Factors associated with early progression of non-small-cell lung cancer treated by epidermal growth factor receptor tyrosine-kinase inhibitors

Pre-treatment Neutrophil-to-Lymphocyte Ratio significantly affects progression free survival in positive EGFR mutation advanced lung adenocarcinoma with EGFR-TKI treatment in Bali, Indonesia

Introduction: Today, recommendations about initial Response Evaluation Criteria in Solid Tumor (RECIST) and its frequency still vary, while early diagnosis of progression affects patient's prognosis and subsequent treatment options. Methods: This study aims to examine Progression Free Survival (PFS) of positive EGFR mutations advanced lung adenocarcinoma receiving Tyrosine Kinase Inhibitor (TKI) and factors that influence it. This was an observational study with retrospective cohort design conducted at Prof IGNG Ngoerah Hospital from January to December 2021. Sample was data from Epidermal Growth Factor Receptor (EGFR) positive mutation advanced lung adenocarcinoma patient who were treated with EGFR-TKI at Prof IGNG Ngoerah Hospital, Denpasar, Bali from January 2017 to February 2021. Total sample was 63. Results: Median PFS was 12 months (95% CI 10.28-13.71) and minimum PFS was 3 months. In univariate analysis, Hazard Ration (HR) of older age, smoker, distant metastasis, brain metastasis, increased Neutrophil-to-Lymphocyte Ration (NLR), and exon 21 mutation to shorter PFS was 0.99 (95% CI 0.95-1.02); 1.03 (95% CI 0.57-1.85); 1.45 (95% CI 0.85-2.49); 2.14 (95% CI 1.02-4.49); 1.08 (95% CI 1.03-1.13); and 1.21 (95% CI 0.67-2.18). Multivariate analysis showed only increased NLR affected PFS significantly with HR 1.06 (95% CI 1.007-1.13). Conclusion: Median PFS of EGFR positive mutation advanced lung adenocarcinoma patients who received TKI was 12 months and minimum value was 3 months. Increased age, smoking, distant metastases, brain metastases, and exon 21 mutations were not associated with PFS. NLR significantly affected PFS.

Impact of Weight Loss at Presentation on Survival in Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors (EGFR-TKI) Sensitive Mutant Advanced Non-small Cell Lung Cancer (NSCLC) Treated with First-line EGFR-TKI

Purpose The aim of this study is to evaluate the impact of weight loss at presentation on treatment outcomes of first-line EGFR-tyrosine kinase inhibitors (EGFR-TKI) in EGFR-TKI sensitive mutant NSCLC patients. Methods We retrospectively analyzed the clinical outcomes of 75 consecutive advanced NSCLC patients with EGFR-TKI sensitive mutations (exon 19 deletion or exon 21 L858R) received first-line gefitinib or erlotinib therapy according to weight loss status at presentation in our single center. Results Of 75 EGFR-TKI sensitive mutant NSCLC patients, 49 (65.3%) patients had no weight loss and 26 (34.7%) had weight loss at presentation, the objective response rate (ORR) to EGFR-TKI treatment were similar between the two groups (79.6% vs. 76.9%, p = 0.533). Patients without weight loss at presentation had significantly longer median progression free survival (PFS) (12.4 months vs. 7.6 months; hazard ratio [HR] 0.356, 95% confidence interval [CI] 0.212-0.596, p < 0.001) and overall survival (OS) (28.5 months vs. 20.7 months; HR 0.408, 95% CI 0.215-0.776, p = 0.006) than those with weight loss at presentation; moreover, the stratified analysis by EGFR-TKI sensitive mutation types also found similar trend between these two groups except for OS in EGFR exon 21 L858R mutation patients. Multivariate analysis identified weight loss at presentation and EGFR-TKI sensitive mutation types were independent predictive factors for PFS and OS. Conclusions Weight loss at presentation had a detrimental impact on PFS and OS in EGFR-TKI sensitive mutant advanced NSCLC patients treated with first-line EGFR-TKI. It should be considered as an important factor in the treatment decision or designing of EGFR-TKI clinical trials.

The strange connection between epidermal growth factor receptor tyrosine kinase inhibitors and dapsone: from rash mitigation to the increase in anti-tumor activity

The presence of an aberrantly activated epidermal growth factor receptor (EGFR) in many epithelial tumors, due to its overexpression, activating mutations, gene amplification and/or overexpression of receptor ligands, represent the fundamental basis underlying the use of EGFR tyrosine kinase inhibitors (EGFR-TKIs). Drugs inhibiting the EGFR have different mechanisms of action; while erlotinib and gefitinib inhibit the intracellular tyrosine kinase, monoclonal antibodies like cetuximab and panitumumab bind the extracellular domain of the EGFR both activating immunomediated anti-cancer effect and inhibiting receptor function. On the other hand, interleukin-8 has tumor promoting as well as neo-angiogenesis enhancing effects and several attempts have been made to inhibit its activity. One of these is based on the use of the old sulfone antibiotic dapsone that has demonstrated several interleukin-8 system inhibiting actions. Erlotinib typically gives a rash that has recently been proven to come out via up-regulated keratinocyte interleukin-8 synthesis with histological features reminiscent of typical neutrophilic dermatoses. In this review, we report experimental evidence that shows the use of dapsone to improve quality of life in erlotinib-treated patients by ameliorating rash as well as short-circuiting a growth-enhancing aspect of erlotinib based on increased interleukin-8 secretion.

Erlotinib augmentation with dapsone for rash mitigation and increased anti-cancer effectiveness

BACKGROUND

The epidermal growth factor receptor tyrosine kinase inhibitor erlotinib has failed in many ways to be as potent in the anti-cancer role as pre-clinical studies would have suggested. This paper traces some aspects of this failure to a compensatory erlotinib-mediated increase in interleukin-8. Many other-but not all- cancer chemotherapeutic cytotoxic drugs also provoke a compensatory increase in a malignant clone's interleukin-8 synthesis. Untreated glioblastoma and other cancer cells themselves natively synthesize interleukin-8. Interleukin-8 has tumor growth promoting, mobility and metastasis formation enhancing, effects as well as pro-angiogenesis effects.

FINDINGS

The old sulfone antibiotic dapsone- one of the very first antibiotics in clinical use- has demonstrated several interleukin-8 system inhibiting actions. Review of these indicates dapsone has potential to augment erlotinib effectiveness. Erlotinib typically gives a rash that has recently been proven to come about via an erlotinib triggered up-regulated keratinocyte interleukin-8 synthesis. The erlotinib rash shares histological features reminiscent of typical neutrophilic dermatoses. Dapsone has an established therapeutic role in current treatment of other neutrophilic dermatoses.

CONCLUSION

Thus, dapsone has potential to both improve the quality of life in erlotinib treated patients by amelioration of rash as well as to short-circuit a growth-enhancing aspect of erlotinib when used in the anti-cancer role.