In NSCLC, large-scale mutational analysis facilitates access to targeted treatments but is still not routinely employed due to significant technological barriers. The Alleanza Contro il Cancro (ACC) network of Italian Cancer Centers developed an affordable targeted sequencing panel for the identification of multiple genetic alterations with potential clinical utility, and designed a prospective multicentric trial to recruit 1000 newly diagnosed advanced NSCLC patients, aiming to i) compare panel performance against a set of externally validated biomarkers, including alterations in standard-of-care (EGFR, ROS1 and ALK) and non-standard-of-care (KRAS, BRAF, MET) biomarkers; ii) identify alterations in a large dataset of driver and potentially actionable genes; iii) correlate genotypes to survival outcomes and toxicity; iv) carry out ancillary studies on additional biomarkers and/or on specific patient groups (e.g. mutational burden, cfDNA, extensive characterization of immunotherapy-treated patients); v) build a centralized data repository for mutation interpretation and clinical recommendation. Through systematic literature mining and ad-hoc developed bioinformatic pipelines we identified: i) a set of 164 potentially actionable genes in solid tumors; ii) additional 18 genes with predicted driver function in NSCLC; iii) 70 actionable fusion transcripts; iii) 141 SNPs associated with pharmacogenomics markers. We designed a custom enrichment panel (∼800 kb target) and compared PCR- and hybridization-based enrichment on semiconductor or by-synthesis sequencing to be subsequently deployed in a large observational trial. Sequencing is decentralized, to allow rapid turnaround time, but raw and processed data are collected in a single informatic infrastructure for centralized quality control and continuous bioinformatic pipeline improvement. PCR/semiconductor sequencing was selected for deployment based on cost and feasibility (2-day, highly automated workflow). 182 patients have been enrolled to date (90% stage IV, 10% IIIB). Of 65 patients with treatment information available, 28 (43%) subsequently received immunotherapy and 13 (20%) targeted therapy. For 56 patients with complete sequencing data, EGFR and KRAS status was concordant in 9/10 and 38/41 cases; discordant cases are being validated with orthogonal methods. Clinically significant MET amplifications were called in 2/2 cases. Remaining target regions did not show pathogenic alterations. Multiple alterations in potentially actionable genes were identified. Large-scale sequencing is reliable, feasible and sustainable across multiple hospitals and provides clinically relevant results. The increased availability of genomic information may result in enhanced access to tailored therapies. Data and sample integration in centralized, shared repositories will allow multiple ancillary studies.

Background: NSCLC is a major cause of cancer-related death in both men and women globally (Ferlay, Steliarova-Foucher et al. 2013). Despite recent advances in early tumor detection, surgical treatment, radio-chemotherapy, and targeted therapy, the NSCLC-related high mortality rate remains a daunting challenge (Jemal, Bray et al. 2011). Since predictive biomarkers are lacking so far, CTC assays have gained interest to assist clinicians in patient management. In NSCLC, CTCs show a different cytokeratin (CK) pattern and a lower expression of full-length Epithelial Cell Adhesion Molecule (EpCAM) compared to other carcinomas (Fong, Seeber et al. 2014). Indeed, 80% of patients were CTC-positive by the EpCAM-independent ISET compared to only 23% by standard CellSearch assay (Krebs, Sloane et al. 2011). We questioned whether we could detect a higher number of CTCs by implementing the standard CellSearch assay with an expanded CK pattern; secondly, we investigated if the implemented assay could better stratify patients' risk. Methods: We evaluated 75 patients, enrolled from December 2012 to February 2015 in the trial no. NCT02407327 (http://www.clinicaltrials.gov). At baseline, we collected two blood draws for performing in parallel the standard and the CK-expanded CTC assay (including CKs 5, 6, 7, 14, and 17). Progression Free Survival (PFS) and Overall Survival (OS) between groups defined by CTC no. < or > 1 cells were compared with the Kaplan-Meier method, and differences were tested with the log-rank test for both standard and CK-expanded assays. Results: We did not find a difference between the percentage of CTC-negative and CTC-positive patients depending on the assay, but, notably, the CK expanded panel identified a discordant CTC status in 21 out of 75 patients (28%) compared to the standard panel. At baseline, CTC-positive patients, as detected with expanded CK panel, had a significant lower median PFS (108 days) than CTC-negative patients (254 days; Kaplan-Meyer, Log-Rank test p = 0.017). Similarly, CTC-positive patients had a significant lower median OS (250 days) than CTC-negative patients (467 days; Kaplan-Meyer, Log-Rank test p = 0.033). Conclusions: The interim analysis demonstrated that the expanded CK panel improves CTC detection and potentially discloses a more aggressive disease. Accrual is ongoing; we will present updated results at the meeting. * This work was supported by grants from Italian Ministry of Health, Proposal No: # GR-2010-2303193A (PI: E. R.).

New oncology drugs in the European Union (EU) are assessed under a centralized procedure by the European Medicines Agency (EMA); however, even if a European marketing authorization (MA) has been granted, this does not imply that the product will be available to patients everywhere in the EU [1.Bergmann L. Enzmann H. Broich K. et al.Actual developments in European regulatory and health technology assessment of new cancer drugs: what does this mean for oncology in Europe.Ann Oncol. 2014; 25: 303-306Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar].In Italy, new provisions on health care have been introduced through the legislative decree nr. 158/2012, so-called Balduzzi Decree, converted by law nr. 189/2012 [2.Paterlini M. Italy's health system reforms on hold.Lancet. 2013; 381: 1085-1086Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Among other things, Italian Agency for Drugs (AIFA) is required by law to MA promptly after the EMA's approval for innovative drugs, also including anticancer agents, even before negotiation begins. Initially, these drugs are not reimbursed and are listed in a newly defined class Cnn, where ‘C’ stands for not reimbursed and ‘nn’ stands for not negotiated. On June 2013 pertuzumab and aflibercet, while on December 2013 regorafenib, were included in the Cnn class and are still waiting for the reimbursement approval.This means that the cost, if sustainable, is covered by the structure in which the drug is prescribed or by the patient. As denounced by the Italian Association of Medical Oncology (AIOM), the Cnn class is resulting in an lower utilization of the new anticancer drugs with a risk of discrimination for the patients.In conclusion, the advantage of an early availability of the new drugs is canceled by the simultaneous absence of certainty of reimbursement, particularly in Italy where the National Health Service (SSN) has historically offered universal coverage with very few restrictions.disclosureThe authors have declared no conflicts of interest. New oncology drugs in the European Union (EU) are assessed under a centralized procedure by the European Medicines Agency (EMA); however, even if a European marketing authorization (MA) has been granted, this does not imply that the product will be available to patients everywhere in the EU [1.Bergmann L. Enzmann H. Broich K. et al.Actual developments in European regulatory and health technology assessment of new cancer drugs: what does this mean for oncology in Europe.Ann Oncol. 2014; 25: 303-306Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. In Italy, new provisions on health care have been introduced through the legislative decree nr. 158/2012, so-called Balduzzi Decree, converted by law nr. 189/2012 [2.Paterlini M. Italy's health system reforms on hold.Lancet. 2013; 381: 1085-1086Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Among other things, Italian Agency for Drugs (AIFA) is required by law to MA promptly after the EMA's approval for innovative drugs, also including anticancer agents, even before negotiation begins. Initially, these drugs are not reimbursed and are listed in a newly defined class Cnn, where ‘C’ stands for not reimbursed and ‘nn’ stands for not negotiated. On June 2013 pertuzumab and aflibercet, while on December 2013 regorafenib, were included in the Cnn class and are still waiting for the reimbursement approval. This means that the cost, if sustainable, is covered by the structure in which the drug is prescribed or by the patient. As denounced by the Italian Association of Medical Oncology (AIOM), the Cnn class is resulting in an lower utilization of the new anticancer drugs with a risk of discrimination for the patients. In conclusion, the advantage of an early availability of the new drugs is canceled by the simultaneous absence of certainty of reimbursement, particularly in Italy where the National Health Service (SSN) has historically offered universal coverage with very few restrictions. disclosureThe authors have declared no conflicts of interest. The authors have declared no conflicts of interest.

Anthracycline-containing chemotherapy (A-CHT) can induce late cardiotoxicity adding a considerable burden to cardiovascular risk. Irradiation of left breast cancer has also been associated to an increased risk of cardiovascular disease. The aim of this observational study is to prove the usefulness of an accurate cardiovascular evaluation in left breast cancer survivors treated with radiotherapy (RT) and A-CHT. Patients with left breast cancer, on follow-up after treatment with A-CHT plus RT in an adjuvant setting, were eligible for this observational study. Patients underwent cardiovascular assessment with myocardial perfusion imaging. Thirty patients were enrolled in the study: mean age at diagnosis 55.8 years; stage: I/III; Er and/or pgR status: positive in 24/30 pts; 3 patients in pre-menopausal status. Twenty-two patients (73.3%) had normal perfusion imaging, 1 patient (3.3%) had a fixed myocardial perfusion defect, 7 patients (23.3%) had reversible myocardial perfusion defects; 1 patient (3%) with normal perfusion scan showed depressed rest and stress LVEF. Only 1 patient had a large defect and underwent coronary angiography and percutaneous coronary intervention. Five patients with small defect showed normal coronary arteries at Multislice Computed Tomography. Cardiovascular follow-up may reveal signs of A-CHT or RT-induced cardiotoxicity. A stress test combined with MPI- and GATED-derived data of ventricular systolic performance after stress can give information on the coronary reserve and the contractile reserve and allow early appropriate treatment.

19618 Background: Protracted infusion of 5FU(PI) increases response rates and reduces toxicity when compared to bolus administration (BA): the mechanism of action of this drug appears to depend on the dose and the schedule of administration. In some trials 5FU was given as a BA: 30% incidence of severe mucositis or diarrhea was observed. These side effect decreased to less than 15% in trials in which 5FU was infused over 30 minutes and even less when the same dose of 5FU was given over 1 hour or over 2 hours. The CMF i.v. schedule with BA of all three drugs in the adjuvant setting of breast cancer has been shown to be associated with frequent gastrointestinal and mielo-toxicity. PI of 5FU in the CMF schedule can reduce toxicity and improve the quality of life. Methods and Results: From July 2003 to October 2006, 95 patients with breast cancer, mean age 56 years (range 40–75) were treated with adjuvant CMF (1, 8 every 28 days) with 5FU PI (1 hour). Toxicity and compliance were compared to those of 75 patients treated in our institution with CMF-5FU BA (10 min). Toxicity was coded by NCI-CTC. We observed that the patients treated with CMF-5FU PI compared to 5FU BA showed G2–3 nausea: 31.5% vs 46%, G2–3 emesis: 26.3% vs 34.6%, G2 diarrhea: 0% vs 2.6%,asthenia: 18.9% vs 33.3%, G2 neutropenia: 21.0% vs 30.6%, G3 neutropenia: 18.9% vs 20.0% ,G4 neutropenia: 9.4% vs 12%,G3–4 mucositis: 12.6% vs 18.6% and hand -foot syndrome 1.0% vs 0%. Compliance in CMF with 5FU PI compared to CMF with 5FU BA was: 6 cycles administered in 92.6% vs 88.0%, day 8 omitted in 11.5% vs 13.3%, dose reduction in 15.7% vs 17.3%. Conclusions: In our experience, 5 FU PI reduces the gastrointestinal toxicity, particularly nausea and emesis compared to BA.We suggest that less toxicity treatment schedule improves the quality of life and is mandatory mainly in frail and elderly patients. No significant financial relationships to disclose.

19539 Background: Peripheral sensory neuropathy is a common side-effect of oxaliplatin based chemotherapy. The neuropathy is cumulative and dose-related. Symptoms include sensory ataxia and dysesthesia of the limbs, mouth, throat and larynx, and may be exacerbated by exposure to cold. Studies suggest that Glutathione (GSH) is neuroprotective against oxaliplatin-induced neuropathy. Methods: From Jan. 2004, 83 consecutive colorectal cancer patients (pts) elegibile to oxaliplatin-based regimen were treated with GSH 1500 mg/mq over a 15-minute infusion period before oxaliplatin. Treatment-related toxicity was evaluated based on National Cancer Institute (NCI) Criteria. Results: After four cycles of chemotherapy, 5 pts (6%) experienced G1 neurotoxicity. After eight cycles, 2 pts (2.4%) experienced G2 sensory neuropathy (duration < 7 days) and 8 (9.6%) pts G1. After 12 cycles, G3 sensory neuropathy was observed in 2 pts (2.4%), G2 in 8 (9.6%) and G1 in 11 pts (13%). Neither G4 sensory neuropathy was registered nor treatment interruption was required. Conclusions: These findings suggest that use of GSH may protect from oxaliplatin-induced neuropathy. In fact, in our series, only 2 (2.4%) pts experienced severe paresthesia interfering with daily activities and none hade permanent sensory loss. However, only a well designed randomised controlled study will definitely prove the protective effect of GSH on oxaliplatin induced neurotoxicity. No significant financial relationships to disclose.