The phase 2 CLL2-BZAG trial tested a measurable residual disease (MRD)-guided combination treatment of zanubrutinib, venetoclax and obinutuzumab after an optional bendamustine debulking in patients with relapsed/refractory CLL. In total, 42 patients were enrolled and two patients with ≤2 induction cycles were excluded from the analysis population per protocol. Patients had a median of one prior therapy (range 1-5), 18 patients (45%) had already received a BTK inhibitor (BTKi), seven patients (17.5%) venetoclax, and of these, five (12.5%) had received both. Fifteen patients (37.5%) had a TP53 mutation/deletion and 31 (77.5%) had unmutated IGHV. With a median observation time of 21.5 months (range 8.0-35.3) the most common adverse events were COVID-19 (n=26 patients), diarrhea (n=15), infusion-related reactions (n=15), thrombocytopenia (n=14), nausea (n=12), fatigue (n=12) and neutropenia (n=12). Two patients had fatal adverse events (COVID-19, fungal pneumonia secondary to COVID-19). After six months of the triple combination all patients responded and 21 (52.5%, 95% confidence interval 36.1%-68.5%) showed uMRD in peripheral blood. In many patients remissions deepened over time with a best uMRD rate of 85%. The best uMRD rate was similar in patients with TP53 aberrations (80%) and patients previously exposed to venetoclax/BTKi (80%). The estimated progression-free and overall survival rates at 18 months were 96% and 96.8%. No patient has yet required a subsequent treatment. In summary, the MRD-guided triple combination of zanubrutinib, venetoclax and obinutuzumab induced deep remissions in a relapsed CLL population enriched for patients previously treated with a BTKi/venetoclax. ClinicalTrials.gov NCT04515238

Background In chronic lymphocytic leukemia (CLL) triple combinations of BTK inhibitors (BTKi), venetoclax (ven) and CD20 antibodies have been tested mostly as first-line treatments and so far sparse data is available on their efficacy in the relapsed/refractory (r/r) setting. In this phase 2 trial, we evaluate the combination of zanubrutinib (zanu), ven and obinutuzumab (obi) in r/r CLL. In order to tailor therapy to the different needs of differently pretreated patients (pts), treatment duration was based on detection of measurable residual disease (MRD). Furthermore, a ctDNA-based MRD monitoring and a ctDNA-based real-time screen of resistance and driver mutations were performed throughout the study. Methods The CLL2-BZAG study evaluated a combination of obi, zanu and ven after an optional debulking with bendamustine in r/r CLL. In the induction, obi was administered 3 times in cycle 1 (days 1/2, 8 & 15) and monthly in cycles 2-6. Zanu was added in cycle 2 and ven in cycle 3 with a dose ramp-up over 5 weeks. Maintenance with continuous zanu and ven and 3-monthly obi was administered either until achievement of a deep remission with undetectable MRD <10 -4 (uMRD) in peripheral blood (PB) or for up to 24 months. The primary endpoint was the uMRD rate by flow cytometry (FCM) in PB at the final restaging (RE, after 6 months of triple therapy). MRD was measured by FCM from PB and by digital droplet PCR (ddPCR) of patient-specific VDJ rearrangements from blood plasma. uMRD was defined as <1 CLL cell/10,000 leukocytes (<10 -4) and no detectable patient-specific VDJ ctDNA. Results Between 11/2020 and 10/2022, 42 pts were enrolled, 2 pts with ≤2 induction cycles were excluded from the analysis population as predefined by the protocol. Median age was 64 years (range 40-82), 32.5% of pts were female. All 40 pts had r/r CLL with a median of 1 prior therapy (range 1-5), 18 pts (45%) had already received a BTKi, 7 pts ven (17.5%), of these 5 pts (12.5%) had received both. Fifteen pts (37.5%) had a del(17p)/ TP53 mutation, 31 (77.5%) had unmutated IGHV and 19 of 38 pts with available information (50%) a complex karyotype. Nineteen pts (47.5%) received bendamustine debulking, 37 pts (92.5%) completed 6 induction cycles and 19 pts (47.5%) have already stopped MRD-guided maintenance treatment with 2 pts who discontinued maintenance early due to adverse events (AEs). With a median observation time of 21.5 months (range 8.0-35.3), 445 AEs were reported, including 90 AEs of CTC grades 3-4. Two pts had fatal AEs (COVID-19, fungal pneumonia secondary to COVID-19). The most common AEs were COVID-19 (n=26 pts), diarrhea (n=15), infusion-related reactions (n=15), thrombocytopenia (n=14), nausea (n=12), fatigue (n=12) and neutropenia (n=12). The most frequent grade ≥3 AEs were neutropenia (n=10 pts), COVID-19 (n=9), thrombocytopenia (n=7) and pneumonia (n=5, Table 1). Two pts had grade ≥3 cardiac AEs (1 pt with grade 3 non-ST-elevation myocardial infarction, 1 pt with 2 AEs of grade 3 atrial fibrillation and a history of atrial fibrillation). At RE all pts responded and 21 (52.5%) showed uMRD in PB ( Figure 1A). In many pts remissions deepened over time, with 34 (85%) achieving uMRD in PB in the course of the study. The proportion of pts with uMRD was similar in pts with TP53 aberrations (80%) and in pts previously exposed to venetoclax and/or BTKi (80%). The estimated PFS and OS rates at 18 months were 96% and 96.8% ( Figure 1B). PFS rates at 18 months were similar for pts with TP53 aberrations (100%) and pts pretreated with BTKi/ven (90%). Two pts had a disease progression per iwCLL criteria, however no pt has yet required a subsequent treatment. Of 22 pts who achieved uMRD and are now off-treatment, only 1 had MRD recurrence (≥10 -4) during follow-up. Serial MRD (FCM) and ctDNA (ddPCR) assessments were done on 281 paired blood/plasma samples throughout the study. At RE, 8 pts who achieved uMRD by FCM still had detectable VDJ ctDNA in blood plasma. Four pts without ctDNA were still MRD positive by FCM at RE. Apart from one PLCG2_S707F mutation that occurred 11 months after the end of treatment, no acquisition of known resistance mutations - in particular in BTK, BCL2 - was observed using ddPCR. Conclusions The time-limited MRD-guided triple combination of zanu, ven and obi induced deep remissions in a r/r CLL population enriched for pts previously treated with BTKi and/or ven. Apart from COVID-19, low rates of infectious AEs were observed and cardiac toxicities were rare.

Doxorubicin represents the standard first-line treatment for metastatic soft-tissue sarcoma. We assessed the efficacy and safety of trofosfamide in elderly patients. In this controlled phase II trial, we randomly (1:2) assigned 120 previously untreated patients with soft-tissue sarcoma, older than 60 years, with an Eastern Cooperative Oncology Group score of 0e2, to receive either doxorubicin for 6 cycles (arm A) or oral trofosfamide (arm B). The primary end-point was a 6-month progression-free rate (PFR) in the experimental arm (clinical trial information: NCT00204568). Between August 2004 and October 2012, forty and 80 patients were randomly assigned to arm A and arm B, respectively, in 16 centres. The median age was 70 years (range, 60-89). The primary study end-point (6-month PFR) was exceeded, with 27.6% in arm B (95% confidence interval [CI], 18.0-39.1) and 35.9% in arm A: (95% CI, 21.2-52.8). Survival data in terms of progression-free survival were 4.3 months (95% CI, 2.2 e6.3) and 2.8 months (95% CI, 1.7-3.6) and in terms of overall survival were 9.8 months (95% CI, 6.7-11.6) and 12.3 months (95% CI, 9.6-16.2), respectively. The number of serious adverse event (SAE) was 59% in arm A and 30.3% in arm B (p = 0.005). Trofosfamide caused more often dyspnoea and low-grade fatigue, whereas with doxorubicin, more often leukocytopenia, neutropenia and mucositis were seen. Discontinuation rates for reasons other than disease progression were 15.4% (arm A) vs. 7.9% (arm B). In an elderly population of patients, oral trofosfamide achieved the estimated primary end-point 6-month PFR and was associated with a favourable toxicity profile compared with doxorubicin. (C) 2019 Elsevier Ltd. All rights reserved.

BACKGROUND:Immuno-oncological (IO) therapies such as PD-1 and PD-L1 antibodies have been introduced in the treatment of advanced non-small cell lung cancer (NSCLC) since 2015 based on randomized trials showing unprecedented advantages in overall survival (OS) with hazard ratios (HRs) between 0.5 and 0.7. The impact of these treatments on OS in routine clinical practice and the role of tumor mass have not been studied.METHODS:557 consecutive patients with inoperable stage III or stage IV NSCLC diagnosed in our certified lung cancer center from 2006 to 2018 were included if they had received at least one line of systemic treatment. OS of immuno-oncologically treated patients (IO patients, n = 144) who received treatment with a PD-1 antibody (nivolumab [n = 77] or pembrolizumab [n = 51]) or a PD-L1 antibody (atezolizumab [n = 4] or durvalumab [n = 12]) was compared to historic controls treated before availability of IO treatment (n = 413) using case-control analysis. IO patients and historic controls were individually matched for stage, performance state, histology, smoking status, gender, age, and initial treatment mode (palliative vs. definitive radio-chemotherapy).RESULTS:Case-control analysis of 91 matched pairs showed significantly longer OS in IO patients compared to historic controls (21.2 vs. 10.9 months, HR 0.526, CI 0.373-0.723). The benefit was more pronounced in patients with lower tumor stage (HR 0.48 [stage III], 0.40 [IVA], 0.63 [IVB]) or smaller tumor size (HR 0.38 [RECIST ≤57 mm], 0.40 [RECIST 58-94 mm], 0.59 [RECIST 95-141 mm], 0.75 [RECIST ≥142 mm]).CONCLUSIONS:IO patients showed significant benefit in OS with HRs comparable to those reported in phase III trials. The benefit tended to be greater in patients with lower tumor mass.

7531 Background: The immunomodulatory drug lenalidomide (len) has shown clinical activity in CLL. It has been associated with an increased rate of second primary malignancies (SPM) in multiple myeloma (MM). In MM degradation of transcription factors Ikaros and Aiolos leads to its anti-tumor activity and T-cell activation; in CLL, its mechanism of action has not been determined yet. In our CLLM1 trial, 2 of 56 pts developed BCR-ABL positive B-ALL during or after len maintenance; there were no B-ALL cases in the placebo group. Methods: We screened all phase III trials using len in CLL pts for reported B-ALL cases, obtained reports of B-ALL cases in CLL from the FDA Adverse Event Reporting System (FAERS) and analysed available data for B-ALL cases in five non-len GCLLSG trials in order to estimate the incidence of B-ALL in CLL pts not exposed to len. In the 2 CLLM1 pts, PCR was performed for detection of BCR-ABL before B-ALL diagnosis and clonal relationships of B-ALL and CLL will be assessed by NGS. Results: In 3 phase III trials (CLLM1, CONTINUUM, ORIGIN) evaluating the use of len in CLL, a total of 846 pts were enrolled, 438 receiving len monotherapy. Five out of 438 pts (1,1%) developed B-ALL during treatment (n = 1) or after discontinuation (n = 4). No B-ALL cases were reported in the control groups including 408 pts. Of the 5 pts, 2 received len as firstline and 3 as maintenance therapy, median length of exposure was 32 months (range 15-47), median age at B-ALL diagnosis was 69 years (range 60-82). Both CLLM1 pts were categorized as ‘high risk’ or ‘very high risk’ according to CLL-IPI, 1 pt featuring a TP53 mutation, both with unmutated IGHV. BCR-ABL could not be detected at any time point before ALL diagnosis, clonal relationship of B-ALL and CLL is currently being analysed. In 2015 pts treated within 5 non-len GCLLSG trials, only 2 cases of B-ALL were identified (0,1%); this underscores the assumption that secondary B-ALL is usually a rare event in CLL. Conclusions: According to a large GCLLSG cohort and in accordance with published data on SPM in CLL, B-ALL is a rare event in CLL patients. In CLL patients treated with len either as firstline or maintenance therapy following chemotherapy, an increased number of B-ALL was observed, the reason for this increase is unknown.

Patients with non-small cell lung cancer (NSCLC) and a prior or synchronous second malignancy are generally excluded from clinical trials. Therefore, little is known on prevalence and prognosis of these patients.

11507 Background: DOX is still the standard in metastatic STS. We assessed the efficacy and safety of oral TRO. Methods: This is a randomized phase 2 trial at 15 german and 1 french centers. We included pts with metastatic high-grade STS, older than 60 yrs of age, with an ECOG of 0-1. They were randomly (1:2) assigned to either (A) DOX (60 or 75 mg/sqm i.v., on day 1, q 22 d for 6 cycles) or arm B (oral TRO, 300 mg, d1-7, then 150mg daily continuously p.o.) as first-line tx. Randomisation was stratified by presence of liver mets, and PS (0 vs 1). Pts were treated until PD or unacceptable toxicity. Primary aim was a 6-months (mos) PFS rate of at least 20 % in Arm B; secondary: safety, ORR, survival. Results: Between 8/04 and 10/12 40 pts were randomly assigned to arm A and 80 to Arm B, median age 70 yrs (60-89). Median duration of f/u of surviving patients was 18.4 mos (range, 3.8-94.7). Median treatment duration was 2.8 mos (0-4.6) in A and 2.8 mos (0.4-41.4) in B. No difference in terms of ORR with 7.7% (1.6-20.9) in arm A and 6.7% (2.2-14.9%) in arm B (p = 0.99); disease control rate (including disease stabilization) (53.8% (95%-CI, 37.2-69.9%) vs. 41.3% (95%-CI, 30.1-53.3%), p = 0.23), PFS (4.3 mos; 95%-CI, 2.2-5.9 vs. 2.8 mos; 95%-CI, 1.6-3.5), p = 0.99) and OS (9.6 mos; 95%-CI, 6.4-11.6 vs. 12.1mos; 95%-CI, 9.5-16.0), p = 0.59) were seen, without difference in ITT- and per-protocol populations. Duration of response lasted 5.0 mos in arm A (range, 1.3-8.0) and 4.0 mos (0-46.6) in arm B; however, in pts achieving a CR or PR duration was longer in favor of cohort B (0 vs. 27.7 mos resp. 4.3 vs. 8.2 mos). Primary study endpoint (6-mos PFR) was 27.6% in Arm B (95%-CI, 18.0-39.1). Safety analyses in 115 pts showed at least one side effect in 97.4% vs. 96.1% pts (p = 0.99); of note, side effects G3-4 were lower in favor of Arm B (59% vs. 30.3%; p = 0.005). TRO caused more often dyspnoe, fatigue (but only minor degree); DOX leukocyto- and neutropenia as well as mucositis, G1-4. Discontinuation rate other than PD was 15.4% vs. 7.9%. Conclusions: In an elderly population of pts who received either standard Dox or oral TRO for metastatic STS, equal median PFS and OS have been achieved. TRO associated with a more favorable toxicity profile. Clinical trial information: 00204568.

Within the EURO-SKI trial, 132 chronic phase CML patients discontinued imatinib treatment. RNA was isolated from peripheral blood in order to analyze the expression of MDR1, ABCG2 and OCT1. ABCG2 was predictive for treatment-free remission in Cox regression analysis. High transcript levels of the ABCG2 efflux transporter (>4.5 parts per thousand) were associated with a twofold higher risk of relapse. Introduction: Tyrosine kinase inhibitors (TKIs) can safely be discontinued in chronic myeloid leukemia (CML) patients with sustained deep molecular response. ABCG2 (breast cancer resistance protein), OCT1 (organic cation transporter 1), and ABCB1 (multidrug resistance protein 1) gene products are known to play a crucial role in acquired pharmacogenetic TKI resistance. Their influence on treatment-free remission (TFR) has not yet been investigated. Materials and Methods: RNA was isolated on the last day of TKI intake from peripheral blood leukocytes of 132 chronic phase CML patients who discontinued TKI treatment within the European Stop Tyrosine Kinase Inhibitor Study trial. Plasmid standards were designed including subgenic inserts of OCT1, ABCG2, and ABCB1 together with GUSB as reference gene. For expression analyses, quantitative real-time polymerase chain reaction was used. Multiple Cox regression analysis was performed. In addition, gene expression cutoffs for patient risk stratification were investigated. Results: The TFR rate of 132 patients, 12 months after TKI discontinuation, was 54% (95% confidence interval [CI], 46%-62%). ABCG2 expression (parts per thousand) was retained as the only significant variable (P=.02; hazard ratio, 1.04; 95% CI, 1.01-1.07) in multiple Cox regression analysis. Only for the ABCG2 efflux transporter, a significant cutoff was found (P=.04). Patients with an ABCG2/GUSB transcript level >4.5 parts per thousand (n=93) showed a 12-month TFR rate of 47% (95% CI, 37%-57%), whereas patients with low ABCG2 expression (<= 4.5 parts per thousand; n=39) had a 12-month TFR rate of 72% (95% CI, 55%-82%). Conclusion: In this study, we investigated the effect of pharmacogenetics in the context of a CML treatment discontinuation trial. The transcript levels of the efflux transporter ABCG2 predicted TFR after TKI discontinuation. (C) 2018 The Authors. Published by Elsevier Inc.

INTRODUCTION:Oncogenic driver mutations activating EGFR, ALK, or BRAF in NSCLC predict sensitivity to specific tyrosine-kinase inhibitors (TKIs). We provide data on prevalence, treatment and survival of driver-mutation positive NSCLC in a predominantly Caucasian population in routine clinical practice.PATIENTS AND METHODS:NSCLC patients diagnosed from 2006-2015 with an EGFR-test result were included (n=265). Testing for EGFR, ALK, or BRAF was performed if specific TKI therapy was considered. Case-control analyses of overall survival (OS) comparing driver-mutation positive and negative patients were performed.RESULTS:44 sensitizing EGFR mutations (17%), 8 ALK translocations (7%, n=111) and 3 BRAF mutations (8%, n=39) were detected in adenocarcinoma or adenosquamous carcinoma. We did not find mutations in tumors without an adenocarcinoma-component. More than 90% of inoperable driver-mutation positive patients received TKI-therapy. Case-control analysis revealed improved OS of driver-mutation positive patients (39.6 vs. 19.4 months, HR 0.51). OS was improved in stage IV patients but not in stage I-III patients.OS of EGFR-TKI treated patients was similar for 1st and 2nd-line EGFR-TKI treatment. Patients not treated with EGFR-TKI had no benefit in OS. Re-biopsies obtained at progression revealed an EGFR-T790M mutation in 73% (n=11). These patients responded to the 3rd-generation EGFR-TKI osimertinib.DISCUSSION:Testing guided by predictive clinical parameters resulted in twice as high rates of mutation-positive patients than expected, and TKI treatment resulted in a strong long-term OS advantage.CONCLUSION:Testing for driver mutations is feasible in routine clinical practice, and identifies patients who benefit from TKI-therapy. OS compares favorably with OS in clinical studies.

Background: Erlotinib is a standard of treatment for metastatic non-small-cell lung cancer after failure of initial therapy. Patient selection based on clinical factors is under discussion. Methods: We analyzed the outcome in relation to clinical factors of 121 consecutive Caucasian patients treated with erlotinib in a routine clinical setting in a comprehensive cancer center and 2 regional oncology centers. Results: For patients with erlotinib treatment at the 1st/2nd/3rd/≧4th line, progression-free survival (PFS) was 4.5/3.5/2.5/3.0 months, and overall survival (OS) was 8.0/8.5/7.8/6.5 months. Patients with adenocarcinoma had an improved PFS, but a similar OS. Never-smokers had longer PFS (7 months) and OS (13 months) than smokers and ex-smokers. Male patients had a slightly longer survival than female patients (PFS 3.0 vs. 2.5 months, OS 8.5 vs. 7.0 months). After adjustment for smoking and histology, the gender difference in OS was significant (adjusted hazard ratio 0.57). Patients with clinically relevant skin toxicity (grade 2, 3) had a significantly prolonged PFS and OS. Patients with partial response on 1st radiological evaluation had a significantly prolonged PFS and OS. Conclusion: Among clinical factors, never-smoking status and male gender predicted a prolonged survival. During treatment, skin toxicity and radiological response were related to better survival.

Recently, mutations of MPL , the gene coding for the thrombopoetin receptor, were demonstrated in ~5% of cases of primary myelofibrosis (PMF) and in ~1% of all cases of essential thrombocytosis (ET).[1][1],[2][2] They represent gain-of-function mutations that confer constitutive activation of the

Recently MPLW515 mutations have been reported in osteomyelofibrosis (OMF) and essential thrombocythemia (ET). To further evaluate this marker for routine diagnostics of CMPD we have analyzed 387 patients (pts) by a melting curve assay and subsequent sequencing of pts with aberrant curves. 97 pts had a diagnosis of ET (79 with unmutated JAK2V617 (V617wt) and 18 with JAK2V617F), 164 had V617wt undefined CMPD with thrombocytosis, 101 had OMF (54 with V617wt and 47 with V617F) and 25 had V617wt/exon12wt polycythemia vera (PV). Overall we detected 3 different mutations in 16 pts: W515L (n=10), W515K (n=5) and a so far undescribed W515S mutation in 1 pt. In 8/97 ET MPLW515 mutations were detected. All 8 pts were V617wt. Thus, the frequency of W515 mutations in V617wt ET was 8/79 (10.1%). In addition, 3/164 (1.8%) CMPD with thrombocytosis were mutated (subsequently classified ET). In OMF MPLW515 mutations were detected in 5 of 54 V617wt pts (9.3%). No MPLW515mut was found in 18 ET and 47 OMF with JAK2V617F and in the 25 V617wt/exon12wt polycythemia vera (PV). In 4 pts the mutation was homozygous (3 W515K, 1 W515L) and all 4 pts were at advanced stage of their disease: 3 OMF 2-6 years (y) after initial diagnosis and 1 ET in transformation 9 y after diagnosis. Mutation/wt ratio in the remaining pts were 10–100% (median: 40%) in ET and 40% in OMF. The female/male ratio in the mutated cases was 9/7. The age was between 30 and 80 y (median 64 y) and thus was in the same range as in V617F mutated ET/OMF (median 65.3 y; n=489) but significantly higher than in V617wt ET/OMF (median 55.6 y; n=410; p