Effectiveness and Safety of Anlotinib Monotherapy for Patients with Extensive-stage Small-Cell Lung Cancer Who Progressed to Chemotherapy: A Real-world Exploratory Study

Off-label use of anlotinib in malignancies' treatment: efficacy and management of adverse reactions

Anlotinib is a novel small-molecule multi-target tyrosine kinase inhibitor (TKIs) independently developed in China, it possesses the functions of inhibiting tumor angiogenesis and suppressing tumor growth. Anlotinib has achieved notable therapeutic effects in approved indications for advanced non-small cell lung cancer, soft tissue sarcoma, small cell lung cancer, and medullary thyroid carcinoma. Additionally, with unanimous expert consensus, it has been used off-label in various other tumors, yielding favorable outcomes. This article reviews the efficacy and common adverse reactions, as well as their management, of off-label use of anlotinib in various malignant tumors.

Risk Factors for Prognosis of Lung Cancer Patients Receiving Anlotinib Treatment: A Retrospective Cohort Study

PURPOSE

Anlotinib is widely used in the treatment of lung cancer. However, there remains a lack of predictive biomarkers to effectively gauge the response to anlotinib therapy. We conducted a retrospective study to preliminarily explore potential risk factors that might predict outcomes in lung cancer patients undergoing anlotinib treatment.

PATIENTS AND METHODS

We retrospectively analyzed lung cancer patients treated with anlotinib at our hospital between 1 June 2018 and 1 June 2021. Data were gathered from electronic medical records. Demographic and clinical characteristics of patients, progression-free survival (PFS), and overall survival (OS) were described. Predictive factors related to treatment efficacy were preliminarily analyzed using Cox regression and Kaplan-Meier survival analyses.

RESULTS

After adjusting for potential confounders, clinical stage IV (hazard ratio [HR] = 2.52, 95% confidence interval [CI], 1.09-5.82, p = 0.0311), N-terminal fragment brain natriuretic peptides (NT-pro-BNP) > 300 pg/mL (HR = 2.54, 95% CI, 1.17-5.52, p = 0.0183), and neuron-specific enolase (NSE) > 16.3 ng/mL (HR = 1.70, 95% CI, 1.03-2.81, p = 0.0389) were associated with shorter OS, whereas age (HR = 0.96, 95% CI, 0.94-0.99, p = 0.0055) was associated with a longer PFS in fully adjusted model. Kaplan-Meier analyses of cumulative risk factors (clinical stage IV, NT-pro-BNP > 300 pg/mL, and NSE > 16.3 ng/mL) indicated that patients with a greater number of coexisting risk factors had significantly shorter OS (p < 0.0001).

CONCLUSION

Clinical stage IV, NT-pro-BNP level, and NSE level were identified as independent prognostic factors for lung cancer patients undergoing anlotinib treatment. Patients with multiple high-risk factors may derive limited benefit from anlotinib.

Anlotinib as Maintenance Therapy After First-Line Chemotherapy Combined with Consolidation Radiation for Extensive-Stage Small Cell Lung Cancer

BACKGROUND

Small cell lung cancer is sensitive to chemotherapy and radiotherapy, but local recurrence and distant metastasis occur shortly after treatment. This study aimed to evaluate the real-world value of anlotinib as a maintenance therapy in patients with extensive-stage small cell lung cancer (ES-SCLC) after first-line chemotherapy and consolidative thoracic radiotherapy (CTRT).

PATIENTS AND METHODS

A total of 150 patients with ES-SCLC treated with first-line chemotherapy and CTRT from April 2017 to December 2021 were retrospectively analyzed. After the completion of chemoradiotherapy, patients received anlotinib according to their desire. The primary endpoints were progression-free survival (PFS) and overall survival (OS) after the first diagnosis, and the secondary endpoints were prognostic factors and safety.

RESULTS

The ORR and DCR of patients with ES-SCLC were 50.0% and 80.3%, respectively, in the anlotinib group and 42.9% and 69.0% in the no-maintenance therapy group. The 3-year OS rates were 27.6% and 12.6% in the anlotinib and observation groups (HR = 2.52, P = 0.003), and the median OS times were 23.8 months and 15.3 months. The 3-year PFS rates were 18.2% and 8.8% in the anlotinib and observation groups (HR = 1.76, P = 0.034) with median PFS times of 11.5 months and 8.8 months. After stratification on the basis of clinical response, patients who achieved CR plus PR after chemoradiotherapy had a longer median OS in the anlotinib and observation groups (34.0 months vs 24.8 months, HR = 2.40, P = 0.009). There were higher incidence rates of hand-foot syndrome (27.3% vs 10.5%, P = 0.001), gingival bleeding/hemoptysis (18.5% vs 4.8%, P = 0.015) and rash (33.3% vs 4.8%, P < 0.001) in the anlotinib group than in the observation group.

CONCLUSION

Maintenance therapy with anlotinib improved the survival of patients with ES-SCLC after first-line chemotherapy and CTRT. Owing to the small sample size of the real-world trial, the reliability of our study needs to be confirmed in more studies.

What Is on the Horizon for Treatments in Idiopathic Pulmonary Fibrosis?

Idiopathic pulmonary fibrosis (IPF) is a progressive and often fatal lung disease most commonly encountered in older individuals. Several decades of research have contributed to a better understanding of its pathogenesis, though only two drugs thus far have shown treatment efficacy, i.e., by slowing the decline of lung function. The pathogenesis of IPF remains incompletely understood and involves multiple complex interactions and mechanisms working in tandem or separately to result in unchecked deposition of extracellular matrix components and collagen characteristic of the disease. These mechanisms include aberrant response to injury in the alveolar epithelium, inappropriate communication between epithelial cells and mesenchymal cells, imbalances between oxidative injury and tissue repair, recruitment of inflammatory pathways that induce fibrosis, and cell senescence leading to sustained activation and proliferation of fibroblasts and myofibroblasts. Targeted approaches to each of these mechanistic pathways have led to recent clinical studies evaluating the safety and efficacy of several agents. This review highlights selected concepts in the pathogenesis of IPF as a rationale for understanding current or future therapeutic approaches, followed by a review of several selected agents and their recent or active clinical studies. Current novel therapies include approaches to attenuating or modifying specific cellular or signaling processes in the fibrotic pathway, modifying inflammatory and metabolic derangements, and minimizing inappropriate cell senescence.

The Efficacy and Safety of Anlotinib Plus Etoposide with Cisplatin/Carboplatin in the First-Line Treatment of Lung Cancer: A Phase II Clinical Study

Background: The primary aim of this phase II clinical study was to assess the safety and efficacy of combining anlotinib, etoposide, and platinum-based drugs as a first-line treatment for ES-SCLC. Methods: Patients underwent the standard chemotherapeutic regimen, consisting of four courses of etoposide plus cisplatin/carboplatin. Additionally, each patient received a 2-week intervention with anlotinib (12 mg/day, once daily). Anlotinib was continued until disease progression, occurrence of unbearable adverse events (AEs), or withdrawal from the research. Progression-free survival (PFS) served as the primary prognostic measure. Secondary measures included the disease control rate (DCR), objective response rate (ORR), overall survival time (OS), and the incidence of AEs. Results: The DCR and ORR were 97.6% and 91.0%, respectively. Estimated PFS and OS were 5.0 months (95% CI: 1.0-10.8 months) and 13.0 months (95% CI: 8.4-18.6 months), respectively. No unexpected adverse effects were reported during the trial. The most common adverse reactions included anemia (42.22%), hypertension (53.33%), alopecia (40.00%), elevated transaminase (24.40%), and elevated alkaline phosphatase (24.44%). Sixteen cases (35.56%) were classified as AEs of grades 3-5. No deaths attributed to treatment-related causes occurred in any patient during the trial. Conclusion: Combination chemotherapy is currently the first-line therapy for extensive small-cell lung cancer (ES-SCLC). Combining anlotinib with conventional platinum-based chemotherapy demonstrated promising therapeutic outcomes and prognosis in the management of ES-SCLC.

Cost-effectiveness of anlotinib vs. pembrolizumab and nivolumab as third-line treatment in recurrent small cell lung cancer in China

BACKGROUND

The study aims to evaluate the cost-effectiveness of anlotinib versus pembrolizumab and nivolumab as the third-line treatment in recurrent small cell lung cancer (SCLC) patients from the Chinese healthcare system perspective.

RESEARCH DESIGN AND METHODS

A Markov model was built to simulate the costs and health outcomes in the 4-year horizon. Efficacy and safety data of anlotinib, pembrolizumab, and nivolumab in patients with recurrent SCLC were derived from three studies. Cost and utility values were derived from local charges, the published literature, and related databases. Three scenario analyses and sensitivity analyses were performed to explore the robustness of the results.

RESULTS

Compared with anlotinib, pembrolizumab and nivolumab were estimated to gain an additional 0.18 and 0.10 quality-adjusted life years (QALYs) at an incremental cost of $10,446 and $5,182, resulting in an increment cost-utility ratio (ICUR) of $58,221/QALY and $56,733/QALY. The sensitivity analyses showed that the likelihood of anlotinib being cost-effective was 87.5% to 99.9% at a willingness-to-pay (WTP) threshold of $11,144 to $33,431/QALY. The scenario analyses indicated that the results varied in different scenarios.

CONCLUSIONS

The findings suggest that anlotinib could be the most cost-effective option versus pembrolizumab and nivolumab in the third-line treatment of recurrent SCLC from the Chinese healthcare system perspective.

Long-term survival in extensive-stage small-cell lung cancer treated with different immune checkpoint inhibitors in multiple-line therapies: A case report and literature review

Background

Extensive-stage small-cell lung cancer (ES-SCLC) is highly malignant, is highly prone to recurrence, and has a short survival period. It is very difficult to achieve long-term survival in ES-SCLC, which has not been significantly improved in the last 20 years. For a long time, platinum-based chemotherapy has occupied the core position in the treatment of small-cell lung cancer (SCLC), but there are few options for treatment drugs or regimens, and if disease progression occurs, the options for follow-up regimens are obviously limited. The advent of immunotherapy has changed this situation to some extent, and immunotherapy has shown some effects in improving efficiency and prolonging survival, whether in first- or third-line therapy, but it is still unsatisfactory.

Case presentation

A 57-year-old patient with ES-SCLC experienced disease progression after four lines of treatment including synchronous radiotherapy, chemotherapy, and antiangiogenesis. However, the patient still benefited when switching to the programmed cell death receptor-1 (PD-1) inhibitor toripalimab in combination with chemotherapy in the fifth line. Even after the development of immune resistance, the patient still benefited after switching to tislelizumab in combination with different chemotherapy regimens or alone in the sixth and seventh lines. Following the progression of tislelizumab in combination with chemotherapy, the patient again profited after switching to durvalumab in combination with anlotinib and again achieved a progressive-free survival (PFS) of 11 months. Overall, the patient achieved a total of 45 months of PFS and 50 months of overall survival (OS), with a shocking and exciting 30 months of PFS achieved in the immune combination phase alone.

Conclusion

We report a patient with ES-SCLC who achieved long-term survival after at least eight lines of therapy including chemotherapy, antiangiogenesis, and different immune checkpoint inhibitors (ICIs). This suggests that long-term survival in SCLC is possible with aggressive, combined, and standardized treatment. Otherwise, immunotherapy postline enablement can still benefit patients, rechallenge after immune resistance is also possible in SCLC, and combination with chemotherapy or antiangiogenic therapy can improve the efficacy and prolong the survival. This will provide new ideas and options for the selection of treatment options for SCLC.

Anlotinib plus etoposide and cisplatin/carboplatin as first-line therapy for extensive-stage small cell lung cancer (ES-SCLC): a single-arm, phase II study

Patients with extensive-stage small-cell lung cancer (ES-SCLC) have high relapse rates and poor prognosis. Anlotinib monotherapy has shown promising efficacy for patients with ES-SCLC and has a non-overlapping toxicity profile with chemotherapy. Therefore, the study aims to assess the efficacy and safety of the addition of anlotinib to platinum-chemotherapy as first-line therapy for patients with ES-SCLC. ES-SCLC patients without systemic chemotherapy and immunotherapy were recruited. Eligible patients received anlotinib (12 mg/day, on day 1-14) of a 21-day cycle, with concomitant etoposide (100 mg/m², on day 1-3) plus cisplatin (75 mg/m², on day 1) or carboplatin (AUC = 4-5, on day 1) for 4-6 cycles, followed by indefinite anlotinib maintenance therapy. The primary endpoint was progression-free survival (PFS). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), overall survival (OS). Between Jan 15, 2019 and Dec 31, 2020, 25 patients were enrolled. At the data cut-off time (November 3, 2021), the median follow-up was 14.3 months. Median PFS was 10.3 months (95% CI: 6.0-14.5) and median OS was 17.1 months (95% CI: 11.1-19.3). The ORR and DCR were 90% and 100%, respectively. The most common grade 3 or worse treatment-related adverse events were neutropenia (50%), leukopenia (35%), thrombocytopenia (25%), fatigue (10%), nausea (10%), hyponatremia (10%), anemia (10%). One patient discontinued treatment due to treatment-related adverse events. No treatment-related death occurred. Anlotinib plus platinum-chemotherapy as first-line therapy for ES-SCLC has anti-tumor activity, and showed acceptable tolerability. These results provide a basis for future randomized controlled trials.

Case Report: Successful Treatment of Kaposi’s Sarcoma With Anlotinib in an HIV-Negative Patient After the Treatment of Drug Reaction With Eosinophilia and Systemic Symptoms Accessory Tragus

Kaposi’s Sarcoma (KS) is a neoplasm derived from endothelial cells and is associated with human herpesvirus-8 (HHV-8) infection. It is mostly seen in patients suffering from AIDS and/or chronic immunosuppression. Currently, systemic chemotherapy is the primary treatment option for the advanced KS. However, there is no consensus on the treatment of KS. In this case, an 84-year-old man with a history of psoriasis developed multiple painful dark purple nodules on the trunk and extremities during the treatment of drug reaction with eosinophilia and systemic symptoms (DRESS). KS was confirmed by the skin biopsy, and the immunohistochemical staining demonstrated the positivity for HHV-8 while the anti-HIV test was negative. The patient then received anlotinib treatment, a tyrosine kinase inhibitor, for 5 months, and his skin lesions subsided. This case indicates that anlotinib may be a potential treatment option for KS.