Neoadjuvant anti-PD-1/PD-L1 therapy for colorectal cancer: Current status and future prospects

Immunotherapy, particularly programmed cell death 1/programmed cell death ligand 1 (PD-1/PD-L1) inhibitors, has made revolutionary progress in the treatment strategies for various types of cancer. Regarding colorectal cancer (CRC), the current clinical application of PD-1/PD-L1 inhibitors is primarily categorized based on mutation patterns, including deficient mismatch repair (dMMR)/high microsatellite instability (MSI-H) and proficient mismatch repair (pMMR) or non-high microsatellite instability (non-MSI-H). PD-1/PD-L1 inhibitors have demonstrated good efficacy against dMMR/MSI-H CRC by increasing T-cell infiltration into tumor tissues. However, the effectiveness of PD-1/PD-L1 inhibitors for pMMR/non-MSI-H CRC remains uncertain. Due to the lower prevalence of dMMR/MSI-H in CRC, recent clinical trials have reported combined applications of PD-1/PD-L1 inhibitors with other anti-tumor treatments such as chemotherapy, radiotherapy, and targeted therapy to achieve better therapeutic outcomes. Neoadjuvant therapy, primarily consisting of chemotherapy and radiotherapy, not only downstages the tumor but also provides benefits from local control, thus improving clinical symptoms and quality of life. Integrating immunotherapy into neoadjuvant therapy may alter the treatment approach for potentially resectable or certain metastatic CRC cases. In this article, we focus on the development of neoadjuvant anti-PD-1/PD-L1 therapy and discuss its future prospects for the treatment of CRC.

Comparison between different neoadjuvant chemotherapy regimens and local therapy alone for bladder cancer: a systematic review and network meta-analysis of oncologic outcomes

PURPOSE

The present systematic review and network meta-analysis (NMA) compared the current different neoadjuvant chemotherapy (NAC) regimes for bladder cancer patients to rank them.

METHODS

We used the Bayesian approach in NMA of six different therapy regimens cisplatin, cisplatin/doxorubicin, (gemcitabine/cisplatin) GC, cisplatin/methotrexate, methotrexate, cisplatin, and vinblastine (MCV) and (MVAC) compared to locoregional treatment.

RESULTS

Fifteen studies comprised 4276 patients who met the eligibility criteria. Six different regimes were not significantly associated with a lower likelihood of overall mortality rate compared to local treatment alone. In progression-free survival (PFS) rates, cisplatin, GC, cisplatin/methotrexate, MCV and MVAC were not significantly associated with a higher likelihood of PFS rate compared to locoregional treatment alone. In local control outcome, MCV, MVAC, GC and cisplatin/methotrexate were not significantly associated with a higher likelihood of local control rate versus locoregional treatment alone. Nevertheless, based on the analyses of the treatment ranking according to SUCRA, it was highly likely that MVAC with high certainty of results appeared as the most effective approach in terms of mortality, PFS and local control rates. GC and cisplatin/doxorubicin with low certainty of results was found to be the best second options.

CONCLUSION

No significant differences were observed in mortality, progression-free survival and local control rates before and after adjusting the type of definitive treatment in any of the six study arms. However, MVAC was found to be the most effective regimen with high certainty, while cisplatin alone and cisplatin/methotrexate should not be recommended as a neoadjuvant chemotherapy regime.

Perspectives in Melanoma: meeting report from the Melanoma Bridge (December 1st-3rd, 2022-Naples, Italy)

Outcomes for patients with melanoma have improved over the past decade with the clinical development and approval of immunotherapies targeting immune checkpoint receptors such as programmed death-1 (PD-1), programmed death ligand 1 (PD-L1) or cytotoxic T lymphocyte antigen-4 (CTLA-4). Combinations of these checkpoint therapies with other agents are now being explored to improve outcomes and enhance benefit-risk profiles of treatment. Alternative inhibitory receptors have been identified that may be targeted for anti-tumor immune therapy, such as lymphocyte-activation gene-3 (LAG-3), as have several potential target oncogenes for molecularly targeted therapy, such as tyrosine kinase inhibitors. Unfortunately, many patients still progress and acquire resistance to immunotherapy and molecularly targeted therapies. To bypass resistance, combination treatment with immunotherapies and single or multiple TKIs have been shown to improve prognosis compared to monotherapy. The number of new combinations treatment under development for melanoma provides options for the number of patients to achieve a therapeutic benefit. Many diagnostic and prognostic assays have begun to show clinical applicability providing additional tools to optimize and individualize treatments. However, the question on the optimal algorithm of first- and later-line therapies and the search for biomarkers to guide these decisions are still under investigation. This year, the Melanoma Bridge Congress (Dec 1st-3rd, 2022, Naples, Italy) addressed the latest advances in melanoma research, focusing on themes of paramount importance for melanoma prevention, diagnosis and treatment. This included sessions dedicated to systems biology on immunotherapy, immunogenicity and gene expression profiling, biomarkers, and combination treatment strategies.

Longitudinal immune monitoring of patients with resectable esophageal adenocarcinoma treated with Neoadjuvant PD-L1 checkpoint inhibition

The analysis of peripheral blood mononuclear cells (PBMCs) by flow cytometry holds promise as a platform for immune checkpoint inhibition (ICI) biomarker identification. Our aim was to characterize the systemic immune compartment in resectable esophageal adenocarcinoma patients treated with neoadjuvant ICI therapy. In total, 24 patients treated with neoadjuvant chemoradiotherapy (nCRT) and anti-PD-L1 (atezolizumab) from the PERFECT study (NCT03087864) were included and 26 patients from a previously published nCRT cohort. Blood samples were collected at baseline, on-treatment, before and after surgery. Response groups for comparison were defined as pathological complete responders (pCR) or patients with pathological residual disease (non-pCR). Based on multicolor flow cytometry of PBMCs, an immunosuppressive phenotype was observed in the non-pCR group of the PERFECT cohort, characterized by a higher percentage of regulatory T cells (Tregs), intermediate monocytes, and a lower percentage of type-2 conventional dendritic cells. A further increase in activated Tregs was observed in non-pCR patients on-treatment. These findings were not associated with a poor response in the nCRT cohort. At baseline, immunosuppressive cytokines were elevated in the non-pCR group of the PERFECT study. The suppressive subsets correlated at baseline with a Wnt/β-Catenin gene expression signature and on-treatment with epithelial-mesenchymal transition and angiogenesis signatures from tumor biopsies. After surgery monocyte activation (CD40), low CD8+Ki67+ T cell rates, and the enrichment of CD206+ monocytes were related to early recurrence. These findings highlight systemic barriers to effective ICI and the need for optimized treatment regimens.

Clinical outcomes and prognostic factors in triple-negative invasive lobular carcinoma of the breast

PURPOSE

Triple-negative invasive lobular carcinoma (TN-ILC) of breast cancer is a rare disease and the clinical outcomes and prognostic factors are not well-defined.

METHODS

Women with stage I-III TN-ILC or triple-negative invasive ductal carcinoma (TN-IDC) of the breast undergoing mastectomy or breast-conserving surgery between 2010 and 2018 in the National Cancer Database were included. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare overall survival (OS) and evaluate prognostic factors. Multivariate logistic regression was performed to analyze the factors associated with pathological response to neoadjuvant chemotherapy.

RESULTS

The median age at diagnosis for women with TN-ILC was 67 years compared to 58 years in TN-IDC (p < 0.001). There was no significant difference in the OS between TN-ILC and TN-IDC in multivariate analysis (HR 0.96, p = 0.44). Black race and higher TNM stage were associated with worse OS, whereas receipt of chemotherapy or radiation was associated with better OS in TN-ILC. Among women with TN-ILC receiving neoadjuvant chemotherapy, the 5-year OS was 77.3% in women with a complete pathological response (pCR) compared to 39.8% in women without any response. The odds of achieving pCR following neoadjuvant chemotherapy were significantly lower in women with TN-ILC compared to TN-IDC (OR 0.53, p < 0.001).

CONCLUSION

Women with TN-ILC are older at diagnosis but have similar OS compared to TN-IDC after adjusting for tumor and demographic characteristics. Administration of chemotherapy was associated with improved OS in TN-ILC, but women with TN-ILC were less likely to achieve complete response to neoadjuvant therapy compared to TN-IDC.

Randomized phase III trial of a neoadjuvant regimen of four cycles of adriamycin plus cyclophosphamide followed by four cycles of docetaxel (AC4-D4) versus a shorter treatment of three cycles of FEC followed by three cycles of docetaxel (FEC3-D3) in node-positive breast cancer (Neo-shorter; NCT02001506)

PURPOSE

To determine whether six cycles of FEC3-D3 has a comparable efficacy to eight of AC4-D4.

METHODS

The enrolled patients (pts) were clinically diagnosed with stage II or III breast cancer. The primary endpoint was a pathologic complete response (pCR), and the secondary endpoints were 3 year disease-free survival (3Y DFS), toxicities, and health-related quality of life (HRQoL). We calculated that 252 pts were needed in each treatment group to enable the detection of non-inferiority (non-inferiority margin of 10%).

RESULTS

In terms of ITT analysis, 248 pts were finally enrolled. The 218 pts who completed the surgery were included in the current analysis. The baseline characteristics of these subjects were well balanced between the two arms. By ITT analysis, pCR was achieved in 15/121 (12.4%) pts in the FEC3-D3 arm and 18/126 (14.3%) in the AC4-D4 arm. With a median follow up of 64.1 months, the 3Y DFS was comparable between the two arms (75.8% in FEC3-D3 vs. 75.6% in AC4-D4). The most common adverse event (AE) was Grade 3/4 neutropenia, which arose in 27/126 (21.4%) AC4-D4 arm pts vs 23/121 (19.0%) FEC3-D3 arm cases. The primary HRQoL domains were similar between the two groups (FACT-B scores at baseline, P = 0.35; at the midpoint of NACT, P = 0.20; at the completion of NACT, P = 0.44).

CONCLUSION

Six cycles of FEC3-D3 could be an alternative to eight of AC4-D4. Trial registration ClinicalTrials.gov NCT02001506. Registered December 5,2013. https://clinicaltrials.gov/ct2/show/NCT02001506.

Intensive cycles of neoadjuvant camrelizumab combined with chemotherapy in locally advanced esophageal squamous cell carcinoma: a single-arm, phase II trial

BACKGROUND

Two cycles of neoadjuvant PD-1 blockade plus chemotherapy induced favorable pathological response and tolerant toxicity in patients with locally advanced esophageal squamous cell carcinoma (ESCC). However, approximately 25% of patients relapsed within 1 year after surgery, indicating that a short course of treatment may not be sufficient. Therefore, exploring the effects of intensive treatment is needed for optimal clinical outcomes.

METHODS

Locally advanced ESCC patients were administered three cycles of camrelizumab plus nab-paclitaxel and capecitabine, followed by thoracoscopic esophagectomy. The primary endpoint was pathologic response. Secondary endpoints included safety, feasibility, radiologic response, survival outcomes, and immunologic/genomic correlates of efficacy.

RESULTS

Forty-seven patients were enrolled in the study. Forty-two patients received surgery, and R0 resection was achieved in all cases. The complete and major pathological response rates were 33.3% and 64.3%, respectively, and the objective response rate was 80.0%. Three cycles of treatment significantly improved T down-staging compared to two cycles (P = 0.03). The most common treatment-related adverse events were grades 1-2, and no surgical delay was reported. With a median follow-up of 24.3 months, the 1-year disease-free survival and overall survival rates were both 97.6%, and the 2-year disease-free survival and overall survival rates were 92.3% and 97.6%, respectively. Three patients experienced disease recurrence or metastasis ranging from 12.5 to 25.8 months after surgery, and one patient died 6 months after surgery due to cardiovascular disease. Neither programmed death-ligand 1 expression nor tumor mutational burden was associated with pathological response. An increased infiltration of CD56dim natural killer cells in the pretreatment tumor was correlated with better pathological response in the primary tumor.

CONCLUSIONS

It seems probable that intensive cycles of neoadjuvant camrelizumab plus nab-paclitaxel and capecitabine increased tumor regression and improved survival outcomes. Randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings. Trial registration Chinese Clinical Trial Registry, ChiCTR2000029807, Registered February 14, 2020, https://www.chictr.org.cn/showproj.aspx?proj=49459 .

Local Excision Versus Total Mesorectal Excision After Favourable Response to Neoadjuvant Therapy in Low Rectal Cancer: a Multi-centre Experience

The gold standard surgical management of curable rectal cancer is proctectomy with total mesorectal excision. Adding preoperative radiotherapy improved local control. The promising results of neoadjuvant chemoradiotherapy raised the hopes for conservative, yet oncologically safe management, probably using local excision technique. This study is a prospective comparative phase III study, where 46 rectal cancer patients were recruited from patients attending Oncology Centre of Mansoura University and Queen Alexandra Hospital Portsmouth University Hospital NHS with a median follow-up 36 months. The two recruited groups were as follows: group (A), 18 patients who underwent conventional radical surgery by TME; and group (B), 28 patients who underwent trans-anal endoscopic local excision. Patients of resectable low rectal cancer (below 10 cms from anal verge) with sphincter saving procedures were included: cT1-T3N0. The median operative time for LE was 120 min versus 300 in TME (p < 0.001), and median blood loss was 20 ml versus 100 ml in LE and TME, respectively (p < 0.001). Median hospital stay was 3.5 days versus 6.5 days (p = 0.009). No statistically significant difference in median DFS (64.2 months for LE versus 63.2 months for TME, p = 0.85) and median OS (72.9 months for LE versus 76.3 months for TME, p = 0.43). No statistically significant difference in LARS scores and QoL was observed between LE and TME (p = 0.798, p = 0.799). LE seems a good alternative to radical rectal resection in carefully selected responders to neoadjuvant therapy after thorough pre-operative evaluation, planning and patient counselling.

Central Giant Cell Reparative Granuloma (CGCRG) of the Jaw in Children Treated with Neoadjuvant Bisposphonates: Review and a Case Report

Central giant cell reparative granuloma (CGCRG) of the jaw is a neoformation localized in the mandible or in the maxillary bone and characterized by fibrous tissue, osteoclast-like giant cells and reactive bone formation. The CGCRG is a less frequent benign tumor but sometimes it is characterized by an aggressive behavior with a very rapid growth. It affects the young adults mainly and the children occasionally. Nowadays no medication therapy is approved for CGCRG in pediatric cases. We present a case of an aggressive form of a mandibular CGCRG in a 5-year child with Arnold-Chiari syndrome. This case is unique for the use of bisphosphonates (BPs) as neoadjuvant therapy in pediatrics. The therapy were administrated with the purpose of arresting the rapid growth of the tumor in order to avoid a demolitive surgery to the young patient. The child was without symptoms and presented an unusual swelling in the left mandible developed in a few weeks. The lesion was diagnosed by a CT scan and it was confirmed by a biopsy performed for histopathological assessment a few days later. The drug therapy consisted of seven cycles iv of Zoledronate associated to Calcium Gluconate. The child was closely observed through clinical and serological evaluations during the following months. About five months after the last cycle of BPs the child underwent CT scan and a conservative surgical treatment, consisted in a deep curettage, was programmed. Seven months after surgery the aesthetic profile of the patient improved and CT scan reported a significant calcic neoapposition in the area of the previous bone lesion. After more than one year from surgery, no relapse was observed. This case report demonstrates that BPs can be used safely in pediatric patients with CGCRG. Especially BPs could have a role as neoadjuvant therapy: If administrated before surgical treatment BPs avoid the necessity of resective surgery and reduce the risk of recurrence in pediatric CGCRG after conservative curettage.

NeoAdjuvant pembrolizumab and STEreotactic radiotherapy prior to nephrectomy for renal cell carcinoma (NAPSTER): A phase II randomised clinical trial

Background

Surgery remains the standard of care for localised renal cell carcinoma (RCC). Nevertheless, nearly 50% of patients with high-risk disease experience relapse after surgery, with distant sites being common. Considering improved outcomes in terms of disease-free survival with adjuvant immunotherapy with pembrolizumab, we hypothesise that neoadjuvant SABR with or without the addition of pembrolizumab before nephrectomy will lead to improved disease outcomes by evoking better immune response in the presence of an extensive reserve of tumor-associated antigens.

Methods and analysis

This prospective, open-label, phase II, randomised, non-comparative, clinical trial will investigate the use of neoadjuvant stereotactic ablative body radiotherapy (SABR) with or without pembrolizumab prior to nephrectomy. The trial will be conducted at two centres in Australia that are well established for delivering SABR to primary RCC patients. Twenty-six patients with biopsy-proven clear cell RCC will be recruited over two years. Patients will be randomised to either SABR or SABR/pembrolizumab. Patients in both arms will undergo surgery at 9 weeks after completion of experimental treatment. The primary objectives are to describe major pathological response and changes in tumour-responsive T-cells from baseline pre-treatment biopsy in each arm. Patients will be followed for sixty days post-surgery.

Outcomes and significance

We hypothesize that SABR alone or SABR plus pembrolizumab will induce significant tumor-specific immune response and major pathological response. In that case, either one or both arms could justifiably be used as a neoadjuvant treatment approach in future randomized trials in the high-risk patient population.

Association of age with outcomes in locally advanced rectal cancer treated with neoadjuvant therapy followed by surgery

INTRODUCTION

We aimed to assess the association of age with outcomes in patients with Locally Advanced Rectal Cancer (LARC) who received neoadjuvant therapy followed by major surgery.

METHODS

Retrospective review of 328 patients with LARC, N = 99 < 70 years (younger) versus N = 229 ≥ 70 years (elderly) from 2004 to 2018.

RESULTS

Elderly patients had a higher American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), length of stay and 30-day readmissions (p < 0.05). They also had worse overall survival (OS) & disease-free survival (DFS) (p < 0.001), but similar disease-specific survival (DSS) compared to younger group. Age was not associated with hazard of death (HR 1.01, 0.98-1.03). Rather, CCI (HR 1.29, 1.01-1.5), extramural vascular invasion (HR 4.98, 2.84-8.74), and adjuvant therapy (0.37, 0.21-0.64) were significantly associated with the hazard of death; when controlled for stage, tumor distance from anal verge, and neoadjuvant completion.

CONCLUSION

Comorbidities and lower rates of adjuvant therapy, and not chronologic age, are associated with poor OS of elderly patients with LARC treated with neoadjuvant therapy and major surgery.

A Systematic Review of Oncological Outcomes Associated with Bladder-sparing Strategies in Patients Achieving Complete Clinical Response to Initial Systemic Treatment for Localized Muscle-invasive Bladder Cancer

CONTEXT

Bladder-sparing strategies (BSSs) have been proposed for the treatment of muscle-invasive bladder cancer (MIBC) patients achieving clinical complete response (cCR) to initial systemic treatment to avoid toxicity related to radical cystectomy.

OBJECTIVE

To systematically review the current literature evaluating oncological outcomes of BSSs in patients achieving cCR to initial systemic treatment for localized MIBC.

EVIDENCE ACQUISITION

A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting oncological outcomes of MIBC patients undergoing either surveillance or radiation therapy after achieving cCR to initial systemic treatment. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we identified 23 noncomparative prospective or retrospective studies published between 1990 and 2021. The mean bladder and metastatic recurrence rates (range) as well as the mean bladder preservation rate (BPR; range) were calculated, and overall survival (OS) was extracted from included reports.

EVIDENCE SYNTHESIS

Overall, 16 and seven studies evaluated surveillance (n = 610) and radiation therapy (n = 175) in MIBC patients achieving cCR to initial systemic treatment, respectively. With regard to surveillance, the median follow-up ranged from 10 to 120 mo, with a mean bladder recurrence rate of 43% (0-71%), including 65% of non-muscle-invasive bladder cancer (NMIBC) and 35% of MIBC recurrences. The mean BPR was 73% (49-100%). The mean metastatic recurrence rate was 9% (0-27%), while 5-yr OS rates ranged from 64% to 89%. With regard to radiation therapy, the median follow-up ranged from 12 to 60 mo, with a mean bladder recurrence rate of 15% (0-29%), including 24% of NMIBC, 43% of MIBC, and 33% of unspecified recurrences. The mean BPR was 74% (71-100%). The mean metastatic recurrence rate was 17% (0-22%), while the 4-yr OS rate was 79%.

CONCLUSIONS

Our systematic review showed that only low-level evidence supports the effectiveness of BSSs in selected patients achieving cCR to initial systemic treatment for localized MIBC. These preliminary findings highlight the need for further prospective comparative research to demonstrate its efficacy.

PATIENT SUMMARY

We reviewed studies evaluating bladder-sparing strategies in patients achieving complete clinical response to initial systemic treatment for localized muscle-invasive bladder cancer. Based on low-level evidence, we observed that selected patients could benefit from surveillance or radiation therapy in this setting, but prospective comparative research is requested to confirm their efficacy.

Integrating Surgery in the Multidisciplinary Care of Advanced Renal Cell Carcinoma

The role of surgery for patients with locally advanced and metastatic renal cell carcinoma (RCC) is not precisely defined in our contemporary era of systemic therapies. Research in this field is focused on the role of regional lymphadenectomy, along with indications and timing of cytoreductive nephrectomy and metastasectomy. As our understanding of the molecular and immunological basis of RCC continues to develop along with the advent of novel systemic therapies, prospective clinical trials will be critical in defining how surgery should be integrated into the treatment paradigm of advanced RCC.

Neoadjuvant immunotherapy in patients with pulmonary lymphoepithelioma-like carcinoma

OBJECTIVES

Neoadjuvant immunotherapy can be used to treat early-stage non-small-cell lung cancer; however, their effects on pulmonary lymphoepithelioma-like carcinomas (LELC) remain unclear.

MATERIALS AND METHODS

Thirty-nine patients with stages I-III LELC were treated with chemotherapy (Chemo) or neoadjuvant immune-checkpoint inhibitors (ICIs) with or without chemo (IO) before radical-intent surgery. Short-term outcomes included objective response rate (ORR), major pathologic response (MPR), pathologic complete response (PCR), and event-free survival. For comparison, we used IO to treat 63 patients with pulmonary squamous cell carcinomas (SQC) and 47 with adenocarcinomas (ADC). Propensity score matching was analyzed to minimize bias.

RESULTS

ORRs of the LELC-IO and LELC-Chemo groups were 62.5% and 42.9%, respectively (odds ratio, 2.2, 95% confidence interval, 0.423-11.678, p = 0.346). Seven (21.9%) and zero patients in LELC-IO and LELC-Chemo groups, respectively, reached PCR. MPR was identified in five (15.6%) of the 32 patients with LELC-IO. The 1-year progression-free survival rates were 96.9% and 71.4% in IO and Chemo groups, respectively (p > 0.05). However, no difference was observed in ORR, PCR, and MPR between LELC and SQC groups (ORR, 63.2% vs. 68.4%, p > 0.05; PCR, 21.1% vs. 47.4, p > 0.05; MPR, 42.1% vs. 57.9%, p > 0.05) and LELC and ADC groups (ORR, 58.8% vs. 41.2%, p > 0.05; PCR, 17.6% vs. 23.5%, p = 0.672; MPR, 29.4% vs. 47.1%, p > 0.05). The plasma Epstein-Barr virus (EBV) DNA level in a patient was altered posttreatment.

CONCLUSION

Patients with LELC could be benefit from neoadjuvant immunotherapy. Distinct histological subtypes demonstrated comparable efficacy with respect to neoadjuvant immunotherapy.

"Major pathologic response" in lymph nodes: a modified nodal classification for non-small cell lung cancer patients treated with neoadjuvant immunochemotherapy

We aim to examine the prognostic value of major pathologic response in metastatic lymph nodes (mLN-MPR) after immunochemotherapy in non-small cell lung cancer (NSCLC), and demonstrate the pathological characteristic of regression in mLN. Adult patients consecutively undergone neoadjuvant immunochemotherapy and radical-intent surgery for initial stage cIII NSCLC between 2020 and 2021 were included. Hematoxylin- and eosin-stained slides of paraffinembedded sections of the degree of pathologic response in the primary tumor (PT) and its paired involved LNs were reviewed. Imaging mass cytometry was conducted to quantify the immunological status. With 10% as residual viable tumor (RVT) cutoff, mLN-MPR (HR: 0.34, 95%CI: 0.14-0.78; P = 0.011, ref: mLN-MPR(-)) showed more significant correlation with DFS than ypN0 (HR: 0.40, 95%CI: 0.17-0.94; P = 0.036, ref: ypN1-N2). And mLN-MPR combined with PT-MPR, compared with ypN stage combined with PT-MPR (p-value: 0.030 vs. 0.117), can better distinguished the DFS curves of the 4 subgroups of patients. mLN-MPR(+)/PT-MPR(+) patients had the best prognosis compared with other subgroups. Pathologic responses of RVT in PT and paired regional LNs [MPR inconsistency rate: 21/53 (39.6%)], and across different LNs could be inconsistent, especially in squamous cell carcinoma. RVT% in mLNs after immunochemotherapy appeared to be polarized [16 (30.2%) cases with RVT ≥ 70%; 34 (64.2%) with RVT ≤ 10%]. Partial regression of LN metastasis could present with distinct immune subtypes: immune-inflamed or immune-evacuation subtype, and the former presented with higher CD3, CD8, and PD-1 expression in the invasive margin. mLN-MPR demonstrated a potential prognostic value in predicting DFS in patients treated with neoadjuvant immunochemotherapy, but further research is needed to validate its usefulness for other survival outcomes, including OS.

The "Great Debate" at Melanoma Bridge 2022, Naples, December 1st-3rd, 2022

The Great Debate session at the 2022 Melanoma Bridge congress (December 1-3) featured counterpoint views from leading experts on five contemporary topics of debate in the management of melanoma. The debates considered the choice of anti-lymphocyte-activation gene (LAG)-3 therapy or ipilimumab in combination with anti-programmed death (PD)-1 therapy, whether anti-PD-1 monotherapy is still acceptable as a comparator arm in clinical trials, whether adjuvant treatment of melanoma is still a useful treatment option, the role of adjuvant therapy in stage II melanoma, what role surgery will continue to have in the treatment of melanoma. As is customary in the Melanoma Bridge Great Debates, the speakers are invited by the meeting Chairs to express one side of the assigned debate and the opinions given may not fully reflect personal views. Audiences voted in favour of either side of the argument both before and after each debate.

Neoadjuvant immune-checkpoint inhibitors in lung cancer - a primer for radiologists

The introduction of neoadjuvant immune checkpoint inhibitors plus platinum-based chemotherapy has changed treatment regimens of patient's early-stage lung cancer. This treatment combination induces high rates of complete pathologic response and improves clinical endpoints. Imaging plays a fundamental role in assessment of treatment response, monitoring of (immune-related) adverse events and enables both the surgeon and pathologist optimal treatment and diagnostic workup of the resected tumor samples. Knowledge of the strengths and weaknesses of diagnostic imaging in this setting are essential for radiologists to provide valuable input in multidisciplinary team decisions.

Dual neoadjuvant blockade plus chemotherapy versus monotherapy for the treatment of women with non-metastatic HER2-positive breast cancer: a systematic review and meta-analysis

BACKGROUND

We aimed to determine the effect of dual anti-HER2 blockade compared to monotherapy on clinically important outcomes.

METHODS

We carried out a systematic review updated until July 2022. The outcomes included pathological complete response (pCR), clinical response, event-free survival, and overall survival.

RESULTS

We identified eleven randomized clinical trials (2836 patients). When comparing paclitaxel plus dual treatment versus paclitaxel plus trastuzumab or lapatinib, dual treatment was associated with a higher probability of achieving a pathological complete response (OR 2.88, 95% CI 2.02-4.10). Addition of a taxane to an anthracycline plus cyclophosphamide and fluorouracil, plus lapatinib or trastuzumab, showed that the dual treatment was better than lapatinib alone (OR 2.47, 95% CI 1.41-4.34), or trastuzumab alone (OR 1.89, 95% CI 1.13-3.16). Dual treatment may result in an increase in survival outcomes and tumour clinical response, although such benefits are not consistent for all the combinations studied.

CONCLUSIONS

The use of dual blockade with combinations of trastuzumab and pertuzumab can be recommended for the neoadjuvant treatment of women with HER2-positive breast cancer. PROSPERO Registration number: CRD42018110273.

Current trends in perioperative treatment of resectable gastric cancer

In the last few decades, the treatment strategy for locally advanced resectable gastric cancer (GC) has shifted to a multimodal approach, which potentially decreases recurrence risk and improves survival rates. Perioperative therapy leads to downstaging, increased curative resection rates, and prolonged disease-free and overall survival, by preventing micrometastases in patients with resectable GC. Application of neoadjuvant therapy provides information about tumor biology and in vivo sensitivity. A consensus regarding the therapeutic approach for non-metastatic GC does not exist, and many clinical trials aim to clarify this aspect. Advances in precision medicine and the role of immunotherapy have been the focus of research in GC treatment. Herein, the current status and possible future developments of perioperative therapy for locally advanced resectable GC are reviewed, based on the most recent randomized clinical trials.

Minimally invasive versus open esophagectomy after neoadjuvant therapy for esophageal cancer: a meta-analysis

OBJECTIVES

Neoadjuvant therapy and minimally invasive esophagectomy (MIE) are widely used in the comprehensive treatment of esophageal cancer. This study aimed to investigate the advantages of MIE for esophageal cancer after neoadjuvant therapy.

METHODS

Published clinical studies were reviewed and survival data and safety data were extracted. We compared the long-term survival and safety of MIE versus open esophagectomy after neoadjuvant surgery in a series of meta-analyses.

RESULTS

6 retrospective studies were included. Overall, MIE could significantly improve the overall survival of patients with esophageal cancer after neoadjuvant therapy compared with open esophagectomy [hazard ratio (HR) = 0.86, 95% confidence interval (CI) (0.75, 0.98)]. Compared with open esophagectomy, MIE could significantly reduce intraoperative blood loss and operative time [mean difference (MD) = -40.28.78, 95% CI (- 62.98, - 17.58); MD = -28.78, 95% CI (- 42.48, - 15.07), respectively]. There was no significant difference in 30-day and 90-day mortality between MIE and open esophagectomy [odds ratio (OR) = 0.42, 95% CI (0.09, 2.01); OR 0.80, 95% CI (0.25, 2.60), respectively]. MIE could not significantly reduce the incidence of anastomotic leakage, recurrent laryngeal nerve palsy and chylothorax [OR 0.70, 95% CI (0.37, 1.32); OR 1.43, 95% CI (0.33, 6.25); HR = 1.79, 95% CI (0.67, 4.75), respectively], but the incidence of pneumonia was significantly reduced [HR = 0.43, 95% CI (0.22, 0.82)]. In addition, the length of hospital stay and the incidence of total complications were significantly reduced after MIE [MD = -2.61, 95% CI (- 3.10, - 2.12); HR = 0.66, 95% CI (0.45, 0.98), respectively].

CONCLUSION

MIE after neoadjuvant therapy is effective and safe. Compared with open esophagectomy, MIE can improve the long-term survival and reduce the incidence of postoperative complications of esophageal cancer patients.

Neoadjuvant chemoradiotherapy plus tislelizumab followed by surgery for esophageal carcinoma (CRISEC study): the protocol of a prospective, single-arm, phase II trial

BACKGROUND

The failure rate after neoadjuvant chemoradiotherapy followed by surgery is approximately 34.6%-48% for resectable esophageal carcinoma. Pathologic complete response after neoadjuvant chemoradiotherapy is an important factor in predicting lower recurrence and better survival. Whether the sequential addition of immunotherapy to neoadjuvant chemoradiotherapy will be beneficial to improving the pathologic complete response rate is unknown.

METHODS

Patients with pathologically confirmed thoracic esophageal squamous cell carcinoma and at clinical T1-2N1-3M0 or T3-4aN0-3M0 (stage II-IVA) according to the eighth edition of American Joint Committee on Cancer staging will be allocated to receive neoadjuvant radiotherapy (41.4 Gy with 23 fractions to planning target volume) with concurrent chemotherapy (albumin-bound paclitaxel, 100 mg/m², once weekly for five weeks; carboplatin, area under the curve of 2 mg/mL/min, once weekly for five weeks) plus tislelizumab monotherapy sequentially (200 mg every three weeks for three cycles, beginning from the first to the 14th day after the end of radiotherapy). Then, subtotal esophagectomy with two-field lymphadenectomy, including the whole mediastinum and abdomen, will be performed. The primary endpoint for this study is the pathologic complete response rate after neoadjuvant chemoradiotherapy plus tislelizumab.

DISCUSSION

The optimal timing of the combination of immunotherapy and neoadjuvant chemoradiotherapy in esophageal carcinoma is not determined. The results of this phase II trial will be helpful to clarify the safety and efficacy of the sequential addition of tislelizumab after neoadjuvant chemoradiotherapy for locally advanced resectable esophageal carcinoma.

TRIAL REGISTRATION

This study was approved on January 26, 2021 and retrospectively registered with ClinicalTrials.gov ( NCT04776590 ) on March 1, 2021.

Trimodality Treatment of Extremity Soft Tissue Sarcoma: Where Do We Go Now?

OPINION STATEMENT

Extremity soft tissue sarcoma (ESTS) constitutes the majority of patients with soft tissue sarcoma (STS). Patients with localized high-grade ESTS > 5 cm in size carry a substantial risk of developing distant metastasis on follow-up. A neoadjuvant chemoradiotherapy approach can enhance local control by facilitating resection of the large and deep locally advanced tumors while trying to address distant spread by treating the micrometastasis for these high-risk ESTS. Preoperative chemoradiotherapy and adjuvant chemotherapy are often used for children with intermediate- or high-risk non-rhabdomyosarcoma soft tissue tumors in North America and Europe. In adults, the cumulative evidence supporting preoperative chemoradiotherapy or adjuvant chemotherapy remains controversial. However, some studies support a possible benefit of 10% in overall survival (OS) for high-risk localized ESTS, especially for those with a probability of 10-year OS < 60% using validated nomograms. Opponents of neoadjuvant chemotherapy argue that it delays curative surgery, compromises local control, and increases the rate of wound complications and treatment-related mortality; however, the published trials do not support these arguments. Most treatment-related side effects can be managed with adequate supportive care. A coordinated multidisciplinary approach involving sarcoma expertise in surgery, radiation, and chemotherapy is required to achieve better outcomes for ESTS. The next generation of clinical trials will shed light on how comprehensive molecular characterization, targeted agents and/or immunotherapy can be integrated into the upfront trimodality treatment to improve outcomes. To that end, every effort should be made to enroll these patients on clinical trials, when available.

Neoadjuvant Camrelizumab for Non-Small Cell Lung Cancer: A Retrospective Multicenter, Real-World Study (CTONG2004)

BACKGROUND

Camrelizumab has shown encouraging efficacy in advanced non-small cell lung cancer (NSCLC), either as monotherapy or combined with chemotherapy. However, evidence of neoadjuvant camrelizumab for NSCLC remains lacking.

METHODS

Patients with NSCLC treated with neoadjuvant camrelizumab-based therapy followed by surgery between December 2020 and September 2021 were retrospectively reviewed. Demographic and clinical data, details of neoadjuvant therapy and surgical information were retrieved.

RESULTS

In this multicenter retrospective real-world study, 96 patients were included. Ninety-five patients (99.0%) received neoadjuvant camrelizumab combined with platinum-based chemotherapy, with a median of 2 cycles (range 1-6). The median interval from the last dose to surgery was 33 days (range 13-102 days). Seventy patients (72.9%) underwent minimally invasive surgery. Lobectomy was the most frequent surgical procedure (94 [97.9%]). The median estimated intraoperative blood loss was 100 mL (range 5-1200 mL), and the median operative time was 3.0 h (range 1.5-6.5 h). The R0 resection rate was 93.8%. Twenty-one patients (21.9%) experienced postoperative complications, with the most common being cough and pain (both 6 [6.3%]). The overall response rate was 77.1% (95% CI 67.4-85.0%), and the disease control rate was 93.8% (95% CI 86.9-97.7%). Twenty-six patients (27.1%, 95% CI 18.5-37.1%) had pathological complete response. Neoadjuvant treatment-related adverse events of grade ≥ 3 were reported in seven patients (7.3%), with the most frequent being abnormal liver enzymes (two [2.1%]). No treatment-related deaths were reported.

CONCLUSION

The real-world data indicated that camrelizumab-based therapy had promising efficacy for NSCLC in the neoadjuvant setting, with manageable toxicities. Prospective studies investigating neoadjuvant camrelizumab are warranted.

Role of Perioperative Immune Checkpoint Inhibitors in Muscle Invasive Bladder Cancer

OBJECTIVE

We aim to describe and highlight the current use of immune checkpoint inhibitors (ICIs) in the muscle invasive bladder cancer (MIBC) treatment landscape, particularly focusing on the perioperative setting. We provide a comprehensive review of key trials of the use of ICI in the perioperative setting, discussing trial outcomes and limitations and reviewing the role of biomarkers.

INTRODUCTION

ICIs have recently been integrated into the treatment algorithm for metastatic urothelial carcinoma. More than 30 published studies have investigated the role of these agents in the radical treatment of MIBC. Some studies have demonstrated conflicting results, affecting widespread adoption in clinical practice.

METHODS

We performed a narrative overview of the literature from databases including PubMed, MEDLINE, Embase, European society of Medical Oncology/American Society of Clinical Oncology Annual Proceedings, and clinicaltrials.gov databases up until December 2021.

DISCUSSION

We described the results of key trials in the neoadjuvant and adjuvant setting, some of the reasons for conflicting study results, and the implications for clinical practice. Relevant biomarkers in the field are discussed, alongside a brief overview of the immune microenvironment in bladder cancer.

CONCLUSIONS

Perioperative ICIs have shown promising efficacy with low toxicity in the neoadjuvant setting. The two large trials in the adjuvant setting have been contradictory. The efficacy of perioperative ICIs combined with favorable tolerability and better toxicity profile compared with chemotherapy, with the potential for biomarker-driven patient selection, may lead to a change in future practice. There is, however, a lack of long-term survival and toxicity data for those treated with ICIs, and this needs to be developed further to demonstrate an added survival benefit by using ICIs.