Bevacizumab increases the risk of infections in cancer patients: A systematic review and pooled analysis of 41 randomized controlled trials

Hereditary haemorrhagic telangiectasia type 1 complicated by recurrent deep-seated MSSA infections necessitating lifelong antibiotic suppression

Hereditary haemorrhagic telangiectasia (HHT) leads to arteriovenous malformations (AVM) that increase the risk of haemorrhage and cause right-left shunting bypassing the reticuloendothelial system increasing the risk for recurrent infections. A 60+ year old male patient with HHT type 1 (status post six pulmonary AVM coiled embolisations) with epistaxis presented with intractable back pain, methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia and spinal MRI revealing spondylodiskitis and L4-L5 epidural phlegmon. He has an extensive history of deep-seated infections including two prior spinal infections, two joint infections and one muscular abscess-all with MSSA. The patient was treated with 6 weeks of intravenous nafcillin with symptom resolution. Infectious disease prescribed cefalexin 500 mg daily for suppression of infection recurrence considering his extensive deep-seated infection history and multiple risk factors. This case raises important questions about preventative antimicrobial management of high-risk patients with HHT, which is a grey area in current international HHT guidelines.

The Impact of Infections in Patients Treated with Atezolizumab Plus Bevacizumab for Unresectable Hepatocellular Carcinoma

Background: The therapeutic landscape of unresectable hepatocellular carcinoma (uHCC) continues to evolve. Atezolizumab, an anti-programmed cell death ligand 1 (PD-1) immune checkpoint inhibitor (ICI), in combination with bevacizumab, has substantially improved outcomes. This study aims to evaluate the incidence, risk factors, and outcomes in patients who develop infections while receiving atezolizumab and bevacizumab for uHCC. Methods: Patients who received atezolizumab and bevacizumab for uHCC at a single hospital network were included. Types and rates of infections were reported. Covariates compared among infected and non-infected cohorts included age, sex, race, comorbidities, Eastern Cooperative Oncology Group (ECOG) performance status, immunosuppressive use, chronic infections, number of cycles of ICIs given, antibiotic or antiviral therapies at ICI initiation, and line of therapy (first-line, second-line, greater than second-line). Results: Out of 810 evaluable patients, 34 uHCC patients were treated with atezolizumab plus bevacizumab. The mean ± SD age was 66.29 ± 9.39; 28 (82.35%) were males. There were 17 (50%) patients with reported infection, with bacterial infection occurring in 12 (70.59%) patients and COVID-19 in 4 (23.5%). Of the infected patients, eight (47.06%) had one infection, five (29.41%) had two infections, and two (11.76%) had three or more infections. Infected and non-infected patients received a median of 12 (IQR: 5-17) and 4 (IQR: 3-12) ICI cycles (p = 0.18), respectively. Infections did not negatively impact OS or PFS but resulted in treatment delays and discontinuation in 11 (64.71%) and 7 (41.18%) patients, respectively. At the last follow-up, 19 (55.88%) patients died, 9 (52.94%) in the non-infected group vs. 10 (58.82%) in the infected group (p = 1.0). Conclusions: While a broad array of infections occurred in 50% of the patients in this cohort, it did not negatively impact survival outcomes. However, it did impact morbidity, with more all-cause admissions and treatment delays.

Risk factors for infection of totally implantable central venous access ports among patients requiring port removal

BACKGROUND

Totally implantable central venous access ports, are required for various purposes, ranging from chemotherapy to nutrition. Port infection is a common complication. In many patients with port infection, the ports are removed because antibiotics are ineffective. We evaluated the risk factors associated with port removal due to port infection.

METHODS

By retrospective chart review, we collected data of 223 patients who underwent port removal for any reason. Port infection was defined as infection symptoms, such as fever; elevated white blood cell counts or C-reactive protein levels; or redness at the port site, in the absence of other infections, which improved with port removal. The characteristics of patients with or without port infection were compared using univariate (chi-squared test, t-test) and multivariate logistic regression analyses.

RESULTS

We compared 172 patients without port infection to 51 patients with port infection. Univariate analysis identified sex (p = 0.01), body mass index (BMI) ⩽20 kg/m2 (p = 0.00004), diabetes mellitus (p = 0.04), and purpose of use (p = 0.0000003) as significant variables. However, male sex (p = 0.03, 95% confidence interval [CI]: 0.01-0.23), BMI ⩽20 kg m2 (p = 0.002, 95% CI: 0.06-0.29), and purpose of use (total parenteral nutrition (TPN); p = 0.000005, 95% CI: 0.31-0.76) remained significant using multivariate analysis. Moreover, the patients with short bowel syndrome and difficulty in oral intake tended to be infected easily. Additionally, Staphylococcus species were the most common microbes involved in port infection.

CONCLUSIONS

Male sex, BMI ⩽20 kg/m2, and purpose of use as a TPN were risk factors for port infection. Ports should not be used for long duration of TPN or used only in exceptional cases.

Influence of antiresorptive/antiangiogenic therapy on changes in periodontal and oral tissue structures: a histomorphometrical analysis in rats

OBJECTIVE

The objective of this study was to investigate the influence of various antiresorptive and antiangiogenic medications on morphological changes in periodontal and oral tissue structures.

MATERIALS AND METHODS

Fifty-five Wistar rats randomly received dual application (i.e., at baseline and after 12-weeks) one of the following medications: (1) amino-bisphosphonate [zoledronate (Zo)], (2) RANKL inhibitor [denosumab (De)], (3) antiangiogenic [bevacizumab (Be)], (4) Zo + Be, (5) De + Be or (6) no medication [Control (Co)]. Periodontal and oral tissue biopsies were obtained at 17 (n = 21 animals, Phase 1, (De = 3, De + Be = 3, Zo = 5, Be = 3, Zo + Be = 2, Co = 5) and 29 (n = 34 animals, (De = 8, De + Be = 6, Zo = 2, Be = 7, Zo + Be = 4, Co = 7, Phase 2) weeks after the second drug application. The following outcomes were histomorphometrically assessed: periodontal space width in the coronal (PLS-C, mm) and apical sections (PLS- A), number of empty alveolar bone lacunae in the coronal, apical sections and at the apex at respective tooth sites (EL - C, EL- A, EL- Ap), mucosal thickness at edentulous alveolar ridge areas (MT, mm), and, when present, associated areas of inflammatory cell infiltrates (ICI, mm2).

RESULTS

Comparable mean PLS-C, PLS-A, ET-A, ET-C, ET-Ap, and MT values were observed in all experimental groups after Phases 1 and 2. The presence of ICI was identified in 3 animals in the Co group (Phase 1: 1, Phase 2: 2), and 17 animals in the test groups (Phase 1: 4; Phase 2: 14). The estimated ICI surface area was significantly higher in the Zo + Be group, followed by the Zo and Be groups compared to that measured in the Co group. The time (i.e., Phases 1 and 2) was not found to be a predictor for the extent of the ICI area. In all groups, the EL-C, EL-A, and EL-Ap values were significantly higher after Phase 2 compared to those assessed after Phase 1. The MT values were significantly reduced in all groups after Phase 2 compared to those measured after Phase 1.

CONCLUSIONS

The present evaluation was not able to find any morphological effects of different antiresorptive and antiangiogenic medications on periodontal and oral tissue structures. The presence of inflammatory cell infiltrates was more frequently observed in the animals administered with antiresorptive and antiangiogenic medications as well as combinations thereof.

CLINICAL RELEVANCE

Administration of antiresorptive and antiangiogenic medications may be capable of inducing inflammatory reactions in periodontal tissues.

Influence of antiresorptive/antiangiogenic therapy on the surgical treatment outcomes of experimentally induced peri-implantitis lesions

OBJECTIVE

To investigate the influence of various antiresorptive and antiangiogenic medications on the resolution of experimentally induced peri-implantitis lesions after different surgical treatment approaches.

MATERIALS AND METHODS

Forty-eight albino rats randomly received a dual application of the following medications: (1) amino-bisphosphonate (zoledronate (Zo)) (n = 8), (2) RANKL inhibitor (denosumab (De)) (n = 8), (3) antiangiogenic (bevacizumab (Be)) (n = 8), (4) Zo + Be (n = 8), (5) De + Be (n = 8), or (6) no medication (control (Co)) (n = 8). Ligature-induced peri-implantitis lesions were established at 2 maxillary implants over 16 weeks. Afterward, animals were randomly treated either with open flap debridement (OFD) or reconstructive therapy (RT). Treatment procedures were followed by a 12-week healing period. The histological outcomes included residual defect length (DL); defect width (DW) at the bone crest (BC-DW); 25%, 50%, and 75% of the DL; and areas of inflammatory cell infiltrate (ICT). When present, areas of bone sequester (BS) were assessed considering the animal as a statistical unit.

RESULTS

A total of 21 animals were analyzed (Zo: RT = 3, OFD = 1; De: RT = 3, OFD = 2; Be: OFD = 1; Zo + Be: RT = 2, OFD = 2; Co: RT = 3, OFD = 2). Implant loss rates were comparable among the experimental groups. Except for the 25% and 75% DW values that were significantly higher in the Zo + Be group compared to the Co group (p = 0.04 and p = 0.03, respectively), no significant differences were found among the experimental groups for the DL (lowest-Be: 0.56 mm; highest-Co: 1.05 mm), BC-DW (lowest-De: 0.86 mm, highest-Co: 1.07 mm), 50% DW (lowest-De: 0.86 mm; highest-Be + Zo: 1.29 mm), and ICT (lowest-Be: 0.56 mm2; highest-Be + Zo: 1.65 mm2). All groups, except for the Zo and Be following RT, showed presence of BS.

CONCLUSIONS

The present findings did not reveal a marked effect of various antiresorptive/antiangiogenic medications on the resolution of experimentally induced peri-implantitis lesions, regardless of the surgical approach employed (OFD and RT).

CLINICAL RELEVANCE

Resolution of peri-implantitis lesions may not be affected by the investigated antiresorptive/antiangiogenic medications.

Influence of antiresorptive/antiangiogenic therapy on the extension of experimentally induced peri-implantitis lesions

OBJECTIVES

To investigate the extension of experimentally induced peri-implantitis lesions under various antiresorptive and antiangiogenic medications.

MATERIAL AND METHODS

Fourty-eight albino rats had randomly received the following medications (dual application, n = 8 each): (1) amino-bisphosphonate (zoledronate) (Zo), (2) RANKL inhibitor (denosumab) (De), (3) antiangiogenic (bevacizumab) (Be), (4) Zo+Be, (5) De+Be, or (6) no medication (Co). Ligature- and lipopolysaccharide-induced peri-implantitis lesions were established at 2 maxillary implants over a period of 16 weeks. Histological (e.g., apical extension and surface area of the inflammatory cell infiltrate-aICT, ICT; defect length; defect width; CD68 positive cells) and bone micromorphometric (μCT) outcomes were assessed. The animal was defined as a statistical unit.

RESULTS

A total of n = 38 animals (Zo = 6, De = 6, Be = 8, Zo + Be = 6, De + Be = 5, Co = 7) were analyzed. ICT's were commonly marked by a positive CD68 antigen reactivity. Comparable median aICT (lowest-Zo: 0.53 mm; highest-Be: 1.22 mm), ICT (lowest-De + Be: 0.00 mm2; highest-Co: 0.49 mm2), defect length (lowest-Zo: 0.90 mm; highest-Co: 1.93 mm) and defect width (lowest-De+Be: 1.27 mm; highest-Be: 1.80 mm) values were noted in all test and control groups. Within an inner (diameter: 0.8 mm) cylindric volume of interest, the bone microstructure did not significantly differ between groups.

CONCLUSIONS

The present analysis did not reveal any marked effects of various antiresorptive/ antiangiogenic medications on the extension of experimentally induced peri-implantitis lesions.

CLINICAL RELEVANCE

The extension of peri-implantitis lesions may not be facilitated by the antiresorptive and antiangiogenic medications investigated.

Efficacy and Safety of Bevacizumab for Treating Glioblastoma: A Systematic Review and Meta-Analysis of Phase II and III Randomized Controlled Trials

OBJECTIVE

To fully investigate the efficacy and safety of bevacizumab for glioblastoma.

METHODS

Databases were searched for phase II/III randomized controlled trials treated with bevacizumab.

RESULTS

Bevacizumab significantly improved the PFS in glioblastoma patients, but did not prolong OS. PFS was significantly prolonged in both first-line and second-line treatment. Bevacizumab plus temozolomide was correlated with improved PFS for patients with different MGMT methylation status. Bevacizumab could increase the risk of hypertension, proteinuria, thromboembolic, and infection. Hypertension should be well concerned.

CONCLUSIONS

Bevacizumab-containing regimen can significantly improve PFS, but did not prolong OS.

Is there a real risk of bacterial infection in patients receiving targeted and biological therapies?

Over the past decades, the advent of targeted and biological therapies has revolutionized the management of cancer and autoimmune, hematological and inflammatory conditions. Although a large amount of information is now available on the risk of opportunistic infections associated with some of these agents, the evidence regarding the susceptibility to bacterial infections is more limited. Biological agents have been shown to entail a variable risk of bacterial infections in pivotal randomized clinical trials and post-marketing studies. Recommendations on risk minimization strategies and therapeutic interventions are therefore scarce and often based on expert opinion, with only a few clear statements for some particular agents (i.e. meningococcal vaccination for patients receiving eculizumab). In the present review the available information regarding the incidence of and risk factors for bacterial infection associated with the use of different groups of biological agents is summarized according to their mechanisms of action, and recommendations based on this evidence are provided. Additional information coming from clinical research and real-world studies is required to address unmet questions in this emerging field.

Risk and Incidence of Infection with Bevacizumab in Non-Small Cell Lung Cancer Patients: A Meta-analysis

BACKGROUND

A previous meta-analysis suggested that use of bevacizumab is associated with an increased risk of infection in cancer patients. With the continuous accumulation of evidence in non-small cell lung cancer (NSCLC), we performed a focused meta-analysis of randomized controlled clinical trials to quantify the relative risk and incidence of infectious complications in those individuals treated with bevacizumab.

METHODS

Electronic databases were searched, including PubMed, Embase, and Cochrane databases. Eligible studies were prospective randomized clinical trials of NSCLC patients treated with bevacizumab with toxicity data on infectious complications. Relative risk (RR), overall incidence rates, and 95% confidence intervals (CI) were calculated using fixed or random effects models depending on the heterogeneity of the included studies.

RESULTS

A total of 4,545 patients from 14 prospective RCTs (randomized controlled trials) were included for the meta-analysis. Treatment with bevacizumab was not associated with an increased risk of all grade (RR 1.12, 95% CI: 0.84 - 1.49) or high grade (RR 1.11, 95% CI: 0.86 - 1.41) infections, respectively. The summary incidences of all-grade and high-grade infection in patients receiving bevacizumab in the treatment group were 16.4% (95% CI: 15.7 - 17.2%) and 4.3% (95% CI: 3.0 - 6.1%), respectively.

CONCLUSIONS

The use of bevacizumab is not associated with a significantly higher risk of infections in NSCLC patients. These data provide reassurance regarding the risk of incidence of infection in patients with NSCLC receiving bevacizumab.

Pharyngeal spreading of peri-implant infections under antiresorptive/antiangiogenic therapy

Objectives

To assess the influence of antiresorptive/antiangiogenic therapy on the spreading of peri-implant infections in the pharyngeal region.

Material and methods

This analysis was based on tissue biopsies obtained from a total of twenty-five albino rats having either received (1) amino-bisphosphonate (Zoledronate) (Zo) (n=4), (2) RANKL inhibitor (Denosumab) (De) (n=4), (3) antiangiogenic medication (Bevacizumab) (Be) (n=4), (4) Zo+Be (n=3), (5) De+Be (n=5), or (6) no medication (Co) (n=5). Drug administration was repeated at 12 weeks. Chronic-type peri-implant infections were induced at titanium implants located in the upper jaws. The surface area (%) of infiltrated connective tissue (ICT) and CD68-positive cells was assessed within the lateral pharyngeal/retropharyngeal connective tissue zone.

Results

Mean (±SD) and median ICT% values and CD68 counts were markedly highest in the De+Be (11.10±6.04; 11.81; 95% CI − 3.89; 26.11) and De (5.70±5.06; 6.19; 95% CI − 2.34; 13.75) groups, reaching statistical significance for De CD68 counts over the Co (0.18±0.25; 0.18; 95% CI −2.14; 2.51) group. In both De+Be and De groups, the ICTs were occasionally associated with an ulceration of the epithelial compartment.

Conclusions

Induced peri-implant infections were not associated with any inflammatory lesions in pharyngeal tissues. While these findings were similar under Zo and Be medication, De and De+Be had a marked effect on ICT and CD68 values. The clinical relevance of these adverse findings needs further investigation.

Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC)

INTRODUCTION

Patients with hematological and advanced solid malignancies have acquired immune dysfunction, often exacerbated by treatment, posing a significant risk for the development of infections. This review evaluates the utility of current clinical and treatment guidelines, in the setting of management of infections in cancer patients.

AREAS COVERED

These include causes of infection in cancer patients, management of patients with high-risk and low-risk febrile neutropenia, management of low-risk patients in an outpatient setting, the role of granulocyte colony-stimulating factor (G-CSF) in the prevention and treatment of neutropenia-related infections, management of lung infections in various clinical settings, and emerging challenges surrounding the risk of infection in cancer patients treated with novel treatments. The literature search was performed by accessing PubMed and other databases, focusing on published clinical trials of relevant anti-cancer agents and diseases, primarily covering the recent past, but also including several key studies published during the last decade and, somewhat earlier in a few cases.

EXPERT REVIEW

Notwithstanding the promise of gene therapy/gene editing in hematological malignancies and some types of solid cancers, innovations introduced in clinical practice include more discerning clinical management such as the generalized use of biosimilar formulations of G-CSF and the implementation of novel, innovative immunotherapies.

Risk of infection associated with targeted therapies for solid organ and hematological malignancies

Higher risks of infection are associated with some targeted drugs used to treat solid organ and hematological malignancies, and an individual patient’s risk of infection is strongly influenced by underlying diseases and concomitant or prior treatments. This review focuses on risk levels and specific suggestions for management, analyzing groups of agents associated with a significant effect on the risk of infection. Due to limited clinical experience and ongoing advances in these therapies, recommendations may be revised in the near future. Bruton tyrosine kinase (BTK) inhibitors are associated with a higher rate of infections, including invasive fungal infection, especially in the first months of treatment and in patients with advanced, pretreated disease. Phosphatidylinositol 3-kinase (PI3K) inhibitors are associated with an increased risk of Pneumocystis pneumonia and cytomegalovirus (CMV) reactivation. Venetoclax is associated with cytopenias, respiratory infections, and fever and neutropenia. Janus kinase (JAK) inhibitors may predispose patients to opportunistic and fungal infections; need for prophylaxis should be assessed on an individual basis. Mammalian target of rapamycin (mTOR) inhibitors have been linked to a higher risk of general and opportunistic infections. Breakpoint cluster region-Abelson (BCR-ABL) inhibitors are associated with neutropenia, especially over the first months of treatment. Anti-CD20 agents may cause defects in the adaptative immune response, hypogammaglobulinemia, neutropenia, and hepatitis B reactivation. Alemtuzumab is associated with profound and long-lasting immunosuppression; screening is recommended for latent infections and prevention strategies against CMV, herpesvirus, and Pneumocystis infections. Checkpoint inhibitors (CIs) may cause immune-related adverse events for which prolonged treatment with corticosteroids is needed: prophylaxis against Pneumocystis is recommended.

The efficacy and safety of lenvatinib in the treatment of solid tumors: an up-to-date meta-analysis

Aim: We performed an updated meta-analysis to evaluate the efficacy and safety of lenvatinib in cancer patients. Materials & methods: Databases were searched to identify relevant trials. Data were extracted to evaluate overall survival, progression-free survival, overall response rate and grade ≥3 adverse events. Results: The pooled analysis demonstrated that lenvatinib significantly improved progression-free survival (hazard ratio: 0.43; 95% CI: 0.23-0.80; p = 0.008), overall survival (hazard ratio: 0.85; 95% CI: 0.75-0.97; p = 0.013) and overall response rate (relative risk: 6.89; 95% CI: 2.22-21.36; p = 0.001) compared with control therapy. However, the use of lenvatinib can increase the risk of severe infection. Conclusion: Lenvatinib-containing regimens are associated with better progression-free survival, overall survival and overall response rate, but can induce severe infection.

Is there a real risk of bacterial infection in patients receiving targeted and biological therapies?

Over the past decades, the advent of targeted and biological therapies has revolutionized the management of cancer and autoimmune, hematological and inflammatory conditions. Although a large amount of information is now available on the risk of opportunistic infections associated with some of these agents, the evidence regarding the susceptibility to bacterial infections is more limited. Biological agents have been shown to entail a variable risk of bacterial infections in pivotal randomized clinical trials and post-marketing studies. Recommendations on risk minimization strategies and therapeutic interventions are therefore scarce and often based on expert opinion, with only a few clear statements for some particular agents (i.e. meningococcal vaccination for patients receiving eculizumab). In the present review the available information regarding the incidence of and risk factors for bacterial infection associated with the use of different groups of biological agents is summarized according to their mechanisms of action, and recommendations based on this evidence are provided. Additional information coming from clinical research and real-world studies is required to address unmet questions in this emerging field.

Biotherapeutics: Challenges and Opportunities for Predictive Toxicology of Monoclonal Antibodies

Biotherapeutics are a rapidly growing portion of the total pharmaceutical market accounting for almost one-half of recent new drug approvals. A major portion of these approvals each year are monoclonal antibodies (mAbs). During development, non-clinical pharmacology and toxicology testing of mAbs differs from that done with chemical entities since these biotherapeutics are derived from a biological source and therefore the animal models must share the same epitopes (targets) as humans to elicit a pharmacological response. Mechanisms of toxicity of mAbs are both pharmacological and non-pharmacological in nature; however, standard in silico predictive toxicological methods used in research and development of chemical entities currently do not apply to these biotherapeutics. Challenges and potential opportunities exist for new methodologies to provide a more predictive program to assess and monitor potential adverse drug reactions of mAbs for specific patients before and during clinical trials and after market approval.

Incidence and risk of infections associated with EGFR-TKIs in advanced non-small-cell lung cancer: a systematic review and meta-analysis of randomized controlled trials

Currently, the overall incidence and risk of infections with epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) in non-small-cell lung cancer (NSCLC) patients remained undetermined. We searched Pubmed for related articles published from 1 January 1990 to 31 November 2015. Eligible studies included prospective randomized controlled trials (RCTs) evaluating therapy with or without EGFR-TKIs in patients with NSCLC. Data on infections were extracted. Pooled incidence, Peto odds ratio (Peto OR), and 95% confidence intervals (CIs) were calculated. A total of 17,420 patients from 25 RCTs were included. The use of EGFR-TKIs significantly increased the risk of developing all-grade infections (Peto OR 1.48, 95%CI: 1.12-1.96, p = 0.006) in NSCLC patients, but not for severe (Peto OR 1.26, 95%CI: 0.96-1.67, p = 0.098) and fatal infections (Peto OR 0.81, 95%CI: 0.43-1.53, p = 0.52). Meta-regression indicated the risk of infections tended to increase with the treatment duration of EGFR-TKIs. No publication of bias was detected. In conclusion, the use of EGFR-TKIs significantly increased the risk of developing all-grade infectious events in NSCLC patients, but not for severe and fatal infections. Clinicians should be aware of the risks of infections with the administration of these drugs in these patients.

ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Cell surface receptors and associated signaling pathways)

BACKGROUND

The present review is part of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections in Compromised Hosts (ESGICH) consensus document on the safety of targeted and biologic therapies.

AIMS

To review, from an infectious diseases perspective, the safety profile of therapies targeting cell surface receptors and associated signaling pathways among cancer patients and to suggest preventive recommendations.

SOURCES

Computer-based Medline searches with MeSH terms pertaining to each agent or therapeutic family.

CONTENT

Vascular endothelial growth factor (VEGF)-targeted agents (bevacizumab and aflibercept) are associated with a meaningful increase in the risk of infection, likely due to drug-induced neutropaenia, although no clear benefit is expected from the universal use of anti-infective prophylaxis. VEGF tyrosine kinase inhibitors (i.e. sorafenib or sunitinib) do not seem to significantly affect host's susceptibility to infection, and universal anti-infective prophylaxis is not recommended either. Anti-epidermal growth factor receptor (EGFR) monoclonal antibodies (cetuximab or panitumumab) induce neutropaenia and secondary skin and soft tissue infection in cases of severe papulopustular rash. Systemic antibiotics (doxycycline or minocycline) should be administered to prevent the latter complication, whereas no recommendation can be established on the benefit from antiviral, antifungal or anti-Pneumocystis prophylaxis. A lower risk of infection is reported for anti-ErbB2/HER2 monoclonal antibodies (trastuzumab and pertuzumab) and ErbB receptor tyrosine kinase inhibitors (including dual-EGFR/ErbB2 inhibitors such as lapatinib or neratinib) compared to conventional chemotherapy, presumably as a result of the decreased occurrence of drug-induced neutropaenia.

IMPLICATIONS

With the exception of VEGF-targeted agents, the overall risk of infection associated with the reviewed therapies seems to be low.

Intra-venous bevacizumab in hereditary hemorrhagic telangiectasia (HHT): A retrospective study of 46 patients

Background

Bevacizumab, an anti-VEGF monoclonal antibody, has recently emerged as a new option for severe forms of hereditary hemorrhagic telangiectasia (HHT). Its utilization in this orphan disease has rapidly spread despite the lack of randomized trials and international guidelines. The objective of this study is to report the main clinical data (baseline characteristics, dose schedule, efficacy, adverse events and deaths) of HHT patients treated by intravenous bevacizumab in France.

Methods

Retrospective observational study of HHT patients treated with bevacizumab for a severe form of the disease in the 14 centers of the French HHT network.

Results

Forty-six patients (median age: 68 years) were treated between March 2009 and May 2015. Ten patients were treated for high output cardiac failure, 20 patients for severe hemorrhages and 16 for both indications. The standard protocol (6 infusions of 5mg/kg every 2 weeks) was initially used in 89% of the cases but diverse strategies were subsequently applied. A clinical improvement was noted by the referent physician for 74% of the patients with a median effect’s duration of 6 months. Wound healing complications led to 2 amputations. Arthralgia/arthritis and arterial hypertension occurred in 5 patients each. One third of the patients were dead at the time of the final update, coherently with age and the poor prognosis of these highly symptomatic patients.

Conclusion

Intravenous bevacizumab seems to provide a clinical benefice in severe HHT patients. Precautions concerning wound healing and vascular pathologies must be respected. Prospective double blinded versus placebo trials are needed.

Treatment-related severe and fatal adverse events with molecular targeted agents in the treatment of advanced gastric cancer: a meta-analysis

AIM

To perform a systematic review and meta-analysis of Phase III randomized controlled trials (RCTs) to determine the incidence and risk of severe adverse events (AEs) with molecular targeted agents (MTAs) in advanced/metastatic gastric cancer (GC) patients.

METHODS

A comprehensive literature search for related trials published up to December 2015 was performed. Eligible studies were Phase III RCTs of advanced/metastatic GC patients assigned to MTAs or control group. Data were extracted by two authors for severe and fatal AEs (FAEs).

RESULTS

A total of nine Phase III RCTs involved 4,934 GC patients were ultimately identified. The pooled results demonstrated that the addition of TAs to therapies in advanced GC significantly increased the risk of developing severe AEs (relative risk: 1.12, 95% confidence interval: 1.02-1.24, P=0.02), but not for FAEs (relative risk: 0.97, 95% confidence interval: 0.65-1.45, P=0.88). Additionally, the most common causes of FAEs with MTAs were infections (16.3%), gastrointestinal hemorrhage (8.2%), and arterial thromboembolic events (8.2%), respectively.

CONCLUSION

With available evidence, the use of TAs in GC patients was associated with an increased risk of severe AEs, but not for FAE. Clinicians should be aware of the risk of severe AEs with the administration of these drugs in these patients.

Efficacy and safety of addition of bevacizumab to FOLFIRI or irinotecan/bolus 5-FU/LV (IFL) in patients with metastatic colorectal cancer: A meta-analysis

Recent studies have paid much attention on the safety of bevacizumab as adjuvant chemotherapy for metastatic colorectal cancer. The aim of this meta-analysis was to study the efficacy and safety of bevacizumab in combination with irinotecan, bolus followed by infusional 5-fluorouracil, and leucovorin (FOLFIRI) and, irinotecan, bolus fluorouracil, leucovorin (IFL) for patients with metastatic colorectal cancer (mCRC).An electronic search of related trials was conducted from PubMed, EMBASE, Cochrane Library databases. Risk ratio (RRs) and its 95% confidence intervals (95% CIs) were calculated by using either DerSimonian-Laird method or Mantel-Haenszel method according to the heterogeneity of included articles. The risk of mortality, therapeutic efficacy, and adverse effect were meta-analyzed.In total, 6 RCTs including 2165 participants (1109 in the treatment group, 1056 in the control group) were included in this meta-analysis. Compared with FOLFIRI-panitumumab/cetuximab, the bevacizumab addition significantly reduced the complete response (CR) rate (RR [95%CI] = 0.31[0.11, 0.89], P = 0.03) and the risk of grade 3/4 adverse event (RR [95%CI] = 0.89[0.80, 0.98], P = 0.01). Compared with FOLFIRI and IFL alone, the addition of bevacizumb significantly increased the partial response (PR) and objective response (OR) rates. Compared with IFL alone, the addition of bevacizumb significantly reduced the mortality risk of PFS (RR [95%CI] = 0.53[0.42, 0.66], P < 0.00001) and OS (RR[95%CI] = 0.70[0.60, 0.82], P < 0.00001), but increased the risk of adverse events (RR[95%CI] = 1.14[1.06, 1.21], P = 0.0002).Combination chemotherapy of bevacizumab plus FOLFIRI or IFL had a relative high efficacy and acceptable safety for treatment of mCRC.

Incidence and risk of severe infections associated with aflibercept in cancer patients: a systematic review and meta-analysis

AIMS

Aflibercept is an engineered humanized vascular endothelial growth factor (VEGF)-targeted agent. Severe infections are serious adverse event associated with aflibercept. However, the contribution of aflibercept to infection is still unknown. We thus conducted this meta-analysis to investigate the overall incidence and risk of developing severe infections in cancer patients treated with aflibercept.

METHODS

Electronic databases including PubMed, Embase and abstracts presented at American Society of Clinical Oncology (ASCO) and European Society of Medical Oncology (ESMO) meeting were searched. Eligible studies were phase II and III prospective clinical trials of aflibercept in cancer patients with toxicity profile on infections. Summary incidences, relative risk (RR), odds ratio (OR) and 95% confidence intervals (95% CIs) were calculated by using either random effects or fixed effect models according to the heterogeneity of included studies.

RESULTS

A total of 4310 patients with a variety of solid tumours from 10 prospective clinical trials were included in the meta-analysis. The incidence of high grade infections associated with aflibercept was 7.3% (95% CI 4.3, 12.0%), with a mortality of 2.2% (95% CI 1.5, 3.1%). In addition, patients treated with aflibercept had a significantly increased risk of developing high grade (RR 1.87, 95% CI 1.52, 2.30; P < 0.001) and fatal (OR 2.16, 95% CI 1.14, 4.11; P = 0.018) infections. No evidence of publication bias was observed. Furthermore, the risk of infections with aflibercept was substantially higher than bevacizumab.

CONCLUSIONS

Aflibercept is associated with a significant increased risk of developing severe infections in patients with solid tumours. Frequent clinical monitoring and appropriate management for infections should be emphasized during aflibercept treatment.

Risk of hematological toxicities in patients with solid tumors treated with ramucirumab: a meta-analysis

BACKGROUND

We performed a meta-analysis of the risk of hematological adverse events associated with ramucirumab.

METHODS

Eligible studies included randomized Phase II and III trials of patients with solid tumors on ramucirumab, describing events of anemia, leucopenia, neutropenia, febrile neutropenia and thrombocytopenia.

RESULTS

A total of 11 clinical trials were considered eligible for the meta-analysis. The relative risks of all-grade anemia, leucopenia, neutropenia, febrile neutropenia and thrombocytopenia were 0.88 (95% CI: 0.80-0.96; p = 0.007), 1.13 (95% CI: 0.85-1.49; p = 0.41), 1.25 (95% CI: 1.08-1.44; p = 0.002), 1.63 (95% CI: 1.30-2.06; p < 0.0001), 1.91 (95% CI: 1.52-2.42; p < 0.00001), respectively.

CONCLUSION

Our meta-analysis has demonstrated an increased risk of febrile neutropenia, all-grade and high-grade neutropenia and thrombocytopenia with ramucirumab-based treatment compared with control.