1. Stem Cells In Clinical Practice: STELLA Experience Manolo D’Arcangelo Department of Oncology Ospedale Civile di Livorno

2. Stem cells in clinical practice: from bench to bedside CSCs are thought to be the only cancer cell population able to sustain tumor development growth and progression. Current therapies are largely ineffective against CSCs, explaining the high rate of failure of standard treatments.

3. STELLA project: our proposal STELLA: A feasibility study on cancer STem cELLs sensitivity Assay Platinum doublet ErlotinibDocetaxel ????? Advanced NSCLC Personalized treatment Tumor tissue/effusion collection for CSCs chemosensitivity assay

4. STELLA project: CSCs isolation Enzimatic digestion CD133+ cells Culture conditions select for immature cancer cells Chemosensitivity assay Flow cytometric analysis Orthotopic xenograft

5. Chemotherapeutic/biological agents up to 96h Orange acridine staining High sensitivity Average sensitivityLow sensitivity STELLA project: chemosensitivity assay - LAB

6. Treatment choice STELLA project: chemosensitivity assay - CLINIC

7. STELLA project: Study End-points Primary: - To evaluate the feasibility of the project in clinical practice. Secondary: - To identify LC, CRC and BC stem cells. - To investigate the sensitivity to anti-tumor agents in vitro. - To identify drugs potentially effective for a specific patient

8. STELLA project: patients selection criteria Inclusion criteria - Histologically/cytologically confirmed diagnosis of metastatic LC, CRC and BC. - Availability of tumor tissue suitable for CSCs extraction. - Performance status of 100% according to Karnofsky score. - Failure of conventional therapies or no therapy of proven efficacy. - Adequate hematological, renal and liver functions. - No concomitant comorbidity potentially interfering with the study. - Informed consent form signature. Exlcusion criteria - No possibility to obtain fresh tumor tissue. - Performance status <100% according to Karnofsky score. - Patient suitable for standard therapies. - Important comorbidity interfering with the study. - Significant alteration of liver, hematological or renal function(s). - No informed consent form signature.

9. STELLA Results: Patients Characteristics Number of patients23 Median age (range; years)66 (42-85) Sex Male Female 15 (65%) 8 (35%) Primary cancer Lung Cancer Colorectal Cancer Breast Cancer Other 18 (78%) 3 (13%) 0 2 (9%) Histology Adenocarcinoma Squamous cell carcinoma Small cell carcinoma Other 18 (78%) 1 (4%) 3 (13%) 1 (4%) Molecular alteration EGFR mutation ALK translocation K-RAS mutation 4 (17%) 1 (4%) 3 (13%) Number of tissue/effusion collections24 Specimen collection site Liver biopsy Lymph node biopsy Lung nodule excision Ascitis/pleural/pericardial effusion 6 (25%) 3 (12,5%) 2 (8%) 13 (54%)

10. STELLA Results: CSCs isolation -15 cases (63%) of the 24 procedures - Failure main reasons: -Inadequate material (8) -Delivery accident (1) -Failure according to primary cancer: - 30% of LC - 67% of CRC

11. STELLA Results: Chemosensitivity Assay -7 assays (29%) performed (preliminary data) - All patients had LC: -5 adenocarcinoma -1 undifferentiated NSCLC -1 SCLC -Median time for results: 51 days (range: 37-95) -Median number of tested drugs: 15 (range: 5-28) -In 6 of the 7 perfomed assays, no drug or combination showed a CSC mortality superior to 50%. In one case 4 regimens produced a CSC mortality >50% and 1 combination gave a mortality of 80%. -To date, no patient treated.

12. Our experience: a case report - 26 yo man - Squamous cell lung carcinoma with metastases to liver and lungs - EGFR, KRAS, HER-2 wild type, no ALK rearrangement - 3 previous treatment lines: CDDP+gemcitabine, CBDCA+paclitaxel, docetaxel Oxaliplatin 130 mg/mq d1 Paclitaxel 175 mg/mq d1 every 21 days

13. Our experience: a case report After two cycles of chemotherapyBasal assessmentAfter four cycles of chemotherapy

14. STELLA project: Conclusions The procedure is feasible in clinical practice. Best results with malignant effusions. Sensitivity assay performed in about 1/3 of patients. Efficacy data still not available.

15. Phase II trial: ready to go!

16. manolo_darc@libero.it A special thanks to: Dr. Matilde Todaro Jessica Salvini Dr. Elisa Lani