Supplementary Figure 1 shows a schematic of the treatment cycle

447 Background: Pre-clinical data support a hypothesis that DNA methyltransferase inhibition will circumvent cisplatin resistance in various cancers including urothelial carcinoma (UC). SPIRE comprised a previously reported phase Ib dose escalation phase for incurable metastatic solid cancers which established a recommended phase II dose (RP2D) for guadecitabine combined with gemcitabine and cisplatin (GC) chemotherapy (Crabb et al, ESMO Congress 2018, abstract 425P). We now report the SPIRE phase IIa randomised dose expansion phase which tested neoadjuvant treatment of bladder UC. Methods: Patients had T2-4a N0 M0 bladder UC intended for radical treatment. All patients received an investigator choice of 3 or 4 planned, 21-day, GC cycles (cisplatin 70 mg/m 2 , IV, day 8; gemcitabine 1000 mg/m 2 , IV, days 8 and 15). 20 patients were randomised (1:1, open label) to whether they also received guadecitabine 20 mg/m 2 , SC, on days 1 to 5, and G-CSF prophylaxis 300 µg, SC, on days 15 to 21. The primary objective for the expansion phase was to confirm a safe and biologically effective dose and schedule for this combination for future investigation. Circulating cell free DNA LINE-1 promotor methylation was measured as a guadecitabine pharmacodynamic endpoint. Trial registration: ISRCTN 16332228. Funding: Cancer Research UK, Astex Pharmaceuticals. Sponsor: University Hospital Southampton NHS Foundation Trust. Results: Median age was 68 (interquartile range (IQR) 59-72). 19 (95%) patients were male and 17 (85%) had T2 stage. The commonest grade ≥3 adverse events were neutropenia and thrombocytopenia with one or both affecting 6 (60%) patients in each treatment arm (no grade 5 events). One episode of neutropenic fever occurred (guadecitabine arm). Addition of guadecitabine to GC, versus GC alone, resulted in similar cisplatin dose intensity (median total doses 408 mg (IQR 384-435 mg) and 435 mg (IQR 384-435 mg) respectively) but modestly reduced gemcitabine dose intensity (median total doses 10,450 mg (IQR 9,500-11,400) and 12,768 mg (IQR 9,500-12,768) respectively). All patients completed post-chemotherapy radical treatment (8 cystectomy, 2 radiotherapy, in each arm) with similar timing post chemotherapy and peri-operative morbidity scores. LINE-1 promotor methylation depletion occurred at cycle day 8 in guadecitabine treated patients. Conclusions: Guadecitabine in combination with GC and G-CSF is safe and tolerable in this combination compared to GC alone as neoadjuvant treatment for UC. Radical surgery or radiotherapy delivery, and cisplatin dose intensity, were not compromised. Pharmacodynamic endpoints are optimal with this treatment schedule. Addition of guadecitabine to GC warrants further investigation. Clinical trial information: 16332228.

Abstract Purpose: Preclinical data indicate that DNA methyltransferase inhibition will circumvent cisplatin resistance in various cancers. Patient and Methods: SPIRE comprised a dose-escalation phase for incurable metastatic solid cancers, followed by a randomized dose expansion phase for neoadjuvant treatment of T2–4a N0 M0 bladder urothelial carcinoma. The primary objective was a recommended phase II dose (RP2D) for guadecitabine combined with gemcitabine and cisplatin. Treatment comprised 21-day gemcitabine and cisplatin cycles (cisplatin 70 mg/m2, i.v., day 8 and gemcitabine 1,000 mg/m2, i.v., days 8 + 15). Guadecitabine was injected subcutaneously on days 1–5, within escalation phase cohorts, and to half of 20 patients in the expansion phase. Registration ID: ISRCTN 16332228. Results: Within the escalation phase, dose-limiting toxicities related predominantly to myelosuppression requiring G-CSF prophylaxis from cohort 2 (guadecitabine 20 mg/m2, days 1–5). The most common grade ≥3 adverse events in 17 patients in the dose-escalation phase were neutropenia (76.5%), thrombocytopenia (64.7%), leukopenia (29.4%), and anemia (29.4%). Addition of guadecitabine to gemcitabine and cisplatin in the expansion phase resulted in similar rates of severe hematologic adverse events, similar cisplatin dose intensity, but modestly reduced gemcitabine dose intensity. Radical treatment options after chemotherapy were not compromised. Pharmacodynamics evaluations indicated guadecitabine maximal target effect at the point of cisplatin administration. Pharmacokinetics were consistent with prior data. No treatment-related deaths occurred. Conclusions: The guadecitabine RP2D was 20 mg/m2, days 1–5, in combination with gemcitabine and cisplatin and required GCSF prophylaxis. Gene promoter methylation pharmacodynamics are optimal with this schedule. Addition of guadecitabine to gemcitabine and cisplatin was tolerable, despite some additional myelosuppression, and warrants further investigation to assess efficacy.

We would like to thank Liepe [1] for his interest in our recent article and giving us the opportunity to further expand upon some additional aspects of the study [2].The data used for the present study [2] belong to two National Institute of Health (NIH) funded activity escalation phase I [3] and fixed administered activity phase II [4] clinical trials.A total of 57 patients were recruited between 1996 and 2003, before availability of 223 Ra-dichloride or chemotherapy agents such as docetaxel and/or abiraterone.The aims of these trials were to investigate the feasibility and toxicity profile of high administered activities of 186 Re-HEDP and autologous peripheral blood stem cell transplantation (PBSCT) in patients with castration-resistant prostate cancer metastatic to bone (mCRPC).The results of these studies were previously pub-

5024 Background: Ra-223 improves overall survival in patients with mCRPC. Imaging criteria to assess response in bone are lacking but could inform treatment strategies. Methods: We did a prospective phase II study to evaluate potential response biomarkers to Ra-223. Patients with chemotherapy-naïve, bone mCRPC were randomised (1:1) to receive Ra-223 at 55 or 88 kBq/kg for 6 cycles, at 4-week intervals. WB-DWMRI was done at baseline, at cycles 2 and 4, and 1 month post-treatment. MRI response was defined as a 30% increase in the mean of the mean Apparent Diffusion Coefficient (ADC) using up to 5 target lesions. PSA response was defined per PCWG2 criteria. Circulating tumour cells (CTC) response was defined as decrease from ≥5 cells/7.5ml to < 5/7.5ml. Results: 27 evaluable patients received a median of 6 cycles of Ra-223. Overall MRI response was seen in 56% (15/27), PSA response in 11% (3/27) and CTC response in 55% (5/9) evaluable patients. There was an association between the greatest percentage increase in ADC and greatest percentage decline in PSA during treatment, rho = -0.59; p = 0.001. Responders on MRI received higher administered activity per cycle of Ra-223 than non-responders (median 5840kBq versus 4820kBq; rank sum test p = 0.04). Discordant ADC response, with both response (ADC ≥30% increase) and non-response (ADC < 30% increase) in different bone metastases, was seen in 44% (12/27) of patients. New bone metastases were seen during the treatment period in 67% (18/27), including 60% (9/15) who had an overall response by MRI. Four patients developed 11 new fractures in uninvolved bone during the treatment period. Conclusions: WB-DWMRI demonstrates marked inter- and intra-patient heterogeneity of response to Ra-223, and a dose-response relationship. Both new bone metastases, and fractures in uninvolved bone, are common during treatment. Future research should aim to test the role of Ra-223 dose-escalation, of intermittent treatment and of combination therapy with bone health agents. Clinical trial information: ISRCTN17805587.

Objective: The aim of this study was to calculate the range of absorbed doses that could potentially be delivered by a variety of radiopharmaceuticals and typical fixed administered activities used for bone pain palliation in a cohort of patients with metastatic castration-resistant prostate cancer (mCRPC). The methodology for the extrapolation of the biodistribution, pharmacokinetics and absorbed doses from a given to an alternative radiopharmaceutical is presented. Methods: Sequential single photon emission CT images from 22 patients treated with 5 GBq of 186Re-HEDP were used to extrapolate the time–activity curves for various radiopharmaceuticals. Cumulated activity distributions for the delivered and extrapolated treatment plans were converted into absorbed dose distributions using the convolution dosimetry method. The lesion absorbed doses obtained for the different treatments were compared using the patient population distributions and cumulative dose–volume histograms. Results: The median lesion absorbed doses across the patient cohort ranged from 2.7 Gy (range: 0.6–11.8 Gy) for 1100 MBq of 166Ho-DOTMP to 21.8 Gy (range: 4.5–117.6 Gy) for 150 MBq of 89Sr-dichloride. 32P-Na3PO4, 153Sm-EDTMP, 166Ho-DOTMP, 177Lu-EDTMP and 188Re-HEDP would have delivered 41, 32, 85, 20 and 64% lower absorbed doses, for the typical administered activities as compared to 186Re-HEDP, respectively, whilst 89Sr-dichloride would have delivered 25% higher absorbed doses. Conclusion: For the patient cohort studied, a wide range of absorbed doses would have been delivered for typical administration protocols in mCRPC. The methodology presented has potential use for emerging theragnostic agents. Advances in knowledge: The same patient cohort can receive a range of lesion absorbed doses from typical molecular radiotherapy treatments for patients with metastatic prostate cancer, highlighting the need to establish absorbed dose response relationships and to treat patients according to absorbed dose instead of using fixed administered activities.

Purpose To investigate the role of patient-specific dosimetry as a predictive marker of survival and as a potential tool for individualised molecular radiotherapy treatment planning of bone metastases from castration-resistant prostate cancer, and to assess whether higher administered levels of activity are associated with a survival benefit. Methods Clinical data from 57 patients who received 2.5 – 5.1 GBq of 186 Re-HEDP as part of NIH-funded phase I/II clinical trials were analysed. Whole-body and SPECT-based absorbed doses to the whole body and bone lesions were calculated for 22 patients receiving 5 GBq. The patient mean absorbed dose was defined as the mean of all bone lesion-absorbed doses in any given patient. Kaplan – Meier curves, log-rank tests, Cox ’ s proportional hazards model and Pearson ’ s correlation coefficients were used for overall survival (OS) and correlation analyses. Results A statistically significantly longer OS was associated with administered activities above 3.5 GBq in the 57 patients (20.1 vs 7.1 months, hazard ratio: 0.39, 95 % CI: 0.10 – 0.58, P = 0.002). A total of 379 bone lesions were identified in 22 patients. The mean of the patient mean absorbed dose was 19 (±6) Gy and the mean of the whole-body absorbed dose was 0.33 (±0.11) Gy for the 22 patients. The patient mean absorbed dose ( r = 0.65, P = 0.001) and the whole-body absorbed dose ( r = 0.63, P = 0.002) showed a positive correlation with disease volume. Significant differences in OS were observed for the univariate group analyses according to disease volume as measured from SPECT imaging of 186 Re-HEDP ( P = 0.03) and patient mean absorbed dose ( P = 0.01), whilst only the disease volume remained significant in a multivariable analysis ( P = 0.004). Conclusion This study demonstrated that higher administered activities led to prolonged survival and that for a fixed administered activity, the whole-body and patient mean absorbed doses correlated with the extent of disease, which, in turn, correlated with survival. This study shows the importance of patient stratification to establish absorbed dose – response correlations and indicates the potential to individualise treatment of bone metastases with radiopharmaceuticals according to patient-specific imaging and dosimetry.

Background: The neutrophil to lymphocyte ratio (NLR) has been shown to be highly prognostic across many tumor types, and predictive of treatment outcome in advanced prostate cancer, and has been postulated to be an indirect measure of tumor inflammation. We evaluated the effect of low-dose steroids on NLR in men suffering from castrationresistant prostate cancer (CRPC). Patients and Methods: The NLR was evaluated in a prospective randomized phase II trial that compared prednisolone 5 mg twice daily and dexamethasone 0.5 mg daily administered to 75 chemotherapy and abiraterone/enzalutamide-naive CRPC patients. NLR was examined at baseline (BL), after 6 and 12 weeks of corticosteroid treatment; associations with > 50% prostate-specific antigen (PSA) response, duration of response (PSA progression-free interval), and overall survival (OS) were tested using logistic regression and Cox regression analysis. Results: The median NLR for all evaluable patients was 2.6 at BL; 2.9 at 6 weeks; and 4.0 at 12 weeks. After low-dose corticosteroid initiation, 46 patients had a decline in PSA with 24 confirmed responders. BL NLR (log10) associated with a PSA response (odds ratio,.029, 95% confidence interval [CI],.002-. 493; P = .014), and with the extent of the PSA decline (P = .009). A favorable BL NLR (less than median) associated with a 5.5-fold higher odds of a PSA > 50% response (95% CI, 1.3-23.9; P = .02). Higher BL NLR (log10) associated with a shorter time to PSA progression (hazard ratio [HR], 9.5; 95% CI, 2.3-39.9; P = .002). In multivariate analysis BL NLR as a discrete variable was independently associated with PSA progression (HR, 3.5; 95% CI, 1.5-8.1; P = .003). NLR at 6 weeks was also associated with duration of benefit; in the favorable NLR category time to PSA progression was 10.8 months, for those who converted to an unfavorable (greater than median) category 4.5 months, and for those remaining in a unfavorable category only 1.5 months (95% CI, 0.5-2.5; P = .003). OS was 33.1 months (95% CI, 24.2-42.0) and 21.9 months (95% CI, 19.3-24.4) for those with an favorable and unfavorable BL NLR, respectively. Conclusion: Treatment-naive CRPC patients with a high BL or during-treatment NLR appear not to benefit from low-dose corticosteroids. The immunological implications of an unfavorable NLR, and whether corticosteroids might drive prostate cancer progression in patients harboring a high NLR, warrant further study. (C) 2017 Elsevier Inc. All rights reserved.

Skeletal tumour burden is a biomarker of prognosis and survival in cancer patients. This study proposes a novel method based on the linear quadratic model to predict the reduction in metastatic tumour burden as a function of the absorbed doses delivered from molecular radiotherapy treatments.The range of absorbed doses necessary to eradicate all the bone lesions and to reduce the metastatic burden was investigated in a cohort of 22 patients with bone metastases from castration- resistant prostate cancer. A metastatic burden reduction curve was generated for each patient, which predicts the reduction in metastatic burden as a function of the patient mean absorbed dose, defined as the mean of all the lesion absorbed doses in any given patient. In the patient cohort studied, the median of the patient mean absorbed dose predicted to reduce the metastatic burden by 50% was 89 Gy ( interquartile range: 83-105 Gy), whilst a median of 183 Gy (interquartile range: 107-247 Gy) was found necessary to eradicate all metastases in a given patient. The absorbed dose required to eradicate all the lesions was strongly correlated with the variability of the absorbed doses delivered to multiple lesions in a given patient (r = 0.98, P < 0.0001). The metastatic burden reduction curves showed a potential large reduction in metastatic burden for a small increase in absorbed dose in 91% of patients.The results indicate the range of absorbed doses required to potentially obtain a significant survival benefit. The metastatic burden reduction method provides a simple tool that could be used in routine clinical practice for patient selection and to indicate the required administered activity to achieve a predicted patient mean absorbed dose and reduction in metastatic tumour burden.

To investigate the role of patient-specific dosimetry as a predictive marker of survival and as a potential tool for individualised molecular radiotherapy treatment planning of bone metastases from castration-resistant prostate cancer, and to assess whether higher administered levels of activity are associated with a survival benefit.

The aim of this single-site, open-label clinical trial was to determine the biodistribution, pharmacokinetics, absorbed doses, and safety from 2 sequential weight-based administrations of 223Ra-dichloride in patients with bone metastases due to castration-refractory prostate cancer. Methods: Six patients received 2 intravenous injections of 223Ra-dichloride, 6 wk apart, at 100 kBq/kg of whole-body weight. The pharmacokinetics and biodistribution as a function of time were determined, and dosimetry was performed for a range of organs including bone surfaces, red marrow, kidneys, gut, and whole body using scintigraphic imaging; external counting; and blood, fecal, and urine collection. Safety was assessed from adverse events. Results: The injected activity cleared rapidly from blood, with 1.1% remaining at 24 h. The main route of excretion was via the gut, although no significant toxicity was reported. Most of the administered activity was taken up rapidly into bone (61% at 4 h). The range of absorbed doses delivered to the bone surfaces from α emissions was 2,331–13,118 mGy/MBq. The ranges of absorbed doses delivered to the red marrow were 177–994 and 1–5 mGy/MBq from activity on the bone surfaces and from activity in the blood, respectively. No activity-limiting toxicity was observed at these levels of administration. The absorbed doses from the second treatment were correlated significantly with the first for a combination of the whole body, bone surfaces, kidneys, and liver. Conclusion: A wide range of interpatient absorbed doses was delivered to normal organs. Intrapatient absorbed doses were significantly correlated between the 2 administrations for any given patient. The lack of gastrointestinal toxicity is likely due to the low absorbed doses delivered to the gut wall from the gut contents. The lack of adverse myelotoxicity implies that the absorbed dose delivered from the circulating activity may be a more relevant guide to the potential for marrow toxicity than that due to activity on the bone surfaces.

We report on the immunogenicity and clinical effects in a phase I/II dose escalation trial of a DNA fusion vaccine in patients with prostate cancer. The vaccine encodes a domain (DOM) from fragment C of tetanus toxin linked to an HLA-A2-binding epitope from prostate-specific membrane antigen (PSMA), PSMA(27-35). We evaluated the effect of intramuscular vaccination without or with electroporation (EP) on vaccine potency. Thirty-two HLA-A2(+) patients were vaccinated and monitored for immune and clinical responses for a follow-up period of 72 weeks. At week 24, cross-over to the immunologically more effective delivery modality was permitted; this was shown to be with EP based on early antibody data, and subsequently, 13/15 patients crossed to the +EP arm. Thirty-two HLA-A2(-) control patients were assessed for time to next treatment and overall survival. Vaccination was safe and well tolerated. The vaccine induced DOM-specific CD4(+) and PSMA(27)-specific CD8(+) T cells, which were detectable at significant levels above baseline at the end of the study (p = 0.0223 and p = 0.00248, respectively). Of 30 patients, 29 had a measurable CD4(+) T-cell response and PSMA(27)-specific CD8(+) T cells were detected in 16/30 patients, with or without EP. At week 24, before cross-over, both delivery methods led to increased CD4(+) and CD8(+) vaccine-specific T cells with a trend to a greater effect with EP. PSA doubling time increased significantly from 11.97 months pre-treatment to 16.82 months over the 72-week follow-up (p = 0.0417), with no clear differential effect of EP. The high frequency of immunological responses to DOM-PSMA(27) vaccination and the clinical effects are sufficiently promising to warrant further, randomized testing.

BACKGROUND:A qualitative assessment of conventional bone scintigraphy with 99mTc methylene diphosphonate is perceived as an insensitive method for monitoring the treatment response of bone metastases, and we postulated that semi-quantitative 18F-fluoride positron emission tomography (PET) might serve as a suitable alternative biomarker of the treatment response. METHODS:Five patients with castrate-resistant prostate cancer and bone metastases with no known soft tissue disease received 100 kBq/kg of radium-223 (223Ra)-chloride (Alpharadin) therapy at 0 and 6 weeks and had whole body 18F-fluoride PET scans at baseline, 6 and 12 weeks with concurrent prostatic-specific antigen (PSA) and alkaline phosphatase (ALP) measurements. A qualitative comparison of the PET scans was performed blinded to the PSA and ALP results. A semi-quantitative comparison was made by measuring the maximum standardised uptake values (SUVmax) in five bone metastases in each patient. The means of the five SUVmax measurements in each subject were used as a quantitative measure of global metastatic activity at each time point. RESULTS:Three patients showed a PSA decline at 12 weeks (-44%, -31%, -27% reduction) whilst two patients showed PSA increases (+10%, +17%). All five patients showed a reduction in ALP of greater than 25%. The qualitative assessment of the 18F-fluoride scans recorded a stable disease in each case. However, the semi-quantitative assessment showed agreement with the PSA decline in three patients (-52%, -75%, -49%) and minimal change (+12%, -16%) in two patients with increased PSA at 12 weeks. Four patients showed similar reductions in mean SUVmax and ALP at 12 weeks. CONCLUSIONS:The semi-quantitative 18F-fluoride PET is more accurate than the qualitative comparison of scans in assessing response in bone metastases, correlating with the PSA response and ALP activity and offering a potential imaging biomarker for monitoring treatment response in bone metastases following treatment with 223Ra-chloride.

PURPOSE:To confirm the efficacy of low-dose involved-field radiation therapy (LD-IFRT) as palliative treatment in patients symptomatic from advanced lymphoma.PATIENTS AND METHODS:A total of 36 patients (47 sites), received 4 Gy in 2 fractions to the lymphoma with a 1.5-2-cm margin. Pathology subtypes included 29 (62%) sites with indolent lymphoma and 18 (36%) sites with aggressive lymphoma histology. Bulky disease was seen in 22 (48%) sites and, of these, 6 sites had disease > 10 cm. A median of 3 previous chemotherapy regimens (range, 0 to 9 regimens) preceded LD-IFRT. The primary endpoint of the study was in-field lymphoma control. Patients completed the European Organization for the Research and Treatment of Cancer QLQ-C30 quality of life (QOL) questionnaire before RT and at 3-4 weeks after treatment.RESULTS:The overall response rate (RR) at 1-3 months after the RT was 75%. A complete remission (CR) was observed in 13 patients (36%) lasting up to a maximum of 31.3 months and ongoing at analysis. A partial remission (PR) was achieved in 14 patients (39%) lasting up to 10 months. The response rate for non-diffuse large B-cell lymphoma (DLBCL) sites was 86%, while it was 50% for sites with DLBCL histology. Median time to local progression for the entire group was 15 months. There was no statistical difference between the QOL before and after LD-IFRT.CONCLUSION:LD-IFRT is an effective and easy treatment for patients with advanced lymphoma that can be repeated at previously irradiated sites, a particularly useful attribute because of the relapsing nature, especially of advanced follicular subtypes.

OBJECTIVETo evaluate the utility of lactate dehydrogenase (LDH), a tumour marker that is frequently elevated at diagnosis and relapse of testicular germ cell tumours (TGCTs), in the follow‐up of TGCTs for detecting tumour relapse, as it has role as a prognostic factor but its role in follow‐up is less certain.PATIENTS AND METHODSWe retrospectively reviewed 499 patients with TGCT who were followed from 1 January 2004 to 31 December 2005, with no clinical evidence of disease after a complete response to treatment or on surveillance for stage I disease.RESULTSOf patients attending for follow‐up or surveillance, in 26 of 1777 (1.4%) ‘patient‐visits’ there was a high LDH level related to disease, and in 137 of 1777 (7.7%) such visits there was a high LDH from unrelated causes. Of the 499 patients who were followed, 15 relapsed; the LDH level was high in six of 15 who relapsed, with LDH being one of the first elevated markers in four and the only elevated marker in one (seminoma). Of the 449 patients, 41 (9.1%) had a persistent false‐positive increase in LDH. The sensitivity of LDH was 40%, the specificity 90.5% and the positive predictive value 12.8% to detect relapse of disease during the follow‐up of TGCTs. When the series of 116 relapsed patients from 1992 to 2005 was analysed, an increase in LDH facilitated the detection of relapse in 2% of non‐seminomatous GCTs and 11% of seminomas, independent of other markers.CONCLUSIONLDH has limited sensitivity, specificity and positive predictive value for detecting relapse of TGCT and false‐positive increases are common. An elevated LDH level contributed to the detection in six of 15 relapses, suggesting that its value in the follow‐up of TGCT might be useful if interpreted cautiously. High LDH levels during the follow‐up might require repeat serial LDH estimates to confirm the elevation, and imaging to detect a relapse.