Treatment updates in advanced thymoma and thymic carcinoma

The pharmacoeconomic benefits of pemetrexed dose individualization in lung cancer patients

Neutropenia is a dose-related treatment-limiting and costly adverse event of pemetrexed. We postulate that individualized dosing reduces the incidence of neutropenia. The aims of this study were to 1) investigate the costs of pemetrexed-related neutropenia and 2) to determine the pharmacoeconomic benefits of individualized dosing of pemetrexed in terms of budget impact, yearly cost savings and reduction in severe neutropenia. Retrospective data on the treatment of ≥grade 3 neutropenia during pemetrexed-based chemotherapy were collected from three Dutch hospitals to determine the mean health care consumption during a neutropenic episode. Subsequently, Monte Carlo simulations were performed using a validated pharmacokinetic/pharmacodynamic (PK/PD) model to predict the neutropenia incidence during four cycles for standard dosing of pemetrexed and individualized dosing. The mean costs per neutropenia and the expected neutropenia incidence were combined to calculate the budget impact and cost savings. We found that the average costs per pemetrexed-associated neutropenic episode to be € 1,490. The neutropenia incidence for the standard and individualized pemetrexed dosing strategies were 12.7 and 9.9%, respectively. This resulted in total expected neutropenia-related costs of approximately € 3.0 million and €2.4 million, respectively. Taking the number of patients eligible for pemetrexed treatment into account, individualized dosing could result in saving €686,000 on a yearly basis in the Netherlands alone. Individualized dosing of pemetrexed can decrease the incidence of neutropenia and thus result in a significant decrease in neutropenia-related costs and decreased risk of hospitalization or even death while maintaining therapeutic exposure.

Racial Disparity in Surgical Therapy for Thymic Malignancies

BACKGROUND

The primary curative treatment for thymic malignancies is surgery. For lung and esophageal cancer, substantive disparities in outcomes by race exist. Many of these disparities are attributed to the decreased use of surgery in non-White patients. Although thymic malignancies are treated by the same specialists as lung and esophageal cancer, it is unknown if there are racial disparities in the treatment of thymic malignancies.

RESEARCH QUESTION

Do racial disparities exist in the surgical treatment of thymic malignancies?

STUDY DESIGN AND METHODS

A retrospective cohort analysis was performed using the National Cancer Data Base of patients diagnosed with thymoma and thymic carcinoma between 2004 and 2016. Univariate comparisons of demographics were compared using χ ² and rank-sum tests. Multivariable analysis was performed to determine if race was an independent variable associated with receiving surgical resection. Preoperative and postoperative care was compared between races.

RESULTS

Seven thousand four hundred eighty-nine patients met inclusion criteria. Four thousand nine hundred sixty-two (66%) were White, 1,311 (18%) were Black, 487 (7%) were Hispanic, 580 (8%) were Asian or Pacific Islander, and 143 (2%) were other races. Black patients with thymic malignancies were more likely to have a median income < $38,000 and not received surgery. Black and Hispanic patients had the lowest median age (54.3 and 53.6 years, respectively) and were most likely to be uninsured (8.2% and 12.5%, respectively). White patients received surgical therapy 1 week sooner and had a postoperative length of stay 1.5 days shorter than Black patients. Multivariable analysis controlling for age, sex, tumor size, insurance status, comorbidity score, histology, and facility type showed that race remained independently associated with the receipt of surgical resection. White patients had the greatest likelihood of receiving surgery with Black patients being least likely to receive surgery (OR, 0.60).

INTERPRETATION

A racial disparity exists in surgical therapy for thymic malignancies.

Cumulative pemetrexed dose increases the risk of nephrotoxicity

INTRODUCTION

Pemetrexed is a pharmacotherapeutic cornerstone in the treatment of non-small cell lung cancer. As it is primarily eliminated by renal excretion, adequate renal function is essential to prevent toxic exposure. There is growing evidence for the nephrotoxic potential of pemetrexed, which even becomes a greater issue now combined immuno-chemotherapy prolongs survival. Therefore, the aim of this study was to describe the incidence of nephrotoxicity and related treatment consequences during pemetrexed-based treatment.

METHODS

A retrospective cohort study was conducted in the Jeroen Bosch Hospital, Den Bosch, the Netherlands. All patients that received at least 1 cycle of pemetrexed based therapy were included in the dataset. The primary outcome was defined as a ≥25 % reduction in eGFR. Additionally, the treatment consequences of decreased renal function were assessed. Logistic regression was used to identify risk factors for nephrotoxicity during treatment with pemetrexed.

RESULTS

Of the 359 patients included in this analysis, 21 % patients had a clinically relevant decline in renal function after treatment and 8.1 % of patients discontinued treatment due to nephrotoxicity. Cumulative dose (≥10 cycles of pemetrexed based therapy) was identified as a risk factor for the primary outcome measure (adjusted OR 5.66 (CI 1.73-18.54)).

CONCLUSION

This study shows that patients on pemetrexed-based treatment are at risk of developing renal impairment. Risk significantly increases with prolonged treatment. Renal impairment is expected to become an even greater issue now that pemetrexed-based immuno-chemotherapy results in longer survival and thus longer treatment duration.

A Population-Based Study of Incidence and Survival of 1588 Thymic Malignancies: Results From the California Cancer Registry

BACKGROUND

Thymic malignancies are rare and there are limited contemporary population-based epidemiological studies for this uncommon cancer.

PATIENTS AND METHODS

Adults aged 20 years and older diagnosed with thymic malignancies between 1988 and 2015 were identified from the California Cancer Registry (n = 1588). Trends in age-adjusted incidence rates were examined overall and according to race/ethnicity, and the proportion diagnosed according to stage was evaluated over time. Cox proportional hazards regression was used to estimate hazard ratios (HRs) for overall survival (OS), and Fine and Gray competing risks regression for cause-specific survival (CSS).

RESULTS

Age-adjusted incidence increased on average 2.08% per year over the study period (95% confidence interval [CI], 1.30%-2.86%; P < .0001), with an incidence of 0.277 cases per 100,000 in 2015. Incidence was highest among Asian/Pacific Islander and non-Hispanic black individuals. The proportion of unknown stage at diagnosis declined as localized diagnoses increased over time. Compared with patients with thymoma, those with thymic carcinoma had significantly worse OS (HR, 1.63; 95% CI, 1.33-2.01; P < .0001) and CSS (subdistribution HR, 2.99; 95% CI, 2.29-3.91; P < .0001). Advanced stage at diagnosis was also associated with worse survival. Surgical intervention was associated with better prognosis for patients with localized (HR, 0.08; 95% CI, 0.02-0.30; P = .0002) or regional disease (HR, 0.14; 95% CI, 0.06-0.34; P < .0001).

CONCLUSION

Thymic malignancy incidence is increasing in California. There was incidence variation across race/ethnicity, which warrants future study. These findings provide contemporary insight into the incidence and prognostic factors of thymic malignancies.

Spontaneous rupture of hepatic metastasis from a thymoma: A case report

Bleeding resulting from spontaneous rupture of the liver is an infrequent but potentially life threatening complication that may be associated with an underlying liver disease. A hepatocellular carcinoma or hepatic adenoma is frequently reported is such cases. However, hemoperitoneum resulting from a hepatic metastatic thymoma is extremely rare. Here, we present a case of a 62-year-old man with hypovolemic shock induced by ruptured hepatic metastasis from a thymoma. At the first hospital admission, the patient had a 45-mm anterior mediastinal mass that was eventually diagnosed as a type A thymoma. The mass was excised, and the patient was disease-free for 6 years. He experienced sudden-onset right upper quadrant pain and was again admitted to our hospital. We noted large hemoperitoneum with a 10-cm encapsulated mass in S5/8 and a 2.3-cm nodular lesion in the right upper quadrant of the abdomen. He was diagnosed with hepatic metastasis from the thymoma, and he underwent chemotherapy and surgical excision.

A Case Series of Patients With Autoimmune Myasthenia Gravis in Association With Invasive Thymoma

OBJECTIVES

In some patients, autoimmune myasthenia gravis (MG) is associated with thymic hyperplasia or thymoma, and in some patients the thymoma is invasive. Little is known about the clinical course of subjects who present with MG and are found to have invasive thymoma.

METHODS

We reviewed the patients at our clinic with MG and invasive thymoma, and have described their clinical features.

RESULTS

Six MG patients were diagnosed with invasive thymoma. The subjects had extensive multimodal therapy. Two subjects died from uncontrolled neuromuscular respiratory failure despite aggressive immunosuppression, 2 subjects had other autoimmune disorders (Morvan syndrome and polymyositis), and 2 subjects are controlled on immunosuppression.

CONCLUSIONS

Patients with invasive thymoma and MG can have a poor outcome, with difficulty in controlling myasthenic symptoms and can have other clinically important autoimmune diseases.

Chemotherapy with paclitaxel plus carboplatin for relapsed advanced thymic carcinoma

OBJECTIVE

For rarity of thymic carcinoma, no definitive chemotherapeutic regimen has been established in second- or further-line settings. The aim of this study was to evaluate the feasibility and safety of paclitaxel plus carboplatin in advanced thymic carcinoma as second- or further-line treatment in our institute.

METHODS

We evaluated the efficacy and toxicity of paclitaxel plus carboplatin as salvage therapy in 12 patients with previously treated advanced thymic carcinoma from 2005 to 2012 in Zhejiang Cancer Hospital. Survival analysis was evaluated by Kaplan-Meier method.

RESULTS

Twelve patients were included in current study. Four patients achieved stable disease (SD), and three achieved partial response (PR), representing a response rate of 25.0% and disease control rate (DCR) of 58.3%. Median progression-free survival (PFS) and overall survival (OS) were 3.5 and 24.0 months, respectively. The toxicities associated with the paclitaxel plus carboplatin was generally acceptable.

CONCLUSIONS

Paclitaxel plus carboplatin appears to have some activity against thymic carcinoma as second-line or later chemotherapy in advanced thymic carcinoma.

Docetaxel-based chemotherapy as second-line regimen for advanced thymic carcinoma

Thymic carcinoma is an uncommon neoplasm. The efficacy of second-line treatment with docetaxel in advanced thymic carcinoma has not been well studied. Therefore, we conducted a review of the efficacy of docetaxel-based chemotherapy as a second-line regimen for advanced thymic carcinoma. Fifteen patients with advanced thymic carcinoma who received second-line chemotherapy with docetaxel singlet or docetaxel/platinum combination chemotherapy regimens were retrospectively reviewed. There were 11 males and four females, with a median age of 53 years. Squamous cell carcinoma was most common (n = 10), followed by undifferentiated carcinoma (n = 4), and small cell carcinoma (n = 1). Eight patients received docetaxel/platinum combination chemotherapy and seven docetaxel mono-therapy. Four patients showed partial responses, representing a response rate of 26.7%. The median progression-free survival and overall survival in the 15 patients were 4.0 (2.8-5.2) and 22.0 (14.6-29.4) months, respectively. There was no difference in progression-free survival between the docetaxel singlet or docetaxel/platinum combination chemotherapy (3.5 months vs. 4.0 months, P = 0.889). A docetaxel-based regimen could be a potential therapeutic option as a second-line chemotherapy for advanced thymic carcinoma.

Thymic neoplasms: an update on the use of chemotherapy and new targeted therapies. A literature review

Thymic malignancies represent a wide range of clinical, histological and molecular entities, with probably considerable heterogeneity even among tumors of the same histotype. Systemic chemotherapy with cisplatin-based regimens continues to represent the standard of care in metastatic or inoperable refractory/recurrent diseases and ADOC regimen (including cisplatin, doxorubicin, vincristine and cyclophosphamide) demonstrated the longer overall response rate and median survival in the first line setting, although no randomized trial is available; and there is still a lack of standard treatment after first-line failure. To date research efforts are focused on translational studies on molecular pathways involved in thymic tumors carcinogenesis, aimed to better understand and predict the efficacy of chemotherapy and targeted therapy. Recent molecular characterization includes identification of a number of oncogenes, tumor suppressor genes, chromosomal aberrations, angiogenic factors, and tumor invasion factors involved in cellular survival and proliferation and in tumor growth. The use of biologic drugs is currently not recommended in a routine practice because there are limited data on their therapeutic role in thymic epitelial tumors. Because of the lack of data from adequate-sized, prospective trials are required for validation and the enrolment of patients with advanced disease into available clinical trials has to be encouraged.