Immune Checkpoint Inhibitors Rechallenge Efficacy in Non-Small-Cell Lung Cancer Patients

Rechallenge with immune-checkpoint inhibitors in patients with advanced-stage lung cancer

Lung cancer remains the leading cause of cancer-related mortality globally, with many patients diagnosed with advanced-stage disease. Treatment in this setting relies on systemic therapies, including chemotherapy, targeted therapy and immunotherapy. Immune-checkpoint inhibitors (ICIs), which promote or restore antitumour immunity by inhibiting immunosuppressive signalling pathways, are currently the most widely used immunotherapies in these patients. However, immune-related adverse events (irAEs) or disease progression often necessitate discontinuation of these agents, leaving many patients with limited subsequent treatment options. In this scenario, ICI rechallenge has emerged as a potential strategy. Despite this potential, evidence for ICI rechallenge after either disease progression or irAEs in patients with non-small-cell lung cancer is limited and evidence for those with small cell lung cancer seems to be non-existent. In this Review, we provide a comprehensive overview of the available data on ICI rechallenge in the context of both disease progression and irAEs, including a summary of current guidance on clinical management and detailed discussions of safety and efficacy. We also highlight important unanswered questions in an attempt to guide future research in this area.

Prospective Multi-Institutional Observational Study of Retreatment with Anti-PD-1/PD-L1 Antibodies in Patients with Non-Small Cell Lung Cancer Previously Treated with Anti-PD-1/PD-L1 Plus Chemotherapy: NJLCG (North Japan Lung Cancer Group) Trial 1901

The emergence of immune checkpoint inhibitors (ICIs) has revolutionized standard therapies for non-small cell lung cancer (NSCLC) [...].

Immunotherapy Strategies After Immune Checkpoint Inhibitor Exposure in Renal Cell Carcinoma: A Review

Importance

Immune checkpoint inhibitors have transformed the treatment landscape for metastatic renal cell carcinoma; however, the failure of first-line therapeutic strategies remains a considerable challenge. Currently, clinicians face various issues, such as managing cases in patients who progress during treatment or relapse after adjuvant immunotherapy.

Observations

This review evaluates different strategies for treating patients with advanced kidney cancer previously exposed to immunotherapy. Evidence from other malignant neoplasms suggests potential effectiveness for rechallenging with immune checkpoint inhibitors. The most important available data are presented, including retrospective, prospective, and randomized clinical trials, to explore the role of immunotherapy in patients with renal cell carcinoma who have experienced prior failure of immune checkpoint inhibitors.

Conclusions and Relevance

Although retrospective data suggest modest effectiveness of an immunotherapy rechallenge treatment, larger phase 3 trials failed to demonstrate substantial benefit in progression-free survival and overall survival. Currently, no randomized evidence supports the use of agents targeting conventional immune checkpoints in patients with renal cell carcinoma who have previously received immunotherapy.

Efficacy of immune checkpoint inhibitors rechallenge and metronomic cyclophosphamide with or without bevacizumab in metastatic nonsmall cell lung cancer

OBJECTIVE

The present study aims to evaluate the efficacy of immune checkpoint inhibitor (ICI) rechallenge in combination with metronomic cyclophosphamide, with or without bevacizumab, in patients with metastatic nonsmall cell lung cancer (NSCLC) and to investigate the clinical characteristics associated with the response to the therapy.

MATERIALS AND METHODS

The study included 43 patients with metastatic NSCLC who responded to ICIs for ≥4 months and subsequently experienced disease progression. The patients then underwent ICI rechallenge along with either oral cyclophosphamide daily alone (n = 24) or cyclophosphamide and bevacizumab (n = 19).

RESULTS

Combining ICI with cyclophosphamide resulted in an objective response rate (ORR) of 16.7%, disease control rate (DCR) of 75.0%, median progression-free survival (PFS) of 5.8 months, and overall survival (OS) of 15.4 months. Oral cyclophosphamide and bevacizumab cohort achieved an ORR of 26.3%, a DCR of 78.9%, a PFS of 6.8 months, and an OS of 17.6 months. No treatment-related adverse events resulted in the discontinuation of the study therapy in either cohort. Multivariate analysis demonstrated that the absence of an objective response to initial ICIs (OS: P = 0.016), poor Eastern Cooperative Oncology Group Performance Status (ECOG PS) (PFS: P = 0.017, OS: P = 0.032), and a neutrophil-to-lymphocyte ratio (NLR) ≥ 3.8 (PFS: P = 0.004, OS: P = 0.007) were negative predictors of rechallenge therapy.

CONCLUSION

The combination showed promising antitumor activity and a well-tolerated safety profile in patients with ICI-pretreated NSCLC. Furthermore, ECOG PS 0-1, objective response, and NLR ≤ 3.8 were predictive of the efficacy of the study therapy.

The efficacy of ICIs rechallenge in advanced small cell lung cancer after progression from ICIs plus chemotherapy: A real-world study

BACKGROUND

Rechallenging immune checkpoint inhibitors(ICIs) after resistance to initial ICIs plus chemotherapy(chemo-ICIs) remains uncertain in advanced small cell lung cancer(SCLC).

METHOD

The study retrospectively enrolled advanced SCLC patients who received ICIs after developing resistance to chemo-ICIs during hospitalization at Hunan Cancer Hospital from January 2020 to November 2023. The clinical outcomes and prognosis factors for ICIs rechallenge were further analyzed.

RESULTS

A total of 175 patients were included, of which 82(46.86 %) patients had primary resistance(PR) and 93(53.14 %) patients developed acquired resistance(AR). The progression-free survival(PFS), objective response rate (ORR), and disease control rate (DCR) of the total group were 3.3 months,16.57 %, and 53.71 %, respectively. The AR group exhibited significantly longer PFS compared to the PR group (4.5 months vs. 3.2 months, p = 0.012). In the PR group, a significantly longer PFS was found for ICIs rechallenge with interval treatment than without interval treatment(4.2 months vs. 3.1 months, p = 0.031). Within the AR group, the "new immunotherapy plus new chemotherapy" regimen showed a significantly longer PFS compared to the regimen of "maintain immunotherapy plus new chemotherapy" (8.3 months vs. 3.2 months, p = 0.014). The multivariate COX regression analyses demonstrated that both resistance pattern(p = 0.007) and treatment regimen(p = 0.039) independently served as risk factors for PFS in ICIs rechallenge.

CONCLUSION

Our study suggests that rechallenge of ICIs could be considered as a potential therapeutic strategy for advanced SCLC after progression from chemo-ICIs, particularly in patients with AR.

Comparative efficacy of immunotherapy-based treatment versus chemotherapy-only in patients with unresectable NSCLC with disease progression post chemoradiation and durvalumab

INTRODUCTION

The current standard of care for fit patients with unresectable stage III NSCLC involves concurrent chemoradiation (CRT) followed by durvalumab. Disease recurrence occurs in approximately 2/3 of patients, often necessitating subsequent systemic therapy. The only available data about re-challenge immune checkpoint blockers (ICB) in this setting derives from small retrospective series. We evaluated progression free survival (PFS) and overall survival (OS) in patients receiving either ICB-based therapy versus a chemotherapy (CT)-only for disease progression after CRT and durvalumab.

MATERIALS AND METHODS

Multicenter retrospective study, conducted across 10 centers in Italy, the USA, Israel, and The Netherlands. Consecutive patients with relapsed NSCLC following CRT and durvalumab were enrolled.

RESULTS

A total of 197 patients met the eligibility criteria: 93 received CT ( ± anti-VEGF), and 104 received an ICB-based treatment ( ± CT). The median PFS for patients receiving an ICB-based versus a CT-only regimen was 5.9 (95 % CI 4.3-7.6) versus 4.9 months (95 % CI 3.9-5.8), respectively (p = 0.011, HR: 0.67, 95 % CI 0.49-0.91). The median OS was 14.6 months (95 % CI 9.9-19.4) versus 8.9 (95 % CI 7.4-10.4), respectively (p = 0.005, HR: 0.61, 95 % CI 0.43-0.86). Patients with PFS ≥ 12 months on durvalumab, treated with subsequent ICB or CT median OS was 22.0 (95 % CI: 12.9-31.2) 9.8 months (95 % CI: 4.3-15.2) respectively (p = 0.024). Among patients with a PFS < 12 months on durvalumab there was no significant OS difference between ICB and CT arms.

CONCLUSIONS

ICB retreatment at disease progression after CRT and durvalumab might offer an OS benefit over CT in patients who do not relapse during durvalumab treatment.

Analysis of ICIs alone or in combination rechallenged outcomes after progression from first-line ICIs plus chemotherapy in patients with advanced non-small cell lung cancer

Immune checkpoint inhibitors (ICIs) plus chemotherapy have become the standard of care for first-line treatment of advanced non-small cell lung cancer (NSCLC) with EGFR/ALK negative. However, there is no clear second-line treatment option after first-line treatment failure. To investigate the efficacy and safety of ICIs alone or in combination rechallenge treatment after first-line ICIs plus chemotherapy progression in advanced NSCLC. We retrospectively analyzed the cases of patients who received ICIs alone or in combination rechallenge treatment after first-line ICIs plus chemotherapy progression in advanced NSCLC at Hunan Cancer Hospital between January 2020 and May 2024. We evaluated the effects of continued immunotherapy on patients' objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and adverse events after first-line treatment progression, and analyzed the relationship between outcomes and clinical characteristics. A total of 154 patients were included, with 146 patients developing resistance, 8 patients showing no progression. The ORR was 16.44%, the DCR was 68.49%, and the median PFS was 4.6 months. Patients treated with the new immune drug therapy had longer PFS than those treated with the original immunotherapy (5.0 months vs. 3.7 months, p = 0.0438). The PFS in patients receiving ICIs plus targeted therapy was significantly longer than that in patients who receiving ICIs alone, chemo-ICIs plus targeted therapy and ICIs plus chemotherapy (chemo-ICIs) (5.7 months vs. 3.6 months vs3.2 months vs. 2.9 months, p = 0.0086). Multivariate analysis showed that treatment regimen was a risk factor for immune rechallenge PFS, but there was no statistical correlation between gender, age, smoking history, pathological type, intermittent treatment or first-line drug resistance and immune rechallenge PFS. Our findings suggest that selecting ICIs plus targeted therapy may improve PFS in patients with advanced NSCLC after first-line chemo-ICIs progression. while replacement with new BSAb/PD-1 may be more beneficial to patients. However, there is a lack of large sample randomized controlled studies and evidence-based medical evidence, and more clinical studies are needed to further confirm.

Immune-related adverse events-pembrolizumab-induced colitis-the importance of early diagnosis and treatment: A case report and review of the literature

Immune Checkpoint Inhibitors (ICIs) are monoclonal antibodies that block inhibitory immune targets, such as cytotoxic T lymphocyte antigen 4 (CTLA-4), programmed cell death protein 1 (PD-1), and programmed death ligand 1 (PD-L). Pembrolizumab targets the PD-1 receptor of lymphocytes in lung cancer treatment. ICI checkpoint blockade enhances immunity against cancer cells. However, loss of immunoregulatory control can cause autoimmune reactions in various organs, leading to immune-related adverse events (irAEs). The most common irAE is ICIs-induced colitis, which usually develops 6-8 weeks after ICI initiation and can involve any part of the gastrointestinal system. Herein, we report a presentation of pembrolizumab-induced colitis in a female patient with metastatic lung cancer and review the most recent findings in the model of checkpoint-induced colitis. It was interesting to learn that the colon mucosa may show normal macroscopic findings, but microscopically, immunotherapy-induced autoimmune colitis could be present. Additionally, patients with grade 2 or higher symptoms should have a colonoscopy, receive systemic corticosteroids as treatment, and, based on their response, receive biologic therapy. Here, we present a case report of in a 45-year-old female who has been a smoker for 25 years, without comorbidities, and with metastatic lung cancer who developed colitis after the seventh cycle of pembrolizumab. This case presentation highlights the importance of early recognition and appropriate intervention in order to prevent permanent interruption of treatment with checkpoint inhibitors, as well as prevention of colitis complications.

Efficacy and safety of immune checkpoint inhibitors rechallenge in advanced solid tumors: a systematic review and meta-analysis

Introduction

The efficacy and safety of re-administration of immune checkpoint inhibitors (ICIs) in advanced solid tumors lacks consensus and is of great concern to clinicians. This study aimed to investigate the efficacy and adverse effects of ICIs rechallenges in advanced solid tumors.

Methods

We systematically searched the databases of PubMed, Embase, the Cochrane Library, and the China National Knowledge Infrastructure (CNKI), and screened the relevant literature according to the inclusion and exclusion criteria. Meanwhile, we conducted a meta-analysis of objective response rates (ORR), disease control rates (DCR), and immune-related adverse events (irAEs) for reuse of ICIs using Freeman-Tukey double arcsine transformation method.

Results

Sixty eligible studies were included in the meta-analysis, and the results revealed that those who discontinued ICIs therapy and reused ICIs had an ORR of 21.6% [95% confidence interval (CI): 17.6, 25.7] and a DCR of 55.8% (95% CI: 50.0, 61.5). The overall incidence for grade ≥ 3 irAEs was 16.7% (95% CI: 11.8, 22.2). In the subgroup analysis, patients with renal cell carcinoma presented superior efficacy with an ORR of 30.9%, which was higher than that of melanoma (24.3%) and non-small cell lung cancer (NSCLC) (10.1%). Patients who have been treated with single-agent ICIs, re-treatment with a combination of ICIs directing different targets presents better outcomes, with ORR of 22.5% and DCR of 38%, respectively, compared with those patients who continue to use a single agent.

Conclusion

Patients with advanced solid tumors who have relapsed or progressed after prior treatment with ICIs may benefit from ICIs rechallenge, with a comparable incidence of grade ≥ 3 irAEs to those previously treated with ICIs.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023407409.

Efficacy of immune checkpoint inhibitor rechallenge in initial immunotherapy responders with advanced non-small cell lung cancer: A single-center retrospective study

BACKGROUND

The efficacy of immune rechallenge in patients with advanced non-small cell lung cancer (NSCLC) who responded well to initial immune checkpoint inhibitor (ICI) treatment is becoming a research hotspot. This study was aimed at describing the survival and clinical characteristics after immune rechallenge in initial immunotherapy responders.

PATIENTS AND METHODS

We retrospectively identified 104 patients with advanced NSCLC who responded well in the first ICI and were rechallenged with immunotherapy to treat progression between January 2018 and June 2023 at Zhejiang Cancer Hospital. Progression-free survival (PFS) 2 and overall survival (OS) were defined as the time from the first day of the second ICI to the date of progression, death, or last follow-up.

RESULTS

Of 104 enrolled patients, 33 received immune monotherapy, and 71 were rechallenged with combination therapy (34 combined with anti-angiogenesis therapy). Patients with an initial immunotherapy duration exceeding 12 months, compared with a duration within 12 months, achieved a significantly prolonged mPFS2 and mOS (PFS2: 9.2 vs. 3.4 months, P < 0.001; OS: 25.5 vs. 10.7 months, P = 0.006). Patients rechallenged with combination therapy had significantly longer PFS2 than those receiving monotherapy (5.8 vs. 2.5 months, P = 0.040), and showed a favorable OS trend (15.9 vs. 10.1 months, P = 0.301). A significant difference in PFS2, particularly for patients receiving combined treatment with anti-angiogenesis therapy (8.7 vs. 4.6 months, P = 0.011), and a tendency toward longer OS (25.3 vs. 13.7 months, P = 0.090), were observed. Multivariate analysis identified long-term treatment duration (P = 0.005) and combined treatment with anti-angiogenesis therapy (P = 0.030) as independent positive factors associated with PFS after rechallenge.

CONCLUSION

Immune rechallenge is recommend for responders with a prolonged initial immunotherapy duration. Combination therapy, particularly that including anti-angiogenic therapy, is an alternative effective approach to immune rechallenge.

Efficacy of subsequent treatment for unresectable locally-advanced non-small cell lung cancer after relapse of concurrent chemoradiotherapy with durvalumab consolidation therapy: A single-center retrospective study

OBJECTIVES

The current standard treatment for locally advanced non-small cell lung cancer (LA-NSCLC) is concurrent chemoradiation therapy (CCRT) followed by durvalumab consolidation therapy. Although the trial revealed the survival benefit of adding an immune checkpoint inhibitor (ICI) to the population, the optimal treatment strategy and efficacy of subsequent treatment after relapse remain unclear.

MATERIALS AND METHODS

We retrospectively collected data from patients with unresectable LA-NSCLC who completed platinum-based CCRT as first-line treatment. Patients who received molecular-targeted therapy for driver gene alterations or did not receive durvalumab as consolidation therapy following the approval were excluded. We assessed differences in regimen and efficacy of subsequent treatment in patients who underwent durvalumab consolidation therapy (D group) and those who did not (CR group).

RESULTS

Among the 62 eligible patients, 32 were assigned to the D group and 30 to the CR group. Patients in the CR group were more frequently treated with an immune checkpoint inhibitor (ICI)-containing regimen than those in the D group (57 % vs. 13 %, p < 0.001). The median overall survival from initiation of subsequent treatment was shorter in the D group than in the CR group (13.0 months vs. 26.7 months, hazard ratio 2.60; 95 % confidence interval: 1.28-2.56, p = 0.008).

CONCLUSIONS

Patients with unresectable LA-NSCLC who relapsed after durvalumab consolidation therapy received an ICI-containing regimen less frequently, and the efficacy of the subsequent treatment was limited.

Immune checkpoint inhibitors rechallenge in non-small cell lung cancer: Current evidence and future directions

Immunotherapy, remarkably immune checkpoint inhibitors (ICIs), has significantly altered the treatment landscape for non-small cell lung cancer (NSCLC). Despite their success, the discontinuation of ICIs therapy may occur due to factors such as prior treatment completion, disease progression during ICIs treatment, or immune-related adverse events (irAEs). As numerous studies highlight the dynamic nature of immune responses and the sustained benefits of ICIs, ICIs rechallenge has become an attractive and feasible option. However, the decision-making process for ICIs rechallenge in clinical settings is complicated by numerous uncertainties. This review systematically analyses existing clinical research evidence, classifying ICIs rechallenge into distinct clinical scenarios, exploring methods to overcome ICIs resistance in rechallenge instances, and identifying biomarkers to select patients likely to benefit from rechallenge. By integrating recent studies and new technologies, we offer crucial recommendations for future clinical trial design and provide a practical guideline to maximize the therapeutic benefits of immunotherapy for NSCLC patients.

Predictive markers of response to immune checkpoint inhibitor rechallenge in metastatic non-small cell lung cancer

Aim

The present study aims to evaluate the efficacy of rechallenge with immune checkpoint inhibitors (ICIs) compared to chemotherapy and the predictive role of clinical parameters in non-small cell lung cancer (NSCLC) patients who were rechallenged.

Methods

The study included 113 metastatic NSCLC patients who had initially responded to ICIs and platinum-based chemotherapy, either in combination in the first line or sequentially in the first and second line, but later experienced disease progression. Of those patients, 52 later received ICI rechallenge and 61 were exposed to chemotherapy.

Results

In the rechallenge cohort, the median age was 67 years, 38 patients were men (73.1%), 26 (50.0%) had squamous cell carcinoma. Patients who underwent ICI rechallenge had longer overall survival (OS) compared to those who received chemotherapy (12.9 months vs. 9.6 months, P = 0.008). Multivariate analysis for progression-free survival (PFS) and OS revealed that poor Eastern Cooperative Oncology Group Performance Status (ECOG PS; PFS: P = 0.013 and OS: P = 0.037), absence of objective response during initial ICI therapy (PFS: P = 0.014 and OS: P = 0.028), and baseline neutrophil-to-lymphocyte ratio (NLR) ≥ 3.8 (PFS: P = 0.001 and OS: P = 0.003) were negative predictive factors of ICI rechallenge. The three parameters were included in a risk model named as the NEO score, which stratified patients who received ICI rechallenge into two predictive groups. Patients with ECOG PS 0-1, objective response during initial ICI treatment, and NLR < 3.8 (favorable group) had longer PFS (8.6 months vs. 3.0 months, P < 0.001) and OS (16.6 months vs. 5.5 months, P < 0.001) compared to those with absence of all three markers (poor group). There was no association between the NEO score and survival outcomes in patients who did not undergo rechallenge.

Conclusions

ICI rechallenge showed a survival benefit, particularly in NSCLC patients with NLR < 3.8, good ECOG PS, and objective response.

Safety and Efficacy of Rechallenge With Immune Checkpoint Inhibitors in Advanced Solid Tumor: A Systematic Review and Meta-Analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have drastically shifted the current landscape toward a wide variety of malignancies. However, ICIs are interrupted owing immune-related adverse events (irAEs), therapy completion, and disease progression. The risk-benefit of rechallenged ICIs remains inconclusive. Herein, a systematic review and meta-analysis were conducted to evaluate the safety and efficacy of ICI rechallenge in the treatment of advanced solid tumor.

METHODS

PubMed, Web of Science, Embase, and Cochrane Library were searched to analyze the efficacy and safety of ICI rechallenge. The study protocol was approved by the PROSPERO International Register of Systematic Reviews (CRD42022372222). The last updated search date was March 2, 2024. Objective response rate (ORR), disease control rate (DCR), overall survival (OS), and incidence rates of all- and high-grade irAEs were evaluated.

RESULTS

A total of 41 retrospective studies comprising 2343 patients were ultimately enrolled for qualitative and quantitative assessments. A total of 1200 (51.2%) individuals were male and the median age was 66 years (range 18-97 years). The majority of the tumors was lung cancer (n = 898, 38.3%). The occurrence rates of all-grade and high-grade (grade 3 or 4) irAEs between initial and readministration ICIs were not significantly different (all-grade: OR, 0.75, 95% CI: 0.39-1.45, p = 0.40; I2 = 87%; high-grade: OR, 0.96, 95% CI: 0.62-1.49, p = 0.87, I2 = 65%). ICIs restart presented a decreased ORR and DCR compared to initial ICI administration (ORR: OR, 0.36, 95% CI: 0.23-0.56, p < 0.00001; I2 = 67%; DCR: OR, 0.62, 95% CI: 0.43-0.89, p = 0.010; I2 = 53%). Seven studies with 513 patients for survival analysis revealed a nonsignificant difference in OS between the ICIs rechallenge and discontinuation cohorts (hazard ratio [HR]: 0.68, 95% confidence interval (CI): 0.35 to 1.35, p = 0.27).

CONCLUSION

Rechallenging immunotherapy is feasible, and patients should be carefully evaluated by a multidisciplinary team prior to initial therapy for close monitoring and assessment of the risk-benefit ratio. Therefore, prospective trials are essential to guide clinicians in the decision-making process. PROSPERO Registration: CRD42022372222.

Retreatment with Immune Checkpoint Inhibitors in the New Scenario of Immunotherapy in Non-Small Cell Lung Cancer

The advent of immunotherapy has transformed the treatment paradigm for metastatic non-small cell lung cancer (NSCLC). In the past few years, several studies have investigated the potential role of immune checkpoint inhibitors (ICIs) in resectable and unresectable locally advanced disease, achieving remarkable results that led to their approval in clinical practice. However, there is limited evidence on immunotherapy rechallenge after recurrence, with the majority of available knowledge coming from retrospective studies which involve heavily pretreated patients with advanced NSCLC. The recent introduction in the curative setting and the potential regulatory restrictions raise questions about the optimal choice of first-line and subsequent therapies for patients with systemic relapse. The role of immunotherapy readministration in this new scenario needs to be clarified, as well as the identification of patients for whom it is more appropriate, including clinical characteristics, duration of response, switching to other ICIs, reasons for discontinuation and immune-related toxicity. Here, we review literature on rechallenge with immunotherapy, including efficacy, safety profile and potential predictive factors of response.

Effectiveness and Safety of Anlotinib Combined with PD-1 Blockades in Patients with Previously Immunotherapy Treated Advanced Non-Small Cell Lung Cancer: A Retrospective Exploratory Study

Objective

This study aimed to investigate the effectiveness and tolerability of anlotinib plus PD-1 blockades in patients with previously immunotherapy treated advanced non-small-cell lung cancer (NSCLC).

Methods

A total of 67 patients with previously immunotherapy treated advanced NSCLC who received anlotinib plus PD-1 blockades in clinical practice were screened retrospectively. All the PD-1 blockades used in this study were approved in China and consisted of sintilimab, camrelizumab, tislelizumab and pembrolizumab. Effectiveness and safety of anlotinib plus PD-1 blockades were assessed, and all patients were followed up regularly. Clinical significance between response status to previous immune-related treatment regimens and therapeutic outcomes of anlotinib plus PD-1 blockades was further explored.

Results

The best overall response among the 67 patients suggested that a partial response was observed in 16 patients, stable disease was noted in 41 patients and progressive disease was found in 10 patients, which yielded an objective response rate of 23.9% (95% CI: 14.3-35.9%) and a disease control rate of 85.1% (95% CI: 74.3-92.6%). Prognostic outcomes indicated that the median progression-free survival (PFS) was 6.1 months (95% CI: 2.37-9.83) and the median overall survival (OS) was 16.5 months (95% CI: 10.73-22.27). Exploratory analysis highlighted that patients who were intolerant to previous immune-related regimens (17 patients) might have a superior prognosis (median OS: 22.3 months vs 12.5 months, P=0.024). Additionally, adverse reactions with any grades during anlotinib plus PD-1 blockades administration were observed in 62 patients (92.5%), of which 31 patients (46.3%) had ≥grade 3 adverse reactions. Most common adverse reactions were fatigue, hypertension, diarrhea and hepatotoxicity.

Conclusion

Anlotinib plus PD-1 blockades demonstrated promising effectiveness and tolerable safety in patients with previously immunotherapy treated advanced NSCLC. Those who were intolerant to previous immune-related regimens might benefit significantly from treatment with anlotinib plus PD-1 blockades. This conclusion should be confirmed in future studies.

Rechallenge of immune checkpoint inhibitors in advanced non-small cell lung cancer

Immune checkpoint inhibitor (ICI) rechallenge in non-small cell lung cancer (NSCLC) is a promising therapeutic strategy. The situation for ICI rechallenge can be divided into three categories: adverse events (AEs); resistance to ICIs, and rechallenge becomes compulsive because of tumor relapse while the patients had completed a 2 year course of immunotherapy. However, these categories are still controversial and should be explored further. Through voting at the 6th Straits Summit Forum on Lung Cancer, in this study we summarize the consensus of 147 experts in ICI rechallenges. A total of 97.74% experts agreed to rechallenge; 48.87% experts rechallenge with the original drug, and the others rechallenge with a different drug; 40.3% agreed to rechallenge directly after progression; 88.06% experts agreed to ICI rechallenge with a combination regimen; and factors such as previous performance status score, PD-1 expression, and age should also be considered. Understanding the the clinical studies in ICI rechallenge could bring us one step closer to understanding the consensus. In patients with advanced NSCLC who have suffered recurrent or distant metastasis after immunotherapy, the option of rechallenge with ICIs is a promising treatment option.

Immune checkpoint inhibitors in non-small cell lung cancer - When should we dare to stop treatment?

Over the last years, the emergence of immune checkpoint inhibitors (ICI) has revolutionized the treatment of non-small cell lung cancer (NSCLC). Patients in a palliative setting with previously very poor prognosis may now show remarkable responses over years. Yet, ICI therapy is very cost-intensive and involves frequent contacts with healthcare resources. Some of the early trial protocols restricted ICI treatment duration to two years. Now follow-up data of these studies is available and reveal the possibility of a persistent response after two or more years without further treatment for patients having successfully completed two years of therapy. May we now dare to think (and speak) of cure in the palliative setting? Does it mean we can stop ICI therapy after an initial two-year treatment? In this review, we try to improve confidence in clinical decision-making for this patient group. To this end, trials with a restricted treatment duration of two years and other data considering potential ICI discontinuation in responding patients were evaluated. Up to 25% of patients successfully complete an initial two-year course of ICI. Within this group about 40-46% of patients are alive at five years without further treatment with five-year survival rates of up to 83%. Data on ICI rechallenge are scarce, yet it does not seem to provide the same level of efficacy as at first exposure. At present there are no established biomarkers to help with decision-making. Possible future (bio-)markers, such as PD-L1, mutations, circulating tumor DNA (ctDNA) or Positron emission tomography (PET) need to be evaluated further in a prospective setting. In conclusion, we propose that the concept of discontinuing ICI therapy in patients with tumor response has to be seriously taken into consideration as it may be of benefit to our patients and health care systems.

Efficacy and safety of immune checkpoint inhibitor rechallenge in non-small cell lung cancer: A systematic review and meta-analysis

BACKGROUND

The aim of the study was to explore the efficacy and safety of immune checkpoint inhibitor (ICI) rechallenge in patients with non-small cell lung cancer (NSCLC).

METHODS

Studies that enrolled NSCLC patients treated with two lines of ICIs were included using four databases. The initial line (1L-) and subsequent lines (2L-) of ICIs were defined as 1L-ICI and 2L-ICI, respectively.

RESULTS

A total of 17 studies involving 2100 patients were included. The pooled objective response rate (ORR), disease control rate (DCR), median progression-free survival (mPFS), and median overall survival (mOS) for 2L-ICIs were 10%, 50%, 3.0 months, and 13.1 months, respectively. The 2L-ICI discontinuation rates caused by toxicities ranged from 0% to 23.5%. Original data were extracted from six studies, covering 89 patients. Patients in whom 1L-ICIs were discontinued following clinical decision (the mPFS of 2L-ICIs was not reach) achieved a more prolonged mPFS of 2L-ICIs than those due to toxicity (5.2 months) and progressive disease (2.1 months) (p < 0.0001). Patients' 1L-PFS for more than 2-years had preferable 2L-ORR (35.0% vs. 9.8%, p = 0.03), 2L-DCR (85.0% vs. 49.0%, p = 0.007), and 2L-mPFS (12.4 vs. 3.0 months, p < 0.0001) than those less than 1-year. Patients administered the same drugs achieved a significantly prolonged mPFS compared with the remaining patients (5.4 vs. 2.3 months, p = 0.0004), and those who did not accept antitumor treatments during the intervals of two lines of ICIs achieved a prolonged mPFS compared to those patients who did accept treatments (7.6 vs. 1.9 months, p < 0.0001).

CONCLUSIONS

ICI rechallenge is a useful therapeutic strategy for NSCLC patients, especially suitable for those who achieve long-term tumor remission for more than 2-years under 1L-ICIs.

The Effectiveness of Cancer Immune Checkpoint Inhibitor Retreatment and Rechallenge-A Systematic Review

Despite a great success of immunotherapy in cancer treatment, a great number of patients will become resistant. This review summarizes recent reports on immune checkpoint inhibitor retreatment or rechallenge in order to overcome primary resistance. The systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed using PubMed, Web of Science and Scopus. In total, 31 articles were included with a total of 812 patients. There were 16 retreatment studies and 13 rechallenge studies. We identified 15 studies in which at least one parameter (overall response rate or disease control rate) improved or was stable at secondary treatment. Interval treatment, primary response to and the cause of cessation for the first immune checkpoint inhibitors seem to be promising predictors of secondary response. However, high heterogeneity of investigated cohorts and lack of reporting guidelines are limiting factors for current in-depth analysis.

What to do after immune-checkpoint inhibitors failure in advanced non-small cell lung cancer: an expert opinion and review

INTRODUCTION

Immune-checkpoint inhibitors (IO) have significantly improved outcomes of patients with non-oncogene-addicted non-small cell lung cancer (NSCLC), becoming the first-line agents for advanced disease. However, resistance remains a significant clinical challenge, limiting their effectiveness.

AREAS COVERED

Hereby, we addressed standard and innovative therapeutic approaches for NSCLC patients experiencing progression after IO treatment, discussing the emerging resistance mechanisms and the ongoing efforts to overcome them. In order to provide a complete overview of the matter, we performed a comprehensive literature search across prominent databases, including PubMed, EMBASE (Excerpta Medica dataBASE), and the Cochrane Library, and a research of the main ongoing studies on clinicaltrials.gov.

EXPERT OPINION

The dynamics of progression to IO, especially in terms of time to treatment failure and burden of progressive disease, should guide the best subsequent management, together with patient clinical conditions. Long-responders to IO might benefit from continuation of IO beyond-progression, in combination with other treatments. Patients who experience early progression should be treated with salvage CT in case of preserved clinical conditions. Finally, patients who respond to IO for a considerable timeframe and who later present oligo-progression could be treated with a multimodal approach in order to maximize the benefit of immunotherapy.

Clinical Efficacy and Safety of Immunotherapy Retreatment in Metastatic Cervical Cancer: A Retrospective Study

Purpose

Metastatic cervical cancer has a poor prognosis, and treatment options are limited. Immunotherapy has been used to achieve disease control in patients with cervical cancer; however, the efficacy of immunotherapy retreatment after disease progression is unclear. This study aimed to explore the efficacy and safety of immunotherapy retreatment in metastatic cervical cancer.

Patients and methods

We retrospectively reviewed the clinical data of patients with metastatic cervical cancer who underwent immunotherapy retreatment after disease progression following previous immunotherapy from June 2019 to April 2021.

Results

Fifteen patients were included in this study. All patients received combination immunotherapy retreatment consisting of camrelizumab, nab-paclitaxel, and apatinib. Four (26.7%) patients achieved partial response while three (20.0%) achieved stable disease. The objective response rate and disease control rate were 26.7% and 46.7%, respectively. The median progression-free survival and overall survival were 3.0 (95% confidence interval: 1.0-5.0) and 8.0 (95% confidence interval: 3.4-12.6) months, respectively. None of the patients discontinued treatment because of intolerable toxicity.

Conclusion

Our findings suggest that the triplet combination immunotherapy retreatment could be a therapeutic option for patients with metastatic cervical cancer who failed initial immunotherapy.

Safety and preliminary activity of pembrolizumab-carboplatin-paclitaxel in heavily pretreated and/or fragile patients with PDL1-positive recurrent/metastatic head and neck cancer

Novel chemo-immunotherapy (chemo-IO) combinations should be evaluated, which may be suitable for cisplatin-unfit or fluoropyrimide-ineligible patients with recurrent or metastatic squamous cell carcinoma of head and neck (R/M SCCHN) to guarantee higher and deeper responses than IO alone. The aim of the present study was to review our experience using pembrolizumab-carboplatin-paclitaxel (pembro + CP) in patients with R/M SCCHN. This was a retrospective study of patients with R/M SCCHN who received pembro + CP in any-line via a compassionate-use program. The present study evaluated safety using Common Terminology Criteria for Adverse Events v4.0, compliance, overall response rate (ORR) and disease control rate (DCR) using Response Evaluation Criteria in Solid Tumors 1.1, duration of treatment, progression-free survival (PFS) and overall survival (OS). Between March 2020 and August 2021, 10 patients were identified (median age, 64 years; female, 60%; Eastern Cooperative Oncology Group 2, 80%). A total of 8 patients received pembro + 3-weekly carboplatin-paclitaxel (3wkCP). A total of 2 patients received pembro + weekly carboplatin-paclitaxel (wkCP). Patients received a median of 3 lines (range, 0-6) of systemic therapy prior to pembro + CP and 80% received IO in previous lines. Grade 1-2 adverse events (AEs) occurred in 100% of patients. Grade 3-5 AEs occurred in 30% of patients [all grade 3 (anemia, neutropenia, thrombopenia, hypertension)]. The mean numbers of pembro + wkCP and pembro + 3wkCP cycles were 2.5 and 6. The ORR (n=7) was 14% (1/7) with one complete response. The DCR was 43% (3/7). The median PFS (n=7) and OS (n=10) times since pembro + CP were 5 months (95% CI, 1-9) and 6 months (95% CI, 0.5-14), respectively. In this small retrospective series of heavily pretreated patients, pembro + CP was well tolerated, and compliance was high. Studies should be conducted to prospectively evaluate the safety and efficacy of this combination in patients with R/M SCCHN.

Safety and efficacy of immunotherapy rechallenge following checkpoint inhibitor-related pneumonitis in advanced lung cancer patients: a retrospective multi-center cohort study

BACKGROUND

Checkpoint inhibitor-related pneumonitis (CIP) induced by immune checkpoint inhibitors (ICIs) is one of the most fatal immune-related adverse events (irAE). However, only limited data are available on rechallenge with ICIs after CIP. We evaluated the efficacy and safety of rechallenge after CIP in patients with advanced lung cancer to identify the potential populations that would benefit.

METHODS

We conducted a multicenter retrospective study of advanced lung cancer patients who received further ICI treatment (rechallenge) or did not undergo re-administration after grade ≥1 CIP between May 2017 and May 2021. Progression-free survival (PFS) and overall survival (OS) were estimated from first or second ICI initiation to disease progression (PFS1 and PFS2, respectively), death, or last follow-up (OS1 and OS2, respectively). The recurrence of CIP and new irAEs in these patients after ICI rechallenge were calculated.

RESULTS

Among 107 patients afflicted with CIP, 45 (42.1%) received ICI rechallenge. Multivariate analysis showed that severe grade (grades ≥3) and ground-glass opacity of pneumonitis lesions were negatively associated with rechallenge. Following rechallenge, 9 (20.0%) patients developed recurrent pneumonitis, and 11 (24.4%) developed a new irAE. Severe grade of CIP and poor performance status at initial CIP as well as levels of interleukin (IL)-6 and C-reactive protein (CRP), and absolute white blood cell and neutrophil counts at the time of ICI rechallenge were associated with a higher recurrence rate. The median (95% confidence interval) PFS1 and PFS2 were 17.9 (9.9-24.2) and 15.5 (5.5-25.6) months, respectively. The median (95% confidence interval) OS1 and OS2 were 23.5 (16.5-30.5) and 18.4 (10.1-26.7) months, respectively. Lower OS2 was observed in patients with severe grade of CIP and poor performance status at the initial CIP, recurrence of CIP, and in patients with high levels of CRP and IL-6 at rechallenge. Only IL-6 was found to affect OS2 on multivariate analysis.

CONCLUSIONS

ICI rechallenge following CIP may be a promising treatment for patients with advanced lung cancer, particularly in those with low-grade of CIP and good performance status at initial CIP, and low levels of IL-6 and CRP at the time of initial challenge. Prospective studies are needed for further verification.

Real-World Data on Pembrolizumab for Pretreated Non-Small-Cell Lung Cancer: Clinical Outcome and Relevance of the Lung Immune Prognostic Index

BACKGROUND

Pembrolizumab is licensed for the treatment of pre-treated and PD-L1 positive non-small cell lung cancer (NSCLC), but response is heterogeneous. In this context, the Lung Immune Prognostic Index (LIPI) has been proposed as tool to prognosticate outcome.

OBJECTIVE

To investigate the real-world efficacy and safety of pembrolizumab in pre-treated NSCLC patients and the clinical utility of LIPI for patients' selection.

PATIENTS AND METHODS

Patients with pre-treated NSCLC and PD-L1 ≥ 1% treated with pembrolizumab were included in this retrospective series. The LIPI was used to classify patients in 3 prognostics subgroups according to the pre-treatment dNLR (derived neutrophil to lymphocyte ratio) and LDH in blood. The prognostic impact of the LIPI on progression free survival (PFS) and overall survival (OS) was evaluated with Cox regression. The combined effect of LIPI and other relevant prognostic factors was explored with multivariate regression.

RESULTS

In total, 113 consecutive patients were included. Median (mPFS) and mOS was 4.3 (2.6-6.7) and 13.5 (10.3-17.7) months, respectively. Good-, intermediate-, and poor-LIPI was found in 54 (47.8%), 45 (39.8%), and 8 (7.1%) patients, respectively. Median PFS was 5.1 (2.8-9.1), 3.0 (2.5-6.8), and 1.4 (0.5-18.7) months, and mOS was 17.2 (12.0-26.4), 11.8 (8.4-17.1), and 3.7 (0.5-not calculable) months for good-, intermediate-, and poor-LIPI group, respectively. Patients with intermediate-LIPI and poor-LIPI had worse PFS versus good-LIPI, and statistically significant worse OS (p = 0.030 and p = 0.013, respectively). In the multivariate analysis, intermediate- versus good-LIPI (p = 0.190) was not independently associated to PFS or OS. Patients with both good-LIPI and high (≥ 50%) PD-L1 had better OS than all other subgroups defined by LIPI and PD-L1. Immune-related adverse events (irAEs) occurred in 47 (41.6%) patients (12.4% grade ≥ 3). In a time-varying analysis, irAEs were statistically associated with longer OS (HR 0.51, 0.31-0.84; p = 0.008).

CONCLUSION

In our series, the outcome of pembrolizumab in pre-treated NSCLC is consistent with the registration trial. Lung Immune Prognostic Index is a readily available tool able to prognosticate outcome, also in PD-L1-high patients. The positive association between irAEs and OS might aid decision making.

Paclitaxel–bevacizumab combination in advanced non-squamous non-small-cell lung cancer (NSCLC): AVATAX, a retrospective multicentric study

Introduction:

Compared with docetaxel, the phase-III trial, ULTIMATE, showed a significant improvement of progression-free survival (PFS) with paclitaxel–bevacizumab combination (PB) as second- or third-line treatment in advanced non-small cell lung cancer (NSCLC). With the increase of immunotherapy treatment in first-line settings, the optimal treatment after first-line failure must be redefined.

Methods:

This multicentric retrospective study identified all advanced NSCLC patients treated with PB as second-line therapy and beyond. The main efficacy outcomes assessed were objective response rate (ORR), disease control rate (DCR), PFS, and overall survival (OS). The adverse events were reported according to Common Terminology Criteria for Adverse Events (CTCAE).

Results:

From January 2010 to February 2020, 314 patients in 16 centers received the PB combination. Most patients were male (55%), with a median age of 60 years (19–82), 95% had adenocarcinoma, 27% had a performance status ⩾2, 45% had brain metastases at the time of inclusion. They mostly received the PB combination either in second (20%) or in third-line (39%), and 28% were treated just after ICI failure. ORR and DCR were 40% and 77%, respectively; median PFS and OS were 5.7 [interquartile range (IQR): 3.2–9.6] and 10.8 [IQR: 5.3–19.6] months, respectively. All grade adverse events concerned 82% of patients, including 53% asthenia and 39% neurotoxicity, and 25% of patients continued monotherapy (mostly with bevacizumab) alone due to toxicity. Median PFS for patients treated after ICI failure (ICI+) was significantly superior compared with those not previously treated with ICI (ICI−): 7.0 [IQR: 4.2–11.0] versus 5.2 [IQR: 2.9–8.8] months, p = 0.01, without statistically significant difference for OS between these two groups. In multivariate analysis, factors associated with superior PFS were previous ICI treatment and performance status of 0–1. Only a performance status of 0–1 was associated with superior OS.

Conclusion:

PB combination as second-line treatment or beyond for advanced non-squamous NSCLC had acceptable toxicity and a clinically relevant efficacy and is an option as salvage treatment for these patients, more particularly after ICI progression.

Immune checkpoint inhibitor (ICI)-based treatment beyond progression with prior immunotherapy in patients with stage IV non-small cell lung cancer: a retrospective study

Background

Although immune checkpoint inhibitors (ICIs) provide unprecedented survival improvement for patients with advanced non-small cell lung cancer (NSCLC), disease progression inevitably occurs. After ICIs failure, limited data exist on whether ICI-based treatment beyond progression (TBP) may be beneficial to advanced NSCLC. This retrospective study aimed to evaluate the efficacy of this treatment approach in advanced NSCLC and identify potential beneficial factors.

Methods

Patients with stage IV NSCLC who received ICI-based treatment after the failure of prior PD-1/PD-L1 inhibitor treatments (monotherapy or combination therapy) between January 2016 and July 2020 were enrolled. Their clinical characteristics and treatment procedures were collected, and the follow-up would be performed.

Results

A total of 204 patients were included. All patients had disease progression after prior immunotherapy, with 49.5% (101/204) of patients presenting with new metastasis lesions and the rest 50.5% (103/204) of patients' progression on originate lesions. Within the entire cohort, the median progression-free survival (PFS) and median overall survival (OS) of ICI-based TBP with prior immunotherapy were 5.0 months (95% CI: 4.5-5.5 months) and 15.7 months (95% CI: 14.7-16.8 months), respectively. The objective response rate (ORR) and disease control rate (DCR) were 9.3% and 74.0%, respectively. According to the multivariate analysis, ICI-based combination therapy [PFS: hazard ratio (HR), 0.48, 95% confidence interval (CI): 0.28-0.84, P=0.011] (OS: HR, 0.44, 95% CI: 0.23-0.85, P=0.014), not having targetable gene alterations (PFS: HR, 0.56, 95% CI: 0.40-0.79, P=0.001) (OS: HR, 0.57, 95% CI: 0.37-0.87, P=0.009), and good response to prior immunotherapy (PFS: HR, 0.36, 95% CI: 0.24-0.53, P<0.0001) (OS: HR, 0.31, 95% CI: 0.19-0.52, P<0.0001) were independently associated with improved PFS and OS. Moreover, disease progression due to appearances of new metastasis (OS: HR, 0.56, 95% CI: 0.37-0.84, P=0.005) was only associated with better OS.

Conclusions

While the ORR in patients with advanced NSCLC receiving ICI-based TBP with prior immunotherapy was limited, the DCR was relatively high in our study which is encouraging. ICI-based treatment strategy may be a reasonable option for patients who progressed from prior immunotherapy. Further prospective studies on larger sample size are warranted.

Heterogeneous Outcomes of Immune Checkpoint Inhibitor Rechallenge in Patients With NSCLC: A Systematic Review and Meta-Analysis

Introduction

Outcomes of immune checkpoint inhibitor (ICI) rechallenge in NSCLC remain uncertain. This study estimated the safety and efficacy of ICI rechallenge and compared rechallenge benefit among different reasons of initial ICI discontinuation in NSCLC.

Methods

PubMed, EMBASE, and Cochrane Library were searched for studies on NSCLC retreated with ICI. Immune-related adverse events (irAEs), overall response rate (ORR), disease control rate (DCR), and progression-free survival (PFS) at initial ICI and rechallenge were analyzed.

Results

A total of 15 studies including 442 patients between 2018 and 2022 were eligible for meta-analysis. The incidence of grade 3 or 4 irAE was lower in rechallenge than initial ICI (8.6% versus 17.8%, p < 0.001). Patients rechallenged with ICI had lower ORR and DCR than initial ICI (13.2% versus 42.4%, p < 0.001; 51.1% versus 74.0%, p < 0.001). The ORR and DCR to ICI rechallenge were both higher in patients who experienced disease progression after stopping ICI or irAE than patients with disease progression during ICI treatment (ORR: 46.2% versus 20% versus 11.4%, p = 0.003; DCR: 84.6% versus 90.0% versus 55.0%, p = 0.002). In addition, 34.7% of 69 patients with individual response to ICI and PFS experienced the same or better response to ICI rechallenge in comparison with initial ICI, although PFS in initial ICI was longer than that in ICI rechallenge (median: 8.90 versus 3.67 mo, hazard ratio = 0.44, 95% confidence interval: 0.33-0.59).

Conclusions

ICI rechallenge had less severe toxicity than initial ICI treatment. Patients undergoing disease progression after ICI cessation or ICI discontinuation owing to irAE are more likely to benefit from ICI rechallenge in NSCLC.

Review of Immune-Related Adverse Events (irAEs) in Non-Small-Cell Lung Cancer (NSCLC)—Their Incidence, Management, Multiorgan irAEs, and Rechallenge

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced malignancies, including non-small cell lung cancer (NSCLC). These agents have improved clinical outcomes and have become quite an attractive alternative alone or combined with other treatments. Although ICIs are tolerated better, they also lead to unique toxicities, termed immune-related adverse events (irAEs). A reconstituted immune system may lead to dysregulation in normal immune self-tolerance and cause inflammatory side effects (irAEs). Although any organ system can be affected, immune-related adverse events most commonly involve the gastrointestinal tract, endocrine glands, skin, and liver. They can occur anytime during the treatment course and rarely even after completion. Owen and colleagues showed that approximately 30% of patients with NSCLC treated with ICIs develop irAEs. Kichenadasse et al. conducted a thorough evaluation of multiorgan irAEs, which is of particular interest because information regarding these types of irAEs is currently sparse. It is important to delineate between infectious etiologies and symptom progression during the management of irAEs. Close consultation with disease-specific subspecialties is encouraged. Corticosteroids are the mainstay of treatment of most irAEs. Early intervention with corticosteroids is crucial in the general management of immune-mediated toxicity. Grade 1–2 irAEs can be closely monitored; hypothyroidism and other endocrine irAEs may be treated with hormone supplementation without the need for corticosteroid therapy. Moderate- to high-dose steroids and other additional immunosuppressants such as tocilizumab and cyclophosphamide might be required in severe, grade 3–4 cases. Recently, increasing research on irAEs after immunotherapy rechallenge has garnered much attention. Dolladille and colleagues assessed the safety in patients with cancer who resumed therapy with the same ICIs and found that rechallenge was associated with about 25–30% of the same irAEs experienced previously (4). However, such data should be carefully considered. Further pooled analyses may be required before we conclude about ICIs’ safety in rechallenge.

Current Understanding and Future Perspectives on Hyperprogressive Disease Highlight the Tumor Microenvironment

Cancer immunotherapy with immune checkpoint inhibitors has revolutionized traditional cancer therapy. Although many patients have achieved long-term survival benefits from immune checkpoint inhibitors treatment, there are still some patients who develop rapid tumor progression after immunotherapy, known as hyperprogressive disease. Here we summarize current knowledge on hyperprogressive disease after immune checkpoint inhibitors treatment to promote more thorough understanding of the disease. This review focuses on multiple aspects of hyperprogressive disease, especially the tumor microenvironment, with the hope that more reliable biomarkers and therapeutics could be established for hyperprogressive disease in the future. This article is protected by copyright. All rights reserved.

REchallenge of NIVOlumab (RENIVO) or Nivolumab-Ipilimumab in Metastatic Renal Cell Carcinoma: An Ambispective Multicenter Study

Introduction. Immune checkpoint inhibitors (ICI) have been approved for front-line therapy in metastatic renal cell carcinoma (mRCC). However, progressive disease often occurs and subsequent therapies are needed. ICI rechallenge may be an option, but there is a lack of data regarding efficacy and prognostic factors. We assessed efficacy of ICI rechallenge and factors associated with better outcomes. Patients and Methods. This ambispective multicenter study included 45 mRCC patients rechallenged with nivolumab ± ipilimumab between 2014 and 2020. Primary endpoint was investigator-assessed best objective response rate (ORR) for ICI rechallenge (ICI-2). Factors associated with ICI-2 progression-free survival (PFS) were evaluated with multivariate Cox models. Results. ORR was 51% (n = 23) at first ICI therapy (ICI-1) and 16% (n = 7) for ICI-2. Median PFS was 11.4 months (95% CI, 9.8–23.5) and 3.5 months (95% CI, 2.8–9.7), and median overall survival was not reached (NR) (95% CI, 37.8–NR) and 24 months (95% CI, 9.9–NR) for ICI-1 and ICI-2, respectively. Factors associated with poorer ICI-2 PFS were a high number of metastatic sites, presence of liver metastases, use of an intervening treatment between ICI regimens, Eastern Cooperative Oncology Group performance status ≥2, and poor International Metastatic RCC Database Consortium score at ICI-2 start. Conversely, ICI-1 PFS >6 months was associated with better ICI-2 PFS. In multivariate analysis, there were only statistical trends toward better ICI-2 PFS in patients with ICI-1 PFS >6 months ( $p=0.07$ ) and toward poorer ICI-2 PFS in patients who received a treatment between ICI regimens ( $p=0.07$ ). Conclusion. Rechallenge with nivolumab-based ICI has some efficacy in mRCC. We identified various prognostic factors in univariate analysis but only statistical trends in multivariate analysis. Our findings bring new evidence on ICI rechallenge and preliminary but unique data that may help clinicians to select patients who will benefit from this strategy.

Safety of Immune Checkpoint Inhibitor Resumption after Interruption for Immune-Related Adverse Events, a Narrative Review

Immune checkpoint inhibitors (ICIs) have become the standard of care for several types of cancer due to their superiority in terms of survival benefits in first- and second-line treatments compared to conventional therapies, and they present a better safety profile (lower absolute number of grade 1-5 adverse events), especially if used in monotherapy. However, the pattern of ICI-related adverse events is totally different, as they are characterized by the development of specific immune-related adverse events (irAEs) that are unique in terms of the organs involved, onset patterns, and severity. The decision to resume ICI treatment after its interruption due to irAEs is challenged by the need for tumor control versus the risk of occurrence of the same or different irAEs. Studies that specifically assess this point remain scarce, heterogenous and mostly based on small samples of patients or focused only on the recurrence rate of the same irAE after ICI resumption. Moreover, patients with grade ≥3 irAEs were excluded from many of these studies. Herein, we provide a narrative review on the field of safety of ICI resumption after interruption due to irAE(s).

Efficacy and predictors of rechallenge with immune checkpoint inhibitors in non-small cell lung cancer

BACKGROUND

The efficacy of rechallenge with immune checkpoint inhibitors (ICIs) in non-small cell lung cancer (NSCLC) patients has not yet been fully clarified. This study aimed to identify the clinical characteristics of patients with NSCLC who benefited from rechallenge with ICIs.

METHODS

We retrospectively reviewed the clinical records of 24 patients who were diagnosed with NSCLC and rechallenged with ICIs between August 2016 and July 2021.

RESULTS

Of the 24 patients included in the study, 11 were in the responder group (45.8%) and 13 in the nonresponder group (54.2%). The number of patients who used a different ICI from that used in the initial therapy was significantly higher in the responder group than in the nonresponder group (p = 0.006). Multivariate analysis identified lung metastasis and female sex as significant independent risk factors for nonresponse to rechallenge with ICIs. Compared to the nonresponder group, the duration of treatment after rechallenge with ICIs was significantly longer in the responder group (p = 0.016), and there was a trend toward longer overall survival (p = 0.059).

CONCLUSIONS

Patients with lung cancer who were rechallenged with ICIs and without progressive disease after initial ICI therapy were able to continue ICI therapy for a longer period of time. This may be associated with longer survival. Patients with lung metastases and female patients are more likely to be nonresponsive to rechallenge with ICIs. Administration of a different type of ICI from that used in the initial ICI therapy may result in disease control.

Immune Checkpoint Inhibitor-Associated Colitis: From Mechanism to Management

Immune checkpoint inhibitors (ICIs), as one of the innovative types of immunotherapies, including programmed cell death-1 (PD-1), programmed cell death-ligand 1 (PD-L1), and cytotoxic T lymphocyte antigen 4 (CTLA-4) inhibitors, have obtained unprecedented benefit in multiple malignancies. However, the immune response activation in the body organs could arise immune-related adverse events (irAEs). Checkpoint inhibitor colitis (CIC) is the most widely reported irAEs. However, some obscure problems, such as the mechanism concerning gut microbiota, the confusing differential diagnosis with inflammatory bowel disease (IBD), the optimal steroid schedule, the reintroduction of ICIs, and the controversial prognosis features, influence the deep understanding and precise diagnosis and management of CIC. Herein, we based on these problems and comprehensively summarized the relevant studies of CIC in patients with NSCLC, further discussing the future research direction of this specific pattern of irAEs.

Common Immune-Related Adverse Events of Immune Checkpoint Inhibitors in the Gastrointestinal System: A Study Based on the US Food and Drug Administration Adverse Event Reporting System

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment; however, immune-related adverse events (irAEs) in the gastrointestinal (GI) system commonly occur. In this study, data were obtained from the US Food and Drug Administration adverse event reporting system between July 2014 and December 2020. Colitis, hepatobiliary disorders, and pancreatitis were identified as irAEs in our study. Reporting odds ratio (ROR) with information components (IC) was adopted for disproportionate analysis. A total of 70,330 adverse events were reported during the selected period, 4,075 records of which were associated with ICIs. GI toxicities have been reportedly increased with ICI, with ROR₀₂₅ of 17.2, 6.7, and 2.3 for colitis, hepatobiliary disorders, and pancreatitis, respectively. The risks of colitis, hepatobiliary disorders, and pancreatitis were higher with anti-CTLA-4 treatment than that with anti-PD-1 (ROR₀₂₅ 2.6, 1.3, and 1.1, respectively) or anti-PD-L1 treatment (ROR₀₂₅ 4.8, 1.3, and 1.3, respectively). Logistic analysis indicated that hepatobiliary disorders and pancreatitis more frequently occurred in female patients (adjusted odds ratio, 1.16 and 1.52; both p < 0.05). Consistently, polytherapy was a strong risk factor for colitis (adjusted odds ratio 2.52, p < 0.001), hepatobiliary disorders (adjusted odds ratio 2.50, p < 0.001), and pancreatitis (adjusted odds ratio 2.29, p < 0.001) according to multivariate logistic analysis. This pharmacovigilance analysis demonstrated an increased risk of all three GI irAEs associated with ICI therapies. The comparative analysis offered supportive insights on selecting GI irAEs for patients treated with ICIs.

Discontinuation of immune checkpoint inhibitor (ICI) above 18 months of treatment in real-life patients with advanced non-small cell lung cancer (NSCLC): INTEPI, a multicentric retrospective study

BACKGROUND

The optimal treatment duration of ICIs for patients with advanced NSCLC remains uncertain. In phase 3 clinical trials, treatment continued for 2 years or until disease progression with similar long-term survival rates. Real-life data are missing.

PATIENTS AND METHODS

This academic multicentric retrospective study aims at analyzing the characteristics of patients who discontinued treatment after at least 18 months of ICI monotherapy, in the setting of controlled disease.

RESULTS

Of the 1127 patients treated with immunotherapy in the given period in six centers, 107 patients had their tumor controlled after at least 18 months of treatment and 54 (50%) of them had discontinued ICI. The median duration of treatment was 26 months. Treatment was stopped due to prescriber choice or toxicity in 46% and 22% of cases, respectively. After a median follow-up of 21 months from ICI discontinuation (95% CI 15.0-26.1 months), 18 (33%) patients experienced tumor progression after a median time of 10.0 months (range 2-33). From discontinuation, 12-month overall survival (OS) and progression-free survival (PFS) were 90% (95% CI 77.7-95.7) and 71% (95% CI 56.8-81.5), respectively; 24-month OS and PFS were 84% (95% CI 68.7-92.2) and 63% (95% CI 46.1-76.2), respectively. Duration of disease control after ICI discontinuation was correlated with tumor response at treatment discontinuation: PFS rate at 12 months was 76% after complete response (CR n = 11) or partial response (PR n = 37) and 22% after only stable disease (SD n = 6) as best response, p-value = 0.0002. PFS rate at 12 months was 80% for CR and/or complete metabolic response with 18F-FDG PET/CT (CMR) and 65% for others. Fourteen patients out of the 18 relapse patients received a subsequent treatment: seven with ICI rechallenge (best response 14% PR and 86% SD) and five with localized therapy with 60% CR.

CONCLUSIONS

This real-life study provides new insight into long-term outcomes of patients with advanced NSCLC treated with ICI for at least 18 months before treatment discontinuation in the absence of PD. Tumor response and CMR with FDG PET just before therapy discontinuation may be a predictive factor of prolonged disease control upon discontinuation. These results call for caution in discontinuing treatment in patients with stable disease as the best response.

Rechallenge of immune checkpoint inhibitors: A systematic review and meta-analysis

BACKGROUND

The role of immune checkpoint inhibitors (ICI) rechallenge in cancer patients is not defined. When ICIs are discontinued due to treatment completion or toxicity, another course of ICIs is feasible in clinical practice, but the amount of data is still quite limited to draw definitive conclusions. Here we report the results of a meta-analysis evaluating efficacy and safety of ICI rechallenge.

METHODS

PubMed, Embase, and Cochrane library were searched for studies reporting efficacy and safety of ICI rechallenge. Pooled analysis of response rate (ORR), median progression-free survival (mPFS) and median overall survival (mOS) were calculated.

RESULTS

A total of 49 studies were included in qualitative and quantitative pooled analysis Overall response rate, mPFS and mOS were 21.8 % (range 0-70 %), 4.9 months (range 0-19.1 months) and 15.6 months (range 5.1-39 months), respectively. Incidence of any grade and grade 3-4 adverse events were 52.2 % (range 4-100 %) and 21.5 % (range 0-97.8 %), respectively. In the subgroup of patients who had previously discontinued ICI because of disease progression ORR, mPFS and mOS were 15.2 %, 2.9 and 7.9 months. Patients who had previously discontinued ICI because of toxicity achieved an ORR of 44 % and a mPFS of 13.2 months with the rechallenge.

CONCLUSIONS

Our results suggest that rechallenge ICI is an active and feasible strategy, and it could be considered on an individual basis. However, this analysis is based on non-randomized studies. Prospective studies are needed to clarify the role of rechallenge after disease progression or adverse events.

Applicability of PD-L1 tests to tailor triple-negative breast cancer treatment in Brazil

Background

Triple-negative breast cancer (TNBC) is a heterogeneous disease that represents 10–20% of breast cancer cases. The prognosis for advanced TNBC is usually poor, with a median overall survival of approximately 18 months or less.

Main text

New targeted therapies such as anti-PD-L1 agents are emerging as an option to treat advanced TNBC. A panel of 6 national experts with an active interest in breast cancer convened online. Panel members had either clinical or pathology experience in breast cancer. The experts pre-defined critical questions in the management of PD-L1 in TNBC, and a literature review was performed for selected topics before the online meeting.

Conclusion

The experts led active discussions involving a multidisciplinary team comprising pathologists and clinical oncologists. The meeting served to discuss the most relevant issues. A total of 10 critical questions for PD-L1+ TNBC were debated and are presented in this review. This article discusses the current landscape for PD-L1 tests in TNBC in Brazil.

Prognostic factors in patients with advanced non-small cell lung cancer after long-term Anti-PD-1 therapy (HOT1902)

OBJECTIVES

Limited information is available on the appropriate treatment duration of immune checkpoint inhibitors (ICIs). We aimed to identify candidates who would benefit from ICI discontinuation after one year of treatment for metastatic non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

This retrospective multi-institutional observational study examined medical records of all consecutive patients with advanced or recurrent NSCLC, who started ICI monotherapy at 15 institutions in Japan between December 2015 and December 2017. Patients who received initial ICI therapy for >1 year without progressive disease were defined as the long-term treatment (LT) group; others were defined as the non-long-term treatment (NLT) group. Primary outcomes included the prognostic factors in the LT group, whereas secondary outcomes included efficacy of ICI rechallenge, safety, and survival outcomes in the overall population.

RESULTS

In total, 676 patients were enrolled, and 114 (16.9 %) were assigned to the LT group. The median time interval from the start of initial ICI administration to data cutoff was 34.3 months (range, 24.1-47.8); thus, all surviving patients were followed-up for at least 2 years from the start of initial ICI. Median progression-free survival (PFS) was longer in the LT than in the NLT group (33.6 months vs. 2.7 months; p < 0.001). On multivariate analysis, significantly better PFS was associated with smoking (hazard ratio [HR]=0.36, p = 0.04), and complete response (CR; HR=uncomputable, p < 0.001) in the LT group. Thirty-seven patients (5.5 %) received ICI rechallenge, including 10 in the LT group. Among patients receiving rechallenge treatment, the median PFS was 2.2 months, with no difference between the LT and NLT groups.

CONCLUSIONS

In the LT group, smoking and achieving CR were significantly associated with better PFS. Since rechallenge treatment was not effective, careful consideration is required for discontinuing ICI. However, these prognostic factors are helpful in considering candidates for ICI discontinuation.

TRIAL REGISTRATION

UMIN ID, UMIN000041403.

Immunotherapy retreatment: case report, review of the literature and proposal for the definition of different scenarios

Immune checkpoint inhibitors have improved the treatment landscape of different tumors and one of the emerging issues is the reintroduction of immunotherapy after discontinuation. Scarce evidence is currently available and different definitions have been used. The case of a patient with pretreated advanced urothelial cancer, who responded to immunotherapy retreatment after long-term benefit from the previous course, is reported. Based on a review of the different clinical scenarios, a definition of immunotherapy retreatment was proposed, as rechallenge or reintroduction, based on the reasons of discontinuation of the previous course. Clinical factors potentially associated with clinical benefit from immunotherapy retreatment are discussed, even though ad hoc studies are needed to assess the efficacy and safety of the different immunotherapy retreatment strategies.

How I Treat Non-Small Cell Lung Cancer Refractory to Immunotherapy

Lung cancer is a leading cause of cancer-related mortality despite continued advances in diagnostic and therapeutic strategies. Although the development of immune checkpoint inhibitors has revolutionized the treatment landscape for advanced non-small cell lung cancer, many patients either have primary resistance to these agents or eventually develop secondary resistance necessitating a change to an alternate therapy. Understanding novel patterns of response to immunotherapy is crucial in determining appropriate selection and sequencing of treatment. Chemotherapy remains the standard of care in immunotherapy-refractory disease, but multiple trials are ongoing to explore the role of combination radioimmunotherapy and rechallenging with immunotherapy either alone or in combination with other antineoplastic agents.