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Trial details imported from ClinicalTrials.gov
For full trial details, please see the original record at
https://clinicaltrials.gov/study/NCT00490139
Registration number
NCT00490139
Ethics application status
Date submitted
20/06/2007
Date registered
22/06/2007
Titles & IDs
Public title
ALTTO (Adjuvant Lapatinib And/Or Trastuzumab Treatment Optimisation) Study; BIG 2-06/N063D
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Scientific title
A Randomised, Multi-centre, Open-label, Phase III Study of Adjuvant Lapatinib, Trastuzumab, Their Sequence and Their Combination in Patients With HER2/ErbB2 Positive Primary Breast Cancer
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Secondary ID [1]
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CLAP016B2301
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Secondary ID [2]
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EGF106708
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Universal Trial Number (UTN)
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Trial acronym
ALTTO
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
Neoplasms, Breast
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Condition category
Condition code
Cancer
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Breast
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Intervention/exposure
Study type
Interventional
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Description of intervention(s) / exposure
Treatment: Drugs - Lapatinib
Treatment: Other - Trastuzumab
Active comparator: Arm 1: Trastuzumab - Design 1: Trastuzumab 8mg/kg IV loading dose followed by 6mg/kg IV every 3 weeks for a total of 52 weeks.
Design 2: Either paclitaxel 80mg/m2 IV weekly for 12 weeks OR docetaxel 75mg/m2 IV every 3 weeks for 4 cycles administered concomitantly with trastuzumab 4mg/kg IV loading dose followed by 2mg/kg IV weekly. After completion of chemotherapy, trastuzumab administered every 3 weeks (6mg/kg IV without loading dose) for an additional 40 weeks (52 weeks total).
Design 2B: Docetaxel 75mg/m2 and carboplatin AUC 6 every 3 weeks for 6 cycles (18 weeks) administered concomitantly with trastuzumab 4mg/kg IV loading dose followed by 2mg/kg IV weekly. After completion of chemotherapy, trastuzumab (6mg/kg without loading dose) every 3 weeks for an additional 40 weeks (52 weeks total).
Experimental: Arm 2: Lapatinib - Based on the IDMC results from 18 August 2011, any patient enrolled onto Arm 2 should be considered for a new treatment strategy based on discussion with their physician.
Design 1: Lapatinib 1500mg oral daily for a total of 52 weeks.
Design 2: Either paclitaxel 80mg/m2 IV weekly for 12 weeks OR docetaxel 75mg/m2 IV every 3 weeks for 4 cycles administered concomitantly with oral lapatinib at 750mg daily. After completion of chemotherapy, oral lapatinib administered at 1500mg daily for an additional 40 weeks (52 weeks total).
Design 2B: Docetaxel 75mg/m2 and carboplatin AUC 6 every 3 weeks for 6 cycles (18 weeks) administered concomitantly with oral lapatinib at 750mg daily. After completion of chemotherapy, the dose of lapatinib will be increased to 1500mg oral daily for an additional 40 weeks (52 weeks total).
Experimental: Arm 3: Trastuzumab followed by Lapatinib - Design 1: Trastuzumab (4mg/kg IV loading dose followed by 2mg/kg IV weekly) for 12 weeks followed by a 6 week treatment-free interval followed by oral lapatinib 1500mg daily for 34 weeks (52 weeks total).
Design 2: Trastuzumab (4mg/kg IV loading dose followed by 2mg/kg IV weekly) for 12 weeks administered concomitantly and either paclitaxel 80mg/m2 IV weekly for 12 weeks OR docetaxel 75mg/m2 every 21 days for 4 cycles; followed by a 6 week treatment-free interval followed by oral lapatinib 1500mg daily for 34 weeks (52 weeks total).
Design 2B: Docetaxel 75mg/m2 and carboplatin AUC 6 every 3 weeks for 6 cycles (18 weeks) administered concomitantly with trastuzumab (4mg/kg IV loading dose followed by 2mg/kg IV weekly) followed by a 6 week treatment-free interval followed by oral lapatinib 1500 mg daily for 28 weeks (52 weeks total).
Experimental: Arm 4: Lapatinib in combination with Trastuzumab - Design 1: Oral lapatinib 1000 mg daily concurrent with trastuzumab 8 mg/kg IV loading dose followed by 6mg/kg IV every 3 weeks (52 weeks total).
Design 2: Trastuzumab (4mg/kg loading dose followed by 2mg/kg IV weekly) concurrent with oral lapatinib 750 mg daily and either paclitaxel 80mg/m2 IV weekly for 12 weeks OR docetaxel 75mg/m2 every 21 days for 4 cycles (12 weeks). After completion of chemotherapy, the dose of lapatinib will be increased to 1000mg daily concurrently with trastuzumab every 3 weeks (6mg/kg without loading dose) for an additional 40 weeks (52 weeks total).
Design 2B: Docetaxel 75mg/m2 and carboplatin AUC 6 every 3 weeks for 6 cycles (18 weeks) administered concurrently with oral lapatinib 750mg plus weekly trastuzumab (4mg/kg IV loading dose followed by 2mg/kg IV. After the completion of chemotherapy, trastuzumab will be administered every 3 weeks (6mg/kg without loading dose) concurrent with lapatinib 1000mg daily for an additional 40 weeks (52 weeks total).
Treatment: Drugs: Lapatinib
Small molecule inhibitor
Treatment: Other: Trastuzumab
Antibody
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Intervention code [1]
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Treatment: Drugs
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Intervention code [2]
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Treatment: Other
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Comparator / control treatment
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Control group
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Outcomes
Primary outcome [1]
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Disease-free Survival (DFS)
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Assessment method [1]
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Disease-free survival is defined as the interval between randomization and the date of the first occurence of disease recurrence (local, regional or distant), a contralateral invasive breast cancer, a second primary cancer (SPC), or death from any cause. DFS was estimated using the Kaplan Meier method.The percentile data values presented here indicate the percentage (95, 90, 85, 80 and 75 percent) of participants who had disease free survival for the indicated years.
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Timepoint [1]
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From randomization until the date of the first occurrence of disease recurrence, a contralateral invasive breast cancer, a second primary cancer, or death from any cause (median follow-up of 4.5 years)
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Secondary outcome [1]
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Overall Survival (OS)
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Assessment method [1]
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Overall survival is defined as the time from randomization until death due to any cause. Overall survival was calculated in years as (date of death minus the date of randomization +1) divided by 365.25. The percentile data values presented here indicate the percentage (99, 98, 97, 96, 95 and 90 percent) of participants who survived for the indicated years.
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Timepoint [1]
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From randomization until death due to any cause (median follow-up of 4.5 years)
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Secondary outcome [2]
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Time to Recurrence
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Assessment method [2]
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Time to recurrence is defined as the interval between the date of randomization and the date of the first occurrence of a disease recurrence (local, regional or distant). The percentile data values presented here indicate the percentage (95, 90, 85, and 80 percent) of participants who did not have disease recurrence for the indicated years. IDMC=Independent Data Monitoring Committee.
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Timepoint [2]
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From randomization until the date of the first occurrence of a disease recurrence (median follow-up of 4.5 years)
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Secondary outcome [3]
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Time to Distant Recurrence
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Assessment method [3]
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Time to distant recurrence is defined as the interval between the date of randomization and the date of the first occurrence of distant recurrence (including central nervous system recurrence). The percentile data values presented here indicate the percentage (95, 90, 85 and 80 percent) of participants who did not have distant recurrence for the indicated years.
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Timepoint [3]
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From randomization until the date of the first occurrence of distant recurrence (median follow-up of 4.5 years)
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Secondary outcome [4]
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Time to Central Nervous System Recurrence
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Assessment method [4]
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Time to central nervous system recurrence is defined as the time from randomization until the first central nervous system recurrence. Both brain metastasis and meningitis carcinomatosa were considered.The percentile data values presented here indicate that 95 percent of participants did not have central nervous system recurrence for the indicated years.
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Timepoint [4]
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From randomization until the first central nervous system recurrence (median follow-up of 4.5 years)
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Secondary outcome [5]
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DFS Ignoring Non-breast Second Primary Malignancies
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Assessment method [5]
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Disease-free survival is defined as the interval between randomization and the date of the first occurence of disease recurrence (local, regional or distant), a contralateral invasive breast cancer, a second primary cancer, or death from any cause. DFS was estimated using the Kaplan Meier method. The non-breast second primary malignancies were not considered events.The percentile data values presented here indicate the percentage (95, 90, 85, 80 and 75 percent) of participants who did not have DFS ignoring non-breast second primary malignancies for the indicated years. Zero participants were analyzed in the lapatinib arm, as the IDMC discontinued the lapatinib-alone arm due to futility at the time of the first interim analysis (lapatinib participants were then offered trastuzumab).
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Timepoint [5]
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From randomization until the date of the first occurrence of disease recurrence, a contralateral invasive breast cancer, a second primary cancer, or death from any cause (median follow-up of 4.5 years)
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Eligibility
Key inclusion criteria
* Age = 18 years
* Eastern Cooperative Oncology Group (ECOG) performance status = 1;
* Non-metastatic operable primary invasive adenocarcinoma of the breast fulfilling the following:
1. Histologically confirmed
2. Adequately excised (exceptions: patients who have 'non-resectable' deep margin invasion are eligible provided they have had or will receive radiotherapy encompassing the region concerned; patients with histologically documented infiltration of the skin (pT4) are eligible provided they have undergone or will receive radiotherapy encompassing the tumour bed);
3. Axilla dissected; sentinel node sampling is allowed provided that axillary dissection follows confirmation of a positive sentinel node; sentinel node sampling alone is NOT acceptable after neoadjuvant chemotherapy (in patients receiving neoadjuvant chemotherapy lymph node status will be considered unknown, regardless of the results of post-chemotherapy axillary dissection);
4. Axillary node positive patient OR node negative patient with a tumour greater than or equal to 1.0 cm in greatest diameter. For clarification, isolated tumour cells (ITC) are considered pN0 and micrometastases are considered pN1
* Known hormone receptor status (ER/PgR or ER alone)
* For Designs 1 and 2: Patients must have received at least four cycles of an approved anthracycline-based (neo-) adjuvant chemotherapy regimen or listed as an exception in Table 5 of the protocol.
For Design 1: Randomization must be performed no longer than 12 weeks from day 1 of the last chemotherapy cycle after obtaining a post-chemotherapy LVEF = 50. Study treatment must start no more than 14 days after randomization For Design 2: Randomization must be performed no longer than 6 weeks from day 1 of the last anthracycline-containing chemotherapy cycle after obtaining a post-anthracycline chemotherapy LVEF = 50. Study treatment must start no more than 14 days after randomization and must be concurrent with taxanes.
For Design 2B: Randomisation must be performed no longer than 8 weeks from definitive surgery. Non-anthracycline platinum containing regimen (docetaxel and carboplatin) and study treatment must start concomitantly and no more than 14 days after randomisation.
* Baseline LVEF =50% measured by echocardiography or MUGA scan. For Design 1 and Design 2 - after completion of all anthracycline-based (neo-) adjuvant chemotherapy and prior to the targeted therapy(ies); for Design 2B - prior to targeted therapy(ies) and chemotherapy (docetaxel and carboplatin)
* Over expression and/or amplification of HER2 in the invasive component of the primary tumour (in case of neoadjuvant treatment, tissue sample used for HER2 testing should be collected before neoadjuvant treatment starts), according to one of the following definitions [Wolff et al 2007] and confirmed by central laboratory prior to randomization:
* 3+ over expression by IHC (> 30% of invasive tumour cells);
* 2+ or 3+ (in 30% or less neoplastic cells) over expression by IHC AND in situ hybridization (FISH/CISH) test demonstrating HER2 gene amplification;
* HER2 gene amplification by FISH/CISH ( > 6 HER2 gene copies per nucleus, or a FISH ratio [HER2 gene copies to chromosome 17 signals] of > than 2.2.) Patients with a negative or equivocal overall result (FISH test ratio of = 2.2, = 6.0 HER2 gene copies per nucleus) and staining scores of 0, 1+, 2+ or 3+ (in 30% or less neoplastic cells) by IHC are not eligible for participation in the trial.
Equivocal local results may be submitted for a final determination by the central laboratory.
* Completion of all necessary baseline laboratory and radiological investigations
* Signed written informed consent (approved by an Independent Ethics Committee (IEC) and obtained prior to any study specific screening procedures).
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Minimum age
18
Years
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Maximum age
No limit
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Sex
Both males and females
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Can healthy volunteers participate?
No
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Key exclusion criteria
* History of any prior (ipsi- and/or contralateral) invasive breast carcinoma;
* Past (less than 10 years) or current history of malignant neoplasms, except for curatively treated 1) basal and squamous cell carcinoma of the skin or 2) carcinoma in situ of the cervix.
NOTE: Patients with a prior malignancy diagnosed greater than 10 years in the past who have been curatively treated with surgery ONLY, WITHOUT radiation therapy or systemic therapy (chemotherapy or endocrine) are eligible for the study. Patients with any prior diagnosis of breast cancer or melanoma, at any time, are excluded from this study.
* Any clinically staged T4 tumour, including inflammatory breast cancer;
* Bilateral tumours;
* This exclusion criterion has been removed as of protocol amendment 1.
NOTE: multifocal/multicentric tumours are permitted:
* If the patient is node-negative: one of the lesions must be equal or greater than 1.0 cm (sum of the lesion diameters is not acceptable) AND must have positive HER2 status centrally-confirmed;
* If patient is node-positive: lesion size does not matter BUT one of the lesions must have HER2 positivity centrally-confirmed. If several lesions are found to be HER2 positive locally, the largest lesion should be considered for central review.
* Maximum cumulative dose of doxorubicin >360mg/m² or maximum cumulative dose of epirubicin >720mg/m² or any prior anthracyclines unrelated to the present breast cancer;
* (Neo-) or adjuvant chemotherapy using peripheral stem cell or bone marrow stem cell support;
* Any prior mediastinal irradiation except internal mammary node irradiation for the present breast cancer;
* Patients with positive or suspicious internal mammary nodes identified by sentinel node technique which have not been irradiated or will not be irradiated, or patients with supraclavicular lymph node involvement (confirmed by fine needle aspirate or biopsy);
* Prior use of anti-HER2 therapy for any reason or other prior biologic or immunotherapy for breast cancer;
* Concurrent anti-cancer treatment, except hormonal therapy or radiotherapy for the present breast cancer;
* Concurrent anti-cancer treatment in another investigational trial with hormone therapy or immunotherapy unless approved by the Executive Committee:
* Serious cardiac illness or medical conditions including but not confined to:
History of documented congestive heart failure (CHF) or systolic dysfunction (LVEF <50%); High-risk uncontrolled arrhythmias (ventricular tachycardia, high-grade AV-block, supraventricular arrhythmias which are not adequately rate-controlled); Angina pectoris requiring antianginal medication; Clinically significant valvular heart disease; Evidence of transmural infarction on ECG; Poorly controlled hypertension (e.g. systolic >180mm Hg or diastolic >100mm Hg);
* Other concurrent serious diseases that may interfere with planned treatment including severe pulmonary conditions/illness;
* Any of the following abnormal laboratory tests immediately prior to randomization:
serum total bilirubin >1.5 x upper limit of normal (ULN), in the case of known Gilbert's syndrome, a higher serum total bilirubin (<2 X ULN) is allowed; alanine amino transferase (ALAT) or aspartate amino transferase (ASAT) >2.5 x ULN; alkaline phosphatase (ALP) > 2.5 x ULN; serum creatinine >2.0 x ULN; total white blood cell count (WBC) <2.5 x 10^9/L; absolute neutrophil count <1.5 x 10^9/L; platelets <100 x 10^9/L.
* Unresolved or unstable serious adverse events from prior adjuvant chemotherapy or radiotherapy;
* Malabsorption syndrome, any disease significantly affecting gastrointestinal function, or resection of the stomach or small bowel, or persons unable to swallow oral medication. Subjects with ulcerative colitis are also excluded;
* Pregnant, lactating or women of childbearing potential without a negative pregnancy test - urine or serum - within 7 days prior to randomization, irrespective of the method of contraception used, including tubal ligation;
* Women of childbearing potential and male participants with partners of child bearing potential, including women whose last menstrual period was <12 months ago (unless surgically sterile) who are unable or unwilling to use adequate contraceptive measures during study treatment (adequate contraceptive measures: intra-uterine device, barrier method - condoms, diaphragm - also in conjunction with spermicidal jelly, or total abstinence. Oral, injectable, or implant hormonal contraceptives are not indicated in this patient population);
* Concomitant use of CYP3A4 inhibitors or inducers.
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Study design
Purpose of the study
Treatment
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Allocation to intervention
Randomised controlled trial
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Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
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Methods used to generate the sequence in which subjects will be randomised (sequence generation)
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Masking / blinding
Open (masking not used)
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Who is / are masked / blinded?
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Intervention assignment
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Other design features
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Phase
Phase 3
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Type of endpoint/s
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Statistical methods / analysis
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Recruitment
Recruitment status
Completed
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Data analysis
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Reason for early stopping/withdrawal
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Other reasons
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Date of first participant enrolment
Anticipated
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Actual
16/05/2007
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Date of last participant enrolment
Anticipated
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Actual
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Date of last data collection
Anticipated
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Actual
1/07/2021
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Sample size
Target
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Accrual to date
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Final
8382
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Recruitment in Australia
Recruitment state(s)
NSW,QLD,SA,TAS,VIC,WA
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Recruitment hospital [1]
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Novartis Investigative Site - Camperdown
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2050 - Camperdown
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2450 - Coffs Harbour
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2139 - Concord
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2747 - Kingswood
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2170 - Liverpool
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2060 - North Sydney
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2444 - Port Macquarie
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2031 - Randwick
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2430 - Taree
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2485 - Tweed Heads
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2650 - Wagga Wagga
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2298 - Waratah
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2145 - Westmead
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4560 - Nambour
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4101 - South Brisbane
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4102 - Woolloongabba
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5000 - Adelaide
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5042 - Bedford Park
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5011 - Woodville
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7000 - Hobart
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3128 - Box Hill
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3165 - East Bentleigh
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3002 - East Melbourne
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3065 - Fitzroy
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3011 - Footscray
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3199 - Frankston
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3084 - Heidelberg
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3002 - Melbourne
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3050 - Parkville
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3135 - Ringwood East
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3355 - Wendouree
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6230 - Bunbury
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6009 - Nedlands
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6008 - Subiaco
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2560 - Campbelltown
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2480 - Lismore
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6150 - Murdoch
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Recruitment outside Australia
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Alabama
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Illinois
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Massachusetts
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Country [23]
0
0
United States of America
Query!
State/province [23]
0
0
Michigan
Query!
Country [24]
0
0
United States of America
Query!
State/province [24]
0
0
Minnesota
Query!
Country [25]
0
0
United States of America
Query!
State/province [25]
0
0
Mississippi
Query!
Country [26]
0
0
United States of America
Query!
State/province [26]
0
0
Missouri
Query!
Country [27]
0
0
United States of America
Query!
State/province [27]
0
0
Montana
Query!
Country [28]
0
0
United States of America
Query!
State/province [28]
0
0
Nebraska
Query!
Country [29]
0
0
United States of America
Query!
State/province [29]
0
0
Nevada
Query!
Country [30]
0
0
United States of America
Query!
State/province [30]
0
0
New Hampshire
Query!
Country [31]
0
0
United States of America
Query!
State/province [31]
0
0
New Jersey
Query!
Country [32]
0
0
United States of America
Query!
State/province [32]
0
0
New Mexico
Query!
Country [33]
0
0
United States of America
Query!
State/province [33]
0
0
New York
Query!
Country [34]
0
0
United States of America
Query!
State/province [34]
0
0
North Carolina
Query!
Country [35]
0
0
United States of America
Query!
State/province [35]
0
0
North Dakota
Query!
Country [36]
0
0
United States of America
Query!
State/province [36]
0
0
Ohio
Query!
Country [37]
0
0
United States of America
Query!
State/province [37]
0
0
Oklahoma
Query!
Country [38]
0
0
United States of America
Query!
State/province [38]
0
0
Oregon
Query!
Country [39]
0
0
United States of America
Query!
State/province [39]
0
0
Pennsylvania
Query!
Country [40]
0
0
United States of America
Query!
State/province [40]
0
0
Rhode Island
Query!
Country [41]
0
0
United States of America
Query!
State/province [41]
0
0
South Carolina
Query!
Country [42]
0
0
United States of America
Query!
State/province [42]
0
0
South Dakota
Query!
Country [43]
0
0
United States of America
Query!
State/province [43]
0
0
Tennessee
Query!
Country [44]
0
0
United States of America
Query!
State/province [44]
0
0
Texas
Query!
Country [45]
0
0
United States of America
Query!
State/province [45]
0
0
Utah
Query!
Country [46]
0
0
United States of America
Query!
State/province [46]
0
0
Vermont
Query!
Country [47]
0
0
United States of America
Query!
State/province [47]
0
0
Virginia
Query!
Country [48]
0
0
United States of America
Query!
State/province [48]
0
0
Washington
Query!
Country [49]
0
0
United States of America
Query!
State/province [49]
0
0
West Virginia
Query!
Country [50]
0
0
United States of America
Query!
State/province [50]
0
0
Wisconsin
Query!
Country [51]
0
0
United States of America
Query!
State/province [51]
0
0
Wyoming
Query!
Country [52]
0
0
Argentina
Query!
State/province [52]
0
0
Buenos Aires
Query!
Country [53]
0
0
Argentina
Query!
State/province [53]
0
0
Santa Fe
Query!
Country [54]
0
0
Argentina
Query!
State/province [54]
0
0
Ciudad Autonoma de Buenos Aires
Query!
Country [55]
0
0
Argentina
Query!
State/province [55]
0
0
Mendoza
Query!
Country [56]
0
0
Argentina
Query!
State/province [56]
0
0
Quilmes
Query!
Country [57]
0
0
Argentina
Query!
State/province [57]
0
0
Tucuman
Query!
Country [58]
0
0
Austria
Query!
State/province [58]
0
0
Guessing
Query!
Country [59]
0
0
Austria
Query!
State/province [59]
0
0
Linz
Query!
Country [60]
0
0
Austria
Query!
State/province [60]
0
0
Rankweil
Query!
Country [61]
0
0
Austria
Query!
State/province [61]
0
0
Salzburg
Query!
Country [62]
0
0
Austria
Query!
State/province [62]
0
0
Steyr
Query!
Country [63]
0
0
Austria
Query!
State/province [63]
0
0
Vienna
Query!
Country [64]
0
0
Austria
Query!
State/province [64]
0
0
Villach
Query!
Country [65]
0
0
Austria
Query!
State/province [65]
0
0
Wien
Query!
Country [66]
0
0
Austria
Query!
State/province [66]
0
0
Wolfsberg
Query!
Country [67]
0
0
Belgium
Query!
State/province [67]
0
0
Aalst
Query!
Country [68]
0
0
Belgium
Query!
State/province [68]
0
0
Antwerpen
Query!
Country [69]
0
0
Belgium
Query!
State/province [69]
0
0
Bonheiden
Query!
Country [70]
0
0
Belgium
Query!
State/province [70]
0
0
Brasschaat
Query!
Country [71]
0
0
Belgium
Query!
State/province [71]
0
0
Brugge
Query!
Country [72]
0
0
Belgium
Query!
State/province [72]
0
0
Brussels
Query!
Country [73]
0
0
Belgium
Query!
State/province [73]
0
0
Brussel
Query!
Country [74]
0
0
Belgium
Query!
State/province [74]
0
0
Bruxelles
Query!
Country [75]
0
0
Belgium
Query!
State/province [75]
0
0
Charleroi
Query!
Country [76]
0
0
Belgium
Query!
State/province [76]
0
0
Edegem
Query!
Country [77]
0
0
Belgium
Query!
State/province [77]
0
0
Genk
Query!
Country [78]
0
0
Belgium
Query!
State/province [78]
0
0
Gent
Query!
Country [79]
0
0
Belgium
Query!
State/province [79]
0
0
Haine Saint Paul
Query!
Country [80]
0
0
Belgium
Query!
State/province [80]
0
0
Hasselt
Query!
Country [81]
0
0
Belgium
Query!
State/province [81]
0
0
Huy
Query!
Country [82]
0
0
Belgium
Query!
State/province [82]
0
0
Kortrijk
Query!
Country [83]
0
0
Belgium
Query!
State/province [83]
0
0
Leuven
Query!
Country [84]
0
0
Belgium
Query!
State/province [84]
0
0
Liege
Query!
Country [85]
0
0
Belgium
Query!
State/province [85]
0
0
Mons
Query!
Country [86]
0
0
Belgium
Query!
State/province [86]
0
0
Namur
Query!
Country [87]
0
0
Belgium
Query!
State/province [87]
0
0
Roeselare
Query!
Country [88]
0
0
Belgium
Query!
State/province [88]
0
0
Sint-Niklaas
Query!
Country [89]
0
0
Belgium
Query!
State/province [89]
0
0
Tournai
Query!
Country [90]
0
0
Belgium
Query!
State/province [90]
0
0
Turnhout
Query!
Country [91]
0
0
Belgium
Query!
State/province [91]
0
0
Verviers
Query!
Country [92]
0
0
Belgium
Query!
State/province [92]
0
0
Wilrijk
Query!
Country [93]
0
0
Belgium
Query!
State/province [93]
0
0
Yvoir
Query!
Country [94]
0
0
Brazil
Query!
State/province [94]
0
0
Bahía
Query!
Country [95]
0
0
Brazil
Query!
State/province [95]
0
0
Minas Gerais
Query!
Country [96]
0
0
Brazil
Query!
State/province [96]
0
0
Rio Grande Do Sul
Query!
Country [97]
0
0
Brazil
Query!
State/province [97]
0
0
São Paulo
Query!
Country [98]
0
0
Brazil
Query!
State/province [98]
0
0
Rio de Janeiro
Query!
Country [99]
0
0
Bulgaria
Query!
State/province [99]
0
0
Shumen
Query!
Country [100]
0
0
Bulgaria
Query!
State/province [100]
0
0
Sofia
Query!
Country [101]
0
0
Bulgaria
Query!
State/province [101]
0
0
Varna
Query!
Country [102]
0
0
Canada
Query!
State/province [102]
0
0
British Columbia
Query!
Country [103]
0
0
Canada
Query!
State/province [103]
0
0
New Brunswick
Query!
Country [104]
0
0
Canada
Query!
State/province [104]
0
0
Ontario
Query!
Country [105]
0
0
Canada
Query!
State/province [105]
0
0
Prince Edward Island
Query!
Country [106]
0
0
Canada
Query!
State/province [106]
0
0
Quebec
Query!
Country [107]
0
0
Canada
Query!
State/province [107]
0
0
Saskatchewan
Query!
Country [108]
0
0
Chile
Query!
State/province [108]
0
0
Región De La Araucania
Query!
Country [109]
0
0
Chile
Query!
State/province [109]
0
0
Región De Los Lagos
Query!
Country [110]
0
0
Chile
Query!
State/province [110]
0
0
Región Metro De Santiago
Query!
Country [111]
0
0
Chile
Query!
State/province [111]
0
0
Valparaíso
Query!
Country [112]
0
0
Chile
Query!
State/province [112]
0
0
Arica
Query!
Country [113]
0
0
China
Query!
State/province [113]
0
0
Guangdong
Query!
Country [114]
0
0
China
Query!
State/province [114]
0
0
Beijing
Query!
Country [115]
0
0
China
Query!
State/province [115]
0
0
Shanghai
Query!
Country [116]
0
0
China
Query!
State/province [116]
0
0
Tianjin
Query!
Country [117]
0
0
Croatia
Query!
State/province [117]
0
0
Varazdin
Query!
Country [118]
0
0
Croatia
Query!
State/province [118]
0
0
Zagreb
Query!
Country [119]
0
0
Czechia
Query!
State/province [119]
0
0
Brno
Query!
Country [120]
0
0
Czechia
Query!
State/province [120]
0
0
Ceske Budejovice
Query!
Country [121]
0
0
Czechia
Query!
State/province [121]
0
0
Chomutov
Query!
Country [122]
0
0
Czechia
Query!
State/province [122]
0
0
Jihlava
Query!
Country [123]
0
0
Czechia
Query!
State/province [123]
0
0
Novy Jicin
Query!
Country [124]
0
0
Czechia
Query!
State/province [124]
0
0
Olomouc
Query!
Country [125]
0
0
Czechia
Query!
State/province [125]
0
0
Pardubice
Query!
Country [126]
0
0
Czechia
Query!
State/province [126]
0
0
Praha 10
Query!
Country [127]
0
0
Czechia
Query!
State/province [127]
0
0
Praha 2
Query!
Country [128]
0
0
Czechia
Query!
State/province [128]
0
0
Praha 4
Query!
Country [129]
0
0
Czechia
Query!
State/province [129]
0
0
Praha 5
Query!
Country [130]
0
0
Czechia
Query!
State/province [130]
0
0
Praha 8
Query!
Country [131]
0
0
Czechia
Query!
State/province [131]
0
0
Usti nad Labem
Query!
Country [132]
0
0
Denmark
Query!
State/province [132]
0
0
Aalborg
Query!
Country [133]
0
0
Denmark
Query!
State/province [133]
0
0
Arhus C
Query!
Country [134]
0
0
Denmark
Query!
State/province [134]
0
0
Esbjerg
Query!
Country [135]
0
0
Denmark
Query!
State/province [135]
0
0
Herlev
Query!
Country [136]
0
0
Denmark
Query!
State/province [136]
0
0
Hilleroed
Query!
Country [137]
0
0
Denmark
Query!
State/province [137]
0
0
Koebenhavn Oe
Query!
Country [138]
0
0
Denmark
Query!
State/province [138]
0
0
Naestved
Query!
Country [139]
0
0
Denmark
Query!
State/province [139]
0
0
Odense
Query!
Country [140]
0
0
Denmark
Query!
State/province [140]
0
0
Roskilde
Query!
Country [141]
0
0
Denmark
Query!
State/province [141]
0
0
Vejle
Query!
Country [142]
0
0
Denmark
Query!
State/province [142]
0
0
Viborg
Query!
Country [143]
0
0
Estonia
Query!
State/province [143]
0
0
Tallinn
Query!
Country [144]
0
0
Estonia
Query!
State/province [144]
0
0
Tartu
Query!
Country [145]
0
0
France
Query!
State/province [145]
0
0
ANGERS Cedex 2
Query!
Country [146]
0
0
France
Query!
State/province [146]
0
0
Annecy
Query!
Country [147]
0
0
France
Query!
State/province [147]
0
0
Avignon
Query!
Country [148]
0
0
France
Query!
State/province [148]
0
0
Bayonne
Query!
Country [149]
0
0
France
Query!
State/province [149]
0
0
Bethune
Query!
Country [150]
0
0
France
Query!
State/province [150]
0
0
Bordeaux
Query!
Country [151]
0
0
France
Query!
State/province [151]
0
0
Brive La Gaillarde
Query!
Country [152]
0
0
France
Query!
State/province [152]
0
0
Bron
Query!
Country [153]
0
0
France
Query!
State/province [153]
0
0
Caen Cedex 05
Query!
Country [154]
0
0
France
Query!
State/province [154]
0
0
Caen
Query!
Country [155]
0
0
France
Query!
State/province [155]
0
0
Clermont Ferrand
Query!
Country [156]
0
0
France
Query!
State/province [156]
0
0
Coudekerque Branche
Query!
Country [157]
0
0
France
Query!
State/province [157]
0
0
Dijon Cedex
Query!
Country [158]
0
0
France
Query!
State/province [158]
0
0
Dijon
Query!
Country [159]
0
0
France
Query!
State/province [159]
0
0
Draguignan
Query!
Country [160]
0
0
France
Query!
State/province [160]
0
0
Grenoble Cedex 9
Query!
Country [161]
0
0
France
Query!
State/province [161]
0
0
Grenoble Cedex
Query!
Country [162]
0
0
France
Query!
State/province [162]
0
0
Hyeres
Query!
Country [163]
0
0
France
Query!
State/province [163]
0
0
La Seyne Sur Mer
Query!
Country [164]
0
0
France
Query!
State/province [164]
0
0
Le Chesnay
Query!
Country [165]
0
0
France
Query!
State/province [165]
0
0
Le Havre
Query!
Country [166]
0
0
France
Query!
State/province [166]
0
0
Le Mans
Query!
Country [167]
0
0
France
Query!
State/province [167]
0
0
Lille
Query!
Country [168]
0
0
France
Query!
State/province [168]
0
0
Lyon
Query!
Country [169]
0
0
France
Query!
State/province [169]
0
0
Marseille Cedex 09
Query!
Country [170]
0
0
France
Query!
State/province [170]
0
0
Marseille cedex 5
Query!
Country [171]
0
0
France
Query!
State/province [171]
0
0
Marseille
Query!
Country [172]
0
0
France
Query!
State/province [172]
0
0
Metz cedex 01
Query!
Country [173]
0
0
France
Query!
State/province [173]
0
0
Mont de Marsan
Query!
Country [174]
0
0
France
Query!
State/province [174]
0
0
Montauban
Query!
Country [175]
0
0
France
Query!
State/province [175]
0
0
Montbeliard
Query!
Country [176]
0
0
France
Query!
State/province [176]
0
0
Mulhouse
Query!
Country [177]
0
0
France
Query!
State/province [177]
0
0
Nancy
Query!
Country [178]
0
0
France
Query!
State/province [178]
0
0
Nice Cedex 2
Query!
Country [179]
0
0
France
Query!
State/province [179]
0
0
Nimes cedex 9
Query!
Country [180]
0
0
France
Query!
State/province [180]
0
0
Paris Cedex 10
Query!
Country [181]
0
0
France
Query!
State/province [181]
0
0
Paris Cedex 14
Query!
Country [182]
0
0
France
Query!
State/province [182]
0
0
Paris Cedex 5
Query!
Country [183]
0
0
France
Query!
State/province [183]
0
0
Perigueux
Query!
Country [184]
0
0
France
Query!
State/province [184]
0
0
Perin Sur Mer
Query!
Country [185]
0
0
France
Query!
State/province [185]
0
0
Perpignan
Query!
Country [186]
0
0
France
Query!
State/province [186]
0
0
Reims
Query!
Country [187]
0
0
France
Query!
State/province [187]
0
0
Rouen cedex 1
Query!
Country [188]
0
0
France
Query!
State/province [188]
0
0
Rouen
Query!
Country [189]
0
0
France
Query!
State/province [189]
0
0
Saint Gregoire
Query!
Country [190]
0
0
France
Query!
State/province [190]
0
0
Saint Jean
Query!
Country [191]
0
0
France
Query!
State/province [191]
0
0
Saint-Cloud
Query!
Country [192]
0
0
France
Query!
State/province [192]
0
0
Saint-Herblain
Query!
Country [193]
0
0
France
Query!
State/province [193]
0
0
Saint-Martin Boulogne
Query!
Country [194]
0
0
France
Query!
State/province [194]
0
0
Saint-Priest en Jarez Cedex
Query!
Country [195]
0
0
France
Query!
State/province [195]
0
0
Strasbourg
Query!
Country [196]
0
0
France
Query!
State/province [196]
0
0
Toulouse
Query!
Country [197]
0
0
France
Query!
State/province [197]
0
0
Tours cedex
Query!
Country [198]
0
0
France
Query!
State/province [198]
0
0
Valenciennes
Query!
Country [199]
0
0
France
Query!
State/province [199]
0
0
Vandoeuvre-Les-Nancy
Query!
Country [200]
0
0
France
Query!
State/province [200]
0
0
Villejuif Cedex
Query!
Country [201]
0
0
Germany
Query!
State/province [201]
0
0
Baden-Wuerttemberg
Query!
Country [202]
0
0
Germany
Query!
State/province [202]
0
0
Bayern
Query!
Country [203]
0
0
Germany
Query!
State/province [203]
0
0
Brandenburg
Query!
Country [204]
0
0
Germany
Query!
State/province [204]
0
0
Bremen
Query!
Country [205]
0
0
Germany
Query!
State/province [205]
0
0
Hessen
Query!
Country [206]
0
0
Germany
Query!
State/province [206]
0
0
Mecklenburg-Vorpommern
Query!
Country [207]
0
0
Germany
Query!
State/province [207]
0
0
Niedersachsen
Query!
Country [208]
0
0
Germany
Query!
State/province [208]
0
0
Nordrhein-Westfalen
Query!
Country [209]
0
0
Germany
Query!
State/province [209]
0
0
Rheinland-Pfalz
Query!
Country [210]
0
0
Germany
Query!
State/province [210]
0
0
Saarland
Query!
Country [211]
0
0
Germany
Query!
State/province [211]
0
0
Sachsen-Anhalt
Query!
Country [212]
0
0
Germany
Query!
State/province [212]
0
0
Sachsen
Query!
Country [213]
0
0
Germany
Query!
State/province [213]
0
0
Schleswig-Holstein
Query!
Country [214]
0
0
Germany
Query!
State/province [214]
0
0
Thueringen
Query!
Country [215]
0
0
Germany
Query!
State/province [215]
0
0
Berlin
Query!
Country [216]
0
0
Germany
Query!
State/province [216]
0
0
Friedrichshafen
Query!
Country [217]
0
0
Germany
Query!
State/province [217]
0
0
Hamburg
Query!
Country [218]
0
0
Germany
Query!
State/province [218]
0
0
Wuerzburg
Query!
Country [219]
0
0
Greece
Query!
State/province [219]
0
0
Athens
Query!
Country [220]
0
0
Greece
Query!
State/province [220]
0
0
Heraklion,Crete
Query!
Country [221]
0
0
Greece
Query!
State/province [221]
0
0
Patra
Query!
Country [222]
0
0
Greece
Query!
State/province [222]
0
0
Thessaloniki
Query!
Country [223]
0
0
Hong Kong
Query!
State/province [223]
0
0
Kowloon
Query!
Country [224]
0
0
Hong Kong
Query!
State/province [224]
0
0
Tuen Mun
Query!
Country [225]
0
0
Hungary
Query!
State/province [225]
0
0
Budapest
Query!
Country [226]
0
0
Hungary
Query!
State/province [226]
0
0
Gyor
Query!
Country [227]
0
0
Hungary
Query!
State/province [227]
0
0
Szeged
Query!
Country [228]
0
0
Hungary
Query!
State/province [228]
0
0
Szombathely
Query!
Country [229]
0
0
India
Query!
State/province [229]
0
0
Gurgaon
Query!
Country [230]
0
0
India
Query!
State/province [230]
0
0
Hyderabad
Query!
Country [231]
0
0
India
Query!
State/province [231]
0
0
Kolkatta (w.b.)
Query!
Country [232]
0
0
India
Query!
State/province [232]
0
0
Mangalore
Query!
Country [233]
0
0
India
Query!
State/province [233]
0
0
Mumbai
Query!
Country [234]
0
0
India
Query!
State/province [234]
0
0
Nagpur
Query!
Country [235]
0
0
India
Query!
State/province [235]
0
0
New Delhi
Query!
Country [236]
0
0
India
Query!
State/province [236]
0
0
Trivandrum
Query!
Country [237]
0
0
Ireland
Query!
State/province [237]
0
0
Dublin
Query!
Country [238]
0
0
Ireland
Query!
State/province [238]
0
0
Galway
Query!
Country [239]
0
0
Ireland
Query!
State/province [239]
0
0
Limerick
Query!
Country [240]
0
0
Ireland
Query!
State/province [240]
0
0
Sligo
Query!
Country [241]
0
0
Ireland
Query!
State/province [241]
0
0
Tallaght, Dublin
Query!
Country [242]
0
0
Ireland
Query!
State/province [242]
0
0
Wilton, Cork
Query!
Country [243]
0
0
Israel
Query!
State/province [243]
0
0
Beer-Sheva
Query!
Country [244]
0
0
Israel
Query!
State/province [244]
0
0
Haifa
Query!
Country [245]
0
0
Israel
Query!
State/province [245]
0
0
Holon
Query!
Country [246]
0
0
Israel
Query!
State/province [246]
0
0
Jerusalem
Query!
Country [247]
0
0
Israel
Query!
State/province [247]
0
0
Kfar Saba
Query!
Country [248]
0
0
Israel
Query!
State/province [248]
0
0
Netanya
Query!
Country [249]
0
0
Israel
Query!
State/province [249]
0
0
Ramat Gan
Query!
Country [250]
0
0
Israel
Query!
State/province [250]
0
0
Rehovot
Query!
Country [251]
0
0
Israel
Query!
State/province [251]
0
0
Tel Aviv
Query!
Country [252]
0
0
Italy
Query!
State/province [252]
0
0
Basilicata
Query!
Country [253]
0
0
Italy
Query!
State/province [253]
0
0
Campania
Query!
Country [254]
0
0
Italy
Query!
State/province [254]
0
0
Emilia-Romagna
Query!
Country [255]
0
0
Italy
Query!
State/province [255]
0
0
Friuli-Venezia-Giulia
Query!
Country [256]
0
0
Italy
Query!
State/province [256]
0
0
Lazio
Query!
Country [257]
0
0
Italy
Query!
State/province [257]
0
0
Liguria
Query!
Country [258]
0
0
Italy
Query!
State/province [258]
0
0
Lombardia
Query!
Country [259]
0
0
Italy
Query!
State/province [259]
0
0
Marche
Query!
Country [260]
0
0
Italy
Query!
State/province [260]
0
0
Piemonte
Query!
Country [261]
0
0
Italy
Query!
State/province [261]
0
0
Puglia
Query!
Country [262]
0
0
Italy
Query!
State/province [262]
0
0
Sardegna
Query!
Country [263]
0
0
Italy
Query!
State/province [263]
0
0
Sicilia
Query!
Country [264]
0
0
Italy
Query!
State/province [264]
0
0
Toscana
Query!
Country [265]
0
0
Italy
Query!
State/province [265]
0
0
Trentino-Alto Adige
Query!
Country [266]
0
0
Italy
Query!
State/province [266]
0
0
Chieti
Query!
Country [267]
0
0
Italy
Query!
State/province [267]
0
0
Cosenza
Query!
Country [268]
0
0
Japan
Query!
State/province [268]
0
0
Aichi
Query!
Country [269]
0
0
Japan
Query!
State/province [269]
0
0
Chiba
Query!
Country [270]
0
0
Japan
Query!
State/province [270]
0
0
Ehime
Query!
Country [271]
0
0
Japan
Query!
State/province [271]
0
0
Fukuoka
Query!
Country [272]
0
0
Japan
Query!
State/province [272]
0
0
Ibaraki
Query!
Country [273]
0
0
Japan
Query!
State/province [273]
0
0
Kanagawa
Query!
Country [274]
0
0
Japan
Query!
State/province [274]
0
0
Kyoto
Query!
Country [275]
0
0
Japan
Query!
State/province [275]
0
0
Osaka
Query!
Country [276]
0
0
Japan
Query!
State/province [276]
0
0
Saitama
Query!
Country [277]
0
0
Japan
Query!
State/province [277]
0
0
Tokyo
Query!
Country [278]
0
0
Korea, Republic of
Query!
State/province [278]
0
0
Gyeonggi-do
Query!
Country [279]
0
0
Korea, Republic of
Query!
State/province [279]
0
0
Incheon
Query!
Country [280]
0
0
Korea, Republic of
Query!
State/province [280]
0
0
Seoul
Query!
Country [281]
0
0
Korea, Republic of
Query!
State/province [281]
0
0
Suwon-si, Gyeonggi-do
Query!
Country [282]
0
0
Malaysia
Query!
State/province [282]
0
0
Kubang Kerian
Query!
Country [283]
0
0
Malaysia
Query!
State/province [283]
0
0
Sarawak
Query!
Country [284]
0
0
Mexico
Query!
State/province [284]
0
0
Estado De México
Query!
Country [285]
0
0
Mexico
Query!
State/province [285]
0
0
Yucatán
Query!
Country [286]
0
0
Mexico
Query!
State/province [286]
0
0
Chihuahua
Query!
Country [287]
0
0
Mexico
Query!
State/province [287]
0
0
Mexico City
Query!
Country [288]
0
0
Mexico
Query!
State/province [288]
0
0
Mexico D.F.
Query!
Country [289]
0
0
Mexico
Query!
State/province [289]
0
0
Mexico DF
Query!
Country [290]
0
0
Netherlands
Query!
State/province [290]
0
0
Amersfoort
Query!
Country [291]
0
0
Netherlands
Query!
State/province [291]
0
0
Amsterdam
Query!
Country [292]
0
0
Netherlands
Query!
State/province [292]
0
0
Arnhem
Query!
Country [293]
0
0
Netherlands
Query!
State/province [293]
0
0
Blaricum
Query!
Country [294]
0
0
Netherlands
Query!
State/province [294]
0
0
Delft
Query!
Country [295]
0
0
Netherlands
Query!
State/province [295]
0
0
Den Haag
Query!
Country [296]
0
0
Netherlands
Query!
State/province [296]
0
0
Eindhoven
Query!
Country [297]
0
0
Netherlands
Query!
State/province [297]
0
0
Gouda
Query!
Country [298]
0
0
Netherlands
Query!
State/province [298]
0
0
Hoofddorp
Query!
Country [299]
0
0
Netherlands
Query!
State/province [299]
0
0
Leeuwarden
Query!
Country [300]
0
0
Netherlands
Query!
State/province [300]
0
0
Leiden
Query!
Country [301]
0
0
Netherlands
Query!
State/province [301]
0
0
Leidschendam
Query!
Country [302]
0
0
Netherlands
Query!
State/province [302]
0
0
Purmerend
Query!
Country [303]
0
0
Netherlands
Query!
State/province [303]
0
0
Rotterdam
Query!
Country [304]
0
0
Netherlands
Query!
State/province [304]
0
0
Sittard-geleen
Query!
Country [305]
0
0
Netherlands
Query!
State/province [305]
0
0
Tilburg
Query!
Country [306]
0
0
Netherlands
Query!
State/province [306]
0
0
Utrecht
Query!
Country [307]
0
0
New Zealand
Query!
State/province [307]
0
0
Hamilton
Query!
Country [308]
0
0
New Zealand
Query!
State/province [308]
0
0
Palmerston North
Query!
Country [309]
0
0
New Zealand
Query!
State/province [309]
0
0
Wellington
Query!
Country [310]
0
0
Norway
Query!
State/province [310]
0
0
Forde
Query!
Country [311]
0
0
Norway
Query!
State/province [311]
0
0
Oslo
Query!
Country [312]
0
0
Norway
Query!
State/province [312]
0
0
Tromso
Query!
Country [313]
0
0
Pakistan
Query!
State/province [313]
0
0
Karachi
Query!
Country [314]
0
0
Pakistan
Query!
State/province [314]
0
0
Lahore
Query!
Country [315]
0
0
Pakistan
Query!
State/province [315]
0
0
Rawalpindi
Query!
Country [316]
0
0
Peru
Query!
State/province [316]
0
0
Callao
Query!
Country [317]
0
0
Peru
Query!
State/province [317]
0
0
Lima
Query!
Country [318]
0
0
Philippines
Query!
State/province [318]
0
0
Cebu
Query!
Country [319]
0
0
Philippines
Query!
State/province [319]
0
0
Quezon City
Query!
Country [320]
0
0
Philippines
Query!
State/province [320]
0
0
Sampaloc Manila
Query!
Country [321]
0
0
Philippines
Query!
State/province [321]
0
0
San Juan
Query!
Country [322]
0
0
Poland
Query!
State/province [322]
0
0
Bydgoszcz
Query!
Country [323]
0
0
Poland
Query!
State/province [323]
0
0
Elblag
Query!
Country [324]
0
0
Poland
Query!
State/province [324]
0
0
Gdansk
Query!
Country [325]
0
0
Poland
Query!
State/province [325]
0
0
Gliwice
Query!
Country [326]
0
0
Poland
Query!
State/province [326]
0
0
Krakow
Query!
Country [327]
0
0
Poland
Query!
State/province [327]
0
0
Olsztyn
Query!
Country [328]
0
0
Poland
Query!
State/province [328]
0
0
Opole
Query!
Country [329]
0
0
Poland
Query!
State/province [329]
0
0
Rzeszow
Query!
Country [330]
0
0
Poland
Query!
State/province [330]
0
0
Szczecin
Query!
Country [331]
0
0
Poland
Query!
State/province [331]
0
0
Warszawa
Query!
Country [332]
0
0
Poland
Query!
State/province [332]
0
0
Wroclaw
Query!
Country [333]
0
0
Romania
Query!
State/province [333]
0
0
Bucharest
Query!
Country [334]
0
0
Romania
Query!
State/province [334]
0
0
Bucuresti
Query!
Country [335]
0
0
Romania
Query!
State/province [335]
0
0
Cluj-Napoca
Query!
Country [336]
0
0
Romania
Query!
State/province [336]
0
0
Iasi
Query!
Country [337]
0
0
Russian Federation
Query!
State/province [337]
0
0
Arkhangelsk
Query!
Country [338]
0
0
Russian Federation
Query!
State/province [338]
0
0
Chelyabinsk
Query!
Country [339]
0
0
Russian Federation
Query!
State/province [339]
0
0
Irkutsk
Query!
Country [340]
0
0
Russian Federation
Query!
State/province [340]
0
0
Kazan
Query!
Country [341]
0
0
Russian Federation
Query!
State/province [341]
0
0
Kirov
Query!
Country [342]
0
0
Russian Federation
Query!
State/province [342]
0
0
Moscow
Query!
Country [343]
0
0
Russian Federation
Query!
State/province [343]
0
0
Novosibirsk
Query!
Country [344]
0
0
Russian Federation
Query!
State/province [344]
0
0
Omsk
Query!
Country [345]
0
0
Russian Federation
Query!
State/province [345]
0
0
Orenburg
Query!
Country [346]
0
0
Russian Federation
Query!
State/province [346]
0
0
Ryazan
Query!
Country [347]
0
0
Russian Federation
Query!
State/province [347]
0
0
Samara
Query!
Country [348]
0
0
Russian Federation
Query!
State/province [348]
0
0
St. Petersburg
Query!
Country [349]
0
0
Russian Federation
Query!
State/province [349]
0
0
Voronezh
Query!
Country [350]
0
0
Singapore
Query!
State/province [350]
0
0
Singapore
Query!
Country [351]
0
0
Slovakia
Query!
State/province [351]
0
0
Bratislava
Query!
Country [352]
0
0
Slovakia
Query!
State/province [352]
0
0
Kosice
Query!
Country [353]
0
0
Slovakia
Query!
State/province [353]
0
0
Poprad
Query!
Country [354]
0
0
Slovakia
Query!
State/province [354]
0
0
Rimavska Sobota
Query!
Country [355]
0
0
Slovakia
Query!
State/province [355]
0
0
Zilina
Query!
Country [356]
0
0
Slovenia
Query!
State/province [356]
0
0
Ljubljana
Query!
Country [357]
0
0
South Africa
Query!
State/province [357]
0
0
Capital Park
Query!
Country [358]
0
0
South Africa
Query!
State/province [358]
0
0
Groenkloof, Pretoria, 0001
Query!
Country [359]
0
0
South Africa
Query!
State/province [359]
0
0
Johannesburg
Query!
Country [360]
0
0
South Africa
Query!
State/province [360]
0
0
Observatory
Query!
Country [361]
0
0
South Africa
Query!
State/province [361]
0
0
Panorama
Query!
Country [362]
0
0
South Africa
Query!
State/province [362]
0
0
Parktown
Query!
Country [363]
0
0
South Africa
Query!
State/province [363]
0
0
Pretoria
Query!
Country [364]
0
0
South Africa
Query!
State/province [364]
0
0
Saxonwold, Johannesburg
Query!
Country [365]
0
0
Spain
Query!
State/province [365]
0
0
Alcoy/Alicante
Query!
Country [366]
0
0
Spain
Query!
State/province [366]
0
0
Barakaldo (Vizcaya)
Query!
Country [367]
0
0
Spain
Query!
State/province [367]
0
0
Barcelona
Query!
Country [368]
0
0
Spain
Query!
State/province [368]
0
0
Burgos
Query!
Country [369]
0
0
Spain
Query!
State/province [369]
0
0
Cadiz
Query!
Country [370]
0
0
Spain
Query!
State/province [370]
0
0
Castellon
Query!
Country [371]
0
0
Spain
Query!
State/province [371]
0
0
Cordoba
Query!
Country [372]
0
0
Spain
Query!
State/province [372]
0
0
Coria
Query!
Country [373]
0
0
Spain
Query!
State/province [373]
0
0
Elda
Query!
Country [374]
0
0
Spain
Query!
State/province [374]
0
0
Granada
Query!
Country [375]
0
0
Spain
Query!
State/province [375]
0
0
Hospitalet de Llobregat (Barcelona)
Query!
Country [376]
0
0
Spain
Query!
State/province [376]
0
0
Huesca
Query!
Country [377]
0
0
Spain
Query!
State/province [377]
0
0
La Laguna (Santa Cruz De Tenerife)
Query!
Country [378]
0
0
Spain
Query!
State/province [378]
0
0
Lerida
Query!
Country [379]
0
0
Spain
Query!
State/province [379]
0
0
Lugo
Query!
Country [380]
0
0
Spain
Query!
State/province [380]
0
0
Madrid
Query!
Country [381]
0
0
Spain
Query!
State/province [381]
0
0
Malaga
Query!
Country [382]
0
0
Spain
Query!
State/province [382]
0
0
Mataro
Query!
Country [383]
0
0
Spain
Query!
State/province [383]
0
0
Mostoles (Madrid)
Query!
Country [384]
0
0
Spain
Query!
State/province [384]
0
0
Murcia
Query!
Country [385]
0
0
Spain
Query!
State/province [385]
0
0
Palma de Mallorca
Query!
Country [386]
0
0
Spain
Query!
State/province [386]
0
0
Pamplona
Query!
Country [387]
0
0
Spain
Query!
State/province [387]
0
0
Salamanca
Query!
Country [388]
0
0
Spain
Query!
State/province [388]
0
0
San Sebastian
Query!
Country [389]
0
0
Spain
Query!
State/province [389]
0
0
Santander
Query!
Country [390]
0
0
Spain
Query!
State/province [390]
0
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Santiago
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Spain
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Segovia
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Tarrasa, Barcelona
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Valencia
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Zamora
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Aarau
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Basel
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Bellinzona
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Bern
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Chur
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Lausanne
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Switzerland
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Locarno
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St Gallen
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Thun
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Zuerich
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Kaohsiung
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Taichung
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Taipei
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Thailand
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Khon Kaen
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Thailand
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Phitsanulok
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Ukraine
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Donetsk
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Ukraine
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Ivano-Frankivsk
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Ukraine
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Kharkiv
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Ukraine
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Kyiv
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Ukraine
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Lviv
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Ukraine
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Simferopol
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Ukraine
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Uzhgorod
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Ukraine
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Uzhorod
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United Kingdom
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Essex
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Gloucestershire
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Kent
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Oxfordshire
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Ashford
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Blackpool
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Bournemouth
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Brighton
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Cheltenham
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Cottingham
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Dorchester
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Exeter
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Lancaster
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Leeds
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Funding & Sponsors
Primary sponsor type
Commercial sector/industry
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Name
Novartis Pharmaceuticals
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Other collaborator category [1]
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Other
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North Central Cancer Treatment Group
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National Cancer Institute (NCI)
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Other
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Breast International Group
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Other
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Canadian Cancer Trials Group
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Summary
Brief summary
This is a randomised, open label multi-centre phase III study comparing the activity of lapatinib alone versus trastuzumab alone versus trastuzumab followed by lapatinib versus lapatinib concomitantly with trastuzumab in the adjuvant treatment of patients with ErbB2 overexpressing and/or amplified breast cancer. Patients will be enrolled according to one of two design schemas, with Design 2 having two chemotherapy options (Design 2 and 2B), and will be randomised to one of four treatment regimens within each design schema. The primary objective of this study is to compare disease-free survival (DFS) in patients with HER2 overexpressing and/or amplified breast cancer randomised to trastuzumab for one year versus lapatinib for one year versus trastuzumab (12 or 18 weeks, according to assigned design) followed by a six-week treatment-free interval followed by lapatinib (28 or 34 weeks, according to assigned design) versus trastuzumab in combination with lapatinib for one year (52 weeks). Secondary objectives include treatment comparisons with respect to overall survival, time to recurrence, time to distant recurrence, safety and tolerability, incidence of brain metastasis, and analyses conducted separately for cohorts of patients defined by presence or absence of cMyc oncogene amplification, expression level of PTEN and presence or absence of the p95HER2 receptor. On August 18, 2011, the ALTTO Independent Data Monitoring Committee (IDMC) met to review the first planned interim analysis. The IDMC reported that the comparison of lapatinib alone versus trastuzumab alone crossed the futility boundary, indicating that the lapatinib alone arm was unlikely to meet the pre-specified criteria to demonstrate non-inferiority to trastuzumab alone with respect to disease-free survival (DFS). The IDMC also stated that the other three arms (trastuzumab alone, sequential trastuzumab/lapatinib arm and the combination arm) should continue as planned with no changes.
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Trial website
https://clinicaltrials.gov/study/NCT00490139
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Trial related presentations / publications
Nader-Marta G, Debien V, Eiger D, Tsourti Z, Caparica R, Kassapian M, Napoleone S, Hultsch S, Korde L, Wang Y, Chumsri S, Pritchard KI, Untch M, Bellet-Ezquerra M, Dornelles Rosa D, Moreno-Aspitia A, Piccart M, Dafni U, de Azambuja E. Outcomes of patients with small and node-negative HER2-positive early breast cancer treated with adjuvant chemotherapy and anti-HER2 therapy-a sub-analysis of the ALTTO study. Br J Cancer. 2022 Nov;127(10):1799-1807. doi: 10.1038/s41416-022-01963-8. Epub 2022 Sep 1. Moreno-Aspitia A, Holmes EM, Jackisch C, de Azambuja E, Boyle F, Hillman DW, Korde L, Fumagalli D, Izquierdo MA, McCullough AE, Wolff AC, Pritchard KI, Untch M, Guillaume S, Ewer MS, Shao Z, Sim SH, Aziz Z, Demetriou G, Mehta AO, Andersson M, Toi M, Lang I, Xu B, Smith IE, Barrios CH, Baselga J, Gelber RD, Piccart-Gebhart M; ALTTO Steering Committee and Investigators. Updated results from the international phase III ALTTO trial (BIG 2-06/Alliance N063D). Eur J Cancer. 2021 May;148:287-296. doi: 10.1016/j.ejca.2021.01.053. Epub 2021 Mar 23. Sonnenblick A, Agbor-Tarh D, de Azambuja E, Hultsch S, Izquierdo M, Liu M, Pruneri G, Harbeck N, Piccart M, Moreno-Aspita A, Granit RZ, Rouas G, Fahoum I, Sotiriou C. STAT3 activation in HER2-positive breast cancers: Analysis of data from a large prospective trial. Int J Cancer. 2021 Mar 15;148(6):1529-1535. doi: 10.1002/ijc.33385. Epub 2020 Nov 23. Eiger D, Ponde NF, Agbor-Tarh D, Moreno-Aspitia A, Piccart M, Hilbers FS, Werner O, Chumsri S, Dueck A, Kroep JR, Gomez H, Lang I, Rodeheffer RJ, Ewer MS, Suter T, de Azambuja E. Long-term cardiac outcomes of patients with HER2-positive breast cancer treated in the adjuvant lapatinib and/or trastuzumab Treatment Optimization Trial. Br J Cancer. 2020 May;122(10):1453-1460. doi: 10.1038/s41416-020-0786-x. Epub 2020 Mar 16. Holmes EM, Bradbury I, Williams LS, Korde L, de Azambuja E, Fumagalli D, Moreno-Aspitia A, Baselga J, Piccart-Gebhart M, Dueck AC, Gelber RD; ALTTO Trial Study Team. Are we assuming too much with our statistical assumptions? Lessons learned from the ALTTO trial. Ann Oncol. 2019 Sep 1;30(9):1507-1513. doi: 10.1093/annonc/mdz195. McCullough AE, Dell'orto P, Reinholz MM, Gelber RD, Dueck AC, Russo L, Jenkins RB, Andrighetto S, Chen B, Jackisch C, Untch M, Perez EA, Piccart-Gebhart MJ, Viale G. Central pathology laboratory review of HER2 and ER in early breast cancer: an ALTTO trial [BIG 2-06/NCCTG N063D (Alliance)] ring study. Breast Cancer Res Treat. 2014 Feb;143(3):485-92. doi: 10.1007/s10549-013-2827-0. Epub 2014 Jan 7.
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Public notes
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Contacts
Principal investigator
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Novartis Pharmaceuticals
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Novartis Pharmaceuticals
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Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
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What data in particular will be shared?
Novartis is committed to sharing with qualified external researchers, access to patient-level data and supporting clinical documents from eligible studies. These requests are reviewed and approved by an independent review panel on the basis of scientific merit. All data provided is anonymized to respect the privacy of patients who have participated in the trial in line with applicable laws and regulations.
This trial data availability is according to the criteria and process described on www.clinicalstudydatarequest.com
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What supporting documents are/will be available?
No Supporting Document Provided
Results publications and other study-related documents
No documents have been uploaded by study researchers.
Results not provided in
https://clinicaltrials.gov/study/NCT00490139