ajho American Journal Hematology/ Oncology The T H E J O U R N A L O F F I C I A L

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1 J O U R N A L O F T H E O F F I C I A L The American Journal of Hematology/ Oncology A Peer-Reviewed Resource for Oncology Education ajho LUNG CANCER Immunotherapeutic Advances in the Treatment of Metastatic Non Small Cell Lung Cancer Srinivasa R. Sanikommu, MD, and Kathryn F. Mileham, MD MULTIPLE MYELOMA Freelite for Measurement of Urine-Free Light Chains in Monoclonal Gammopathies Montgomery Lobe, MD, and Donald Pasquale, MD OVARIAN CANCER New Biologic Frontiers in Ovarian Cancer: Olaparib Update Rebecca A. Previs, MD, Heather J. Dalton, MD, and Robert L. Coleman, MD RENAL CELL CARCINOMA Case Report: Metastatic Renal Cell Carcinoma Invading the Pulmonary Vein and Left Atrium: An Extremely Rare Occurrence Treated with Temsirolimus Sameer Tolay, MD, Ranju Gupta, MD, and Alcee J. Jumonville, MD GLIOBLASTOMA CME CME-certified enduring materials sponsored by Physicians Education Resource, LLC Current Standards and Emerging Approaches in Glioblastoma David A. Reardon, MD Volume 12 Number ISSN (print) ISSN (online)

2 Table of Contents 4 LUNG CANCER Immunotherapeutic Advances in the Treatment of Metastatic Non-Small Cell Lung Cancer Srinivasa R. Sanikommu, MD, and Kathryn F. Mileham, MD The field of immunotherapy in lung cancer treatment is evolving rapidly. Sanikommu and Mileham provide an overview of studies that are underway that evaluate immunotherapeutic combinations and sequences of checkpoint inhibitors with chemotherapy that will continue to evolve the treatment landscape. 8 MULTIPLE MYELOMA Freelite for Measurement of Urine-Free Light Chains in Monoclonal Gammopathies Montgomery Lobe, MD, and Donald Pasquale, MD Lobe and Pasquale studied 23 individuals with monoclonal gammopathies to determine whether Freelite, an assay that aids in the detection of kappa and lambda free light chains (FLCs), could be used to measure FLCs from spot urine. 13 OVARIAN CANCER New Biologic Frontiers in Ovarian Cancer: Olaparib Update Rebecca A. Previs, MD, Heather J. Dalton, MD, and Robert L. Coleman, MD The authors review the early clinical investigation of olaparib, emerging phase II and III data, and future directions, including forthcoming clinical trials and methods to predict response and expand the populations eligible to receive this innovative biologic therapy. 22 RENAL CELL CARCINOMA Case Report: Metastatic Renal Cell Carcinoma Invading the Pulmonary Vein and Left Atrium: An Extremely Rare Occurrence Treated with Temsirolimus Sameer Tolay, MD, Ranju Gupta, MD, and Alcee J. Jumonville, MD Cardiac metastasis from renal cell carcinoma involving the left atrium and pulmonary vein is a rare occurrence that has only been reported 4 times in the literature, according to the researchers. 26 GLIOBLASTOMA CME CME-certified enduring materials sponsored by Physicians Education Resource, LLC Current Standards and Emerging Approaches in Glioblastoma David A. Reardon, MD David A. Reardon, MD, clinical director of the Center for Neuro-Oncology at the Dana-Farber Cancer Institute offered his insights on current and emerging treatment approaches in patients with glioblastoma. Searching for a past article? Visit and find it in the archives. Get Social! Visit us on:

3 AJHO Editorial Board / PER Executive Board The American Journal of Hematology/Oncology is the official journal of Physician s Education Resource, LLC. Edward Ambinder, MD Clinical Professor Division of Medicine, Hematology, and Medical Oncology Mount Sinai Hospital New York, NY Patrick I. Borgen, MD Chairman, Department of Surgery Maimonides Medical Center Director, Brooklyn Breast Cancer Program Brooklyn, NY David R. Gandara, MD Professor of Medicine Director, Thoracic Oncology Program Senior Advisor to the Director Division of Hematology/Oncology UC Davis Comprehensive Cancer Center Sacramento, CA Andre Goy, MD, MS Chairman and Director Chief of Lymphoma Director, Clinical and Translational Cancer Research John Theurer Cancer Center at Hackensack University Medical Center Hackensack, NJ Omid Hamid, MD Chief, Translational Research and Immunotherapy Director, Melanoma Therapeutics The Angeles Clinic and Research Institute Los Angeles, CA Roy S. Herbst, MD, PhD Ensign Professor of Medicine (Medical Oncology) Professor of Pharmacology Chief of Medical Oncology Associate Director for Translational Research Yale Cancer Center Yale School of Medicine New Haven, CT Benjamin Levy, MD Assistant Professor Division of Medicine, Hematology, and Medical Oncology Mount Sinai Hospital New York, NY Thomas J. Lynch, Jr, MD CEO and Chairman Massachusetts General Physicians Organization Massachusetts General Hospital Boston, MA Maurie Markman, MD President, Medicine and Science National Director, Medical Oncology Cancer Treatment Centers of America Philadelphia, PA John L. Marshall, MD Chief, Hematology and Oncology Director, Otto J. Ruesch Center for the Cure of Gastrointestinal Cancers Lombardi Comprehensive Cancer Center Georgetown University Medical Center Washington, DC Franco Muggia, MD Professor of Medicine New York University Langone Medical Center New York, NY Joyce A. O Shaughnessy, MD Co-Director, Breast Cancer Research Baylor Charles A. Sammons Cancer Center Texas Oncology The US Oncology Network Dallas, TX Daniel P. Petrylak, MD Professor of Medicine (Medical Oncology) and of Urology Co-Director, Signal Transduction Research Program Yale Cancer Center and Smilow Cancer Hospital New Haven, CT Roman Perez-Soler, MD Chairman, Department of Oncology Montefiore Medical Center Bronx, NY Antoni Ribas, MD, PhD Professor of Medicine Professor of Surgery University of California, Los Angeles Los Angeles, CA Naiyer Rizvi, MD Director of Thoracic Oncology and Director of Immunotherapeutics Columbia University Medical Center New York, NY Gilles A. Salles, MD, PhD Professor of Medicine Hospices Civils de Lyon Lyon, France Heather A. Wakelee, MD Associate Professor, Medicine (Oncology) Stanford University Medical Center Stanford, CA Jeffrey S. Weber, MD, PhD Senior Member and Director Donald A. Adam Comprehensive Melanoma Research Center Moffitt Cancer Center Tampa, FL Anas Younes, MD Chief, Lymphoma Service Memorial Sloan Kettering Cancer Center New York, NY PER s Mission Physicians Education Resource, LLC (PER ) is dedicated to advancing cancer care through professional education. Accredited by the Accreditation Council for Continuing Medical Education (ACCME) and approved as a nursing continuing education provider by the California Board of Registered Nursing (CBRN), PER is the educational resource of choice for live and online activities focusing on oncology and hematology. Based on identified needs and practice gaps, PER provides high-quality, evidence based activities featuring leading national and international faculty with a focus on practice changing advances and standards of care in treatment and disease management. Activities may also include topics on emerging strategies currently under investigation, supportive care, diagnosis and staging, prevention, screening and early detection, and practice management. PER plans, develops, implements, and evaluates educational activities using a wide variety of formats targeted to the needs of the healthcare providers we serve. Our CME/CE-certified activities enable health care providers to remain current and responsive to advances in medical care for patients with cancer, from diagnosis through treatment, with the ultimate goal of improving patient outcomes. PER serves the oncology health care community, including physicians, nurses, nurse practitioners, physician assistants, pharmacists, and other health care providers who are involved in the treatment and management of patients with cancer.

4 Chairman s Letter This month s stories cover a mixed bag of tumor types, including a case report of metastatic renal cell carcinoma that spread to the pulmonary vein and left atrium. Tolay and colleagues report in, Metastastic Renal Cell Carcinoma Invading the Pulmonary Vein and Left Atrium: An Extremely Rare Occurrence Treated With Temsirolimus, that this is a rare occurrence, with only four articles cited in the literature. Traditionally managed surgically, the authors report on the use of temsirolimus, which led to tumor regression and the relief of symptoms for the patient. In an update of olaparib data, Previs and colleagues note in, New Biologic Frontiers in Ovarian Cancer: Olaparib Update, that olaparib and PARP inhibition, are an exciting addition to currently available treatment options for patients with ovarian cancer. They emphasize the need to determine optimal settings and combinations in which to administer olaparib, and which will be further investigated in future trials. Lobe and Pasquale studied 23 patients with monoclonal gammopathies in their article, Freelite for Measurement of Urine-Free Light Chains in Monoclonal Gammopathies. They note that the Freelite assay could be used to measure free light chains (FLCs) from a spot urine. The researchers conclude that the measurement of spot urine FLCs using Freelite may replace 24-hour urine total protein and immunofixation electrophoresis. The utilization of immunotherapy in advanced non small cell lung cancer has completely altered the approach to treating this disease, says Sanikommu and Mileham in their article, Immunotherapeutic Advances in the Treatment of Metastatic Non-Small Cell Lung Cancer. They note that multiple immunotherapeutics are being evaluated in combinations, sequences, and various stages in the treatment of all lung cancer. The result is a shift in the long-term paradigm in lung cancer treatment. In this month s CME article, David A. Reardon, MD, of the Dana-Farber Cancer Institute discusses the current and emerging treatment approaches in patients with glioblastoma. Michael J. Hennessy, Sr Chairman and Chief Executive Officer The content of this publication is for general information purposes only. The reader is encouraged to confirm the information presented with other sources. American Journal of Hematology/Oncology makes no representations or warranties of any kind about the completeness, accuracy, timeliness, reliability, or suitability of any of the information, including content or advertisements, contained in this publication and expressly disclaims liability for any errors and omissions that may be presented in this publication. American Journal of Hematology/ Oncology reserves the right to alter or correct any error or omission in the information it provides in this publication, without any obligations. American Journal of Hematology/Oncology further disclaims any and all liability for any direct, indirect, consequential, special, exemplary, or other damages arising from the use or misuse of any material or information presented in this publication. The views expressed in this publication are those of the authors and do not necessarily reflect the opinion or policy of American Journal of Hematology/Oncology. 2

5 From the Editor In the November issue of AJHO, the review on PARP inhibitors for ovarian cancer by Previs and colleagues illustrates two important and recurring themes in cancer biology and treatment. One is the concept of synthetic lethality that is, knocking out more than one critical pathway that together can synergistically disable malignant cell growth and survival. The other tenet is the potential to target cancer pathways that involve multiple tumor types, but require proper selectivity of patients with a diverse set of cancers. DNA repair is a critical cellular pathway that is necessary due to the ongoing assault on our genome, which must replicate 3 billion base pairs with every cell division. These repair pathways are redundant (as are most critical processes), so knocking out more than one could make a big difference. In the laboratory, cells that are already double stranded DNA repair-deficient Debu Tripathy, MD Editor-in-Chief owing to a BRCA mutation are exquisitely sensitive to disruption of other pathways such as base excision repair with PARP inhibitors. The second theme applies in this situation because BRCA-deficient tumors also include some breast, prostate, pancreatic, and other tumors. Additionally, several other aberrations such as methylation of BRCA 1 promoter, and mutations/alterations in other DNA repair pathway genes may also results in sensitivity to PARP inhibitors and indeed, testing of these drugs in diverse cancer types that exhibit DNA repair deficiency (sometimes termed homologous repair deficiency) is underway with varying degrees of success seen so far. But this story is not as clean this is highlighted nicely in the review article. The impact of PARP inhibitors in the clinic is not nearly as dramatic as in the laboratory a common finding given that intratumoral diversity and host-tumor interactions are not mirrored in preclinical models. In the clinic, not all BRCA-deficient or mutant cancers are sensitive to PARP inhibitors even from the start, and those that are initially sensitive ultimately develop clinical resistance. One alarming resistance mechanism is the development of additional mutations that even repair the BRCA 1 gene back to its wildtype version. Certainly other bypass pathways are also operative, and this is an area of active research, with pathways such as PI3K/mTOR, MET, Wee1 and others being targeted. In addition, BRCA 1/2 and other DNA repair gene aberrations may have different biological manifestations across the range of tumor types this is due to the fact that these cells may have an altogether different set of expressed genes that may affect the function of the DNA repair machinery and associated bypass pathways. This may limit the power of the new trend to conduct basket trials across multiple tumor types with common genomic aberrations therefore, many of these basket trials are followed by cohort expansions for each tumor type to further understand tumor-specific biology and clinical outcomes. As pointed out in this article, more fundamental basic research and exploration of rational combinations are needed to tackle this problem even with these new and exciting drugs. The American Journal of Hematology/Oncology is accepting manuscripts for immediate consideration. Articles of interest include: Original research Reviews Emerging guidelines Case reports Pivotal trials Please send manuscripts to Anthony Berberabe (aberberabe@mjhassoc.com). EDITORIAL STAFF Editor-in-Chief Debu Tripathy, MD Professor and Chair Department of Breast Medical Oncology The University of Texas MD Anderson Cancer Center Houston, TX Associate Editor Jason J. Luke, MD, FACP Assistant Professor of Medicine University of Chicago Chicago, IL Managing Editor Tony Berberabe, MPH aberberabe@mjhassoc.com Art Director Paul Tresten Editorial Offices Physicians Education Resource, LLC 666 Plainsboro Road, Ste 356 Plainsboro, NJ (609) President Phil Talamo, CHCP Medical Director Michael Perlmutter, PharmD, MS CORPORATE OFFICERS Chairman and CEO Michael J. Hennessy, Sr Vice Chairman Jack Lepping President Mike Hennessy, Jr Chief Financial Officer Neil Glasser, CPA/CFE Executive Vice President, Oncology Professional Relations Donna Short Chief Marketing Officer Warren Dardine Chief Digital Strategy Officer Steve Ennen Vice President of Editorial Services and Production Kerrie Keegan Vice President, Digital Media Jung Kim Chief Creative Officer Jeff Brown Human Resource Director Shari Lundenberg VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 3

6 LUNG CANCER Immunotherapeutic Advances in the Treatment of Metastatic Non-Small Cell Lung Cancer Srinivasa R. Sanikommu, MD, and Kathryn F. Mileham, MD Abstract Lung cancer remains the leading cause of cancer-related mortality in the United States. Most patients are diagnosed with advanced disease, and while progress has been made in targeted therapy, very few changes in the platinum backbone have been made for those patients without actionable mutations or PD-L1 positivity. The utilization of immunotherapy in advanced non small cell lung cancer (NSCLC) has completely altered the approach to treating this disease. Within less than two years, multiple agents have been FDA approved for the treatment of second-line therapy in metastatic NSCLC. Even more recently, a PD-1 antibody was approved for the first-line treatment of metastatic NSCLC in patients whose tumors have 50% PD-L1 expression. Multiple immunotherapeutics are being evaluated in combinations, sequences, and various stages in the treatment of all lung cancer. These immunotherapeutic advances have shifted a long-term paradigm in lung cancer treatment. AJHO. 2016;12(11):4-8 Background Lung cancer is the leading cause of cancer-related mortality in the United States 1. Most patients with newly diagnosed non small cell lung cancer (NSCLC) have incurable disease. For decades, standard first-line treatment for metastatic NSCLC (mnsclc) has been platinum-doublet chemotherapy with anticipated response rates (RR) of about 30% and median overall survivals (mos) of 10 to 12 months. 2 Second-line chemotherapy with single-agent docetaxel has anticipated RR around 5% to 10% with mos of 7 months. 3 The identification of driver mutations such as EGFR, ALK and ROS1 has led to the approval of multiple agents targeting these specific tumor alterations, resulting in improved RR and even mos with fewer toxicities when compared with chemotherapy. Acquired resistance limits next-line treatment options. Additionally, the frequency of these mutations is low and broader applications of novel interventions for all NSCLC has been prioritized. The capacity of the host immune system to disrupt tumors is not a new concept. However, prior immunological approaches to the treatment of lung cancer were not successful. With the introduction of checkpoint inhibitors, immunotherapy re-emerged as a potential intervention in lung cancer. Programmed cell death 1 (PD-1) is a type I transmembrane protein expressed on the surface of activated T cells. When PD-1 binds to one of its ligands (PD-L1 or PD-L2), T-cell activity is downregulated. Tumor cells can express PD-L1, and interaction with PD-1 on T cells can enable tumor growth via immune evasion. New immunotherapies block the binding of PD-1 and PD-L1, allowing ongoing activation of T cells. Within 18 months, three different checkpoint inhibitors were FDA-approved with multiple indications in mnsclc (Table 1). These unprecedented advances have led to a completely different approach to mnsclc treatment. First-line Treatment Although different immunotherapies had already proven similar benefits in the second-line setting, phase 3 data on two agents in the first-line treatment of mnsclc yielded very different results. KEYNOTE-024 is the pivotal trial that led to the first FDA approval of immunotherapy in first-line treatment of patients with mnsclc. 4 Of 1934 patients screened, 305 with previously untreated mnsclc with 50% PD-L1 expression on tumor cells by immunohistochemistry (IHC) and without EGFR mutation or ALK rearrangement were randomized to pembrolizumab (Keytruda) 200 mg every 3 weeks versus investigator-choice platinum-based doublet chemotherapy. Patients in control arm could cross over to pembrolizumab at progression. Progression free survival (PFS), the primary endpoint, was 10.3 months with pembrolizumab versus 6 months with chemotherapy, including 43.7% of patients who crossed over to pembrolizumab (HR, 0.50; P <.001). Six-month OS was 80.2% with pembrolizumab compared with 72.4% with chemotherapy (HR, 0.60; P <.005). Overall RR was also higher with pembrolizumab (45% versus 28%), and median duration of response (DoR) was longer with pembrolizumab (not reached versus 6.3 months). Pembrolizumab was better tolerated with 27% 4 NOVEMBER 2016

7 IMMUNOTHERAPEUTIC ADVANCES IN THE TREATMENT OF METASTATIC NON-SMALL CELL LUNG CANCER of patients experiencing grade 3 to 5 treatment-related toxicities compared with 53% of patients receiving chemotherapy. Based on these results, the FDA approved pembrolizumab in October 2016 as first-line treatment in patients with mnsclc whose tumors have 50% PD-L1 expression and no EGFR or ALK genomic tumor aberrations. These significant results changed the multi-decade-old treatment paradigm in first-line mnsclc, offering an effective and tolerable treatment for approximately 30% of the patients with high PD-L1 expressing tumors. Nivolumab, an IgG4 anti PD-1 monoclonal antibody, failed to meet expectations in the same setting. CheckMate 026 randomized 541 patients for first-line treatment of mnsclc with PD-L1-positive tumors ( 5% expression by IHC) to nivolumab 3 mg/kg every 2 weeks versus investigator-choice platinum-based doublet chemotherapy. 5 The study did not meet its primary endpoint of PFS (4.2 months with nivolumab versus 5.9 months with chemotherapy; HR, 1.15; P =.25), including 60% of patients who crossed over to nivolumab. One-year PFS was 23.6% versus 23.2%, respectively. In patients with PD-L1 tumor expression >5%, OS was 14.4 months with nivolumab versus 13.2 months TABLE. Important Immunotherapy Clinical Trials in mnsclc Trial Agent Study Design First line KEYNOTE-024 Second line CheckMate 017 CheckMate 057 Phase 3, mnsclc with PD-L1 50% # of Patients 305 ORR (%) mpfs (mos) mos (mos) G 3-4 Tox (%) Pembrolizumab 200 mg NR 27 Platinum-doublet chemo NR 53 Phase 3, squamous mnsclc, platinum refractory Nivolumab 3 mg/m Docetaxel 75 mg/m Phase 3, non-squamous mns- CLC, platinum refractory Nivolumab 3 mg/kg Docetaxel 75 mg/m KEYNOTE-001 Pembrolizumab Phase 1, mnsclc KEYNOTE-010 Phase 2/3, mnsclc 1034 POPLAR OAK Pembrolizumab 2 mg/kg Pembrolizumab 10 mg/ kg Docetaxel 75 mg/m Phase 2, mnsclc, platinum refractory Atezolizumab 1200 mg Docetaxel 75 mg/m Phase 3, mnsclc, platinum refractory (850 analyzed) Atezolizumab 1200 mg Docetaxel 75 mg/m Chemo indicates chemotherapy; G, grade; mnsclc, metastatic non-small cell lung cancer; mos, median overall survival; mos, months; mpfs, media progression-free survival; NR, not reached; ORR, overall response rate; Tox, toxicity. VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 5

8 LUNG CANCER with chemotherapy. Overall RR was not higher with nivolumab (26% versus 34%), although those who did respond, median DoR was longer with nivolumab (12.1 versus 5.7 months). Nivolumab was well tolerated with 18% grade 3/4 treatment-related toxicities compared with 51% with chemotherapy. Interestingly and quite surprisingly, subgroup analysis of those patients with PD-L1 tumor expression 50% did not show significantly improved PFS or OS. Other immunotherapeutics including anti-pd-l1 antibodies atezolizumab and durvalumab are being evaluated in first-line treatment for mnsclc. Second-line Treatment Immune checkpoint inhibitors were first approved in mnsclc in the second-line setting. Currently two PD-1 inhibitors and one PD-L1 inhibitor are FDA-approved as second-line treatment with varied indications in mnsclc. Two large phase 3 randomized trials were conducted comparing nivolumab 3 mg/kg every 2 weeks to docetaxel 75 mg/m² every 3 weeks in mnsclc, one in squamous histology (CheckMate 017) 6 and another in non-squamous histology (CheckMate 057). 7 CheckMate-017 randomized 272 patients with squamous mns- CLC with disease progression on platinum-based doublet chemotherapy to either nivolumab or docetaxel. Primary endpoint OS was improved with nivolumab (9.2 versus 6 months; HR, 0.59; 95% CI ). RR was higher with nivolumab, 20% versus 9%. Eighty-three percent of patients had quantifiable PD-L1 expression on archived tumor tissue. Expression of PD-L1 was neither prognostic nor predictive of efficacy in patients with squamous NSCLC. Nivolumab was well tolerated with 7% grade 3/4 toxicities compared with 55% in docetaxel group. Based on these results, in March 2015, FDA approved nivolumab for squamous mnsclc with disease progression after first-line chemotherapy. CheckMate-057 randomized 582 patients with non-squamous mnsclc whose disease failed platinum-based doublet chemotherapy to nivolumab or docetaxel. Median OS, primary endpoint, was prolonged with nivolumab compared with docetaxel (12.2 versus 9.4 months; HR, 0.73; 95% CI ). Nivolumab demonstrated superior 1-year and 18-month survival rates (51% versus 39% and 39% versus 23%, respectively). PD-L1 expression was measured on archived samples in 78% of patients; unlike the squamous trial, PD-L1 expression was predictive of response to nivolumab with trend toward higher RR as PD-L1 expression level increased. Nivolumab was well tolerated with 10% grade 3/4 toxicities compared with 54% with docetaxel. In October 2015, nivolumab received FDA approval for all patients with non-squamous mnsclc whose disease progressed after first-line platinum-based chemotherapy. KEYNOTE-001 is a phase 1 study of 495 evaluable patients with mnsclc to determine safety, side-effect profile, and antitumor activity of pembrolizumab. 8 Unlike the CheckMate trials, patients were required to have biopsy-proven PD-L1 expression and previously untreated patients were also allowed to enroll. Overall RR was 19.4%, including RR of 18% in 394 previously treated patients and 24.8% in 101 previously untreated patients. Additionally, in 61 previously treated patients with 50% PD-L1 tumor expression, RR was 41%. In addition to the frontline, FDA granted accelerated approval to pembrolizumab for the treatment of patients with mnsclc whose tumors express PD-L1 on 50% of all cells with disease progression after platinum-containing chemotherapy. KEYNOTE-010 is a phase 2/3 study of 1034 patients with mnsclc who received either pembrolizumab 2 mg/kg or 10 mg/kg or docetaxel 75 mg/m² every 3 weeks. 9 Primary endpoints were OS and PFS, both in the total population and in patients with 50% PD-L1 tumor expression. Median OS was significantly longer with pembrolizumab 2 mg/kg at 10.4 months (HR, 0.71; 95% CI, ; P =.0008) and with pembrolizumab 10 mg/ kg at 12.7 months (HR, 0.61; 95% CI, ; P <.0001) compared with 8.5 months with docetaxel. Median PFS was not significantly different with either pembrolizumab 2 mg/kg (3.9 months) or pembrolizumab 10 mg/kg (4 months) compared with docetaxel (4 months). Among patients with 50% PD-L1 tumor expression, mos was significantly longer with pembrolizumab 2 mg/kg at 14.9 months (HR, 0.54; 95% CI, ; P =.0002) and pembrolizumab 10 mg/kg at 17.3 months (HR 0.50; 95% CI ; P <.0001) compared with 8.2 months with docetaxel. PFS was significantly longer with both pembrolizumab dosing groups (5 and 5.2 months) versus docetaxel (4.1 months). The researchers reported that pembrolizumab was well tolerated with 13% to 16% grade 3/4 treatment-related toxicities compared with 35% in the docetaxel group. POPLAR 10 is an open-label, phase 2 trial of 287 patients with mnsclc who failed platinum-based chemotherapy randomized to atezolizumab 1200 mg or docetaxel 75 mg/m 2 every 3 weeks. Primary endpoint was met with OS of 12.6 months with atezolizumab versus 9.7 months with docetaxel (HR, 0.73; 95% CI, ; P =.04). Patients were stratified based on percentage of PD-L1-expressing tumor cells (TC) by IHC to TC3 50%, TC2 5% and <50%, TC1 1% and <5%, and TC0 <1% and percentage of tumor-infiltrating immune cells (IC) to IC3 10%, IC2 5% and <10%, IC1 1% and <5%, and IC0 <1%. Increasing improvement in OS was associated with increasing PD-L1 expression. Atezoluzumab was well tolerated with 11% treatment-related grade 3/4 toxicities compared with 39% patients in the docetaxel group. OAK, 11 a randomized phase 3 study comparing atezolizumab with docetaxel in previously treated mnsclc, confirmed the efficacy of atezolizumab seen in POPLAR. In the trial, 1225 patients stratified by PD-L1 status, prior chemotherapy regimens, and histology were randomized to atezolizumab 1200 mg every 3 weeks or docetaxel 75 mg/m 2 every 3 weeks. Co-primary 6 NOVEMBER 2016

9 IMMUNOTHERAPEUTIC ADVANCES IN THE TREATMENT OF METASTATIC NON-SMALL CELL LUNG CANCER endpoints were OS in the entire study population and in a PD-L1- defined subgroup. Secondary endpoints included PFS, ORR, DoR and safety. Within 850 evaluable patients, mos was 13.8 months with atezolizumab versus 9.6 months with docetaxel (HR, 0.74; 95% CI, ; P =.0003). Survival was improved regardless of PD-L1 expression levels, including in patients with no PD-L1 expression (TC0 and IC0) (HR, 0.82; 95% CI, ). However, there was pronounced benefit in patients with high PD-L1 expression (TC3 or IC3; HR, 0.41; 95% CI, ). The benefit was consistent across histologic subgroups, smoking status, or baseline brain metastasis status. PFS was 2.8 versus 4.0 months, ORR was 13.6% versus 13.4%, and DoR was 16.3 versus 6.2 months for atezoluzumab versus docetaxel, respectively. Atezolizumab was well tolerated with 15% grade 3/4 toxicities compared with 43% in docetaxel group. Atezolizumab was approved by the FDA in October 2016 for treatment of mnsclc progressing after platinum-containing chemotherapy irrespective of PD-L1 status. Combination Treatment Combination of immunotherapies such as PD-1/PD-L1 inhibitors with anti CTLA-4 antibodies is being evaluated in both first- and next-line mnsclc treatment. CheckMate-227 is an open-label randomized phase 3 trial investigating nivolumab or nivolumab plus ipilumumab versus platinum-doublet chemotherapy in patients with chemotherapy-naïve mnsclc. 12 MYSTIC is a phase 3 trial evaluating durvalumab or durvalumab plus tremelimumab versus chemotherapy as first-line therapy for mnsclc. 13 ARCTIC is a phase 3 trial evaluating durvalumab or tremelimumab alone or durvalumab plus tremelimumab versus chemotherapy in PD L1 negative patients after at least 2 lines of chemotherapy. 14 Another active area of research is combining immunotherapy with chemotherapy. Multiple ongoing trials are combining PD-1/ PD-L1 inhibitors or anti CTLA-4 antibodies with chemotherapy. KEYNOTE-021 is a phase 2 multi-cohort study of pembrolizumab combination therapies in mnsclc. 15 One cohort included treatment with four cycles of carboplatin-pemetrexed-pembrolizumab followed by 24 months of pembrolizumab and indefinite pemetrexed maintenance or four cycles of carboplatin-pemetrexed followed by pemetrexed maintenance. RR was 55% with pembrolizumab combination compared with 29% with chemotherapy alone. RR was 57% in patients with <1% PD-L1 expression while RR was 80% in patients with 50% PD-L1 expression. This treatment combination may be effective and tolerable and is being evaluated in a phase 2 study. Multiple phase 3, multicenter, randomized open-label studies are evaluating atezolizumab in combination with platinum-based chemotherapy or chemotherapy plus bevacizumab. 16 Patient Selection As indicated by the variability in results with different agents and different PD-L1 tumor expression levels, appropriate identification of those patients most likely to garner responses to those agents has been challenging. Regardless of assay or treating agent, high expression of PD-L1 is associated with better response. However, PD-L1 may be an imperfect surrogate marker, as levels may be affected by intra-tumoral heterogeneity, dynamic expression, and assay variability. Interestingly, some patients with no PD-L1 expression benefit from immunotherapy, suggesting another mechanism for response. Current evidence supports use of PD-L1 assay to guide management until a better biomarker is identified. Higher somatic nonsynonymous mutation burden in tumors was associated with better response to PD-L1 therapy than total mutation burden, indicating that neoantigens likely associated with smoking might play an important role in response to therapy. 17 Higher RRs were observed in patients with history of smoking across multiple studies 1,6 with response rates up to 30% in patients with 5 pack-year tobacco history compared with no response in patients with <5 pack-year tobacco history. 18 This continues to be an area of active research and debate. Conclusion The field of immunotherapy in lung cancer treatment is evolving rapidly. Although lung cancer was previously thought to be non-immunogenic, immunotherapy has shown durable responses with fewer side effects compared with traditional chemotherapy in treatment of mnsclc. Although PD-L1 expression has been associated with better response to therapy, other biomarkers such as mutational load need further investigation for improved patient selection. Additional studies are underway evaluating combinations and sequences of checkpoint inhibitors with chemotherapy and other immunotherapies that will continue to evolve the treatment landscape of lung cancer. Author affiliations: Srinivasa Sanikommu and Kathryn F. Mileham are with Levine Cancer Institute, Carolinas Health- Care System. Author disclosures: Srinivasa Sanikommu and Kathryn F. Mileham report no conflicts of interest. Address correspondence to: Kathryn F. Mileham, MD, Chief, Section of Thoracic Medical Oncology, Levine Cancer Institute, Carolinas HealthCare System, 1021 Morehead Medical Drive, Suite 3100, Charlotte, NC 28204; telephone: (980) , fax: (980) ; kathryn.mileham@carolinashealthcare.org. References 1. Siegel RL, Miller KD, Jemal A. Cancer statistics, CA Cancer J Clin. 2016;66(1):7-30. doi: /caac Schiller JH, Harrington D, Belani C, et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 7

10 LUNG CANCER cancer. N Engl J Med. 2002;346(2): Hanna N, Shepherd FA, Fossella FV, et al. Randomized phase lll trial of pemetrexed versus docetaxel in patients with non-small-cell lung cancer previously treated with chemotherapy. J Clin Oncol. 2004;22(9): Reck M, Rodriguez-Abreu D, Robinson A, et al. Pembrolizumab versus chemotherapy for PD-L1 positive non-small-cell lung cancer. N Engl J Med. 2016;375(19): Socinski MA, Creelan B, Horn L, et al. CheckMate 026: A phase 3 trial of nivolumab vs investigator s choice (IC) of platinum-based doublet chemotherapy (PT-DC) as first-line therapy for stage IV/recurrent programmed death ligand 1 (PD-L1)-positive NSCLC. Ann Oncol. 2016;27(suppl 6): vi552 vi Brahmer J, Reckamp KL, Baas P, et al. Nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer. N Engl J Med Jul 9;373(2): doi: / NEJMoa Borghaei H, Paz-Ares L, Horn L, et al. Nivolumab versus docetaxel in advanced nonsquamous non-small-cell lung cancer. N Engl J Med. 2015;373(17): doi: / NEJMoa Garon E, Rizvi NA, Hui R, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med. 2015;372(21): doi: /NEJMoa Herbst RS, Baas P, Kim DW, et al. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial. Lancet. 2016;387(10027): doi: /S (15) Fehrenbacher L, Spira A, Ballinger M, et al. Atezolizumab versus docetaxel for patients with previously treated non-small-cell lung cancer (POPLAR): a multicentre, open-label, phase II randomized control trial. Lancet. 2016;387(10030): doi: /S (16) Barlesi F, Park K,Ciadiello J, et al. Primary analysis from OAK, a randomized phase III study comparing atezolizumab with docetaxel in 2L/3L NSCLC. Ann Oncol. 2016;27 (suppl 1): Abstract LBA44_PR. 12. Hellman M, Ramalingam S, Reck M, et al. An open label randomized phase III trial of nivolumab or nivolumab plus ipilimumab vs platinum doublet chemotherapy (PT-DC) in patients with chemotherapy-naïve stage IV or recurrent nonsmall cell lung cancer (NSCLC) (CheckMate 227). J Immunother Cancer. 2015;3(suppl 2): P Peters S, Antonia S, Goldberg SB, et al. MYSTIC: a global, phase 3 study of durvalumab (MEDI4736) plus tremelimumab combination therapy or durvalumab monotherapy versus platinum-based chemotherapy in the first-line treatment of patients with advanced stage IV NSCLC. J Thorac Oncol. 2016;11(suppl 4): S139-S Planchard D, Yokoi T, McCleod MJ, et al. A phase III study of durvalumab (MEDI4736) with or without tremelimumab for previously treated patients with advanced NS- CLC: rationale and protocol design of the ARCTIC study. Clin Lung Cancer. 2016;17(3): e1. doi: /j. cllc Langer C, Gadgeel SM, Borghaei H, et al. Carboplatin and pemetrexed with or without pembrolizumab for advanced non-small cell lung cancer: a randomised, phase 2 cohort of open label KEYNOTE-021 study. Lancet Oncol. 2016;17(11): doi: /S (16) Mok T, Cappuzzo F, Jotte R, et al. Phase lll clinical trials of atezolizumab in combination with chemotherapy in chemotherapy negative patients with advanced NSCLC. Ann Oncol. 2015;26(suppl 9): Rizvi N, Hellmann M, Snyder A, et al. Mutational landscape determinants sensitivity to PD-1 blockade in nonsmall cell lung cancer. Science. 2015;348(6230): doi: /science.aaa Gettinger SN, Horn L, Gandhi L, et al. Overall survival and long-term safety of nivolumab (anti-programmed death 1 antibody, BMS , ONO-4538) in patients with previously treated advanced non-small-cell lung cancer. J Clin Oncol. 2015;33(18): doi: /JCO NOVEMBER 2016

11 FREELITE FOR MEASUREMENT OF URINE-FREE LIGHT CHAINS IN MONOCLONAL GAMMOPATHIES Freelite for Measurement of Urine-Free Light Chains in Monoclonal Gammopathies Montgomery Lobe, MD, and Donald Pasquale, MD Abstract Monoclonal gammopathies are characterized by production of monoclonal immunoglobulin heavy or light chains. Historically, the standard for measuring monoclonal light chains was indirect, requiring 24-hour urine collection, measurement of total protein, and extrapolation of light chain concentration using electrophoresis. In 2001, Freelite was developed allowing direct detection of serum-free light chains (FLCs) with sensitivity >2-log higher than immunofixation electrophoresis (IFE), and became standard for diagnosis and monitoring of these disorders. However, cases are missed when urine FLCs are not measured. We studied 23 individuals with monoclonal gammopathies to determine whether Freelite could be used to measure urine FLCs from a spot urine. We concurrently measured serum and urine FLCs using Freelite and serum heavy chains. Monoclonal urine and serum FLCs correlated in 39% of patients. Both urine and serum monoclonal FLCs correlated with clonal serum heavy chains in 25%, serum in only 30%, and urine in only 10%. We conclude that measurement of spot urine FLCs using Freelite may replace 24-hour urine total protein and IFE. While serum FLCs are adequate in most patients, we found a small number of patients for whom urine FLCs outperformed serum FLCs. AJHO. 2016;12(11):-9-13 Introduction Monoclonal gammopathies represent a spectrum of clonal plasma cell disorders that form monoclonal gammopathy of undetermined significance (MGUS) through active multiple myeloma (MM) that are characterized by production of monoclonal immunoglobulin heavy and/or light chains. 1-3 In these disorders, detection of free light chains (FLCs) has been an evolving and, at times, critical analysis for diagnosis, prognosis, and management of treatment. 4-8 Historically, the standard for evaluating monoclonal light chain production has been the measurement of urine excretion of light chains determined by collecting a 24-hour urine specimen, measuring 24-hour urine total protein, and extrapolating the quantity of light chains using data from a urine protein electrophoresis (UPEP) and immunofixation electrophoresis (IFE). 1 In 2001, Freelite was developing the utilization of immunonephelometric technology that allowed for improved detection of serum FLCs. 9 Sensitivity of UPEP is 500 to 2000 mg/l, IFE is 150 to 500 mg/l, and Freelite is 1.5 to 3.0 mg/l. 10 It was then demonstrated that serum Freelite alone detected more plasma cell disorders than older methods, 7 with the higher detection rate likely due to the increased sensitivity and ability to measure the ratio of abnormal to normal light chains. Serum FLCs utilizing Freelite is now integrated into the standard of care in diagnosis and monitoring of plasma cell disorders. However, this should not replace obtaining urine IFE, as a small number of cases were missed when FLCs were not also measured. 1,6 It has been our practice to use Freelite to measure the quantity of FLCs in single urine samples instead of obtaining a 24-hour urine sample with total protein and IFE. However, this has not been recommended for routine screening due to paucity of data using this assay for urinary measurements, and due to the concern for possibly confounding variable excretion of FLCs because of changes in renal function and variable renal reabsorption and degradation of light chains. 10 The goal of this study was to evaluate the utility of using Freelite for measurement of spot urine FLCs. Methods This study was approved by the Albany VA Medical Center Institutional Review Board. We identified individuals with the diagnosis of MGUS, smoldering MM (SMM), or MM, who had multiple concurrent measurements of serum and urine FLCs using Freelite, and serum heavy chains (quantitative immunoglobulins). Urine and serum FLCs were measured using Freelite (Binding Site Ltd, Birmingham, UK) by a reference laboratory (Lab Corp, Burlington, NC). All analyses were performed using the involved/monoclonal FLC levels and involved/monoclonal heavy chain levels, when affected. Serum immunoglobulins (immunonephelometry) along with other serum and urine VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 9

12 MULTIPLE MYELOMA TABLE 1. Patients Age, Diagnosis, Mean Serum Creatinine, Number of Paired Data Points, and Number of Months Between Obtaining First and Last Paired Samples. Disease Type Age at Diagnosis Mean Serum Creatinine mg/dl (N) Urine/Serum Light Chain Matched Points Months Between First and Last Paired Samples IgG κ Active MM (20) IgG κ Active MM* (7) 7 29 IgG κ Active MM (6) 6 6 IgG κ Active MM (18) IgG κ Active MM (8) 8 16 IgG κ Active MM (6) 6 19 IgG κ Active MM (13) IgG κ Active MM (8) 8 8 IgG λ Active MM (13) IgG κ Active MM (3) 3 3 IgG κ Active MM (5) 5 5 IgG λ Active MM (19) λlc Active MM (20) λlc Active MM (18) IgG κ SMM (4) 4 6 IgG κ SMM (4) 4 10 IgG λ SMM (6) 6 25 IgA κ SMM (6) 6 12 IgG κ MGUS (6) 6 19 IgG λ MGUS (5) 5 17 IgG λ MGUS (5) 5 22 IgA κ MGUS (5) 5 23 IgA κ MGUS (4) 4 13 Mean ± SD 71 ± ± ± ± 8.4 * Prior MGUS. + Insufficient heavy chain data for comparisons. IgA indicates immunoglobulin A; IgA κ, immunoglobulin A kappa; IgA λ, immunoglobulin A lambda; IgG, immunoglobulin G; IgG κ, immunoglobulin G kappa; IgG λ, immunoglobulin G lambda; λ LC, lambda light chain; MGUS, monoclonal gammopathy of undetermined significance; MM, multiple myeloma; SD, standard deviation; and SMM, smoldering multiple myeloma. parameters were measured using standard and widely available techniques by the study s American College of Pathologists accredited medical center chemistry laboratory. Data were analyzed for correlation between parameters using Pearson product-moment correlation. P values <.05 were considered significant. 11 Results Characteristics of the study population are illustrated in Table 1. We identified 23 individuals (all male, consistent with our veteran patient population) with mean (± standard deviation [SD]) age of 71 ± 10.6 years at diagnosis. Five individuals had MGUS, 4 had SMM, and 14 had MM. 12 Two of the 14 patients with MM progressed from MGUS. Twenty-one of 23 patients had intact monoclonal disease, and FLCs were measurable in all 21 of these patients. Two of the 13 patients with MM had lightchain-only disease. A mean (±SD) of 9.2 ± 5.9 matched serum and urine FLC determinations per patient (range, 4 21) was obtained over a mean 17.9 ± 8.4 months. Mean (±SD) serum creatinine of the patients was 1.2 ± 0.4 mg/dl (range, ). 10

13 FREELITE FOR MEASUREMENT OF URINE-FREE LIGHT CHAINS IN MONOCLONAL GAMMOPATHIES FIGURE 1. Comparisons Between Abnormal/Monoclonal Urine and Serum FLCs with Abnormal/Monoclonal Serum Heavy Chain. Panels A and B Illustrate 2 Patients for Whom Both Serum and Urine FLCs Correlate with Serum Heavy Chain. Panel C Illustrates a Patient for Whom Only the Serum FLC Correlates with the Serum Heavy Chain. Panel D Illustrates a Patient for Whom Only the Urine FLC Correlates With the Serum Heavy Chain. 2,500 Urine Kappa: R 2 = 0.522; P = 0.006; N =12 Serum Kappa: R 2 = 0.949; P <.001; N = ,500 Urine Lambda: R 2 =.974; P =.001; N =14 Serum Lambda: R 2 =.978; P <.001; N =14 1,200 Urine Kappa (mg/l) 2,000 1,500 1, Serum Kappa (mg/l) Urine Lambda (mg/l) 3,000 2,500 2,000 1,500 1, , Serum Lambda (mg/l) 0 0 1,000 2,000 3,000 4,000 5,000 6,000 Serum lgg (mg/dl) 0 0 1,500 3,000 4,500 6,000 7,500 Serum lgg (mg/dl) 0 Urine Kappa (mg/l) Urine Kappa: R 2 =.057; P =.531; N = 7 Serum Kappa: R 2 =.808; P <.001; N = ,000 3,500 4,000 4,500 5,000 5,500 Serum lgg (mg/dl) Serum Kappa (mg/l) Urine Lambda (mg/l) Urine Lambda: R 2 =.346; P =.007; N = 20 Serum Lambda: R 2 =.012; P <.656; N = Serum lgg (mg/dl) Serum Lambda (mg/l) FLC indicates free light chain; IgA, immunoglobulin A; and IgG, immunoglobulin G One individual with SMM was excluded from the heavy chain correlations due to insufficient serum FLC data. Results of comparisons between immunoglobulin parameters are illustrated in Table 2. Overall, the urine FLCs correlated with serum FLCs in 9 (39%) individuals, including both patients with light-chain MM. Both urine and serum FLCs correlated with heavy chain in 5 (25%) patients. Serum FLCs, but not urine FLCs, correlated with serum heavy chain in 6 (30%). Urine FLCs, but not serum FLCs, correlated with heavy chain in 2 (10%). There was no correlation between urine or serum FLCs with serum heavy chain in 7 (35%) patients. Use of FLC ratio instead of FLCs and normalization of urine FLCs based on concurrent urine and serum creatinine determinations did not change any of the correlations in any of the 23 participants (data not shown). Figure 1 illustrates comparisons between urine and serum FLCs with serum heavy chains in 4 patients. Panels A and B illustrate patients for whom both urine and serum FLCs correlate with serum heavy chain; Panel C illustrates an individual for whom only the serum FLCs correlated with the serum heavy chain; and Panel D illustrates an individual for whom only the urine FLCs correlated with the serum heavy chain. Figure 2 illustrates 2 patients for whom the urine FLCs correlated with the serum FLCs. Discussion Due to its greater sensitivity in the detection of monoclonal immunoglobulins, serum FLCs have become important for VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 11

14 MULTIPLE MYELOMA FIGURE 2. Correlation in 2 Patients Between Abnormal/Monoclonal Serum and Urine FLCs. Serum Free Kappa (mg/l) R 2 = 0.995; P <.001 (N = 18) 7,000 6,000 5,000 4,000 3,000 2,000 1, ,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 Urine Free Kappa Light Chain (mg/l) Serum Free Lambda (mg/l) R 2 =.999; P <.001 (N = 18) Urine Free Lambda Light Chain (mg/l) FLC indicates free light chain; IgA, immunoglobulin A; and IgG, immunoglobulin G diagnosis, prognosis, and management of plasma-cell disorders. This method is incorporated into current guidelines for assessing patients with monoclonal gammopathies. However, measurement of urine FLCs continues to be required because a small number of individuals are detected only by measurement of urine FLC excretion. 1,6 Methodology for measuring urine FLCs continues to be collecting 24-hour urine specimen and extrapolating the quantity of light chains excreted based on urine IFE. 1,4 This process is subject to error when collection is incomplete, and the sensitivity of IFE is about 2-log less than the Freelite assay. Use of Freelite for measurement of urine FLCs has not been promoted because of a paucity of data using this method, and because of concern regarding using a spot urine due to variability in renal function and tubular handling of light chains, 10,13 TABLE 2. Correlations Between Abnormal/Monoclonal Urine and Serum FLCs, and Between Abnormal/ Monoclonal Urine and Serum FLCs and Abnormal/ Monoclonal Serum Heavy Chain (P <.05) Serum FLCs correlation to urine FLCs (N = 23) Urine and serum FLCs correlate with serum heavy chain (N = 20) Serum FLCs only correlate with serum heavy chain (N = 20)* Urine FLCs only correlate with serum heavy chain (N = 20) No correlation between urine and serum FLCs and serum heavy chain (N = 20) 9 (39%) 5 (25%) 6 (30%) 2 (10%) 7 (35%) * 4 individuals with active MM; 2 with MGUS. Both individuals with active MM. FLC indicates free light chain; MGUS, monoclonal gammopathy of undetermined significance; and MM, multiple myeloma. with prior studies failing to show association between urine FLCs and serum FLCs. 4,8,13 We also failed to show association with aggregated data. However, there was a clear association in 39% of patients between the serum and urine FLCs, and clear associations in 25% of patients between urine FLCs and serum heavy chain. We did not specifically compare head-to-head measurement of spot urine FLCs using Freelite with 24-hour collection quantitation via IFE; however, we feel that with the 2-log increased sensitivity of Freelite, Freelite will outperform IFE. We also observed a small but defined minority of patients for whom urine FLCs outperformed serum FLCs. Use of Freelite as an assay for immunoglobulin light chains does not substitute for urinalysis to screen for albuminuria, which may be an indication of renal light-chain amyloid. If proteinuria is indicated on the screening urinalysis, a 24-hour urine collection should be considered to determine the quantity of albumin as a part of an evaluation for amyloid disease. We feel that due to the increased (2-log) sensitivity of Freelite over IFE, the ability to quantitate the kappa-to-lambda light chain ratio as an indication of clonality, and the convenience of a spot urine over a 24-hour collection, this assay is a valid alternative to the currently promoted methodology. Conclusion The measurement of urine FLCs from a single urine collection using the Freelite assay is a convenient and valid tool, and in a minority of patients with monoclonal gammopathies, it adds unique information about disease activity. Author affiliations: Montgomery Lobe, MD, is from the Department of Medicine, Albany Medical College, Albany, NY; Donald Pasquale, MD, is from the Medical VA Care Line, Stratton VA Medical Center, Albany. Author disclosures: The authors report no relevant conflicts of interest. Address correspondence to: Donald Pasquale, MD, Medical VA 12

15 FREELITE FOR MEASUREMENT OF URINE-FREE LIGHT CHAINS IN MONOCLONAL GAMMOPATHIES Care Line, Stratton VA Medical Center, 113 Holland Avenue, Albany, New York 12208; Author contributions: Dr. Pasquale designed the study. Dr. Lobe collected data. Drs. Pasquale and Lobe analyzed the data and wrote the manuscript. Supported by: Department of Veterans Affairs References 1. Dimopoulos M, Kyle R, Fermand JP, et al; on behalf of the International Myeloma Workshop Consensus Panel 3. Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3. Blood. 2011;117: doi: /blood Palumbo A, Anderson K. Multiple myeloma. N Engl J Med. 2011;364(11): Weiss BM, Abadie J, Verma P, et al. A monoclonal gammopathy precedes multiple myeloma in most patients. Blood. 2009;113(22): doi: /blood Bradwell AR, Carr-Smith HD, Mead GP, et al. Serum test for assessment of patients with Bence Jones myeloma. Lancet. 2003;361(9356): Bradwell AR. Serum free light chain measurements move to center stage. Clin Chem. 2005;51(5): Dispenzieri A, Kyle R, Merlini, G, et al; International Myeloma Working Group. International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Hematology. 2009;23(2): Katzmann JA, Dispenzieri A, Kyle RA, et al. Elimination of the need for urine studies in the screening algorithm for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc. 2006;81(12): Nowrousian MR, Brandhorst D, Sammet C, et al. (2005) Serum free light chain analysis and urine immunofixation electrophoresis in patients with multiple myeloma. Clin Cancer Res. 2005;11(24 pt 1): Bradwell AR, Carr-Smith HD, Meed GP, et al. Highly sensitive automated immunoassay for immunoglobulin free light chains in serum and urine. Clin Chem. 2001;47(4): Bradwell AR. Biology of immunoglobulin light chains. In: Serum Free Light Chain Analysis (Plus Hevylite). 6th edition. Birmingham, UK: The Binding Site Group Ltd.; Bruning J, Kintz BL. Computational Handbook of Statistics. 4th edition. Reading, MA: Addison Wesley Longman, Inc; Campo E, Swerdlow SH, Harris NL, et al. The 2008 WHO classification of lymphoid neoplasms and beyond: evolving concepts and practical applications. Blood. 2011;117(19), doi: Le Bricon T, Bengoufa D, Benlakehal M, et al. Urinary free light chain analysis by the Freelite immunoassay: a preliminary study in multiple myeloma. Clin Biochem. 2002;35(7): VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 13

16 OVARIAN CANCER New Biologic Frontiers in Ovarian Cancer: Olaparib Update Rebecca A. Previs, MD, Heather J. Dalton, MD, and Robert L. Coleman, MD Abstract Poly (ADP-ribose) polymerase (PARP) inhibition was first introduced as a cancer-targeting strategy in 2005 and has made rapid clinical progression, culminating in the Food and Drug Administration approval of olaparib as a fourth-line-and-beyond treatment in relapsed BRCA-mutated ovarian cancer in December This approval followed exciting phase 1/2 data showing anti-tumor efficacy in patients with ovarian cancer, particularly in BRCA-deficient and platinum-sensitive populations. This article will review the early clinical investigation of olaparib, emerging phase 2 and 3 data, and future directions, including forthcoming clinical trials and methods to predict response and expand the populations eligible to receive this innovative biologic therapy. AJHO. 2016;12(11):14-22 Introduction Poly (ADP-ribose) polymerase (PARP) inhibition was first introduced as a novel cancer-targeting strategy in 2005, following the publication of preclinical work showing activity in BRCA-mutated tumor cells. Compared with wild-type cells, BRCA1- and BRCA2-deficient cells were up to 1000-fold more sensitive to PARP inhibition. 1 In vivo, the growth of BRCA2-deficient tumors was decreased by PARP inhibitors, the first demonstration that inhibition of a DNA repair mechanism could be used to target cancer cells. 2 These studies highlighted the application of synthetic lethality as a potentially effective anticancer therapy and inspired further clinical investigation. PARP inhibitors are now known to work through a variety of mechanisms, in addition to inducing synthetic lethality. 1,2 PARP inhibition stimulates nonhomologous end joining (NHEJ) selectively in homologous repair-deficient cells. 3 This is achieved via inhibition of DNA-dependent protein kinase substrates, leading to genetic instability, chromosome rearrangement, and cell death. PARP inhibitors have also been shown to trap PARP- 1 and PARP-2 on DNA, leading to PARP-DNA complexes. 4 This concept, known as PARP trapping, is thought to be responsible for the synergism seen with PARP inhibition and alkylating agents and does not occur with all PARP inhibitors. Since their introduction, PARP inhibitors have been studied in many BRCA-deficient cancers, including ovarian cancer, where they have had notable success. The most extensively studied PARP inhibitor in ovarian cancer is olaparib, an orally available compound with activity against PARP-1 and PARP-2. The recent FDA approval of olaparib in relapsed ovarian cancer brings this drug class to the forefront of new anticancer therapy in this disease. This review will update our previous review 5 and discuss the emerging clinical trial data and future directions of research on PARP inhibitors and ovarian cancer. Phase 1 Investigation Early phase 1 investigation of olaparib confirmed activity in BRCA-mutated breast and ovarian cancers. 6 Sixty patients with solid tumors refractory to standard therapy were enrolled, including 21 patients with ovarian cancer and 9 patients with breast cancer. The majority of patients had received at least 4 prior lines of treatment. Nineteen BRCA1 and BRCA2 mutation carriers were evaluable following treatment, 9 of whom had a partial response (PR) or complete response (CR) to olaparib by Response Evaluation Criteria in Solid Tumors (RECIST; 8 patients with ovarian cancer and 1 with breast cancer). 7 Of the patients with ovarian cancer, 6 had a decrease of 50% or more in their CA125 levels. Twelve of the 19 patients (63%) with BRCA1/2 mutation derived clinical benefit, defined by a decrease in tumor markers, radiographic response, or stable disease (SD) for 4 or more months. Further, olaparib was found to have an acceptable side-effect profile, with grade 1 and 2 nausea and fatigue being the most commonly experienced adverse events (AEs). In a confirmatory trial, patients with BRCA1/2-mutated ovarian cancer were treated with olaparib as a part of a dose-escalation and expansion study. 8 This included 50 patients, 48 of whom had BRCA1 or BRCA2 mutation, 1 with a missense BRCA2 mutation of unclear significance, and 1 with a strong family history of BRCA1/2 cancers who declined testing. Of the patients enrolled, 13 had platinum-sensitive disease, 24 had platinum-resistant disease, and 13 had platinum-refractory disease 14

17 NEW BIOLOGIC FRONTIERS IN OVARIAN CANCER: OLAPARIB UPDATE (progression of disease while receiving platinum chemotherapy). The majority of patients (39 of 50) received olaparib 200 mg twice daily as a part of the expansion cohort. The 11 patients in the escalation group received olaparib at dosages ranging from 40 mg daily up to 600 mg twice daily. Of the 50 patients, 4 were not evaluable and an additional 8 had no measureable disease by RECIST. Partial response or CR was seen in 14 patients (28.0%; 95% CI, ). An additional 3 patients had SD for greater than 4 cycles (6.0%; 95% CI, ). Of the patients with platinum-sensitive disease, 61.5% responded to treatment, as measured by RECIST or The Gynecological Cancer InterGroup (GCIG) criteria. Patients with platinum-resistant disease saw a 41.7% response rate, while no RECIST responses were observed in the platinum-refractory group. Two patients in this cohort did have response by GCIG criteria and 1 patient had SD. This trend toward decreasing response rates with decreasing platinum sensitivity was significant, although the responses seen in the platinum-resistant/refractory groups were better than those seen in many other studies of this cohort. Early Phase 2 Studies in Ovarian Cancer Following the activity demonstrated in the phase 1 study, a proof-of-concept phase 2 study was initiated. 9 This multicenter trial enrolled BRCA1 and BRCA2 mutation carriers with recurrent ovarian cancer and at least 1 previous line of therapy to continuous olaparib at either 100 mg twice daily, demonstrated to be pharmacodynamically active, or 400 mg twice daily, the maximum tolerated dose in the initial phase 1 study, until disease progression. 6 Platinum status was also assessed at the time of enrollment. The primary endpoint was objective response rate (ORR). Fifty-eight patients were enrolled, with 1 patient death prior to treatment initiation, leaving 57 patients available for analysis, including 40 with BRCA1 mutations and 17 with BRCA2 mutations. The ORR in the 400 mg cohort was 33% (11 of 33 patients; 95% CI, 20-51), with 2 CRs and 9 PRs.An additional 36% of patients had SD and a median duration of response (DoR) of 290 days. In contrast, the ORR in the 100-mg cohort was 13% (3 of 24 patients; 95% CI, 4-31) with no CRs. Seven patients (29%) had SD. The median progression-free survival (PFS) was 5.8 (95% CI, ) versus 1.9 (95% CI, ) months in the 400-mg and 100-mg cohorts, respectively. The authors concluded that olaparib had antitumor activity in a heavily pretreated population of patients with BRCA1- and BRCA2-mutated ovarian cancer. Further, olaparib was noted to have activity in platinum-sensitive and platinum-resistant disease, with 38% (5 of 13 patients) and 30% (6 of 20 patients) responding to treatment, respectively. Importantly, this trial was not randomized, and the lower-dosage cohort had poorer prognostic features, perhaps confounding the apparent dose-dependent activity. This and other subsequently presented phase 2 studies are summarized in the Table. An additional phase 2 study investigated olaparib versus pegylated liposomal doxorubicin (PLD) as monotherapy in relapsed BRCA1/2-mutated ovarian cancer with an interval of less than 12 months after previous platinum-based chemotherapy. 10 This study also sought to determine the most appropriate dosage of olaparib, either 200 mg or 400 mg twice daily, although it was not powered to detect a difference between these groups. PFS was the primary outcome of this multicenter, randomized prospective trial, in which 97 patients were enrolled in a 1:1:1 ratio to olaparib at 200 mg twice daily or 400 mg twice daily, or to PLD at 50 mg/ m2 every 28 days. Crossover from PLD to olaparib 400 mg twice daily was allowed at the time of disease progression. Median PFS was 6.5 months (95% CI, ), 8.8 months (95% CI, ), and 7.1 months (95% CI, ) for the olaparib 200 mg, olaparib 400 mg, and PLD groups, respectively. There was no significant difference between either of the dosing cohorts of olaparib and PLD. The 31% ORR of patients receiving olaparib 400 mg was similar to previously published data. 6,9 While 50% of the patients enrolled were classified as platinum-resistant, response rates were not reported by platinum status. Notably, the PLD group performed better than expected, with a PFS of 7.1 months compared with a PFS of 4 months in a previously published large prospective trial of patients with relapsed ovarian cancer with unknown BRCA1/2 mutation status. 11 Subsequently published data suggest that BRCA1/2 mutation carriers may derive more clinical benefit from anthracycline-based chemotherapy than nonselected patients, as these compounds may capitalize on homologous repair deficiency. 12,13 BRCA Status and Response to Olaparib Kaufman et al 14 published the results of a large, multicenter, nonrandomized phase 2 trial in recurrent BRCA1/2 mutant solid tumors, including breast, ovarian, prostate, and pancreatic cancer, among others. Enrolled patients with ovarian cancer were required to be platinum-resistant. The primary endpoint was tumor response rate by RECIST, with secondary endpoints of ORR, PFS, and DoR. A total of 298 patients were enrolled to receive oral olaparib 400 mg twice daily until disease progression, including 193 with epithelial ovarian, primary peritoneal, or fallopian tube cancer. BRCA1 germline mutations made up 77% of this cohort, while 23% carried BRCA2 mutations. The tumor response rate was 26.2% (95% CI, ) in patients with ovarian cancer, with 40.4% (95% CI, ) achieving SD. Median PFS was 7.0, 3.7, 4.6, and 7.2 months in the ovarian, breast, pancreatic, and prostate cancer groups, respectively. Importantly, ovarian cancer response rates were similar to those seen in previous studies, despite the platinum-resistant patient population, suggesting that the mechanisms of platinum resistance may not always confer resistance to PARP inhibition. 9,10 This study highlights the activity of olaparib in a variety VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 15

18 OVARIAN CANCER TABLE. Phase II Studies of Olaparib in High-Grade Seous Ovarian Cancer. Study Patient Population BRCA Status Study Arms Primary Objective Results Audeh et al 8 Recurrent HGSOC, n = 57 Mutated Olaparib 400 mg twice daily vs 100 mg twice daily ORR 33% (95% CI, 20-51) olaparib 400 mg vs 13% (95% CI, 4-31) olaparib 100 mg Kaye et al 9 Recurrent platinum-sensitive HGSOC, n = 97 Mutated Olaparib 200 mg twice daily vs 400 mg twice daily vs PLD (50 mg/m 2 q 28 day) PFS 6.5 vs 8.8 vs 7.1 months No significant difference in PFS Gelmon et al 14 Recurrent HGSOC and TNBC, n = 91 Mutated and wild-type Olaparib 400 mg twice daily ORR ORR not achieved in breast cancer cohort 41% (95% CI, 22-64) BRCA 1/2-mutated HGSOC 24% (95% CI, 14-38) in BRCA wild-type Liu et al 15 Recurrent platinum-sensitive HGSOC, n = 90 Mutated, wildtype, or unknown Olaparib 400 mg twice daily vs olaparib 200 mg twice daily plus cediranib 30 mg daily PFS 9.0 vs 17.7 months (HR, 0.42; 95% CI, ; P=.005) Oza et al 17 Recurrent platinum-sensitive HGSOC, n = 162 Mutated, wildtype, or unknown Olaparib 200 mg twice daily (days 1-10), paclitaxel (175 mg/m 2, day 1) and carboplatin (AUC 4 mg/ml per minute, day 1); then olaparib at 400 mg twice daily until disease progression vs paclitaxel (175 mg/ m 2 ) and carboplatin (AUC 6 mg/ ml/minute) PFS 12.2 vs 9.6 months (HR, 0.51; 95% CI, ; P =.0012) No OS difference Ledermann et al 20 Recurrent platinum-sensitive HGSOC, n = 265 Mutated, wildtype, or unknown Olaparib 400 mg twice daily following completion of platinumbased chemotherapy vs placebo PFS 8.4 months vs 4.8 months (HR, 0.35; 95% CI, ; P <.001) No OS difference AUCº indicates area under the curve; HGSOC, high-grade serous ovarian cancer; HR, hazard ratio; ORR, objective response rate; OS, overall survival; PFS, progression-free survival; PLD, pegylated liposomal doxorubicin; TNBC; triple-negative breast cancer. of germline BRCA-mutated solid tumors and helped to pave the way for FDA approval of this agent in fourth-line, relapsed, BRCA-mutated ovarian cancer on December 19, An update to the long term safety and efficacy of this study population has recently been reported. ORR was 34% (46/137) and median DoR was 7.9 months (95% CI, ). ORR was 30% in platinum-resistant tumors. Median DoR for platinum sensitive and platinum-resistant tumors was 8.2 (95% CI, ) and 8 months (95% CI, ), respectively. Three percent had an adverse outcome, which was death. No new safety signals were identified. 15 The role of BRCA mutations in predicting response to olaparib in advanced high-grade serous ovarian cancer or undifferentiated ovarian cancer and triple-negative breast cancer was assessed in a phase 2 multicenter study by Gelmon et al. 16 In this nonrandomized, open-label trial, patients were stratified according to BRCA mutation status and received olaparib 400 mg twice daily. Ninety-one patients were enrolled, with 90 receiving treatment, including 17 patients with BRCA1/2 mutations and 46 without mutations. The primary outcome of ORR was not met in the breast cancer cohort. Of the 63 patients with ovarian cancer who were evaluable, objective responses were seen in 7 of 17 patients (41%; 95% CI, 22-64) with BRCA1 or BRCA2 mutations and 11 of 46 patients (24%; 95% CI 14 38) without mutations. Post-hoc analyses revealed that 50% (10 of 20 patients) with BRCA1/2 wild-type platinum-sensitive 16

19 NEW BIOLOGIC FRONTIERS IN OVARIAN CANCER: OLAPARIB UPDATE ovarian cancer had an objective response, while 60% (3 of 5) of patients with platinum-sensitive BRCA1/2-mutated disease had a response. Responses were seen in 4 patients (33%) with platinum-resistant BRCA1/2-mutated ovarian cancer compared with only 1 (4%) of those in the BRCA1- or BRCA2-negative cohort. Although activity was seen in both platinum-sensitive and platinum-resistant cohorts, a greater response was observed in the platinum-sensitive cohort. While the majority of patients with BRCA mutations were noted to have a response, this study importantly demonstrates the activity of olaparib in patients without germline BRCA1 or BRCA2 mutations. Olaparib in Platinum-Sensitive Ovarian Cancer Based on previous studies suggesting a greater response to olaparib in patients with platinum-sensitive ovarian cancer, several trials selectively enrolled this population. 8,16 One such trial investigated olaparib alone versus the combination of olaparib plus cediranib. 17 Cediranib is an oral tyrosine kinase inhibitor with anti-angiogenic effects mediated through VEG- FR1, VEGFR2, and VEGFR3, which has demonstrated activity in relapsed ovarian cancer. 17,18 Ninety-three patients were assessed for eligibility, with 3 patients not qualifying. The remaining patients were randomized to receive either olaparib alone at 400 mg twice daily or olaparib plus cediranib (200 mg twice daily and 30 mg daily, respectively). Patients were also stratified according to their BRCA status (mutation carrier, noncarrier, or unknown). Forty-six patients received olaparib alone; while 44 received combination treatment. Similar to previous studies, olaparib monotherapy resulted in a PFS of 9.0 months (95% CI, ), whereas the combination group saw a PFS of 17.7 months (14.7 not reached; hazard ratio [HR], 0.42; 95% CI, ; P =.005). 9,14 Objective response rates of 47.8% and 79.6% were seen in the olaparib-only and olaparib-plus-cediranib groups, respectively. Six of 7 CRs occurred in patients with BRCA-mutated disease. A post hoc analysis of PFS and ORR data revealed a greater response to combination therapy in patients with BRCA wild-type disease and in those with unknown status. While this warrants further investigation, this analysis should be interpreted with caution, as the BRCA-mutated group may have performed better than expected with a PFS of 16.5 months. The combination group more frequently experienced grade 3 diarrhea, fatigue, and hypertension, with 75% of the cohort requiring dosage reductions. This study provides the first investigation into PARP inhibition in combination with an anti-angiogenic agent, and has paved the way for phase 3 trials (NCT , NCT ). Olaparib has demonstrated activity in combination with chemotherapy in recurrent, platinum-sensitive ovarian cancer. 19 In a phase 2, randomized study, 162 eligible patients were enrolled 1:1 to olaparib plus carboplatin and paclitaxel followed by olaparib monotherapy as maintenance or carboplatin and paclitaxel alone. The olaparib-plus-chemotherapy group received olaparib 200 mg twice daily on days 1 to 10 of a 21-day cycle plus paclitaxel (175 mg/m 2 ) and carboplatin (area under the curve [AUC] 4 mg/ml/minute) on day 1 for 6 cycles, followed by maintenance olaparib 400 mg twice daily until disease progression. The chemotherapy group received paclitaxel (175 mg/m 2 ) and carboplatin (AUC 6) on day 1 of a 21-day cycle for 6 cycles or disease progression. Thirty-eight percent of patients carried BRCA1 or BRCA2 mutations and were balanced between groups. The primary endpoint was PFS; overall survival (OS) served as a secondary endpoint. The majority of patients (75%) in both groups received 6 cycles of treatment. More AEs were reported in patients receiving olaparib plus chemotherapy, with 53 of 81 patients (65%) experiencing grade 3 or higher AEs compared with 43 of 75 patients (57%) receiving only chemotherapy. The addition of olaparib to standard chemotherapy significantly improved PFS compared with chemotherapy alone, with a median of 12.2 (95% CI, ) versus 9.6 months (95% CI, ), respectively (HR, 0.51; 95% CI, ; P =.0012). The improvement in PFS was even more pronounced in patients with BRCA mutations, where PFS was not reached in this group after a median follow-up of 9.8 months (HR, 0.21; 95% CI, ; P =.0015). While there was no significant difference in OS between the groups by treatment cohort or BRCA status, exploratory analyses showed an improvement in time to first subsequent therapy or death favoring the combination therapy with olaparib (HR = 0.60; 95% CI, ; P =.0053). This has been proposed to reflect post-progression efficacy of maintenance therapy with olaparib. A phase 3 ongoing study includes NRG GY004, which is comparing single agent olaparib or the combination of cediranib and olaparib to standard platinum-based chemotherapy in women with recurrent platinum-sensitive ovarian carcinoma (NCT ). In this study, patients are randomized 1:1:1 to either olaparib monotherapy or cediranib and olaparib combination or platinum-based chemotherapy. Platinum-based chemotherapy options may include carboplatin and paclitaxel, carboplatin and gemcitabine, or carboplatin and pegylated liposomal doxorubicin. Olaparib in Platinum-Resistant Ovarian Cancer While response to olaparib has been correlated with platinum sensitivity, multiple studies have demonstrated activity in patients with platinum-resistant ovarian cancer. 8,16 Audeh et al 9 saw ORRs of 30% (6 of 20 patients) in this cohort. Other studies have shown ORRs ranging from 33% to 42% in platinum-resistant populations. 8,16 Kaufman et al 14 specifically enrolled patients with platinum-resistant BRCA1/2-mutated ovarian cancer in a phase 2 study and found an ORR of 26.2%, with 40.4% of patients achieving SD. Median PFS was 7 months, comparing favorably with other studies in platinum-resistant ovarian cancer. 20,21 VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 17

20 OVARIAN CANCER Further clinical investigation of olaparib in platinum-resistant ovarian cancer is warranted. Early phase 1 studies are evaluating a newer PARP inhibitor, veliparib, in combination with pegylated liposomal doxorubicin, carboplatin, in combination with bevacizumab. 22 This NRG Oncology/Gynecologic Oncology Group study s objective was to determine the maximum tolerated dose and dose-limiting toxicities of this combination. Patient received PLD (30 mg/m 2, IV) and carboplatin (AUC 5, IV) on day 1 with veliparib on days 1 to 7 (intermittent) or days 1 to 28 (continuous). A design was used in the dose escalation phase. Once the maximum tolerated dose was determined, a cohort of six patients were enrolled in each regimen with bevacizumab (10 mg/kg on days 1 and 15) to determine the feasibility. A total of 27 patients were treated at three dose levels and dose-limiting toxicities were noted in six patients, which included four patients with grade 4 thrombocytopenia and three patients with neutropenia greater than seven days. The maximum tolerated dose of veliparib was determined to be 80 mg twice daily for both arms and myelosuppresion was the primary dose-limiting toxicity. Twelve patients were treated at this dose with the addition of bevacizumab, and nine patients experienced dose-limiting toxicities, which included thrombocytopenia, prolonged neutropenia, hypertension, and one patient experienced sepsis. Previous studies have hypothesized that the continuous dosing of veliparib would be the best dosing strategy for patients with BRCA mutations, while intermittent dosing may suffice when using PARP inhibition for chemo-sensitization in patients with homologous recombination deficiency. 23 Significant hematologic toxicity was encountered in this early study, but warrant further research pre-clinically. PARP Synergy With Anti-Angiogenic Therapies Mounting pre-clinical evidence has suggested a synergistic or combinatory effect with PARP inhibitors when combined with anti-angiogenic inhibitors. 24 The mechanism for this rationale includes the downregulation of homologous recombination repair genes in hypoxic setting, which resests PARP inhibitor sensitivity. In addition, BRCA1 and BRCA2 have been found to be downregulated in ovarian cancer cells with VEGF inhibition. 25,26 The safety and tolerability in a phase 1 study of bevacizumab in combination with another PARP inhibitor in development, niraparib, in platinum-sensitive ovarian cancer patients, the ENGOT-OV24/AVANOVA1 trial. 27 This single-arm study evaluated patients in a design. The patients received fixed dose bevacizumab (15 mg/kg IV every 21 days) with dose escalation of niraparib (100, 200, 300 mg orally daily). The objective was to establish the maximum tolerated dose and dose-limiting toxicities. Twelve patients were enrolled to three dose levels, of which three had a germline BRCA2 mutation. Commonly related toxicities included hypertension, anemia, thrombocytopenia, fatigue, constipation and nausea. The recommended phase 2 dose established was bevacizumab 15 mg/kg every 21 days with niraparib 300 mg orally daily. A phase 2 trial is currently ongoing (NCT ). PARP Inhibitors As a Maintenance Strategy Ledermann et al 28 investigated olaparib as a maintenance strategy in relapsed, platinum-sensitive patients in a randomized, multi-center phase 2 trial. Patients were required to have received 2 or more platinum-based chemotherapy regimens and to have had a PR or CR with their most recent platinum therapy. Both patients with BRCA-mutant and wild-type disease were eligible for enrollment. A total of 265 patients were randomized, including 136 to the olaparib-400-mg-twice-daily cohort and 129 to the placebo arm. The primary endpoint of PFS was noted to be significantly longer in patients receiving olaparib maintenance than those receiving placebo at 8.4 months versus 4.8 months (HR, 0.35; 95% CI, ; P <.001). At the cutoff point for data analysis, the median exposure to olaparib was days compared with 141 days for placebo. More AEs were seen in patients receiving olaparib, with the most common side effects being nausea, vomiting, and fatigue. A subsequently published preplanned retrospective analysis of the original study assessed the efficacy of olaparib maintenance according to BRCA mutation status. 29 Of the 136 patients originally randomized to the olaparib maintenance arm, 74 of 131 patients (56%) with known mutation status carried germline BRCA mutations, while 62 of 123 (50%) had tumor mutations of BRCA. Patients with a BRCA mutation receiving olaparib had a significantly longer PFS at 11.2 months compared with 4.3 months in those with a BRCA mutation receiving placebo (HR, 0.18; 95% CI, ; P <.0001). No OS differences were noted between the groups by treatment or BRCA mutation status. In the previously presented study by Oza et al, 19 olaparib was administered with chemotherapy followed by maintenance olaparib. No separation in the PFS curves was seen during concomitant use relative to control chemotherapy; however, the curves separated significantly during the maintenance phase. Although the study was not designed to assess the contributions of each treatment phase, the late separation of the PFS curves seen in the trial suggests the maintenance phase to be the most important contributor to the improvement in PFS. This finding led the authors to conclude that olaparib plus chemotherapy does not provide any advantage over olaparib maintenance alone. The findings from these trials have led to the development of 2 phase 3 trials investigating olaparib maintenance. SOLO-1 (NCT ) is a randomized, double-blind, placebo-controlled, multicenter trial investigating olaparib maintenance in advanced BRCA-mutated ovarian cancer following completion of first-line platinum chemotherapy. The primary endpoint is PFS, with secondary endpoints of OS and quality of life, among others. Planned accrual is 397 patients, and no longer recruiting 18

21 NEW BIOLOGIC FRONTIERS IN OVARIAN CANCER: OLAPARIB UPDATE patients. Patients randomized to the treatment arm will receive olaparib 300 mg twice daily for up to 2 years or until disease progression. SOLO-2 (NCT ) is a randomized, double-blind, placebo-controlled, multicenter phase 3 trial investigating olaparib maintenance in platinum-sensitive, recurrent BRCA-mutated ovarian cancer. Patients must have received 2 prior platinumbased chemotherapy regimens, with disease progression greater than 6 months after completion of their last dose of platinum chemotherapy. Randomization must occur within 8 weeks of completion of platinum-based chemotherapy. The olaparib maintenance arm will receive olaparib 300 mg twice daily until disease progression. PFS is the primary objective. Accrual for this trial has completed. The effectiveness of olaparib is being compared with chemotherapy in recurrent, platinum-sensitive germline BRCA-mutated ovarian cancer in the SOLO-3 trial (NCT ). In this phase 3 study, patients are randomized to either olaparib 300 mg twice daily or single-agent, non-platinum-based chemotherapy, as chosen by the treating clinician. Patients must have completed 2 previous lines of platinum-based chemotherapy. The primary endpoint is PFS. This trial is open and currently recruiting patients. Of note, SOLO-1, SOLO-2, and SOLO-3 utilize the tablet form of olaparib rather than the capsule form studied in the phase 1 and 2 trials. While the dosage of 300 mg is lower than that used in many trials, it has higher bioavailability and provides equivalent drug exposure. Resistance to PARP Inhibition Despite their clinical promise, resistance to PARP inhibition remains a challenge to the implementation of these agents. Acquired resistance to both platinum-based chemotherapy and PARP inhibition has been linked to secondary mutations in BRCA2 that restore the wild-type reading frame. 30 Cisplatin-resistant cells were found to acquire a variety of mutations, all of which restored the wild-type BRCA2 reading frame and conferred resistance to both cisplatin and PARP inhibition. In an evaluation of recurrent BRCA2-mutated patient samples originally treated with cisplatin, those resistant to cisplatin were found to have reverted to a wild-type BRCA2 phenotype. Ashworth 31 confirmed that resistance to PARP inhibition could be acquired through deletion of a BRCA2 mutation. Additional mechanisms include increased activity of BRCA1 or BRCA2 variants encoded by hypomorphic alleles and rescue of DNA end-resection in BRCA1-deficient tumors through loss of 53BP1. 32 Resistance to PARP inhibition has also been shown to develop through increased expression of P-glycoproteins in BRCA1-mutated breast cancers. 33 This resistance was overcome with administration of 6-thioguanine (6TG), which in the case of BRCA1-mutated cancer probably results from it being a poor substrate for P-glycoprotein. However, it was also noted that 6TG was effective in inducing cell death among PARP inhibitor-resistant BRCA2-mutated tumors harboring a functional BRCA2 reversion. Detailed investigation suggested that 6TG induces both mismatch-dependent and -independent DNA damage requiring homologous recombination repair. 6TG has been proposed as a potential strategy to combat acquired resistance to PARP inhibition. Homologous Recombination Deficiency in Non-BRCA Mutant Patients Patients with non-germline mutations in BRCA but have homologous recombination deficiency due to defects in this DNA damage pathway have been investigated. The ARIEL2 trial sought to prospectively identify patients with non-germline BRCA1 or BRCA2 mutations who may have a homologous recombination deficiency by using a next-generation sequencing assay. An analysis algorithm was developed to predict rucaparib sensitivity by detecting tumor BRCA status and whether there is a high genomic loss of heterozygosity representing a DNA scar reflecting prior loss of HR repair. Part 1 of ARIEL2 included 204 patients with recurrent, platinum-sensitive, high grade ovarian carcinoma and were classified into three homologous recombination deficiency subgroups based on tumor analysis: BRCA mutant (deleterious germline or somatic); BRCA wild type/loss of heterozygosity (LOH) high; or BRCA wild type/loh low. Patients received 600 mg of rucaparib twice daily. The primary endpoint was PFS, but secondary endpoints also included response rate, response duration, and safety. The risk of progression during treatment was significantly reduced in the BRCA mutant subgroup (HR, 0.27; 95% CI, ; P <.0001) and in the BRCA wild type/ LOH high subgroup (HR, 0.62; 95% CI, ) subgroup compared to the BRCA wild type/loh low subgroup. More patients in the BRCA mutant subgroup (50.4%; P <.0001 for HR) and in the BRCA wild type/loh high subgroup (28.0%; P =.011 for HR) were progression free at 12 months than the BRCA wild type/loh low subgroup (9.6%). This study suggests that assessment of tumoral LOH can identify patients that have BRCA wild type platinum-sensitive ovarian cancers that may benefit from PARP inhibition with rucaparib. 34 Future Directions and Conclusions An estimated 11% to 15% of unselected patients with ovarian cancer have germline BRCA1 or BRCA2 mutations. 35,36 Given the demonstrated activity of PARP inhibition in germline BRCA1/2- mutated ovarian cancer, Hennessy et al 37 sought to investigate whether loss of BRCA function can also occur through somatic mutations, potentially expanding the number of patients who could benefit from this treatment. Two-hundred thirty-five ovarian cancer samples were randomly selected and analyzed for BRCA mutations. Forty-four BRCA mutations were detected in 43 tumors, including 1 cancer in which both BRCA1 and BRCA2 mutations were detected. Of these tumors, 28 samples VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 19

22 OVARIAN CANCER had DNA available for analysis. Eleven mutations (9 BRCA1 and 2 BRCA2) were found to be somatic, whereas 17 mutations were found in both tumor and germline DNA. There was no significant difference in clinical variables or PFS between patients with germline BRCA mutations and somatic BRCA mutations. BRCA1/2 deficiency, as defined by the presence of germline or somatic mutations, deletion of BRCA1 or BRCA2, or loss of expression of BRCA1 or BRCA2, was present in 30% of the ovarian tumors analyzed and was associated with significantly prolonged PFS following surgical cytoreduction when compared with BRCA nonmutants (20.1 and 13.8 months, respectively). The surprising frequency of somatic aberrations found in BRCA1/2 ovarian cancers, with resultant disruption in homologous repair, was postulated to increase the sensitivity of these tumors to PARP inhibition. The authors also suggest that somatic mutations and BRCA1/2 expression loss be routinely assessed in clinical trials investigating the effectiveness of PARP inhibition, in addition to standard germline mutation testing. The heterogeneous mechanisms by which tumors can acquire defects in homologous repair has been referred to as BRCAness or BRCA-like status. 38,39 A gene expression profile for the BRCA-like state has been developed and is associated with response to platinum-based chemotherapy, as well as response to PARP inhibition. 40 This 60-gene profile was developed after analysis of microarray data from 61 patients with somatic or germline BRCA mutations. Using the gene profile, the authors were able to predict platinum sensitivity in 8 of 10 patient-derived samples. They also were able to predict sensitivity or resistance to PARP inhibition in 100% (4 of 4) of cell lines. This profile was then used to categorize 70 patients with sporadic ovarian cancer as BRCA-like (BL) or non BRCA-like (NBL). Patients with a BL profile had improved disease-free survival (34 versus 15 months; logrank P =.013) and OS (72 versus 41 months; log-rank P =.006) compared with patients with a NBL profile. In a multi- variate analysis, the BL profile maintained independent prognostic value when other clinical variables were controlled. BRCA- like phenotypes have also been observed with hypermethylation of the BRCA promoter and with alterations of BRCA-associated proteins, including BARD1. 41,42 Although further investigation is needed, this BL profile could potentially be used to offer PARP inhibition to a much larger population of patients with ovarian cancer, independent of BRCA mutation status. Methods to predict response to PARP inhibition are currently being investigated. Homologous recombination deficiency (HRD) assays are in development, which use next-generation sequencing to identify genome-wide loss of heterozygosity, seen in patients lacking genes involved in homologous repair, not just BRCA1 and BRCA2. These assays have been successful in predicting response to rucaparib, another PARP inhibitor. 43 The efficacy of HRD assays in predicting response to olaparib and other PARP inhibitors is now being investigated (NCT ). The production of Rad51, a known marker of homologous repair, following irradiation of patient-derived xenographs, has been shown to predict response to PARP inhibition ex vivo, with sensitive samples consistently having a low Rad51 foci formation rate. 44 CDK12 activity also has been proposed as a marker for resistance to PARP inhibition. 45 This kinase promotes homologous repair and confers resistance to PARP inhibitors. FOXO3a expression also is being explored as a potential biomarker in predicting response to inhibition of PARP. 46 Further clinical investigation of olaparib is under way. A planned phase 2 study aims to detect a biomarker signature that correlates with durable response or SD to cediranib and olaparib in patients with platinum-sensitive ovarian cancer (NCT ). Cediranib in combination with olaparib also is being investigated in the phase 3 setting, following promising phase 2 results. 17 Other phase 1/2 studies are on- going with olaparib in combination with PI3K pathway inhibitors (NCT ), AKT inhibitors (NCT ), and mtorc1/2 inhibitors (NCT ), Wee1 (NCT ), among others. PARP inhibitors also are being investigated in patients with wild-type BRCA-associated disease (NCT ). Other PARP inbhitiors are being evaluated in combination with over targeted therapies including niraparib and pembrolizumab (NCT ). Olaparib and PARP inhibition as an anticancer strategy is an exciting addition to currently available treatment options for ovarian cancer. More studies are needed to determine the optimal settings and combinations in which to administer olaparib. A profile of a BRCA-like state may allow expansion of the population able to derive clinical benefit from PARP inhibition, and should be investigated in future trials. Acknowledgments: Dr Previs is supported by NIH T32 training grant CA Dr Coleman is supported in part by CPRIT RP120214, Ovarian Cancer Research Fund Program Project Development Grant, the Judy Reis, Albert L. Pisani MD Ovarian Cancer Research Fund, and the Ann Rife Cox Chair in Gynecology. Author affiliations: Drs Previs and Coleman are from the Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston. Dr Dalton is from the Department of Arizona Oncology, Phoenix. Author disclosures: Drs Previs and Dalton report no relevant financial conflicts of interest to disclose. Dr Coleman has served as an uncompensated advisor for AstraZeneca; he also has received nonfinancial support and a grant from Merck, and has received clinical trial grants from the following companies: Janssen Pharmaceuticals, Clovis Oncology, Amgen, Novartis, Merrimack Pharmaceuticals, Millennium Pharmaceuticals, OncoMed, Array 20

23 NEW BIOLOGIC FRONTIERS IN OVARIAN CANCER: OLAPARIB UPDATE BioPharma, and EMD Serono. Address correspondence to: Robert L. Coleman, MD, Department of Gynecologic Oncology and Cancer Biology, Unit 1362, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX Phone: (713) ; fax: (713) ; References 1. Farmer H, McCabe N, Lord CJ, et al. Targeting the DNA repair defect in BRCA mutant cells as a therapeutic strategy. Nature. 2005; 434(7035): Bryant HE, Schultz N, Thomas HD, et al. Specific killing of BRCA2-deficient tumours with inhibitors of poly(adp-ribose) polymerase. Nature. 2005;434(7035): Patel AG, Sarkaria JN, Kaufmann SH. Nonhomologous end joining drives poly(adp-ribose) polymerase (PARP) inhibitor lethality in homologous recombination-deficient cells. Proc Natl Acad Sci. 2011;108(8): doi: /pnas Murai J, Huang SY, Das BB, et al. Trapping of PARP1 and PARP2 by clinical PARP inhibitors. Cancer Res. 2012;72: doi: / CAN Dalton HJ CR. New biologic frontiers in ovarian cancer: olaparib and PARP inhibition. American Journal of Hematology/ Oncology. 2015;11: Fong PC, Boss DS, Yap TA, et al. Inhibition of poly(adp-ribose) polymerase in tumors from BRCA mutation carriers. N Engl J Med. 2009;361(2): doi: /NEJMoa Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst. 2000;92(3): Fong PC, Yap TA, Boss DS, et al. Poly(ADP)-ribose polymerase inhibition: frequent durable responses in BRCA carrier ovarian cancer correlating with platinum-free interval. J Clin Oncol. 2010;28(15): doi: /JCO Audeh MW, Carmichael J, Penson RT, et al. Oral poly(adp-ribose) polymerase inhibitor olaparib in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer: a proof-of-concept trial. Lancet. 2010; 376(9737): doi: /S (10) Kaye SB, Lubinski J, Matulonis U, et al. Phase II, open-label, randomized, multicenter study comparing the efficacy and safety of olaparib, a poly (ADP-ribose) polymerase inhibitor, and pegylated liposomal doxorubicin in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer. J Clin Oncol. 2012; 30(4): doi: /JCO Gordon AN, Fleagle JT, Guthrie D, Parkin DE, Gore ME, Lacave AJ. Recurrent epithelial ovarian carcinoma: a randomized phase III study of pegylated liposomal doxorubicin versus topotecan. J Clin Oncol. 2001;19(14): Graeser M, McCarthy A, Lord CJ, et al. A marker of homologous recombination predicts pathologic complete response to neoadjuvant chemotherapy in primary breast cancer. Clin Cancer Res. 2010; 16(24): doi: / CCR Safra T, Rogowski O, Muggia FM. The effect of germ-line BRCA mutations on response to chemotherapy and outcome of recurrent ovarian cancer. Int J Gynecol Cancer. 2014; 24(3): doi: /IGC Kaufman B, Shapira-Frommer R, Schmutzler RK, et al. Olaparib monotherapy in patients with advanced cancer and a germline BRCA1/2 mutation. J Clin Oncol. 2015; 33(3): doi: /JCO Domchek SM, Aghajanian C, Shapira-Frommer R, et al. Efficacy and safety of olaparib monotherapy in germline BRCA1/2 mutation carriers with advanced ovarian cancer and three or more lines of prior therapy. Gynecol Oncol. 2016; 140(2): doi: /j.ygyno Gelmon KA, Tischkowitz M, Mackay H, et al. Olaparib in patients with recurrent high-grade serous or poorly differentiated ovarian carcinoma or triple-negative breast cancer: a phase 2, multicentre, open-label, non-randomised study. Lancet Oncol. 2011;12(9): doi: /S (11) Liu JF, Barry WT, Birrer M, et al. Combination cediranib and olaparib versus olaparib alone for women with recurrent platinum-sensitive ovarian cancer: a randomised phase 2 study. Lancet Oncol. 2014;15(11): doi: /S (14) Matulonis UA, Berlin S, Ivy P, et al. Cediranib, an oral inhibitor of vascular endothelial growth factor receptor kinases, is an active drug in recurrent epithelial ovarian, fallopian tube, and peritoneal cancer. J Clin Oncol. 2009;27(33): Oza AM, Cibula D, Benzaquen AO, et al. Olaparib combined with chemotherapy for recurrent platinum-sensitive ovarian cancer: a randomised phase 2 trial. Lancet Oncol. 2015; 16(1): doi: /S (14) Vergote I, Finkler N, del Campo J, et al. Phase 3 randomised study of canfosfamide (Telcyta, TLK286) versus pegylated liposomal doxorubicin or topotecan as third-line therapy in patients with platinum-refractory or -resistant ovarian cancer. Eur J Cancer. 2009;45(13): doi: /j.ejca Cannistra SA, Matulonis UA, Penson RT, et al. Phase II study of bevacizumab in patients with platinum-resistant ovarian cancer or peritoneal serous cancer. J Clin Oncol. 2007;25(33): Landrum LM, Brady WE, Armstrong DK, et al. A phase I trial of pegylated liposomal doxorubicin (PLD), carboplatin, bevacizumab and veliparib in recurrent, platinum-sensitive ovarian, primary peritoneal, and fallopian tube cancer: An NRG Oncology/Gynecologic Oncology Group study. Gynecol Oncol. 2016;140(2): doi: /j.ygyno VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 21

24 OVARIAN CANCER 23. Curtin NJ, Szabo C. Therapeutic applications of PARP inhibitors: anticancer therapy and beyond. Mol Aspects Med. 2013; 34(6): doi: /j.mam Tentori L, Lacal PM, Muzi A, et al. Poly(ADP-ribose) polymerase (PARP) inhibition or PARP-1 gene deletion reduces angiogenesis. Eur J Cancer. 2007;43(14): Bindra RS, Gibson SL, Meng A, et al. Hypoxia-induced down-regulation of BRCA1 expression by E2Fs. Cancer Res. 2005;65(24): Lim JJ, Yang K, Taylor-Harding B, Wiedemeyer WR, Buckanovich RJ. VEGFR3 inhibition chemosensitizes ovarian cancer stemlike cells through down-regulation of BRCA1 and BRCA2. Neoplasia. 2014;16(4): e1-2. doi: /j. neo Mirza MR, Christensen RD. A phase I study of bevacizumab in combination with niraparib in patients with platinum-sensitive epithelial ovarian cancer: The ENGOT-OV24/AVANOVA1 trial. J Clin Oncol. 2016; Ledermann J, Harter P, Gourley C, et al. Olaparib maintenance therapy in platinum-sensitive relapsed ovarian cancer. N Engl J Med. 2012;366(15): doi: /NEJ- Moa Ledermann J, Harter P, Gourley C, et al. Olaparib maintenance therapy in patients with platinum-sensitive relapsed serous ovarian cancer: a preplanned retrospective analysis of outcomes by BRCA status in a randomised phase 2 trial. Lancet Oncol. 2014;15(8): doi: /S (14) Sakai W, Swisher EM, Karlan BY, et al. Secondary mutations as a mechanism of cisplatin resistance in BRCA2-mutated cancers. Nature. 2008; 451(7182): doi: /nature Ashworth A. Drug resistance caused by reversion mutation. Cancer Res. 2008;68(24): doi: / Bouwman P, Jonkers J. Molecular pathways: how can BRCA-mutated tumors become resistant to PARP inhibitors? Clin Cancer Res. 2014;20(3): doi: / CCR Issaeva N, Thomas HD, Djureinovic T, et al. 6-thioguanine selectively kills BRCA2-defective tumors and overcomes PARP inhibitor resistance. Cancer Res. 2010;70(15): doi: / Swisher E. LK, Oza A. et al. Rucaparib in relapsed, platinum-sensitive high-grade ovarian carcinoma (ARIEL2 Part 1): an international, multicentre, open-label, phase 2 trial. Lancet Oncol. [Ahead of print]. 35. Risch HA, McLaughlin JR, Cole DE, et al. Population BRCA1 and BRCA2 mutation frequencies and cancer penetrances: a kin-cohort study in Ontario, Canada. J Natl Cancer Inst. 2006;98: Pal T, Permuth-Wey J, Betts JA, et al. BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases. Cancer. 2005;104(12): Hennessy BT, Timms KM, Carey MS, et al. Somatic mutations in BRCA1 and BRCA2 could expand the number of patients that benefit from poly (ADP ribose) polymerase inhibitors in ovarian cancer. J Clin Oncol. 2010;28(22): doi: /JCO Tan DS, Rothermundt C, Thomas K, et al. BRCAness syndrome in ovarian cancer: a case-control study describing the clinical features and outcome of patients with epithelial ovarian cancer associated with BRCA1 and BRCA2 mutations. J Clin Oncol. 2008;26(34): doi: /JCO Turner N, Tutt A, Ashworth A. Hallmarks of BRCAness in sporadic cancers. Nat Rev Cancer. 2004;4(10): Konstantinopoulos PA, Spentzos D, Karlan BY, et al. Gene expression profile of BRCAness that correlates with responsiveness to chemotherapy and with outcome in patients with epithelial ovarian cancer. J Clin Oncol. 2010;28(22): doi: /JCO Ibragimova I, Cairns P. Assays for hypermethylation of the BRCA1 gene promoter in tumor cells to predict sensitivity to PARP-inhibitor therapy. Methods Mol Biol. 2011;780: doi: / _ Gudmundsdottir K, Ashworth A. The roles of BRCA1 and BRCA2 and associated proteins in the maintenance of genomic stability. Oncogene. 2006;25(43): Swisher E BJ KS, Oza A, et al. ARIEL2: a phase 2 study to prospectively identify ovarian cancer patients likely to respond to rucaparib. Presented at: the 26th EORTC-NCI-AACR Symposium on Molecular Targets and Cancer Therapeutics; November 18, 2014; Barcelona, Spain. Abstract Shah MM, Dobbin ZC, Nowsheen S, et al. An ex vivo assay of XRT-induced Rad51 foci formation predicts response to PARP-inhibition in ovarian cancer. Gynecol Oncol. 2014;134(2): doi: /j.ygyno Joshi PM, Sutor SL, Huntoon CJ, Karnitz LM. Ovarian cancer-associated mutations disable catalytic activity of CDK12, a kinase that promotes homologous recombination repair and resistance to cisplatin and poly(adp-ribose) polymerase inhibitors. J Biol Chem. 2014; 289(13): doi: /jbc. M Lee JM, Hays JL, Annunziata CM, et al. Phase I/Ib study of olaparib and carboplatin in BRCA1 or BRCA2 mutation-associated breast or ovarian cancer with biomarker analyses. J Natl Cancer Inst. 2014;106(6):dju089. doi: /jnci/dju

25 METASTATIC RENAL CELL CARCINOMA INVADING THE PULMONARY VEIN AND LEFT ATRIUM: AN EXTREMELY RARE OCCURRENCE TREATED WITH TEMSIROLIMUS Metastatic Renal Cell Carcinoma Invading the Pulmonary Vein and Left Atrium: An Extremely Rare Occurrence Treated with Temsirolimus Sameer Tolay, MD, Ranju Gupta, MD, and Alcee J. Jumonville, MD Abstract Metastatic renal cell carcinoma involving the left atrium and pulmonary vein is a very rare entity and has only been reported 4 times in the literature to our knowledge. This has traditionally been managed surgically but we report our experience with mammalian target of rapamycin (mtor) inhibitor therapy temsirolimus. The treatment resulted in significant regression of the tumor but more importantly, dramatically improved patient s symptoms. AJHO. 2016;12(11):23-26 Introduction Most cases of cardiac metastasis from renal cell carcinoma (RCC) involve the vena cava or right atrium. 1 Left heart metastases are relatively uncommon, and involvement of the pulmonary vein is an extremely rare and challenging scenario with only four cases reported to date. 1 All the previously reported cases were treated with surgical resection of the intra-atrial mass. Surprisingly, there is paucity of documented reports of using mammalian target of rapamycin (mtor) inhibitors in cardiac metastases from RCC. We report a case in which clear cell RCC invaded the left atrium via the right pulmonary vein and was treated non-surgically with temsirolimus. To our knowledge, this is only the fifth occurrence of its kind and only second time when an experience with mtor inhibitor has been shared in cardiac metastases from RCC. 1,2 This case demonstrates no obvious involvement of the inferior vena cava. The treatment resulted in significant regression of the intrathoracic disease with dramatic symptomatic relief to the patient. Case History A 56-year-old woman came to our clinic with gross hematuria and left flank pain. Computed tomographic (CT) scan showed a large inhomogeneous mass arising from the left kidney for which she underwent open radical nephrectomy. Pathology reports from the specimen confirmed a cm, grade 4 clear cell RCC contained within the renal capsule. All surgical margins (renal artery, renal vein, ureter, and Gerota fascia) and examined lymph nodes were negative for malignancy. The patient was doing reasonably well for approximately 2 years when a CT scan of the chest showed a left upper lobe mass and a right lower lobe nodular density measuring mm and mm, respectively. Results of a CT-guided fine needle biopsy of the left upper lobe mass showed clear cell metastatic RCC and overall findings were suggestive of bilateral pulmonary metastatic disease. There was no evidence of metastatic disease elsewhere in the body. The patient was given 7 cycles of sunitinib resulting in resolution of the right lung metastasis and significant reduction in the size of left lung metastasis. Patient thereafter underwent a successful thoracotomy with left upper lobectomy. At this point, patient was radiographically rendered no evidence of disease. The patient had a stable course for approximately a year, at which time she reported acute onset dyspnea on exertion. A chest CT scan showed right hilar lymphadenopathy, tumor in the right inferior pulmonary vein, and lobulated tumor thrombus in the left atrium (Figure 1). After several multidisciplinary discussions, it was concluded that the metastases were not amenable to surgery, and that radiation could cause catastrophic pulmonary vein rupture. Thus, it was decided to start intravenous temsirolimus therapy at a dose of 25 mg weekly. Patient tolerated the treatment well with minimal adverse effects and after 14 weeks of temsirolimus therapy, CT scan showed significant regression of the intrathoracic disease (Figure 2) with relief in symptoms and dramatic improvement in dyspnea. Patient is currently reported to have stable disease at almost 11 months from the diagnosis of cardiac metastasis. Discussion Cardiovascular involvement from RCC, although rare and limited to case reports, is a reasonably well-recognized entity. The usual pattern of spread (Table 1) involves renal vein (33%), inferior vena cava (5%-15%) and right atrium (1%). 3,4 Right ventricular metastases are relatively uncommon (10-15 cases reported to date), and while metastasis to the left side of the heart is exceedingly rare, involvement of the pulmonary veins has only been reported 4 times. 1,5 Some other unconventional vascular sites include superior vena cava, hepatic-portal system, and the carotid artery. 6-8 Despite such underwhelming numbers, VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 23

26 RENAL CELL CARCINOMA TABLE 1. Distribution of Cardiovascular Metastases in Renal Cell Carcinoma. Metastatic Site Frequency Renal vein 2,3 33% Inferior vena cava 2,3 5% to15% Right atrium 2,3 1% Right ventricle 4 Left atrium and Left ventricle 2,3 Pulmonary veins 1 Others including superior vena cava, portal vein and carotid artery 5-7 ~15 cases reported to date Rare (<10 cases) 4 cases reported to date Exceedingly rare (~1 case each) it is interesting to note that cardiac metastases were shown to be present in 11% of patients who died of RCC. 9 Cardiac involvement is presumed to be due to 1 of 2 mechanisms: (1) hematogenous spread from the renal vein to the right side of the heart, or (2) through lymphatic vessels of the thorax that allow for the spread of disease to the myocardium and left pericardium, the latter being associated with poorer prognosis. 9,10 Also, in the great majority of cases, the tumor reaches the heart through a neoplastic thrombus within the inferior vena cava. 3 Cardiac metastases without inferior vena cava involvement is extremely rare but can occur through systemic hematogenous seeding or by direct extension from either mediastinal or lung lesions. 1 In the context of left atrial metastases via pulmonary vein, in 3 of the 4 reported cases the tumor originated from the metastatic lung mass, and in the remaining case, from the mediastinal lymph node. 1 Our case is highly unusual in this regard because the left atrial invasion via pulmonary vein was detected approximately a year after left upper lobectomy with no evidence of a pulmonary lesion on previous surveillance CT scan, which makes hematogenous seeding as the possible mode of spread. Furthermore, left heart metastases tend to be clinically silent and often appear late in the course compared with those on the right side, but in our case it appeared quite abruptly with rapid onset of dyspnea. 11 Two of the four reported patients were asymptomatic at the time of detection of left atrial/pulmonary vein metastases, while the other two experienced syncope and dyspnea. 1 Surgical metastasectomy using a cardiopulmonary bypass with or without hypothermia remains the generally preferred modality for isolated cardiac and inferior vena cava metastases. Sternotomy is the most commonly used approach, but a thoraco-abdominal incision has also been successfully employed Serial echo-guided percutaneous coil embolization has also been used successfully for surgically inoperable cardiac metastases from RCC. 15 Radiation therapy is avoided in pulmonary venous metastases not only due to the risk of catastrophic pulmonary vein rupture, but also because RCC is often resistant to radiation therapy. All of the four reported cases with pulmonary vein/left atrial metastases were treated with resection of the left atrial mass accompanied by pneumonectomy, but cardiothoracic surgeons deemed our patient s disease inoperable. Therefore, we opted for a conservative mtor inhibitor therapy with temsirolimus. The use of targeted therapy has been very rarely reported in cardiac metastasis from RCC. More so, the experience with mtor inhibitor therapy has only been reported once prior to this case but the treatment response is unclear from that study. 2 Our patient showed decent tolerability to the drug with excellent radiographic and clinical response. Some of the other indications for mtor inhibitor therapy in RCC are high lactate dehydrogenase level, low hemoglobin, high calcium, TABLE 2. Reported Cases of Left Atrium and Pulmonary Vein Metastasis in Renal Cell Carcinoma. Author Pt Age/Sex Presenting symptom Source of cardiac metastasis 1 Fogel R 77, male Dizziness, syncope, dyspnea Lung metastasis 2 Patane J 3 Miyamoto M 4 Cochnnec F 5 Present report 58, female Asymptomatic 56, male Syncope 42, female 56, female Asymptomatic Dyspnea Lung metastasis Mediastinal node Lung metastasis Hematogenous or adjacent lymph node Treatment Atrectomy, pneumonectomy Atrectomy, lobectomy Atrectomy, lymphadenectomy Atrectomy, lobectomy Temsirolimus Outcome Died postoperatively 13 months, no recurrence 4 months, no recurrence 8 months, no recurrence 11 months, stable disease 24

27 METASTATIC RENAL CELL CARCINOMA INVADING THE PULMONARY VEIN AND LEFT ATRIUM: AN EXTREMELY RARE OCCURRENCE TREATED WITH TEMSIROLIMUS poor performance status, >2 sites of metastatic disease and <1 year from diagnosis to start of systemic therapy. 16 These parameters are generally indicative of an aggressive disease process and have also been incorporated in the National Comprehensive Cancer Network (NCCN) guidelines. A few case reports have also described tyrosine kinase inhibitors (TKI) such as pazopanib and sunitinib in both, neoadjuvant (prior to cardiac metastasectomy), and inoperable settings. 17,18 Some potential therapeutic options include other TKI s like axitinib and the newly approved FIGURE 1. Chest CT showing Metastatic RCC Invading the Right Inferior Pulmonary Vein and Lobulated Tumor Thrombus in the Left Atrium. cabozantinib, immunotherapy such as high dose IL-2 and checkpoint inhibitors but their utility and safety in inoperable cardiac metastases is not known. Affiliations: Sameer Tolay, MD, and Ranju Gupta, MD, are with Hematology and Medical Oncology, Lehigh Valley Health Network, PA, and Alcee J. Jumonville, MD, is with the department of Medical Oncology, Gundersen Health System, WI. Address correspondence to: Sameer Tolay, Lehigh Valley Health Network, Suite 411, 1240 S Cedar Crest Boulevard, Allentown, PA, Phone: , fax: ; and Sameer.tolay@lvhn.org. Author disclosures: The authors declare no financial, personal, or commercial conflict of interest while submitting this manuscript. FIGURE 2. CT Scan After 14 Weeks of Temsirolimus Showing Significant Regression of the Left Atrial Mass. References 1. Cochennec F, Seguin A, Riquet M, Fabiani JN. Intracardiac renal cell carcinoma metastasis. Eur J Cardiothorac Surg. 2008; 34(3): doi: /j. ejcts Zhang B1, Malouf J, Young P, Kohli M, Dronca R. Cardiac metastasis in renal cell carcinoma without vena cava or atrial involvement: an unusual presentation of metastatic disease. Rare Tumors. 2013;5(3):e29. doi: /rt.2013.e Posacioglu H, Ayik MF, Zeytunlu M, Amanvermez D, Engin C, Apaydin AZ. Management of renal cell carcinoma with intracardiac extension. J Card Surg. 2008;23(6): doi: /j x. 4. Atik FA, Navia JL, Krishnamurthi V, et al. Solitary massive right ventricular metastasis of renal cell carcinoma without inferior vena cava or right atrium involvement. J Card Surg. 2006; 21(3): Sato T, Takeda A, Yamada S, Numata I, Sakamoto K. Metastatic renal cell carcinoma to right ventricle without vena caval involvement. Int J Urol. 2008; 15(4): doi: /j x. 6. Ozer N, Deniz A, Pişkinpaşa S, et al. Renal cell carcinoma extending from superior vena cava into right atrium. J Am Soc Echocardiogr. 2007;20(5):538.e7-e8. 7. Kyoda Y, Kobayashi K, Takahashi A, et al. Liver metastasis with portal vein tumor VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 25

28 RENAL CELL CARCINOMA thrombosis as a late recurrence of chromophobe renal cell carcinoma. Hinyokika Kiyo. 2009; 55(1): Erbay SH, O Callaghan MG, Bhadelia RA, Polak JF. Unusual case of 2 renal cell carcinoma metastases ipsilateral to an occluded internal carotid artery. J Neuroimaging. 2006; 16(2): Zustovich F, Gottardo F, De Zorzi L, et al. Cardiac metastasis from renal cell carcinoma without inferior vena involvement: a review of the literature based on a case report. Two different patterns of spread? Int J Clin Oncol. 2008; 13(3): doi: /s Ishida N, Takemura H, Shimabukuro K, Matsuno Y. Complete resection of asymptomatic solitary right atrial metastasis from renal cell carcinoma without inferior vena cava involvement. J Thorac Cardiovasc Surg. 2011; 142(3):e142-e144. doi: /j. jtcvs Eckman PM, Westensee JC, Missov E, Liao KK, Truskinovsky AM, Panetta C. Renal cell carcinoma in the left ventricular outflow tract. Int J Cardiol. 2008; 126(1):e1-e Radak D, Milojevic P, Babic S, et al. Renal tumor with tumor thrombus in inferior vena cava and right atrium: the report of five cases with long-term follow-up. Int Urol Nephrol. 2011; 43(4): doi: /s Alejo JL, George TJ, Beaty CA, Allaf ME, Black JH,3rd, Shah AS. Novel approach to recurrent cavoatrial renal cell carcinoma. Ann Thorac Surg May;93(5):e doi: /j.athoracsur Juraszynski Z, Szpakowski E, Biederman A. Giant metastatic intrapericardial tumor 20 years after nephrectomy. Ann Thorac Surg Jul;90(1): doi: /j.athoracsur Butz T, Schmidt HK, Fassbender D, et al. Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract. Eur J Echocardiogr. 2008;9(5): doi: /ejechocard/jen Hudes G1, Carducci M, Tomczak P, et al. Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. N Engl J Med. 2007;356(22): Czarnecka AM, Sobczuk P, Lian F, Szczylik C. Renal cell carcinoma with intramyocardial metastases. BMC Urol. 2014;14:73. doi: / Karakiewicz PI, Suardi N, Jeldres C, et al. Neoadjuvant sutent induction therapy may effectively down-stage renal cell carcinoma atrial thrombi. Eur Urol. 2008;53(4):

29 CURRENT STANDARDS AND EMERGING CME APPROACHES IN GLIOBLASTOMA Current Standards and Emerging Approaches in Glioblastoma Dates of certification: November 30, 2016, to November 30, 2017 Medium: Print with online posttest, evaluation, and request for credit The American Journal of Hematology/Oncology Editorial Board Debu Tripathy, MD Professor and Chairman Department of Breast Medical Oncology Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX Disclosure: Grant/research support from Genentech/Roche, Pfizer, Puma Biotechnology Inc, and Novartis (clinical trial support contracted to the University of Southern California and MD Anderson Cancer Center); consultant for Eisai, OncoPlex Diagnostics, Merck, and Novartis. Faculty David A. Reardon, MD Clinical Director, Center for Neuro-Oncology Physician Dana-Farber Cancer Institute Professor of Medicine, Harvard Medical School Disclosure: Grant/Research Support - Celldex; Incyte; Midatech. Consultant - Abbvie; Amgen; BMS; Cavion; Genentech/Roche; Merck; Midatech; Momenta Pharmaceuticals; Novartis; Novocure; Regeneron; Stemline Therapeutics. Speaker s Bureau- Merck; Genentech/Roche Staff/Planner Disclosures and Conflict of Interest Resolution The staff of Physicians Education Resource, LLC (PER ), and the editorial staff of The American Journal of Hematology/Oncology have no relevant financial relationships with commercial interests to disclose. It is the policy of PER to ensure fair balance, independence, objectivity, and scientific objectivity in all of our CME/CE activities. In accordance with ACCME guidelines, PER requires everyone who is in a position to control the content of an educational activity, including spouses/partners, to disclose all relevant financial relationships with any commercial interest to participants as part of the activity planning process. PER has implemented mechanisms to identify and resolve all conflicts of interest prior to release of this activity. Overview This activity is designed to inform physicians about current and emerging treatment approaches in patients with glioblastoma. Target Audience This activity is directed toward medical oncologists, primary care physicians, nurses, and nurse practitioners who treat and/or manage patients with hematologic malignancies. Surgical oncologists, radiation oncologists, pathologists, internists, fellows, physician assistants, and other healthcare providers with an interest in the current topic are also invited to participate. Summarize the main findings of studies investigating the prognostic and predictive value of O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status in patients with glioblastoma Characterize the technology currently used to identify MGMT promoter methylation status in patients with glioblastoma State the contributions of The Cancer Genome Atlas (TCGA) researchers to the genomic understanding of glioblastoma Accreditation/Credit Designation Physicians Education Resource, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Physicians Education Resource, LLC, designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians Education Resource, LLC, is approved by the California Board of Registered Nursing, Provider #16669 for 1.0 Contact Hour. This activity is funded by PER. Instructions for Participation/How to Receive Credit: 1. Read the article in its entirety. 2. Use the QR code or type into your Web browser to access the posttest. 3. Complete and pass the posttest with a score of 70% or higher. 4. Complete the evaluation and request for credit. Participants may immediately download a CME/CE certificate upon successful completion of these steps. Off-Label Disclosure and Disclaimer This continuing medical and nursing education activity may or may not discuss investigational, unapproved, or off-label uses of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent medical judgment of a physician or nurse relative to diagnostic, treatment, and management options for a specific patient s medical condition. Disclaimer The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians Education Resource, LLC. Contact information for questions about the activity: Physicians Education Resource, LLC 666 Plainsboro Road, Suite 356 Plainsboro, NJ Phone: (888) info@gotoper.com Learning Objectives After participating in this CME/CE activity, learners should be better prepared to: Discuss the challenges associated with effective drug delivery to patients with glioblastoma VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 27

30 CME Introduction Glioblastoma, the most common malignant primary brain tumor in adults, is a highly aggressive cancer associated with substantial morbidity and mortality. 1-8 Despite advances in surgery, radiotherapy, and chemotherapy, current treatment options for glioblastoma remain suboptimal, and patients face a bleak outcome. 4,9,10 Median overall survival (OS) from the time of glioblastoma diagnosis is 12 to 15 months among all patients and only 4 to 5 months among those aged 65 years. 2,11,12 Less than 5% of patients with glioblastoma survive beyond 5 years. 13 Glioblastoma remains one of the most difficult of all human cancers to treat because of its invasive nature and the presence of the blood brain barrier. 4,7,9,14 Complete surgical removal of glioblastoma is not possible due to invasion of the tumor into surrounding healthy tissue; furthermore, secondary tumor foci may develop close to the resected site. 7 Residual tumor cells are often resistant to standard radiotherapy, and the potential efficacy of radiotherapy is limited by toxicity to healthy tissue. 7 Additionally, the treatment of glioblastoma is complicated by the inability of many drugs administered systemically to overcome the blood brain barrier and attain adequate concentrations at the site of the tumor. 15 The current standard of care in younger patients with glioblastoma is maximal safe tumor resection followed by fractionated radiotherapy in combination with concomitant and adjuvant temozolomide therapy. 9,16 A multicenter, randomized, phase 3 study in 573 patients (median age, 56 years) with newly diagnosed glioblastoma showed that the addition of temozolomide to radiotherapy was associated with a statistically significant survival benefit compared with radiotherapy alone. 17 At median follow-up of 28 months, median survival was 14.6 months in patients receiving radiotherapy plus temozolomide and 12.1 months in those receiving radiotherapy alone; the 2-year survival rate was 26.5% and 10.4%, respectively. 17 The current standard of care in elderly patients with glioblastoma remains a matter of debate; therefore, until a consensus is reached, current therapeutic options (ie, surgery, radiotherapy, and temozolomide) should be utilized based on patient-specific factors and patient preference. 2 In a phase 3 study investigating radiotherapy regimens in elderly and/or frail patients with newly diagnosed glioblastoma, short-course radiotherapy (25 Gy in 5 daily fractions over 1 week) and commonly used radiotherapy (40 Gy in 15 daily fractions over 3 weeks) were shown to result in similar median progression-free survival (PFS), median OS, and quality-of-life outcomes. 18 A systematic review of the medical literature to identify articles containing survival data in elderly patients with glioblastoma who were treated with either temozolomide alone or radiotherapy alone between 2005 and 2013 showed support for the use of hypofractionated radiotherapy or temozolomide monotherapy. 19 Of interest, the literature review also showed variability in the definition of elderly and a lack of randomized clinical studies comparing temozolomide alone with radiotherapy alone in elderly patients with glioblastoma. 19 As noted above, radiation therapy is a critical component in the treatment of glioblastoma. 3,20 In 2016, the American Society for Radiation Oncology (ASTRO) published evidence-based clinical practice guidelines for the use of radiation therapy in patients with glioblastoma to help facilitate treatment decision-making. 3,20 The ASTRO guideline focuses on (1) indications for the use of radiation therapy after biopsy/resection and the ways in which systemic therapies modify the effect of radiation therapy; (2) the optimal dose-fractionation schedule for external beam radiation therapy after biopsy/resection; (3) ideal target volumes for curative-intent external beam radiation therapy; and (4) the role of re-irradiation in disease recurrence after completion of standard front-line therapy. 3,20 The methylation status of the promoter of the O-6-methylguanine-DNA methyltransferase (MGMT) gene is a prognostic and predictive biomarker in glioblastoma. 21 Inactivation of MGMT by promoter methylation has been shown to be associated with longer survival in patients with glioblastoma who are treated with radiation and temozolomide In a phase 2 study in 38 patients with glioblastoma who underwent resection and were treated with radiation and temozolomide, 18-month survival was 62% versus 8% in patients with methylated and unmethylated MGMT promoters, respectively. 23 A study evaluating the effect of MGMT promoter methylation status in 206 patients with glioblastoma who received either radiotherapy alone or radiotherapy combined with concomitant and adjuvant treatment with temozolomide found that MGMT promoter methylation was an independent favorable prognostic factor irrespective of treatment assignment. 24 In the study, OS was 15.3 months in patients with a methylated MGMT promoter versus 11.8 months in those with an unmethylated MGMT promoter in the cohort receiving radiotherapy alone and 21.7 versus 12.7 months, respectively, in the cohort receiving radiotherapy in combination with temozolomide. 24 Of interest, data have also shown that unmethylated MGMT promoter status is associated with unfavorable clinical outcome in a subpopulation of patients with non-resectable glioblastoma after adjuvant therapy. 25 Data from two clinical trials support consideration of MGMT methylation status in older patients with glioblastoma to aid in treatment decision-making In the phase 3 Nordic 28

31 CURRENT STANDARDS AND EMERGING APPROACHES IN GLIOBLASTOMA trial, which randomized 291 patients aged 60 years with newly diagnosed glioblastoma to temozolomide, hypofractionated radiotherapy, or standard radiotherapy, OS was significantly longer in temozolomide-treated patients with a methylated MGMT promoter than in those with an unmethylated MGMT promoter (9.7 vs 6.8 months, respectively); however, no difference in OS was observed in patients with methylated and unmethylated MGMT promoters who were treated with radiotherapy (hazard ratio, 0.97). 27 In the randomized phase 3 NOA-08 study, which randomly allocated 373 patients aged >65 years with anaplastic astrocytoma or glioblastoma to temozolomide alone or radiotherapy alone, OS was longer in those with MGMT promoter methylation than without MGMT promoter methylation (11.9 vs 8.2 months, respectively). 28 Event-free survival was longer in patients with MGMT promoter methylation who received temozolomide than in those who received radiotherapy (8.4 vs 4.6 months, respectively); however, the opposite was true in patients with an unmethylated MGMT promoter (3.3 vs 4.6 months, respectively). 28 Researchers recently conducted a retrospective analysis of all MGMT promoter methylation testing performed at the Center for Advanced Molecular Diagnostics between 2009 and 2013 to investigate the clinical implication of inconsistently methylated results from glioblastoma tumor samples on replicate methylation-specific polymerase chain reaction (PCR) testing. 21 MGMT test results were reported as methylated, unmethylated, or inconsistently methylated. 21 An inconsistently methylated result was defined as one in which a methylated peak was noted in some but not all replicates from a single DNA sample. 21 In brief, the analysis showed that (1) inconsistently methylated results occurred in 12% of cases; (2) inconsistent methylation was correlated with relatively poor OS; and (3) a dose-response association may exist between OS and the degree of methylation across replicates in the inconsistently methylated cases. 21 The most suitable method of clinical MGMT testing remains unclear, as numerous assays have been associated with suboptimal analytic performance. 16 Additionally, the measurement of MGMT is not standardized, which leads to a high degree of variability in test results. 5 Although MGMT testing has been promoted in patients with glioblastoma, inaccessibility and cost limit its use in general clinical practice. 5 A recent study described the first validated pyrosequencing-based MGMT methylation test using clinical formalin-fixed paraffin-embedded biopsy tissue from 33 patients with glioblastoma. 29 A meta-analysis of 11 studies conducted to evaluate the prognostic value of MGMT promoter status in patients with glioblastoma using a pyrosequencing assay showed that methylation positivity is associated with increased survival. 8 Nearly all glioblastomas recur, 13 and treatment options are limited in patients with recurrent disease. 1 In 2009, the anti-angiogenic agent bevacizumab was granted accelerated approval by the FDA for use as monotherapy in patients with recurrent glioblastoma based on data from two phase 2 studies. 13 In the multicenter, open-label, non-comparative AVF3708g study, which included 167 patients with recurrent glioblastoma who received bevacizumab with or without irinotecan, estimated 6-month PFS was 42.6% in the bevacizumab arm and 50.3% in the bevacizumab/irinotecan arm; median OS was 9.2 and 8.7 months, respectively, and the objective response rate was 28.2% and 37.8%, respectively. 30 In the second pivotal study, which included 48 heavily pretreated patients with recurrent glioblastoma who received single-agent bevacizumab, median PFS and median OS were 16 weeks and 31 weeks, respectively; the 6-month PFS and OS rates were 29% and 57%, respectively. 31 In general, the use of bevacizumab has been associated with a reduction in cerebral edema, improvement in neurologic symptoms, and a reduction in corticosteroid usage 31 ; however, once a patient becomes refractory to bevacizumab, median OS is approximately 1.1 to 4.5 months irrespective of the treatment strategy used. 1,32,33 A biodegradable polymer wafer containing carmustine was approved by the FDA in February 1997 for implantation in patients with recurrent glioblastoma as an adjunct to surgery. 34 FDA approval was based on data from a placebo-controlled study in which median survival in patients with malignant recurrent gliomas was 31 weeks in those receiving carmustine wafer implantation and 23 weeks in those receiving placebo implantation. 35 A recent meta-analysis evaluating survival outcome in patients with recurrent high-grade glioma found that median OS was 9.7 months in those who received carmustine wafer implantation versus 8.6 months in those who did not receive such treatment; 2-year OS was 15% and 12%, respectively. 36 In February 2003, the indication for carmustine wafer was extended to include implantation in patients with newly diagnosed high-grade malignant gliomas as an adjunct to surgery and radiation. 34 At present, many patients who have received carmustine wafer implantation are excluded from clinical trial participation due to concerns about potential toxicities, confounding of results, and a lack of reliable survival data. 36 Optune (previously known as NovoTTF-100A), a portable device approved by the FDA to treat adults with recurrent and newly diagnosed glioblastoma, delivers tumor-treating fields (TTFs) to selectively disrupt mitosis via noninvasive transducer arrays. 1,37,38 In April 2011, Optune was approved as monotherapy, and as an alternative to standard medical therapy after surgical and radiation options have been exhausted, in patients with histologically or radiologically confirmed recurrent VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 29

32 CME glioblastoma in the supratentorial region of the brain after receiving chemotherapy. 39 In the randomized phase 3 EF-11 study, which investigated the efficacy and safety of TTF alone versus physicians choice of chemotherapy in patients with recurrent glioblastoma, median OS was 6.6 and 6.0 months, respectively, and 1-year survival was 20% in both treatment arms. 40 In general, TTF was associated with lower toxicity and greater improvement in quality of life compared with chemotherapy; the most commonly reported TTF-related adverse events were mild to moderate skin reactions. 40 Of interest, a post hoc analysis of data from the pivotal EF-11 trial found that median OS was significantly higher in patients receiving 1 course of TTF therapy compared with those receiving physicians best choice of chemotherapy (7.7 vs 5.9 months, respectively). 33 Analysis of data from a post marketing registry of 457 patients with glioblastoma who received treatment with the NovoTTF-100A system between October 2011 and November 2013 in a US clinical practice setting showed that median OS was 9.6 months, and 1-year and 2-year survival rates were 44% and 30%, respectively. 6 In April 2015, the indication for Optune was expanded to include the treatment of adults with newly diagnosed, supratentorial glioblastoma in combination with temozolomide following maximal debulking surgery and completion of radiation therapy together with concomitant standard of care chemotherapy. 38,39 Data from several retrospective uncontrolled case series and a post hoc analysis of the registration trial for temozolomide have shown that the use of valproic acid improved survival in patients with newly diagnosed glioblastoma; however, other analyses suggest that antiepileptic drug use does not confer a survival benefit in such patients. 41 For example, in a pooled analysis of data from four prospective randomized clinical trials that included 1869 patients with newly diagnosed glioblastoma, PFS and OS in patients receiving valproic acid at chemoradiotherapy initiation was not improved compared with those not receiving valproic acid (hazard ratios for PFS and OS = 0.91 and 0.96, respectively). 41 In addition, PFS and OS in patients receiving valproic acid at chemoradiotherapy initiation, as well as after chemoradiotherapy, did not differ from those not receiving valproic acid at both of these time points. 41 Furthermore, no correlation with improved survival outcome was noted with the use of the antiepileptic drug levetiracetam. 41 In recent years, much progress has been made in understanding the molecular landscape in glioblastoma due to the efforts of The Cancer Genome Atlas (TCGA) research network, a collaborative initiative jointly funded and managed by the National Cancer Institute and the National Human Genome Research Institute, both of which are part of the National Institutes of Health. 42 The TCGA was established to comprehensively catalogue somatic genomic changes in more than 25 different cancer types, the first of which was glioblastoma. 42 The systematic genomic analysis of tumor samples by the TCGA has led to the discovery of genetic mutations and DNA alterations that could help to elucidate important biological pathways relevant for the diagnosis and treatment of glioblastoma Furthermore, an enhanced understanding of the relationship between the tumor microenvironment and the immune system has generated much interest in the use of immunotherapeutic strategies to improve outcome in patients with glioblastoma. 4,10,46 Several immunotherapies, including checkpoint blockade, cancer vaccines, adoptive T-cell immunotherapy, and oncolytic virotherapy, are currently being investigated in glioblastoma clinical trials based on promising preclinical data. 4,9,47,48 In particular, the development of agents that target immune checkpoint pathways in glioblastoma has garnered much attention, but numerous challenges have also been acknowledged, including the lack of standardized and validated assays to measure immune response and how best to manage immune-related adverse events in the central nervous system. 46 Recent data suggest that an effective treatment strategy in glioblastoma will likely require the use of combination therapy (ie, surgery, chemotherapy, radiation and immune stimulatory approaches) 4 with appropriate consideration of dosage, toxicity, and sequencing. 46 David A. Reardon, MD, Clinical Director of the Center for Neuro-Oncology at the Dana-Farber Cancer Institute (Boston, MA) offered his insights on current and emerging treatment approaches in patients with glioblastoma. Moderator: Would you discuss the prognostic and predictive value of MGMT promoter methylation status in patients with glioblastoma? Dr. Reardon: MGMT is a validated biomarker for patients with glioblastoma undergoing our current standard of care therapy with radiation and temozolomide. MGMT effectively neutralizes the DNA-damaging effect that temozolomide renders in cancer cells and allows them to basically be resistant to chemotherapy. Data have clearly demonstrated, now prospectively, that patients whose tumors have MGMT promoter methylation which effectively turns expression of the gene off, leading to a low level of this enzyme in the tumor have a better outcome in terms of PFS and OS with the current standard of care therapy relative to patients whose tumors have an unmethylated MGMT promoter in which the MGMT gene is expressed and associated with a higher level in tumor tissue. Studies have shown that patients who have an MGMT-methylated promoter have significantly longer survival with our current standard of care therapy than do patients who have an 30

33 CURRENT STANDARDS AND EMERGING APPROACHES IN GLIOBLASTOMA unmethylated promoter. The studies that have been done show that in unmethylated patients, median PFS and median OS are only 0.9 months longer with the addition of temozolomide compared with radiation therapy alone. So, these statistics show the averages, or the median, and it s important to elaborate that the value of this MGMT testing is helpful, but it s not a perfect biomarker. In other words, a number of my patients over the years have had an MGMT tumor level that is low due to a methylated promoter, but unfortunately, they have not responded well to the current standard of care therapy. Conversely, there are patients in whom the gene level is high due to lack of methylation of the promoter, and they have done quite well. So, we use the test as a predictor, a general predictor, but it is by no means 100 percent sensitive. There are plenty of exceptions on either side. And, part of the reason for that, I think, is related to the way that the MGMT level of the tumor is evaluated. Moderator: What technology is currently used to identify MGMT promoter methylation status in patients with glioblastoma? Does the technology differ in research versus clinical settings? Dr. Reardon: A variety of different techniques are currently used to identify MGMT-promoter methylation status, including methylation-specific polymerase chain reaction (MSP), a MethyLight assay, pyrosequencing, methylation-specific multiplex ligation-dependent probe amplification, and protein immunohistochemistry to detect the actual MGMT protein in surgical tumor specimens. The MSP technique, or methylation-specific reverse-transcriptase PCR, is the gold standard or the standard way of evaluating MGMT. But, the variability of the tests that are done, as well as the challenges associated with each assay and the heterogeneity of tumor tissue, can make interpretation of MGMT quite challenging. How best to accurately define the MGMT status of a tumor remains a controversial area in glioblastoma research. But, at this point, I think that it s fair to say that with any of these assays, there are clearly negative tumors, there are clearly positive tumors, and there are a number of tumors that fall in the middle, where it can be challenging to know where to draw the line in terms of discriminating them as an MGMT-low or an MGMT-high tumor, depending on the assay that is used. Moderator: ASTRO recently published evidence-based clinical practice guidelines on the use of radiation therapy in patients with glioblastoma. Would you highlight some of the most important recommendations? Dr. Reardon: I think that the ASTRO guidelines are an important document for the neuro-oncology community because they provide a consensus established by a panel of experts with significant experience in the treatment of glioblastoma. These guidelines can be incorporated and utilized at all levels both the academic and community level to help guide practitioners in how best to apply a critical cornerstone of therapy, radiation therapy, into the care plan for patients with glioblastoma. The panel of experts discussed a variety of different areas that will help provide some guidance. One area, in particular, was defining the optimal dose-fractionation schedule after biopsy/resection for patients with glioblastoma what to consider for radiotherapy relative to a patient s chronologic age as well as physiologic age. There are variations now in radiation therapy that are being applied and appropriately considered for chronologically elderly patients (those older than 70 years of age) who have a decent performance status, where a hypofractionated dosing schedule, typically around 40 Gy, is administered over 3 weeks, as opposed to the standard 60 Gy administered over 6 weeks. The panel also discussed some of the issues related to ideal target volumes. There has been some debate about that topic amongst radiation oncologists over the last several years, and the data and literature regarding target volumes were summarized in guidance provided in the paper. Finally, the guidelines concluded with commentary on the role of re-irradiation, a practice that has gained significant interest and is becoming increasingly utilized in the care of patients following progression after initial standard-of-care therapy. So, our hope is that this guidance will be very helpful across the spectrum of practitioners involved in the care of patients with glioblastoma, specifically with regard to some of these issues. Moderator: Would you describe the contribution of TCGA researchers to the genomic understanding of glioblastoma? Dr. Reardon: TCGA has fortunately prioritized the evaluation of glioblastoma tumors. The TCGA was initially launched by the National Institutes of Health in 2005 and utilizes stateof-the-art genomic sequencing, bioinformatics, and integrated multidimensional platforms to catalogue and discover genetic factors associated with different cancers. The platforms include genomic next-generation DNA sequencing involving RNA sequencing for transcriptomic evaluation, epigenomic data evaluating DNA methylation sequencing, and proteomics using reverse-phase protein array analyses. TCGA has currently evaluated more than 33 different human tumor types and more than 11,000 tumor normal tissue matched paired samples. All of the data from these analyses are publicly, freely available in datasets to help drive and stimulate research. TCGA, in the initial phase of effort, which ran from 2005 to 2008, focused on three very poor-prognosis VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 31

34 CME tumor types glioblastoma, lung cancer, and ovarian cancer to initiate this multiplatform analysis. A $50 million investment was utilized to get this work up and running. During phase 2, which was initiated in 2009, the work has continued to expand and to include an additional 30 different tumor types. TCGA has contributed very significant information regarding the biology of glioma and glial tumors in glioblastoma, including the characterization of genetic mutations and dysregulated cell signaling pathways in now 2000 to 3000 glioblastoma tumor samples. Glial tumors have been identified by looking at a variety of these different methodologies the genomics, the transcriptomics, proteomics, and methylation profiling which has really given us remarkable insight into the biology and the heterogeneity of these tumors. We have identified many different targetable mutations and dysregulated cell signaling pathways for therapeutic exploitation and dramatically increased our understanding of the biology and the physiology of glial tumors. So, the TCGA I d have to say is probably the most important effort that has contributed to our understanding of the biology of glioblastoma tumors in the last 10 years. Moderator: What targeted agents, immunotherapeutic agents, and vaccines currently being investigated in glioblastoma are of greatest interest to you? Dr. Reardon: We ve gone through several eras of therapeutic intervention, if you will, in the treatment of this disease. In the early 2000s, cytotoxic chemotherapeutics were heavily investigated, and this era of clinical research led to the identification of temozolomide as a chemotherapy that was able to get into the brain and have an impact on glioblastoma. The second era, I think, began, thereafter, looking at some of the locally administered therapies to try to bypass the blood brain barrier and administer therapies directly into the tumor. This led to the development and approval of the carmustine-impregnated polymer wafer Gliadel, which is currently available and utilized, placed in the resection cavity of patients. In this era, there was also a lot of interest in developing therapies locally administered into the tumor by convection-enhanced delivery. The next era of therapeutic development began to take advantage of some of the data identified through the TCGA work, identifying specific mutations that were frequently identified in tumors, as well as dysregulated cell signaling pathways, primarily the PI3K/Akt pathway due to PI3K activation or PTEN loss. And, along with other cancer indications, the era of targeted therapies began for glioblastoma tumors. Not long thereafter, targeting angiogenesis became quite a high level interest, not only for glioblastoma but across the spectrum of different cancer indications. I think that each of these treatment eras has led to a lot of information and a lot of experience in trying to learn how to optimally treat these very challenging tumors. Unfortunately, although a tremendous amount of work evolved evaluating these different eras of therapeutic intervention, their impact on overall outcome for patients with these tumors has been fairly modest. There is still a fair amount of interest in targeted therapies, and the whole idea of precision medicine is evolving further to try to characterize the genetic mutations associated with an individual patient s tumor and match them up with an appropriate drug to target that mutation or dysregulated cell signaling pathway. Anti-angiogenic agents have been extensively evaluated, including in registration studies. And, although these agents have not been associated with an improvement in OS, they have had a significant impact in improving PFS, and I d have to say on quality of life for patients with brain cancer. The most recent era of therapeutic intervention for brain cancer in glioblastoma has focused on immunotherapies, and this is obviously an area where there is a tremendous amount of interest across a spectrum of different cancer indications. A number of immunotherapeutic drugs have now been approved for a variety of different cancer indications. Glioblastoma is not one of them not yet but, several ongoing studies are now evaluating a variety of different novel, innovative vaccine approaches, as well as immunomodulatory agents, such as immune checkpoint inhibitors targeting programmed death 1 (PD-1), programmed death ligand 1 (PD-L1), cytotoxic T lymphocyte antigen 4 (CTLA-4), and others. Very encouraging preclinical work has shown the efficacy of these interventions in immunocompetent syngeneic glioblastoma tumor models, and significant advanced clinical trials are now ongoing, evaluating a number of these therapeutics for patients with both newly diagnosed and recurrent disease. We are anxiously awaiting readouts from these trials, which we should be getting in the next 6 to 12 months, which we hope will put immunotherapy in the standard of care, if you will, for patients with brain cancer, as it has become for other cancer indications like melanoma, lung cancer, renal cancer, bladder cancer, and others. Moderator: Would you discuss the challenges associated with effective drug delivery to patients with glioblastoma? What is the evidence supporting the use of FDA-approved carmustine wafer implantation? Also, what are some of the main drug delivery methods currently under investigation in glioblastoma? For example, what is the status of convection-enhanced delivery? Dr. Reardon: Brain cancer is unique and different from other cancers in that it is not only a very challenging, aggressive, 32

35 CURRENT STANDARDS AND EMERGING APPROACHES IN GLIOBLASTOMA destructive tumor, but it s unique in that we have the blood brain barrier to overcome in order to get therapies delivered to the tumor. I m very envious of my colleagues who focus on leukemia and melanoma and other solid tumors where the drugs can readily be administered orally or intravenously, and you can count on them being delivered effectively to the tumor. The blood brain barrier is a natural protective mechanism that is in place above and beyond what is present in any other organ system to protect the brain from potentially harmful or damaging agents. And that, unfortunately, frequently includes treatments for cancers. Most chemotherapies and biologically-based targeted-therapies are excluded from the central nervous system by the blood brain barrier quite effectively. Brain cancers, like glioblastoma, are remarkably invasive and infiltrative tumors. The reason, which nobody has ever explained, is that they do not metastasize, but they make up for that by being extremely invasive and infiltrative into the adjacent brain tissue. When I see patients in the clinic, I talk to them about their tumor and tell them that it really is composed of two different components. The first part is the main mass that we can see the part that typically lights up with contrast. The blood brain barrier is broken down in the enhancing part of the tumor; that is the reason that contrast persists on delayed imaging. But, in the leading edge of the tumor, where the microscopic cells are infiltrating and invading into the adjacent brain tissue, we can see swelling in some of those areas, but they typically don t demonstrate any contrast uptake. And, that s the part of the tumor the second part of the tumor where the blood brain barrier is relatively intact, which is the leading edge of microscopic infiltrative disease. And, that s the part that really is most threatening to patients because it is where the tumor is growing and advancing and extending, and that s the part that is most challenging to deliver therapies to be effective against this type of cancer. If we can only get therapies into the enhancing part of the tumor, where the blood brain barrier is disrupted and not working properly, it is not going to help patients. The drugs, the treatments, have to effectively get into the nonenhancing, invading, infiltrating part of the tumor if we re really going to have an impact on this disease, and that has not been effectively evaluated for most therapies that are going forward for patients with brain cancer. I think that it is a deficiency that we, in the community, really need to be very proactive in addressing. We have to be more careful and deliberate about evaluating exactly how well therapies are getting into the brain, into the tumor including, and most especially, the leading edge of nonenhancing disease before launching into large heavily resourced trials of therapies. If therapies don t penetrate effectively, they are not going to be effective, and we really should not waste patients time, effort, and resources in evaluating those drugs. So, I think this is a critical area where the field of neuro-oncology needs to focus and put a lot more emphasis as we develop therapies for our patients. I think that one appealing aspect of immunotherapy is that we know that these drugs modulate immune responses against the tumor. The immune response can effectively penetrate into the brain, all areas of the brain, on an as-needed basis, and the blood brain barrier really is not a prohibitive obstacle for that class of therapeutics. Moderator: You and your colleagues published an article in the March 2016 issue of the Journal of Clinical Oncology discussing the association between the use of valproic acid or levetiracetam and survival in patients with newly diagnosed glioblastoma. Would you comment on your findings? Dr. Reardon: There is a lot of interest on the part of patients families, as well as treating clinicians, in trying to utilize approved drugs for repurposed treatment approaches. And, I think that there is particularly a lot of interest fueled by the desperate need to improve outcome for patients with glioblastoma to look at drugs that are approved for other indications to determine if they will have a therapeutic benefit by having an antitumor effect in patients with brain cancer. Historically, there has been a debate as to whether two of the more commonly utilized antiepileptic agents valproic acid, otherwise known as Depakote, and levetiracetam, otherwise known as Keppra have potential anticancer properties that could translate into a therapeutic benefit for patients. There is some preclinical data to suggest valproic acid and levetiracetam, when used in the test-tube and in the Petri dish, and even in orthotopic glioblastoma animal models, could have some antitumor benefit. So, we conducted a large international meta-analysis that evaluated nearly 2000 patients who were enrolled in 4 major randomized glioblastoma trials in newly diagnosed patients and looked at outcome for all of those patients based on whether they were using any valproic acid or levetiracetam during the course of their therapy. This analysis showed that, unfortunately, the use of either of these antiepileptic drugs, although they work well to control and protect patients from seizures, was not associated with any therapeutic benefit in terms of an improved PFS or OS for these patients with newly diagnosed glioblastoma. So, I think that there may be individual subsets of patients with specific subtypes of glioblastoma for whom these agents could potentially be further evaluated, but I think that for the vast majority of patients, these data help to confirm that these are good antiepileptic agents, but unfortunately, they should not be used solely for the purpose of trying to improve outcome of the tumor, be- VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 33

36 CME cause they really do not have a therapeutic benefit. Moderator: Numerous challenges have been identified in the design of glioblastoma clinical trials, including patient selection, monitoring immune and imaging response, and assessment of clinical outcome. Would you comment on the implications of these challenges and what progress has been made to overcome them? Dr. Reardon: Glioblastoma is a very challenging disease that significantly impacts the neurologic function of patients, which translates into difficulties with physical function like movement, strength, dexterity, and balance. In addition, it can affect the ability to communicate with speech and reading and writing. It can affect vision. It can affect cognition being able to think and understand and it can affect behavior by impacting on personality. So, glioblastoma tumors, I think, are very challenging because of the breadth of impact they can have on patients, and that translates into a significant need for caregiver support and assistance for patients going forward. These factors, I think, make it innately very challenging for patients to participate in clinical trials, and that is something we need to work harder to improve to make clinical trials more readily available and doable for patients and families. The only way we re going to move forward and improve outcome for patients with these very challenging tumors is through well-designed clinical trials. But, patients have to be able to get to the treatment centers and be compliant with their checkups and all the tests and other things that need to be done. And, I think that it s just much more challenging for this disease, this cancer indication, than it is for most others because of the impact of the cancer on patients and the increased challenges it poses for caregivers as well. In terms of the actual trials, going forward, we have to be very careful as we design trials to make sure that we are very articulate in the primary question we want to answer in the trial whether it is a phase 1, a phase 2, a phase 3, or even a phase 0 trial. We also need to make sure that the appropriate patients are selected for the trial and that appropriate evaluations are conducted in terms of defining safety, as well as ultimate impact in outcome on the tumor, as the trial proceeds. Evaluating that can be very challenging. We certainly rely on the clinical status of patients, and we have recently worked very hard to develop a scale of neurologic function called a neurologic assessment and neuro-oncology scale that can be readily incorporated into a routine office visit. This scale was designed by a multinational group of experts to help provide a tool that could be used routinely and readily to assess the neurologic function of patients as they proceed with treatment. The scale provides a scorecard of how patients are doing neurologically with their treatment, which is critical and very important. My patients tell me that they want to live longer, but they also prioritize wanting to live well and being able to preserve as much neurologic function as possible. So, for the first time, we have a scale that we can objectively utilize to assess how well we re doing and how well patients are doing in maintaining their neurologic function. And, then, we rely very heavily on imaging. The technology for imaging is improving and advancing, and we need to continue to make this a priority. The evaluation of brain cancers on magnetic resonance imaging (MRI) imaging can be quite challenging, particularly for therapies that can enhance an immune response or cause a fair amount of inflammation. Like immunotherapies and radiation therapy, assessment of what is happening on an MRI scan can be very muddied and difficult to assess if the tumor is actually responding or not. So, it is critical that our neuroradiology colleagues continue to work hard to advance the technology that will better allow us to accurately assess response for our patients going forward with treatment. References 1. Ansstas G, Tran DD. Treatment with tumor-treating fields therapy and pulse dose bevacizumab in patients with bevacizumab-refractory recurrent glioblastoma: a case series. Case Rep Neurol. 2016;8(1):1-9. doi: / Arvold ND, Reardon DA. Treatment options and outcomes for glioblastoma in the elderly patient. Clin Interventions Aging. 2014;9: doi: /CIA.S Cabrera AR, Kirkpatrick JP, Fiveash JB, et al. Radiation therapy for glioblastoma: an ASTRO evidence-based clinical practice guideline. Practical Radiat Oncol (4): doi: /j.prro Kamran N, Calinescu A, Candolfi M, et al. Recent advances and future of immunotherapy for glioblastoma. Expert Opin Biol Ther. 2016;16(10): doi: / McNamara MG, Sahebjam S, Mason WP. Emerging biomarkers in glioblastoma. Cancers (Basel). 2013;5(3): doi: /cancers Mrugala MM, Engelhard HH, Dinh Tran D, et al. Clinical practice experience with NovoTTF-100A system for glioblastoma: The Patient Registry Dataset (PRiDe). Semin Oncol. 2014;41(suppl 6):S4-S13. doi: /j.seminoncol Namba H, Kawaji H, Yamasaki T. Use of genetically engineered stem cells for glioma therapy. Oncol Lett. 2016;11(1): Zhao H, Wang S, Song C, Zha Y, Li L. 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37 CURRENT STANDARDS AND EMERGING APPROACHES IN GLIOBLASTOMA 9. Neagu MR, Reardon DA. An update on the role of immunotherapy and vaccine strategies for primary brain tumors. Curr Treat Options Oncol. 2015;16(11):54. doi: /s Zhou Q, Wang Y, Ma W. The progress of immunotherapy for glioblastoma. Hum Vaccine Immunother. 2015;11(11): doi: / Barnholtz-Sloan JS, Maldonado JL, William VL, et al. Racial/ethnic differences in survival among elderly patients with a primary glioblastoma. J Neurooncol. 2007;85(2): Iwamoto FM, Reiner AS, Panageas KS, Elkin BB, Abrey LE. Patterns of care in elderly glioblastoma patients. Ann Neurol. 2008;64(6): doi: /ana National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Central nervous system cancers. NCCN website. physician_gls/pdf/cns.pdf. Accessed October 25, van Tellingen O, Yetkin-Arik B, de Gooijer MC, Wesseling P, Wurdinger T, de Vries HE. Overcoming the blood-brain tumor barrier for effective glioblastoma treatment. Drug Resist Updat. 2015;19:1-12. doi: /j.drup Frosina G. Advances in drug delivery to high grade gliomas. Brain Pathol. 2016;26(6): doi: /bpa Bienkowski M, Berghoff AS, Marosi C, et al. Clinical neuropathology practice guide : MGMT methylation pyrosequencing in glioblastoma: unresolved issues and open questions. Clin Neuropathol. 2015;34(5): Stupp R, Mason WP, van den Bent MJ, et al; European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005;352(10): Roa W, Kepka L, Kumar N, et al. International Atomic Energy Agency randomized phase III study of radiation therapy in elderly and/or frail patients with newly diagnosed glioblastoma multiforme. J Clin Oncol. 2015;33(35): doi: /JCO Zarnett OJ, Sahgal A, Gosio J, et al. Treatment of elderly patients with glioblastoma: a systematic evidence-based analysis. JAMA Neurol. 2015;72(5): doi: /jamaneurol Cabrera AR, Kirkpatrick JP, Fiveash JB, et al. Radiation therapy for glioblastoma: executive summary of an American Society for Radiation Oncology evidence-based clinical practice guideline. Pract Radiat Oncol. 2016:6(4): doi: /j. prro Xia D, Reardon DA, Bruce JL, Lindeman NI. The clinical implications of inconsistently methylated results from glioblastoma MIGMT testing by replicate methylation-specific PCR. J Mol Diagn. 2016;18(6): doi: /j.jmoldx American Brain Tumor Association. Glioblastoma and malignant astrocytoma. ABTA website. secure/glioblastoma-brochure.pdf. Accessed October 31, Hegi ME. Diserens AC, Godard S, et al. Clinical trial substantiates the predictive value of O-6-methylguanine-DNA methyltransferase promoter methylation in glioblastoma patients treated with temozolomide. Clin Cancer Res. 2004;10(6): Hegi ME, Diserens AC, Gorlia T, et al. MGMT gene silencing and benefit from temozolomide in glioblastoma. N Eng J Med. 2005;352(10): Iaccarino C, Orlandi E, Ruggeri F, et al. Prognostic value of MGMT promoter status in non-resectable glioblastoma after adjuvant therapy. Clin Neurol Neurosurg. 2015;132:1-8. doi: /j.clineuro Berghoff AS, Preusser M. Clinical neuropathology practice guide : MGMT testing in elderly glioblastoma patients yes, but how? Clin Neuropathol. 2012;31(6): Wick W, Platten M, Meisner C, et al; NOA-08 Study Group of Neuro-oncology Working Group (NOA) of German Cancer Society. Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in the elderly: the NOA-08 randomised, phase 3 trial. Lancet Oncol. 2012;13(7): doi: /S (12)70164-X. 28. Malmstrom A, Gronberg BH, Marosi C, et al; Nordic Clinical Brain Tumour Study Group (NCBTSG). Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomized, phase 3 trial. Lancet Oncol. 2012;13(9): Xie H, Tubbs R, Yang B. Detection of MGMT promoter methylation in glioblastoma using pyrosequencing. Int J Clin Exp Pathol. 2015;8(1): Friedman HS, Prados MD, Wen PY, et al. Bevacizumab alone and in combination with irinotecan in recurrent glioblastoma. J Clin Oncol. 2009;27(28): doi: / JCO Kreisl TN, Kim L, Moore K, et al. Phase II trial of single-agent bevacizumab followed by bevacizumab plus irinotecan at tumor progression in recurrent glioblastoma. J Clin Oncol. 2009;27(5): doi: /JCO Zuniga RM, Torcuator R, Jain R, et al. Rebound tumour progression after the cessation of bevacizumab therapy in patients with recurrent high-grade glioma. J Neurooncol. 2010;99(2): doi: /s Kanner AA, Wong ET, Villano JL, Ram Z, on behalf of the EF-11 Investigators. Post hoc analyses of intention-to-treat VOL. 12, NO. 11 THE AMERICAN JOURNAL OF HEMATOLOGY/ONCOLOGY 35

38 CME population in phase III comparison of NovoTTF-100A System versus best physician s choice chemotherapy. Semin Oncol. 2014;41(suppl 6):S25-S34. doi: /j.seminoncol Carmustine implant [package insert]. Eisai, Inc: Woodcliff Lake, NJ; August Brem H, Piantadosi S, Burger PC, et al. Placebo-controlled trial of safety and efficacy of intraoperative controlled delivery by biodegradable polymers of chemotherapy for recurrent gliomas. The Polymer-brain Tumor Treatment Group. Lancet. 1995;345(8956): Chowdhary SA, Ryken T, Newton HB. Survival outcomes and safety of carmustine wafers in the treatment of high-grade gliomas: a meta-analysis. J Neurooncol. 2015;122(2): doi: /s Lok E, Swanson KD, Wong ET. Tumor treating fields therapy device for glioblastoma: physics and clinical practice considerations. Expert Rev Med Devices. 2015;12(6): doi: / U.S. Food and Drug Administration. FDA approves expanded indication for medical device to treat a form of brain cancer. October FDA website. NewsEvents/Newsroom/PressAnnouncements/ucm htm. Accessed November 6, Optune [instructions for use]. Novocure. Document number:qsd-qr-703. Revision 01. Issue date: July Stupp R, Wong ET, Kanner AA, et al. NovoTTF-100A versus physician s choice chemotherapy in recurrent glioblastoma: a randomized phase III trial of a novel treatment modality. Eur J Cancer. 2012;48(14): doi: /j ejca Happold C, Gorlia T, Chinot O, et al. Does valproic acid or levetiracetam improve survival in glioblastoma? A pooled analysis of prospective clinical trials in newly diagnosed glioblastoma. J Clin Oncol. 2016;34(7): doi: / JCO National Cancer Institute. Genomic understanding of glioblastoma expanded. October National Cancer Institute website. Accessed November 8, National Cancer Institute. Glioblastoma multiforme. January National Cancer Institute website. gov/cancersselected/glioblastomamultiforme. Accessed October 27, The Cancer Genome Atlas Research Network. Comprehensive genomic characterization defines human glioblastoma genes and core pathways. Nature. 2008;455(7216): doi: / nature Brennan CW, Verhaak RG, McKenna A, et al; TCGA Research Network. The somatic genomic landscape of glioblastoma. Cell. 2013;155(2): doi: /j.cell Preusser M, Lim M, Hafler DA, Reardon DA, Sampson JH. Prospects of immune checkpoint modulators in the treatment of glioblastoma. Nat Rev Neurol. 2015;11(9): doi: / nrneurol Desai R, Suryadevara CM, Batich KA, Farber SH, Sanchez-Perez L, Sampson JH. Emerging immunotherapies for glioblastoma. Expert Opin Emerg Drugs. 2016;21(2): doi: / Swartz AM, Li QJ, Sampson JH. Rindopepimut : a promising immunotherapeutic for the treatment of glioblastoma multiforme. Immunotherapy. 2014;6(6): doi: /imt

39 Call for Papers For immediate consideration, send a cover letter, manuscript complete with references, graphs, and artwork to Anthony Berberabe (aberberabe@mjhassoc.com). Volume 12 Number Researchers who are interested in publishing their work should consider The American Journal of Hematology/Oncology. The rapid pace of discovery in the field of oncology presents practicing oncologists with the difficult challenge of implementing novel research findings into clinical practice. To accelerate the translation of academic advances to communitybased practice, The American Journal of Hematology/ Oncology aims to provide practical interpretations of the latest advances in medical and hematologic oncology and to help practicing oncologists gain a better understanding of how these advances are changing the treatment landscape for both solid and hematologic malignancies. OF FF JO URNAL of THE O ICIAL R BREAS T CANCE METAS TATIC Articles of interest include: Original research Reviews State-of-the-Art Updates Emerging Guidelines Editorials and perspectives Pivotal Trials New Technologies Case Reports Detailed descriptions of each category can be found in the Instructions for Authors at ent Assessing Treatm atic Breast Cancer Response in Metast Shlomit Strulov METASTATI C BRE AST ajho The editors are pleased to consider manuscripts on a wide range of topics related to the journal s mission. A Peer -Rev iewe d Reso urce for Onco logy Educ ation The Shachar, MD, and Hyman B. Muss, CAN CER Assessing Treatme nt Response in Met astatic Breast Can har, MD, and cer Shlomit Strulov Shac Hyman B. Muss, MD MA LE BRE AST CAN CER Case Report: Mal e Breast Cancer Lucy R Khan, BSc (Hons) MB ChB MRC SEd, and J. Michael ChB MD FRCS FRCS Dixon, BSc (Hons) Ed FRCPEd OBE MB FOL LIC UL AR LYM How to Refine Trea PHO MA tment Choice in Follicular Lympho From Low-Tumor Burden to High-R ma: isk Follicular Lym Peter A. Riedell, MD, phoma and Brad S. Kahl, MD THR OM BOC Y TOP ENI A Complement Bloc kad Refractory Immune e with C1 Esterase Inhibitor in Thrombocytopenia Erin Roesch, MD, and Catherine Broome, MD BRE AST CAN CER CME-certified enduri ng materials sponso red by Physicians Education Resource Recent Developm, LLC ents in the Treatme nt of HER2Positive Breast Can cer MD ly utili FO zed in LL IC more assessi UL AR of LY MP treatm the GEL ng tumor HO MA F criter ent as bu oppo ia are rden. Patie sed to m Appr a W/W ore likely nts who ha oach rbor approa to requ to th The 1 ire or e Pa di ch. 7 immed disease, they of an agnosis of tient W positive metastatic iate HER2ith TA with clasen FL one Newly large BL sh therapy in women on survival. In be re Pr og E 1. Fo Diag served d lymph ould be very modest effects were or who none no no ba had women ISSN cu no sed FL st ic 163lli(print) have that periton for ca sed on de, wh In de la r Ly m se and colleagues found an ex ile a x arac and early 1900s ph om Abstract ISSNCh a nodu eal nodes). s withou sic study, Bloom terist cisio core 274 in the late 1800s 7 a In t most ic (online) te rn Age sed with breast cancer l of 2.7 years. We tectu lar growth On histolo easily acce needle bi nal biopsy diagno s incurable, and 00_AJHO_616_ at io Cover.i re ndd 1 had a median surviva cancer remain op ssi na l gic ev sysprog y, and/ Metastatic breast Stage disco. 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In in ev mo +/.12 n asse DNA is in survival in MBC setting, survival of about ting er y pa mus - MR ap th nority of those treated ssi d in the metastatic major improvements single treatment selecte e or lym t assess di ng a newl propriate. 11 for hepatit ose with po versu r study, after adjust-agen A few studies suggest Regardless of the ent are to manag sease s s5,6 while anothe t ritu is y treatm ph sis of decade di B suggest goals om xim several ag antig burd Single ve and the Symp a, ab l disease An -free interval), over the last en or en, pr nosed FL -agen therapy is palliati tomati of life and contro algor medical es (such as disease Watch e variabl quality improv es t e pa ritu other en cingly or improv co c for ith /W ms, tie ment ximab ce of -mor depicte m ait agents convin prevent sympto physical, psychologic, versu sympt nt, practit s.4 Most newer d in Ta for approa bidities, s R-che least amount of on of chemotherthe om no major change io with excepti the pa sion mo ne s ching ble 3. attrib progres tient rs +/- MR -2) survival but, with ut newly pr R-che progression-free Ther factor receptor 2(HER mo diagno eference, able to ap MR ind epidermal growth and ag sed FL The ad y for Sym apy and anti-human chem icates ma e. ptom patie other JUNE 2016 atic, signific dition of nts is apy intenance High rit ritux Tum overall ant improv uximab to imab or Bu ; R-ch stand em surviva ered emo, l (OS) ent in prog ard chem rden FL ritux stand imab ard of re ot versu 6 have -base s chem ssion-free herapy ha tra ca d PM 7/28/16 5:21 s led su mide, ditionally re.12,13 Im othera to m py alo rvival (PFS in 16 uxim doxorubicin cluded R- unochem ne an ) ab ot d is co and R-FM, cycloph, vincristi CHOP (ri herapy op nsidos tu ne tions Cancer.indd 6 tastatic Breast these (rituximab phamide,, and pr ximab, cy in FL 01_AJHO_616_Me clo ed three, flu vin ni ph cristi so da os regim 03_AJH ens we rabine, an ne, and ne), R-CV phao_616 P predni re com d _Follicu sone), (ritpared mitoxant lar Lym ro phoma in a ra an jho.co.indd ndom ne). 14,15 W d m 16 hen ized fas hion, all JUNE /28/1 6 5:2 2 PM All manuscripts will undergo peer review, and authors of accepted articles will receive a $500 honorarium and will be required to sign an authorship form disclosing any possible conflicts of interest. To submit an article to The American Journal of Hematology/Oncology or if you wish to speak to an editor, please Anthony Berberabe at aberberabe@mjhassoc.com