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Background: Biologically distinct sub-types of diffuse large B-cell lymphoma (DLBCL) can be identified using gene expression analysis to determine their cell of origin (COO), corresponding to germinal centre (GCB) or activated B‐cells (ABC). This study investigated whether adding bortezomib(B) to standard therapy could improve outcomes in these subtypes.Methods: The REMoDL-B trial is an open-label adaptive two-stage randomised controlled trial at 107 centres in the United Kingdom and Switzerland. Eligible patients (pts) had previously untreated, histologically confirmed DLBCL with sufficient diagnostic material for gene expression profiling and pathology review; age 18 years or older; Eastern Cooperative Oncology Group performance status of ≤2; bulky stage I or stage II-IV requiring full course chemotherapy; measurable disease, and cardiac, lung, renal and liver function sufficient to tolerate chemotherapy. Pts initially received 1 cycle of standard R‐CHOP. During this time, gene expression profiling by whole genome cDNA-mediated annealing, selection, extension and ligation assay was performed on routine diagnostic biopsy material. Patients were then centrally assigned (1:1) via a web-based system, with block randomisation stratified by international prognostic index and COO subtype to continue R‐CHOP +/‐ bortezomib (1.3 mg/m2 IV or 1.6 mg/m2 SC) days 1+8 for cycles 2‐6. The primary endpoint was 30 month progression‐free survival (PFS) for the GCB + ABC population. The primary analysis was intention-to-treat. The safety population consisted of all participants who received at least one dose of study drug. The study was registered at ClinicalTrials.gov: NCT01324596. We report the PFS and safety outcomes for patients in the follow-up phase after the required number of events occurred. Recruitment and treatment has completed for all participants, with long-term follow-up continuingFindings: Between June 2011 and June 2015, 1128 eligible pts were registered and a total of 918 randomised. There was no evidence for a difference in PFS in the combined GCB + ABC population between R‐CHOP (N=361)and RB‐CHOP (N=358) (30 month PFS: 70.6% vs 75.2% respectively) adjusted HR = 0.82, 95% CI 0.63 - 1.08; P=0.16. The most common Grade ≥3 adverse event experienced was haematological toxicity, with 178 (39.8%) and 187 (42.1%) of pts receiving R-CHOP and RB-CHOP experienced, respectively. However, RB‐CHOP was not associated with increased haematological toxicity and 87% of pts completed 6 cycles; Grade ≥3 neuropathy occurred in 3.8% RB‐CHOP vs 1.8% R‐CHOP pts. Serious adverse events occurred in 190 (42.5%) and 223 (50.2%) of pts, including 5 and 4 treatment-related deaths in pts receiving R-CHOP and RB-CHOP, respectively.Interpretation: This is the first large-scale study in DLBCL to use real-time molecular characterisation for prospective stratification and randomisation, and subsequent analysis of biologically distinct subgroups. The addition of bortezomib did not improve outcomes in the ABC subgroup as expected, but proteosome inhibition could be investigated as a possible means to improve the treatment of cytogenetic 'double-hit' DLBCL.Funding: Janssen-Cilag, Bloodwise and Cancer Research UK.

Background: Src is involved in cancer invasion and metastasis. AZD0424, an oral inhibitor of Src and ABL1, has shown evidence of anti-tumour activity in pre-clinical studies. Methods: A phase Ia, dose escalation study was performed to assess the safety of continuous oral dosing with AZD0424 in advanced solid tumours. Secondary objectives included investigation of AZD0424 pharmacokinetics, effect on Src activity using markers of bone turnover, and anti-tumour activity. Results: 41 patients were treated; 34 received AZD0424 o.d. at doses ranging from 5 mg to 150 mg, and seven received 40 mg b.d. 41.5% of patients experienced at least one AZD0424-related adverse event that was Grade 3-5 in severity, with patients treated at doses above 60 mg/day experiencing multiple treatment-related toxicities. The most commonly observed AZD0424-related adverse events were nausea, fatigue, anorexia and alopecia. Cmax and AUC increased linearly with dose and the mean ± SD t1/2 was 8.4 ± 2.8 hours. Clear evidence of Src target inhibition was seen at doses ≥ 20 mg/day. No responses were observed and seven patients (17.1%) achieved stable disease lasting 6 weeks or more. Conclusion: AZD0424 displayed no evidence of efficacy as monotherapy despite a clear pharmacodynamic effect. Further evaluation of AZD0424 monotherapy in patients with solid tumours is not recommended.

Purpose: A phase I trial of AT9283 (a multitargeted inhibitor of Aurora kinases A and B) was conducted in children and adolescents with solid tumors, to identify maximum-tolerated dose (MTD), safety, efficacy, pharmacokinetics, and pharmacodynamic (PD) activity. Experimental Design: AT9283 was administered as a 72-hour continuous intravenous infusion every 3 weeks. A rolling-six design, explored six dose levels (7, 9, 11.5, 14.5, 18.5, and 23 mg/m2/d). Pharmacokinetic and PD assessments, included inhibition of phospho-histone 3 (pHH3) in paired skin punch biopsies. Results: Thirty-three patients were evaluable for toxicity. There were six dose-limiting toxicities and the MTD was 18.5 mg/m2/d. Most common drug-related toxicities were hematologic (neutropenia, anemia, and thrombocytopenia in 36.4%, 18.2%, and 21.2% of patients), which were grade ≥3 in 30.3%, 6.1%, and 3% of patients. Nonhematologic toxicities included fatigue, infections, febrile neutropenia and ALT elevation. One patient with central nervous system–primitive neuroectodermal tumor (CNS-PNET) achieved a partial response after 16 cycles and 3 cases were stable for four or more cycles. Plasma concentrations were comparable with those in adults at the same dose level, clearance was similar although half-life was shorter (4.9 ± 1.5 hours, compared with 8.4 ± 3.7 hours in adults). Inhibition of Aurora kinase B was shown by reduction in pHH3 in 17 of 18 patients treated at ≥11.5 mg/m2/d. Conclusion: AT9283 was well tolerated in children and adolescents with solid tumors with manageable hematologic toxicity. Target inhibition was demonstrated. Disease stabilization was documented in intracranial and extracranial pediatric solid tumors and a phase II dose determined. Clin Cancer Res; 21(2); 267–73. ©2014 AACR.