Development of autoimmune diabetes with severe diabetic ketoacidosis and immune-related thyroiditis secondary to durvalumab: a case report

Immune-mediated endocrinopathies are among the most frequent immune-related adverse events (irAEs) with immune checkpoint inhibitors (ICIs) targeting programmed death-ligand 1 (PD-L1)/PD-1. However, the development of auto-immune diabetes is an uncommon event during PD(L)-1 blockade, either as monotherapy or in combination therapy. Here we report a case of a 75-year-old male with a mediastinal recurrence from a stage IA squamous cell carcinoma of the lung previously treated with stereotactic body radiotherapy (SBRT) who early developed a severe diabetic ketoacidosis (DKA) caused by new-onset auto-immune diabetes, with positive glutamic acid decarboxylase (GAD65) autoantibodies, during durvalumab consolidation therapy after concurrent chemoradiation. The patient had no personal or family history of diabetes or auto-immune diseases and was admitted after the second cycle of durvalumab to the intensive care unit (ICU) with severe DKA. During his hospitalization, insulin and fluid therapy were started and the patient had a favorable clinical course. Durvalumab treatment was interrupted and thyroiditis was verified during follow-up, without anti-thyroid antibodies, that progressed to subsequent hypothyroidism with need of thyroid hormone replacement therapy. This case highlights the rare irAE of autoimmune type 1 diabetes during anti-PD(L)-1 therapy, which can be life-threatening and requires adequate patient education and prompt medical treatment within a multidisciplinary team, including endocrinology and emergency medicine. Besides its low incidence, this case show how irAE must be taken in account about decision of ICI treatment, especially in curative setting, as they can be potentially fatal and impair overall survival. Furthermore, as reported in the present case, multiple endocrine irAEs can occur in the same patient either simultaneously or sequentially, suggesting that active surveillance is needed in those who develop endocrinopathies as a result of ICI treatment. Immune-mediated endocrinopathies are generally irreversible and cause life-long morbidity, which must be taken into consideration when deciding on further lines of treatment.

Immunotherapy for extensive stage small cell lung cancer

Small cell lung cancer (SCLC) is an aggressive malignancy. Until recently the standard of care for newly diagnosed patients with extensive-stage disease was chemotherapy consisting of etoposide plus a platinum (EP). The median overall survival (OS) was only about 10 months with this systemic therapy. Immune checkpoint inhibitors were first evaluated as second or subsequent line treatments in extensive stage disease and later in combination with EP in the first-line setting. Recently two randomized phase III trials have demonstrated statistically improved OS with addition of a programmed death ligand-1 (PD-L1) inhibitor to EP. As a result, the standard of care for newly diagnosed patients with extensive-stage SCLC has changed for the first time in decades. However, many patients do not derive benefit from the addition of a PD-L1 inhibitor to EP. In this review we discuss first-line trials of chemoimmunotherapy in extensive stage SCLC and summarize data on second and subsequent line treatment with immune checkpoint inhibitors in immunotherapy-naïve patients. Additionally, we discuss potential biomarkers that could be utilized to select for which patients derive benefit from addition of a PD-L1 inhibitor to EP and propose ways to improve on first-line chemoimmunotherapy.

Immunotherapy in Small Cell Lung Cancer

Simple Summary

Small cell lung cancer (SCLC) accounts for about 15% of lung cancers and it has limited therapeutic options and poor prognosis. There has been no real progress for over 30 years in the treatment of this aggressive tumor type and platinum based chemotherapy represented the cornerstone of therapy. Immune checkpoint inhibitors are the first agents in the last decades to determine an improvement in outcomes of patients with extensive stage (ES) SCLC patients. In the IMpower 133 and CASPIAN studies, the addition of atezolizumab or durvalumab, respectively, to first-line chemotherapy produced a significant improvement in overall survival with an acceptable safety profile in previously untreated patients with ES-SCLC, leading to a new standard of care. This review summarizes the main results observed with checkpoint inhibitors in SCLC, discussing the critical issues related to the use of novel checkpoint inhibitors and the future research with immunotherapy agents in SCLC.

Abstract

Small-cell lung cancer (SCLC) is an aggressive tumor type with limited therapeutic options and poor prognosis. Chemotherapy regimens containing platinum represent the cornerstone of treatment for patients with extensive disease, but there has been no real progress for 30 years. The evidence that SCLC is characterized by a high mutational burden led to the development of immune-checkpoint inhibitors as single agents or in combination with chemotherapy. Randomized phase III trials demonstrated that the combination of atezolizumab (IMpower-133) or durvalumab (CASPIAN) with platinum-etoposide chemotherapy improved overall survival of patients with extensive disease. Instead, the KEYNOTE-604 study demonstrated that the addition of pembrolizumab to chemotherapy failed to significantly improve overall survival, but it prolonged progression-free survival. The safety profile of these combinations was similar with the known safety profiles of all single agents and no new adverse events were observed. Nivolumab and pembrolizumab single agents showed anti-tumor activity and acceptable safety profile in Checkmate 032 and KEYNOTE 028/158 trials, respectively, in patients with SCLC after platinum-based therapy and at least one prior line of therapy. Future challenges are the identification predictive biomarkers of response to immunotherapy in SCLC and the definition of the role of immunotherapy in patients with limited stage SCLC, in combination with radiotherapy or with other biological agents.

The tumor microenvironment of pancreatic adenocarcinoma and immune checkpoint inhibitor resistance: a perplex relationship

Pancreatic cancer is one of the most aggressive cancers with a high mortality rate even among patients with early-stage disease. Although recent studies with novel therapeutic approaches have led to modest improvement in survival outcomes, limited progress is achieved for the use of immunotherapeutics in this challenging cancer. Immune checkpoint inhibitors, thus far, single-agent or in combination, have not yielded significant improvement in survival outcomes except in mismatch repair-deficient pancreatic cancer. The tumor microenvironment of pancreatic cancer has been considered as an attractive target for over a decade based on preclinical studies that suggested it may adversely affect drug delivery and antitumor immunity. In this review article, we elaborate on the biology of pancreatic cancer microenvironment, its highly complicated interaction with cancer cells, and the immune system. We also discuss plausible explanations that led to the failure of immune checkpoint inhibitors as therapeutic agents and the potential impacts of pancreatic cancer stroma on these negative studies.

Immune Checkpoint Inhibitor-associated Uveitis: Review of Treatments and Outcomes

Purpose: Immune checkpoint inhibitors (ICPIs), novel immunotherapy agents employed in the treatment of metastatic melanoma and other solid tumors, are associated with immune-related adverse events, including ocular inflammation. We review the current literature on immune checkpoint inhibitor-associated uveitis (ICIPU).Methods: A comprehensive literature review utilizing MEDLINE/PubMed, Cochrane, and Web of Science databases was conducted. One hundred and twenty-six cases of ICPIU reported in the literature prior to January 31, 2020 were identified and reviewed.Results: ICPIs were associated with 126 cases of anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis from 67 reports in the literature. Patients typically developed intraocular inflammation a median of 9 weeks after initiation of ICPI and 83.6% of the patients developed uveitis within 6 months. The vast majority of patients recovered to within one line of baseline vision in response to topical, local, and/or systemic steroid treatment as well as the cessation of medication.Conclusions: Prompt recognition and steroid treatment of ICPIU are critical to the care of patients receiving ICPIs.

A case of durvalumab-treated double primary cancers of the colon and lung

Cases of double primary cancers of the colon and lung are rare, and the treatment regimens are highly individualized. Here, we report a case of double primary cancers of the colon and lung. The patient underwent radical resection for cancer of the left colon (pT4aN0Mx, IIb). Two months later, he sought treatment due to chest pain and painful swelling in his left axilla for one month and was diagnosed with adenocarcinoma of the right lung (cT4N3M1c, stage IVB). At the time before receiving radical resection of the left colon tumor, a chest computed tomography examination showed a space-occupying lesion in the upper lobe of the right lung, but the histological analysis was not performed at that time because abdominal computed tomography examination suggested the presence of incomplete obstruction, and emergency radical resection for colon cancer was conducted. Molecular pathological examination of the lung mass at the most recent admission suggested KRAS mutation and strongly positive programmed cell death-ligand 1 (PD-L1). Considering the patient's pain and compression symptoms, he was given palliative radiotherapy for the lung lesion, followed by sequential durvalumab maintenance therapy, along with a capecitabine plus oxaliplatin (CAPOX) regimen for colon cancer for 3 months. The patient signed informed consent forms for all treatments. After the treatments, the patient achieved partial remission of the lung lesion and complete remission of the lymph node metastases in the neck and left axilla. The only toxic effects were chemotherapy-related grade II bone marrow suppression and grade I radiation-induced lung injury. No recurrence or metastasis was observed during the 6-month follow-up. After a trade-off between the efficacy and toxicity of the treatment regimen of double cancers, this patient was given an individualized treatment regimen-maintenance treatment with the low-toxicity durvalumab for anti-PD-L1 immunotherapy following palliative radiotherapy and evidence-supported 3-month CAPOX chemotherapy after surgery for high-risk stage II colon cancer. The regimen not only avoided possible toxic effects but also achieved a sufficient treatment intensity. We believe that the combined use of radiotherapy, chemotherapy and lowtoxicity immune-targeted drugs has good application prospects in the individualized treatment of patients with multiple cancers.

Emerging drugs for small cell lung cancer: a focused review on immune checkpoint inhibitors

INTRODUCTION

Small cell lung cancer (SCLC) is an aggressive malignancy that accounts for 15% of all lung cancers. It is characterized by initial responsiveness to therapy followed by rapid disease progression that is relatively resistant to further treatment. Recently, the addition of an immune checkpoint inhibitor (ICI) to chemotherapy has improved survival in patients with advanced disease, the first advance in systemic therapy in SCLC in over 30 years.

AREAS COVERED

In this review, we present an overview of SCLC with a focus on the scope of the problem and standard treatment, followed by a critical assessment of scientific rationale for immunotherapy in SCLC and the clinical trials that have been performed with ICIs in SCLC. Finally, we address ongoing hurdles for the development of ICIs in SCLC and potential avenues for further study.

EXPERT OPINION

Despite solid biological rationale, the results of clinical trials of ICIs in SCLC have yielded modest benefits. A small subset of patients does achieve long-term benefit, but further development of ICIs in SCLC will depend on the identification of predictive biomarkers and the design of combination regimens that take advantage of the molecular alterations that drive the immune-avoidance mechanisms and survival of SCLC cells.

Cutaneous Immune-Related Adverse Events (irAEs) to Immune Checkpoint Inhibitors: A Dermatology Perspective on Management [Formula: see text]

Immune checkpoint inhibitors have proven to be efficacious for a broad spectrum of solid organ malignancies. These monoclonal antibodies lead to cytotoxic T-cell activation and subsequent elimination of cancer cells. However, they can also lead to immune intolerance and immune-related adverse event (irAEs) that are new and specific to these therapies. Cutaneous irAEs are the most common, arising in up to 34% of patients on PD-1 inhibitors and 43% to 45% on CTLA-4 inhibitors. The most common skin manifestations include maculopapular eruption, pruritus, and vitiligo-like lesions. A grading system has been proposed, which guides management of cutaneous manifestations based on the percent body surface area (BSA) involved. Cutaneous irAEs may prompt clinicians to reduce drug doses, add systemic steroids to the regiment, and/or discontinue lifesaving immunotherapy. Thus, the goal is for early identification and concurrent management to minimize treatment interruptions. We emphasize here that the severity of the reaction should not be graded based on BSA involvement alone, but rather on the nature of the primary cutaneous pathology. For instance, maculopapular eruptions rarely affect <30% BSA and can often be managed conservatively with skin-directed therapies, while Stevens-Johnson syndrome (SJS) affecting even 5% BSA should be managed aggressively and the immunotherapy should be discontinued at once. There is limited literature available on the management of the cutaneous irAEs and most studies present anecdotal evidence. We review the management strategies and provide recommendations for psoriatic, immunobullous, maculopapular, lichenoid, acantholytic eruptions, vitiligo, alopecias, vasculitides, SJS/toxic epidermal necrolysis, and other related skin toxicities.

The changing landscape of stage III lung cancer: a literature review

INTRODUCTION

The treatment of stage III non-small cell lung cancer (NSCLC) remains challenging and associated with overall poor outcomes. Since seminal studies in the early 90s introduced concurrent chemo-radiotherapy as standard of care for treatment of this disease, no major advances have been introduced in this landscape. Both radiation dose escalation and neoadjuvant/adjuvant chemotherapy strategies were unsuccessful to improve the survival over standard of care radiation dose and chemotherapy schedule: five-year overall survival (OS) ranging from 15-20%. However, in 2017 the PACIFIC Trial demonstrated that the addition of consolidative immune checkpoint inhibitor durvalumab for 1 year led to superior progression-free survival (PFS) and 3-year overall survival with no significant increase in toxicity compared to placebo in patients who achieved disease control with concurrent chemo-RT.

AREAS COVERED

This article reviews the treatment evolution of stage III NSCLC over the past decades, discusses current standard of care strategies, and highlights potential future directions for the management of this condition.

EXPERT OPINION

Ongoing trials incorporating upfront checkpoint inhibitors with radiotherapy will answer whether adding checkpoint inhibitors to chemotherapy or substituting them for chemotherapy altogether will improve long-term outcome.

Permanent diabetes insipidus in a patient with mesothelioma treated with immunotherapy

Checkpoint inhibitors have substantially improved the prognosis for patients with advanced malignancy. Treatment with immunomodulants has the ability to reactivate the immune system against tumor cells, but can also trigger the development of immune-related adverse events that reflects a loss of tolerance of the immune system for self-antigens. Regarding the endocrine system, thyroid and pituitary are the most frequent glands involved; in particular hypophysitis is commonly observed with anti-CTLA4 with a variable impaired anterior pituitary dysfunction (mainly ACTH and TSH dysregulation) while a posterior pituitary dysfunction has been rarely described. A 68-year-old man with a diagnosis of metastatic mesothelioma started in September 2016 first-line treatment with tremelimumab and durvalumab. After 3 cycles he presented sudden onset of polydipsia and polyuria without other symptoms. Diagnostic work-up, including a water deprivation test, established a diagnosis of central diabetes insipidus. Patient started sublingual desmopressin 60 mcg three times a day, that was subsequently increased up to 480 mcg/die. At magnetic resonance imaging the posterior lobe of pituitary gland did not show high signal intensity on T1-weighted images. After regression of diabetes insipidus symptoms under desmopressin, patient restarted cancer treatment and received additional 10 doses without worsening of endocrinological toxicity or further treatment-related toxicities, maintaining the same desmopressin dosage. Posterior pituitary dysfunction has been rarely observed in patients treated with immunomodulants. To our knowledge, this is the first observation of permanent central diabetes insipidus in patients treated with combined immune checkpoint inhibitors (tremelimumab and durvalumab).

Novel cucurmosin-based immunotoxin targeting programmed cell death 1-ligand 1 with high potency against human tumor in vitro and in vivo

Immunotoxins are Ab‐cytotoxin chimeric molecules with mighty cytotoxicity. Programmed cell death 1‐ligand 1 (PD‐L1), is a transmembrane protein expressed mainly in inflammatory tumor tissues and plays a pivotal role in immune escape and tumor progression. Although PD‐L1 immune checkpoint therapy has been successful in some cases, many patients have not benefited enough due to primary/secondary resistance. In order to optimize the therapeutic efficacy of anti‐PD‐L1 mAb, we used durvalumab as the payload and CUS_245C, a type I ribosome‐inactivating protein isolated from Cucurbita moschata, as the toxin moiety, to construct PD‐L1‐specific immunotoxin (named D‐CUS_245C) through the engineered cysteine residue. In vitro, D‐CUS_245C selectively killed PD‐L1⁺ tumor cells. In vivo studies also showed that D‐CUS_245C had obvious antitumor effect on PD‐L1⁺ human xenograft tumors in nude mice. In conclusion, in the combination of the toxin with mAb, this study developed a new immunotoxin targeting PD‐L1, emphasizing a novel and promising treatment strategy and providing a valuable way to optimize cancer immunotherapy.

Durvalumab monotherapy as a third-line treatment for extensive-stage small-cell lung cancer: a case report

The global incidence and mortality rates of lung cancer are the highest of any cancer. Smallcell lung cancer (SCLC) is an undifferentiated carcinoma which accounts for 15-20% of all lung cancers. Compared with the other major lung cancer type, non-small cell lung cancer, SCLC exhibits worse biological behavior, has a higher degree of malignancy, and develops more rapidly. The majority of SCLC present with extensive-stage disease, and the prognosis for these patients remains poor. Recently, immunotherapy has been demonstrated clinical activity in extensive-stage SCLC (ES-SCLC); however, the efficacy and safety of immunotherapy in ES-SCLC needs further confirmation. Durvalumab, a selective, high-affinity human IgG1 monoclonal antibody that blocks PD-L1 binding to PD-1 and CD80, showed durable clinical activity and a manageable safety profile in patients with pretreated ES-SCLC as a first-line treatment. Here, we report the case of an ES-SCLC patient who achieved complete remission (CR) of local lesions after receiving durvalumab monotherapy as a third-line treatment, experiencing no obvious immune-related side effects, such as rash, diarrhea, fatigue, myelosuppression, or thyroid dysfunction. No immune-related pulmonary or hepatorenal toxicities occurred. The case suggests that immunotherapy can be selected for third-line or multi-line treatment of ES-SCLC, and anti-PD-L1 antibody may be the better choice for patients who have poor performance status (PS) scores.

Durvalumab after concurrent chemoradiotherapy in a patient with chemotherapy-resistant unresectable stage III non-small cell lung cancer: a case report

Durvalumab as consolidative immunotherapy following concurrent chemoradiotherapy (cCRT) is the standard treatment for patients with unresectable stage III non-small cell lung cancer (NSCLC). Here, we describe a case of unresectable stage III NSCLC who was chemotherapy resistant, benefit from cCRT and durvalumab. Contrast-enhanced computed tomography (CT) evaluation of the patient detected a mass in the left upper mediastinum. The biopsy specimen showed evidence of poorly differentiated pulmonary carcinoma. Brain magnetic resonance imaging (MRI) and bone scan found no evidence of distant metastasis. The clinical stage was defined as T4N2M0 IIIB. The patient underwent one cycle of induction chemotherapy with cisplatin and etoposide. Positron-emission tomography/computed tomography (PET-CT) after induction chemotherapy showed the tumor increased in size. The patient received volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) and the radiation dose was 60.2 Gy/2.15 Gy/28 F. Concurrent chemotherapy was delivered and the regimen was weekly paclitaxel liposome combined with nedaplatin. Durvalumab was given one day after the final fraction of radiotherapy. CT evaluation performed one month and three months after treatment found partial response (PR). Grade 1 pneumonitis was reported as a toxicity. The use of durvalumab following cCRT was feasible and efficient in this patient who was resistant to chemotherapy and that its early use was safe.

Update on Targeted Therapies for Advanced Non-Small Cell Lung Cancer: Durvalumab in Context

Immune checkpoint inhibitors (ICIs) have transformed the therapeutic strategy and prognosis of advanced non-small cell lung cancer (NSCLC) patients. Nowadays, ICIs as monotherapy or in combination with chemotherapy are the standard of care treatment in advanced NSCLC, and in stage III, durvalumab (a programmed death ligand 1 inhibitor) is the unique drug approved as consolidation treatment after chemo-radiotherapy. This article reviews the pharmacological properties, clinical activity and safety of durvalumab as monotherapy or in combination with chemotherapy or other ICIs in the therapeutic strategy of NSCLC patients.

Durvalumab and tremelimumab combination therapy versus durvalumab or tremelimumab monotherapy for patients with solid tumors: A systematic review and meta-analysis

BACKGROUND

The combination of durvalumab and tremelimumab results in clinical benefit, with a tolerable safety profile in patients with solid tumors.

OBJECTIVE

To evaluate the efficacy and safety of durvalumab in combination with tremelimumab compared with either drug alone.

METHODS

The online databases (PubMed, Web of Science, EMBASE, and Cochrane Library) were searched for potential clinical studies up to Nov 26, 2019. Eligible studies were prospective and registered clinical trials. Pooled odds ratios for objective response rate and disease control rate and pooled risk ratios for treatment-related adverse events were meta-analyzed. A random-effect model was used due to the synthesis of different cancer types.

RESULTS

Overall, 5 studies were eligible for systematic review, 3 of which were further meta-analyzed. Durvalumab plus tremelimumab was superior to tremelimumab monotherapy in improving disease control rate in head and neck squamous cell carcinoma. However, there were no significant differences between dual immunotherapy and mono-immunotherapy in pancreatic ductal adenocarcinoma and gastric and gastroesophageal junction adenocarcinoma. Additionally, pooled analyses illustrated that no significant differences in treatment-related adverse events were displayed between the 2 groups.

CONCLUSION

Durvalumab and tremelimumab combination therapy had a good safety profile and resulted in clinical benefit in head and neck squamous cell carcinoma. Future explorations are needed to further confirm the application of durvalumab plus tremelimumab.

Durvalumab-induced de novo annular psoriasiform drug eruption successfully treated with a combination of narrowband ultraviolet B phototherapy and topical treatment

Immune checkpoint inhibitors, including anti-programmed death 1 and anti-programmed death ligand 1, have become prominent treatment options for various types of cancers. However, immune checkpoint inhibitors are associated with various cutaneous adverse events, one of which is psoriasiform drug eruption. Some cases of psoriasiform drug eruption can only be controlled through the cessation of immune checkpoint inhibitors and administration of systemic immunosuppressants, such as corticosteroids and methotrexate. However, no clear guideline is available on the management of this specific rash, and the use of systemic immunosuppressants is contraindicated in selected conditions. In this article, we report a case of annular psoriasiform drug eruption induced by an anti-programmed death ligand 1 monoclonal antibody, durvalumab. The patient responded well to the combination of phototherapy and topical treatment, which allowed continuation of durvalumab treatment without concomitant systemic immunosuppressants in a 2-year follow up.

Destroyed lung due to sustained inflammation after chemoradiotherapy followed by durvalumab

A 68-year-old male patient with squamous cell carcinoma (cT4N2M0) of the left upper lobe received chemoradiotherapy followed by durvalumab, an immune checkpoint inhibitor. The tumour responded well to the therapy, but an infiltrative shadow appeared in the left upper lobe, which was outside the radiation field. Despite treatment with corticosteroid and antibiotics, the development of a cavitary lesion was noted. As Aspergillus fumigatus was isolated from the bronchoscopy specimen, antifungal agents were also administered, but the cavitary lesion further developed. Because his general condition worsened and the entire left lung was destroyed, the patient underwent a left pneumonectomy and recovered without recurrence. The pathology of the removed lung revealed a scarred nodule with granulation tissue around and a cavernous lesion having a necrotic substance inside. We considered that durvalumab might further accelerate the inflammatory response, which had been introduced by fungal infection, leading to uncontrollable inflammation of the lung.

Peripheral Blood Biomarkers Associated With Outcome in Non-small Cell Lung Cancer Patients Treated With Nivolumab and Durvalumab Monotherapy

Background: Selecting patients who potentially benefit from immune checkpoint inhibitors (ICIs) is critical. Programmed death ligand-1 (PD-L1) protein immunohistochemical expression on cancer cells or immune cells and next-generation sequencing-based tumor mutational burden (TMB) are hot spots in studies on ICIs, but there is still confusion in the testing methods. Because blood samples are much easier for clinical application, many potential peripheral biomarkers have been proposed. This study identified blood parameters associated with the outcome of non-small cell lung cancer (NSCLC) patients with ICI monotherapy. Materials and Methods: Data from 76 NSCLC patients were analyzed retrospectively. To assess the connection between survival and peripheral blood markers measured before the first and fifth doses of ICI treatment, we utilized Cox regression model survival analysis and receiver operating characteristic (ROC) curve analysis to assess the markers. Results: In the nivolumab cohort, the optimal cutoffs for predicting 11-month overall survival (OS) were 168.13 and 43 g/L for platelet-to-lymphocyte ratio (PLR) and albumin, respectively. When patients were grouped with PLR and albumin, a significant difference in SD-PR vs. PD rate was found between the high and low groups, which was not found when the patients were grouped by PD-L1 expression. Patients with high PLR (>168.13) or low albumin ( ≤ 43 g/L) before ICI had a significantly increased hazard of progression, separately (for PLR, P = 0.006; for albumin, P = 0.033), and of death (for PLR, P = 0.014; for albumin, P = 0.009) compared with those patients who had low PLR or albumin levels. More importantly, we found that a higher PLR (>168.13) before the fifth dose of ICIs was also a prognostic biomarker, which significantly correlated with shorter OS in both the nivolumab (P = 0.046) and durvalumab cohorts (P = 0.028). Conclusions: PLR and albumin may help in the stratification of high progression and death risk groups in advanced NSCLC patients treated with nivolumab and durvalumab monotherapy.

Durvalumab for stage III non-small-cell lung cancer patients: clinical evidence and real-world experience

Stage III non-small cell lung cancer (NSCLC) has a dismal prognosis, with only 15–20% of patients alive at 5 years after concomitant chemo–radiotherapy, which represents the standard treatment. Targeting immune-checkpoint inhibitors represents a standard option for advanced NSCLC. Improvements in understanding of the immune profile of NSCLC has led to the development of immunotherapeutic strategies, including inhibitory molecules responsible for abrogating an anticancer immune response such as programmed cell-death 1 and programmed cell-death ligand 1. A recently published phase III trial (PACIFIC) showed for the first time an improved overall survival in stage III NSCLC patients with consolidative durvalumab.

The aim of this review is to summarize and discuss the clinical evidence for the use of durvalumab in stage III NSCLC, with a brief overview on future perspectives in this setting.

Extended-Interval Dosing Strategy of Immune Checkpoint Inhibitors in Lung Cancer: Will it Outlast the COVID-19 Pandemic?

Patients with lung cancer are particularly vulnerable to complications from coronavirus disease-2019 (COVID-19). Recurrent hospital visits and hospital admission are potential risk factors for acquiring infection with its causative pathogen, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). As immune checkpoint inhibitors (ICIs) constitute the therapeutic backbone for the vast majority of patients with advanced lung cancer in the absence of actionable driver oncogenes, there have been intense discussions within the oncology community regarding risk-benefit of delaying these treatments or use of alternative extended-interval treatment strategies to minimize the risk of viral transmission secondary to unintended nosocomial exposures. In the midst of the COVID-19 pandemic, the U.S. Food and Drug Administration (FDA) granted accelerated approval for extended-interval strategy of pembrolizumab at a dose of 400 mg every 6 weeks for all already approved oncologic indications. Herein, we summarize the evidence from the in silico pharmacokinetic modeling/simulation studies supporting extended-interval dosing strategies for the ICIs used in lung cancer. We further review the evolving clinical evidence behind these approaches and predict that they will continue to be used in routine practice even long after the pandemic, particularly for patients with durable disease control.

A randomised phase II study investigating durvalumab in addition to an anthracycline taxane-based neoadjuvant therapy in early triple-negative breast cancer: clinical results and biomarker analysis of GeparNuevo study

BACKGROUND

Combining immune-checkpoint inhibitors with chemotherapy yielded an increased response rates in patients with metastatic triple-negative breast cancer (TNBC). Therefore, we evaluated the addition of durvalumab to standard neoadjuvant chemotherapy (NACT) in primary TNBC.

PATIENTS AND METHODS

GeparNuevo is a randomised phase II double-blind placebo-controlled study randomising patients with TNBC to durvalumab or placebo given every 4 weeks in addition to nab-paclitaxel followed by standard EC. In the window-phase durvalumab/placebo alone was given 2 weeks before start of nab-paclitaxel. Randomisation was stratified by stromal tumour-infiltrating lymphocyte (sTILs). Patients with primary cT1b-cT4a-d disease, centrally confirmed TNBC and sTILs were included. Primary objective was pathological complete response (pCR) (ypT0 ypN0).

RESULTS

A total of 174 patients were randomised, 117 participated in the window-phase. Median age was 49.5 years (range 23-76); 47 patients (27%) were younger than 40 years; 113 (65%) had stage ≥IIA disease, 25 (14%) high sTILs, 138 of 158 (87%) were PD-L1-positive. pCR rate with durvalumab was 53.4% (95% CI 42.5% to 61.4%) versus placebo 44.2% (95% CI 33.5% to 55.3%; unadjusted continuity corrected χ2P = 0.287), corresponding to OR = 1.45 (95% CI 0.80-2.63, unadjusted Wald P = 0.224). Durvalumab effect was seen only in the window cohort (pCR 61.0% versus 41.4%, OR = 2.22, 95% CI 1.06-4.64, P = 0.035; interaction P = 0.048). In both arms, significantly increased pCR (P < 0.01) were observed with higher sTILs. There was a trend for increased pCR rates in PD-L1-positive tumours, which was significant for PD-L1-tumour cell in durvalumab (P = 0.045) and for PD-L1-immune cell in placebo arm (P = 0.040). The most common immune-related adverse events were thyroid dysfunction any grade in 47%.

CONCLUSIONS

Our results suggest that the addition of durvalumab to anthracycline-/taxane-based NACT increases pCR rate particularly in patients treated with durvalumab alone before start of chemotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT02685059.

Durvalumab Immunotherapy: Nursing Management of Immune-Related Adverse Events During the Journey of Patients With Stage III Non-Small Cell Lung Cancer

BACKGROUND

When resection is not an option, platinum-based chemoradiotherapy (CRT) has been the historic standard of care in non-small cell lung cancer (NSCLC). Prognosis remains poor with CRT alone. Durvalumab has shown significant improvement (versus placebo) in progression-free and overall survival in patients with unresectable stage III NSCLC without progression following CRT.

OBJECTIVES

This article aims to provide an overview of the efficacy and safety outcomes with durvalumab in patients with stage III NSCLC and identify management strategies for potential adverse events (AEs).

METHODS

A review of published literature and guidelines was performed to evaluate durvalumab clinical outcomes and AE management strategies.

FINDINGS

Durvalumab has established efficacy in patients with unresectable stage III NSCLC and is now the standard of care following CRT. Nurses need to be trained to recognize potential immune-related AEs in patients treated with immune checkpoint inhibitors.

Safety evaluation of durvalumab for the treatment of non-small-cell lung cancer

INTRODUCTION

The development of immune checkpoint inhibitors (ICIs), such as anti-programmed death 1/programmed death ligand 1 (PD-1/PD-L1) inhibitors, has been a breakthrough in the treatment of non-small-cell lung cancer (NSCLC). Durvalumab, a PD-L1 inhibitor, has shown survival benefit as a maintenance therapy for patients with unresectable stage III NSCLC following definitive chemoradiotherapy, and is approved by the U.S. Food and Drug Administration and the European Medicines Agency.

AREAS COVERED

In this article, we review the development of durvalumab, its pharmacology, and its safety profile as a monotherapy and in combination with other agents, including epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), ICIs such as cytotoxic T-lymphocyte antigen 4 (CTLA-4) blockers, and cytotoxic chemotherapy.

EXPERT OPINION

ICIs, including durvalumab, cause unique side effects, known as immune-mediated adverse events, which are commonly manageable with standard treatment algorithms. The safety profile of durvalumab monotherapy is similar to those of other PD-1/PD-L1 inhibitors. In the PACIFIC trial, durvalumab after radiotherapy resulted in a slight increase in pulmonary toxicity, but most cases were mild. The enhanced effect of ICIs when used in combination therapies is accompanied by an increased risk of side effects. Therefore, the authors evaluated the safety profile and risk-benefit balance of durvalumab combined with various agents.

Radiation pneumonitis in lung cancer patients treated with chemoradiation plus durvalumab

Introduction

Durvalumab after concurrent chemoradiation (cCRT) is now standard of care for unresected stage III non–small cell lung cancer (NSCLC). However, there is limited data on radiation pneumonitis (RP) with this regimen. Therefore, we assessed RP and evaluated previously validated toxicity models in predicting for RP in patients treated with cCRT and durvalumab.

Methods

Patients treated with cCRT and ≥ 1 dose of durvalumab were evaluated to identify cases of ≥ grade 2 RP. The validity of previously published RP models was assessed in this cohort as well a reference cohort treated with cCRT alone. The timing and incidence of RP was compared between cohorts.

Results

In total, 11 (18%) of the 62 patients who received cCRT and durvalumab developed ≥ grade 2 RP a median of 3.4 months after cCRT. The onset of RP among patients treated with cCRT and durvalumab was significantly longer vs the reference cohort (3.4 vs 2.1 months; P = .01). Numerically more patients treated with cCRT and durvalumab developed RP than patients in the reference cohort (18% vs 9%, P = .09). Among patients treated with cCRT and durvalumab, 82% (n = 9) were responsive to treatment with high‐dose glucocorticoids. Previously published RP models widely underestimated the rate of RP in patients treated with cCRT and durvalumab [AUC ~ 0.50; p(Hosmer‐Lemeshow): 0.98‐1.00].

Conclusions

Our data suggest a delayed onset of RP in patients treated with cCRT and durvalumab vs cCRT alone, and for RP to develop in a greater number of patients treated with cCRT and durvalumab. Previously published RP models significantly underestimate the rate of symptomatic RP among patients treated with cCRT and durvalumab.

Dermatologic toxicities to immune checkpoint inhibitor therapy: A review of histopathologic features

Antineoplastic agents that use the immune system have revolutionized cancer treatment. Specifically, implementation of immune checkpoint inhibitors, monoclonal antibodies that block cytotoxic T-lymphocyte-associated antigen-4, programmed cell death protein 1, or programmed cell death ligand 1 show improved and sustained responses in patients with cancer. However, these agents are associated with a plethora of adverse events, many manifesting in the skin. As the clinical application of cancer immunotherapies expands, understanding the clinical and histopathologic features of associated cutaneous toxicities becomes increasingly important to dermatologists, oncologists, and pathologists to ensure timely diagnosis and appropriate care. This review discusses cutaneous reactions to immune checkpoint inhibitors, focusing on histopathologic features.

Cost-effectiveness and Net Monetary Benefit of Durvalumab Consolidation Therapy Versus No Consolidation Therapy After Chemoradiotherapy in Stage III Non-small Cell Lung Cancer in the Italian National Health Service

PURPOSE

The aim of this study was to evaluate the cost-effectiveness and net monetary benefit of durvalumab consolidation therapy compared with no consolidation therapy after chemoradiotherapy in patients with stage III non-small cell lung cancer with programmed cell death 1 ligand 1 expression ≥1% from the Italian National Health Service perspective.

METHODS

We developed a 12-month decision tree combined with a lifetime cohort Markov model in which patients were assigned to receive durvalumab consolidation therapy or active follow-up (Italian standard of care) after chemoradiotherapy to compare cost-effectiveness and net monetary benefit of the two strategies during a 40-year period. Clinical outcomes data were obtained from the respective clinical trials and extrapolated using survival analysis; cost data were derived from Italian official sources and relevant real-world studies. The incremental cost-effectiveness ratio, incremental cost-utility ratio, and incremental net monetary benefit were computed and compared against a 16,372 € per quality-adjusted life-year (QALY) willingness-to-pay threshold. We performed deterministic sensitivity analysis and probabilistic sensitivity analysis to assess how uncertainty affected results; we also performed scenario analyses to compare results under different pricing settings.

FINDINGS

In the base-case scenario, during a 40-year period, the total costs for patients treated with durvalumab consolidation therapy and active follow-up were €59,860 and €49,840 respectively; life-years gained were 3.47 and 3.31, respectively; and QALYs gained were 2.73 and 2.50, respectively, with an incremental cost-effectiveness ratio of €62,131 per life-year, an incremental cost-utility ratio of €42,322 per QALY, and an incremental net monetary benefit of €-6,144. We found that durvalumab was cost-effective (incremental net monetary benefit = 0) when a discount of 13% and 30% on its official price was applied, considering all other drugs priced according to official or maximum selling prices, respectively. Results were most sensitive to the progression-free survival rate for durvalumab and active follow-up, health utility in progression-free state, and price of subsequent treatments.

IMPLICATIONS

Our analysis indicates that durvalumab consolidation is cost-effective when a discount is applied on its official price. These results suggest that durvalumab may deliver an incremental health benefit with a contained upfront cost during a 40-year period, from the Italian National Health Service perspective, providing added value in a potentially curative care setting.

Reactivation of TB during administration of durvalumab after chemoradiotherapy for non-small-cell lung cancer: a case report

Background: Tuberculosis (TB) is considered to be an adverse effect of treatment with immune checkpoint inhibitors. Methodology & results: Our case was a 75-year-old woman diagnosed with unresectable stage III non-small-cell lung cancer. After radical chemoradiotherapy was completed, durvalumab was initiated as a consolidation therapy. However, since chest CT showed appearances of infiltration shadows scattered in the periphery of the lungs after five doses of immunotherapy, duruvalumab was discontinued. 6 weeks later, the patient was aware of intermittent fever. Chest CT scan showed the appearance of a tree-in-bud pattern in the right lung. Acid-fast bacilli stain of sputum was positive and the PCR test was positive for Mycobacterium tuberculosis. Conclusion: Duruvalumab as PD-L1 blockade may activate TB.

Consolidation treatment of durvalumab after chemoradiation in real-world patients with stage III unresectable non-small cell lung cancer

Background

Treatment for stage III non‐small cell lung cancer (NSCLC) of unresectable disease mainly involves concurrent chemoradiation (CRT). Post‐CRT consolidation treatment with durvalumab is a major therapeutic advance that provides survival benefit in this group of patients. However, the performance of this treatment strategy remains to be studied in a real‐world setting.

Methods

A total of 31 patients who had disease control post‐CRT were included in the durvalumab early access program (EAP) as an intent‐to‐treat cohort and retrospectively reviewed for post‐CRT progression‐free survival (PFS) and time to metastatic disease or death (TMDD). The neutrophil‐to‐lymphocyte ratio (NLR) at the initiation of durvalumab was analyzed in 29 patients.

Results

The median time from the completion of concurrent CRT to the initiation of durvalumb was 2.8 months. The objective response was 25.8% and the 12 month PFS and TMDD‐free rate were 56.4% and 66.9%, respectively. The low NLR patients showed a significantly longer post‐CRT PFS (not reach vs. 12.0 months [95% CI: 5.5–not estimable]; P = 0.040; the hazard ratio for disease progression or death, 0.23 [95% CI: 0.05–1.00]; P = 0.048) and the 12 month post‐CRT PFS rate (82.5 vs. 42.6%). The post‐CRT TMDD (not reach vs. 12.6 months, [95% CI: 10.8–not estimable]; P = 0.010; the hazard ratio for distant metastasis or death, 0.11 [95% CI: 0.01–0.88]; P = 0.037) and 12 month post‐CRT TMDD‐free rate (90.9 vs. 57.1%) were also significantly higher in the low NLR patients.

Conclusions

Durvalumab consolidation treatment in real‐world patients showed substantial efficacy and the correlation with the NLR level warrants further investigation.

Durvalumab with or without tremelimumab in patients with recurrent or metastatic head and neck squamous cell carcinoma: EAGLE, a randomized, open-label phase III study

BACKGROUND

Targeting the programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) axis has demonstrated clinical benefit in recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC). Combining immunotherapies targeting PD-L1 and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) has shown evidence of additive activity in several tumor types. This phase III study evaluated the efficacy of durvalumab (an anti-PD-L1 monoclonal antibody) or durvalumab plus tremelimumab (an anti-CTLA-4 monoclonal antibody) versus standard of care (SoC) in R/M HNSCC patients.

PATIENTS AND METHODS

Patients were randomly assigned to receive 1 : 1 : 1 durvalumab (10 mg/kg every 2 weeks [q2w]), durvalumab plus tremelimumab (durvalumab 20 mg/kg q4w plus tremelimumab 1 mg/kg q4w × 4, then durvalumab 10 mg/kg q2w), or SoC (cetuximab, a taxane, methotrexate, or a fluoropyrimidine). The primary end points were overall survival (OS) for durvalumab versus SoC, and OS for durvalumab plus tremelimumab versus SoC. Secondary end points included progression-free survival (PFS), objective response rate, and duration of response.

RESULTS

Patients were randomly assigned to receive durvalumab (n = 240), durvalumab plus tremelimumab (n = 247), or SoC (n = 249). No statistically significant improvements in OS were observed for durvalumab versus SoC [hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.72-1.08; P = 0.20] or durvalumab plus tremelimumab versus SoC (HR: 1.04; 95% CI: 0.85-1.26; P = 0.76). The 12-month survival rates (95% CI) were 37.0% (30.9-43.1), 30.4% (24.7-36.3), and 30.5% (24.7-36.4) for durvalumab, durvalumab plus tremelimumab, and SoC, respectively. Treatment-related adverse events (trAEs) were consistent with previous reports. The most common trAEs (any grade) were hypothyroidism for durvalumab and durvalumab plus tremelimumab (11.4% and 12.2%, respectively), and anemia (17.5%) for SoC. Grade ≥3 trAE rates were 10.1%, 16.3%, and 24.2% for durvalumab, durvalumab plus tremelimumab, and SoC, respectively.

CONCLUSION

There were no statistically significant differences in OS for durvalumab or durvalumab plus tremelimumab versus SoC. However, higher survival rates at 12 to 24 months and response rates demonstrate clinical activity for durvalumab.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02369874.

Quality of life with second or third line nab-paclitaxel-based regimens in advanced non-small-cell lung cancer

Aim: Evaluate quality of life (QoL) in patients with advanced non-small cell lung cancer treated with second or third line nab-paclitaxel ± durvalumab. Patients & methods: Longitudinal QoL was assessed using Lung Cancer Symptom Scale, EuroQoL Five-Dimensions Five-Levels and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item core. Results: QoL was generally stable through eight treatment cycles (both arms). Clinically meaningful improvement from baseline was noted in Lung Cancer Symptom Scale (overall constitutional score and three-item index [nab-paclitaxel + durvalumab]) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item core (global health status/QoL and emotional functioning [both arms] and pain [nab-paclitaxel + durvalumab]) analyses. EuroQoL Five-Dimensions Five-Levels domains were stable/improved or completely resolved at least once in 19-56% and 9-51% of patients, respectively. Conclusion: While QoL trends were promising, additional data are required to support these regimens in this setting.

Outcomes with durvalumab by tumour PD-L1 expression in unresectable, stage III non-small-cell lung cancer in the PACIFIC trial

BACKGROUND

In the PACIFIC trial, durvalumab significantly improved progression-free and overall survival (PFS/OS) versus placebo, with manageable safety, in unresectable, stage III non-small-cell lung cancer (NSCLC) patients without progression after chemoradiotherapy (CRT). We report exploratory analyses of outcomes by tumour cell (TC) programmed death-ligand 1 (PD-L1) expression.

PATIENTS AND METHODS

Patients were randomly assigned (2:1) to intravenous durvalumab 10 mg/kg every 2 weeks or placebo ≤12 months, stratified by age, sex, and smoking history, but not PD-L1 status. Where available, pre-CRT samples were tested for PD-L1 expression (immunohistochemistry) and scored at pre-specified (25%) and post hoc (1%) TC cut-offs. Treatment-effect hazard ratios (HRs) were estimated from unstratified Cox proportional hazards models (Kaplan-Meier-estimated medians).

RESULTS

In total, 713 patients were randomly assigned, 709 of whom received at least 1 dose of study treatment durvalumab (n = 473) or placebo (n = 236). Some 451 (63%) were PD-L1-assessable: 35%, 65%, 67%, 33%, and 32% had TC ≥25%, <25%, ≥1%, <1%, and 1%-24%, respectively. As of 31 January 2019, median follow-up was 33.3 months. Durvalumab improved PFS versus placebo (primary-analysis data cut-off, 13 February 2017) across all subgroups [HR, 95% confidence interval (CI); medians]: TC ≥25% (0.41, 0.26-0.65; 17.8 versus 3.7 months), <25% (0.59, 0.43-0.82; 16.9 versus 6.9 months), ≥1% (0.46, 0.33-0.64; 17.8 versus 5.6 months), <1% (0.73, 0.48-1.11; 10.7 versus 5.6 months), 1%-24% [0.49, 0.30-0.80; not reached (NR) versus 9.0 months], and unknown (0.59, 0.42-0.83; 14.0 versus 6.4 months). Durvalumab improved OS across most subgroups (31 January 2019 data cut-off; HR, 95% CI; medians): TC ≥ 25% (0.50, 0.30-0.83; NR versus 21.1 months), <25% (0.89, 0.63-1.25; 39.7 versus 37.4 months), ≥1% (0.59, 0.41-0.83; NR versus 29.6 months), 1%-24% (0.67, 0.41-1.10; 43.3 versus 30.5 months), and unknown (0.60, 0.43-0.84; 44.2 versus 23.5 months), but not <1% (1.14, 0.71-1.84; 33.1 versus 45.6 months). Safety was similar across subgroups.

CONCLUSIONS

PFS benefit with durvalumab was observed across all subgroups, and OS benefit across all but TC <1%, for which limitations and wide HR CI preclude robust conclusions.

Review of Indications of FDA-Approved Immune Checkpoint Inhibitors per NCCN Guidelines with the Level of Evidence

Cancer is associated with higher morbidity and mortality and is the second leading cause of death in the US. Further, in some nations, cancer has overtaken heart disease as the leading cause of mortality. Identification of molecular mechanisms by which cancerous cells evade T cell-mediated cytotoxic damage has led to the modern era of immunotherapy in cancer treatment. Agents that release these immune brakes have shown activity to recover dysfunctional T cells and regress various cancer. Both cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and Programmed Death-1 (PD-1) play their role as physiologic brakes on unrestrained cytotoxic T effector function. CTLA-4 (CD 152) is a B7/CD28 family; it mediates immunosuppression by indirectly diminishing signaling through the co-stimulatory receptor CD28. Ipilimumab is the first and only FDA-approved CTLA-4 inhibitor; PD-1 is an inhibitory transmembrane protein expressed on T cells, B cells, Natural Killer cells (NKs), and Myeloid-Derived Suppressor Cells (MDSCs). Programmed Death-Ligand 1 (PD-L1) is expressed on the surface of multiple tissue types, including many tumor cells and hematopoietic cells. PD-L2 is more restricted to hematopoietic cells. Blockade of the PD-1 /PDL-1 pathway can enhance anti-tumor T cell reactivity and promotes immune control over the cancerous cells. Since the FDA approval of ipilimumab (human IgG1 k anti-CTLA-4 monoclonal antibody) in 2011, six more immune checkpoint inhibitors (ICIs) have been approved for cancer therapy. PD-1 inhibitors nivolumab, pembrolizumab, cemiplimab and PD-L1 inhibitors atezolizumab, avelumab, and durvalumab are in the current list of the approved agents in addition to ipilimumab. In this review paper, we discuss the role of each immune checkpoint inhibitor (ICI), the landmark trials which led to their FDA approval, and the strength of the evidence per National Comprehensive Cancer Network (NCCN), which is broadly utilized by medical oncologists and hematologists in their daily practice.

Chemoradiotherapy followed by durvalumab in patients with unresectable advanced non-small cell lung cancer: Management of adverse events

BACKGROUND

Chemoradiotherapy followed by durvalumab is the standard treatment for the patients with local advanced non-small cell lung cancer (NSCLC). There is a real-world data about the management of adverse events, such as pneumonitis, according to the different institutions. Here, we present the experience regarding the management of adverse events after the initiation of durvalumab as daily practice.

METHODS

From July 2018 to August 2019, 41 patients with locally advanced NSCLC, who underwent chemoradiotherapy followed by durvalumab, were retrospectively analyzed in the study using our medical records.

RESULTS

The median age of patients was 72 years (range: 51-80 years). A total of 33 patients were male and eight were female, and 40 patients (98%) received a total radiation dose of 60 Gy as concomitant chemoradiotherapy. The median V20 for the entire cohort was 18.9% (range: 3.5-29.9). Any adverse events during chemoradiotherapy and durvalumab were observed in 32 patients (78.0%), while three patients (7.3%) experienced grade 3 toxicities. In total, 25 (61.0%) patients experienced pneumonitis, four (9.8%) thyroid dysfunction, three (7.3%) myopathy, two (4.9%) rash or eruption, one (2.4%) bowel disease and one (2.4%) malaise. Grade 3 pneumonitis, thyroid dysfunction and myopathy were observed in one (2.4%), one (2.4%) and one (2.4%), respectively. A total of 22 (53.7%) patients were unable to continue durvalumab due to pneumonitis. However, durvalumab was finally readministered to six patients.

CONCLUSIONS

The adherence to lung dose constraints such as V20 as well as close treatment monitoring are a prerequisite for the management of pneumonitis during maintenance therapy with durvalumab.

Identifying and treating candidates for checkpoint inhibitor therapies in multiple myeloma and lymphoma

Introduction: One of the hallmarks of cancerogenesis is the ability of tumor cells to evade the immune system. They can achieve it by abusing inhibitory immune checkpoint pathways, which, under normal circumstances, maintain peripheral tolerance during infection. Immune checkpoint inhibitors, especially anti-PD-1/PD-L1 monoclonal antibodies, currently represent a widely discussed treatment option not only in solid oncology, but in hematology-oncology as well.Areas covered: The manuscript is focused on clinical research concerning PD-1/PD-L1 blockade in lymphoma and multiple myeloma in order to identify the patients who would profit the most from this treatment modality. The authors reviewed articles on the topic on PubMed and relevant clinical trials on clinicaltrials.gov before October 2019.Expert opinion: So far, nivolumab and pembrolizumab have been approved for treating patients with relapsed/refractory classical Hodgkin lymphoma and primary mediastinal B cell lymphoma. Nevertheless, monotherapy alone is not curative and a combinational approach is needed. Modern treatment strategies and combinations are comprehensively summarized in this manuscript. There is no approved immune checkpoint inhibitor for the multiple myeloma indication. Although the combination of PD-1/PD-L1 inhibitors with immunomodulatory agents initially seemed promising, unexpected immune related toxicities have stopped any further development. Novel strategies and more potent combinations in myeloma and lymphoma are further discussed in the manuscript.

Long-term response with durvalumab after chemoradiotherapy for pulmonary pleomorphic carcinoma: A case report

Pulmonary pleomorphic carcinoma (PPC) is a non-small-cell lung cancer, resistant to chemotherapy and no standard therapy has as yet been established. We herein report the case of a 59-year-old man with PPC who showed a long-term response with durvalumab after chemoradiotherapy. He was referred to our hospital with a mass shadow at the right upper lung. PPC clinical stage IIIB was diagnosed, and the tumor proportion score of programmed death-ligand 1 (PD-L1) was 100%. Six days after transbronchial biopsy, he had difficulty walking owing to sensory abnormalities. We found that the primary tumor had invaded the spinal cord and compressed the cord at T1-T4, resulting in the abnormalities. He underwent tumor resection and received chemotherapy involving cisplatin (CDDP) + S-1 and concurrent radiotherapy (66 Gy). Subsequently, durvalumab treatment as consolidation therapy was commenced. After one year of durvalumab treatment had been completed, he had no apparent signs of relapse or severe adverse events. This case suggests that a long-term response can be achieved with durvalumab after chemoradiotherapy for stage III inoperable PPC showing high PD-L1 expression. KEY POINTS: Significant findings of the report A long-term response might be achieved with durvalumab after chemoradiotherapy in patients with stage III inoperable pulmonary pleomorphic carcinoma showing high expression of programmed death-ligand What this study adds It is possible to continue durvalumab treatment for one year without any severe adverse events. Although pulmonary pleomorphic carcinoma is considered to have a poor prognosis, the combination therapy of immune checkpoint inhibitors and radiotherapy may be an effective treatment option.

A cost-effectiveness analysis of consolidation immunotherapy with durvalumab in stage III NSCLC responding to definitive radiochemotherapy in Switzerland

BACKGROUND

Consolidation immunotherapy with the programmed death ligand 1 (PD-L1) inhibitor durvalumab improves survival in patients with stage III non-small-cell lung cancer responding to radiochemotherapy. The aim of this study was to assess the cost-effectiveness of durvalumab in Switzerland based on the most recent PACIFIC survival follow-up.

MATERIALS AND METHODS

We constructed a Markov model based on the 3-year follow-up data of the PACIFIC trial and compared consolidation durvalumab with observation. We used published utility values and assessed costs for treatment strategies from the perspective of the Swiss health care payers. Cost-effectiveness was tested both in the intention-to-treat population of the PACIFIC trial unselected for PD-L1 tumor expression and in patients with PD-L1-expressing tumors (≥1%).

RESULTS

In the unselected/PD-L1-positive patients, durvalumab showed an incremental effectiveness of 0.76/1.18 quality-adjusted life year (QALY) and incremental costs of Swiss Francs (CHF) 67 239/78 177, resulting in incremental cost-effectiveness ratios of CHF 88 703/66 131 per QALY gained, respectively. The most influential factors for the incremental cost-effectiveness ratio were the utility before first progression, costs for durvalumab, and the hazard ratio for overall survival under durvalumab versus observation. The cost-effectiveness of durvalumab was better than CHF 100 000 per QALY gained in 75% of the simulations in probabilistic sensitivity analysis.

CONCLUSION

Assuming a willingness-to-pay threshold of CHF 100 000 per QALY gained, consolidation durvalumab is likely to be cost-effective both in patients with inoperable stage III non-small-cell lung cancer (NSCLC) unselected for PD-L1 status and in patients with PD-L1-expressing tumors in Switzerland.

Effectiveness of durvalumab versus chemotherapy in metastatic urothelial cancer: an observational, indirect comparison

Aim: To compare the overall survival of patients with metastatic urothelial carcinoma (mUC) who failed platinum-based chemotherapy and received durvalumab or chemotherapy. Patients & methods: In an indirect comparison of patients with mUC who failed platinum-based chemotherapy, those who received durvalumab in a single-arm study were matched to patients from the Flatiron oncology electronic medical record database who received chemotherapy (n = 158 for each cohort). Matching was based on propensity scores. Kaplan-Meier methods and Cox regression models were utilized. Results: Median overall survival was 11.2 months (95% CI: 7.2-16.9) for durvalumab versus 8.2 months (95% CI: 6.7-9.8) for chemotherapy (hazard ratio: 0.63; 95% CI: 0.48-0.84). Conclusion: As a second-line therapy for mUC, durvalumab was associated with longer overall survival than chemotherapy.

Current Perspectives in Immunotherapy for Liver Cancer

Liver cancer is a particularly aggressive group of malignancies with historically low survival rates. Despite advancements in cancer treatments in general in the last few decades, incidence and mortality have not changed. Even though some phase 1 and 2 studies have shown promising results, many medication have failed to reach a sustainable level of efficacy to move into the clinical setting. Immunotherapy drugs have shown impressive results in the treatment of specific immunogenic cancers, prompting the possibility of their use in liver cancers. Immunotherapy medications approved for other cancers have received FDA accelerated approval for treatment of hepatocellular carcinoma. But, these approvals are contingent upon verification and description of clinical benefit in confirmatory trials. With more treatments in development involving cancer vaccines and natural killer cell-mediated therapy, liver cancer treatment is being reinvigorated with a broad array of new treatment angles. In this review article, we discuss these treatments, focusing on mechanism of action and clinical trials. Much needed advancements in treating late- and early-stage liver cancers will require new and innovative immunotherapeutic treatments.

Immune Checkpoint Inhibitors for the Treatment of Unresectable Stage III Non-Small Cell Lung Cancer: Emerging Mechanisms and Perspectives

There has been no improvement in outcome for patients with unresectable locally advanced (stage III) non-small cell lung cancer (NSCLC) for more than 10 years. The standard treatment for these patients is definitive concurrent chemotherapy and radiation (CCRT). Although the goal of treatment in this setting is to achieve a cure, most patients progress and their prognosis is poor, with a 5-year survival rate of 15-30%. There is thus an urgent need for the development of novel anticancer treatments in this patient population. Recent advances in cancer immunotherapy have led to a marked improvement in clinical outcome for advanced NSCLC. Such immunotherapy mainly consists of the administration of immune checkpoint inhibitors (ICIs) such as antibodies to cytotoxic T lymphocyte-associated protein-4 (CTLA-4) or to either programmed cell death-1 (PD-1) or its ligand PD-L1. Durvalumab (MEDI4736) is a high-affinity human immunoglobulin G1 monoclonal antibody that blocks the binding of PD-L1 on tumor cells or antigen-presenting cells to PD-1 on T cells. The PACIFIC study recently evaluated consolidation immunotherapy with durvalumab versus placebo administered after concurrent chemoradiotherapy (CCRT) in patients with unresectable stage III NSCLC. It revealed a significant improvement in both progression-free and overall survival with durvalumab, and this improvement was associated with a favorable safety profile. This achievement has made durvalumab a standard of care for consolidation after CCRT in patients with unresectable stage III NSCLC, and it has now been approved in this setting by regulatory agencies in the United States, Canada, Japan, Australia, Switzerland, Malaysia, Singapore, India, and the United Arab Emirates. In this review, we briefly summarize the results of the PACIFIC trial, including those of post hoc analysis, and we address possible molecular mechanisms, perspectives, and remaining questions related to combined treatment with CCRT and ICIs in this patient population.

Prognostic Factors and Biomarkers of Responses to Immune Checkpoint Inhibitors in Lung Cancer

Manipulation of the immune response is a game changer in lung cancer treatment, revolutionizing management. PD1 and CTLA4 are dynamically expressed on different T cell subsets that can either disrupt or sustain tumor growth. Monoclonal antibodies (MoAbs) against PD1/PDL1 and CTLA4 have shown that inhibitory signals can be impaired, blocking T cell activation and function. MoAbs, used as both single-agents or in combination with standard therapy for the treatment of advanced non-small cell lung cancer (NSCLC), have exhibited advantages in terms of overall survival and response rate; nivolumab, pembrolizumab, atezolizumab and more recently, durvalumab, have already been approved for lung cancer treatment and more compounds are in the pipeline. A better understanding of signaling elicited by these antibodies on T cell subsets, as well as identification of biological determinants of sensitivity, resistance and correlates of efficacy, will help to define the mechanisms of antitumor responses. In addition, the relevance of T regulatory cells (Treg) involved in immune responses in cancer is attracting increasing interest. A major challenge for future research is to understand why a durable response to immune checkpoint inhibitors (ICIs) occurs only in subsets of patients and the mechanisms of resistance after an initial response. This review will explore current understanding and future direction of research on ICI treatment in lung cancer and the impact of tumor immune microenvironment n influencing clinical responses.

Immune checkpoint inhibitors for hepatocellular carcinoma

The position of immunotherapy as a pillar of systemic cancer treatment has been firmly established over the past decade. Immune checkpoint inhibitors are a welcome option for patients with different malignancies. This is in part because they offer the possibility of durable benefit, even for patients who have failed other treatment modalities. The recent demonstration that immunotherapy is effective for patients with hepatocellular carcinoma (HCC) is a milestone in the history of this recalcitrant disease. The treatment of HCC has been a challenge, and for many years was limited to the tyrosine kinase inhibitor sorafenib and to several novel tyrosine kinase inhibitors that have shown efficacy and have been approved. The current role of immune checkpoint inhibitors in the management of HCC, and how this role is likely to evolve in the years ahead, are key. Other than efforts evaluating single checkpoint inhibitors, potential combination strategies, including combinations with existing local and systemic approaches, including novel therapies are evolving. This is understandably of special interest considering the potential unique immune system of the liver, which may impact the use of immunotherapy in patients with HCC going forward, and how can it be enhanced further.

Molecular Biomarkers of Response to PD-1/ PD-L1 Immune Checkpoint Blockade in Advanced Bladder Cancer

BACKGROUND

The activity of PD-1/PD-L1 inhibitors in the treatment of advanced bladder cancer (BC) is promising for many patients. However, a subset of patients do not benefit from treatment, thus leading to an effort to better identify predictive molecular biomarkers of response.

OBJECTIVE

To conduct a systematic review of the literature on predictive molecular biomarkers associated with response to PD-1 and PD-L1 inhibitors in advanced bladder cancer, defined as locally-advanced, unresectable, or metastatic (mBC) disease.

METHODS

A search of the literature was performed using Embase (1947 - January 2019), Medline (1946 - January 2019), and EBM Reviews for Cochrane Central Register of Controlled Trials (as of December 2018). Studies examining the association of molecular biomarkers with clinical outcome in BC treated with PD-1 or PD-L1 monotherapy were included. Outcomes of interest were overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), duration of response, and objective response rate (ORR).

RESULTS

Using the study search criteria, 899 unique abstract citations were found, of which 834 did not meet the eligibility criteria. Full text of the remaining 65 citations were screened, and 50 studies excluded, including 18 review articles. Eight additional studies from the bibliography of the review papers were included, making a total of 23 studies. Five PD-1 / PD-L1 antibodies have been tested in BC immunohistochemistry (IHC). These studies used different expression scoring criteria and generally had poor ability to discriminate likelihood for response. Overall, the data suggests CD8⁺ T cell infiltration is necessary to mediate an antitumor immune response, but other immune cell populations, such as neutrophils may suppress T cell-mediated immunity and efficacy of PD-1/PD-L1 blockade. An IFNγ signature is a promising predictor, but there needs to be consensus on the optimal gene panel composition, and prospective validation. Tumor mutation burden (TMB) is a promising predictor in six studies reporting on 1200 patients, but there is not a consensus on the optimal definition of "high TMB". Detection of T cell receptor (TCR) clonal expansion has only been conducted in small studies and so its predictive value remains inconclusive. Epithelial-mesenchymal transformation (EMT) and transforming growth factor β (TGFβ) are associated with poor prognosis and possibly intrinsic resistance to PD-1/PD-L1 checkpoint blockade, but more work needs to be done to build upon and confirm the initial findings.

CONCLUSIONS

Currently no molecular biomarker is sufficiently mature for routine clinical use, while some candidates, or a combination show great promise and need further study.

Relapse of membranous nephropathy with cancer immunotherapy

Advances in monoclonal antibody technology have enabled the application of engineered antibodies to interfere with specific immune pathways. Checkpoint inhibitors have shown promising results in treating certain cancers by employing patients’ own immune systems to attack cancer cells. Checkpoint inhibitors release the brake on the immune system and can cause immune-related diseases. Theoretically this could be disadvantageous in patients with autoimmune diseases. Here I describe a case of nephrotic syndrome relapse in a patient with a history of membranous nephropathy during programmed death-ligand 1 inhibitor therapy for lung cancer. It is postulated that enhancement of the immune system triggered the relapse of nephrotic syndrome by leading to an escape of immune tolerance and increased susceptibility.

Combining immunotherapies to treat non-small cell lung cancer

Introduction: In recent years, immunotherapy has become an integral part of the treatment of many cancers, including non-small cell lung cancer (NSCLC). Precious therapeutic weapons impacting survival are monoclonal antibodies directed against the programmed death protein-1 (PD-1)/programmed death ligand-1 (PD-L1) immune checkpoint. Areas covered: Unfortunately, not all patients treated with checkpoint inhibitors have durable clinical responses. However, a better understanding of the complexity of interactions between the immune system and cancer, the latter capable of adopting evasion mechanisms, indicates different opportunities to enhance anti-tumor immunity. Expert opinion: In this paper, we review multiple strategies of combining immunotherapies that exploit not only additional immune checkpoint receptors and ligands but also other synergistic approaches such as vaccines or indoleamine 2,3-dioxygenase (IDO) inhibitors with the potential to extend the number of NSCLC patients achieving successful outcomes.

Patients with unresectable stage III non-small cell lung cancer eligible to receive consolidation therapy with durvalumab in clinical practice based on PACIFIC study criteria

BACKGROUND

Compared to a placebo, durvalumab has been reported to significantly prolong progression-free and overall survival in patients with stage III unresectable non-small cell lung cancer (NSCLC) after chemoradiotherapy. The aim of this retrospective study was to evaluate the eligibility of patients with unresectable stage III NSCLC able to receive consolidation therapy with durvalumab in clinical practice based on the PACIFIC study criteria.

METHODS

From January 2011 to May 2018, electronic data were collected from patients diagnosed with unresectable stage III NSCLC treated with definitive chemoradiotherapy. A total of 81 patients were identified. Of these, 73 were treated with platinum-based chemotherapy based on the PACIFIC study criteria.

RESULTS

Radiation pneumonitis of any grade occurred in 54 patients (73.9%) who received definitive chemoradiotherapy. Of these, 12 (16.4%) developed radiation pneumonitis of grade 2 or more within 42 days after chemoradiotherapy and were excluded from durvalumab treatment. Two patients (2.7%) developed other pneumonitis, seven patients (9.6%) showed poor performance status, and three patients (4.1%) displayed disease progression at the initial assessment. After considering overlapping cases mentioned above, 22 patients (30.1%) were ineligible to receive durvalumab by the criteria utilized in the PACIFIC study.

CONCLUSION

In clinical practice, approximately 70% of patients with unresectable stage III NSCLC would be eligible to receive consolidation therapy with durvalumab.

Tolerability and efficacy of durvalumab in Japanese patients with advanced solid tumors

Blockade of programmed cell death ligand‐1 with durvalumab has shown efficacy and safety in large, international studies of patients with advanced solid tumors. A phase 1, non‐randomized, open‐label multicenter study was initiated to evaluate durvalumab in a Japanese population. The first part of this study used a standard 3 + 3 dose‐escalation design to determine the optimal dosing schedule of durvalumab. Primary objective was evaluation of safety and tolerability of durvalumab monotherapy. Secondary objectives were to evaluate maximum tolerated dose (MTD), immunogenicity, pharmacokinetics, and efficacy. Twenty‐two patients (median age, 61.5 years; range, 41‐76; 64% male) received durvalumab at doses of 1, 3, or 10 mg/kg every 2 weeks (q2w), 15 mg/kg q3w, or 20 mg/kg q4w. Twenty patients discontinued before completing 12 months of treatment as a result of progressive disease and two due to adverse events (AE). The most common treatment‐related AE (trAE) were rash (18%) and pruritus (14%); two patients had grade ≥3 trAE including one patient each with hyponatremia and hypothyroidism. No patient experienced a dose‐limiting toxicity (DLT) during the DLT evaluation period and the MTD was not identified. There were no AE leading to a fatal outcome during study treatment. Durvalumab showed dose‐proportional pharmacokinetics across the 1‐20 mg/kg dose range; incidence of positive titers for antidrug antibodies was 9%. One patient with lung cancer had a partial response and disease control rate at 12 weeks was 36%. In conclusion, durvalumab at the doses and regimens evaluated was safe and well tolerated in Japanese patients with advanced solid tumors.

Durvalumab for the management of urothelial carcinoma: a short review on the emerging data and therapeutic potential

Urothelial carcinoma (UC) is the second most frequent urogenital malignancy with high incidence in the United States and Europe. Despite poor prognosis, new treatments have emerged with great efficacy and safety such as immune checkpoint inhibitors. Durvalumab, an anti Programmed Death Ligand 1, has been given breakthrough in UC in 2017 in patients who have disease progression during or following platinum-containing chemotherapy or who have disease progression <12 months after neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. Food and Drug Administration approval was given on the results of the Phase I/II study of MEDI 4736. In this article, we will review available data on durvalumab in the treatment of locally advanced and metastatic UC and discuss therapeutic potential.