JCO-2006-Jackman-4517-20

HIV and human papillomavirus (HPV)coinfected patients are at high risk of developing precancerous anal lesions (anal intraepithelial neoplasia)and anal malignancies.1The natural history (that is,pro-gression and persistence)of HPV-associated lesions is accelerated by HIV-related immunosuppression,which may result in the reactiva-tion of previously acquired HPV infection and loss of control of HPV viral replication.2The longer life expectancy of these coinfected pa-tients in the era of HAART provides an opportunity for invasive anal carcinoma to develop from its dysplastic precursor.The prognosis of anal squamous cell carcinoma is poor in HIV-positive patients,who often present with advanced tumors.3The appropriate treatment of patients with advanced anal cancer and HIV infection is uncertain.4Concomitant radiation therapy and chemotherapy (?uorouracil and mitomycin-C)is the current standard of care for HIV-negative pa-tients with invasive anal carcinoma,and that approach has been inves-tigated and applied successfully in HIV-positive patients with similar anal cancers,particularly those with CD4?T-lymphocyte counts greater than 200cells/?L.5,6HIV-positive patients with anal cancer treated with HAART tend to fare better than those patients who are not receiving HAART.7It is prudent to point out that our patient never had an anal Papanicolaou (Pap)test (Fig 3,high-grade dysplas-tic squamous cells;ThinPrep,Cytyc Corporation,Marlborough,MA).HIV-associated anal carcinoma appears to mirror cervical car-cinoma in unscreened women,presenting late in the course of the disease and having a protracted,ultimately fatal,course.8Screening of HIV-positive patients for anorectal dysplasia and/or malignancy by means of an anal Pap test could save lives.9

Panagiotis A.Konstantinopoulos,Hans P.Schlecht,and Bradley Bryan

Divisions of Hematology/Oncology and Infectious Diseases,and Department of Pathology,Beth Israel Deaconess Medical Center,Harvard Medical School,Boston,MA

Liron Pantanowitz

Department of Pathology,Baystate Medical Center,Tufts University School of Medicine,Spring?eld,MA Bruce J.Dezube

Beth Israel Deaconess Medical Center,Harvard Medical School,Boston,MA

?2006by American Society of Clinical Oncology

REFERENCES

1.Frisch M,Biggar RJ,Goedert JJ:Human papillomavirus-associated cancers in patients with human immunode?ciency virus infection and acquired immuno-de?ciency syndrome.J Natl Cancer Inst 92:1500-1510,2000

2.Holly EA,Ralston ML,Darragh TM,et al:Prevalence and risk factors for anal squamous intraepithelial lesions in women.J Natl Cancer Inst 93:843-849,2001

3.Vatra B,Sobhani I,Aparicio T,et al:Anal canal squamous-cell carcinomas in HIV positive patients:Clinical features,treatments and prognosis.Gastroenterol Clin Biol 26:150-156,2002

4.Chadha M,Rosenblatt EA,Malamud S,et al:Squamous-cell carcinoma of the anus in HIV-positive patients.Dis Colon Rectum 37:861-865,1994

5.Bartelink H,Roelofsen F,Eschwege F,et al:Concomitant radiotherapy and chemotherapy is superior to radiotherapy alone in the treatment of locally advanced anal cancer:Results of a phase III randomized trial of the European Organisation for Research and Treatment of Cancer Radiotherapy and Gastroin-testinal Cooperative Groups.J Clin Oncol 15:2040-2049,1997

6.Flam M,John M,Pajak TF,et al:Role of mitomycin in combination with ?uorouracil and radiotherapy,and of salvage chemoradiation in the de?nitive nonsurgical treatment of epidermoid carcinoma of the anal canal:Results of a phase III randomized intergroup study.J Clin Oncol 14:2527-2539,1996

7.Kim JH,Sarani B,Orkin BA,et al:HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients.Dis Colon Rectum 44:1496-1502,2001

8.Leiman G:Anal screening cytology.Cytojournal 2:5,2005

9.Panther LA,Schlecht HP,Dezube BJ:Spectrum of human papillomavirus-related dysplasia and carcinoma of the anus in HIV-infected patients.AIDS Read 15:79-82,2005

DOI:10.1200/JCO.2006.06.2224

■■■

Authors’Disclosures of Potential Con?icts of Interest

The authors indicated no potential con?icts of interest.

Response and Resistance in a Non–Small-Cell Lung Cancer Patient With an Epidermal Growth Factor Receptor Mutation and Leptomeningeal Metastases Treated With

High-Dose Ge?tinib

A53-year-oldwhitemanwithnopreviouscigarettesmokinghistory

presentedwithstageIVadenocarcinomaofthelung,witha2-cmprimary

Fig

Fig 3.

tumor in the right lower lobe,a malignant right pleural effusion,medias-tinal adenopathy,and metastases to liver and bone in January2004.The patient achieved a partial response to six cycles of treatment with carbo-platin,paclitaxel,and ge?tinib at the recommended dose of250mg/d. DNA sequencing of his tumor specimen obtained before treatment re-vealed a deletion mutation in exon19(2239_2247delTTAAGAGAA)of the epidermal growth factor receptor(EGFR).This mutation has been associated with sensitivity to treatment with ge?tinib.1A tumor cell line, DFCILU-011,was established from the pleural effusion in this patient, and in vitro drug testing showed the cell line had an IC50of10to50 nmol/L to ge?tinib.1,2Repeat evaluation in June2004showed develop-ment of multiple brain metastases despite systemic control of his non–small-cell lung cancer.The patient continued ge?tinib treatment while receiving whole-brain radiation therapy to a total dose of40Gy.In Sep-tember2004,the patient developed word-?nding dif?culty and a tremor in his left hand.Evaluation by chest and abdominal computed tomogra-phy showed that his systemic disease was stable,but a brain magnetic resonance imaging in September2004(Fig1A)demonstrated evidence of progressive intracranial metastases(Fig1A;dashed arrows),new leptomeningeal involvement(Fig1A;open arrows),and enhance-ment of the seventh and eighth nerve complex in the left auditory canal(Fig1A;solid arrow).A lumbar puncture in September2004 showed adenocarcinoma cells in the CSF.Oral temozolomide and intrathecal liposomal cytarabine were added to his ge?tinib regimen. The ge?tinib was administered at an increased dose of500mg/d.In mid-November2004,an Ommaya reservoir was placed to facilitate intrathecal drug administration and to control increased intracranial pressure by withdrawing CSF.After completing2months of temozo-lomide and four doses of intrathecal liposomal cytarabine in late November2004,the patient had some reduction in the size of his brain metastases,but his leptomeningeal metastases persisted.His clinical course was also complicated by seizures,orthostatic hypotension, thrombocytopenia,and a decline in his performance status to a Euro-pean Cooperative Oncology Group performance status of3that led to a hospital admission.The symptoms were attributed to toxicity from temozolomide administration and persistent leptomeningeal metas-tases.Therefore,temozolomide and intrathecal cytarabine treatment were discontinued.The CSF concentration of ge?tinib on the dose of 500mg/d was examined using previously described methods3but at neutral pH;the ge?tinib concentration was6.2and18nmol/L—less than the level needed to inhibit the growth of his lung cancer cell line (DFCI-LU011)in vitro.1,2Considering these observations,the patient provided informed consent to increasing the ge?tinib dose in the hopes of achieving inhibitory concentrations of ge?tinib in the CSF. His ge?tinib dose was increased from500mg/d to750mg/d and then

to1,000mg/d over a period of10weeks.The resulting CSF con-centrations of ge?tinib increased and were measured to be as high as 42nmol/L.Table1displays the correlation between ge?tinib dose and CSF ge?tinib concentrations.At the highest ge?tinib CSF concentra-tion,two consecutive cytologic examinations of the CSF revealed no evidence of malignant cells.As the carcinomatous meningitis im-proved both radiographically and cytologically,the patient noted a concomitant improvement in his symptoms of headache and tremor. His attention span and memory improved,and he was able to return to work.Repeat magnetic resonance imaging in December2004(Fig 1B)showed marked improvement,with only a minimal amount of leptomeningeal enhancement(Fig1B;solid arrows).With ge?tinib administered at such high doses,the patient eventually demonstrated somnolence and rising hepatic transaminases,previously described adverse effects of ge?tinib as determined in phase I trials.4,5The ge-?tinib dose was decreased to500mg,and his somnolence and transaminase elevations improved.Cytology from a repeat lumbar puncture in late January2005documented recurrent leptomeningeal metastases.His ge?tinib dosage was again increased to1,250mg daily for2weeks,achieving a serum ge?tinib concentration of3,730nmol/L and a corresponding CSF concentration of39.4nmol/L.Despite these changes,the patient’s condition continued to deteriorate,complicated by a deep vein thrombosis,urinary tract infection,and progression of disease in the lungs and liver.He died in March2005from progres-sive non–small-cell lung cancer.Postmortem examination of the tu-mor cells from?ve metastatic sites(intestine,lung,liver,and two A

Fig1.

leptomeningeal specimens)were collected and analyzed for EGFR mutations in exons 18to 21using endonuclease digestion followed by analysis using the Transgenomic WAVE Nucleic Acid High Sensitivity Fragment Analysis System (WAVE HS;Transgenomic Inc,Cam-bridge,MA).6This platform has been studied prospectively and has a 100%sensitivity and 87%speci?city for detecting EGFR mutations.All ?ve specimens demonstrated the initial exon 19deletion described in his pretreatment specimen.Additionally,the tumors from the lung,liver,and intestine had a T790M (2369C ?T)mutation detected.This mutation was not detected in any of the original pretreatment tumor specimens,nor was it detected in the postmortem tumor spec-imens from the CNS.Figure 2shows analysis of EGFR exon 20follow-ing SURVEYOR (Transgenomic Inc)digestion,with a new fragment (Fig 2;asterisk)signifying the T790mutation.This secondary muta-tion in exon 20has been correlated with the development of resistance to ge?tinib in patients with sensitizing mutations who were initially responsive to the drug.7,8

Our patient highlights important developments in our understand-ing of sensitivity and resistance with the use of EGFR–tyrosine kinase inhibitors.However,the use of chemotherapeutic drugs together with ge?tinib confound the ?ndings somewhat and have an impact on the conclusionsonecandrawfromthispatient.Nonetheless,theinitialtumor specimen contained an exon 19deletion that has been associated with clinical responses to ge?tinib treatment.1,9However,the patient devel-opedbrainandleptomeningealmetastasesdespiteadequatecontrolofthe lung cancer outside the CNS.Our ?ndings demonstrate that even 500mg/d of ge?tinib did not achieve CSF drug levels that were adequate enough to cause tumor growth inhibition based on the IC 50values re-quired to inhibit the growth of a cell line established from the patient’s pretreatment tumor specimen.This discordance between systemic and CNS response eventually led to two critical developments.First,the ad-ministration of increased ge?tinib dosages was correlated with higher concentrations of the drug in the CSF and a subsequent clinical and radiographicresponseinthepatient’sleptomeningealdisease.Second,the extended ge?tinib exposure in the systemic lung cancer sites was associ-ated with the development of a systemic T790M resistance mutation,whereas CNS metastases did not undergo this secondary change.Our ?ndingssuggestthatthereasonfortheabsenceoftheT790Mmutationin the CNS specimens was the lack of a prolonged selection pressure for a T790Mcontainingallele.Ultimately,itwasthege?tinib-resistantsystemic disease progression that had undergone prolonged exposures to thera-peutic concentrations of ge?tinib that would lead to the patient’s death

Table 1.Relationship Between Ge?tinib Dose,Ge?tinib Concentration,CSF Cytology,and Transaminases

Date

Ge?tinib Dose

(mg)

CSF Site Ge?tinib Concentration,

CSF (nM)

CSF Cytology

Result

ALT/AST (mg/dL)September 5,2004500LP 6.2?18/15September 21,2004500LP 18??19/15October 13,2004750LP

32?30/20November 23,2004750Ommaya NA ?32/20December 15,20041,000Ommaya 42?81/57January 7,20051,000Ommaya 42?122/47

February 16,2005

1,250

Ommaya

43/35

Abbreviations:LP,lumbar puncture;NA,not available.?

On September 8,2004,the patient’s treatment was changed from phenytoin (an enzyme-inducing antiepileptic drug)to levetiracetam (a nonenzyme-inducing antiepileptic drug).

Fig 2.

from lung cancer.The development of CNS metastases in this patient is consistentwithsimilar?ndingsinotherpatientswithnon–small-celllung cancer who show an initial response to ge?tinib.In21patients who achieved a partial response to ge?tinib,seven(33%)developed CNS metastases as their?rst site of recurrence(?ve brain metastases,two leptomeningeal metastases).10Moreover,two additional patients devel-oped brain metastases after they had recurred in the lungs.It is possible thatinadequatepenetrationofge?tinibintotheCSFmightpartlyaccount forthehighfrequencyofCNSrecurrenceinthisgroupofpatients.Further study of the penetration of ge?tinib into the CNS and the development of resistance to EGFR tyrosine kinase inhibitors is needed.

Authors’Note

The LocusLink(https://www.360docs.net/doc/a018323461.html,/LocusLink/)acces-sion number for the EGFR sequences discussed in this article is1956;the GenBank(https://www.360docs.net/doc/a018323461.html,/Genbank/)accession number for the EGFR sequences discussed in this article is NT_033968.

David M.Jackman

Department of Medical Oncology,Dana-Farber Cancer Institute;Department of Medicine,Brigham and Women’s Hospital;Harvard Medical School,Boston,MA Alison J.Holmes

Department of Medical Oncology,Dana-Farber Cancer Institute,Boston,MA Neal Lindeman

Department of Pathology,Brigham and Women’s Hospital;Harvard Medical School,Boston,MA

Patrick Y.Wen and Santosh Kesari

Department of Medical Oncology,Dana-Farber Cancer Institute;Department of Neurology,Brigham and Women’s Hospital;Harvard Medical School,Boston,MA Ana M.Borras

Translational Research Laboratory,Dana-Farber Cancer Institute,Boston,MA Christopher Bailey

Department of Drug Metabolism and Pharmokinetics,AstraZeneca Pharmaceuticals,Maccles?eld,United Kingdom Francisca de Jong

Analytico Medinet BV,Breda,the Netherlands

Pasi A.Ja¨nne and Bruce E.Johnson

Department of Medical Oncology,Dana-Farber Cancer Institute;Department of Medicine,Brigham and Women’s Hospital;Harvard Medical School,Boston,MA ?2006by American Society of Clinical Oncology

REFERENCES

1.Paez JG,Janne PA,Lee JC,et al:EGFR mutations in lung cancer:Correlation with clinical response to ge?tinib therapy.Science304:1497-1500,2004

2.Mukohara T,Engelman JA,Hanna NH,et al:Differential effects of ge?tinib and cetuximab on non-small-cell lung cancers bearing epidermal growth factor receptor mutations.J Natl Cancer Inst97:1185-1194,2005

3.Jones HK,Stafford LE,Swaisland HC,et al:A sensitive assay for ZD1839 (Iressa)in human plasma by liquid-liquid extraction and high performance liquid chromatography with mass spectrometric detection:Validation and use in phase

I clinical trials.J Pharm Biomed Anal29:221-228,2002

4.Baselga J,Rischin D,Ranson M,et al:Phase I safety,pharmacokinetic,and pharmacodynamic trial of ZD1839,a selective oral epidermal growth factor receptor tyrosine kinase inhibitor,in patients with?ve selected solid tumor types. J Clin Oncol20:4292-4302,2002

5.Nakagawa K,Tamura T,Negoro S,et al:Phase I pharmacokinetic trial of the selective oral epidermal growth factor receptor tyrosine kinase inhibitor ge?tinib(?Iressa’,ZD1839)in Japanese patients with solid malignant tumors.Ann Oncol14:922-930,2003

6.Janne PA,Borras AM,Kuang Y,et al:A rapid and sensitive enzymatic method for epidermal growth factor receptor mutation screening.Clin Cancer Res12:751-758,2006

7.Kobayashi S,Boggon TJ,Dayaram T,et al:EGFR mutation and resistance of non-small-cell lung cancer to ge?tinib.N Engl J Med352:786-792,2005

8.Pao W,Miller V,Politi KA,et al:Acquired resistance of lung adenocarci-nomas to ge?tinib or erlotinib is associated with a second mutation in the EGFR kinase domain.PLoS Med2:e73,2005

9.Lynch TJ,Bell DW,Sordella R,et al:Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to ge?tinib.N Engl J Med350:2129-2139,2004

10.Omuro AM,Kris MG,Miller VA,et al:High incidence of disease recurrence in the brain and leptomeninges in patients with nonsmall cell lung carcinoma after response to ge?tinib.Cancer103:2344-2348,2005

DOI:10.1200/JCO.2006.06.6126

■■■

Acknowledgment

This study is supported by grants from the National Institutes of Health(1K12CA87723-01;P.A.J.;1RO1CA114465-01;B.E.J.and P.A.J.)and the National Cancer Institute Lung SPORE(P20CA90578-02;B.E.J.),as well as support from the Doris and William Krupp Research Fund in

Thoracic Oncology.

Authors’Disclosures of Potential Con?icts of Interest

Although all authors completed the disclosure declaration,the following authors or their immediate family members indicated a?nancial interest.No con?ict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation.For a detailed description of the disclosure categories,or for more information about ASCO’s con?ict of interest policy,please refer to the Author Disclosure Declaration and the Disclosures of Potential Con?icts of Interest section in Information for Contributors.

Authors Employment Leadership Consultant Stock Honoraria Research Funds Testimony Other Christopher Bailey AstraZeneca(N/R)

Pasi A.Ja¨nne Pending

EGFR patent

application

(A) Bruce E.Johnson Genzyme(A)Pending

patent

application

for EGFR

mutation

testing(A)

Dollar Amount Codes(A)?$10,000(B)$10,000-99,999(C)?$100,000(N/R)Not Required