapy regimen consisting of irinotecan, paclitaxel and oxaliplatin (IPO) and assess the role of IPO as an alternative to standard cisplatin-based chemotherapy regimens in this setting. The results of 72 consecutive patients were reviewed retrospectively. IPO was used either as a second-line treatment (29 patients), of which 20 patients subsequently received high-dose chemotherapy (HDCT), or third-line (43), of which 32 patients proceeded to HDCT. The 2-year progression-free survival (PFS) and 3-year overall survival (OS) rates for the whole cohort were 30.2% (95% confidence interval [CI] 17.3-40.5%) and 33.4% (95% CI 20.1-43.8%), respectively. Complete remission was achieved in 3%, marker-negative partial response (PR) in 41%, marker-positive PR in 18%, stable disease in 17% and progressive disease in 20%. In the second-line setting, the 2-year PFS rate was 43.5% (95% CI 21.7-60.8%) and 3-year OS 49.1% (95% CI 24.2-65.1%). In the third-line setting, the 2-year PFS rate was 21.0% (95% CI 9.5-35.4%) and the 3-year OS rate was 23.9% (95% CI 11.7-38.2). According to the current international prognostic factor study group criteria for first relapse for the high- and very high-risk group the 2-year PFS rates were 50% and 30%, respectively. There were two treatment-related deaths from IPO, and four from HDCT. Grade 3 or 4 toxicities included neutropenia (35%), thrombocytopaenia (18%), infection (15%), diarrhoea (11%) and lethargy (8%). IPO offers an effective, well-tolerated, non-nephrotoxic alternative to cisplatin-based salvage regimens for patients with relapsed GCTs. It appears particularly useful in high-risk patients and for those in whom cisplatin is ineffective or contra-indicated.