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Gandhi KA, Shirsat A, Hj SK, Chavan A, Dicholkar P, Shah S, Menon N, Noronha V, Joshi A, Prabhash K, Patil V, Gota V. Pharmacokinetics and clinical outcomes of low-dose nivolumab relative to conventional dose in patients with advanced cancer. Cancer Chemother Pharmacol 2024:10.1007/s00280-024-04697-x. [PMID: 39060628 DOI: 10.1007/s00280-024-04697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 07/05/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE Nivolumab is approved at various doses, including 3 mg/kg, 240 mg and 480 mg flat doses at various dosing intervals. The concept of low-dose immunotherapy is gaining traction in recent years. However, there is a need to better understand the pharmacokinetics and clinical outcomes at lower doses. METHODS Patients were either administered 40 mg flat dose or 3 mg/kg Q2W/Q3W, depending on affordability as per prevailing hospital practice. All patients were hospitalized on day 1 and pharmacokinetic samples were collected at 0, 0.5, 1.0, 6.0, 24.0, 72.0 h and day 14 following administration of the first dose of nivolumab. Plasma nivolumab levels were measured by ELISA. Patients were followed up for response and toxicity. RESULTS Twenty five patients were included in the study. Fourteen received nivolumab at conventional dose (3 mg/kg), while 11 patients received low-dose (40 mg flat). The geometric means of dose normalized Cmax and AUC0-t were comparable between those who received conventional dose and low-dose of nivolumab (0.28 versus 0.23 µg/mL/mg and 0.0014 versus 0.0011 d/mL respectively). Nineteen patients were evaluable for response. ORR among patients who received conventional dose was 5/11 (45.5%) whereas it was 4/9 (44.4%) in the low-dose cohort. All 14 (100%) patients in conventional dosing group and 7/11 patients (63.64%) in low-dose group had treatment emergent adverse events. Grade ≥ 3 toxicities were observed in 4/14 patients in conventional dose group and none in low-dose group. CONCLUSION Low-dose nivolumab leads to lower exposure in patients as compared with conventional dose, but low-dose was better tolerated, while response rates were comparable to conventional dose.
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Affiliation(s)
- Khushboo A Gandhi
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Aditi Shirsat
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Sharat Kumar Hj
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Ashish Chavan
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Parnika Dicholkar
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Saniya Shah
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India
| | - Nandini Menon
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, 400012, India
- Homi bhabha National Institute, Mumbai, 400094, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, 400012, India
- Homi bhabha National Institute, Mumbai, 400094, India
| | - Amit Joshi
- Homi bhabha National Institute, Mumbai, 400094, India
- Department of Medical Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC), Kharghar, Navi Mumbai, 410210, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, 400012, India
- Homi bhabha National Institute, Mumbai, 400094, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, 400012, India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre (TMC) Sector- 22, Kharghar, Navi Mumbai, 410210, India.
- Homi bhabha National Institute, Mumbai, 400094, India.
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Patel A, Hande V, Mr K, Dange H, Das AK, Murugesan V, Bhatt T, Shankaran R. Effectiveness of Immune Checkpoint Inhibitors in Various Tumor Types Treated by Low, Per-Weight, and Conventional Doses at a Tertiary Care Center in Mumbai. JCO Glob Oncol 2024; 10:e2300312. [PMID: 38181308 DOI: 10.1200/go.23.00312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/17/2023] [Accepted: 10/31/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE The cost of immune checkpoint inhibitors (ICIs) limits their accessibility to a small number of patients with cancer in low- and middle-income countries. Early-phase clinical trials have shown target inhibition and high activity at doses lower than those registered and evaluated in clinical trials. Here, we report everyday experience of using ICIs in 100 Indian patients, many of whom received lower doses of ICIs. METHODS Consecutive patients who received at least one dose of an ICI irrespective of tumor type at a tertiary care hospital in Mumbai, India, that was able to access ICIs for its patients were enrolled. The objectives were to study the doses used over a 3-year time period, and the effectiveness of therapy, assessed primarily by the overall response rate (ORR), overall survival (OS), and progression-free survival were secondary end points. RESULTS Twenty-five patients were treated with conventional doses of ICIs, 29 patients received lower doses per body weight, and 46 patients received low-dose treatment. The median number of cycles received was 5 (range, 1-28). Seventy-eight patients received ICIs in a palliative setting. The median follow-up time was 10.2, 9.8, and 3.9 months for those receiving fixed approved dosing, per body weight dosing, and low-dose treatment, respectively. There was a trend with time to prescribe lower doses. Response evaluation was available for 92 patients. Twenty-one (five-adjuvant and 16-palliative) patients received ICIs only. The ORR did not differ statistically among different dosing groups, but comparisons are confounded by inclusion of different ICIs, different tumor sites, and concurrent treatments. The median OS was 6.8 (range, 4.6-9.0) months. CONCLUSION Adoption of per-body weight and lower dosing of ICIs appears to give acceptable outcomes. Lower dosing can improve access and timely delivery of ICIs in low- and middle-income countries.
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Affiliation(s)
- Amol Patel
- Department of Medical Oncology, Indian Naval Hospital Ship, Asvini, Mumbai, India
| | - Vivek Hande
- Department of Medicine, Indian Naval Hospital Ship, Asvini, Mumbai, India
| | - Kaushik Mr
- Department of Medical Oncology, Indian Naval Hospital Ship, Asvini, Mumbai, India
| | - Hemendra Dange
- Medical Stores, Indian Naval Hospital Ship, Asvini, Mumbai, India
| | - Amit Kumar Das
- Department of Pathology, Indian Naval Hospital Ship, Asvini, Mumbai, India
| | | | - Trilok Bhatt
- Department of Radiology, Indian Naval Hospital Ship, Asvini, Mumbai, India
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Kowata S, Seki Y, Tsukushi Y, Sato T, Asano K, Maeta T, Yashima-Abo A, Sasaki R, Okano Y, Oyake T, Ito S. Association of CD8 + T cells expressing nivolumab-free PD-1 with clinical status in a patient with relapsed refractory classical Hodgkin lymphoma. Int J Hematol 2023; 118:751-757. [PMID: 37488284 DOI: 10.1007/s12185-023-03644-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 07/26/2023]
Abstract
A 37-year-old man with refractory classical Hodgkin lymphoma (cHL) underwent PD-1 blockade therapy with nivolumab, which resulted in a partial response. However, treatment was discontinued due to immune-related adverse events (irAEs), including myasthenia gravis and myositis. Retreatment with nivolumab resulted in a complete metabolic response and hepatic irAE. Subsequently, nivolumab was administered at extended dosing intervals. Intermittent infusion of ten doses of nivolumab for a total dose of 2400 mg/body helped control the relapsed/refractory cHL over three years. During nivolumab treatment, disease progression and emergence of irAEs were associated with the proportion of CD8 + T cells expressing nivolumab-free PD-1 relative to the total number of CD8 + T cells. The findings in this nivolumab-sensitive patient highlight the clinical utility of monitoring immune cells expressing nivolumab-free PD-1 in patients with cHL who have been treated with nivolumab and have experienced irAEs.
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Affiliation(s)
- Shugo Kowata
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan.
| | - Yuki Seki
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Yasuhiko Tsukushi
- Department of Hematology, Hachinohe Red Cross Hospital, Hachinohe, Japan
| | - Tsuyoshi Sato
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Kazuya Asano
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Takahiro Maeta
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Akiko Yashima-Abo
- Division of Biomedical Research & Development, Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Ryosei Sasaki
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Yoshiaki Okano
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Tatsuo Oyake
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
| | - Shigeki Ito
- Hematology and Oncology, Department of Internal Medicine, School of Medicine, Iwate Medical University, 2-1-1 Idaidori, Shiwa-gun, Yahaba-cho, Iwate, Japan
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4
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Thomas Z, Jambunathan P, Jibi A, John AO, Singh A. Low-dose nivolumab and cabozantinib in recurrent intestinal-type papillary adenocarcinoma of the sinonasal region. BMJ Case Rep 2023; 16:e255021. [PMID: 37923331 PMCID: PMC10626912 DOI: 10.1136/bcr-2023-255021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Intestinal-type sinonasal adenocarcinoma is a rare epithelial malignancy primarily treated with surgery and chemoradiation. The combination of low-dose immunotherapy and a tyrosine kinase inhibitor in recurrent disease has not been previously studied.A man in his 20s with papillary adenocarcinoma of the sinonasal region, following surgical resection, was treated with six cycles of concurrent chemoradiotherapy, followed by four cycles of docetaxel, cisplatin and capecitabine. While on treatment, he was found to have extensive residual disease and he was started on low-dose nivolumab and cabozantinib. Repeat imaging after ten months of treatment revealed a significant reduction in lesions.Non-squamous head and neck cancers are often excluded from major trials, and the effect of immunotherapy in these histologies is poorly understood. The response seen with low-dose immunotherapy underscores the need for further research in this setting.
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Affiliation(s)
- Zachariah Thomas
- Department of Medical Oncology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Prashant Jambunathan
- Department of Medical Oncology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Anjali Jibi
- Department of General Pathology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Ajoy Oommen John
- Department of Medical Oncology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Ashish Singh
- Department of Medical Oncology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
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5
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Tsumura A, Levis D, Tuscano JM. Checkpoint inhibition in hematologic malignancies. Front Oncol 2023; 13:1288172. [PMID: 37920162 PMCID: PMC10619902 DOI: 10.3389/fonc.2023.1288172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023] Open
Abstract
Checkpoint inhibitor therapy has emerged as an effective therapeutic strategy for many types of malignancies, especially in solid tumors. Within the last two decades, numerous monoclonal antibody drugs targeting the CTLA-4 and PD-1/PD-L1 checkpoint pathways have seen FDA approval. Within hematologic malignancies, Hodgkin Lymphoma has seen the greatest clinical benefits thus far with more recent data showing efficacy in the front-line setting. As our understanding of checkpoint inhibition expands, using these pathways as a therapeutic target has shown some utility in the treatment of other hematologic malignancies as well, primarily in the relapsed/refractory settings. Checkpoint inhibition also appears to have a role as a synergistic agent to augment clinical responses to other forms of therapy such as hematopoietic stem cell transplant. Moreover, alternative checkpoint molecules that bypass the well-studied CTLA-4 and PD-1/PD-L1 pathways have emerged as exciting new therapeutic targets. Most excitingly is the use of anti-CD47 blockade in the treatment of high risk MDS and TP-53 mutated AML. Overall, there has been tremendous progress in understanding the benefits of checkpoint inhibition in hematologic malignancies, but further studies are needed in all areas to best utilize these agents. This is a review of the most recent developments and progress in Immune Checkpoint Inhibition in Hematologic Malignancies in the last decade.
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Affiliation(s)
- Aaron Tsumura
- Division of Malignant Hematology/Cellular Therapy and Transplantation, University of California Davis, Sacramento, CA, United States
| | - Daniel Levis
- School of Medicine, University of California Davis, Sacramento, CA, United States
| | - Joseph M. Tuscano
- Division of Malignant Hematology/Cellular Therapy and Transplantation, University of California Davis, Sacramento, CA, United States
- School of Medicine, University of California Davis, Sacramento, CA, United States
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Tamma R, Ingravallo G, Gaudio F, d'Amati A, Masciopinto P, Bellitti E, Lorusso L, Annese T, Benagiano V, Musto P, Specchia G, Ribatti D. The Tumor Microenvironment in Classic Hodgkin's Lymphoma in Responder and No-Responder Patients to First Line ABVD Therapy. Cancers (Basel) 2023; 15:2803. [PMID: 37345141 DOI: 10.3390/cancers15102803] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/23/2023] Open
Abstract
Although classical Hodgkin lymphoma (CHL) is typically curable, 15-25% of individuals eventually experience a relapse and pass away from their disease. In CHL, the cellular microenvironment is constituted by few percent of H/RS (Hodgkin/Reed-Sternberg) tumor cells surrounded from a heterogeneous infiltration of inflammatory cells. The interplay of H/RS cells with other immune cells in the microenvironment may provide novel strategies for targeted immunotherapies. In this paper we analyzed the microenvironment content in CHL patients with responsive disease (RESP) and patients with relapsed/refractory disease to treatment (REL). Our results indicate the increase of CD68+ and CD163+ macrophages, the increase of PDL-1+ cells and of CD34+ microvessels in REL patients respective to RESP patients. In contrast we also found the decrease of CD3+ and of CD8+ lymphocytes in REL patients respective to RESP patients. Finally, in REL patients our results show the positive correlation between CD68+ macrophages and PDL-1+ cells as well as a negative correlation between CD163+ and CD3+.
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Affiliation(s)
- Roberto Tamma
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
| | - Giuseppe Ingravallo
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Francesco Gaudio
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Antonio d'Amati
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Pierluigi Masciopinto
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Emilio Bellitti
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Loredana Lorusso
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
| | - Tiziana Annese
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
- Department of Medicine and Surgery, Libera Università del Mediterraneo (LUM) Giuseppe Degennaro University, 70124 Bari, Italy
| | - Vincenzo Benagiano
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Giorgina Specchia
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Medical School, 70124 Bari, Italy
| | - Domenico Ribatti
- Department of Translational Biomedicine and Neuroscience, University of Bari Medical School, 70124 Bari, Italy
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van den Haak DAC, Otten L, Koenen HJPM, Smeets RL, Piet B, Pickkers P, Kox M, ter Heine R. Evidence‐based rationale for low dose nivolumab in critically ill patients with sepsis‐induced immunosuppression. Clin Transl Sci 2023. [DOI: 10.1111/cts.13503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/28/2023] [Accepted: 02/17/2023] [Indexed: 04/03/2023] Open
Affiliation(s)
- Demy A. C. van den Haak
- Department of Pharmacy and Research Institute for Medical Innovation Radboud University Medical Center Nijmegen The Netherlands
| | - Leila‐Sophie Otten
- Department of Pharmacy and Research Institute for Medical Innovation Radboud University Medical Center Nijmegen The Netherlands
| | - Hans J. P. M. Koenen
- Laboratory Medicine, Laboratory for Medical Immunology Radboud University Medical Center Nijmegen The Netherlands
| | - Ruben L. Smeets
- Laboratory Medicine, Laboratory for Medical Immunology Radboud University Medical Center Nijmegen The Netherlands
| | - Berber Piet
- Department of Pulmonology Radboud University Medical Center Nijmegen The Netherlands
| | - Peter Pickkers
- Department of Intensive Care and Radboud Center for Infectious Diseases (RCI) Radboud University Nijmegen Medical Centre Nijmegen The Netherlands
| | - Matthijs Kox
- Department of Intensive Care and Radboud Center for Infectious Diseases (RCI) Radboud University Nijmegen Medical Centre Nijmegen The Netherlands
| | - Rob ter Heine
- Department of Pharmacy and Research Institute for Medical Innovation Radboud University Medical Center Nijmegen The Netherlands
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8
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Mitchell AP, Goldstein DA. Cost Savings and Increased Access With Ultra-Low-Dose Immunotherapy. J Clin Oncol 2023; 41:170-172. [PMID: 36265102 PMCID: PMC9839306 DOI: 10.1200/jco.22.01711] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 01/19/2023] Open
Affiliation(s)
- Aaron P. Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel A. Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Clalit Health Service, Tel Aviv-Yafo, Israel
- Optimal Cancer Care Alliance, Ann Arbor, MI
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9
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Kiamanesh Z, Ayati N, Sadeghi R, Hawkes E, Lee ST, Scott AM. The value of FDG PET/CT imaging in outcome prediction and response assessment of lymphoma patients treated with immunotherapy: a meta-analysis and systematic review. Eur J Nucl Med Mol Imaging 2022; 49:4661-4676. [PMID: 35932329 DOI: 10.1007/s00259-022-05918-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Treatment strategies of lymphoid malignancies have been revolutionized by immunotherapy. Because of the inherent property of Hodgkin lymphoma and some subtypes of non-Hodgkin lymphoma as a highly FDG-avid tumor, functional 18F-FDG PET/CT imaging is already embedded in their routine care. Nevertheless, the question is whether it is still valuable in the context of these tumors being treated with immunotherapy. Herein, we will review the value of 18F-FDG PET/CT imaging lymphoid tumors treated with immunotherapy regimens. METHODS A comprehensive literature search of the PubMed database was conducted on the value of the 18F-FDG PET/CT for immunotherapy response monitoring of patients with malignant lymphoma. The articles were considered eligible if they met all of the following inclusion criteria: (a) clinical studies on patients with different types of malignant lymphoma, (b) treatment with anti-CD20 antibodies, immune checkpoint inhibitors or immune cell therapies, (c) and incorporated PET/CT with 18F-FDG as the PET tracer. RESULTS From the initial 1488 papers identified, 91 were ultimately included in our study. In anti-CD20 therapy, the highest pooled hazard ratios (HRs) of baseline, early, and late response monitoring parameters for progression-free survival (PFS) belong to metabolic tumor volume (MTV) (3.19 (95%CI: 2.36-4.30)), maximum standardized uptake value (SUVmax) (3.25 (95%CI: 2.08-5.08)), and Deauville score (DS) (3.73 (95%CI: 2.50-5.56)), respectively. These measurements for overall survival (OS) were MTV (4.39 (95%CI: 2.71-7.08)), DS (3.23 (95%CI: 1.87-5.58)), and DS (3.64 (95%CI: 1.40-9.43)), respectively. Early and late 18F-FDG PET/CT response assessment in immune checkpoint inhibitors (ICI) and immune cell therapy might be an effective tool for prediction of clinical outcome. CONCLUSION For anti-CD20 therapy of lymphoma, the MTV as a baseline 18F-FDG PET/CT-derived parameter has the highest HRs for PFS and OS. The DS as visual criteria in early and late response assessment has higher HRs for PFS and OS compared to the international harmonization project (IHP) visual criteria in anti-CD20 therapy. Early changes in 18F-FDG PET parameters may be predictive of response to ICIs and cell therapy in lymphoma patients.
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Affiliation(s)
- Zahra Kiamanesh
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Narjess Ayati
- Department of Nuclear Medicine, Ultrasound & PET, Sydney Westmead Hospital, Sydney, NSW, Australia.,Olivia Newton-John Cancer Research Institute and School of Cancer Medicine, La Trobe University, Victoria, Australia
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Eliza Hawkes
- Olivia Newton-John Cancer Research Institute and School of Cancer Medicine, La Trobe University, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia.,Department of Medical Oncology & Clinical Haematology, Austin Health, Heidelberg, VIC, Australia.,School of Public Health & Preventative Medicine, Monash University, Melbourne, Australia
| | - Sze Ting Lee
- Olivia Newton-John Cancer Research Institute and School of Cancer Medicine, La Trobe University, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia.,Department of Molecular Imaging & Therapy, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Andrew M Scott
- Olivia Newton-John Cancer Research Institute and School of Cancer Medicine, La Trobe University, Victoria, Australia. .,Department of Medicine, University of Melbourne, Victoria, Australia. .,Department of Molecular Imaging & Therapy, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
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10
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Jiang M, Hu Y, Lin G, Chen C. Dosing Regimens of Immune Checkpoint Inhibitors: Attempts at Lower Dose, Less Frequency, Shorter Course. Front Oncol 2022; 12:906251. [PMID: 35795044 PMCID: PMC9251517 DOI: 10.3389/fonc.2022.906251] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a revolutionary breakthrough in the field of cancer by modulating patient's own immune system to exert anti-tumor effects. The clinical application of ICIs is still in its infancy, and their dosing regimens need to be continuously adjusted. Pharmacokinetic/pharmacodynamic studies showed a significant plateau in the exposure-response curve, with high receptor occupancy and plasma concentrations achieved at low dose levels. Coupled with concerns about drug toxicity and heavy economic costs, there has been an ongoing quest to reevaluate the current ICI dosing regimens while preserving maximum clinical efficacy. Many clinical data showed remarkable anticancer effects with ICIs at the doses far below the approved regimens, indicating the possibility of dose reduction. Our review attempts to summarize the clinical evidence for ICIs regimens with lower-dose, less-frequency, shorter-course, and provide clues for further ICIs regimen optimization.
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Affiliation(s)
| | | | | | - Chao Chen
- Department of Radiotherapy, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, China
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11
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Nakhoda S, Rizwan F, Vistarop A, Nejati R. Updates in the Role of Checkpoint Inhibitor Immunotherapy in Classical Hodgkin's Lymphoma. Cancers (Basel) 2022; 14:2936. [PMID: 35740598 PMCID: PMC9220999 DOI: 10.3390/cancers14122936] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 12/18/2022] Open
Abstract
Classical Hodgkin's lymphoma is a highly curable disease, but 10-25% of patients with higher-risk disease relapse. The introduction of checkpoint inhibitors (CPIs) targeting PD-1 have changed the landscape of treatment for patients with relapsed/refractory disease to multiple lines of therapy. The depth of response to CPI as a monotherapy is highest in the first relapse as salvage therapy based on outcomes reported in several phase II studies. With earlier use of CPI and brentuximab vedotin, the optimal sequencing of therapy is evolving. In this review, we will summarize clinical investigation of anti-PD-1 mAb in earlier line settings to provide insights on utilizing these agents as chemotherapy- and radiation-sparing approaches, increasing depth of response, and as part of combination regimens.
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Affiliation(s)
- Shazia Nakhoda
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA; (A.V.); (R.N.)
| | - Farsha Rizwan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA 19140, USA;
| | - Aldana Vistarop
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA; (A.V.); (R.N.)
| | - Reza Nejati
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA; (A.V.); (R.N.)
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12
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Pathak N, Pramanik R, Bakhshi S, Kumar A, Sharma MC, Shamim SA, Kumar S, Thulkar S, Sharma A. Modified Protocol of Nivolumab in Relapsed/Refractory Hodgkin Lymphoma: A Brief Communication of Real World Data. J Immunother 2022; 45:239-242. [PMID: 35404324 DOI: 10.1097/cji.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022]
Abstract
Immune check point inhibitors such as nivolumab are changing the treatment paradigm of relapsed/refractory Hodgkin lymphoma (r/rHL). Data from single arm studies have shown nivolumab to be an effective and safe therapy. Real world data from resource constrained settings are limited. Our study is a retrospective single center analysis of nivolumab in r/rHL from India. Data regarding baseline and pretreatment characteristics were collected for 20 patients treated with nivolumab from January 2016 to March 2021. Of 20, 15 patients received nivolumab in modified protocol, because of financial limitations. Postnivolumab therapy, the overall response rate was 90%, with 40% in complete remission. The median progression free survival was 13.1 month (95% confidence interval 8.33 mo, not reached) and median overall survival not reached, at a follow up of 24.3 months. No patients discontinued nivolumab because of side effects. Univariate and multivariate analysis showed no effect of dose reduction or increased duration of administration. Most common adverse effect seen was autoimmune hypothyroidism. Possible delayed immune-related side effects were seen in 3 out 5 patients in peritransplant period, in those who received nivolumab as salvage regimen before autologous stem cell transplant. In conclusion, nivolumab shows comparable efficacy and safety even with compromised dosing and schedule of administration of the drug in real world setting.
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Affiliation(s)
| | | | | | | | | | | | | | - Sanjay Thulkar
- Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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13
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Araujo DV, Uchoa B, Soto-Castillo JJ, Furlan LL, Oliva M. When Less May Be Enough: Dose Selection Strategies for Immune Checkpoint Inhibitors Focusing on AntiPD-(L)1 Agents. Target Oncol 2022; 17:253-270. [PMID: 35687223 DOI: 10.1007/s11523-022-00890-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 10/18/2022]
Abstract
Early clinical trials investigating antiPD(L)-1 agents rarely reached a maximum tolerated dose (MTD), and efficacy signals were observed even at the lowest dose levels. Most extended treatment intervals investigated indicated that these drugs do not follow a direct dose-toxicity or dose-efficacy relationship. Within this context and considering the high cost of antiPD(L)-1 agents, there is a significant debate on whether lower doses or the administration of such agents at an extended interval should be prospectively evaluated in already-approved agents, or at least be considered in novel combination trials involving antiPD(L)-1 drugs. Herein, we review the dosing, overall response rates, and incidence of treatment-related adverse events of antiPD(L)-1 agents in early dose-escalation trials and discuss the appropriateness of recommended Phase 2 dose selection as well as the final regulatory approved doses of such agents. Efficacy and safety data from randomized dose-range Phase 2 trials and real-world data (RWD) on the usage of lower doses and/or non-standard extended treatment intervals are also examined. As the accumulating evidence suggests lower doses or extended dosing intervals of antiPD(L)-1 may achieve a similar clinical benefit in comparison to the currently approved doses, we address the clinical and financial toxicity implications of using potentially higher doses than necessary. Last, we discuss ways to resolve the current dosing conundrum of antiPD-(L)1 agents such as performing near-equivalence studies and propose a framework for future development of immunotherapeutics to find the lowest efficacious dose instead of MTD.
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Affiliation(s)
- Daniel V Araujo
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil.
| | - Bruno Uchoa
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil
| | - Juan José Soto-Castillo
- Department of Medical Oncology, Institut Català d'Oncologia (ICO), L'Hospitalet de Llobregat, Av. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain
| | - Larissa L Furlan
- Department of Medical Oncology, Hospital de Base/HB Onco, FUNFARME/FAMERP, Av. Brigadeiro Faria Lima 5544, São José do Rio Preto, SP, Brazil
| | - Marc Oliva
- Department of Medical Oncology, Institut Català d'Oncologia (ICO), L'Hospitalet de Llobregat, Av. Gran Via de L'Hospitalet 199-203, 08908, Barcelona, Spain. .,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
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14
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Schwarze JK, Garaud S, Jansen YJL, Awada G, Vandersleyen V, Tijtgat J, de Wind A, Kristanto P, Seremet T, Willard-Gallo K, Neyns B. Low-Dose Nivolumab with or without Ipilimumab as Adjuvant Therapy Following the Resection of Melanoma Metastases: A Sequential Dual Cohort Phase II Clinical Trial. Cancers (Basel) 2022; 14:682. [PMID: 35158952 PMCID: PMC8833641 DOI: 10.3390/cancers14030682] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Optimal dosing and duration of adjuvant treatment with PD-1 and CTLA-4 immune checkpoint inhibitors have not been established. Prior to their regulatory approval we investigated a low-dose regimen of nivolumab with or without ipilimumab in a sequential dual-cohort phase II clinical trial. METHODS Following the complete resection of melanoma metastases, patients were treated with a single fixed dose of ipilimumab (50 mg) plus 4 bi-weekly fixed doses of nivolumab (10 mg) (cohort-1), or nivolumab for 1 year (10 mg fixed dose, Q2w x9, followed by Q8w x4) (cohort-2). Twelve-months relapse-free survival (RFS) served as the primary endpoint. RESULTS After a median follow-up of 235 weeks for cohort-1 (34 patients), and 190 weeks for cohort-2 (21 patients), the 12-months RFS-rate was, respectively, 55.9% (95% CI, 39-72), and 85.7% (95% CI, 70-100). Treatment-related adverse events occurred in 27 (79%), and 18 (86%) patients, with 3 (9%), and 1 (5%) grade 3 adverse events in cohort-1 and -2, respectively. Immunohistochemical quantification of intra- and peritumoral CD3+ T cells and CD20+ B cells, but not PD-1/PD-L1 staining, correlated significantly with RFS. CONCLUSIONS One year of adjuvant low-dose nivolumab could be an effective and economically advantageous alternative for standard dosing, at the condition of further confirmation in a larger patient cohort. A shorter low-dose nivolumab plus ipilimumab regimen seems inferior and less tolerable.
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Affiliation(s)
- Julia Katharina Schwarze
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
| | - Soizic Garaud
- Molecular Immunology Unit, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Brussels, Belgium;
| | - Yanina J. L. Jansen
- Department of Thoracic Surgery, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (Y.J.L.J.); (K.W.-G.)
| | - Gil Awada
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
| | - Valérie Vandersleyen
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
| | - Jens Tijtgat
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
| | - Alexandre de Wind
- Department of Pathology, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Brussels, Belgium;
| | - Paulus Kristanto
- Data Center, Institut Jules Bordet, Université Libre de Bruxelles, 1000 Brussels, Belgium;
| | - Teofila Seremet
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
| | - Karen Willard-Gallo
- Department of Thoracic Surgery, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (Y.J.L.J.); (K.W.-G.)
| | - Bart Neyns
- Department of Medical Oncology, Vrije Universiteit Brussel (VUB)/Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090 Brussels, Belgium; (G.A.); (V.V.); (J.T.); (T.S.); (B.N.)
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15
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Fedorova LV, Lepik KV, Volkov NP, Kotselyabina PV, Borzenkova ES, Popova MO, Beynarovich AV, Baykov VV, Kozlov AV, Moiseev IS, Mikhailova NB, Kulagin AD. Efficacy and safety of nivolumab combined with brentuximab vedotin after nivolumab monotherapy failure in patients with relapsed and refractory classic Hodgkin lymphoma. Int J Clin Oncol 2021; 27:626-632. [PMID: 34826011 PMCID: PMC8619646 DOI: 10.1007/s10147-021-02085-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/10/2021] [Indexed: 11/26/2022]
Abstract
Objectives Therapy of patients with relapsed and refractory classic Hodgkin lymphoma (r/r cHL) after PD-1 inhibitors failure remains an unresolved issue. The aim of this study was to evaluate the efficacy and safety of the combination of nivolumab with brentuximab vedotin (Nivo + BV) after nivolumab monotherapy failure. Methods This study retrospectively analyzed 21 patients with r/r cHL who were treated with the combination of Nivo + BV after Nivo failure. The response was evaluated by PET–CT scan according to the LYRIC criteria. Adverse events (AEs) were assessed according to NCI CTCAE v.4.03. Results Median follow-up was 19 (9–47) months. The ORR was 57%. The median OS was not reached, 24 month OS was 80% (95% CI 50–93%). Median PFS was 12 months with 24 month PFS of 31% (95% CI 12–53%). Any grade AEs were observed in 12 patients (63%), 3–4 grade AEs in 2 patients (10%). Allogeneic hematopoietic stem cell transplantation (allo-HSCT) after Nivo + BV was performed in 8 (38%) patients. The median time between Nivo + BV and allo-HSCT was 8 (5–21) months. Conclusions Combination of Nivo + BV in r/r cHL after nivolumab monotherapy failure is potentially an effective and safe approach. Supplementary Information The online version contains supplementary material available at 10.1007/s10147-021-02085-6.
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Affiliation(s)
- Liudmila V Fedorova
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia.
| | - Kirill V Lepik
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Nikita P Volkov
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Polina V Kotselyabina
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Evgenia S Borzenkova
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Marina O Popova
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Anastasia V Beynarovich
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Vadim V Baykov
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Andrey V Kozlov
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Ivan S Moiseev
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Natalia B Mikhailova
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
| | - Alexander D Kulagin
- RM Gorbacheva Research Institute, Pavlov University, 6-8 L'va Tolstogo, 197022, St. Petersburg, Russia
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16
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Gusak A, Fedorova L, Lepik K, Volkov N, Popova M, Moiseev I, Mikhailova N, Baykov V, Kulagin A. Immunosuppressive Microenvironment and Efficacy of PD-1 Inhibitors in Relapsed/Refractory Classic Hodgkin Lymphoma: Checkpoint Molecules Landscape and Macrophage Populations. Cancers (Basel) 2021; 13:cancers13225676. [PMID: 34830831 PMCID: PMC8616219 DOI: 10.3390/cancers13225676] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Classic Hodgkin lymphoma contains rare malignant Hodgkin/Reed–Sternberg cells and abundant reactive populations in the tumor microenvironment. Many aspects of the interaction between tumor cells and immune cells remain unclear. Nevertheless, the microenvironment is believed to play a crucial role in tumor resistance and progression. Current knowledge about the role and dynamics of the tumor microenvironment in Hodgkin lymphoma during anti-PD-1 treatment is limited. The aim of this study was to identify possible predictive and prognostic morphological markers in the treatment of patients with relapsed or refractory classic Hodgkin lymphoma treated with nivolumab and to assess the variability of reactive cell populations after nivolumab therapy. The study was aimed to optimize therapeutic strategy in patients with relapsed or refractory classic Hodgkin lymphoma. Abstract To date, the impact of the tumor microenvironment on the prognosis of patients with classic Hodgkin lymphoma (cHL) during anti-PD-1 therapy has been studied insufficiently. This retrospective study included 61 primary samples of lymph nodes from patients who had relapsed/refractory (r/r) cHL and were treated with nivolumab. Repeated samples were obtained in 15 patients at relapse or disease progression after immunotherapy. Median follow-up was 55 (13–63) months. The best overall response rate and progression-free survival (PFS) were analyzed depending on the expression of CD68, CD163, PD-1, LAG-3, TIM-3, CTLA-4, TIGIT, CD163/c-maf in the tumor microenvironment in primary and sequential biopsies. The combination of CD163/c-maf antibodies was used for the identification of M2 macrophages (M2). A low number of macrophages in primary samples was associated with inferior PFS during nivolumab treatment (for CD163-positive cells p = 0.0086; for CD68-positive cells p = 0.037), while a low number of M2 with higher PFS (p = 0.014). Complete response was associated with a lower level of M2 (p = 0.011). In sequential samples (before and after nivolumab therapy) an increase in PD-1 (p = 0.011) and LAG-3 (p = 0.0045) and a depletion of CD68 (p = 0.057) and CD163 (p = 0.0049)-positive cells were observed. The study expands understanding of the cHL microenvironment structure and dynamics during nivolumab therapy in patients with r/r cHL.
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17
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Cencini E, Bocchia M, Fabbri A. Nivolumab in relapsed/refractory Hodgkin lymphoma: towards a new treatment strategy? AMERICAN JOURNAL OF BLOOD RESEARCH 2021; 11:261-265. [PMID: 34322289 PMCID: PMC8303013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/11/2021] [Indexed: 06/13/2023]
Abstract
Chemo-refractory Hodgkin lymphoma (HL), especially after failure of high-dose therapy and autologous stem cell transplantation (ASCT), has a very poor prognosis. Nivolumab, an anti-PD-1 monoclonal antibody, demonstrated durable responses and manageable toxicity in a significant proportion of HL patients who fail both ASCT and brentuximab vedotin. Although anti-PD-1 treatment is often well tolerated, immune-related adverse events (iAE) were frequently observed. New perspectives could be represented by treatment discontinuation in patients with prolonged response or toxicity with the possibility of a re-treatment at relapse, subsequent chemotherapy or a modification of the dose-intensity or treatment duration. The efficacy of anti-PD-1 re-treatment was demonstrated in several cases and we have successfully managed 1 case with this strategy. With the main aim of avoiding the relapse-related psychophysical stress for the patient with manageable toxicity, we have successfully administered nivolumab every 4 weeks to 3 patients in prolonged complete remission, who presented with iAE during treatment. We believe that nivolumab should not only represent a bridge to allogeneic SCT, but it may play an important role also beyond the approved indication and current standard clinical care.
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Affiliation(s)
- Emanuele Cencini
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena Siena, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena Siena, Italy
| | - Alberto Fabbri
- Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena Siena, Italy
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18
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Groenland SL, Ratain MJ, Chen LS, Gandhi V. The Right Dose: From Phase I to Clinical Practice. Am Soc Clin Oncol Educ Book 2021; 41:92-106. [PMID: 34010057 DOI: 10.1200/edbk_319567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To realize the full potential of promising new anticancer drugs, it is of paramount importance to administer them at the right dose. The aim of this educational article is to provide several opportunities to optimize anticancer drug dosing, focusing on oral targeted therapies. First, therapeutic drug monitoring can optimize exposure in individual patients, if the optimal concentration is known. This approach is of particular interest in regard to oral kinase inhibitors with high interindividual pharmacokinetic variability. If exposure is related to response, then therapeutic drug monitoring is potentially feasible, although the clinical utility of this approach has not yet been established. Other approaches to reduce variability include administration of more frequent, smaller doses and administration under optimal prandial conditions. However, for many drugs, the labeled dose has not been demonstrated to be the optimal dose; for such agents, the vast majority of patients may be receiving excessive doses, which results in excessive toxicity. Furthermore, administration of lower off-label doses may reduce both medical and financial toxicity. These strategies should be applied from registration studies to clinical practice, with the goal of better optimizing anticancer treatment.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa S Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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19
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Fedorova LV, Lepik KV, Mikhailova NB, Kondakova EV, Zalyalov YR, Baykov VV, Babenko EV, Kozlov AV, Moiseev IS, Afanasyev BV. Nivolumab discontinuation and retreatment in patients with relapsed or refractory Hodgkin lymphoma. Ann Hematol 2021; 100:691-698. [PMID: 33528609 DOI: 10.1007/s00277-021-04429-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 01/14/2021] [Indexed: 11/25/2022]
Abstract
Immune checkpoint inhibitors (ICI) have demonstrated high therapeutic efficacy in relapsed or refractory classical Hodgkin lymphoma (r/r cHL). Nevertheless, despite the accumulated data, the question of the ICI therapy duration and efficacy of nivolumab retreatment remains unresolved. In this retrospective study, in a cohort of 23 adult patients with r/r cHL who discontinued nivolumab in complete response (CR), the possibility of durable remission achievement (2-year PFS was 55.1%) was demonstrated. Retreatment with nivolumab has demonstrated efficacy with high overall response rate (ORR) and CR (67% and 33.3% respectively). At the final analysis, all patients were alive with median PFS of 16.5 months. Grade 3-4 adverse events (AEs) were reported in 36% of patients, and there was no deterioration in terms of nivolumab retreatment-associated complications.
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Affiliation(s)
- Liudmila V Fedorova
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation.
| | - Kirill V Lepik
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Natalia B Mikhailova
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Elena V Kondakova
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Yuri R Zalyalov
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Vadim V Baykov
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Elena V Babenko
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Andrey V Kozlov
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Ivan S Moiseev
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Boris V Afanasyev
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
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