New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228-247. [PMID: 19097774 DOI: 10.1016/j.ejca.2008.10.026]

PET- and CT-Based Imaging Criteria for Response Assessment of Gastroenteropancreatic Neuroendocrine Tumors Under Radiopharmaceutical Therapy

Despite well-documented limitations, current guidelines recommend the use of size-based RECIST 1.1 for response assessment of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) under radiopharmaceutical therapy (RPT). We hypothesize that functional criteria are superior to RECIST 1.1 for response assessment and progression-free survival (PFS) prediction, and molecular scores can be used in prognosticating PFS. Methods: This single-center, retrospective study included 178 patients with GEP-NETs (G1 and G2) who were treated with at least 2 consecutive cycles of RPT with [177Lu]Lu-DOTATATE and who underwent somatostatin receptor PET/CT at baseline and after 2 cycles of RPT (follow-up). PFS was defined as the time between baseline and clinical progression, as reported by a GEP-NET multidisciplinary tumor board (MDT) assessment or reported death. The differences in categorization and PFS between RECIST 1.1, Choi (functional criteria), and the MDT were evaluated, and 3-y PFS with MDT defined PFS as the reference. The predictive values of the different scores in somatostatin receptor standardized reporting and data system and Krenning (molecular scores) for PFS were analyzed. Results: Choi criteria classified a higher number of patients as having progressive disease and partial response and a lower number of patients as having stable disease compared with RECIST 1.1 (P < 0.01). The PFS of patients with progressive disease according to RECIST 1.1 and Choi criteria was shorter than that of patients with stable disease and partial response (P < 0.05). Choi criteria showed a nonsignificantly higher concordance with the MDT than with RECIST 1.1. There was a shift in category from a Krenning score of 4 to a score of 3 between baseline and follow-up (P < 0.01). At baseline, a Krenning score of 3 was associated with a shorter median PFS compared with a score of 4 (P < 0.05). Conclusion: In addition to RECIST 1.1, further PET- and CT-based imaging criteria have the potential to assess response and predict PFS in patients with GEP-NETs undergoing RPT. Our data support the assumption to use Choi criteria for prediction of PFS and agreement in response assessment. At baseline, the Krenning score can be used to predict therapy response after 2 cycles of RPT.

Exceptional responses to systemic treatment in metastatic breast cancer: clinical features and long-term outcomes

BACKGROUND

Interest in metastatic solid tumors patients achieving exceptionally durable responses to systemic treatment is progressively increasing; however, available evidence still remains limited. This study characterizes patients with metastatic breast cancer (mBC) achieving an exceptional response, with a focus on patients discontinuing systemic treatment.

METHODS

In this retrospective monocentric study, patients with mBC achieving exceptional responses (2021-2023) were identified; clinical features, hormone receptor (HR) and HER2 status, and radiological responses were collected. Exceptional response was defined as complete (CR) or partial response (PR) lasting for more than twice the expected progression-free survival (PFS). No evidence of disease (NED) was defined as radiological absence of disease achieved integrating locoregional treatments.

RESULTS

We identified 58 exceptional responders: 31 HER2+ (53.5 %), 16 HR+ /HER2- (27.6 %), and 11 HR-/HER2- (19.0 %). 5-year PFS was 89.1 % and 5-year OS was 94.6 % overall, and numerically better in HR-/HER2- mBC (5-year PFS/OS: 100 %) compared to HER2+ (90.2 %/93.5 %) and HR+ /HER2- (80.8 %/93.8 %) mBC. Best radiological response was CR/NED in 69.0 % and PR in 31.0 % of patients. CR/NED status was significantly associated with better outcomes compared to PR (5-year OS: 100 % vs. 83.0 %, p = 0.004). Eleven patients (9 with CR/NED, 2 with PR) discontinued treatment in absence of disease progression; subsequent progression was observed only in one patient with PR.

CONCLUSION

mBC patients achieving exceptional responses exhibit favorable long-term survival outcomes, particularly if achieving CR/NED. These findings highlight the importance of further research to refine management strategies and explore the potential for systemic treatment discontinuation in these patients.

Validation and development of a refined M1 category for nasopharyngeal carcinoma based on the version-nine of AJCC/UICC TNM staging system in the immunotherapy era: A multicenter cohort study

OBJECTIVE

To evaluate the applicability of the M1 category of the version-nine of AJCC/UICC TNM staging system (TNM-9) for M1 nasopharyngeal carcinoma (M1-NPC) in immunotherapy era and propose potential refinements.

METHODS

M1-NPC patients who underwent palliative chemotherapy and immune checkpoint inhibitors (ICIs) between January 2019 and June 2023 across five institutions were included and re-staged according to TNM-9. Overall survival (OS) and Progression-free survival (PFS) were analyzed. A recursive partitioning analysis (RPA) model was employed to derive a new RPA-M1 category.

RESULTS

Among the 472 patients included, 219 were M1a and 253 were M1b. With a median follow-up time of 27 months, the M1a subgroup exhibited significantly higher 2-year OS (90.4 % vs. 73.7 %) and PFS (69.2 % vs. 40.6 %) than M1b subgroup (all P<0.001), which was further confirmed by multivariate analysis (MVA). Additionally, number of involved organs was found to be another independent predictor. New RPA-M1 category were then developed: RPA-M1a (≤3 metastatic lesions and confined to one single organ), RPA-M1b (≤3 metastatic lesions but involving multiple organs or >3 lesions and confined to one single organ), and RPA-M1c (patients with >3 metastatic lesions and involving multiple organs), with 2-year OS rates of 91.5 %, 81.4 %, and 69.8 %, respectively (P < 0.05) and PFS rates of 72.4 %, 54.3 % and 29.1 %, respectively (P < 0.005). Compared to the M1 Category in TNM-9, RPA-M1 category had a lower Akaike Information Criterion (AIC) and a higher concordance index (C-index) for OS and PFS.

CONCLUSION

The M1 category in the TNM-9 is applicable in the immunotherapy era. The RPA-M1 category offers improve depiction of survival outcomes compared to TNM-9, allowing for more refined stratification of patient outcomes and individulized decision-tailoring.

Efficacy and safety of routine corticosteroid premedication in enfortumab vedotin therapy for advanced urothelial carcinoma

OBJECTIVE

This study aims to evaluate the efficacy and safety of routine corticosteroid premedication with dexamethasone for preventing chemotherapy-induced nausea and vomiting (CINV) in patients receiving enfortumab vedotin (EV) for previously treated advanced urothelial carcinoma (UC). Furthermore, we assessed the impact of this strategy on treatment continuity and the incidence of dermatologic toxicities.

METHODS

We retrospectively analyzed 48 patients with unresectable or metastatic UC who received EV at our institution. All patients received 6.6 mg of intravenous dexamethasone prior to each EV infusion (1.25 mg/kg on Days 1, 8, and 15 of each 28-day cycle). Adverse events (AEs) were graded according to the National Cancer Institute Common Terminology Criteria for AEs version 5.0. Progression-free survival (PFS) and overall survival (OS) were evaluated using the Kaplan-Meier method, and factors influencing time to cutaneous toxicity onset were analyzed using Cox proportional hazards regression.

RESULTS

The median PFS was 4.6 months (95% CI: 3.5-10.8), and the median OS was 14.8 months (95% CI: 7.4-20.0). Grade 1-2 nausea was observed in six patients (14.6%), with no Grade ≥ 3 nausea reported. Dermatologic toxicity occurred in 13 patients (31.7%), all Grade 1-2, and none required systemic corticosteroid therapy. Patients with normal serum albumin levels experienced significantly earlier cutaneous toxicity onset compared with those with abnormal levels (p = 0.015). Treatment continuity was largely maintained, with minimal severe AEs leading to discontinuation. However, the study's single-center, retrospective design and small sample size may limit the generalizability of these findings, warranting further prospective validation.

CONCLUSION

Routine dexamethasone premedication in patients receiving EV was feasible and associated with a low incidence of severe nausea and cutaneous toxicity. While these findings suggest a potential role for corticosteroids in CINV control and cutaneous toxicity mitigation, the retrospective design and absence of a control group preclude definitive conclusions. Further prospective studies are needed to clarify the impact of corticosteroid premedication in this setting.

Comparative Evaluation of Volumetric-Modulated Arc Therapy and Intensity-Modulated Radiotherapy in Postoperative Breast Cancer Treatment

Aims/Background Breast cancer (BC) is one of the most prevalent malignancies among women globally, with postoperative radiotherapy playing a pivotal role in its multidisciplinary management. Volumetric-modulated arc therapy (VMAT) and intensity-modulated radiotherapy (IMRT) are advanced radiotherapy techniques that improve dose distribution uniformity within the target volume while minimizing damage to surrounding normal tissues. This study aimed to compare the effects of VMAT and IMRT on immune function and prognosis in postoperative BC patients, providing a scientific basis for clinical decision-making and optimizing BC treatment strategies. Methods Between January 2022 and January 2024, 265 postoperative BC patients who underwent radiotherapy with VMAT or IMRT at Nantong First People's Hospital were retrospectively analyzed. Based on the radiotherapy technique, patients were categorized into the VMAT group (129 cases) and the IMRT group (136 cases). The efficacies of the 2 radiotherapy techniques were compared by assessing overall radiotherapy effectiveness, levels of cancer biomarkers, levels of immune factors, quality of life and the incidence of adverse reactions. Results The overall objective response rate (ORR) and disease control rate (DCR) were significantly higher in the VMAT (75.97% and 93.80%, respectively) compared to the IMRT group (63.24% and 86.03%, respectively, p < 0.05). Serum levels of cancer antigen 15-3 (CA15-3), human epidermal growth factor receptor 2 (HER2), carcinoembryonic antigen (CEA), and interleukin-6 (IL-6) significantly decreased in both groups at 1-, 3-, and 6-month post-radiotherapy compared to levels immediately after radiotherapy (p < 0.05). Conversely, levels of interleukin-2 (IL-2) and interferon-α (IFN-α) demonstrated a significant increase over the same time points (p < 0.05). Notably, at 1-month post-radiotherapy, the VMAT group exhibited significantly lower serum levels of CA15-3, HER2, CEA, and IL-6 and significantly higher levels of IL-2 and IFN-α compared to the IMRT group (p < 0.05). Post-radiotherapy, quality of life (QoL) scores encompassing mental health, physical health, environmental conditions, and social relationships significantly improved in both groups compared to pre-radiotherapy levels (p < 0.05). However, no statistically significant differences in QoL were observed between the two groups after treatment (p > 0.05). The incidence of adverse reactions was significantly lower in the VMAT group (9.30%) compared to the IMRT (19.12%) group (p < 0.05). Conclusion VMAT and IMRT effectively improve cancer marker profiles, modulate immune factors, and enhance QoL in postoperative BC patients. VMAT exhibited superior efficacy, achieving higher ORR and DCR and a significant reduction in radiotherapy-related adverse reactions compared to IMRT. These findings highlight the advantages of VMAT in comprehensive BC treatment.

ChemoID-guided therapy improves objective response rate in recurrent platinum-resistant ovarian cancer randomized clinical trial

Patients with recurrent platinum-resistant ovarian cancer (PROC) have poor clinical outcomes, owing mainly to the presence of therapy-resistant cancer stem cells (CSCs). The NCT03949283 randomized clinical trial enrolled patients with recurrent PROC to receive ChemoID-guided chemotherapy or the best physician-choice regimen selected from the same list of thirteen mono or combination chemotherapies. The primary outcome was objective response rate (ORR) assessed on CT scans using the RECIST 1.1 criteria at 6 months follow-up. Subjects treated with the ChemoID assay had an ORR of 55% (CI95 39% - 73%), compared to 5% (CI95 0% - 11%) for those treated with physician's choice chemotherapy (p <0.0001). Secondary endpoints of duration of response (DOR) and progression-free survival (PFS) of subjects treated with chemotherapies guided by the ChemoID assay versus physician's choice chemotherapy were a median of 8 months vs. 5.5 months (p <0.0001), and 11.0 months (CI95 8.0- NA) vs 3.0 months (CI95 2.0- 3.5) with 27% of hazard ratio (CI95, 0.15-0.49; p <0.001), respectively.

FDG-PET associations with pathological response and survival with neoadjuvant immunotherapy for melanoma

BACKGROUND

Neoadjuvant immunotherapy has become the new standard of care for stage III melanoma. This study sought to describe the metabolic changes seen with fludeoxyglucose-18-positron emission tomography (FDG-PET) following neoadjuvant immunotherapy in patients with melanoma and explore associations with pathological response and recurrence-free survival (RFS).

METHODS

Data from patients with macroscopic stage III nodal melanoma treated with neoadjuvant checkpoint inhibitor therapy were pooled from five melanoma centers. All patients underwent baseline and preoperative FDG-PET and CT assessments, and all had surgery. Pathological response was determined using the International Neoadjuvant Melanoma Consortium criteria, radiological response using Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and FDG-PET response using European Organization for Research and Treatment of Cancer (EORTC) criteria. The primary endpoint was to explore the associations of metabolic and radiological responses with pathological response; secondary endpoints were RFS outcomes stratified by each response category.

RESULTS

115 patients were included, 69% male, median age 59 years (27-92), 43% BRAF mutant, and median follow-up was 22.2 months (95% CI 13.7 to 26.4). 40 patients received anti-PD-1 monotherapy, 20 patients received pembrolizumab combined with lenvatinib, and 55 patients received ipilimumab and nivolumab. The major pathological response (MPR) rate was 62%, and the pathological complete response rate was 51%. RECIST response underestimated pathological response; patients achieving RECIST stable disease (38%) had a 50% chance of achieving MPR. The FDG-PET metabolic response rate was 73%, with most achieving an MPR (80%), especially in patients with a complete metabolic response (CMR, 96% MPR). A small proportion of patients (10%) had stable metabolic disease on FDG-PET, and all these patients were non-MPR. Patients with progressive metabolic disease were also in the majority non-MPR (79%). Patients with MPR, complete response/partial response on CT, and CMR/partial metabolic response on FDG-PET had a favorable 24-month RFS (95.6%, 97.3%, and 93.7%, respectively), with FDG-PET able to identify a greater proportion of patients with favorable progression-free survival (PFS) than pathology or CT (73%, 62%, and 43%, respectively).

CONCLUSION

Neoadjuvant immunotherapy has high FDG-PET response rates in melanoma. FDG-PET response associates with pathological response and confers impressive RFS, suggesting this could be an important clinical tool.

Subcutaneous Versus Intravenous Pembrolizumab, in Combination With Chemotherapy, for Treatment of Metastatic Non-Small Cell Lung Cancer: The Phase 3 3475A-D77 Trial

BACKGROUND

Pembrolizumab with berahyaluronidase alfa is for subcutaneous (SC) administration. The phase 3 open-label 3475A-D77 study (NCT05722015) assessed SC pembrolizumab versus intravenous (IV) pembrolizumab, plus chemotherapy, for treatment of metastatic non-small-cell lung cancer (mNSCLC).

PARTICIPANTS AND METHODS

Participants with newly diagnosed stage IV squamous or nonsquamous NSCLC without sensitizing EGFR, ALK, or ROS1 alterations were randomized 2:1 to pembrolizumab SC 790 mg every 6 weeks (Q6W) or pembrolizumab IV 400 mg Q6W (18 cycles), each given with platinum doublet chemotherapy. Dual primary endpoints were pharmacokinetics exposure measures of cycle 1 area-under-the-curve (AUC0-6wks) and steady-state trough concentration (Ctrough) of pembrolizumab. The noninferiority margin for AUC0-6wks and Ctrough geometric mean ratios (GMR) of pembrolizumab SC versus IV was specified as 0.8. Secondary endpoints included additional pharmacokinetics exposure measures, pembrolizumab immunogenicity, efficacy, and safety.

RESULTS

377 participants were randomized to the pembrolizumab SC (n=251) or IV (n=126) arms. Median time from randomization to data cutoff (12Jul2024) was 9.6 months (range 6.2-16.4). Median injection time for pembrolizumab SC was 2.0 minutes (range 1-12). The GMR (96% CI) for cycle 1 AUC0-6wks was 1.14 (1.06-1.22); P<0.0001. The GMR (94% CI) for steady-state Ctrough was 1.67 (1.52-1.84); P<0.0001. Secondary pharmacokinetics endpoints were within established bounds for pembrolizumab. Anti-pembrolizumab antibodies were detected in 1.4% (pembrolizumab SC arm) and 0.9% (pembrolizumab IV arm) of participants. For the pembrolizumab SC versus IV arms, objective response rates were 45.4% vs 42.1% (ORR ratio 1.08, 95% CI 0.85-1.37). Other efficacy measures were similar and safety profiles were consistent between treatment arms.

CONCLUSIONS

Overall exposure and trough concentrations of pembrolizumab SC 790 mg Q6W were noninferior to those of pembrolizumab IV 400 mg Q6W given with chemotherapy in participants with treatment-naïve mNSCLC. Results support pembrolizumab SC as a treatment option in all indications where pembrolizumab IV can be used.

Evaluating the prognostic significance of the pre-treatment neutrophil-to-lymphocyte and monocyte-to-lymphocyte ratios in 177Lu-DOTATATE PRRT treated patients with advanced metastatic neuroendocrine tumors

PURPOSE

This study aimed to investigate the role of pre-treatment neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) in the prognosis assessment of 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy (PRRT) treated patients with advanced metastatic neuroendocrine tumors (NETs).

METHODS

Eligible PRRT-treated patients (n = 247, 2010-2019) were included. Pre-PRRT NLR and MLR were calculated from complete blood count data. Data on tumor characteristics, response to PRRT, progression-free survival (PFS), and overall survival (OS) were evaluated using COXPH analyses.

RESULTS

In NET patients, median values of NLR and MLR were 2.21 (IQR = 1.66-3.00) and 0.14 (IQR = 0.06-0.24), respectively. NLR showed significant positive association with G3 tumors (median = 3.64, IQR = 2.1-4.26, p = 0.022) and high 18F-FDG avidity (SUVmax>5) (median = 2.5, IQR = 1.82-3.56, p = 0.003). MLR was significantly associated with high disease burden (median = 0.18, IQR = 0.08-0.29, p = 0.0083). MLR distinguished between the PRRT non-responders with progressive disease and responders with complete/partial response (median 0.19 versus 0.12, p = 0.043) or responders with stable disease (median 0.19 versus 0.14, p = 0.045). The ratios independently correlated with disease progression and OS. Patients in NLRhigh (>3.5) group displayed significantly shorter median PFS and OS (48 and 58 months) compared to NLRlow (≤3.5) group (108 and 96 months) (p < 0.01). Patients in MLRhigh (>0.25) group displayed significantly shorter median PFS and OS (40 and 52 months) compared to MLRlow (≤0.25) group (108 and 102 months) (p < 0.01).

CONCLUSION

Pre-treatment NLR and MLR had an independent prognostic impact on disease progression and OS in PRRT-treated NET patients. This routine, inexpensive CBC-based test in the standard pre-PRRT workup demonstrates the prognostic value and may aid clinicians in the risk stratification of NET patients.

[18F]FluorThanatrace PET imaging as a biomarker of response to PARP inhibitors in breast cancer

BACKGROUND

Poly (ADP-ribose) polymerase inhibitors (PARPi) are approved for Breast Cancer gene (BRCA)-mutant HER2- breast cancer, and there is clinical interest in expanding indications to include homologous recombination deficient (HRD) breast cancers. Yet, response in these populations remains variable, suggesting clinical utility in developing a better biomarker to select patients for PARPi and predict response. Here, we evaluate a radiolabeled PARPi, [18F]FluorThanatrace ([18F]FTT), as a functional biomarker of PARPi response in breast cancer.

METHODS

A single-arm prospective observational trial was conducted at the University of Pennsylvania. [18F]FTT-PET uptake was measured in 24 women with untreated primary breast cancer and correlated with tumor HRD score. In a separate cohort of ten subjects with metastatic HER- breast cancer, [18F]FTT-PET uptake was measured at baseline and after a short interval on a PARPi (a measure of drug-target engagement) and correlated to progression free survival (PFS).

RESULTS

Here we show that baseline [18F]FTT-PET uptake does not correlate to HRD tissue score, supporting that [18F]FTT provides distinct information from genetic features. Baseline [18F]FTT-PET uptake and the change in uptake from baseline to after PARPi initiation significantly correlates to PFS in woman with breast cancer who received a PARPi (ρ = 0.74, P = 0.023 and ρ = -0.86, P = 0.012, respectively).

CONCLUSIONS

These early results suggest the potential of [18F]FTT-PET to select patients for PARPi treatment and monitor in vivo pharmacodynamics after therapy start. Absence of association with HRD scores supports [18F]FTT uptake as a novel measure that may be leveraged as a biomarker. Further studies are warranted.

Circulating tumor DNA to monitor treatment response in solid tumors and advance precision oncology

Circulating tumor DNA (ctDNA) has emerged as a dynamic biomarker in cancer, as evidenced by its increasing integration into clinical practice. Carrying tumor specific characteristics, ctDNA can be used to inform treatment selection, monitor response, and identify drug resistance. In this review, we provide a comprehensive, up-to-date summary of ctDNA in monitoring treatment response with a focus on lung, colorectal, and breast cancers, and discuss current challenges and future directions.

Next-generation sequencing for guiding matched targeted therapies in people with relapsed or metastatic cancer

BACKGROUND

Matched targeted therapies (MTT) given alone or in combination with systemic anti-cancer therapies have delivered proven survival benefit for many people with newly diagnosed cancer. However, there is little evidence of their effectiveness in the recurrent or late-stage setting. With this uncertainty, alongside the perception that late-stage cancers are too genetically heterogenous or too mutationally diverse to benefit from matched targeted therapies, next-generation sequencing (NGS) of tumours in people with refractory cancer remains a low priority. As a result, next-generation sequencing testing of recurrent or late-stage disease is discouraged. We lack evidence to support the utility of next generation sequencing in guiding matched targeted therapies in this setting.

OBJECTIVES

To evaluate the benefits and harms of matched targeted therapies in people with advanced cancers in randomised controlled trials.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organisation International Clinical Trials Registry Platform (WHO-ICTRP) search portal up to 30th October 2024. We also screened reference lists of included studies and also the publications that cited these studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that had enroled participants with advanced/refractory solid or haematological cancers who had progressed through at least one line of standard anti-cancer systemic therapy. To be eligible, all participants should have received matched targeted therapy based on next-generation sequencing carried out on their tumour (tumour tissue, blood or bone marrow).

DATA COLLECTION AND ANALYSIS

We systematically searched medical databases (e.g. MEDLINE, Embase) and trial registers for randomised controlled trials (RCTs). Outcomes of interest were progression-free survival (PFS), overall survival (OS), overall response rates (ORR), serious (grade 3 or 4) adverse events (AEs) and quality of life (QOL). We used a random-effects model to pool outcomes across studies and compared predefined subgroups using interaction tests. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment of certainty was used to evaluate the quality of evidence.

MAIN RESULTS

We identified a total of 37 studies, out of which 35 studies (including 9819 participants) were included in the meta-analysis. All included studies compared a matched targeted therapy intervention to standard-of-care treatment, non-matched targeted therapies or no treatment (best supportive care): Matched targeted therapy versus standard-of-care treatment Matched targeted therapy (MTT) compared with standard systematic therapy probably reduces the risk of disease progression by 34% (hazard ratio (HR) = 0.66, 95% confidence interval (CI) 0.59 to 0.74; 14 studies, 3848 participants; moderate-certainty evidence). However, MTT might have little to no difference in risk of death (HR = 0.85, 95% CI 0.75 to 0.97; 14 studies, 3848 participants; low-certainty evidence) and may increase overall response rates (low-certainty evidence). There was no clear evidence of a difference in severe (grade 3/4) adverse events between matched targeted therapy and standard-of-care treatment (low-certainty evidence). There was limited evidence of a difference in quality of life between groups (very low-certainty of evidence). Matched targeted therapy in combination with standard-of-care treatment versus standard-of-care treatment alone Matched targeted therapy in combination with standard-of-care treatment compared with standard-of-care treatment alone probably reduces the risk of disease progression by 39% (HR = 0.61, 95% CI 0.53-0.70, 14 studies, 2,637 participants; moderate-certainty evidence) and risk of death by 21% (HR = 0.79, 95% CI 0.70 to 0.89; 11 studies, 2575 participants, moderate-certainty evidence). The combination of MTT and standard-of-care treatment may also increase overall response rates (low-certainty evidence). There was limited evidence of a difference in the incidence of severe adverse events (very low-certainty evidence) and quality of life between the groups (very low-certainty of evidence). Matched targeted therapy versus non-matched targeted therapy Matched targeted therapy compared with non-matched targeted therapy probably reduces the risk of disease progression by 24% (HR = 0.76, 95% CI 0.64 to 0.89; 3 studies, 1568 participants; moderate-certainty evidence) and may reduce the risk of death by 25% (HR = 0.75, 95% CI 0.65 to 0.86, 1307 participants; low-certainty evidence). There was little to no effect on overall response rates between MTT and non-MTT. There was no clear evidence of a difference in overall response rates (low-certainty evidence) and severe adverse events between MTT and non-MTT (low-certainty evidence). None of the studies comparing MTT and non-MTT reported quality of life. Matched targeted therapy versus best supportive care Matched targeted therapy compared with the best supportive care (BSC) i.e. no active treatment probably reduces the risk of disease progression by 63% (HR 0.37, 95% CI 0.28 to 0.50; 4 studies, 858 participants; moderate-certainty evidence). There was no clear evidence of a difference in overall survival between groups (HR = 0.88, 95% CI 0.73 to 1.06, 3 studies, 783 participants; low-certainty evidence). There was no clear evidence of a difference in overall response rates (very low-certainty of evidence) and incidence of severe adverse events (very low-certainty of evidence) between the groups. Quality of life was reported in a single study but did not provide composite scores. Risk of bias The overall risk of bias was judged low for eight studies, unclear for two studies, and the remaining 27 studies were high risk.

AUTHORS' CONCLUSIONS

Matched targeted therapies guided by next-generation sequencing in people with advanced cancer prolongs the time before cancer progresses compared to standard therapies. However, there is limited evidence to suggest that it prolongs overall survival, improves the quality of life or increases adverse events. Importantly, this review supports equitable access to next-generation sequencing technology for all people with advanced cancer and offers them the opportunity to access genotype-matched targeted therapies.

Multi-cohort study in gastric cancer to develop CT-based radiomic models to predict pathological response to neoadjuvant immunotherapy

BACKGROUND

Neoadjuvant immunotherapy has been shown to improve survival in patients with gastric cancer. This study sought to develop and validate a radiomics-based machine learning (ML) model for patients with locally advanced gastric cancer (LAGC), specifically to predict whether patients will achieve a major pathological response (MPR) following neoadjuvant immunotherapy. With its predictive capabilities, this tool shows promise for enhancing clinical decision-making processes in the future.

METHODS

This study utilized a multicenter cohort design, retrospectively gathering clinical data and computed tomography (CT) images from 268 patients diagnosed with advanced gastric cancer who underwent neoadjuvant immunotherapy between January 2019 and December 2023 from two medical centers. Radiomic features were extracted from CT images, and a multi-step feature selection procedure was applied to identify the top 20 representative features. Nine ML algorithms were implemented to build prediction models, with the optimal algorithm selected for the final prediction model. The hyperparameters of the chosen model were fine-tuned using Bayesian optimization and grid search. The performance of the model was evaluated using several metrics, including the area under the curve (AUC), accuracy, and Cohen's kappa coefficient.

RESULTS

Three cohorts were included in this study: the development cohort (DC, n = 86), the internal validation cohort (IVC, n = 59), and the external validation cohort (EVC, n = 52). Nine ML models were developed using DC cases. Among these, an optimized Bayesian-LightGBM model, demonstrated robust predictive performance for MPR following neoadjuvant immunotherapy in LAGC patients across all cohorts. Specifically, within DC, the LightGBM model attained an AUC of 0.828, an overall accuracy of 0.791, a Cohen's kappa coefficient of 0.552, a sensitivity of 0.742, a specificity of 0.818, a positive predictive value (PPV) of 0.586, a negative predictive value (NPV) of 0.867, a Matthews correlation coefficient (MCC) of 0.473, and a balanced accuracy of 0.780. Comparable performance metrics were validated in both the IVC and the EVC, with AUC values of 0.777 and 0.714, and overall accuracies of 0.729 and 0.654, respectively. These results suggested good fitness and generalization of the Bayesian-LightGBM model. Shapley Additive Explanations (SHAP) analysis identified significant radiomic features contributing to the model's predictive capability. The SHAP values of the features wavelet.LLH_gldm_SmallDependenceLowGrayLevelEmphasis, wavelet.HHL_glrlm_RunVariance, and wavelet.LLH_glszm_LargeAreaHighGrayLevelEmphasis were ranked among the top three, highlighting their significant contribution to the model's predictive performance. In contrast to existing radiomic models that exclusively focus on neoadjuvant chemotherapy, our model integrates both neoadjuvant immunotherapy and chemotherapy, thereby offering more precise predictive capabilities.

CONCLUSION

The radiomics-based ML model demonstrated significant efficacy in predicting the pathological response to neoadjuvant immunotherapy in LAGC patients, thereby providing a foundation for personalized treatment strategies.

Functional combinatorial precision medicine for predicting and optimizing soft tissue sarcoma treatments

Soft tissue sarcomas (STS) are rare, heterogeneous tumors with poor survival outcomes, primarily due to reliance on cytotoxic chemotherapy and lack of targeted therapies. Given the uniquely individualized nature of STS, we hypothesized that the ex vivo drug sensitivity platform, quadratic phenotypic optimization platform (QPOP), can predict treatment response and enhance combination therapy design for STS. Using QPOP, we screened 45 primary STS patient samples, and showed improved or concordant patient outcomes that are attributable to QPOP predictions. From a panel of approved and investigational agents, QPOP identified AZD5153 (BET inhibitor) and pazopanib (multi-kinase blocker) as the most effective combination with superior efficacy compared to standard regimens. Validation in a panel of established patient lines and in vivo models supported its synergistic interaction, accompanied by repressed oncogenic MYC and related pathways. These findings provide preliminary clinical evidence for QPOP to predict STS treatment outcomes and guide the development of novel therapeutic strategies for STS patients.

Stereotactic Radiosurgery and Surgical Resection for Jugular Foramen Schwannomas: A Retrospective Comparative Study of Outcomes

BACKGROUND AND OBJECTIVES

Jugular foramen schwannomas (JFS) are rare benign tumors arising from lower cranial nerves. In this study, we aim to compare the outcomes of surgical resection (SR) and stereotactic radiosurgery (SRS) in the treatment of JFS.

METHODS

We conducted a retrospective analysis of 31 patients with JFS who underwent SRS (13 patients [41.9%]) or surgical resection (18 patients [58.1%]) as their primary management modality over a two-decade period. Outcomes included progression-free survival, post-treatment adverse events based on Common Terminology Criteria for Adverse Events, symptom improvement, overall survival, and the necessity for secondary interventions. Local tumor control was also evaluated in all patients who received SRS.

RESULTS

Significant differences were observed in baseline characteristics between the SRS and SR groups, including median age (58 vs 48 years, P = .001), largest tumor diameter (32.0 vs 47.5 mm, P = .02), and total tumor volume (6.50 vs 20.5 mm3, P = .01). There were no significant differences in sex or lesion morphology (dumbbell vs nondumbbell shaped). After adjusting for baseline characteristics, no significant differences were noted in progression-free survival (90.9 vs 86.2%), overall survival (92.3 vs 100%), symptom improvement (61.5 vs 55.5%), or median Common Terminology Criteria for Adverse Events grade (1 in both groups) between the SRS and SR groups, respectively. SRS patients had significantly lower odds of requiring secondary treatment procedures after their primary intervention as compared with those who underwent SR (odds ratio = 0.02, 95% CI: 0.001-0.88, P-value = .04). Local tumor control in all SRS patients (19 patients) was 93.7% and 79.1% at six-month and five-year time points, respectively.

CONCLUSION

SRS and SR demonstrate comparable effectiveness in treating JFS. However, SRS may be a more favorable option because of a reduced need for secondary interventions. Future controlled prospective studies are needed to draw more definitive conclusions.

The prognostic role of circulating CA19-9 and CEA in patients with colorectal cancer

BACKGROUND

Carcinoembryonic antigen (CEA) is the only prognostic circulating biomarker used in clinical practice for recurrence free (RFS), progression free (PFS) and overall survival (OS) in patients with colorectal cancer (CRC). Not all CRC tumors express this protein and carbohydrate antigen (CA)19-9 has been proposed as an adjunctive in prognostication. We aimed to test if CA19-9 yielded additional information to CEA regarding prognosis.

PATIENTS AND METHODS

We included 886 patients with CRC across eight clinical cohorts. Preoperative serum samples were collected from 376 patients with stage I-III CRC and from 510 with metastatic (m)CRC before 1st (n = 233), 3rd (n = 178) and 3rd/4th (n = 99) line chemotherapy. CA19-9 and CEA were determined by routine assays, the values were log-2 transformed and entered as variables in Cox regression models with RFS (stage I-III), PFS and OS as the outcomes, adjusted for age, sex, and site of primary tumor and mutual adjustment between CA199 and CEA. Random effects meta-analyses were conducted for stage I-III,1st line, and 3rd/4th line mCRC cohorts separately.

RESULTS

Meta-analyses showed that higher pre-treatment CA19-9 and CEA were associated with shorter RFS (CA19-9: hazard ratio per doubling of concentration (HR)=1.20, 95 % confidence interval (CI) 1.05-1.38; CEA: HR=1.22, 95 % CI 1.05-1.41) in stage I-III CRC. Only higher CEA was associated with shorter OS in 1st line mCRC (HR=1.07, 95 % CI 1.00-1.07).

CONCLUSION

CA19-9 might aid in identifying patients with a high risk of recurrence after primary radical resection. Further studies are needed to validate these findings.

Role of radiomics in predicting early disease recurrence in locally advanced breast cancer patients: integration of radiomic features and RECIST criteria

BACKGROUND

Breast cancer (BC) is a major global health issue with significant heterogeneity among its subtypes. Neoadjuvant treatment (NAT) has been extended to include early BC patients, particularly those with HER2 + and triple-negative subtypes, to achieve pathological complete response and improve long-term outcomes. However, disease recurrence remains a challenge, highlighting the need for predictive biomarkers. This study evaluates the role of radiomics from pre-treatment breast MRI, integrated with clinical and radiological variables, in predicting early disease recurrence (EDR) after NAT.

METHODS

A retrospective analysis was conducted on 238 BC patients treated with NAT and assessed using pre- and post-treatment breast MRI. Radiomic features were extracted and combined with clinical and radiological data to develop predictive models for EDR. Models were evaluated using AUC, accuracy, sensitivity, and specificity metrics.

RESULTS

The radiological-radiomic model, which integrated pre-treatment MRI radiomics with RECIST response data, demonstrated the highest predictive performance for EDR (AUC 0.77, sensitivity 0.85). Internal validation confirmed the robustness of the model.

CONCLUSION

Combining radiomic features from pre-NAT MRI with RECIST response evaluation from post-NAT MRI enhances the prediction of EDR in BC patients, supporting precision medicine in treatment strategies and follow-up planning. Further validation on larger cohorts is needed to confirm these findings.

Long-term results of dynamic tumor-tracking stereotactic body radiotherapy with real-time monitoring using a gimbal-mounted linac for liver tumors: a multicenter observational study

BACKGROUND

Despite advancements in liver tumor treatments, a persistent need remains for minimally invasive therapies with high efficacy and long-term outcomes. In a previous multicenter phase II study, the safety and efficacy of dynamic tumor-tracking stereotactic body radiotherapy with real-time monitoring of liver tumors were evaluated using a gimbal-mounted system. Herein, we report the updated long-term results of this technique.

METHODS

This observational study examined patients with a single liver tumor, respiratory movement of at least 10 mm, performance status of 0-2, and Child-Pugh score of < 9. Patients who agreed to participate in the trial underwent dynamic tumor-tracking stereotactic body radiotherapy (prescribed dose, 40 Gy in five fractions for the planning target volume [D95]; 70% of the maximum dose). The primary endpoint was the 4-year overall survival rate. Secondary endpoints included 4-year local control and progression-free survival rates and the incidence of adverse events.

RESULTS

Between September 2015 and March 2019, 48 patients (median age, 74 years; median tumor diameter, 17.5 mm) underwent dynamic tumor-tracking stereotactic body radiotherapy. All lesions were successfully treated (hepatocellular carcinoma, 39 patients; liver metastases, 9 patients). The median observation period was 46 months, and the 4-year overall survival, local control, and progression-free survival rates were 67.4%, 97.9%, and 29.1%, respectively. Eight patients had grade 3 hepatobiliary enzyme elevation, hematologic toxicity, or hyponatremia; none had grade ≥ 4 adverse events.

CONCLUSION

These findings demonstrate the long-term safety and efficacy of dynamic tumor-tracking stereotactic body radiotherapy for liver tumors, with an excellent local control rate.

DNA damage response signatures are associated with frontline chemotherapy response and routes of tumor evolution in extensive stage small cell lung cancer

INTRODUCTION

A hallmark of small cell lung cancer (SCLC) is its recalcitrance to therapy. While most SCLCs respond to frontline therapy, resistance inevitably develops. Identifying phenotypes potentiating chemoresistance and immune evasion is a crucial unmet need. Previous reports have linked upregulation of the DNA damage response (DDR) machinery to chemoresistance and immune evasion across cancers. However, it is unknown if SCLCs exhibit distinct DDR phenotypes.

METHODS

To study SCLC DDR phenotypes, we developed a new DDR gene analysis method and applied it to SCLC clinical samples, in vitro, and in vivo model systems. We then investigated how DDR regulation is associated with SCLC biology, chemotherapy response, and tumor evolution following therapy.

RESULTS

Using multi-omic profiling, we demonstrate that SCLC tumors cluster into three DDR phenotypes with unique molecular features. Hallmarks of these DDR clusters include differential expression of DNA repair genes, increased replication stress, and heightened G2/M cell cycle arrest. SCLCs with elevated DDR phenotypes exhibit increased neuroendocrine features and decreased "inflamed" biomarkers, both within and across SCLC subtypes. Clinical analyses demonstrated treatment naive DDR status was associated with different responses to frontline chemotherapy. Using longitudinal liquid biopsies, we found that DDR Intermediate and High tumors exhibited subtype switching and coincident emergence of heterogenous phenotypes following frontline treatment.

CONCLUSIONS

We establish that SCLC can be classified into one of three distinct, clinically relevant DDR clusters. Our data demonstrates that DDR status plays a key role in shaping SCLC phenotypes and may be associated with different chemotherapy responses and patterns of tumor evolution. Future work targeting DDR specific phenotypes will be instrumental in improving patient outcomes.

Phase II Trial of Risk-Enabled Therapy After Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer (RETAIN 1)

PURPOSE

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by cystectomy is the standard of care for patients with muscle-invasive bladder cancer (MIBC). Mutations in DNA damage repair genes are associated with pathologic downstaging after NAC. We hypothesized that a combination of biomarker selection and clinical staging would identify patients for cystectomy-sparing active surveillance (AS).

PATIENTS AND METHODS

We conducted a single-arm, phase II, noninferiority trial to evaluate a risk-adapted approach for MIBC. Patients with cT2-T3N0M0 MIBC underwent NAC with accelerated methotrexate, vinblastine, doxorubicin, and cisplatin (AMVAC). Pre-NAC transurethral bladder tumor specimens were sequenced for mutations in ATM, ERCC2, FANCC, and RB1. Patients with ≥1 mutation and cT0 post-NAC began AS. The primary end point was metastasis-free survival (MFS) at 2 years for the entire cohort with the null hypothesis rejected if the lower bound exact one-sided 95% CI exceeds 64%.

RESULTS

Seventy patients were enrolled, 33 (47%) had a mutation, and 25 (36%) began per-protocol AS. With a median follow-up of 40 months, the 2-year MFS for all patients was 72.9% (lower bound exact one-sided 95% CI, 62.8). The 2-year MFS was 76.0% in the AS group (95% CI, 54.2 to 88.4) and 71.1% (95% CI, 55.5 to 82.1) in the remaining patients. In the AS group, 17 patients (68%) had some recurrence and 12 (48%) were metastasis-free with an intact bladder. The 2-year overall survival (OS) was 84.3% (95% CI, 73.4 to 91.0); OS was 88.0% (95% CI, 67.3 to 96.0) and 82.2% (95% CI, 67.6 to 90.7) in the AS and not-AS groups, respectively.

CONCLUSION

Patients with MIBC treated with AMVAC followed by a risk-adapted approach to local consolidation achieved a 2-year MFS rate of 73%. The primary end point was not met, but 17% of all enrolled patients and 48% of the AS group avoided cystectomy without metastatic disease.

Whole genome sequencing of 378 prostate cancer metastases reveals tissue selectivity for mismatch deficiency with potential therapeutic implications

BACKGROUND

Survival of patients with metastatic castration-resistant prostate cancer (mCRPC) depends on the site of metastatic dissemination.

METHODS

Patients with mCRPC were prospectively included in the CPCT-02 metastatic site biopsy study. We evaluated whole genome sequencing (WGS) of 378 mCRPC metastases to understand the genetic traits that affect metastatic site distribution.

RESULTS

Our findings revealed that RB1, PIK3CA, JAK1, RNF43, and TP53 mutations are the most frequent genetic determinants associated with site selectivity for metastatic outgrowth. Furthermore, we explored mutations in the non-coding genome and found that androgen receptor (AR) chromatin binding sites implicated in metastatic prostate cancer differ in mutation frequencies between metastatic sites, converging on pathways that impact DNA repair. Notably, liver and visceral metastases have a higher tumor mutational load (TML) than bone and lymph node metastases, independent of genetic traits associated with neuroendocrine differentiation. We found that TML is strongly associated with DNA mismatch repair (MMR)-deficiency features in these organs.

CONCLUSIONS

Our results revealed gene mutations that are significantly associated with metastatic site selectivity and that frequencies of non-coding mutations at AR chromatin binding sites differ between metastatic sites. Immunotherapeutics are thus far unsuccessful in unselected mCRPC patients. We found a higher TML in liver and visceral metastases compared to bone and lymph node metastases. As immunotherapeutics response is associated with mutational burden, these findings may assist in selecting mCRPC patients for immunotherapy treatment based on organs affected by metastatic disease.

TRIAL REGISTRATION NUMBER

NCT01855477.

Acquired resistance to immune checkpoint therapy is caused by glycoprotein non-metastatic melanoma protein B signal cascade

BACKGROUND

Acquired resistance (AR) is a major limitation of immune checkpoint inhibitor (ICI) therapy when treating renal cell carcinoma (RCC). Understanding who will get AR is currently unknown. We hypothesized the T-cell-inhibitory glycoprotein non-metastatic melanoma protein B (GPNMB) to be a prognostic marker for patients with AR.

METHODS

Alongside other markers, GPNMB was measured in the blood of RCC patients (n = 39) several times after starting ICI treatment and analyzed for association with Response Evaluation Criteria in Solid Tumors (RECIST) tumor response. To better understand the role of GPNMB in AR, we created an ICI-resistant RenCa mouse kidney cancer model by repeatedly selecting the largest tumors that grew in ICI-treated mice.

RESULTS

Here we show that among patients who positively respond to ICI, a subset of patients (n = 9) acquire resistance within 2 years that coincides with an increase in serum GPNMB. Our mouse model recapitulates this elevation in GPNMB at the onset of AR which is triggered by cytoplasmic motif signaling via the Programmed cell death ligand 1 (PDL1) receptor that is known to protect tumors from Interferon-gamma (IFN-γ) cytotoxicity. This PDL1-induced signal leads to upregulation of the SRY-box transcription factor 10 (SOX10), dysregulation of the microphthalmia-associated transcription factor (MITF) pathway, and overexpression of GPNMB. Indeed, activation of SOX10-MITF signaling is present in plasma cell-free RNA from RCC patients who develop AR.

CONCLUSIONS

Elevation of the SOX10-MITF-GPNMB signal cascade via the PDL1 receptor leads to AR. Therefore, GPNMB can be both a prognosticator of and a potential treatment target for overcoming AR to ICI treatment in RCC.

First-Line Lenvatinib Plus Pembrolizumab Versus Chemotherapy for Advanced Endometrial Cancer: A Randomized, Open-Label, Phase III Trial

PURPOSE

Lenvatinib plus pembrolizumab (len + pembro) significantly improved progression-free survival (PFS) and overall survival (OS) versus chemotherapy in previously treated advanced or recurrent endometrial cancer (aEC) in the phase III Study 309/KEYNOTE-775. We report results from the phase III, randomized, open-label European Network of Gynaecological Oncological Trial-en9/LEAP-001 study (ClinicalTrials.gov identifier: NCT03884101) that evaluated len + pembro versus chemotherapy in first-line aEC.

METHODS

Patients with stage III to IV or recurrent, radiographically apparent EC and no previous chemotherapy or disease progression ≥6 months after neo/adjuvant platinum-based chemotherapy were randomly assigned 1:1 to lenvatinib 20 mg once daily plus pembrolizumab 200 mg once every 3 weeks or paclitaxel 175 mg/m2 plus carboplatin AUC 6 mg/mL/min once every 3 weeks. Primary end points were PFS and OS, evaluated in the mismatch repair-proficient (pMMR) and all-comers populations. Noninferiority was assessed for OS at final analysis (FA) for len + pembro versus chemotherapy (multiplicity-adjusted, one-sided nominal alpha, .0159; null hypothesis-tested hazard ratio [HR], 1.1).

RESULTS

Eight hundred forty-two patients were randomly assigned (len + pembro, n = 420 [pMMR population, n = 320]; chemotherapy, n = 422 [pMMR population, n = 322]). At FA (data cutoff, October 2, 2023), median PFS (95% CI) in the pMMR population was 9.6 (8.2 to 11.9) versus 10.2 (8.4 to 10.5) months with len + pembro versus chemotherapy (hazard ratio [HR], 0.99 [95% CI, 0.82 to 1.21]) and among all-comers was 12.5 (10.3 to 15.1) versus 10.2 (8.4 to 10.4) months (HR, 0.91 [95% CI, 0.76 to 1.09]; descriptive analyses). Median OS (95% CI) in the pMMR population was 30.9 (25.4 to 37.7) versus 29.4 (26.2 to 35.4) months with len + pembro versus chemotherapy (HR, 1.02 [95% CI, 0.83 to 1.26]; noninferiority P = .246, not statistically significant per multiplicity control strategy) and among all-comers was 37.7 (32.2 to 43.6) versus 32.1 (27.2 to 35.7) months (HR, 0.93 [95% CI, 0.77 to 1.12]). Grade ≥3 treatment-related adverse events occurred in 331/420 (79%) versus 274/411 (67%) treated patients.

CONCLUSION

First-line len + pembro did not meet prespecified statistical criteria for PFS or OS versus chemotherapy in pMMR aEC.

Intra-arterial lidocaine improves long-term survival in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolisation: a retrospective propensity score-matched study

BACKGROUND

Lidocaine, the most widely used local anaesthetic, has anticancer effects in both laboratory findings and retrospective clinical studies. We explored the potential benefits of intra-arterial lidocaine on long-term survival in patients with hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolisation (TACE).

METHODS

This retrospective cohort study included patients with HCC who received TACE as initial treatment from August 2011 to October 2016. Eligible patients were categorised into no lidocaine and lidocaine groups. Propensity score matching was undertaken. Progression-free survival (PFS) and overall survival were compared between the two groups. Subgroup analysis was performed to explore the survival benefit of combining intra-arterial lidocaine with platinum-based chemotherapy during TACE.

RESULTS

Of 374 eligible patients, 96 were in the lidocaine group and 278 were in the no lidocaine group. Survival analysis showed that intra-arterial lidocaine was associated with longer PFS (P=0.004) and overall survival (P<0.001). After propensity score matching, PFS (P<0.001) and overall survival (P=0.001) benefits of lidocaine remained. Multivariate analysis showed that intra-arterial lidocaine was an independent prognostic factor for PFS (P=0.011) and overall survival (P=0.044). The impact of intra-arterial lidocaine was similar in patients receiving the TACE regimen with platinum (PFS: P=0.014; overall survival: P=0.023).

CONCLUSIONS

Intra-arterial lidocaine might improve long-term survival in patients with HCC undergoing TACE and in the subgroup of patients receiving platinum. The study highlights the potential antitumour benefits of combining lidocaine and chemotherapeutics in patients with cancer.

CRES3T: A single-arm confirmatory trial of S-1 plus cisplatin with concurrent radical-dose radiotherapy followed by surgery for superior sulcus tumors

PURPOSE

This multicenter single-arm confirmatory trial (CRES3T) investigated the efficacy and safety of S-1 + cisplatin and concurrent radical-dose radiotherapy followed by surgery in patients with a superior sulcus tumor.

METHODS

Patients received induction therapy comprising three cycles of S-1 + cisplatin with concurrent radiotherapy (66 Gy in 33 fractions) followed by surgery. S-1 was administered orally at 40 mg/m2 twice/day on days 1-14, with an intravenous infusion of cisplatin (60 mg/m2) on day 1. The primary endpoint was the 3-year overall survival rate; key secondary endpoints included progression-free survival rate, objective response rate, pathological complete response rate, and toxicity.

RESULTS

Sixty-one patients with a superior sulcus non-small cell lung cancer received induction therapy. Radiological tumor invasion sites were the chest wall (n = 57), subclavian artery (n = 18), and subclavian vein (n = 10). Forty-nine patients underwent a lobectomy and combined resection of the involved structures. The objective and pathological complete response rates were 42 % (95 % confidence interval: 29-54 %) and 33 % (95 % confidence interval: 20-46 %), respectively. The 3-year overall survival and progression-free survival rates were 73.2 % (95 % confidence interval: 60.1-82.7 %) and 53.3 % (95 % confidence interval: 40.0-65.0 %), respectively. The patterns of first tumor relapse were locoregional only in one, distant metastasis only in 18, and both in four patients. Two pneumonia cases during induction therapy and one cardiac-arrest case on postoperative day 3 resulted in death.

CONCLUSIONS

Induction therapy using S-1 + cisplatin and concurrent radical-dose radiotherapy followed by surgery maximized local control and improved overall survival without impairing safety, potentially representing a new standard treatment.

Predictive value of pretreatment peripheral blood N/CD4 and N/CD8 ratios for the efficacy of radiotherapy for esophageal cancer

BACKGROUND

This study aimed to explore the predictive value of pretreatment peripheral blood immune cell subsets in analyzing the outcomes of patients who underwent radiation therapy for esophageal cancer at their first visit.

PATIENTS AND METHODS

This study included 72 patients with esophageal cancer (EC) treated at Jiangsu University Hospital from December 2021 to December 2023. Among them, 48 were males and 24 were females, with a median age of 64 years (range: 52-98 years). Comprehensive clinical data, laboratory results, and imaging findings were collected to analyze survival differences. The log-rank test was used for univariate analysis to assess the sensitivity of these patients to radiotherapy. The statistically significant and clinically relevant factors identified from the univariate analysis were subsequently incorporated into a Cox proportional hazards regression model for multivariate analysis to investigate the associations between pretreatment peripheral blood immune cell subsets and patient survival.

RESULTS

Univariate Cox regression analysis revealed that the Eastern Cooperative Oncology Group (ECOG) score, CD4+ T-cell ratio, neutrophil-to-CD4+ T-cell ratio (N/CD4), neutrophil-to-CD8+ T-cell ratio (N/CD8), and neutrophil-to-B-cell ratio (N/B) were significantly correlated with survival outcomes in patients receiving radiotherapy for tumors. Furthermore, multivariate Cox regression analysis identified N/CD4+ T cells and N/CD8+ T cells as critical prognostic indicators for these patients. Receiver operating characteristic curve analysis was employed to evaluate the work characteristics of the subjects, resulting in area under the curve values of 0.763 for both N/CD4 and N/CD8. The analysis also revealed that the optimal cutoff values for N/CD4+ T cells and N/CD8+ T cells were 0.01053329 and 0.01184294, respectively.

CONCLUSIONS

N/CD4 and N/CD8 have emerged as viable prognostic predictors for patients undergoing radiotherapy for EC, offering valuable insights for clinicians to strategize further treatment options. However, the retrospective nature of this study introduces potential bias in assessment, underscoring the necessity for large-scale, prospective, randomized controlled trials to substantiate and validate these findings.

Variability of HCC Tumor Diameter and Density Measurements on Dynamic Contrast-Enhanced Computed Tomography

PURPOSE

In cancers imaged using contrast-enhanced protocols, such as hepatocellular carcinoma (HCC), formal guidelines rely on measurements of lesion size (in mm) and radiographic density (in Hounsfield units [HU]) to evaluate response to treatment. However, the variability of these measurements across different contrast enhancement phases remains poorly understood. This limits the ability of clinicians to discern whether measurement changes are accurate.

METHODS

In this study, we investigated the variability of maximal lesion diameter and mean lesion density of HCC lesions on CT scans across four different contrast enhancement phases: non-contrast-enhanced phase (NCE), early arterial phase (E-AP), late arterial phase (L-AP), and portal venous phase (PVP). HCC lesions were independently segmented by two expert radiologists. For each pair of a lesion's scan timepoints, one was selected randomly as the baseline measurement and the other as the repeat measurement. Both absolute and relative differences in measurements were calculated, as were the coefficients of variance (CVs). Analysis was further stratified by both contrast enhancement phase and lesion diameter.

RESULTS

Lesion diameter was found to have a CV of 5.11% (95% CI: 4.20-6.01%). About a fifth of the measurement's relative changes were greater than 10%. Although there was no significant difference in diameter measurements across different phases, there was a significant negative correlation (R = -0.303, p-value = 0.030) between lesion diameter and percent difference in diameter measurement. Lesion density measurements varied significantly across all phases, with the greatest relative difference of 47% in the late arterial phase and a CV of 22.84% (21.48-24.20%). The overall CV for lesion density measurements was 26.19% (24.66-27.72%).

CONCLUSIONS

Changes in tumor diameter measurements within 10% may simply be due to variability, and lesion density is highly sensitive to contrast timing. This highlights the importance of paying attention to these two variables when evaluating tumor response in both clinical trials and practice.

Dual-energy CT for evaluating the tumor regression grade of gastric cancer after neoadjuvant chemotherapy

OBJECTIVES

To evaluate the clinical value of dual-energy CT (DECT) parameters in estimating tumor regression grade (TRG) of gastric cancer after neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

In this retrospective study, the patients with pathologically confirmed gastric cancer were classified into two groups based on TRG results: the effective group and the ineffective group. DECT parameters, including iodine concentration (IC), normalized iodine concentration (NIC), and slope of the energy spectrum curve (λ), were obtained. Quantitative parameters and their change rates were compared before and after chemotherapy. The receiver operating characteristic (ROC) curves were plotted.

RESULTS

A total of 54 patients were included and divided into the effective group (n = 21) and the ineffective group (n = 33). After NAC, the change rates of parameters in the venous phase (%ΔIC-v, %ΔNIC-v, and %Δλ-v) were notably higher in the effective group were higher than in the ineffective group (all p < 0.05). The consistency between the response evaluation criteria in solid tumors version 1.1 (RECIST 1.1) and TRG was fair, with a Kappa value of 0.299 (p < 0.05). The %ΔIC-v, %ΔIC-d, %ΔNIC-v, %ΔNIC-d, and %Δλ-v exhibited moderate or strong correlations with TRG, with correlation coefficients (r) of -0.624, -0.475, -0.766, -0.516, and -0.431, respectively (all p < 0.05). %ΔNIC-v achieved a significantly greater area under the curve (AUC) compared to RECIST 1.1 (AUC, 0.877; 95% CI: 0.772-0.957; vs AUC, 0.649; 95% CI: 0.496-0.803; p < 0.05) for estimating TRG in gastric cancer.

CONCLUSION

DECT parameters, particularly %ΔNIC-v, show promise in assessing the efficacy of NAC for gastric cancer.

KEY POINTS

Question Two-dimensional morphological change is insufficient for accurately assessing the pathological TRG following NAC in gastric cancer. Findings DECT parameters show higher preoperative predictive efficacy than RECIST 1.1 for TRG in gastric cancer. Clinical relevance DECT-derived quantitative parameters offer a reliable and noninvasive tool for the preoperative prediction of pathological response in gastric cancer patients undergoing NAC.

Continuous replenishment of the dysfunctional CD8 T cell axis is associated with response to chemoimmunotherapy in advanced breast cancer

Chemotherapy combined with immune checkpoint blockade has shown clinical activity in breast cancer. Response, however, occurs in only a low proportion of patients. How the immune landscape of the tumor determines the immune and clinical responses to chemoimmunotherapy is not well understood. Here, using a combination of single-cell RNA sequencing (scRNA-seq) and single-cell T cell receptor sequencing (scTCR-seq), we profile 40 biopsies from 27 patients with metastatic triple-negative breast cancer (TNBC), receiving chemotherapy and anti-PD-L1 alone or in combination with anti-CD73, in a phase 2 randomized clinical trial. Our results show an enrichment of late-dysfunctional, clonally expanded CD8+ T cells in responder (R) patients. On treatment, R display an influx of newly emerging clonotypes, as well as expansion of the CD8+ precursors. Collectively, our data suggest that baseline clonal expansion could be a potential predictor of response and that both clonal reinvigoration of pre-existing tumor-reactive T cells and clonal replacement on-treatment are important for a protective response to chemoimmunotherapy.

Neoadjuvant Chemoimmunotherapy for Resectable Head and Neck Squamous Cell Carcinoma: Systematic Review and Meta-analysis

BACKGROUND

Neoadjuvant chemoimmunotherapy provides a good pathological response in patients with resectable head and neck squamous cell carcinoma (HNSCC). Currently, there is no comprehensive systematic review that rigorously evaluates and summarizes the existing studies. In this study, we aimed to synthesize the results on the efficacy of neoadjuvant chemoimmunotherapy in resectable HNSCC to obtain higher-level evidence.

METHODS

The PubMed, Web of Science, Scopus, and Academic Search Complete (EBSCO) databases, along with ClinicalTrials.gov, Google Scholar, and conference abstracts, were comprehensively searched. The publication dates of the literature were limited to January 2015-July 2024. Meta-analysis was performed using a random-effects model. The percentage of major pathological response (MPR), pathological complete response (pCR), and overall disease-free survival (DFS) were synthesized. The odds ratios of a combined positive score (CPS) ≥ 20 for MPR and the diagnostic performance of using radiological objective response to determine MPR were further explored.

RESULTS

A total of 13 studies with 458 patients who received neoadjuvant chemoimmunotherapy and 443 patients who underwent curative surgery were included. The pooled MPR, pCR, and overall DFS rates were 61%, 37%, and 91%, respectively. The odds ratios of a CPS ≥ 20 for achieving MPR was 2.09 compared with those with a CPS < 20. The sensitivity of using radiological objective response to determine MPR was 0.91 and the specificity was 0.46, with an area under the curve of 0.76.

CONCLUSION

Neoadjuvant chemoimmunotherapy showed promising results for resectable HNSCC. A CPS ≥ 20 can be used to screen for treatment-sensitive patients, and radiological examinations can be used to detect pathological response. Definitive conclusions require data from longer follow-up periods and controlled studies.

Safety and efficacy of combined treatment with tumor-infiltrating lymphocytes and oncolytic adenovirus TILT-123 in metastatic melanoma

Tumor-infiltrating lymphocytes (TILs) are effective in the treatment of metastatic melanoma (MM), but toxicity limits its application. TILT-123 (igrelimogene litadenorepvec) is an oncolytic adenovirus producing interleukin-2 (IL-2) and tumor necrosis factor (TNF) upon replication. In this phase 1 trial, 17 patients with metastatic checkpoint inhibitor-resistant melanoma are treated with TILT-123 and TILs without preconditioning chemotherapy or postconditioning IL-2. The treatment is safe and feasible. According to computed tomography (CT), the objective response rate is 11.7% (2/17) and disease control is observed in 35% (6/17), including a partial response lasting >8 months and a durable complete response in a mucosal melanoma patient. According to positron emission tomography (PET), disease control is observed in 7/15 (47%) with minor or partial responses in 4/15 (27%). In the initial TILT-123 monotherapy phase of the trial, disease control is observed in 6/17 (35%) and 10/16 (63%) in CT and PET, respectively. The study demonstrates good tolerability and preliminary efficacy.

LDH and hemoglobin outperform systemic inflammatory indices as prognostic factors in patients with soft tissue sarcoma undergoing neoadjuvant treatment

BACKGROUND

The current understanding of the prognostic value of routine pre-treatment laboratory parameters in patients with high-risk soft tissue sarcoma (HR-STS) is limited. We sought to analyze several inflammatory biomarkers in a large cohort of HR-STS patients undergoing neoadjuvant therapy followed by curative surgical resection.

METHODS

123 patients with locally advanced high-risk undifferentiated pleomorphic sarcoma (UPS), liposarcoma (LPS), leiomyosarcoma (LMS), and synovial sarcoma (SS) who underwent preoperative chemotherapy and regional hyperthermia (RHT) between 2014 and 2022 were retrospectively evaluated. The association of several pre-treatment laboratory parameters with radiologic treatment response, event-free survival (EFS), and overall survival (OS), were analyzed.

RESULTS

Low pre-treatment hemoglobin (HR 2.51, p = 0.018; HR 2.78, p = 0.030) and lactate dehydrogenase (LDH, HR 0.29, p = 0.0044; HR 0.23, p = 0.010) were significantly associated with EFS and OS in the multivariable analysis. Systemic inflammatory indices such as the neutrophil-to-lymphocyte ratio (NLR) did not have a significant impact on survival. Low C-reactive protein (CRP) and high albumin values were associated with poor radiologic response according to RECIST (p = 0.021 and p = 0.010, respectively).

CONCLUSION

Pre-treatment LDH and hemoglobin are strong independent predictors of survival in HR-STS patients. Systemic inflammatory indices based on circulating immune cells may not serve as reliable prognostic factors for HR-STS patients undergoing curative-intent treatment. Higher pre-treatment albumin levels and lower CRP values may reflect a reduced inflammatory status and could be associated with a poorer radiologic response to preoperative treatment.

Comparison of the prognostic effect of taxane regimens combined with ramucirumab before nivolumab for advanced gastric cancer

BACKGROUND

Ramucirumab with either solvent-based or nanoparticle albumin-bound paclitaxel is a standard second-line treatment for advanced gastric cancer. Reportedly, nanoparticle albumin-bound paclitaxel has activated the immune system, but the efficacy of taxane-based agents before nivolumab remains unclear. Therefore, we investigated the prognostic effect of ramucirumab with solvent-based or nanoparticle albumin-bound paclitaxel as second-line therapy, followed by nivolumab as third-line therapy.

METHODS

This retrospective study enrolled 115 patients with gastric cancer treated with ramucirumab in combination with solvent-based paclitaxel or nanoparticle albumin-bound paclitaxel from 2017 to 2019 at six hospitals. All patients received nivolumab as a third-line therapy. Ramucirumab + solvent-based paclitaxel and ramucirumab + nanoparticle albumin-bound paclitaxel were administered to 57 and 58 patients, respectively.

RESULTS

The progression-free survival of the ramucirumab + solvent-based paclitaxel group was slightly better than that of the ramucirumab + nanoparticle albumin-bound paclitaxel group but with no statistically significant difference (5.3 months vs. 4.2 months). Contrary, the overall survival of the ramucirumab + nanoparticle albumin-bound paclitaxel group was slightly better than the ramucirumab + solvent-based paclitaxel group but with no statistically significant difference (19.0 months vs. 12.5 months). The multivariate analysis of progression-free survival revealed that ramucirumab + nanoparticle albumin-bound paclitaxel was an independent risk factor for poor prognosis, whereas ramucirumab + nanoparticle albumin-bound paclitaxel was an independent factor for good overall survival.

CONCLUSIONS

Ramucirumab + nanoparticle albumin-bound paclitaxel may prolong overall survival when administered before nivolumab, despite its limited effect on progression-free survival.

Translational Selenium Nanoparticles Promotes Clinical Non-small-cell Lung Cancer Chemotherapy via Activating Selenoprotein-driven Immune Manipulation

Reconstructing the tumor immune microenvironment is an effective strategy to enhance therapeutic efficacy limited by immunosuppression in non-small-cell lung cancer (NSCLC). In this study, it is found that selenium (Se) depletion and immune dysfunction are present in patients with advanced NSCLC compared with healthy volunteers. Surprisingly, Se deficiency resulted in decreased immunity and accelerated rapid tumor growth in the mice model, which further reveals that the correlation between micronutrient Se and lung cancer progression. This pioneering work achieves 500-L scale production of Se nanoparticles (SeNPs) at GMP level and utilizes it to reveal how and why the trace element Se can enhance clinical immune-mediated treatment efficacy against NSCLC. The results found that translational SeNPs can promote the proliferation of NK cells and enhance its cytotoxicity against cancer cells by activating mTOR signaling pathway driven by GPXs to regulate the secretion of cytokines to achieve an antitumor response. Moreover, a clinical study of an Investigator-initiated Trial shows that translational SeNPs supplementation in combination with bevacizumab/cisplatin/pemetrexed exhibits enhanced therapeutic efficacy with an objective response rate of 83.3% and a disease control rate of 100%, through potentiating selenoprotein-driven antitumor immunity. Taken together, this study, for the first time, highlights the translational SeNPs-enhanced therapeutic efficacy against clinical advanced NSCLC.

Targeting tumor-intrinsic S100 calcium-binding protein A1 augments antitumor immunity and potentiates immunotherapy efficacy

Immune checkpoint blockade (ICB) has revolutionized cancer treatment, but the therapeutic response is highly heterogeneous, which highlights the necessity for developing predictive biomarkers and overcoming ICB resistance. Cancer cell-intrinsic features, especially those that can be dynamically monitored via liquid biopsy, represent a broader scope for biomarker development. In addition, a potential mode of ICB resistance is tumor-intrinsic mechanisms leading to an immunosuppressive tumor microenvironment (TME). However, the underlying interactive network remains elusive, and the generalizable biomarkers and targeting strategies are still lacking. Here, we uncovered the potential of plasma S100 calcium-binding protein A1 (S100A1) for determining ICB efficacy via liquid biopsy of patients with lung cancer. Multiomics and functional studies have suggested that tumor-intrinsic S100A1 expression correlated with an immunologically "cold" TME and resistance to ICB in multiple syngeneic murine tumors and tissue samples from patients with lung cancer. Mechanistic investigations demonstrated that interfering with the tumor-intrinsic S100A1/ubiquitin-specific protease 7/p65/granulocyte-macrophage colony-stimulating factor (GM-CSF) modulatory axis could potentiate an inflamed TME by promoting M1-like macrophage polarization and T cell function. GM-CSF priming was sufficient to enhance the ICB response in tumors with high S100A1 expression in preclinical models. These findings define S100A1 as a potential blood-based biomarker and a novel synergistic target for cancer immunotherapy.

Randomized Phase II Study of Bevacizumab with Weekly Anetumab Ravtansine or Weekly Paclitaxel in Platinum-Resistant/Refractory High-Grade Ovarian Cancer (NCI Trial)

PURPOSE

Mesothelin (MSLN) is highly expressed in high-grade serous/endometrioid ovarian cancers (HGOC). Anetumab ravtansine (AR) is an antibody-drug conjugate directed at the MSLN antigen with a tubulin polymerization inhibitor. We assessed the safety, activity, and pharmacokinetics of the combination AR/bevacizumab (Bev; ARB) versus weekly paclitaxel/Bev (PB) in patients with platinum-resistant/refractory HGOC (prrHGOC).

PATIENTS AND METHODS

Following a run-in phase I study to assess ARB safety, patients with prrHGOC with centrally confirmed MSLN-positive expression were randomized to ARB or PB (weekly paclitaxel 80 mg/m2 with Bev 10 mg/kg biweekly). Patients were stratified by platinum resistance/refractory and prior Bev. The primary endpoint was progression-free survival (PFS), and secondary endpoints were overall response rate, safety, and blood-based angiome biomarker assessment. A futility analysis was planned after 35 PFS events.

RESULTS

The combination of Bev (10 mg/kg) biweekly with AR (2.2 mg/kg) weekly was well tolerated. About phase II results, MSLN positivity was 88%, and 57 patients were randomized (28 ARB and 29 PB). Forty-two percentage of patients received prior Bev, and 23% were platinum-refractory. At futility analysis, the median PFS was 5.3 and 12.7 months for ARB and PB, respectively [P = 0.03; HR = 2.02 (1.06-3.86)]. The overall response rate was 21% with ARB and 65% with PB. The most common treatment-related grade ≥3 adverse events were anemia (18%) with ARB and neutropenia (24%) with PB. Higher baseline levels of circulating IL6 were associated with worse PFS, and its levels decreased with PB treatment.

CONCLUSIONS

Our study stopped at interim analysis highlighting the benefit of PB in prrHGOC as the standard of care.

Impact of Co-mutations and Transcriptional Signatures in Non-Small Cell Lung Cancer Patients Treated with Adagrasib in the KRYSTAL-1 Trial

PURPOSE

KRAS inhibitors are revolutionizing the treatment of non-small cell lung cancer (NSCLC), but clinico-genomic determinants of treatment efficacy warrant continued exploration.

EXPERIMENTAL DESIGN

Patients with advanced KRASG12C-mutant NSCLC treated with adagrasib [KRYSTAL-1 (NCT03785249)] were included in the analysis. Pretreatment next-generation sequencing data were collected per protocol. HTG EdgeSeq Transcriptome Panel was used for gene expression profiling. Clinical endpoints included objective response, progression-free survival (PFS), and overall survival (OS). KRASG12C-mutant NSCLC cell lines and xenograft models were used for sensitivity analyses and combination drug screens.

RESULTS

KEAP1 MUT and STK11MUT were associated with shorter survival to adagrasib [KEAP1: PFS 4.1 vs. 9.9 months, HR 2.7, P < 0.01; OS 5.4 vs. 19.0 months, HR 3.6, P < 0.01; STK11: PFS 4.2 vs. 11.0 months, HR 2.2, P < 0.01; OS 9.8 months vs. not reached (NR), HR 2.6, P < 0.01]. KEAP1WT/STK11WT status identified adagrasib-treated patients with significantly longer PFS (16.9 months) and OS (NR). Preclinical analyses further validate the association between KEAP1 loss of function and adagrasib resistance. Adagrasib and mTOR inhibitor combinations produced higher treatment efficacy in NSCLC models harboring STK11 and KEAP1 co-mutations. NRF2HIGH signaling was associated with shorter survival to adagrasib (PFS: 4.2 vs. 8.4 months, HR 2.0, P = 0.02; OS: 6.5 vs. 19.0 months, HR 2.8, P < 0.01) even in patients with KEAP1WT NSCLC. KEAP1WT/STK11WT/NRF2LOW status identified patients-32%-with longer survival to adagrasib (PFS 12.0 vs. 4.2 months, HR 0.2, P < 0.01; OS NR vs. 8.0 months, HR 0.1, P < 0.01).

CONCLUSIONS

KEAP1, STK11, and NRF2 status define patients with KRASG12C-mutant NSCLC with markedly distinct outcomes to adagrasib. These results further support the use of genomic features-mutational and nonmutational-for the treatment selection of patients with KRASG12C-mutant NSCLC.

A Post Hoc Analysis of Older Patients with Metastatic Colorectal Cancer Receiving Oxaliplatin-Based Chemotherapy Plus Bevacizumab: The Randomized Obelics Study

BACKGROUND

Phase II trials and subgroup analyses of clinical studies suggest that bevacizumab plus an oxaliplatin-based chemotherapy doublet is effective and tolerable in fit older patients with metastatic colorectal cancer (mCRC).

OBJECTIVE

To evaluate the influence of age on the incidence of side effects and efficacy of this combination in patients with mCRC randomized in the prospective phase III OBELICS study.

METHODS

In total, 230 patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 out of 1 were retrieved on the basis of age (190 < 70 years and 40 ≥ 70 years). They received bevacizumab 5 mg/kg administered either on the same day as chemotherapy (standard arm) or 4 days before chemotherapy (experimental arm) and oxaliplatin 85 mg/m2 on day 1, plus capecitabine 1000 mg/m2 twice a day (bid) orally on days 1-10 or levofolinic acid, 200 mg/m2, bolus 5-fluorouracil (5-FU) 400 mg/m2, and a 46-h intravenous infusion of 5-FU 2400 mg/m2, every 14 days; oxaliplatin was discontinued after 12 cycles. The primary end point was the overall response rate (ORR).

RESULTS

Efficacy and toxicity analyses are reported in aggregate form because there were no statistically significant differences between the two arms. Patient characteristics are well balanced between older and younger patients. No difference in ORR was observed between the two groups (50% for the older patients versus 57.9% for the younger ones; p = 0.36). The median PFS was 10.8 (95% confidence interval [CI], 9.9-12.2) and 11.3 (95% CI 8.3-13.0) months, respectively, for subjects younger than 70 years and those aged ≥ 70 years, with an adjusted hazard ratio (HR) of 1.16 (95% CI 0.80-1.68; p = 0.43). The median OS was 26.2 (95% CI 23.3-32.7) for the former and 23.2 (95% CI 17.3-35.3) months for the latter, respectively, with an adjusted HR of 1.60 (95% CI 1.08-2.37; p = 0.027). Considering all forms of toxicity, the most severe ones were not statistically different between the two groups (65% for the older patients and 60.6% for the younger ones, p = 0.61).

CONCLUSIONS

Bevacizumab plus an oxaliplatin-based chemotherapy doublet were effective in older patients randomized in the OBELICS trial, and the adverse event profile was not dissimilar from that of younger patients; no new safety concerns were identified. This post hoc analysis confirms that fit older patients with mCRC should be considered for treatment with this regimen.

Neutrophil-to-apolipoprotein A1 ratio predicted the efficiency of chemotherapy in advanced pancreatic cancer

BACKGROUND

Identification of a biomarker predicting chemotherapy efficacy in patients with advanced pancreatic cancer (APC) is urgently needed. This study aimed to determine the association between the neutrophil-to-apolipoprotein A1 ratio (NEAPO) and chemotherapy efficacy in APC patients.

METHODS

This retrospective study involved 236 APC patients who underwent first-line chemotherapy, including FOLFIRINOX (FFX), nab-paclitaxel plus gemcitabine (AG), or SOXIRI. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of NEAPO, and patients were divided into low and high NEAPO groups. Kaplan-Meier curves and Cox regression analyses were used to evaluate the effect of NEAPO on overall survival (OS) and progression-free survival (PFS).

RESULTS

The optimal cutoff of NEAPO was 4.69. High NEAPO levels were associated with shorter OS (p = 0.046) and PFS (p = 0.001). In the NEAPO low subgroup, the median PFS of SOXIRI was longer than that in AG group (7.2 months vs. 5.5 months, p = 0.029), with no significant difference of PFS between SOXIRI and FFX (p = 0.691). There is a trend but not significant difference in PFS between AG and FFX (p = 0.096). The proportion of disease control rate (DCR) was higher in SOXIRI group. In the NEAPO high subgroup, there was no significant difference in PFS among the three regimens, while the DCR was higher in AG group.

CONCLUSIONS

NEAPO levels were significantly associated with OS, PFS and treatment response in APC patients who underwent chemotherapy and might be a useful biomarker for predicting chemotherapy efficacy.

NNMT promotes acquired EGFR-TKI resistance by forming EGR1 and lactate-mediated double positive feedback loops in non-small cell lung cancer

BACKGROUND

Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are remarkably effective for treating EGFR-mutant non-small cell lung cancer (NSCLC). However, patients inevitably develop acquired drug resistance, resulting in recurrence or metastasis. It is important to identify novel effective therapeutic targets to reverse acquired TKI resistance.

RESULTS

Bioinformatics analysis revealed that nicotinamide N-methyltransferase (NNMT) was upregulated in EGFR-TKI resistant cells and tissues via EGR1-mediated transcriptional activation. High NNMT levels were correlated with poor prognosis in EGFR-mutated NSCLC patients, which could promote resistance to EGFR-TKIs in vitro and in vivo. Mechanistically, NNMT catalyzed the conversion of nicotinamide to 1-methyl nicotinamide by depleting S-adenosyl methionine (the methyl group donor), leading to a reduction in H3K9 trimethylation (H3K9me3) and H3K27 trimethylation (H3K27me3) and subsequent epigenetic activation of EGR1 and ALDH3A1. In addition, ALDH3A1 activation increased lactic acid levels, which further promoted NNMT expression via p300-mediated histone H3K18 lactylation on its promoter. Thus, NNMT mediates the formation of a double positive feedback loop via EGR1 and lactate, EGR1/NNMT/EGR1 and NNMT/ALDH3A1/lactate/NNMT. Moreover, the combination of a small-molecule inhibitor for NNMT (NNMTi) and osimertinib exhibited promising potential for the treatment of TKI resistance in an NSCLC osimertinib-resistant xenograft model.

CONCLUSIONS

The combined contribution of these two positive feedback loops promotes EGFR-TKI resistance in NSCLC. Our findings provide new insight into the role of histone methylation and histone lactylation in TKI resistance. The pivotal NNMT-mediated positive feedback loop may serve as a powerful therapeutic target for overcoming EGFR-TKI resistance in NSCLC.

MR Imaging Features Predictive of Pathologic Complete Response and Survival Outcomes for Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy

PURPOSE

This study aims to evaluate the predictive value of MRI features for pathologic complete response (pCR) and survival outcomes in patients with breast cancer (BC) undergoing neoadjuvant chemotherapy (NAC).

METHODS

A retrospective analysis was conducted on 168 BC patients treated with NAC between 2018 and 2022. Pre-NAC breast MRI scans were evaluated for enhancement patterns, time-intensity curve (TIC), peritumoral edema, and background enhancement. Both pre- and post-NAC MRIs were assessed for Epeak %, mean apparent diffusion coefficient (ADC) value, and ADC ratio (mean ADC of lesion/contralateral normal breast parenchyma). Survival outcomes were analyzed using Kaplan-Meier and Cox regression models.

RESULTS

pCR was achieved in 34% of patients. MRI demonstrated a sensitivity of 74% and a specificity of 86% in predicting pCR, with an overall accuracy of 82%. The post-NAC percentage of initial peak enhancement (Epeak) was significantly lower in the pCR group (P < 0.001). Multivariate analysis identified a pre-NAC Epeak ≤ 96 (hazard ratio [HR]: 6.26, P < 0.001) and a post-NAC Epeak > 188 (HR: 18.40, P < 0.001) as independent risk factors for disease-free survival. Additionally, a lower pre-NAC ADC ratio (≤0.65) was associated with poorer overall survival (HR: 2.8, P: 0.041). Pre-NAC peritumoral edema, background enhancement, and TIC were not significant predictors of survival outcomes.

CONCLUSION

MRI features, including Epeak % and ADC ratio, are important predictors of pCR and survival outcomes in BC patients undergoing NAC. Incorporating these biomarkers into clinical practice may improve treatment planning and optimize patient outcomes.

Significance of monitoring imatinib plasma concentration in second-line treatment decisions for c-kit 11 gene-mutated gastrointestinal stromal tumors

BACKGROUND

For patients with advanced gastrointestinal stromal tumors (GISTs) carrying the c-kit exon 11 mutation, imatinib (IM) at a standard dosage of 400 mg per day is the preferred first-line treatment. In cases where treatment with IM fails, there is an urgent need for a more precise assessment method to determine whether to switch therapies or escalate the IM dosage. This approach will enhance clinical decision-making and optimize patient outcomes.

AIM

To investigate IM plasma concentration's role in second-line treatment decisions for c-kit 11-mutated advanced GISTs post-IM failure.

METHODS

Patients with advanced GIST harboring c-kit 11 mutation who experienced failure with IM 400 mg per day as first-line treatment at our hospital were retrospectively analyzed. Patients were categorized into a low plasma (LP) concentration group (LP group, < 1100 ng/mL) and high plasma (HP) concentration group (HP group, ≥ 1100 ng/mL). Each group was further subdivided into Group A (dose-escalation group) and Group B (drug-switch group). Baseline characteristics were compared and Kaplan-Meier curves were used to analyze the survival of patients.

RESULTS

Seventy-five patients were included in the analysis. For the LP group (n = 28), Group A (n = 14) had longer overall survival (OS) than Group B (n = 14) (P = 0.02). No differences were observed between the two subgroups in disease control rate (DCR), objective response rate, and progression-free survival (PFS) (P > 0.05). For the HP group (n = 47), Group B (n = 18) had a higher DCR and longer PFS than Group A (n = 29) (P = 0.008 and P = 0.03, respectively). No difference in OS was observed between the two subgroups (P > 0.05).

CONCLUSION

Increasing IM dosage for c-kit 11-mutated advanced GISTs post-IM failure may prolong OS if plasma concentration is < 1100 ng/mL. Switching tyrosine kinase inhibitors may improve DCR and PFS if ≥ 1100 ng/mL.

Efficacy and safety of a novel multihole fully covered self-expandable metallic stent for malignant distal biliary obstruction: Multicenter retrospective study

OBJECTIVES

Covered self-expandable metallic stents (CSEMS) are effective for managing malignant distal biliary obstruction (MDBO). However, migration is a significant problem, which requires prevention. The novel multihole fully CSEMS (MHSEMS), which features multiple small holes on the covered membrane, is expected to prevent migration. This study aimed to evaluate the efficacy and safety of MHSEMS for MDBO.

METHODS

This multicenter retrospective cohort study included 111 patients with MDBO who underwent MHSEMS placement between September 2022 and August 2023. The primary outcome was the recurrent biliary obstruction (RBO) rate. The secondary outcomes were adverse event (AE) rates, removability, technical and clinical success rates, and time to RBO.

RESULTS

The technical success rate was 100%, and the clinical success rate was 94.6%. AEs occurred in 34.2% of patients, with RBO in 21.0% and non-RBO AEs in 17.1%. RBO included stent migration in 1.9%, stent occlusion in 11.7% (including ingrowth in 5.7%, biliary debris in 2.9%, hemobilia in 1.9%, and food impaction in 1.0%), and nonocclusion cholangitis (requiring biliary drainage) in 5.7%. Non-RBO AEs included post-endoscopic retrograde cholangiopancreatography pancreatitis in 11.7%, cholecystitis in 2.7%, and nonocclusion cholangitis in 2.7%. Stent removal was successful in 88.9% of attempts. The median time to RBO was 446 days.

CONCLUSION

The placement of MHSEMS for MDBO was effective and feasible, demonstrating low migration rates, acceptable AEs, and removability.

Neoadjuvant cadonilimab plus FLOT chemotherapy in locally advanced gastric/gastroesophageal junction adenocarcinoma: A multicenter, phase 2 study

BACKGROUND

Treatment with cadonilimab and chemotherapy has shown promise as a first-line treatment for gastric or gastroesophageal junction (G/GEJ) adenocarcinoma. However, its application in neoadjuvant settings has not yet been documented.

METHODS

This multicenter, phase 2 trial (ChiCTR2200066893) was conducted at four hospitals across China. Treatment-naive patients with locally advanced G/GEJ adenocarcinoma (cT3/4, N+, M0) and who were human epidermal growth factor receptor 2 negative received 3-cycle or 4-cycle neoadjuvant treatment of cadonilimab plus FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) chemotherapy, followed by gastrectomy and 4-cycle adjuvant FLOT chemotherapy. The primary endpoint was the pathological complete response (pCR) rate. Secondary endpoints included major pathological response (MPR), overall response rate (ORR), disease control rate (DCR), R0 resection rate, downstaging rate, and safety.

FINDINGS

Between December 23, 2022, and December 15, 2023, 32 of 38 patients completed the scheduled treatment, achieving an R0 resection rate of 100% (32/32). The pCR rate was 21.1% (8/38, 90% confidence interval [CI]: 9.7-32.4), and the MPR rate was 44.7% (17/38, 90% CI: 30.9-58.5). Radiological evaluations were available for 28 of 38 patients by blinded independent central review. The ORR was 60.7% (17/28, 90% CI: 44.7-76.7), and the DCR was 100.0% (28/28, 90% CI: 100.0-100.0). Tumor downstaging occurred in 71.9% of patients (23/32), with consistent efficacy across all populations observed in the subgroup analysis. Grade 3 adverse events occurred in 31.6% of patients without severe safety issues.

CONCLUSIONS

Neoadjuvant cadonilimab plus FLOT chemotherapy treatment exhibits promising efficacy with manageable toxicities in locally advanced G/GEJ adenocarcinoma, providing preliminary evidence for further investigation.

FUNDING

This study was funded by Akeso Biopharma.

Effects of gut microbiota on immune checkpoint inhibitors in multi-cancer and as microbial biomarkers for predicting therapeutic response

BACKGROUND

Gut bacteria are related to immune checkpoint inhibitors (ICIs). However, there is inconsistency in ICI-associated species, while the role of non-bacterial microbes in immunotherapy remains elusive. Here, we evaluated the association of trans-kingdom microbes with ICIs by multi-cohort multi-cancer analyses.

METHODS

We retrieved fecal metagenomes from 1,359 ICI recipients with four different cancers (metastatic melanoma [MM], non-small cell lung carcinoma [NSCLC], renal cell cancer [RCC], and hepatocellular carcinoma) from 12 published datasets. Microbiota composition was analyzed using the Wilcoxon rank test. The performance of microbial biomarkers in predicting ICI response was assessed by random forest. Key responder-associated microbes were functionally examined in vitro and in mice.

FINDINGS

Trans-kingdom gut microbiota (bacteria, eukaryotes, viruses, and archaea) was significantly different between ICI responders and non-responders in multi-cancer. Bacteria (Faecalibacterium prausnitzii, Coprococcus comes) and eukaryotes (Nemania serpens, Hyphopichia pseudoburtonii) were consistently enriched in responders of ≥2 cancer types or from ≥3 cohorts, contrasting with the depleted bacterium Hungatella hathewayi. Responder-associated species in each cancer were revealed, such as F. prausnitzii in MM and 6 species in NSCLC. These signature species influenced ICI efficacy by modulating CD8+ T cell activity in vitro and in mice. Moreover, bacterial and eukaryotic biomarkers showed great performance in predicting ICI response in patients from discovery and two validation cohorts (MM: area under the receiver operating characteristic curve [AUROC] = 72.27%-80.19%; NSCLC: AUROC = 72.70%-87.98%; RCC: AUROC = 83.33%-89.58%).

CONCLUSIONS

This study identified trans-kingdom microbial signatures associated with ICI in multi-cancer and specific cancer types. Trans-kingdom microbial biomarkers are potential predictors of ICI response in patients with cancer.

FUNDING

Funding information is shown in the acknowledgments.

A CT-based deep learning-driven tool for automatic liver tumor detection and delineation in patients with cancer

Liver tumors, whether primary or metastatic, significantly impact the outcomes of patients with cancer. Accurate identification and quantification are crucial for effective patient management, including precise diagnosis, prognosis, and therapy evaluation. We present SALSA (system for automatic liver tumor segmentation and detection), a fully automated tool for liver tumor detection and delineation. Developed on 1,598 computed tomography (CT) scans and 4,908 liver tumors, SALSA demonstrates superior accuracy in tumor identification and volume quantification, outperforming state-of-the-art models and inter-reader agreement among expert radiologists. SALSA achieves a patient-wise detection precision of 99.65%, and 81.72% at lesion level, in the external validation cohorts. Additionally, it exhibits good overlap, achieving a dice similarity coefficient (DSC) of 0.760, outperforming both state-of-the-art and the inter-radiologist assessment. SALSA's automatic quantification of tumor volume proves to have prognostic value across various solid tumors (p = 0.028). SALSA's robust capabilities position it as a potential medical device for automatic cancer detection, staging, and response evaluation.

Efficacy and safety of DV in HER2-negative and HER2-low locally advanced or metastatic urothelial carcinoma: Results of a phase 2 study

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) has emerged as a new target for metastatic urothelial carcinomas (mUCs). Disitamab vedotin (DV), an anti-HER2 antibody-drug conjugate (ADC), demonstrates a promising efficacy in patients with HER2-positive mUC. However, the role of DV in HER2-negative and HER2-low mUCs remains unknown.

METHODS

Patients with HER2-negative and HER2-low (immunohistochemistry [IHC] 0 or 1+) mUCs who received ≥1 line of systemic chemotherapy were included. Patients received 2 mg/kg DV intravenously once every 2 weeks. The primary endpoint was the objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and safety.

FINDINGS

Nineteen patients with UC were enrolled from September 2019 to December 2021. The median age was 64.0 years. 15 patients (79%) had visceral metastases. HER2 IHC 0 and 1+ were detected in 6 and 13 patients, respectively. As of September 30, 2022, the confirmed ORR was 31.6% (95% confidence interval [CI]: 12.6, 56.6), and the disease control rate was 94.7% (18/19). The median PFS and OS were 5.5 (95% CI: 3.9, 5.7) and 16.4 (6.8, 26.8) months, respectively. Common treatment related adverse events were mostly grade 1 or 2, including leukopenia (52.6%) and hypoesthesia (47.4%).

CONCLUSIONS

This is the first exploratory trial demonstrating substantial anti-tumor activity and a manageable safety profile using a HER2-targeting agent in patients with HER2-low mUC. This study was registered at ClinicalTrials.gov (ClinicalTrials.gov: NCT04073602).

FUNDING

The study was funded by the Natural Science Foundation of China, the Natural Science Foundation of Tibet Autonomous Region, the Beijing Xisike Clinical Oncology Research Foundation, and RemeGen, Ltd.

Assessment of the Mechanisms of Action of Eribulin in Patients with Advanced Liposarcoma Through the Evaluation of Radiological, Functional, and Tissue Responses: A Prospective Monocentric Study (Malibu Study)

Background: Liposarcoma (LPS) is one of the most frequent histotypes of soft tissue sarcoma (STS). Eribulin is a cytotoxic agent that has improved overall survival in patients with advanced LPS. Additionally, preclinical and clinical evidence suggests its influence on vascularization and cellular differentiation. Based on these data, we developed this study to investigate non-mitotic effects of eribulin in patients with advanced LPS. Methods: In this prospective monocentric observational study, we included patients with advanced LPS eligible to receive eribulin. An assessment with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and a biopsy were planned before treatment and after four cycles of eribulin. DCE-MRI scans were elaborated to obtain perfusion and permeability maps. Results: From September 2019 to January 2024, 11 patients were enrolled. Among them, 8/11 (73%) had successful pre- and post-treatment assessment. At the time of the analysis, 8/11 (73%) patients had disease progression and 4 (36%) had died, median progression-free survival (mPFS) was 3.3 months, and median overall survival (mOS) was 8.7 months. Among the evaluable patients, DCE-MRI perfusion decreased after eribulin treatment in patients with disease control (partial response or stable disease), while perfusion values increased in patients with progressive disease (PD). No significant change in permeability was found. Post-treatment histological changes were seen nearly in all patients, with decreased cellularity the most common change (50%), followed by vascularization modifications (20%). Conclusions: Eribulin appears to exhibit non-mitotic activity involving both vascularization and cell differentiation in LPS patients. Further studies are needed to better define these effects.

A Nomogram Based on Tumor Response to Induction Chemotherapy and Plasma Epstein-Barr Virus DNA Level after Induction Chemotherapy to Explore Individualized Treatment of Patients with Locally Advanced Nasopharyngeal Carcinoma

Purpose

To explore the influence of Epstein-Barr virus (EBV) DNA levels before and after induction chemotherapy (IC), tumor response to IC, and baseline factors on overall survival (OS) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC). A nomogram was subsequently constructed to explore the individualized optimal cumulative cisplatin dose (CCD) in concurrent chemoradiotherapy (CCRT).

Methods

A total of 581 LA-NPC patients were included, randomly divided into training and validation cohorts in a 7:3 ratio. In the training cohort, a nomogram was subsequently established based on multivariate Cox regression analysis and then validated. Subsequently, patients were classified into different risk groups based on the nomogram, and the impact of different levels of CCD on survival outcomes was evaluated.

Results

EBV DNA levels after IC, tumor response to IC, age, and LDH were independent prognostic factors of OS. Schoenfeld residual analysis indicated overall satisfaction of the proportional hazards assumption for the Cox regression model. The C-index of the nomogram was 0.758 (95% CI: 0.695-0.821) for the training cohort and 0.701 (95% CI: 0.589-0.813) for the validation cohort. Calibration curves demonstrated good correlation between the nomogram and actual survival outcomes. DCA confirmed the clinical utility enhancement of the nomogram over the TNM staging system. For OS, patients in the medium/high-risk group with a CCD > 200 mg/m² had better outcomes than those with CCD ≤ 200 mg/m², although the difference was not statistically significant (p = 0.097). No significant difference was observed in local relapse-free survival (LRFS), distant metastasis-free survival (DMFS), and progression-free survival (PFS) across various levels of CCD in different risk subgroups (p > 0.05).

Conclusion

The nomogram based on EBV DNA levels after IC, tumor response, LDH, and age effectively predicts OS in LA-NPC patients, aids in risk stratification, and may guide treatment decisions.