Association between Immune-Related Adverse Events and Atezolizumab in Previously Treated Patients with Unresectable Advanced or Recurrent Non-Small Cell Lung Cancer

PURPOSE

Real-world, large-scale studies on the association between immune-related adverse events (irAE) and immune checkpoint inhibitor therapy effectiveness are limited. We evaluated overall survival (OS) and progression-free survival based on the occurrence and grade of irAEs.

PATIENTS AND METHODS

We used data from Japanese patients with unresectable advanced or recurrent non-small cell lung cancer (NSCLC) who received atezolizumab and were enrolled in J-TAIL, a multicenter, prospective, single-arm observational study.

RESULTS

Among the 1,002 patients, 190 (19.0%) developed irAEs. The most common irAEs were skin disorders (3.8%) of any grade and interstitial lung disease (1.5%) of grade ≥3. Patients who developed irAEs within 4 or 6 weeks of treatment initiation had higher baseline C-reactive protein levels than those without irAEs. OS was longer in patients with irAEs [HR, 0.66; 95% confidence interval (CI), 0.54-0.82], particularly in those with low-grade irAEs (HR, 0.45; 95% CI, 0.33-0.62), than in patients without irAEs. The HR (95% CI) for OS in patients with low-grade and high-grade skin or endocrine disorder-related irAEs was 0.42 (0.28-0.64) and 0.37 (0.15-0.88), respectively. The HR (95% CI) for OS in patients with low-grade and high-grade irAEs other than skin or endocrine disorders was 0.44 (0.30-0.65) and 1.27 (0.96-1.69), respectively.

CONCLUSIONS

In patients with unresectable advanced or recurrent NSCLC treated with atezolizumab in real-world settings, irAEs are associated with a clinical benefit except in those with high-grade irAEs other than skin and endocrine disorders.

SIGNIFICANCE

Immune checkpoint inhibitors are useful for treating NSCLC but can cause life-threatening irAEs. This study had a large sample size and stratified the analysis by irAE type and grade. The results suggest that improved management of irAEs may improve the therapeutic effect of atezolizumab.

A retrospective review of intramuscular olanzapine and parenteral benzodiazepine coadministration in the emergency department

Introduction

Acute agitation is a common presenting symptom in medical and mental health emergencies that may require pharmacologic intervention. There is a manufacturer recommendation against intramuscular coadministration of olanzapine with parenteral (intramuscular or intravenous) benzodiazepines despite a deficiency of high-quality evidence. The purpose of this study was to contribute to available literature regarding intramuscular olanzapine and parenteral benzodiazepine use in acutely agitated patients in the emergency department (ED).

Methods

This was a single-center retrospective chart review of adult ED patients who received intramuscular olanzapine and a parenteral benzodiazepine within 2 hours. The composite primary endpoint evaluated the occurrence of cardiac or respiratory compromise within 2 hours of medication administration. Secondary endpoints mirrored the primary endpoint within 30 minutes and evaluated the occurrence of cardiac arrest or desaturation in the ED outside the 2-hour window.

Results

One hundred eleven patients were included in the analysis, 64 (57.7%) of whom had documented vitals or oxygen status within 2 hours of medication administration. The composite primary endpoint occurred in 8 patients (12.5%), with only 1 patient requiring intervention with intravenous fluids. The secondary composite endpoint occurred in 2 (9.5%) of 21 patients with documented vitals or oxygen status within 30 minutes of treatment, neither of which required intervention. There were no identified events of intubation or significant cardiac events.

Discussion

Until better evidence is available, this combination therapy should, at minimum, include appropriate patient monitoring. Future studies should investigate risk factors for serious adverse effects.

A phase II study of atezolizumab with bevacizumab, carboplatin, and paclitaxel for patients with EGFR-mutated NSCLC after TKI treatment failure (NEJ043 study)

INTRODUCTION

Treatment options for patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) after EGFR-tyrosine kinase inhibitor (TKI) treatment failure are limited. An exploratory analysis of 26 patients in the IMpower150 study indicated that treatment with atezolizumab, bevacizumab, carboplatin, and paclitaxel (ABCP) was effective in patients with EGFR-mutated NSCLC. This phase II study was conducted to assess the efficacy of ABCP in EGFR-mutated NSCLC patients after TKI treatment.

METHODS

Patients with non-squamous NSCLC harboring sensitizing EGFR mutations were enrolled. ABCP therapy was administered every 3 weeks for four cycles, followed by maintenance therapy with atezolizumab and bevacizumab. The primary endpoint was progression-free survival (PFS) according to extramural review (ER). Key secondary endpoints and preplanned analysis included overall survival (OS), overall response rate (ORR), and differences in the efficacy of ABCP according to prior EGFR-TKI administration, liver metastases, and brain metastases.

RESULTS

Sixty patients from 26 centers were enrolled. Median PFS was 7.4 months (95% confidence interval [CI]: 5.7-8.2). The median OS was 23.1 months (95% CI: 13.1-not reached), and the ORR was 55.9%. PFS was significantly shorter in patients who had received osimertinib as a first-line treatment (7.2 months vs. 7.4 months, hazard ratio [HR] 1.932, p = 0.023), those with brain metastases (5.7 months vs. 8 months, HR 1.86, p = 0.032), or those with liver metastases (5.4 months vs. 7.9 months, HR 2.779, p = 0.003).

CONCLUSIONS

Although this study did not meet the primary endpoint, ABCP showed clinically meaningful efficacy in EGFR-mutated NSCLC patients.

Real-world data on the efficacy and safety of immune-checkpoint inhibitors in elderly patients with non-small cell lung cancer

PURPOSE

Immune-checkpoint inhibitors (ICIs) are effective against advanced non-small cell lung cancer (NSCLC). However, whether the efficacy and safety of ICI treatment in elderly patients are similar to those in younger patients is unclear. This study was designed to address this question.

METHODS

We enrolled patients who received ICI monotherapy in Japan between December 2015 and December 2017; those ≥75 years of age comprised the elderly group. We compared the efficacy and safety of ICI monotherapy in elderly patients with those in younger patients and explored prognostic factors in elderly patients.

RESULTS

We enrolled 676 patients; 137 (20.3%) were assigned to the elderly group. The median age of the elderly and younger groups was 78 (range, 75-85) and 66 (range, 34-74) years. The median progression-free survival (4.8 months vs. 3.3 months, p = 0.1589) and median overall survival (12.3 months vs. 13.0 months, p = 0.5587) were similar between the elderly and younger groups. Multivariate analysis revealed that a significantly better OS in the elderly group was associated with better responses to first- or second-line ICI treatment (p = 0.011) and more immune-related adverse events (irAEs) (p = 0.02). IrAEs that led to ICI discontinuation occurred in 34 of 137 patients (24.8%) in the elderly group, and their survival was significantly higher than that in those who did not have irAEs.

CONCLUSION

ICI is also effective in elderly NSCLC patients, and treatment discontinuation due to irAEs may be a good prognostic marker.

Additional clinical impact of plaque analysis for on-site CT-derived FFR in coronary CT angiography on midterm prognosis

Background

We previously reported that per-patient on-site computed tomography-fractional flow reserve (CT-FFR), which can be acquired on-site workstation using fluid structure interaction during the multiple optimal diastolic phases measured 1 to 2 cm distal to a target lesion may be feasible for risk stratification based on future cardiac events for patients who did not undergo planned revascularization. However, per-vessel CT-FFR and the additional impact of plaque analysis on CT-FFR have not been evaluated.

Purpose

The aim of this study is to assess the clinical and additional impact of novel plaque analysis using labeling method for per-vessel CT-FFR on midterm prognosis.

Methods

A total of 254 consecutive patients with 354 vessels showing 50–90% stenosis but not revascularized within 90 days from coronary CT angiography (CCTA) on 320-row CT were retrospectively analyzed and followed during a median follow up 3.6 years. Plaque characteristics by labeling method (necrotic core/total plaque volume (% necrotic core), non-calcified plaque (NCP)/vessel volume (%NCP), and total plaque/vessel volume (%total plaque) for both total vessel volume (mm3) and at minimum lumen area (MLA, mm2)), positive remodeling (PR) and CT-FFR were analyzed on per-target vessels. The endpoint was vessel oriented-composite outcome (VOCO), including cardiac death, non-fatal MI, and unplanned revascularization.

Results

The incidence of VOCO occurred in 6.8% (24/354). In the cox proportional hazard model, a multivariate analysis identified CT-FFR≤0.80 was the most associated factor with VOCO (all values <0.01 for other plaque morphologies), but %necrotic core, %NCP, %total plaque at MLA and PR were significantly independent of CT-FFR≤0.80. (%necrotic core HR; 3.43 (p<0.01 [95% confidence interval (CI) 1.42–8.29]), %NCP HR; 4.05 (p=0.03 [95% CI 1.19–13.71]), %total plaque at MLA HR; 2.82 (p=0.02 [95% CI 1.18–6.76]), and PR HR; 2.90 (p<0.01 [95% CI 1.30–6.51]), respectively.)

Conclusion

From a view point of clinical outcomes for vessels with moderate to severe stenosis but not revascularized at initial CCTA, CT-FFR demonstrated the significant impact on per-vessel analysis. Moreover, %necrotic core, %NCP and %total plaque at MLA analyzed by labeling method provided better prognostic value in addition to CT-FFR.

Funding Acknowledgement

Type of funding sources: None.

Clinical impact of novel pericoronary adipose tissue measurement on ECG-gated non-contrast chest CT scan

Background

Pericoronary adipose tissue (PCAT) quantified from coronary computed tomography angiography (CCTA) is a new predictor of CT-derived high-risk plaque (HRP) and adverse cardiac events. There has been no report investigating the method to assess PCAT from non-contrast CT so far. In this present study, we developed a brand-new method to quantify the value of PCAT from electrocardiogram (ECG)-gated non-contrast CT (NC-PCAT).

Purpose

To develop a brand-new method to quantify NC-PCAT accurately, and evaluate its prognostic value.

Methods

We retrospectively studied two independent cohorts of patients undergoing CCTA and ECG-gated non-contrast CT for clinical indication of coronary artery disease (CAD). For former cohort of consecutive 300 patients, we validated the agreement between the NC-PCAT and PCAT, and evaluated the association between NC-PCAT and the prevalence of HRP. For latter cohort of consecutive 333 patients, we dichotomized them into two groups with median NC-PCAT, and assessed the prognostic value of NC-PCAT. To quantify NC-PCAT, we placed 15x15mm region of interest at epicardial fat tissue dorsally adjacent to right coronary ostium in axial slice of ECG-gated non-contrast CT, and defined NC-PCAT as the mean CT value of each 1x1mm pixel there. PCAT was quantified from CCTA using conventional method as described in former researches. Primary endpoint was defined as major adverse cardiac events (MACE), composite of all-cause death and non-fatal myocardial infarction. HRP was defined as coronary artery plaque which has two or more following features; positive remodeling, low attenuation, spotty calcification, and napkin-ring sign.

Results

NC-PCAT was well-correlated with PCAT (r=0.68, p<0.0001). In former cohort, we found HRP in 34 (11.3%) patients. In multivariable logistic regression analysis, higher NC-PCAT (OR 1.06, 95% CI 1.03–1.10, p=0.0001), coronary artery calcium score (CACS) (OR 1.01 per 10 CACS increase, 95% CI 1.00–1.02, p=0.013), and current smoking (OR 2.58, 95% CI 1.03–6.49, p=0.044) were independent predictors of the prevalence of HRP. Among patients with CACS more than zero (n=193), NC-PCAT (OR 1.06, 95% CI 1.03–1.10, p=0.0002), current smoking (OR 3.02, 95% CI 1.17–7.82, p=0.027), and male (OR 2.81, 95% CI 1.06–7.48, p=0.028) were independent predictors of the prevalence of HRP, whereas CACS was not (p=0.15). In latter cohort, the median duration of follow-up was 2.9 years (IQR 1.9–3.9), and 16 (4.8%) cases of MACE were identified. The cumulative incidence of MACE was significantly higher in high NC-PCAT group. Multivariable cox hazard regression analysis revealed that higher NC-PCAT was an independent predictor of primary endpoint, even after adjustment for sex and age (HR 4.28, 95% CI 1.20–12.52, p=0.012).

Conclusions

There was a positive correlation between NC-PCAT and PCAT. Higher NC-PCAT is significantly associated with not only the prevalence of HRP, but also worse clinical outcome.

Funding Acknowledgement

Type of funding sources: None.

NEJ043: A phase 2 study of atezolizumab (atezo) plus bevacizumab (bev) plus carboplatin (carbo) plus paclitaxel (pac; ABCP) for previously treated patients with NSCLC harboring EGFR mutations (EGFRm)

9110

Background: Previous studies have demonstrated poor clinical outcomes of patients (pts) with EGFRm NSCLC treated with PD-1/PD-L1 inhibitors. However, a recent subgroup analysis of the IMpower150 trial suggested the effectiveness of ABCP in NSCLC with EGFRm. The aim of this study is to further evaluate efficacy and safety of ABCP in patients with EGFRm NSCLC. Methods: This single-arm multicenter phase 2 study included pts with nonsquamous NSCLC harboring sensitizing EGFRm with prior EGFR-TKI therapy. Pts received the combination dose of atezo 1200 mg, bev 15 mg/kg, carbo AUC 6 mg/mL/min and pac 175 mg/m2 every 3 weeks up to 4 cycles followed by atezo plus bev until loss of clinical benefit. The primary endpoint was PFS by extramural review (ER). The key secondary endpoints included OS, ORR, DoR, relative dose intensity of pac, and safety. Results: 60 pts were enrolled (median age 68 y [40–74 y], 67% were female, 55% were Ex19del and 40% were L858R). At data cutoff (November 30, 2021), median follow-up was 12.8 months in the ITT population. Median cycles of induction and maintenance therapy were 4 and 9, respectively. Median PFS was 7.4 month (95% CI, 5.7-8.2) and median OS was 18.9 month (95% CI, 13-not reached). Confirmed ORR by ER was 56% (95% CI, 43-69) and median DoR was 7.1 months (95% CI, 4.9-9.8). T790M was associated with a favorable PFS and response to the combination therapy (PFS 8.1 vs 6.8, ORR 71% vs 50%). Relative dose intensity of pac was 84%. Grade ≥3 adverse events (AEs) were reported in 92% of pts and the most common grade ≥3 AE was neutropenia (63%). Interstitial lung disease occurred in one patient (2%). AEs leading to treatment discontinuation occurred in 12% of pts. Conclusions: NEJ043 study showed that the median PFS of ABCP was 7.4 months with good tolerability. We will continue to investigate the tail plateau phenomenon of PFS and OS to conclude the clinical efficacy. Clinical trial information: 031190066.

Use of bronchoalveolar lavage in diagnosing angioimmunoblastic T-cell lymphoma: A case report

Angioimmunoblastic T-cell lymphoma (AITL) is a type of peripheral T-cell tumour that belongs to the group of non-Hodgkin's lymphomas. Pulmonary lesions can be found in 7%-10% of AITL cases. Imaging findings of the lungs varied; however, immunoblastic infiltration in the lungs is rare. Our patient was a 73-year-old man who received repeated chemotherapy for AITL. Fourth-line therapy using romidepsin controlled the illness, but the patient was hospitalized for dyspnoea and an infiltrative shadow. We performed bronchoalveolar lavage (BAL), and the culture was positive for Haemophilus influenzae. The patient was initially discharged with antibiotic therapy, but hospitalized again. Antibiotics were ineffective and the patient required mechanical ventilation. BAL was performed again, after which fluid cytology revealed immunoblast-like atypical cells. Therefore, the patient was diagnosed with pulmonary infiltration due to AITL. Steroid therapy proved ineffective, and the patient died. BAL was used to effectively diagnose pulmonary AITL infiltration.

Comparison of the clinical features of invasive pneumococcal disease with those of pneumococcal pneumonia in adults

Background: Invasive pneumococcal disease (IPD) is an infectious disease where Streptococcus pneumoniae can be detected in the cerebrospinal fluid or blood.

Methods: Eight patients presented to our hospital with adult IPD. We compared with 69 cases of pneumococcal pneumonia treated in our department between 2012 and 2014. None of the patients had a history of pneumococcal vaccine administration.

Results: Hematological examination showed the platelet count was significantly lower and the serum C-reactive protein level was significantly higher in the IPD group. There was a significant difference in the use of a respirator and mortality in the IPD group. About antibiotics, Carbapenem and quinolone were used for the treatment of many patients in the IPD group. In the fatal three cases of IPD, the age of all members were 65 years or younger. Two of three had no underlying disease.

Conclusion: IPD develops without elderly people and in those without underlying disease. Also, the patients who took a sudden course may result in death. In line with previous studies that have reported the effectiveness of the pneumococcal vaccine, our study findings emphasize the need of administering vaccination for prevention of IPD in person who was younger than 65 years old.

Optimal measurement location of on-site based CT-derived FFR on midterm prognosis

Background

Fractional Flow Reserve (FFR) derived from coronary computed tomography angiography (CCTA) enables anatomical and hemodynamical assessment of coronary artery disease. CT-FFR, which can be acquired on-site workstation using fluid structure interaction during the multiple optimal diastolic phase, has an incremental diagnostic value over conventional CCTA. However, few studies are focused on investigating the appropriate measurement location of CT-FFR, considering the prognosis, using CCTA as a standalone modality.

Purpose

The aim of this study is to assess the clinical impact on CT-FFR with an appropriate measurement.

Methods

A total of 370 consecutive patients who underwent CCTA in a single-heartbeat scan with a phase window of 70% to 99% of the R-R interval, showing 50–90% stenosis of at least one major epicardial vessel measuring ≥1.8 mm in diameter on CCTA were retrospectively analyzed and followed during a median follow up 2.9 years. CT-FFR values were measured at three points: 1, 2 cm distal to a target lesion (CT-FFR1cm, 2cm) and the vessel terminus (CT-FFRlowest), and a CT-FFR value ≤0.80 was considered abnormal. The endpoint was MACE, a composite of cardiac death, non-fatal MI, and unplanned revascularization.

Results

The incidence of MACE occurred in 8.4% (31/370) of the whole patients, including four cardiac deaths, ten all cause deaths, two non-fatal MI, and twenty unplanned revascularization. The Kaplan-Meier survival analysis demonstrated a significantly higher cumulative MACE rate in patients with positive CT-FFR1cm and 2cm than those with negative CT-FFR1cm and 2cm, while there was no significant difference between negative and positive in CT-FFRlowest, among patients with negative CT-FFR1cm and 2cm (Figure 1). Among 221 patients, who did not perform early revascularization within 90 days from CCTA, there was no significant difference in CT-FFRlowest in the incidence of MACE. In contrast, the risk of MACE was significantly higher in both positive CT-FFR1cm and CT-FFR2cm (Figure 2).

Conclusion

From a view point of clinical outcome for patients with moderate to severe stenosis on CCTA, a CT-FFR value when measured at 1-to-2 cm distal to a target lesion could be feasible for the deferral of unnecessary invasive coronary angiography safely. Moreover, CT-FFR1–2cm showed better risk stratification measurement rather than CT-FFRlowest, based on future adverse cardiac event.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Canon Medical Systems Corporation Kaplan-Meier 1Kaplan-Meier 2

Prognostic significance of OX40+ lymphocytes in tumor stroma of surgically resected small-cell lung cancer

OX40 (CD134) is a co-stimulatory molecule mostly expressed on activated T lymphocytes. Previous reports have shown that OX40 can be an immuno-oncology target and a clinical biomarker for cancers of various organs. In this study, we collected formalin-fixed paraffin-embedded tumor samples from 124 patients with small-cell lung cancer (SCLC) who had undergone surgery. We analyzed the expression profiles of OX40 and other relevant molecules, such as CD4, CD8, and Foxp3, in tumor stroma and cancer nest using immunohistochemistry and investigated their association with survival. High infiltration of OX40⁺ lymphocytes (OX40^high) in tumor stroma was positively associated with relapse-free survival (RFS) and overall survival (OS) compared with low infiltration of OX40⁺ lymphocytes (OX40^low) (RFS, median, 26.0 months [95% confidence interval (CI), not reached (NR)–NR] vs 13.2 months [9.1–17.2], p = .024; OS, NR [95% CI, NR–NR] vs 29.8 months [21.3–38.2], p = .049). Multivariate analysis revealed that OX40^high in tumor stroma was an independent indicator of prolonged RFS. Moreover, RFS of patients with OX40^high/CD4^high in tumor stroma was significantly longer than that of patients with OX40^low/CD4^low. The RFS of patients with tumor stroma with OX40^high/CD8^high was significantly longer than that of patients with tumor stroma with OX40^low/CD8^high, OX40^high/CD8^low, or OX40^low/CD8^low. These findings suggest that OX40⁺ lymphocytes in tumor stroma play a complementary role in regulating the relapse of early-stage SCLC. Reinforcing immunity by coordinating the recruitment of OX40⁺ lymphocytes with CD4⁺ and CD8⁺ T cells in tumor stroma may constitute a potential immunotherapeutic strategy for patients with SCLC.

A Case of Hb Aalborg (HBB: c.223G>C) with Chronic Obstructive Pulmonary Disease: A First Familial Presentation in Japan

The proband was a male in his seventies who came to our facility because of shortness of breath. He was not anemic but presented dissociation between oxygen saturation (SpO₂) and partial pressure of oxygen (PaO₂) by blood gas analysis, and also demonstrated hemoglobinopathy after measurement of Hb A_1c using high performance liquid chromatography (HPLC). Twenty-three percent of unknown hemoglobin (Hb) bands were detected. After sequencing the β-globin gene, we noted a missense mutation at codon 74 (GGC>CGC) (Gly→Arg) of the β-globin chain and he was diagnosed with Hb Aalborg (HBB: c.223G>C). One of the proband's siblings was diagnosed to have a low SpO₂ level and also diagnosed to carry Hb Aalborg; she was also mildly anemic. This is the first known familial case of Hb Aalborg in Japan. In addition to Hb Aalborg, our case had underlying chronic obstructive pulmonary disease (COPD). Herein we present this case as a rare addition to the hematological literature.

Prognostic factors in patients with advanced non-small cell lung cancer after long-term Anti-PD-1 therapy (HOT1902)

OBJECTIVES

Limited information is available on the appropriate treatment duration of immune checkpoint inhibitors (ICIs). We aimed to identify candidates who would benefit from ICI discontinuation after one year of treatment for metastatic non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

This retrospective multi-institutional observational study examined medical records of all consecutive patients with advanced or recurrent NSCLC, who started ICI monotherapy at 15 institutions in Japan between December 2015 and December 2017. Patients who received initial ICI therapy for >1 year without progressive disease were defined as the long-term treatment (LT) group; others were defined as the non-long-term treatment (NLT) group. Primary outcomes included the prognostic factors in the LT group, whereas secondary outcomes included efficacy of ICI rechallenge, safety, and survival outcomes in the overall population.

RESULTS

In total, 676 patients were enrolled, and 114 (16.9 %) were assigned to the LT group. The median time interval from the start of initial ICI administration to data cutoff was 34.3 months (range, 24.1-47.8); thus, all surviving patients were followed-up for at least 2 years from the start of initial ICI. Median progression-free survival (PFS) was longer in the LT than in the NLT group (33.6 months vs. 2.7 months; p < 0.001). On multivariate analysis, significantly better PFS was associated with smoking (hazard ratio [HR]=0.36, p = 0.04), and complete response (CR; HR=uncomputable, p < 0.001) in the LT group. Thirty-seven patients (5.5 %) received ICI rechallenge, including 10 in the LT group. Among patients receiving rechallenge treatment, the median PFS was 2.2 months, with no difference between the LT and NLT groups.

CONCLUSIONS

In the LT group, smoking and achieving CR were significantly associated with better PFS. Since rechallenge treatment was not effective, careful consideration is required for discontinuing ICI. However, these prognostic factors are helpful in considering candidates for ICI discontinuation.

TRIAL REGISTRATION

UMIN ID, UMIN000041403.

Characterization of inpatient care for patients admitted to a psychiatric hospital with a home opioid prescription

Introduction

Patients with mental illness are particularly at risk for OUD, and due to this higher risk, providers may be more inclined to withhold their home opioids when they are admitted to a psychiatric hospital. Patients whose home opioids are continued or withheld during admission may be treated differently with respect to pain control, orders for nonopioid adjunctive pain agents, orders for intramuscular as-needed medications, orders for seclusion and/or restraints, and outpatient referrals for OUD treatment. The objective of this retrospective pilot study was to characterize inpatient care for these 2 patient populations.

Methods

Thirty-one inpatient encounters were reviewed for patients who had opioid prescriptions before admission and were discharged from the medical center's psychiatric service from June 1 through August 31, 2019.

Results

Orders for nonopioid adjunctive pain agents and intramuscular as-needed medications trended higher for the opioid-withheld group, suggesting greater polypharmacy and patient dissatisfaction compared with the opioid-continued group. Additionally, what became evident was the lack of consistent and clear documentation regarding the discharge plans for the patients' home opioid and OUD treatment.

Discussion

These findings may prompt inpatient interdisciplinary teams to develop a better process of documentation to facilitate continuity of care.

Delta-like 1 homolog (DLK1) as a possible therapeutic target and its application to radioimmunotherapy using 125I-labelled anti-DLK1 antibody in lung cancer models (HOT1801 and FIGHT004)

OBJECTIVES

Delta-like 1 homolog (DLK1) is a non-canonical Notch ligand known to be expressed in several cancers but whose role in lung cancer is not yet fully understood. We sought to confirm DLK1 expression in small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC), and to examine DLK1's clinical significance. Furthermore, we examined the possible utility of DLK1 as a novel target in radioimmunotherapy (RIT).

METHODS

We retrospectively assessed the correlation between clinical features and DLK1 expression by immunohistochemistry in resected specimens from 112 patients with SCLC and 101 patients with NSCLC. Moreover, we performed cell and animal experiments, and examined the possibility of RIT targeting DLK1 in SCLC using iodine-125 (¹²⁵I) -labeled anti-DLK1 antibody, knowing that ¹²⁵I can be replaced with the alpha-particle-emitter astatine-211 (²¹¹At).

RESULTS

In SCLC and NSCLC, 20.5 % (23/112) and 16.8 % (17/101) of patients (respectively) had DLK1-positive tumors. In NSCLC, DLK1 expression was associated with recurrence-free survival (P < 0.01) but not with overall survival. In SCLC, there was no association between DLK1 expression and survival. In addition, ¹²⁵I-labeled anti-DLK1 antibody specifically targeted DLK1 on human SCLC tumor cell lines. Furthermore, ¹²⁵I-labeled anti-DLK1 antibody was incorporated into tumor tissue in a mouse model.

CONCLUSION

A proportion of SCLC and NSCLC exhibits DLK1 expression. As a clinical feature, DLK1 expression could be a promising prognostic factor for recurrence in patients with resected NSCLC. In addition, DLK1 could serve as a new therapeutic target, including RIT, as suggested by our pilot study using a radiolabeled anti-DLK1 antibody in SCLC.

Detection of somatic TP53 mutation in surgically resected small-cell lung cancer by targeted exome sequencing: association with longer relapse-free survival

OBJECTIVES

Few reports have explored clinical biomarkers, including those identified by targeted exome sequencing (TES) of surgically resected small-cell lung cancer (SCLC) and correlation with patient survival.

PATIENTS AND METHODS

We collected formalin-fixed paraffin-embedded tumor samples from 127 patients with SCLC who had undergone surgery and analysed nonsynonymous somatic gene mutation profiles by TES of 26 cancer-related genes using next-generation sequencing (NGS) and web databases (UMIN Registration No. 000010117).

RESULTS

We detected 38 nonsynonymous somatic tumor protein p53 (TP53) mutations in 43 (54.4%) patients. Among these TP53 lesions, we identified clinically relevant mutations including those encoding Y220C, R248W, R249M, M237I, and R273L substitutions in the p53 protein. These mutations have been reported to be associated with certain clinical outcomes or biology in other types of malignancies but not in SCLC. Moreover, nonsynonymous somatic mutations of TP53 were positively associated with relapse-free survival (RFS) (median, 17.33 months [95% confidence interval (CI), 3.86-30.79] in a mutation-positive group vs 10.39 months (6.96-13.82) in a mutation-negative group, p = 0.042). Multivariate analysis revealed that nonsynonymous somatic TP53 mutation was an independent factor of prolongation of RFS (hazard ratio: 0.51, 95% CI: 0.29-0.89, p = 0.019) but not overall survival (OS).

CONCLUSION

These data suggested that TES may play a critical role for promoting reverse-translational studies, including investigations of the biology of TP53 mutations in different stages of SCLC. Accumulation of the data using cancer panels with a broader range of genes, including TP53, is expected to be useful for future clinical applications for patients with SCLC.

Open-label, multicenter, randomized phase II study on docetaxel plus bevacizumab or pemetrexed plus bevacizumab for treatment of elderly (aged ≥75 years) patients with previously untreated advanced non-squamous non-small cell lung cancer: TORG1323

Background

The effectiveness of bevacizumab monotherapy in elderly patients with non-squamous non-small cell lung cancer (NSCLC) is unclear. The efficacy of the combinations for elderly patients was explored.

Methods

Untreated patients (≥75 years; performance status 0–1) with stage IIIB, IV, or recurrent non-squamous NSCLC were included. Patients with epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) gene rearrangements were eligible even if they received tyrosine kinase inhibitors. Patients were randomized 1:1 to receive docetaxel (50 mg/m²) (DB) or pemetrexed (500 mg/m²) (PB) with bevacizumab (15 m/kg). The primary endpoint was progression-free survival (PFS). Treatment was administered every 3 weeks until disease progression or unacceptable toxicity.

Results

Overall, 103 patients (DB: n=51; PB: n=52) were enrolled. In the DB and PB arms, median ages [range] were 78 [75–88] and 79 [75–94] years, respectively; median PFS were 6.1 and 4.6 months, respectively [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.66–1.61]; and response rates were 43%, and 40%, respectively (P=0.840). Grade ≥3 leukopenia, neutropenia, and fatigue incidences were significantly higher in the DB arm. Febrile neutropenia incidence did not differ significantly (16% vs. 12%, P=0.578). One patient in the PB arm died from a ruptured abdominal aortic aneurysm. Quality of life (QoL) analysis revealed less deterioration in the PB arm.

Conclusions

In previously untreated elderly patients with non-squamous NSCLC, PB shows feasibility, better QoL, and promising efficacy in terms of PFS, and an objective response rate for further analysis (UMIN000012786).

Gefitinib Alone Versus Gefitinib Plus Chemotherapy for Non–Small-Cell Lung Cancer With Mutated Epidermal Growth Factor Receptor: NEJ009 Study

PURPOSE

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor combined with cytotoxic chemotherapy is highly effective for the treatment of advanced non–small-cell lung cancer (NSCLC) with EGFR mutations; however, little is known about the efficacy and safety of this combination compared with that of standard therapy with EGFR- tyrosine kinase inhibitors alone.

METHODS

We randomly assigned 345 patients with newly diagnosed metastatic NSCLC with EGFR mutations to gefitinib combined with carboplatin plus pemetrexed or gefitinib alone. Progression-free survival (PFS), PFS2, and overall survival (OS) were sequentially analyzed as primary end points according to a hierarchical sequential testing method. Secondary end points were objective response rate (ORR), safety, and quality of life.

RESULTS

The combination group demonstrated a better ORR and PFS than the gefitinib group (ORR, 84% v 67% [ P < .001]; PFS, 20.9 v 11.9 months; hazard ratio for death or disease progression, 0.490 [ P < .001]), although PFS2 was not significantly different (20.9 v 18.0 months; P = .092). Median OS in the combination group was also significantly longer than in the gefitinib group (50.9 v 38.8 months; hazard ratio for death, 0.722; P = .021). The rate of grade ≥ 3 treatment-related adverse events, such as hematologic toxicities, in the combination group was higher than in the gefitinib group (65.3% v 31.0%); there were no differences in quality of life. One treatment-related death was observed in the combination group.

CONCLUSION

Compared with gefitinib alone, gefitinib combined with carboplatin plus pemetrexed improved PFS in patients with untreated advanced NSCLC with EGFR mutations with an acceptable toxicity profile, although its OS benefit requires further validation.

P6173Plaque characteristics on coronary CT angiography in case of discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (IFR)

Background

The usefulness of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) evaluation has been confirmed in the determination of revascularization of coronary artery disease. When FFR≤0.8 and iFR≤0.89 were regarded as the criteria for positivity, the discordance was noted in approximately 20%, but this cause has not been well established.

Purpose

The purpose of this study was to investigate the patient background and features on coronary CT angiography (CCTA) showing the discordance between FFR≤0.8 and iFR≤0.89.

Methods

The subjects were consecutive 85 cases with 108 vessels in which stenosis of 30–90% was detected at one vessel of at least 2mm or more in the major epicardial vessels and FFR and iFR was performed within subsequent 90 days, among suspected cases of coronary arterial diseases which underwent CCTA. The factors showing the discordance between FFR and iFR (patient background, coronary artery calcification score, high risk plaque features on CCTA (positive remodeling, low attenuation plaque), plaque characteristics by a plaque analysis software using a new algorithm called labeling method (vessel volume, plaque volume, lumen volume, plaque length, maximum plaque burden, necrotic core area, fibrous area and calcium area) were evaluated using logistic regression analysis on per-patient and per-vessel basis.

Results

There were no significant both FFR and iFR positive definite factors on per-patient basis. The lumen volume/vessel volume (OR: 0.93, 95% CI: 0.88–0.98, P=0.0032) (OR: 0.90, 95% CI: 0.85–0.95, P<0.0001),minimum lumen area (MLA) (OR: 0.59, 95% CI: 0.41–0.85, P=0.0006) (OR: 0.64, 95% CI: 0.44–0.92, P=0.0047), the plaque volume/vessel volume (OR: 1.05, 95% CI: 1.01–1.10, P=0.0114) (OR: 1.09, 95% CI: 1.04–1.15, P=0.0002) and maximum plaque burden (OR: 1.08, 95% CI: 1.01–1.15, P=0.0095) (OR: 1.06, 95% CI: 1.00–1.13, P=0.0406) were significant both FFR and iFR positive definite factors on per-vessels basis. Discordance between FFR≤0.8 and iFR≤0.89 was observed in 23 vessels (21.3%) of 19 patients. In FFR positive and iFR negative group (15 vessels, 13.9%), positive remodeling (PR) (OR: 4.38, 95% CI: 1.13–17.00, P=0.0294) was only significant predictor. In FFR negative and iFR positive group, there was no significant predictors.

Conclusions

In both FFR and iFR, only lumen volume /vessel volume, MLA, plaque volume/vessel volume and plaque burden were significant positive definite factors. As for the discordance between FFR and iFR, PR is significant predictor in FFR positive and iFR negative group.