Cost-effectiveness analysis of regorafenib dose optimization for refractory metastatic colorectal cancer

BACKGROUND

New regimens have emerged as third-line or later therapies for metastatic colorectal cancer (mCRC), including regorafenib dose optimization (ReDO), trifluridine/tipiracil and bevacizumab (TAS-BEV) combination therapy, and fruquintinib. We evaluated relative cost-effectiveness of these therapies in patients with mCRC from a US payer's perspective.

MATERIALS AND METHODS

A partitioned survival model (PSM) was constructed to estimate total costs and quality-adjusted life years (QALYs). Clinical parameters were obtained from pivotal trials of the respective therapies and incremental cost-effectiveness ratios (ICERs) were estimated to assess relative cost-effectiveness of these treatments. Model robustness was assessed using deterministic (DSA) and probabilistic sensitivity analysis (PSA). Three scenario analyses were conducted: (1) assuming equal efficacy across treatments, (2) with prior exposure to anti-vascular endothelial growth factor (VEGF) therapy, and (3) alternative clinical inputs for fruquintinib from a different clinical trial.

RESULTS

Under the conventional willingness-to-pay (WTP) threshold in US ($150,000 per QALY gained), ReDO was cost-effective when compared with TAS-BEV and was dominant over fruquintinib. TAS-BEV was associated with an incremental QALY of 0.197 over ReDO, resulting in an ICER at $554,567 per QALY gained. The base case results were robust in DSA and PSA. Most influential parameters were treatment cost and effectiveness. In patients with prior anti-VEGF therapy, ReDO remained cost-effective compared to TAS-BEV and fruquintinib under the conventional WTP threshold.

LIMITATION

Differences in trial populations may affect the comparability of the outcomes. Sensitivity and scenario analyses were conducted to address these limitations.

CONCLUSION

ReDO was cost-effective compared with TAS-BEV from the US payer's perspective despite a higher QALY gain associated with TAS-BEV. ReDO was dominant over fruquintinib, consistently having a higher QALY gain and lower cost.

Symptom Management for Well-Differentiated Gastroenteropancreatic Neuroendocrine Tumors: ASCO Guideline

PURPOSE

To develop a clinical practice guideline and recommendations for symptom management of patients with well-differentiated grade 1 to grade 3 metastatic gastroenteropancreatic neuroendocrine tumors.

METHODS

ASCO convened an Expert Panel to develop a clinical practice guideline by reviewing the literature for relevant guidelines, systematic reviews, randomized controlled trials (RCTs), and observational studies to develop recommendations for clinical practice.

RESULTS

The literature review identified eight guidelines, 19 systematic reviews, and three RCTs that informed the development of guideline recommendations.

RECOMMENDATIONS

Recommendations are included for carcinoid syndrome, carcinoid heart disease and carcinoid crisis, and functional pancreatic neuroendocrine tumor syndromes. Recommendations are provided for surgical management, liver-directed therapy, and systemic therapy options, as well as palliative care. Limited guidance is provided for sequencing of interventions.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.

Twenty-one-year report from the Danish Health Authority Expert Advisory Panel for review of treatment of 10 000 cancer patients

BACKGROUND

Patients with hard-to-treat or rare cancers and those not responding to standard-of-care (SoC) treatment have unmet needs. Limited access to novel drugs is an increasing additional challenge. In 2003, the Danish government adopted a Health Act to ensure that treatment of patients with life-threatening disease could be reevaluated by independent experts. The Danish Health Authority (DHA) set up an Expert Advisory Panel to provide advice on possibilities for further treatment of patients, including treatment not approved nationally. A few years later, clinical units were established that could offer unestablished treatment to patients by referral from the Panel. The treatment was first reimbursed by the Government and later by regional authorities.

MATERIALS AND METHODS

We present the structure, workflow, and impact of the Health Act for 21 years for patients with cancer. Annual reports from the DHA were the primary data source.

RESULTS

11 034 cases from 9603 cancer patients were evaluated by the Panel from 2003 to 2023, representing a median of 372 unique cases yearly. In 53%, the Panel advised on further treatment in Denmark, and of these, 56% were recommended nationally nonapproved treatment, 21% SoC treatment or workup, and 19% clinical trial participation. In 4.5% of cases, advice was given on treatment abroad. A significant decline in admissions to the Panel from a peak of 1167 patients in 2008 to 3-400 yearly from 2012 to 2017 followed the conversion of nonapproved treatments to SoC practice. A shift in drug reimbursement, independent of Panel advise, reduced the clinical impact and explained the further decline observed in admissions lately to only 51 patients in 2023.

CONCLUSIONS

This unique national scheme provided early access to treatment for patients with no further SoC options and facilitated the introduction of new cancer treatments, initiation of clinical trials, and establishment of trial units in the country. The scheme may be adapted to other countries with a public healthcare system. Results of the current report indicate that impact is dependent on delivering clinical units and reimbursement associated with the recommended treatment.

A Meta-Analysis: Anti-Inflammatory Medicinal Plants for Age-Related Menopause-Like Symptoms and Psychological Problems in Breast Cancer and Healthy Perimenopausal Women

BACKGROUND

Medicinal plant supplements (MPS) have benefits in improving menopause-like symptoms (MLS).

OBJECTIVES

To investigate the effectiveness of MPS in reducing MLS in healthy women and those with breast cancer (BC).

SEARCH STRATEGY

PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang database and Chinese Scientific Journals Database were searched from the date of library construction until 30 January 2024.

SELECTION CRITERIA

Randomised controlled trials were selected that involved healthy perimenopausal women, BC patients treated with herbal medicines, and the effects of plant-based compounds on MLS.

DATA COLLECTION AND ANALYSIS

The review included 12 studies with 917 patients with BC and 15 studies with 2104 healthy perimenopausal women. The data were analysed using the Meta-mar tool.

MAIN RESULTS

MPS improved Kupperman's Index (KMI) and menopause rating scale (MRS) scores compared with the comparator. Patients with BC experienced a greater reduction in KMI and MRS because of treatment than healthy perimenopausal women. Patients with BC had a more significant reduction in KMI than women who received hormone therapy. In both healthy perimenopausal women and women with BC, MPS treatment resulted in significantly higher response rates and fewer psychological problems. Women with BC experienced a decrease in anxiety and insomnia by MPS. Network analysis showed that the response rate was the factor most associated with MPS use.

CONCLUSIONS

Anti-inflammatory MPS may assist women with BC or healthy perimenopausal women experience less MLS.

Characteristics of Patients and Prognostic Factors Across Treatment Lines in Metastatic Colorectal Cancer: An Analysis From the Aide et Recherche en Cancérologie Digestive Database

PURPOSE

Several lines of treatment can be used sequentially in patients with metastatic colorectal cancer. We investigated the evolution of patient/tumor characteristics and their prognostic impact across treatment lines to develop an overall prognostic score (OPS).

PATIENTS AND METHODS

Individual patient data from 48 randomized trials were analyzed. The end point was overall survival (from random assignment to death). Missing data were imputed. The complete data set was then separated into construction (80%) and validation sets (20%). The Cox's model was used to define risk groups for survival using the OPS. The discrimination capability was assessed in each treatment-line via bootstrapping to obtain optimism-corrected calibration and discrimination C-indices. Internal validation was done in the validation set.

RESULTS

A total of 37,560 patients (26,974 in first-line [1L], 7,693 in second-line [2L], and 2,893 in third-line [3L]) were analyzed. Some clinical, biological, and molecular characteristics of patients/tumors included in therapeutic trials evolve over the lines. Seven independent prognostic variables were retained in the final multivariate model common to all lines: Eastern Cooperative Oncology Group performance status, hemoglobin, platelet count, WBC/absolute neutrophil count ratio, lactate dehydrogenase, alkaline phosphatase, and the number of metastatic sites. The OPS was used to define four patient subgroups with significantly different prognoses in 1L, 2L, and 3L, separately, with adequate C-indices: 0.65, 0.66, and 0.69 in the construction set and 0.65, 0.66, and 0.68 in the validation set, respectively. The OPS was not predictive, with 3L drugs (v placebo) or subsequent line (2L/1L or 3L/2L) extending survival in all prognostic groups.

CONCLUSION

The same prognostic model using practical variables can be used before all treatment lines. The OPS could better stratify patients in future clinical trials and help to therapeutic decision in routine practice.

Impact of baseline proteinuria on progression-free survival after regorafenib treatment for metastatic colorectal cancer

PURPOSE

Regorafenib improves the survival of patients with metastatic colorectal cancer (mCRC). However, proteinuria frequently occurs in regorafenib treatment, and development of severe hypertension, which is closely related to proteinuria, is associated with better treatment outcomes. We previously reported that patients with baseline proteinuria exhibit regorafenib-induced problematic symptoms. In this study, we aimed to assess the effect of baseline proteinuria on the treatment efficacy of regorafenib for mCRC.

METHODS

Patients with mCRC receiving regorafenib (n = 100) were categorized into control (without baseline proteinuria) and pre-existing proteinuria (baseline grades 1-2) groups and retrospectively evaluated. The primary endpoint was the progression-free survival (PFS).

RESULTS

Patients in the pre-existing proteinuria group exhibited significantly worse PFS than those in the control group (median with 95% confidence interval [CI] = 51 (46-56) and 56 (49-81) days, respectively; P = 0.04). Overall survival and disease control rate were lower in the pre-existing proteinuria group than in the control group although the difference was not statistically significant (P = 0.11 and 0.10, respectively). Similar results were obtained in the propensity score-matched population. Multivariate Cox hazard regression analyses revealed that baseline pre-existing proteinuria was associated with poor PFS (adjusted hazard ratio = 1.67; 95% CI = 1.03-2.72; P = 0.04). Additionally, ratio of drug suspension duration during all treatment cycles was higher in patients with pre-existing proteinuria than those without symptoms.

CONCLUSION

Our results suggest that patients with baseline proteinuria experience poor PFS following regorafenib treatment for mCRC, although we should consider the clinical significance of the difference.

Systemic Therapy for Metastatic Colon Cancer: New Frontiers

We have made steady gains in improving overall survival in patients with metastatic, unresectable, colon cancer in the last 5 to 10 years. The backbone of systemic treatment for most patients remains combination chemotherapy, but the field is becoming increasingly biomarker driven, with exciting new targeted therapies on the horizon. This review is organized in sections corresponding to currently relevant biomarkers in colon cancer and will summarize first-, second-, and third-line standard of care for metastatic, unresectable, colon cancer. The last section is intended to introduce the reader to promising agents and novel therapeutic strategies currently under investigation.

Efficacy assessment in phase I clinical trials: endpoints and challenges

The scope of phase I clinical trials in oncology goes beyond the conventional safety evaluation-only objectives of these trials in other specialties. Rather, most first-in-human oncology clinical trials have therapeutic intent, and efficacy signals observed in phase I trials can drive a go/no-go decision of advancing a new molecule to phase II testing. The complexity of efficacy assessment in the context of a small, heterogeneous patient population and a complex study design requires a more liberal perspective compared with later trial phases when looking into efficacy endpoints. Classically, in later-phase clinical trials, these endpoints would include the objective response rate, progression-free survival, and overall survival. However, new, evolving endpoints may be worth investigating when looking into the antitumor activity signals in phase I trials. Integration of all these endpoints into trial designs can improve the assessment of therapeutic efficacy during early drug development and guide decisions related to the further advancement of novel molecules into later phases. In this review, we discuss the advantages and pitfalls of different classic efficacy endpoints when evaluated as part of phase I trials in oncology and describe how challenges in assessing the antitumor activity of new drugs can be overcome through the incorporation of novel endpoints that have thus far proven successful in clinical trials.

Multi-Targeted Kinase Inhibitor Therapy in Pediatric Bone and Soft Tissue Sarcoma Patients-A Single Centre Experience

BACKGROUND

Patients with relapsed or refractory soft tissue and bone sarcomas have dismal outcomes. Multi-targeted kinase inhibitors (mTKI) have proven to be potent agents in several malignancies, both as primer therapy and as a salvage option. Our aim was to evaluate the clinical outcomes of mTKI treatment in a heterogeneous group of pediatric sarcoma patients retrospectively.

PROCEDURES

A total of 18 patients were treated with sorafenib, regorafenib, or pazopanib; 13 of them had osteosarcoma (OSC), 3 had synovial sarcoma (SySa), and 1-1 patient had chondrosarcoma and rhabdomyosarcoma. Indication for mTKI treatment was primarily progressive, inoperable, relapsed, or chemotherapy-resistant disease after completion of first- and second-line chemotherapy.

RESULTS

At the time of the beginning of mTKI treatment, the median age was 16.5 years, and the median time to progression from initiation of mTKI was 4 months. The overall response rate was 16%. We conducted a comparison of the survival outcomes of OSC patients receiving mTKIs against a retrospective, non-randomized control group. Overall survival was evaluated from the time of progression or relapse after second-line treatment to the time of death. The log-rank test revealed a significant difference in the survival distribution between patients receiving mTKIs and those who did not (chi2(1) = 8.13 p = 0.004). We observed benefits from mTKI treatment in 3 SySa patients, with pazopanib demonstrating effectiveness and no progression observed thus far.

CONCLUSIONS

Our findings suggest that mTKIs are well-tolerated and can serve as a therapeutic option for refractory bone sarcomas as palliative treatment, aiming to slow disease progression and uphold a good quality of life.

Sequential Treatment of Metastatic Colorectal Cancer in Taiwan: Real-World Evidence From Regorafenib and Trifluridine/Tipiracil Use

OBJECTIVE

This study aims to evaluate the real-world effectiveness and safety of sequential treatment with regorafenib and trifluridine/tipiracil (FTD-TPI) in patients with metastatic colorectal cancer (mCRC) in Taiwan.

METHODS

Data were obtained from Taiwan's National Health Insurance Research Database (NHIRD) to assess clinical outcomes in mCRC patients who were treated with both drugs in either sequential order from 2016 to 2019. Overall survival (OS) was analyzed using Kaplan-Meier curves and Cox's proportional hazard models, with adjustments made for age, gender, Quan-CCI score, presence of liver metastases, number of metastatic sites, and the use of anti-epidermal growth factor receptor medications. Additionally, age-stratified subgroups and sensitivity analyses were conducted to examine the robustness of our findings.

RESULTS

Five hundred and twenty-eight patients receiving both study drugs were included. The regorafenib/FTD-TPI group demonstrated a longer median OS of 14.1 months compared with 10.2 months in the FTD-TPI/regorafenib group (p = 0.007). The survival benefit for the regorafenib/FTD-TPI sequence remained significant after adjustment (adjusted HR, 1.49; p = 0.002). The mean treatment duration was also longer for regorafenib/FTD-TPI than FTD-TPI/regorafenib (337 vs. 214 days; p < 0.01). No significant difference between the sequential treatment groups was observed in any adverse event of interest. Both subgroup and sensitivity analyses yielded outcomes consistent with the main analysis.

CONCLUSION

The findings indicated that initiating treatment with regorafenib followed by FTD-TPI had superior clinical outcomes compared with the reverse sequence among mCRC patients. This study offers real-world evidence for clinical decision-making and treatment optimization.

Targeting VEGF signaling for tumor microenvironment remodeling and metastasis inhibition: Therapeutic strategies and insights

The tumor microenvironment (TME) plays a pivotal role in cancer progression and metastasis, with vascular endothelial growth factor (VEGF) signaling serving as a key regulator of tumor angiogenesis and immune evasion. VEGF induces abnormal blood vessel formation, promoting tumor growth, immune suppression, and metastasis through epithelialmesenchymal transition (EMT). As a result, VEGF signaling has become a critical therapeutic target in cancer treatment. This review examines the molecular mechanisms driving VEGF-mediated tumor growth and angiogenesis, with a focus on the interaction between tumor and endothelial cells and the dual role of VEGF in fostering vascularization and immune suppression. Current anti-VEGF therapies, including monoclonal antibodies (e.g., bevacizumab) and tyrosine kinase inhibitors (TKIs), have demonstrated efficacy and have received FDA approval for various cancers; however, therapeutic resistance remains a significant challenge. Strategies to overcome resistance, such as novel VEGF inhibitors, vascular normalization approaches, and combination therapies with immune checkpoint inhibitors, have been explored. Additionally, future directions emphasize the need for personalized approaches to improve treatment efficacy and reduce metastasis. A comprehensive understanding of VEGF signaling in the TME may pave the way for more effective cancer therapies.

Relationship Between Best Tumor Shrinkage and Progression-Free Survival and Overall Survival in Patients With Progressive Midgut Neuroendocrine Tumors Treated With [177Lu]Lu-DOTA-TATE: Ad Hoc Analysis of the Phase III NETTER-1 Trial

BACKGROUND

In many solid tumors, early tumor shrinkage predicts the durability of treatment response. It is unclear whether this is the case for neuroendocrine tumors treated with peptide receptor radionuclide therapy (PRRT).

METHODS

Data from the phase III NETTER-1 study of [177Lu]Lu-DOTA-TATE (177Lu-DOTATATE) for the treatment of advanced, well-differentiated, midgut NETs were used to investigate whether objective tumor shrinkage (local review) with 177Lu-DOTATATE is associated with progression-free survival (PFS) and overall survival (OS) duration.

RESULTS

Overall, 117 patients were treated with 177Lu-DOTATATE (four cycles of 7.4 GBq every 8 weeks). In a landmark analysis, best tumor shrinkage from baseline until data cut-off (prior to first progression) was not associated with PFS (n = 102; hazard ratio: 1.002 [95% confidence interval (CI): 0.99-1.02]; nominal p = 0.7808). In further ad hoc analyses, patients on the 177Lu-DOTATATE arm were dichotomized into ≥ 30% tumor shrinkage from baseline (18/117 [15.4%]) and < 30% shrinkage (99/117 [84.6%]). Median (95% CI) PFS was 17.6 (16.5-30.3) months in the ≥ 30% shrinkage group and 25.0 (19.4-31.0) months in the < 30% group. OS was not significantly different for the two tumor shrinkage groups (not estimable [31.0 months-not estimable] and 44.3 [34.9-53.8] months, respectively).

CONCLUSIONS

These results suggest the benefit of PRRT and the potential PFS and OS benefit of 177Lu-DOTATATE should not be based on tumor shrinkage (objective response versus stable disease) and that lack of tumor shrinkage should not impact application of the approved four cycles of 177Lu-DOTATATE.

Beneath the surface of colorectal cancer: Unmasking the evolving nature of (Neo)RAS

Metastatic colorectal cancer (mCRC) remains a major clinical challenge, despite therapeutic advancements. Mutations in KRAS and NRAS (RAS) oncogenes drive resistance to anti-EGFR drugs, necessitating RAS mutational analysis prior to treatment. While tissue biopsy remains the gold standard for molecular profiling, it has limitations such as invasiveness, intra-tumoral heterogeneity, and delayed results. Liquid biopsy (LB), on the other hand, offers a non-invasive alternative by analyzing circulating tumor DNA (ctDNA) and it provides a dynamic view of molecular changes over time. Indeed, ctDNA analysis has expanded the understanding of the mCRC's molecular landscape, revealing that RAS mutated (MT) subclones undergo both a positive and a negative selection during treatment. This negative selection has been described as the "NeoRAS WT phenomenon." The temporary disappearance of RAS mutations opens "RAS WT windows," thus making potential candidates for anti-EGFR therapies even patients initially diagnosed as RAS MT. This review examines numerous studies investigating the clinical significance of the "NeoRas WT phenomenon" as a distinct pathological entity. It also highlights the key limitations arising from the variability in study designs, detecting methods and ctDNA shedding rates. The results of ongoing prospective trials are necessary to determine whether NeoRAS WT stands as a reliable marker for guiding anti-EGFR treatment strategies in RAS-mutated patients.

KRAS G12C inhibitors as monotherapy or in combination for metastatic colorectal cancer: A proportion and comparative meta-analysis of efficacy and toxicity from phase I-II-III trials

BACKGROUND

1-2 % of metastatic colorectal cancers (mCRC) harbor an activating KRAS-G12C mutation. This study aims to pool the results of available clinical trials of KRAS-G12C inhibitors, comparing monotherapy and combinations.

METHODS

A systematic literature search was conducted in the MEDLINE database and ESMO/ASCO meeting abstracts. Phase I-II-III trials that investigated a KRAS-G12C inhibitor in patients with mCRC were included. The primary endpoints were objective response rate (ORR) and progression-free survival (PFS). Pooled proportions and comparative subgroup analyses for monotherapy and combinations were presented with the random effects model.

RESULTS

596 patients with previously treated mCRC in 14 study cohorts treated with one of sotorasib, adagrasib, divarasib, or olomorasib as monotherapy or in combination with cetuximab/panitumumab were included. Combination treatment revealed an ORR of 33.9 % (95 %CI: 20.7-48.4) (I2: 87.1), which is significantly higher than monotherapy [16.7 %, (95 %CI: 8.3-27.3) (I2: 73.2)] (p = 0.045). Median PFS was significantly longer with the combination [5.7 months (95 %CI: 4.4-7.1) (I2: 80.8) vs. 4.2 months (95 %CI: 3.6-4.7) (I2:0.0), p = 0.027]. Grade 3-4 treatment-related adverse events (TRAEs) were significantly more frequent with the combination [32.8 % (95 %CI: 26.4-39.6) (I2:42.5) vs.16.5 % (95 %CI: 4.9-33.1) (I2: 84.2), p = 0.047]. Common adverse events specific to the combinations were skin toxicities, paronychia, and hypomagnesemia.

CONCLUSION

This analysis suggests that KRAS-G12C inhibitors in combination with anti-EGFR agents may provide a doubled ORR and 1.5-month PFS benefit compared to monotherapy in previously treated mCRC patients, but with a doubled grade 3-4 TRAEs, including skin toxicities, paronychia, and hypomagnesemia. Treatment preferences should be individualized in these highly pretreated patients.

Decoding tumor angiogenesis: pathways, mechanisms, and future directions in anti-cancer strategies

Angiogenesis, a crucial process in tumor growth and metastasis, necessitates targeted therapeutic intervention. This review reviews the latest knowledge of anti-angiogenesis targets in tumors, with emphasis on the molecular mechanisms and signaling pathways that regulate this process. We emphasize the tumor microenvironment's role in angiogenesis, examine endothelial cell metabolic changes, and evaluated potential therapeutic strategies targeting the tumor vascular system. At the same time, we analyzed the signaling pathway and molecular mechanism of tumor angiogenesis in detail. In addition, this paper also looks at the development trend of tumor anti-angiogenesis drugs, including their future development direction and challenges, aiming to provide prospective insight into the development of this field. Despite their potential, anti-angiogenic therapies encounter challenges like drug resistance and side effects, necessitating ongoing research to enhance cancer treatment strategies and the efficacy of these therapies.

Real-World Comparison of Trifluridine-Tipiracil with or Without Bevacizumab in Patients with Refractory Metastatic Colorectal Cancer

Background/Objectives: Patients with metastatic colorectal cancer (mCRC) who are refractory to standard chemotherapy face limited treatment options. While trifluridine-tipiracil (FTD-TPI) and regorafenib have shown modest efficacy in prior clinical trials, recent data from the SUNLIGHT trial demonstrated that combining FTD-TPI with bevacizumab (FTD-TPI+BEV) may improve overall survival compared to FTD-TPI alone. However, supporting evidence from real-world populations remains scarce. Methods: This retrospective study assessed the real-world effectiveness and safety of FTD-TPI+BEV versus FTD-TPI monotherapy in patients with refractory mCRC treated at two institutions from June 2020 to October 2024. Results: A total of 106 patients were included, with 47 treated with FTD-TPI+BEV and 59 with FTD-TPI alone. Median progression-free survival (PFS) was significantly longer with FTD-TPI+BEV compared to FTD-TPI alone (4.1 vs. 2.1 months; HR = 0.56; p = 0.004), while median overall survival showed a non-significant trend favoring FTD-TPI+BEV (8.4 vs. 6.3 months; HR = 0.74; p = 0.189). The disease control rate was also significantly higher with FTD-TPI+BEV (59.6% vs. 25.4%, p = 0.001). Subgroup analyses showed consistent PFS benefits. Grade 3-5 adverse events occurred at comparable rates between groups. Conclusions: FTD-TPI+BEV may represent a preferred salvage treatment option for refractory mCRC.

CAN-Scan: A multi-omic phenotype-driven precision oncology platform identifies prognostic biomarkers of therapy response for colorectal cancer

Application of machine learning (ML) on cancer-specific pharmacogenomic datasets shows immense promise for identifying predictive response biomarkers to enable personalized treatment. We introduce CAN-Scan, a precision oncology platform, which applies ML on next-generation pharmacogenomic datasets generated from a freeze-viable biobank of patient-derived primary cell lines (PDCs). These PDCs are screened against 84 Food and Drug Administration (FDA)-approved drugs at clinically relevant doses (Cmax), focusing on colorectal cancer (CRC) as a model system. CAN-Scan uncovers prognostic biomarkers and alternative treatment strategies, particularly for patients unresponsive to first-line chemotherapy. Specifically, it identifies gene expression signatures linked to resistance against 5-fluorouracil (5-FU)-based drugs and a focal copy-number gain on chromosome 7q, harboring critical resistance-associated genes. CAN-Scan-derived response signatures accurately predict clinical outcomes across four independent, ethnically diverse CRC cohorts. Notably, drug-specific ML models reveal regorafenib and vemurafenib as alternative treatments for BRAF-expressing, 5-FU-insensitive CRC. Altogether, this approach demonstrates significant potential in improving biomarker discovery and guiding personalized treatments.

Kinase-Targeted Therapies for Glioblastoma

Protein phosphorylation and dephosphorylation are key mechanisms that regulate cellular activities. The addition or removal of phosphate groups by specific enzymes, known as kinases and phosphatases, activates or inhibits many enzymes and receptors involved in various cell signaling pathways. Dysregulated activity of these enzymes is associated with various diseases, predominantly cancers. Synthetic and natural single- and multiple-kinase inhibitors are currently being used as targeted therapies for different tumors, including glioblastoma. Glioblastoma IDH-wild-type is the most aggressive brain tumor in adults, with a median overall survival of 15 months. The great majority of glioblastoma patients present mutations in receptor tyrosine kinase (RTK) signaling pathways responsible for tumor initiation and/or progression. Despite this, the multi-kinase inhibitor regorafenib has only recently been approved for glioblastoma patients in some countries. In this review, we analyze the history of kinase inhibitor drugs in glioblastoma therapy.

Angiogenesis causes and vasculogenic mimicry formation in the context of cancer stem cells

Tumor occurrence, development, invasion, and metastasis are regulated by multiple mechanisms. Among these, angiogenesis promotes tumor progression mainly by supplying tumor tissue and providing channels for tumor metastasis. Cancer stem cells (CSCs) are another important factor affecting tumor progression by involving in tumor initiation and development, while remaining insensitive to conventional antitumor treatments. Among treatment strategies for them, owing to the existence of alternative angiogenic pathways or the risk of damaging normal stem cells, the clinical effect is not ideal. Angiogenesis and CSCs may influence each other in this process. Tumor angiogenesis can support CSC self-renewal by providing a suitable microenvironment, whereas CSCs can regulate tumor neovascularization and mediate drug resistance to anti-angiogenic therapy. This review summarized the role of vascular niche formed by angiogenesis in CSC self-renewal and stemness maintenance, and the function of CSCs in endothelial progenitor cell differentiation and pro-angiogenic factor upregulation. We also elucidated the malignant loop between CSCs and angiogenesis promoting tumor progression. Additionally, we summarized and proposed therapeutic targets, including blocking tumor-derived endothelial differentiation, inhibiting pro-angiogenic factor upregulation, and directly targeting endothelial-like cells comprising CSCs. And we analyzed the feasibility of these strategies to identify more effective methods to improve tumor treatment.

Safety, efficacy, and cost-effectiveness evaluation of systemic treatments for refractory colorectal cancer: a systematic review and modeling study

OBJECTIVES

To conduct pooled estimates and comparative evaluations of safety and efficacy, alongside cost-effectiveness and value-based pricing analyses, for systemic treatments recommended by the National Comprehensive Cancer Network in refractory colorectal cancer.

METHODS

A comprehensive search for related randomized controlled trials was conducted on PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov. Safety was evaluated by aggregating treatment-related adverse events (TRAEs) and performing Bayesian network meta-analysis (NMA) for indirect comparisons. Pooled survival estimates of overall survival (OS) and progression-free survival (PFS) were conducted to assess treatment efficacy. For NMA of OS and PFS, time-variant fractional polynomial models were employed as the primary analysis, with Cox proportional hazards models used for result validation. Economic evaluations were performed using partitioned survival models from the US public sector perspective. Clinical parameters were sourced from meta-analyses; cost parameters included drug treatment, follow-up and administration, end-of-life care, and adverse event management expenses, which were obtained from the Federal Supply Schedule, public databases or published literature. Utility values were sourced from the CORRECT trial. Price simulations were also conducted. Robustness of results was confirmed by sensitivity and scenario analyses RESULTS: We included nine studies comprising 3,978 patients and incorporating six treatments recommended by NCCN, including best supportive care (BSC), regorafenib, regorafenib dose optimization (REDo), trifluridine/tipiracil (TAS-102), TAS-102 with bevacizumab (TAS-BEV), and fruquintinib. Targeted treatments increased serious TRAEs and grade 3 + TRAEs compared to BSC. However, no significant safety differences were found among the targeted therapies. Regarding efficacy, REDo led in median OS, while fruquintinib led in median PFS. NMA indicated that TAS-BEV had the greatest PFS and OS survival benefit, followed by fruquintinib and REDo. Cost-effectiveness analysis favored BSC as the least expensive and the most cost-effective profile. TAS-BEV had the greatest effectiveness, with TAS-102 being the most cost-effective among targeted therapies. For cost-effectiveness against BSC, the price reductions of TAS-102, fruquintinib, REDoS, regorafenib, and TAS-BEV were 39%, 24%, 14%, 8%, and 7%, respectively.

CONCLUSIONS

Targeted therapies have comparable safety; TAS-BEV is highly effective, TAS-102 is the top cost-effective targeted therapy. Treatment choice should balance individual patient needs with safety, efficacy, and cost.

Burden and Trends of Diet-Related Colorectal Cancer in OECD Countries: Systematic Analysis Based on Global Burden of Disease Study 1990-2021 with Projections to 2050

Background: An unhealthy diet is a major risk factor for colorectal cancer (CRC). This study assessed the diet-related CRC burden from 1990 to 2021 in Organisation for Economic Co-operation and Development (OECD) nations and estimated the burden until 2050. Methods: Data for OECD countries on diet-related CRC disability-adjusted life years (DALYs) and deaths were obtained from the Global Burden of Disease 2021 study. The estimated annual percent change (EAPC) was calculated to analyse the CRC burden attributable to dietary factors. A generalised additive model with a negative binomial distribution was used to predict the future burden of CRC attributable to dietary factors from 2021 to 2050. Results: In 2021, the age-standardised percentages of diet-related CRC DALYs and deaths were 39.1% (95% uncertainty interval (UI): 9.3, 61.3) and 39.0% (95% UI: 9.7, 60.9), respectively, in the OECD countries. Between 1990 and 2021, the age-standardised DALYs decreased from 185 to 129 per 100,000, and deaths decreased from 8 to 6 per 100,000 population for OECD countries. Similarly, the EAPC in the rates showed a downward trend (EAPCdeaths = -1.26 and EAPCDALYs = -1.20). The estimated diet-related CRC DALYs and deaths are projected to increase to 4.1 million DALYs and 0.2 million deaths by 2050. There is a downward trend in CRC deaths (EAPC = 1.33 for both sexes) and in DALYs (-0.90 for males and -1.0 for females) from 1990 to 2050. Conclusions: The diet-related CRC burden remains significant. Implementing nutrition intervention programmes is necessary to promote access to affordable and nutritious foods and raise awareness about the importance of a healthy diet in reducing CRC risk.

Regorafenib as maintenance therapy after first-line doxorubicin-based chemotherapy in advanced non-adipocytic soft tissue sarcomas patients: a double-blind randomised trial

BACKGROUND

There is no approved maintenance therapy in advanced non-adipocytic soft tissue sarcomas (NASTS). We explore here the role of regorafenib as a potential maintenance therapy after first line treatment.

PATIENTS AND METHODS

EREMISS (NCT03793361) was a double-blind, placebo-controlled, comparative, 1:1 randomised phase 2 trial assessing the activity and safety of regorafenib (120 mg/d, 3 weeks / 4) in patients with NASTS, who had stable disease or partial response after 6 cycles of doxorubicin-based chemotherapy as first line treatment for advanced disease. The primary endpoint was progression-free survival (PFS) according to RECIST 1.1 evaluated by blinded central review (BCR). Based on the following assumptions: PFS (placebo)=4 months, expected PFS (regorafenib)=7 months, Hazard Ratio HR=0.57, 1-sided α=0.05 and β=0.10, 110 events and 126 patients were required. This study was supported by French National Cancer Institute, a patient advocacy group and Bayer HealthCare.

RESULTS

The study population consisted of 126 patients enrolled in 17 centres from May 2019 to Nov 2022. Female patients accounted for 55% of total enrolment. The median age was 58 years (range, 18-85). The most common histological subtype was leiomyosarcoma (59%). The primary objective was assessable in 122 patients (109 events). Median PFS by BCR was 3.5 (Placebo) versus 5.6 months (regorafenib) (HR=0.53; 95%CI, 0.36-0.78; p=0.001). Median overall survival was 20.5 versus 27.6 months (HR=0.78; 95%CI, 0.50-1.22; p=0.28). The proportion of patients with Grade≥3 adverse events was 4.8% (placebo) versus 56.3% (regorafenib). The most common Grade≥3 clinical adverse events in regorafenib arm were asthenia (9%), arterial hypertension (8%), and rash (8%).

CONCLUSION

This trial met its primary objective, regorafenib significantly delayed disease progression after first-line treatment in advanced NASTS. This was associated with a non-significant trend of overall survival improvement.

HBx/WDR5 enhances IGF-1 transcription in hepatocellular carcinoma cells and promotes recruitment, infiltration, and activity of Treg cells

HBV X protein (HBx), the smallest open reading frame in the hepatitis B virus (HBV) genome, can promote hepatocellular carcinoma (HCC) tumorigenesis by activating the expression of multiple oncogenes through inducing epigenetic alterations and interacting with the underlying transcriptional machinery. HBV non-infected HepG2 and Huh7 cells were transfected with HBx expression plasmids. The transcriptional, protein expression, and secretion levels of IGF-1 were detected by RT-qPCR, western blot, and ELISA, respectively. ChIP-qPCR was used to analyze the binding proteins on the IGF-1 gene. A co-culture system of HCC and Treg cells was designed using Transwell chambers. IGF-1 mRNA, protein, and secretion levels were increased in HepG2 and Huh7 cells exogenously expressing HBx. HBx was able to enter the nucleus and interact with the enhancer region of the IGF-1 gene. Levels of WDR5 and H3K4me1, which bind to the enhancer region of the IGF-1 gene, were also increased in HepG2 and Huh7 cells ectopically expressing HBx. Knockdown of WDR5 counteracted the upregulation of IGF-1 mRNA and protein levels by HBx. In the cell co-culture system, HBx/IGF-1 signaling in HCC cells promoted Treg cells expansion, IL-10 secretion, and infiltration, which was blocked by the IGF-1R inhibitor picropodophyllin. HBx/WDR5 promoted IGF-1 transcription in HCC cells through enhancers. HBx could promote Treg cell recruitment, infiltration, and activity by enhancing IGF-1 expression. IGF-1/IGF-1R signaling plays an important role in the communication between HCC cells and Treg cells. Targeting WDR or IGF-1/IGF-1R would be beneficial for the treatment of HCC.

Decoding colorectal cancer targeted therapy: a bibliometric journey of the last decade (2015-2024)

Colorectal cancer remains one of the most commonly diagnosed cancers globally, with a significant impact on public health. Targeted therapies have revolutionized the treatment landscape for colorectal cancer by offering increased specificity and reduced systemic toxicity compared to conventional chemotherapy. This study provides a comprehensive bibliometric analysis of global research on targeted therapy for colorectal cancer, focusing on publications from 2015 to 2024. A total of 3213 publications were retrieved from the Web of Science Core Collection and analyzed using bibliometric tools to construct knowledge maps and visualize research trends. The regression analysis shows a strong upward trend in publications from 2015 to 2024 (P < 0.001, R2 = 0.889). China leads in publication output, with the University of Texas MD Anderson Cancer Center contributing the highest number of studies. Tabernero and Kopetz are the core authors in the field. Research in this domain has primarily concentrated on the development and clinical assessment of drugs targeting the EGFR, RAS, VEGF, and BRAF signaling pathways, as well as investigating the pathogenesis, drug resistance, and metastatic mechanisms of colorectal cancer. Current advancements emphasize Artificial Intelligence-driven multi-omics integration, the creation of novel therapeutics targeting established molecular pathways, and the execution of global clinical trials to validate personalized treatment strategies.

Colon cancer biology and treatment in the era of precision oncology: A primer for Radiologists

In the era of precision oncology, systemic therapies for colon cancer are becoming increasingly biomarker-led, with implications for patients in the neoadjuvant, adjuvant and metastatic settings. As the landscape for colon cancer treatment evolves and becomes more complex, it is important that all members of the multidisciplinary team keep abreast of developments to ensure the most effective care is delivered to patients. As core members of the colorectal multidisciplinary team, Radiologists play a central role throughout the patient journey. This review serves as an educational summary of current and emerging treatment pathways in colon cancer, standards for biomarker testing, mechanisms of action for key drugs, important treatment-related complications, relevant tumour biology that underpins patterns of disease and treatment response, and the specific implications systemic therapies have for cancer imaging and Radiologists. We also highlight the increasing role for radiology in patient stratification and the importance of imaging biomarkers. It is crucial that Radiologists understand the current landscape of colon cancer treatment and emerging strategies on the horizon in clinical trials. Only through engagement across the wider multidisciplinary team will we deliver true personalised medicine for patients with colon cancer.

PMDA Perspective on Use of Real-World Data and Real-World Evidence as an External Control: Recent Examples and Considerations

Recent discussions about the utilization of real-world data (RWD) and real-world evidence (RWE) have been more focused on drug development for regulatory approval rather than during the post-marketing stage. In Japan, RWD/RWE have been practically utilized as an external control for drug approval. Most cases were related to orphan diseases where the feasibility of conducting randomized controlled clinical trials was generally low. The utilization of RWD/RWE as an external control provides additional information that can support regulatory review for drug approval. However, many points should be taken into consideration through all stages of a study that is based on RWD/RWE, including planning, analysis, and interpretation. In this article, we present our recent review experience focusing on efficacy evaluations with an external control based on RWD/RWE that were submitted as a part of new drug applications in Japan, and we describe our regulatory consideration of the utilization of RWD/RWE for drug evaluation and approval. Points described in this article promote appropriate drug development based on RWD/RWE and facilitate a proper discussion about RWD/RWE utilization with PMDA. Further accumulation of regulatory experience in PMDA with RWD/RWE utilization will enhance our knowledge and contribute to better regulatory decision making for drug approvals based on RWD/RWE.

Neuroendocrine tumors and diabetes mellitus: which treatment and which effect

Diabetes mellitus (DM) and neuroendocrine tumors (NET) can exert unfavorable effects on each other prognosis. In this narrative review, we evaluated the effects of NET therapies on glycemic control and DM management and the effects of anti-diabetic therapies on NET outcome and management. For this purpose, we searched the PubMed, Science Direct, and Google Scholar databases for studies reporting the effects of NET therapy on DM as well as the effect of DM therapy on NET. The majority of NET treatments appear to impair glycaemic control, both inducing hypoglycemic or, more commonly, hyperglycemia and even new-onset DM. However, glucose metabolism imbalance can be effectively managed by modulating anti-diabetic therapy and adopting an appropriate nutritional approach. On the other hand, the effects of anti-diabetic treatment, like insulin, sulfonylureas, thiazolidinediones, ipeptidyl-peptidase-4 inhibitors, Glucagon-like peptide-1 receptor agonists, and Sodium-glucose cotransporter-2 inhibitors on NET are unclear. Recently, metformin has been investigated in patients with gastroenteropancreatic NET resulting in improved progression free survival suggesting a potential antineoplastic role. Finally, the management of DM in patients with NET is of great clinical relevance to correctly perform radiological procedures and even more functional imaging procedures, as well as to optimize the therapy and avoid treatment withdrawal or discontinuation. In conclusion, understanding the mechanisms underlying therapy-induced DM and implementing appropriate monitoring and management strategies of DM are essential for optimizing NET patient outcome and quality of life.

Advances in bevacizumab in colorectal cancer: a bibliometric analysis from 2004 to 2023

Background

Bevacizumab is a primary focus in the clinical application and research of metastatic colorectal cancer (mCRC) patients. This study aims to analyze publications on bevacizumab and CRC to explore and identify the trends and frontiers of this field.

Methods

We collected 4,164 articles on bevacizumab and CRC from the Web of Science Core Collection (WoSCC). CiteSpace, VOSviewer, R-bibliometrix, and Microsoft Excel were utilized for analysis and visualization.

Results

The United States, Japan, and China are the leading countries in this field. The National Cancer Institute and the University of Pisa share the top position for the highest number of publications. Personalized therapy, innovative combination treatments, mechanisms of resistance, and new drug development are enduring focal points and future research directions.

Conclusions

This study provides the first bibliometric analysis of research on bevacizumab and CRC, revealing the current status and future directions of this field.

Regorafenib exerts an inhibitory effect on the proliferation of human lung fibroblasts by reducing the production of several cytokines in vitro study

BACKGROUND

Pulmonary fibrosis is a disease that leads to respiratory failure and death. There has been little progress in therapeutic strategies for pulmonary fibrosis. There have been several reports on the cytokines associated with pulmonary fibrosis, including IL-6 and TGF-β1. Angiogenesis is one of the most important phenomena in the pathogenesis of pulmonary fibrosis. Previously, we reported the preventive effects of thalidomide against pulmonary fibrosis via the inhibition of neovascularization by angiogenic factors such as VEGF. Regorafenib is a multikinase inhibitor, which inhibits tyrosine kinase receptors such as VEGFR1-3 and TIE2. In the clinical setting, regorafenib has been widely used for anti-cancer therapy for metastatic colorectal cancer. In this study, we examined the preventive effects of regorafenib against pulmonary fibrosis.

METHODS

We investigated whether regorafenib had an inhibitory effect on the proliferation, viability, and production of several cytokines in lung fibroblasts.

RESULTS

We demonstrated an inhibitory effect of regorafenib on the proliferation and viability of lung fibroblasts. Moreover, regorafenib reduced the production of several cytokines associated with the pathogenesis of pulmonary fibrosis, including IL-6, VEGF and TGF- β1, and collagen synthesis from lung fibroblasts.

CONCLUSIONS

These data suggest that regorafenib may have potential clinical applications in the prevention of pulmonary fibrosis.

Efficacy of disitamab vedotin-containing therapy in metastatic colorectal cancer: A case report

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. In cases of metastatic CRC (mCRC) that are resistant to conventional chemotherapy-based treatments, the efficacy of available therapeutic options is typically low. CRC exhibiting overexpression or amplification of the human epidermal growth factor receptor 2 (HER2) gene has shown responsiveness to HER2-targeted therapies.

CASE SUMMARY

We present the case of a 69-year-old woman diagnosed with mCRC with an NRAS p.G12V mutation and microsatellite stability, identified through tumor sequencing, along with HER2 overexpression detected by immunohistochemistry. She exhibited an excellent response to disitamab vedotin-containing therapy. To our knowledge, this is the first reported case of mCRC with HER2 overexpression and an NRAS p.G12V mutation achieving a remarkable clinical response to anti-HER2 therapy.

CONCLUSION

Disitamab vedotin demonstrates promising anti-tumor effects in HER2-overexpressing mCRC, offering patients an additional treatment option.

Artificial intelligence system for predicting hand-foot skin reaction induced by vascular endothelial growth factor receptor inhibitors

Hand-foot skin reaction (HFSR) is a common adverse effect of vascular endothelial growth factor receptor (VEGFR) inhibitors that significantly impacts patients' quality of life. Prevention and management of HFSR require individualized approaches, but risk factors remain unclear. This study aimed to develop artificial intelligence (AI) models to predict grade ≥ 2 HFSR using clinical data and foot sole images from 93 instances of VEGFR inhibitor administration in 76 patients. Image-based, clinical information-based, and ensemble AI models achieved areas under the curve of 0.550, 0.693, and 0.699, respectively. At a high-specificity cutoff, the ensemble AI had a positive predictive value of 0.824, suggesting potential clinical utility for identifying high-risk patients. Feature importance analysis revealed heavier weight, good performance status, lack of prior VEGFR inhibitor exposure, and baseline skin toxicity as risk factors. These findings represent the first AI-based HFSR prediction models and provide insights for preventive interventions, but further accuracy improvements are needed.

A randomized, open-label, two-period crossover study to evaluate the bioequivalence and food effect between two formulations of regorafenib in healthy adult participants

Background

This research aimed to compare the bioequivalence of a test formulation (regorafenib produced by Beijing SL Pharmaceutical Co., Ltd.) with a reference formulation (the original drug Stivarga®) in Chinese healthy subjects under fasting conditions and two postprandial states: after low-fat and high-fat meals.

Methods

The research design was a randomized, open-label, two-period crossover trial involving a single 40 mg oral dose. Three separate studies were conducted. Study 1 enrolled 64 subjects who were dosed under fasting conditions; Study 2 involved 76 subjects dosed after a low-fat breakfast; and Study 3 also involved 76 subjects dosed after a high-fat breakfast. Plasma concentrations of regorafenib and M-2 were determined using a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. The primary endpoints were the peak plasma concentration (Cmax), the area under the concentration-time curve from time 0 to 168 h (AUC0-168h), and the extrapolated area under the curve from time zero to infinity (AUC0-∞) of regorafenib, with pharmacokinetics (PK) parameters of the metabolite M-2 serving as reference data.

Results

The results showed that, under fasting, post-low-fat meal, and post-high-fat meal conditions, the 90% confidence intervals (CIs) of geometric mean ratios (GMRs) for Cmax of test to reference regorafenib were 96.39%-114.94%, 93.81%-106.67% and 94.23%-107.21%, respectively. For AUC0-168h were 88.40%-102.04%, 92.40%-102.97% and 92.50%-102.60%. For AUC0-∞ were 85.86%-100.01%, 90.26%-101.79% and 90.15%-101.36%. All of these fell within the 80.00%-125.00% range, meeting the equivalence criteria. Food intake had some impact on the PK parameters of regorafenib, but the effect was minor. Administration of a single 40 mg dose of regorafenib to healthy subjects demonstrated good safety and tolerability.

Conclusion

Under different dietary conditions, a single oral dose of 40 mg of generic drug regorafenib was bioequivalent to the original drug Stivarga® in healthy Chinese subjects, and the food effect was limited.

Clinical Trial Registration

http://www.chinadrugtrials.org.cn/, identifier CTR20210575, CTR20210576, CTR20223278.

Sequential Treatment with Regorafenib and Trifluridine/Tipiracil ± Bevacizumab in Refractory Metastatic Colorectal Cancer in Community Clinical Practice in the USA

Background: Regorafenib (R) and Trifluridine/Tipiracil ± bevacizumab (T) are approved for treating refractory metastatic colorectal cancer (mCRC) but their optimal sequence is unclear. This study describes the characteristics/clinical outcomes of patients with mCRC in U.S. clinical practice treated sequentially with R-T or T-R. Methods: A retrospective cohort study of 818 patients treated with R-T or T-R between January 2015 and November 2022 was conducted using an electronic health record-derived database. The primary objective was to describe the demographic/clinical characteristics and biomarker status of patients treated with R-T or T-R, stratified by treatment line/age. Secondary objectives were to evaluate/estimate the frequency of neutropenia and myelosuppression-related treatments, the number/type of subsequent therapies, time to treatment discontinuation (TTD), and overall survival (OS). Results: Baseline characteristics were similar among patients who received R-T (n = 393) or T-R (n = 425). Lower rates of moderate/severe neutropenia (26%/12% vs. 32%/16%) and granulocyte colony-stimulating factor/erythropoietin use (22% vs. 24%) were observed with R-T versus T-R. The median TTD was 8.7 months and 8.5 months with R-T versus 8.1 months and 7.9 months with T-R as third- and fourth-line treatment, respectively. The median OS was 13.1 months and 11.6 months with R-T versus 11.5 months and 10.3 months with T-R as third- and fourth-line treatment, respectively. Conclusions: This study did not show a statistically significant difference in OS with R-T versus T-R. Although limited by its retrospective nature, the study suggested R-T may be preferable to T-R given the observed reduction in neutropenia/myelosuppression-related treatments.

What Is Next for Refractory Colorectal Cancer CRC? Looking Beyond SUNLIGHT, FRESCO2, RECURSE and CORRECT

The treatment landscape of metastatic colorectal cancer (mCRC) has undergone significant evolution, with the introduction of targeted therapies and immunotherapy dramatically altering the management of microsatellite instability-high (MSI-H) tumors. However, the majority of patients, particularly those with microsatellite-stable (MSS) disease, remain refractory to immunotherapy, necessitating the exploration of alternative therapeutic strategies. This review summarizes the current treatment options for heavily pretreated mCRC patients who are not eligible for targeted therapies or clinical trials. Approved therapies for refractory mCRC, including regorafenib, trifluridine/tipiracil (FTD/TPI), and fruquintinib, demonstrate modest survival benefits but are often associated with significant toxicities. Additionally, innovative approaches targeting specific mutations such as KRAS G12C, HER2 amplification, and BRAF V600E are discussed, highlighting emerging combination regimens with immune checkpoint inhibitors and other agents to overcome resistance mechanisms. The potential of rechallenge strategies using previously administered therapies, such as oxaliplatin and anti-EGFR agents, is examined, supported by retrospective and prospective studies. Furthermore, the role of older drugs like mitomycin C in combination with capecitabine is revisited, offering insights into their viability in advanced treatment settings. Ongoing clinical trials with novel agents and combinations are expected to provide further clarity on optimizing sequential treatment regimens and personalizing therapy for mCRC patients. This review emphasizes the need for comprehensive molecular profiling and shared decision-making to improve outcomes and quality of life in this challenging patient population.

Health-related quality of life associated with fruquintinib in patients with metastatic colorectal cancer: Results from the FRESCO-2 study

INTRODUCTION

Maintaining or improving health-related quality of life (HRQoL) is as important as extending survival in metastatic colorectal cancer. We report an HRQoL analysis from FRESCO-2 (NCT04322539).

METHODS

Patients were randomized to fruquintinib +best supportive care (BSC; n = 461) or placebo +BSC (n = 230). Instruments of EORTC QLQ-C30 and 5-level EQ-5D, and ECOG performance status (PS) were assessed. Changes from baseline scores for QLQ-C30 and EQ-5D were evaluated and minimally important difference thresholds were used to define stable, improved, or deteriorated QoL. Time to deterioration (TTD) was assessed.

RESULTS

With fruquintinib versus placebo, baseline QLQ-C30 global health status (GHS) and EQ-5D visual analog scale (VAS) scores were 65.2 versus 64.6 and 67.0 versus 66.6, respectively. Least-squares mean changes from baseline fluctuated throughout treatment. At end of treatment (EOT), mean scores with fruquintinib versus placebo were 53.8 versus 52.3 (QLQ-C30 GHS) and 58.9 versus 58.5 (EQ-5D VAS). For QLQ-C30 GHS, 38.3 % versus 36.5 % of patients receiving fruquintinib versus placebo had stable or improved scores at EOT; median TTD was 2.1 versus 1.8 months (HR, 0.9; 95 % CI, 0.7-1.0). For EQ-5D VAS, 47.9 % versus 42.7 % had stable or improved scores at EOT; median TTD was 2.6 versus 1.9 months (HR, 0.8; 95 % CI, 0.6-0.9). Median TTD to ECOG PS ≥ 2 or death within 30+ /7 days after EOT was 6.6 versus 2.9 months with fruquintinib versus placebo (HR, 0.6; 95 % CI, 0.4-0.7).

CONCLUSIONS

Fruquintinib delayed TTD of ECOG PS and did not negatively impact HRQoL versus placebo.

Fruquintinib versus placebo in patients with refractory metastatic colorectal cancer: safety analysis of FRESCO-2

BACKGROUND

Fruquintinib is a highly selective, oral inhibitor of all 3 VEGF receptors. The global, randomized, double-blind phase 3 FRESCO-2 trial (NCT04322539) met its primary endpoint demonstrating significantly improved overall survival in patients with refractory metastatic colorectal cancer (mCRC) who received fruquintinib plus best supportive care (BSC) versus placebo plus BSC. Here we report detailed safety data from FRESCO-2 including an analysis of treatment-related adverse events of special interest (AESIs).

PATIENTS AND METHODS

Patients with mCRC eligible for FRESCO-2 had received all standard chemotherapies and prior anti-VEGF and anti-EGFR therapies if indicated, and displayed progression on, or intolerance to, TAS-102 and/or regorafenib. Prespecified AESIs based on VEGFR tyrosine kinase inhibitor drug classes were evaluated.

RESULTS

Incidences of treatment-related AESIs were 64.9% with fruquintinib + BSC versus 23.0% with placebo + BSC. The most frequent all-grade treatment-related AESIs for fruquintinib were hypertension (28.9%; grade ≥3 10.7%), palmar-plantar erythrodysesthesia syndrome/hand-foot skin reaction (PPE 18.6%; grade ≥3 6.1%), and hypothyroidism (15.6%; grade ≥3 0.4%). Dose reductions due to treatment-related AESIs were reported in 10.3% of patients who received fruquintinib + BSC versus 0.4% with placebo + BSC. The most common treatment-related AESIs resulting in dose reduction for fruquintinib were PPE syndrome (5.0%), hypertension (2.9%), and proteinuria (1.3%). Overall, 5.9% versus 0.9% had treatment-related AESIs resulting in study drug discontinuation.

CONCLUSION

Fruquintinib + BSC demonstrated a predictable and manageable safety profile in pretreated patients with mCRC and is a novel oral treatment option that prolongs survival and enriches the continuum of care in this population.

Basic science and translational implications of current knowledge on neuroendocrine tumors

Neuroendocrine tumors (NETs) are a diverse group of malignancies that can occur in various organs, with a notable prevalence in the lungs and gastrointestinal tract, which are the focus of this Review. Although NETs are rare in individual organs, their incidence has increased over recent decades, highlighting the urgent need for current classification systems to evolve by incorporating recent advances in the understanding of NET biology. Several omics studies have revealed molecular subtypes, which, when integrated into existing classification frameworks, may provide more clinically relevant insights for patients with NETs. This Review examines recent progress in elucidating the biology of NETs, with a particular emphasis on the tumor microenvironment and cells of origin. The existence of different cells of origin, which may contribute to distinct molecular groups, along with profiles of immune infiltration - despite being generally low - could explain the emergence of more aggressive cases and the potential for metastatic progression. Given the molecular heterogeneity of NETs and the diversity of their microenvironments and different cells of origin, there is an urgent need to develop morphomolecular classification systems. Such systems would make it possible to better characterize tumor progression, identify new therapeutic targets, and, ultimately, guide the development of personalized therapies.

Quality-adjusted survival in patients with metastatic colorectal cancer treated with fruquintinib plus best supportive care: results from FRESCO-2

BACKGROUND

Treatment toxicity and disease-related symptoms of metastatic colorectal cancer (mCRC) can adversely affect quality of life (QoL). Maintaining QoL is an important treatment goal alongside improving survival outcomes. Quality-adjusted time without symptoms of disease or toxicity (Q-TWiST) measures the quality of patients' survival by assessing the proportion of survival time that is free of symptoms/toxicity. The phase III FRESCO-2 study met its primary endpoint, demonstrating improved overall survival with fruquintinib plus best supportive care (BSC) versus placebo plus BSC [hazard ratio 0.66, 95% confidence interval (CI) 0.55-0.80, P < 0.001]. This post hoc Q-TWiST analysis compared the benefit-risk of fruquintinib versus placebo in all patients randomized in FRESCO-2.

METHODS

Patients with refractory mCRC in the USA, Europe, Japan, and Australia were randomized to receive fruquintinib (n = 461) or placebo (n = 230) plus BSC until disease progression or unacceptable toxicity. Patients' survival time was partitioned as follows: time from randomization with grade 3/4 treatment-emergent adverse events (TEAEs) before progression (TOX); time from randomization to progression without grade 3/4 TEAEs (TWiST); and time from progression to death/censoring (REL). Q-TWiST was calculated as the combined utility-weighted mean durations of each health state, assuming utility coefficients of 1 for TWiST and 0.5 for TOX and REL.

RESULTS

Q-TWiST was improved when fruquintinib (versus placebo) was added to BSC, with a between-treatment difference of 2.0 months (95% CI 1.5-2.6 months, P < 0.05) and a relative improvement of 31.4%. This effect was primarily driven by the difference in the TWiST component [mean difference 2.1 months (95% CI 1.8-2.5 months), P < 0.05]. Q-TWiST improvements were consistent in all subgroups, including by age, sex, liver metastases, and primary tumor site. The subgroup and sensitivity analysis results confirmed the robustness of the primary analysis findings.

CONCLUSIONS

Fruquintinib provides a clinically meaningful quality-adjusted survival benefit versus placebo in refractory mCRC.

FOLFIRINOX-3 plus bevacizumab (bFOLFIRINOX3) in chemo-refractory metastatic colorectal cancer: a multicenter phase II trial

PURPOSE

A phase I study of FOLFIRINOX3-bevacizumab (bFOLFIRINOX3)defined the RP2D for irinotecan at 70 mg/m² and showed promising activity. This phase II trial aimed to evaluate the efficacy of bFOLFIRINOX-3 in chemorefractory metastatic colorectal cancer (mCRC).

METHODS

In phase II, chemorefractory mCRC were enrolled. The regimen tested consisted of bevacizumab (5 mg/kg), folinic acid(400 mg/m²), 5-fluorouracil (2400 mg/m² for 46 h), oxaliplatin (85 mg/m²) and irinotecan (70 mg/m² administered before and after infusion of 5-fluorouracil). The primary endpoint was efficacy defined by 2-month progression-free survival(PFS). Secondary endpoints included objective response, median PFS, overall survival (OS) and toxicity.

RESULTS

32 patients were enrolled (October 2018 to December 2022); median age 62.5 years (range 32-78). The majority had been treated with several previous lines of chemotherapy (median 3, range [1-8]). Median follow up was 12 months (range [1.5-12]). Two-month PFS was 96.9%. Best objective response rate (ORR) was 28.1%. Median PFS was 9.4 months (95%CI [6.9;11.5]) and median OS was not reached (95% [11.6; NR]). Grade 3 adverse events occurred in 81.2%; mostly diarrhea (37.5%) and neutropenia (12.5%). Grade 3 diarrhea consistently resolved after irinotecan dose reduction. The most common drug-related adverse events (all grades) were diarrhea (96.9%), fatigue (68.8%), nausea (68.7%), anemia (56.3%), peripheral neuropathy (53.4%) and thrombopenia (40.6%).

CONCLUSION

The combination of bFOLFIRINOX-3 yielded 2-month PFS of 96.9% and best ORR of 28.1%, and was well tolerated. These results are promising in chemotherapy refractory mCRC and provide a rationale for future randomized phase III trials.

CLINICAL TRIAL REGISTRATION

NCT03795311 (clinicaltrials.gov).

Percutaneous hepatic artery infusion chemotherapy with oxaliplatin and fluoropyrimidines in treatment-resistant colorectal cancer patients with unresectable liver metastases: a retrospective cohort study

BACKGROUND

Subsequent lines of therapy for chemotherapy-resistant metastatic colorectal cancer (CRC) have shown limited efficacy. Herein, we retrospectively investigated the efficacy and safety of hepatic artery infusion chemotherapy (HAIC) using oxaliplatin plus 5-FU/FUDR in patients with unresectable colorectal liver metastases (CRLM) who progressed following standard chemotherapy regimens.

METHODS

From March 2017 to April 2023, CRC patients with unresectable CRLM who progressed following standard chemotherapy and subsequently received HAIC oxaliplatin plus 5-FU/FUDR were evaluated. Objective response rate (ORR), disease control rate (DCR), median depth of tumor response (DpR), no evidence of disease (NED) rate, progression-free survival (PFS), overall survival (OS), and safety were assessed.

RESULTS

A total of 21 patients who progressed after a median of two (range: 1-4) lines of standard systemic chemotherapy were included. The ORR and DCR were 28.6 % and 95.2 %, respectively, with six patients reaching partial response. Additionally, the median DpR was 10.6 %, and seven patients underwent successful conversion surgery. Stratification revealed significantly better PFS in patients with liver-limited metastases compared to those with concurrent hepatic and extrahepatic metastases (P = 0.0003).

CONCLUSION

HAIC oxaliplatin plus 5-FU/FUDR is a robust regimen for treatment-resistant CRC patients with unresectable CRLM, particularly those with liver-limited disease.

Real-world dosing patterns of regorafenib for patients with metastatic colorectal cancer in Spain: the RE-SEARCH study

PURPOSE

To describe the dosing patterns of regorafenib in a real-world population of patients with metastatic colorectal cancer (mCRC) in a routine clinical practice setting in Spain, focusing on the starting dose of regorafenib.

METHODS

An observational, retrospective, multicenter study that included patients ≥ 18 years old who had histologically documented mCRC and who had initiated treatment with regorafenib since January 2017. Post hoc categorization of dosing patterns revealed the following: initial dose < 160 mg and dose escalation, initial dose < 160 mg and maintenance, initial dose equal to 160 mg and maintenance, and initial dose equal to 160 mg and dose reduction.

RESULTS

Most patients (152/241, 63.8%) initiated treatment with regorafenib at doses < 160 mg. There was large variation in the starting dose of regorafenib over time: in 2017, most patients (59%) initiated regorafenib at a dose of 160 mg, this proportion decreased to 6% in 2021. There were no significant differences in the median progression-free survival according to the regorafenib dose patterns during the first two cycles. The proportion of patients who reported at least one adverse event (AE), had a grade 3-4 AE or had an AE leading to dose reduction was greater in the group of patients who received an initial dose equal to 160 and reduction.

CONCLUSIONS

Our results indicate that physicians in Spain have gradually adopted a dose-escalation approach during cycle 1, which is a common practice for starting treatment with a reduced dose (< 160 mg/day), a strategy that seems to improve tolerability while maintaining efficacy.

TRIAL REGISTRATION

Not applicable.

Theranostics in Lung Neuroendocrine Tumors

In the last 2 decades, there has been a noticeable increase in the incidence of neuroendocrine tumors, in part due to improved understanding of pathology and/or availability of more sensitive and accurate diagnostic tests. While gastrointestinal tract and pancreas are the most common sites of origin, lung neuroendocrine tumors (LNETs) are also frequently reported and need special considerations from diagnostic as well as therapeutic aspects. Radiopharmaceutical therapy (Theranostics) is a novel approach which utilizes a pair of diagnostic and therapeutic agents that share a common target on tumor sites. Precise treatment of the disease with minimum side effects is the principal aim of Theranostics. It's a known fact that somatostatin receptors (SSTR) are abundantly expressed in neuroendocrine tumors. With the advent of highly specific radiopharmaceuticals targeting SSTR receptors for both diagnosis as well as treatment and other targeted therapies, management of LNETs has become less challenging. Still, there exists significant ambiguity in relation to management of LNETs with a scope of novel diagnostic and therapeutic strategies to pitch in. This review focuses on the role of established evidence for Theranostics strategies in the management of LNETs and highlights the potential future role of newer targets which would be of promising value in addressing such rare and complex tumor biology.

Chemotherapy Rechallenge or Reintroduction Compared to Regorafenib or Trifluridine/Tipiracil for Pretreated Metastatic Colorectal Cancer Patients: A Propensity Score Analysis of Treatment Beyond Second Line (Proserpyna Study)

BACKGROUND

The optimal treatment for metastatic colorectal cancer (mCRC) beyond second line is still questioned. Besides the standard of care agents (regorafenib, REG, or trifluridine/tipiracil, FTD/TPI), chemotherapy rechallenge or reintroduction (CTr/r) are commonly considered in clinical practice, despite weak supporting evidence. The prognostic performance of CTr/r, REG and FTD/TPI in this setting are herein evaluated.

PATIENTS AND METHODS

PROSERpYNa is a multicenter, observational, retrospective study, in which patients with refractory mCRC, progressing after at least 2 lines of CT, treated with CTr/r, REG or FTD/TPI, are considered eligible and were enrolled in 2 independent data sets (exploratory and validation). Primary endpoint was overall survival (OS); secondary endpoints were investigator-assessed progression-free survival (PFS), objective response rate (RR) and safety. A propensity score adjustment was accomplished for survival analyses.

RESULTS

Data referring to patients treated between Jan-10 and Jan-19 from 3 Italian institutions were gathered (341 and 181 treatments for exploratory and validation data sets respectively). In the exploratory cohort, median OS (18.5 vs. 6.5 months), PFS (6.1 vs. 3.5 months) and RR (28.6% vs. 1.4%) were significantly longer for CTr/r compared to REG/FTD/TPI. Survival benefits were retained at the propensity score analysis, adjusted for independent prognostic factors identified at multivariate analysis. Moreover, these results were confirmed within the validation cohort analyses.

CONCLUSIONS

Although the retrospective fashion, CTr/r proved to be a valuable option in this setting in a real-world context, providing superior outcomes compared to standard of care agents at the price of a moderate toxicity.

Collagen remodeling-mediated signaling pathways and their impact on tumor therapy

In addition to their traditional roles in maintaining tissue morphology and organ development, emerging evidence suggests that collagen (COL) remodeling-referring to dynamic changes in the quantity, stiffness, arrangements, cleavage states, and homo-/hetero-trimerization of COLs-serves as a key signaling mechanism that governs tumor growth and metastasis. COL receptors act as switches, linking various forms of COL remodeling to different cell types during cancer progression, including cancer cells, immune cells, and cancer-associated fibroblasts. In this review, we summarize recent findings on the signaling pathways mediated by COL arrangement, cleavage, and trimerization states (both homo- and hetero-), as well as the roles of the primary COL receptors-integrin, DDR1/2, LAIR-1/2, MRC2, and GPVI-in cancer progression. We also discuss the latest therapeutic strategies targeting COL fragments, cancer-associated fibroblasts, and COL receptors, including integrins, DDR1/2, and LAIR1/2. Understanding the pathways modulated by COL remodeling and COL receptors in various pathological contexts will pave the way for developing new precision therapies.

Neoadjuvant Treatment With Regorafenib and Capecitabine Combined With Radiotherapy in Locally Advanced Rectal Cancer: A Multicenter Phase Ib Trial (RECAP)-SAKK 41/16

BACKGROUND

The multi tyrosine kinase inhibitor regorafenib is active in metastatic colorectal cancer. Improvement in clinical outcome by adding regorafenib to long-course chemoradiotherapy (LcCRT) was investigated in molecularly undefined LARC.

METHODS

Patients with T3-4 and/or N+ but M0 rectal cancer were included. Neoadjuvant LcRCT consisted in capecitabine (C) 825mg/m2 d1-d38 and 28 fractions of 1.8Gy (50.4Gy). Regorafenib was added d1-14 and d22-35 in 3 dose escalation (DE) cohorts (40mg/80mg/120mg). The recommended dose (RD) was used for the expansion (EXP) cohort. Primary endpoints were dose-limiting toxicity (DLT) for DE and pathological response (near-complete regression [npCR] or complete regression [pCR]) for EXP.

RESULTS

Overall, 25 patients were included. Two DLTs occurred at the regorafenib dose level of 120 mg, thereby establishing the RD at 80mg daily. Among the 19 patients who were treated at the RD, 8 (42.1%; 1-sided 80% confidence interval [CI] (lower bound): 30.7%; 95% CI, 20.3%-66.5%) reached the primary endpoint (5 [26.3%] had npCR and 3 [15.8%] pCR). One additional patient received no surgery due to clinical complete response. All patients had R0 resections and clear circumferential margins. Postoperative complications occurred in 6 patients (35.3%). The most common grade ≥ 3 treatment-related adverse event in the EXP cohort was diarrhea (2 patients).

CONCLUSION

Adding regorafenib 80 mg to LcCRT in LARC resulted in both primary endpoints being met and yielded an expected pathological response rate. Toxicity was manageable, and postoperative complications were as expected.

A Review of FDA-Approved Multi-Target Angiogenesis Drugs for Brain Tumor Therapy

Neovascularization is an important process in brain tumor development, invasion and metastasis. Several research studies have indicated that the VEGF signaling target has potential for reducing angiogenesis in brain tumors. However, targeting VEGF signaling has not met the expected efficacy, despite initial enthusiasm. This is partly because tumors cleverly use alternative growth factor pathways, other than VEGF signaling, to restore angiogenesis. Multi-target inhibitors have been developed to inhibit several receptor kinases that play a role in the development of angiogenesis. By simultaneously affecting various receptor kinases, these treatments can potentially obstruct various angiogenic pathways that are involved in brain cancer advancement, often offering a more holistic strategy than treatments focusing on just one kinase. Since 2009, the FDA has approved a number of multi-kinase inhibitors that target angiogenic growth factor receptors (e.g., VEGFR, PDGFR, FGFR, RET, c-KIT, MET, AXL and others) for treatment of malignant diseases, including brain cancer. Here, we present some recent results from the literature regarding the preclinical and clinical effects of these inhibitors on brain tumors.

Raltitrexed, S-1 and fruquintinib (RSF) in the treatment of refractory metastatic colorectal cancer: study protocol for a multicenter, prospective, single-arm, phase II trial

BACKGROUND

Metastatic colorectal cancer (mCRC) remains a significant clinical challenge, particularly for patients who have failed standard first- and second-line therapies. Despite advancements in targeted therapies, options for third-line treatments are limited, with current regimens such as regorafenib, fruquintinib, and TAS-102 demonstrating modest efficacy. The RS regimen, combining raltitrexed and S-1, has shown improved objective response rates (ORR) and progression-free survival (PFS) compared to standard therapies. Fruquintinib, a vascular endothelial growth factor receptor (VEGFR) inhibitor, has also demonstrated efficacy in heavily pretreated mCRC patients, including those resistant to prior anti-VEGF therapies. Combining these agents in the RSF regimen leverages complementary mechanisms of action to address resistance and improve outcomes.

METHODS

This multicenter, prospective, single-arm, open-label Phase II clinical trial evaluates the efficacy and safety of the RSF regimen in mCRC patients who have failed first- and second-line therapies. Eligible patients will receive S-1 orally (14 days), raltitrexed intravenously (day 1), and fruquintinib orally (14 days) in a 21-day cycle. The primary endpoint is ORR, assessed using RECIST v1.1 criteria. Secondary endpoints include PFS, overall survival (OS), disease control rate (DCR), and quality of life (QoL). Safety will be monitored per NCI-CTCAE v4.0 criteria.

DISCUSSION

The RSF regimen represents a novel approach to third-line treatment in mCRC, integrating chemotherapy and targeted therapy to enhance tumor response while managing toxicity. By leveraging complementary mechanisms of action, this study aims to optimize therapeutic outcomes in heavily pretreated patients. Further clinical research is essential to validate efficacy, safety, and potential biomarkers for patient selection.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06427005, registered on 19 June 2024.

Inflammation, microbiota, and pancreatic cancer

Pancreatic cancer (PC) is a malignancy of gastrointestinal tract threatening the life of people around the world. In spite of the advances in the treatment of PC, the overall survival of this disease in advanced stage is less than 12%. Moreover, PC cells have aggressive behaviour in proliferation and metastasis as well as capable of developing therapy resistance. Therefore, highlighting the underlying molecular mechanisms in PC pathogenesis can provide new insights for its treatment. In the present review, inflammation and related pathways as well as role of gut microbiome in the regulation of PC pathogenesis are highlighted. The various kinds of interleukins and chemokines are able to regulate angiogenesis, metastasis, proliferation, inflammation and therapy resistance in PC cells. Furthermore, a number of molecular pathways including NF-κB, TLRs and TGF-β demonstrate dysregulation in PC aggravating inflammation and tumorigenesis. Therapeutic regulation of these pathways can reverse inflammation and progression of PC. Both chronic and acute pancreatitis have been shown to be risk factors in the development of PC, further highlighting the role of inflammation. Finally, the composition of gut microbiota can be a risk factor for PC development through affecting pathways such as NF-κB to mediate inflammation.

Clinical Progress of Fruquintinib in Colorectal Cancer: An Overview

Colorectal cancer (CRC) is one of the most common malignancies worldwide, with high morbidity and mortality rates. Conventional treatments, including surgery, radiotherapy, and chemotherapy, have limited effects on advanced and metastatic CRC (mCRC). Fruquintinib, a novel and highly selective vascular endothelial growth factor receptor (VEGFR) inhibitor, has shown significant efficacy and tolerance in treating mCRC. The FRESCO and FRESCO-2 trials demonstrated that fruquintinib significantly prolongs progression-free survival and the overall survival of refractory mCRC patients, establishing it as the standard third-line treatment strategy for mCRC. In addition, the combination of fruquintinib with other anticancer drugs and immune checkpoint inhibitors demonstrated potential for enhanced efficacy, which warrants further exploration. In this review, we aimed to systematically summarize the current knowledge about the pharmacological mechanisms, pharmacokinetic characteristics, adverse events, and corresponding treatment options of fruquintinib and provide an update on the clinical trials related to fruquintinib in CRC by conducting a comprehensive literature search of PubMed and consulting the relevant clinical trials via ClinicalTrials.gov and the ChiCTR website, aiming to offer new insights into the role of fruquintinib in the comprehensive treatment of CRC.

Potential of photon-counting detector CT technology for contrast medium reduction in portal venous phase thoracoabdominal CT

OBJECTIVES

To compare image quality and iodine attenuation intra-individually in portal venous phase photon-counting detector CT (PCD-CT) scans using protocols with different contrast medium (CM) volume.

MATERIALS AND METHODS

A prospectively acquired patient cohort between 04/2021 and 11/2023 was retrospectively screened if patients had the following combination of portal venous phase thoracoabdominal CT scans: (a) PCD-CT with 120 mL CM volume (PCD-CT120 mL), (b) PCD-CT with 100 mL CM volume (PCD-CT100 mL), and (c) prior energy-integrating detector CT (EID-CT) with 120 mL CM volume. On PCD-CT, virtual monoenergetic image (VMI) reconstructions at 70 keV were applied for both groups as well as additional VMI at 60 keV for PCD‑CT100 mL. Quantitative analyses including signal-to-noise (SNR) and contrast-to-noise ratios (CNR) and qualitative analyses were performed using a mixed linear effects model.

RESULTS

The final study cohort comprised 49 patients (mean age 67 [31-86] years, 12 female). Comparison to EID-CT was available in 33 patients. In standard 70 keV VMI reconstructions, PCD-CT100 mL was non-inferior to PCD-CT120 mL as well as to EID-CT120 mL for CNR in abdominal organs (all p > 0.050). The mixed linear effects model revealed significant differences between contrast volume groups for both contrast enhancement and image quality ratings. PCD-CT100 mL/70 keV demonstrated the smallest deviation from optimal contrast enhancement (-0.306, p < 0.001).

CONCLUSION

In portal venous phase thoracoabdominal PCD-CT, a nearly 17% reduction in CM was achievable while maintaining subjective and objective image quality compared to prior higher CM volume PCD-CT scans within the same patients and still surpassing image quality of previous exams on an EID-CT system.

KEY POINTS

Question How do image quality and iodine attenuation intra-individually compare in portal venous phase photon-counting detector CT (PCD-CT) scans using protocols with different contrast medium volume. Findings PCD-CT scans exhibit superior quantitative and qualitative image quality compared to energy-integrating detector-CT acquisitions and are not negatively affected by contrast volume reductions up to 17%. Clinical relevance This study provides further evidence that PCD-CT enables a considerable reduction in iodine dose for portal venous phase acquisition, benefiting both patients and healthcare system costs.