EClinicalMedicine 9 (2019) 35–43 Contents lists available at ScienceDirect EClinicalMedicine journal homepage: https://www.journals.elsevier.com/ eclinicalmedicine Research Paper Trabectedin and RAdiotherapy in Soft Tissue Sarcoma (TRASTS): Results of a Phase I Study in Myxoid Liposarcoma from Spanish (GEIS), Italian (ISG), French (FSG) Sarcoma Groups Alessandro Gronchi a,⁎, Nadia Hindi b,c, Josefina Cruz d, Jean-Yves Blay e, Antonio Lopez-Pousa f, Antoine Italiano g, Rosa Alvarez h, Antonio Gutierrez i, Inmaculada Rincón c, Claudia Sangalli a, Jose Luis Pérez Aguiar d, Jesús Romero j, Carlo Morosi a, Marie Pierre Sunyach e, Roberta Sanfilippo a, Cleofe Romagosa k, Dominique Ranchere-Vince e, Angelo P. Dei Tos l,m, Paolo G. Casali a,b,c,d,e,f,g,h,i,j,k,l,m,n, Javier Martin-Broto b,c a Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy b Biomedicine Institute of Seville (IBIS), Spain c University Hospital Virgen del Rocio, Seville, Spain d University Hospital Canarias, Tenerife, Spain e Center Leon Berard, Lyon, France f Hospital Sant Pau, Barcelona, Spain g Institute Bergonie – Bourdeaux, France h University Hospital Gregorio Marañon, Madrid, Spain i Son Espases University Hospital/IdISBa, Palma, Illes Baleares, Spain j Puerta de Hierro University Hospital, Madrid, Spain k Vall d'Hebron University Hospital, Barcelona, Spain l Treviso General Hospital, Treviso, Italy m Department of Medicine, University of Padova, Padova, Italy n Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy a r t i c l e i n f o a b s t r a c t Article history: Background: Myxoid liposarcoma (ML) exhibits a special sensitivity to trabectedin (T) and radiation therapy (RT). Received 5 September 2018 Preclinical data suggest a synergistic effect. We aimed to study safety, feasibility and activity of the administration Received in revised form 1 March 2019 of pre-operative concurrent T and RT in patients affected by localized resectable ML. Accepted 5 March 2019 Methods: Patients received 3 cycles (C) of T in combination with RT (45 Gy) in 25 fractions (1.8 Gy/fraction). Dose Available online 11 March 2019 Levels for T were: −1 (1.1 mg/m2), 0 (1.3 mg/m2) and 1 (1.5 mg/m2). Primary endpoint was safety; antitumor activity was assessed by RECIST and Choi criteria. This study is registered at ClinicalTrials.gov, number Keywords: Sarcoma NCT02275286. The phase 1 part of the study is complete and phase 2 is ongoing. Myxoid Liposarcoma Findings: From February 2015 to May 2016, 14 patients (M/F 7/7), median age 36 years (range 24–70) and me- Trabectedin dian tumor size 12.5 cm (range 7–17 cm), were enrolled. One dose limiting toxicity (G3 transaminitis) occurred Radiotherapy at Level 0 and one (sepsis due to catheter infection) at Level 1. All patients completed RT. Five patients achieved Chemotherapy PR (36%), 8 SD (57%), 1 distant PD (7%) by RECIST, while 12 achieved PR (86%), 1 SD (7%) and 1 distant PD (7%) by Neoadjuvant Choi criteria. Twelve patients underwent surgery. Median viable residual tumor was 5% (0–60). Prognosis Interpretation: T in combination with RT showed a favorable safety profile and antitumor activity in localized ML. Survival T dose of 1.5 mg/m2 is the recommended dose for the phase 2 study, which is ongoing. Funding: This study was partially supported by Pharmamar. © 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction ⁎ Corresponding author at: Department of Surgery, Fondazione IRCCS Istituto Nazionale Myxoid liposarcoma (ML) is a rare soft tissue sarcoma (STS) subtype, dei Tumori, Via Venezian 1, 20133, Milan, Italy. accounting for 30% of all Liposarcoma and 10% of all STS [1,2]. It arises E-mail address: alessandro.gronchi@istitutotumori.mi.it (A. Gronchi). predominantly in the extremities of young adults and is characterized https://doi.org/10.1016/j.eclinm.2019.03.007 2589-5370/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 36 A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 A phase II study on neoadjuvant T in 23 patients affected by localized Research in context resectable ML showed a 24% response rate by RECIST and a 13% patho- logical complete response in the surgical specimen with a very favorable Evidence before this study toxicity profile [8]. Some preclinical data of the synergistic activity of RT and T have We searched PubMed for published preclinical or clinical stud- been reported [9] based on the fact that T typically causes S blockade ies about the combination of trabectedin (T) and radiotherapy and G2/M arrest and it is well known that this latter is the most sensitive (RT) in sarcomas from January 1997 to June 2018. We used the fol- cell cycle phase to radiation treatment [10]. lowing search terms: “sarcoma”, “soft tissue sarcoma”, “myxoid Aim of the present study was to test the safety, feasibility and activ- liposarcoma”, “trabectedin”, “radiotherapy”, “neoadjuvant che- ity of the administration of pre-operative T with concurrent RT in pa- motherapy”, “neoadjuvant radiotherapy”, “phase I study”, “phase tients affected by localized resectable ML. This study included also a II study”. We identified only 2 preclinical studies suggesting a syn- separate group of metastatic STS patients, where the same was tested ergistic activity between the use of T and RT, based on the fact that to treat metastatic STS to the lung not suitable to surgical resection. T typically causes S blockade and G2M arrest and the latter is the We present herein data from the phase 1 part of the study limited to most sensitive cell cycle phase to radiation treatment. There was the cohort of localized ML patients. The phase 2 part of the study is no single published clinical study testing the feasibility and activ- ongoing. ity of this combination in patients affected by soft tissue sarcoma or localized myxoid liposarcoma. 2. Methods Added value of this study 2.1. Study Design and Participants This is the first-in-human clinical study showing the feasibility This is an international, open label, phase 1 study aimed at testing of the concurrent administration of T and RT in patients affected the safety and feasibility of the concurrent administration of T and RT by localized myxoid liposarcoma. No cumulative toxicity was and finding the appropriate T dose to use in the phase 2 part of the shown and no treatment related deaths were recorded. The rec- study. Patients were enrolled in 4 centres in Spain, 1 in Italy and 2 in ommended T dose for the phase 2 study was 1.5 mg/m2, which France. is the same dose registered for the use of T alone. In addition Patients were eligible if they were aged between 18 and 70 years; 85% of the patients had Choi partial response and 75% had b than had a histologically proven and centrally reviewed (before inclusion) 10% residual visible tumor in the surgical specimen. A confirma- diagnosis of localized resectable ML, originating in an extremity or tory phase 2 trial is ongoing. trunk wall, with a longest diameter ≥ 5 cm if deeply or 10 cm if superfi- cially located relative to the investing fascia; had an Eastern Cooperative Implications of all the available evidence Oncology Group performance status equal or less than 1; had adequate baseline bone marrow (white blood cell count N 3000 cells per μL, neu- Neoadjuvant combined chemo-radiation therapy has been ex- trophil N1500 cells per μL, platelets N100,000 platelets per μL, and tensively explored in localized. STS. A recent randomized trial haemoglobin N10 g/L), renal function (creatinine b 1·6 mg/dL), hepatic showed a benefit of neoadjuvant AI versus a histology-driven che- function (total bilirubin ≤ upper normal value [UNV], transaminase and motherapy in terms of OS and RFS, thus pointing to efficacy of neo- phosphatase alkaline ≤2·5 the UNV), creatine phoshokinase (≤2·5 the adjuvant treatment as such in a subset of STS. In the myxoid UNV) and cardiac function (left ventricular ejection fraction N50%). liposarcoma stratum of this trial, the interim analysis showed Patients were ineligible if they had unresectable disease with limb the non-inferiority of T, with a much better toxicity profile. This sparing surgery or distant metastases; had disease located outside the study is still recruiting in the myxoid liposarcoma stratum and is extremities or trunk wall; had other malignancies within the past expected to complete the accrual in a year. It is thus possible 5 years, with the exception of carcinoma in situ of cervix and that the efficacy of T be confirmed to be not inferior to that of AI. basocellular skin cancers treated with eradicating intent; had previous The results of this phase I study provide the basis for the combina- T or RT involving the tumor bed; had serious psychiatric disease; had tion of T and RT for the phase II part, since no relevant toxicity was medical disease limiting survival to less than 2 years; had cardiovascular observed and both radiological and pathologic assessments of re- diseases resulting in a New York Heart Association Functional Status of 2 sponse indicate a synergy between both modalities. In the near fu- or higher; or had uncontrolled bacterial, viral, or fungal infection. Other ture T combined with radiation therapy may become a standard inclusion and exclusion criteria can be found in the appendix. neoadjuvant therapy for a subset of localized ML. The trial protocol and all amendments were approved by the appro- priate institutional review board or independent ethics committee at each trial centre. The trial was done in accordance with the provisions by a balanced translocation, most commonly t(12;16)(q13;p11) fus- of the Declaration of Helsinki. All patients provided written informed ing FUS (also named as TLS) with CHOP (also named as DDIT3) and consent before enrolment. The full protocol is available in the appendix. rarely t(12;22)(q13;q12), where EWS (Ewing's Sarcoma protein) substitutes for its homologous FUS [3]. The classic myxoid variant 2.2. Procedures shows low cellularity, conspicuous vascular network and myxoid stroma, whereas the cellular variant shows high cellularity made The dose escalation rules proceeded according to the traditional 3 up of closely packed roundish cells, little or no intervening stroma + 3 design [11] being the prespecified dose-limiting toxicity (DLT) as and a capillary pattern not easy to be visualized. Diagnosis of cellular follows: neutrophil count b0.5 × 109/L during ≥5 days, febrile neutrope- variant requires the presence of a cellular component exceeding 5% nia, platelet count b50 × 109/L and non-haematological toxicity of grade [2,4]. This amount is of prognostic relevance as within the ML spec- 3 or above, excluding nausea/vomiting without appropriate antiemetic trum, the 5-year survival varies between 20 and 70% and the cellular treatment and grade 3 transaminitis if not leading to T delay. Biochem- variant falls in the shortest figures. istry and full blood count was performed on day 1 and weekly, in the Evidence of a significant activity of both anthracycline and two first cycles at least. Patients received 3 cycles of T in combination trabectedin (T) as well as radiotherapy (RT) has been consistently re- with RT (total dose of 45 Gy) in 25 fractions (1.8 Gy/fraction). For ported in patients affected by metastatic ML [5–7]. those patients with micro or macroscopic positive margins after A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 37 Fig. 1. Outline of the trial design. surgery, a boost of post-op RT (total dose 16 Gy) in 8 fractions (2 Gy/ The primary end-point was to describe the safety profile of the com- fraction) was allowed (Fig. 1). bination of T plus RT in order to find the recommended T dose for the T was administered intravenously as a 24 h infusion every 3 weeks. phase II part of the study. The planned dose-levels for T were as follows: − 1 (1.1 mg/m2), 0 Secondary end-points were radiological response, measured by (1.3 mg/m2) and 1 (1.5 mg/m2). Oral dexamethasone 4 mg was admin- RECIST 1.1 and Choi criteria, and pathological response; recur- istered 24 h and 12 h before chemotherapy administration and i.v. rence free survival (RFS), disease free survival (DFS) and overall dexametasone 20 mg was given 30 min before treatment, as previously survival (OS); quality of Life measured by QLQ-C30 EORTC described to minimize toxicity [12]. Administration of T through a cen- questionnaire. tral venous catheter was mandatory, due to fibrotic phlebitis encoun- tered during peripheral administration. The starting dose-level for T, 2.4. Statistical Analysis 1.3 mg/m2 was chosen based on previous accumulated experience, since this dose had shown activity in the context of myxoid liposarcoma. We did a 3 + 3 dose escalation with review of available safety before RT started within 1 h after completion of the first T infusion (cycle initiating the next dose level. Sample size for dose escalation was based 1 day 2), and was given daily for 25 days. Patients were treated with on the 3 + 3 design rules with three to six patients per dose level. Three 3D conformal radiotherapy (3D-CRT) or intensity modulated radiother- patients were treated at a given dose level. If at least 2 patients were ob- apy (IMRT). Gross tumor volume (GTV) included gross tumor defined in served to have dose-limiting toxicity (DLT), the prior dose level was de- the planning CT or contrast enhanced MRI T1 images. Clinical target vol- fined as the maximum tolerable dosage (MTD) (unless only 3 patients ume (CTV) included GTV plus longitudinal margins (proximal and dis- have been treated at that level, in which case it is the tentative MTD). tal) of 5 cm and a radial margin of 2 cm. If after applying these If 0 of the 3 patients were observed to have DLT, the dose level was es- margins the field extended beyond an intact fascia, the field could be calated one step for the next cohort of 3 patients, and the process con- shortened to include the entire compartment. Planning target volume tinued as above. If exactly 1 of the 3 patients treated showed DLT, 3 (PTV) included the CTV plus an additional margin to compensate for additional patients were treated at the current dose level. If none of organ motion and set-up uncertainties. Typically, this was CTV + 0 these additional 3 patients showed DLT, the dose level was escalated .5cm. for the next cohort of 3 patients, and the process continues as above; In the interval period, the tests were repeated at the discretion of the otherwise, the prior dose level was defined as the MTD. treating physician. We graded toxic effects using the National Cancer In- The dose-escalation levels were: − 1: Trabectedin 1.1 mg/m2; 0: stitute Common Terminology Criteria for Adverse Events version 4.03. Trabectedin 1.3 mg/m2 and 1: Trabectedin 1.5 mg/m2. The starting Acute T mediated cardiac toxicity was not expected at protocol spec- dose-level was 1.3 mg/m2 and it was designed a de-escalation dose ified dose. However, an intermediate LVEF evaluation was mandatory (−1) of 1.1 mg/m2 in the case of observing more than one DLT over 6 within 2 weeks after last day of RT treatment with the same method patients in the starting dose, and one escalation dose (1) at as in the initial evaluation. If a decrease N 15% was observed the patient 1.5 mg/m2, the ceiling dose recommended for trabectedin, in case of was to be withdrawn from the study. If a patient experienced a grade N 1 finding ≤ 1 DLT in the starting dose. It was not allowed de-escalating toxicity and did not recover to grade ≤ 1 after a maximum 3-weeks or escalating the dose on an individual basis, beside the defined dose re- delay, the patient was to be withdrawn from the study. ductions according to the protocol. Cardiac toxicities grade ≥ 4 were considered SUSAR (suspected un- Dose reductions were done taking into account the highest tox- expected serious adverse reaction) and should have been reported in icity in the prior cycle. Only two dose reductions were allowed in less than 24 h. the same patient, except in cases of evident clinical benefit for We assessed response according to Response Evaluation Criteria in the patient however, discussion with and approval by the steering Solid Tumours (RECIST) 1.1 [13] and Choi criteria [14] at the time of sur- committee (SC) and the Sponsor were mandatory. Once a dose re- gery with contrast-enhanced MRI or CT scan, or both, in all patients. A duction had taken place, re-escalation was not permitted in subse- central radiological review of responses was performed in all cases at quent cycles. Every dose-reduction would imply decrease the dose the Fondazione IRCCS Istituto Nazionale dei Tumori – Milan – Italy. in 0.2 mg/m 2. Surgery was planned 3–4 weeks after the administration of last pre- Haematological toxicity: With any of the following toxicities re- operative cycle and not until 4 weeks after the end of preoperative RT. duced one dose level: Following the resection, pathologic specimens were mapped in tumor sections to estimate the histologic changes and viable tumor after neo- • Neutropenia b0,5 × 109/l, for more than 5 days adjuvant treatment. • Febrile neutropenia We followed up patients every 4 months with chest and abdominal • Thrombocytopenia b25 × 109/l CT and MRI or CT of the affected site. Non-haematological toxicity: With any of the following toxicities re- 2.3. Outcomes duced one dose level: Aim of the study was to confirm that the combination of T plus RT • Vomiting ≥ grade 3 in spite of adequate treatment is feasible and safe and shows potential synergic activity with low • Transaminases elevation ≥ grade 3, not recovering to grade 1 previous toxicity. to T administration. 38 A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 • Alkaline phosphatase (liver fraction) or bilirubin ≥ grade 1 at any time (range 7–20 cm) were enrolled. Clinical and pathological characteristics during treatment. of the study cohort are listed in Table 1. • Other toxicities ≥ grade 3. 7 patients received T at dose Level 0 and 7 patients at Level 1. All pa- tients completed the 3 planned cycles of T, but one who had a sepsis Safety and efficacy analyses were done on all patients receiving at after cycle 1 and received definitive RT. The median total dose of T least one cycle of trabectedin. was 2.6 mg per cycle in both cohorts (range 2.11–2.85 in dose level 0 Treatment related adverse events (AEs) were those reported as pos- and 2.4–3.2 in dose level 1). Seven patients were allowed to be enrolled sibly or probably related to treatment by the treating physician. Analysis in each dose-level, instead of the prespecified six, because one patient AEs included any unfavorable and unintended sign (including abnormal had an early treatment discontinuance, and another did not undergo laboratory findings), symptom or disease temporally associated with T surgery. Even though DLT analysis was based on first cycle, it was con- and/or RT. sidered that at least 6 patients had to complete the whole treatment Time to event variables (RFS, DFS and OS) were measured from the program for a better safety assessment. No dose reductions were ob- date of surgery for RFS, and from onset of trial therapy for DFS and OS served in the enrolled patients. There were no treatment related deaths. and were estimated according to the Kaplan–Meier method. All underwent RT to a median total dose of 45 Gy (range 45–50 Gy). This study is registered with ClinicalTrials.gov, number One DLT (G3 transaminitis) occurred at Level 0 and another (sepsis due NCT02275286 to catheter infection) at Level 1. Overall the combination of T and RT was well tolerated. Regardless of the dose attribution the most common 2.5. Role of the Funding Source grade 3/4 AE was ALT elevation (n = 6, 43%). In addition gammaGT el- evation, neutropenia, anemia, epithelitis and sepsis were observed in 1 The TRASTS trial was an international academic trial designed by the patient each (7%). Other common grade 1/2 AEs were nausea (n = 7, members of the steering committee of the trial who were appointed by 50%) and vomiting (n = 3, 21%), fatigue (n = 6, 43%) and anorexia the National Cooperative Sarcoma groups. No pharmaceutical company (n = 3, 21%), skin disorders (n = 4, 28%) and AST (n = 6, 43%) and had any role in study design, data collection, data analysis, data inter- gammaGT (n = 3, 21%) elevation. The complete list of side effects pretation, or writing of the report. PharmaMar provided the study and grade is shown in Table 2, overall and by dose level. Confidence drug T and a small support for data management. Data were collected interval for the major toxicities is reported in Table 3. by investigators and associated site personnel, analyzed by statisticians All patients were evaluable for centralized assessment of response working in the independent trial centre of the Spanish Sarcoma Group by RECIST and Choi criteria: 5 achieved PR (36%), 8 SD (57%), 1 distant (GEIS), and interpreted by the members of the steering committee. PD (7%) by RECIST, while 12 achieved PR (86%), 1 SD (7%) and 1 distant The corresponding author had final responsibility for the decision to PD (7%) by Choi criteria (Fig. 2). submit for publication. 12/14 patients underwent surgery. All had a macroscopic complete resection. Microscopic surgical margins were negative (R0) in 7 patients 3. Results and positive (R1) in 5. Two patients were not operated, one because de- veloped metastatic disease during neoadjuvant therapy and one be- From February 2015 to May 2016, 14 patients (M/F 7/7) with me- cause developed a sepsis due to central venous catheter infection and dian age of 36-years (range 24–70) and median tumor size of 12.5 cm was treated by definitive RT. Table 1 Patients and treatment characteristics. Global series (n = 14) 1.3 mg/m2 dose (n = 7) 1.5 mg/m2 dose (n = 7) Median age (range) 36 (24–71) 31 (24–71) 53 (28–68) Sex (M/F) 7 (50%)/7 (50%) 4 (57%)/3 (43%) 3 (43%)/4 (57%) ECOG PS -0 9 (62%) 5 (71%) 4 (57%) -1 5 (38%) 2 (29%) 3 (43%) Grade -1 11 (79%) 7 (100%) 4 (57%) -3 3 (21%) 0 (0%) 3 (43%) Location - Thigh 10 (71%) 6 (86%) 4 (57%) - Leg 3 (21%) 0 (0%) 3 (43%) - Buttock 1 (7%) 1 (14%) 0 Median size mm. (range) 130 (70–200) 130 (30–170) 110 (57–200) Depth - Deep 14 (100%) 7 (100%) 7 (100%) - Superficial 0 0 0 Radiotherapy dose - 45 G 13 (93%) 7 (100%) 6 (86%) - 50 Gy 1 (7%) 0 1 (14%) Surgery - Yes 12 (86%) 6 (86%) 6 (86%) - No (n = 2) 2 (14%)a 1 (14%) 1 (14%) Surgical margin - Free 7 (58%) 4 (67%) 3 (50%) - Positive 5 (42%) 2 (33%) 3 (50%) CHOP rearrangement - Positive 12 (86%) 6 (86%) 6 (86%) - Not available 2 (14%)b 1 (14%) 1 (14%) a 2 patients did not undergo surgery, one because developed metastatic disease during neoadjuvant therapy and one because developed a sepsis due to central venous catheter infection and was treated by definitive RT. b 2 not evaluable for limited material on the biopsy and lack of residual tumor on the surgical specimen. A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 39 Table 2 Haematological and non-haematological toxicity. Any grade Grade 3–4 Grade 1–2 Type of adverse event (n = 14) Any grade Dose level 0 Dose level 1 Grade 3–4 Dose level 0 Dose level 1 Grade 1–2 Dose level 0 Dose level 1 N (%) (1.3 mg/m2) (1.5 mg/m2) N (%) (1.3 mg/m2) (1.5 mg/m2) N (%) (1.3 mg/m2) (1.5 mg/m2) Haematological Anemia 11 (78.5) 6 (42.8) 5 (35.7) 1 (7.1) 1 (7.1) 0 (0) 10 (71.4) 5 (35.7) 5 (35.7) Neutropenia 8 (57.1) 2 (14.3) 6 (42.8) 2 (14.3) 0 (0) 2 (14.3) 6 (42.8) 2 (14.3) 4 (28.5) Lymphopenia 8 (57.1) 4 (28.5) 4 (28.5) 1 (7.1) 1 (7.1) 0 (0) 7 (50.0) 3 (21.4) 4 (28.5) Leukopenia 6 (42.8) 1 (7.1) 5 (35.7) 0 (0) 0 (0) 0 (0) 6 (42.8) 1 (7.1) 5 (35.7) Thrombocytopenia 3 (21.4) 1 (7.1) 2 (14.3) 0 (0) 0 (0) 0 (0) 3 (21) 1 (7.1) 2 (14.3) Non-haematological ALT/GPT increased 12 (85.7) 7 (50.0) 5 (35.7) 7 (50) 6 (42.8) 1 (7.1) 5 (35.7) 1 (7.1) 4 (28.5) AST/GOT increased 12 (85.7) 7 (50.0) 5 (35.7) 0 (0) 0 (0) 0 (0) 12 (85.7) 7 (50.0) 5 (35.7) Nausea 7 (50.0) 4 (28.5) 3 (21.4) 0 (0) 0 (0) 0 (0) 7(50.0) 4 (28.5) 3 (21.4) Fatigue 6 (42.8) 3 (21.4) 3 (21.4) 0 (0) 0 (0) 0 (0) 6 (42.8) 3 (21.4) 3 (21.4) Skin disorders (dermatitis, epitelitis, erythema) 5 (35.7) 2 (14.3) 3 (21.4) 1 (7.1) 1 (7.1) 0 (0) 4 (28.5) 1 (7.1) 3 (21.4) GGT increased 10 (71.4) 6 (42.8) 4 (28.5) 1 (7.1) 1 (7.1) 0 (0) 9 (64.2) 5 (35.7) 4 (28.5) Anorexia 4 (28.5) 2 (14.3) 2 (14.3) 0 (0) 0 (0) 0 (0) 4 (28.5) 2 (14.3) 2 (14.3) CPK increased 4 (28.5) 2 (14.3) 2 (14.3) 0 (0) 0 (0) 0 (0) 4 (28.5) 2 (14.3) 2 (14.3) Vomiting 3 (21.4) 1 (7.1) 2 (14.3) 0 (0) 0 (0) 0 (0) 3 (21.4) 1 (7.1) 2 (14.3) Diarrhea 2 (14.3) 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 2 (14.3) 1 (7.1) 1 (7.1) Dyspepsia 2 (14.3) 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 2 (14.3) 1 (7.1) 1 (7.1) Epigastralgia 2 (14.3) 2 (14.3) 0 (0) 0 (0) 0 (0) 0 (0) 2 (14.3) 2 (14.3) 0 (0) Alkaline phosphatase increased 2 (14.3) 0 (0) 2 (14.3) 0 (0) 0 (0) 0 (0) 2 (14.3) 0 (0) 2 (14.3) Sepsis 1 (7.1) 0 (0) 1 (7.1) 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0) 0 (0) Catheter related infection 1 (7.1) 0 (0) 1 (7.1) 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0) 0 (0) Abdominal pain 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0) 0 (0) 1 (7.1) 0 (0) 1 (7.1) Dizziness 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (7.1) 1 (7.1) 0 (0) Headache 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0) 0 (0) 1 (7.1) 0 (0) 1 (7.1) Myalgia 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (7.1) 1 (7.1) 0 (0) Haemoglobinuria 1 (7.1) 0 (0) 1 (7.1) 0 (0) 0 (0) 0 (0) 1 (7.1) 0 (0) 1 (7.1) Limb cramps 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (7.1) 1 (7.1) 0 (0) Hypersialorrea 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (7.1) 1 (7.1) 0 (0) Venous injury 1 (7.1) 1 (7.1) 0 (0) 0 (0) 0 (0) 0 (0) 1 (7.1) 1 (7.1) 0 (0) Median visible residual tumor in the surgical specimen was 5% 4. Discussion (0–60) with 9/12 patients (75%) with ≤ 10% visible remaining tumor. Three of them (3/12, 25%) had a complete pathological response, with In this phase 1 study in patients affected by localized ML, the neoad- no visible residual tumor (Fig. 3). juvant administration of concurrent T and RT was well tolerated. No cu- Median follow-up from surgery was 26 months (range 24–41). One mulative toxicity was shown and no treatment-related deaths were patient developed local and distant progression at the end of the neoad- observed. The recommended T dose for the phase 2 study was juvant treatment and one patient developed distant metastases 1.5 mg/m2, which is the same dose approved for T alone. In addition, 15 months after surgery. This latter recurred in the central nervous sys- both radiological and pathological responses were promising. A confir- tem and finally died 5 months later. This case was the only registered matory phase 2 trial is ongoing. death of this series. This is the first-in-human study of the combination of T and RT. Both The corresponding RFS, DFS and OS at 3-yr were 92% (95%CI: T and RT are known to have exceeding activity in patients affected by 76–100), 86% (95%CI: 67–100) and 93% (95%CI: 79–100), respectively ML. However, while preclinical data about the concurrent administra- (Fig. 4). tion of the two modalities are available, no clinical studies had been Table 3 Overall 95% Confidence Interval of the major toxicities. Type of adverse event (n = 14) Any grade Grade 3–4 Grade 1–2 N (%; 95%CI) N (%; 95%CI) N (%; 95%CI) Haematological Anemia 11 (78; 54–100) 1 (7; 0–23) 10 (71; 44–98) Neutropenia 8 (57; 27–87) 2 (14; 0–35) 6 (43; 13–72) Lymphopenia 8 (57; 27–87) 1 (7; 0–23) 7 (50; 20–80) Leukopenia 6 (43; 13–72) 0 (0) 6 (43; 13–72) Thrombocytopenia 3 (21; 0–46) 0 (0) 3 (21; 0–46) Non-haematological ALT/GPT increased 12 (86; 65–100) 7 (50; 20–80) 5 (36; 7–64) AST/GOT increased 12 (86; 65–100) 0 12 (86; 65–100) Nausea 7 (50; 20–80) 0 7(50; 20–80) Fatigue 6 (43; 13–72) 0 6 (43; 13–72) Skin disorders (dermatitis, epitelitis, erythema) 5 (36; 7–64) 1 (7; 0–23) 4 (29; 1–56) GGT increased 10 (71; 44–98) 1 (7; 0–23) 9 (64; 36–93) Anorexia 4 (28; 1–56) 0 4 (28; 1–56) CPK increased 4 (29; 1–56) 0 4 (29; 1–56) 40 A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 Fig. 2. Waterfall plot of radiological responses after treatment by Choi criteria, including both tumor size and density information. *Patient with progressive disease due to new distant lesions while achieving CHOI partial response on primary tumor. performed so far. Of note the dose of RT was slightly lower (45 Gy) than studies are available [23–25]. However this combination was consis- the one conventionally used in sarcomas in the preoperative setting tently shown to be more toxic as compared to the administration of AI (50 Gy). A study specifically addressing to which extent the dose of RT alone. A marked thrombocitopenia in as many as 35% of the patients can be reduced in ML without compromising activity is presently ongo- along with the other expected haematological toxicities was observed. ing (DOREMY trial, NCT02106312). The next question to answer may Nonetheless the dose intensity of AI was maintained. Of note the admin- well be if the addition of T can be of any help also in this perspective. istration of the 2 treatments together proved to offset the negative prog- The use of preoperative chemo-radiotherapy is increasingly nostic impact of planned positive surgical margins on outcome [26,27]. employed in localized high-risk STS of the extremities and trunk wall, As far as the efficacy of neoadjuvant chemotherapy on the systemic as it theoretically allows covering both the local and systemic risks risk is concerned, at an interim analysis, another randomized study [28] [15–20], while helping maximize local control in a proportion of chal- comparing neoadjuvant AI versus a neoadjuvant histology-driven che- lenging cases. This is of particular relevance when function preservation motherapy showed a statistically significant benefit in RFS and OS in is a goal, or the tumor is of borderline resectability and subsequent re- favor of AI, thus pointing to a distinct effect of neoadjuvant chemother- currences may directly lead to death [21]. Indeed, the preoperative de- apy as such in localized STS. If the final analysis confirms these results, livery of anthracycline + ifosfamide (AI) and RT was proven to be neoadjuvant chemotherapy may become standard treatment in a subset feasible in an Italian and Spanish Sarcoma Group phase 3 randomized of localized STS patients. However, in the same trial, T was the study comparing the use of 3 and 5 cycles of AI [22]. Other single-arm histology-driven chemotherapy for ML, and at the moment it is the Fig. 3. Panel a and d are examples of non-treated low grade and high grade myxoid liposarcoma respectively. Panels b, c, e and f are examples of different patterns of pathological response observed after the combination of trabectedin and radiotherapy: mature adipocytic differentiation (panel b), necrosis (panel c), sclero-hyalinosis (panel e) and areas of fibrosis with inflammatory infiltrate, vascular reactive proliferation and haemosideraphages (panel f). All changes can coexist in the same case. A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 41 Fig. 4. Relapse-free survival of the 12 operated patients (panel A); disease-free survival (panel B) and overall survival (panel C) of the 14 included patients. only stratum in which the two arms were superimposable with regard With regard to the combination of RT with targeted therapies, the to RFS and OS. T had a much better toxicity profile. This study is still combination of Vascular Endothelial Growth Factor Receptor (VEGFR) recruiting in the ML stratum and is expected to complete the accrual inhibitors and RT has also been studied in the latter years [31–33]. Suni- in a year. It is thus possible that the efficacy of T be confirmed to be tinib, Pazopanib or Sorafenib and combined RT to a total dose of 50 Gy not inferior to that of AI. have been tested in phase I studies, in patients affected by high risk If so, in the near future T combined with radiation therapy may be- STS in an extremity or trunk wall. The combination has proven to be fea- come a standard neoadjuvant therapy for a subset of localized ML. For sible. However grade ≥ 3 haematological and hepatic toxicities were ob- the moment, this Phase 1 study actually showed the feasibility of the served in up to 50% of the patients. In addition the effect of VEGFR combination of T with pre-operative radiation therapy. inhibitors against the metastatic risk of localized high risk STS is far Other studies have explored so far the combination of RT with che- from being demonstrated and a limited activity in advanced motherapy in localized STS. A phase 1 study on preoperative continuous liposarcoma has consistently been reported for all these compounds. infusion Adriamycine over 5 days for 5 courses and concurrent RT to a Their use is mainly intended at enhancing RT activity. A confirmatory total dose of 50 Gy was performed on 27 patients affected by localized phase II study on the combination of Pazopanib and RT is presently high risk STS of an extremity or trunk wall. The treatment was fairly ongoing. well tolerated, but 30% of the patients developed a ≥ 3 skin toxicity, Another approach explored the combination of intratumoral injec- along with the expected haematological side effects [29]. This regimen tion of hafnium oxide nanoparticles (NBTXR3; a radioenhancer) and has not been further developed, mainly due to the observed skin toxicity RT in a phase 1 study in 22 patients affected by STS in an extremity or and the use of a single agent regimen, which is not the standard chemo- trunk wall [34]. The treatment proved to be feasible, with limited local therapy approach used in localized high risk STS when a decision for an toxicity. A promising pathological response rate was observed. A confir- adjuvant/neoadjuvant chemotherapy is taken. More recently a phase 1 matory phase 3 study has recently been completed. However this mo- study on Gemcitabine administered 5 times and concurrent RT to a dality is not intended to impact the metastatic and survival risk as the total dose of 50 Gy was performed. The treatment was well tolerated. activity of both modalities is limited to the site of the primary tumor. No significant ≥3 skin toxicity was observed. The main side effect was As a matter of fact, in the 14 patients of this Phase 1 component of myelosuppression, which did not prevent the patients to complete the the trial, an impressive activity of the combination of T with RT was ob- preoperative treatment [30]. A formal phase 2 study to assess the activ- served, especially when radiological response was measured by modi- ity of this regimen was warranted, but no results are available as of yet. fied Choi criteria [14,35] (Fig. 2), known to better predict both However Gemcitabine is not active in ML and therefore its use in com- pathological response and final outcome. Indeed the 75% rate of very bination with RT in this disease would not be the first choice. good pathological response (≤ 10% residual visible tumor) looks very 42 A. Gronchi et al. / EClinicalMedicine 9 (2019) 35–43 promising. These results compare favorably with previous experiences Dr. Martin-Broto reports grants from LILLY, other from NOVARTIS, using either T or RT alone as neoadjuvant therapies in localized ML [7, grants and other from PHARMAMAR, other from EISAI, outside the sub- 8]. However, if the phase II part of this study confirmed the promising mitted work; activity reported herein, a comparative trial would be needed to dem- Dr. Sanfilippo reports grants and personal fees from Pharmamar, onstrate the superiority of T plus RT over either single therapeutic mo- outside the submitted work; dality in localized ML. Dr. Romagosa reports grants from Grupo GEIS, during the conduct of the study; other from Farmamar, outside the submitted work; Acknowledgements All other authors report no conflict of interest. The authors would like to thank Melissa Fernández, Ana Arcas, Patricio Appendix A. Supplementary Data Ledesma, Emanuela Marchesi, Lorella Rusi and Julien Gautier for clinical trial management tasks and Dr. Carlo Morosi and Dr. Moreno Marino for Supplementary data to this article can be found online at https://doi. central radiology reviews. The authors would also like to thank the Grupo org/10.1016/j.eclinm.2019.03.007. Espaniol por la Investigacion in Sarcoma (GEIS), the Italian Sarcoma Group (ISG) and the French Sarcoma Group (FSG) for supporting the study and PharmaMar for funding trial organizational and logistics costs. References [1] Antonescu CR, Ladany M. Myxoid liposarcoma. In: Fletcher CDM, Bridge JA, Authors' Contribution Hogendoorn PCW, Mertens F, editors. WHO classifications of tumors of soft tissue and bone. Lyon: IARC; 2013. p. 39–41. [2] Fiore M, Grosso F, Lo Vullo S, et al. Myxoid/round cell and pleomorphic A. 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