The impact of tumor size change after target therapy on survival: analysis of patients enrolled onto three clinical trials of advanced NSCLC from one institution

Pre-Treatment Tumor Growth Rate Predicts Clinical Outcomes of Patients With Advanced Non-Small Cell Lung Cancer Undergoing Anti-PD-1/PD-L1 Therapy

Tumor growth rate (TGR; percent size change per month [%/m]) is postulated as an early radio-graphic predictor of response to anti-cancer treatment to overcome limitations of RECIST. We aimed to evaluate the predictive value of pre-treatment TGR (TGR₀) for outcomes of advanced non-small cell lung cancer (aNSCLC) patients treated with anti-PD-1/PD-L1 monotherapy. We retrospectively screened all aNSCLC patients who received PD-1 axis inhibitors in Sun Yat-Sen University Cancer Center between August 2016 and June 2018. TGR₀ was calculated as the percentage change in tumor size per month (%/m) derived from two computed tomography (CT) scans during a "wash-out" period before the initiation of PD-1 axis inhibition. Final follow-up date was August 28, 2019. The X-tile program was used to identify the cut-off value of TGR₀ based on maximum progression-free survival (PFS) stratification. Patients were divided into two groups per the selected TGR₀ cut-off. The primary outcome was the difference of PFS between the two groups. The Kaplan-Meier methods and Cox regression models were performed for survival analysis. A total of 80 eligible patients were included (54 [67.5%] male; median [range] age, 55 [30-74] years). Median (range) TGR₀ was 21.1 (-33.7-246.0)%/m. The optimal cut-off value of TGR₀ was 25.3%/m. Patients with high TGR₀ had shorter median PFS (1.8 months; 95% CI, 1.6 - 2.1 months) than those with low TGR₀ (2.7 months; 95% CI, 0.5 - 4.9 months) (P = 0.005). Multivariate Cox regression analysis revealed that higher TGR₀ independently predicted inferior PFS (hazard ratio [HR] 1.97; 95% CI, 1.08-3.60; P = 0.026). Higher TGR₀ was also significantly associated with less durable clinical benefit rate (34.8% vs. 8.8%, P = 0.007). High pre-treatment TGR was a reliable predictor of inferior PFS and clinical benefit in aNSCLC patients undergoing anti-PD-1/PD-L1 monotherapy. The findings highlight the role of TGR₀ as an early biomarker to predict benefit from immunotherapy and could allow tailoring patient's follow-up.

Timing in combination with radiotherapy and patterns of disease progression in non-small cell lung cancer treated with EGFR-TKI

OBJECTIVES

Tyrosine kinase inhibitor (TKI) has been the standard of care for advanced non-small cell lung cancers (NSCLC) harboring epidermal growth factor receptor (EGFR) mutation, but these tumors invariably develop drug resistance. As progression most frequently advances in sites of original disease, our study sought to explore the time to response for NSCLC to TKI therapy and the patterns of disease progression, to provide evidence for timing and candidates for local therapy intervention.

MATERIALS AND METHODS

A cohort of 105 EGFR-mutated IIIB or IV NSCLC patients treated with EGFR-TKI were retrospectively analyzed. The disease progression patterns were divided into 3 categories: progression in sites of original disease, progression in new distant sites, and combined progression.

RESULTS

Before cut-off date, 80 patients had disease progression. Thirty-three (41.25 %) patients had progression in sites of original disease, 34 (42.5 %) patients had progression in new sites and 13 (16.25 %) patients had combined progression, respectively. The median time to response for responders was 2.00 months (95 %CI 1.28-2.92 months), and the median time to maximal tumor shrinkage for SD patients was 2.00 months (95 %CI 1.42-2.58 months). Multivariate logistic regression model showed that the 21 exon mutation is related to the incidence of original site failure.

CONCLUSION

Over 1/3 of the patients progress at the original sites, which indicated that this subset of patients may benefit from local therapy. Moreover, as the results indicate that considerable shrinkage for TKI therapy occurs in first two months after TKI initiation, local therapy can be adopted after this timepoint, before disease progression. We also propose EGFR gene mutation type as potential inclusion criteria to identify candidates for combined local therapy.

Modification of the tumor response threshold in patients of advanced non-small cell lung cancer treated with chemotherapy plus targeted agents: a pooled study from five clinical trials in one institution

Background

Chemotherapy with targeted therapy is a promising therapeutic option for advanced non-small cell lung cancer (NSCLC) patients. Response Evaluation Criteria in Solid Tumors (RECIST) criteria were used in tumor response evaluation. We assumed an optimal threshold for this therapeutic setting and tried to seek a new tumor shrinkage cutoff with the data from five clinical trials in one institution.

Methods

The X-tile program was used to identify the optimal cut-off value of tumor shrinkage. PFS and OS were compared in the current study. Kaplan-Meier method was used to describe PFS and OS. 95% CI was calculated for PFS and OS outcomes to assess the treatment efficacy. A P value of less than 0.05 was considered statistically significant. SPSS 23.0 was used for all statistical analysis.

Results

X-tile analysis yielded -10% in the ∆SLD of the target lesions as the optimal threshold for response/non-response. The 10% tumor shrinkage could discriminate responders from non-responders in PFS (10.1 vs. 2.50 months, P=0.0007) and OS (23.00 vs. 7.66 months, P<0.0001). Univariate and multivariable analysis showed that 10% tumor shrinkage was a valid prognostic factor for PFS (P=0.018) and OS outcome (P<0.0001).

Conclusions

A 10.0% tumor shrinkage in the SLD indicated an indicative efficacy evaluation threshold for NSCLC patients treated with chemotherapy plus targeted agents.

The relationship between preliminary efficacy and prognosis after first-line EGFR tyrosine kinase inhibitor (EGFR-TKI) treatment of advanced non-small cell lung cancer

Background

Nowadays, patients with EGFR tyrosine kinase inhibitor (EGFR-TKI)-sensitive advanced non-small cell lung cancer (NSCLC) receive EGFR-TKIs as first-line treatment. We aimed to analyze the relationship between preliminary efficacy (tumor shrinkage within 1 month) and progression-free survival (PFS) after first-line EGFR-TKI treatment.

Methods

A total of 82 patients with EGFR-TKI-sensitive advanced NSCLC confirmed by histopathology from January 2013 to January 2017 were retrospectively analyzed. All patients received first-line EGFR-TKI treatment and follow-up at Shanghai Chest Hospital.

Results

Of a total of 82 patients, 42 (51.2%) patients achieved partial response (PR) within 1 month, and 40 (48.8%) patients achieved stable disease (SD: -30% to 0) within 1 month. The median PFS among all patients was 10 months. The median PFS in patients achieving PR within 1 month was 10.0 months. The median PFS in patients achieving SD (-30% to 0) within 1 month was 9.3 months. There was no statistically significant difference between PR within 1 month and SD (-30% to 0) within 1 month (P=0.620). In the EGFR-sensitive mutation subgroup, there was also no statistically significant difference between PR within 1 month and SD (-30% to 0) within 1 month. Univariate and multivariate analysis of first-line EGFR-TKI treatment showed that age, EGFR mutation type, and T staging had effects on PFS. Patients who were more than 65 years old, had EGFR 19del mutation, along with a T staging less than 4, had a longer PFS; these differences were statistically significant. Liver metastasis, bone metastasis, and brain metastasis were not shown to be related to PFS.

Conclusions

For patients with EGFR-TKI-sensitive advanced NSCLC, there is no correlation between preliminary efficacy (tumor shrinkage within 1 month) and PFS after first-line EGFR-TKI treatment.

[Clinical Predictive Factors associated with First Line EGFR-TKI Efficacy in Advanced NSCLC Patients with EGFR Mutations]

背景与目的

一线应用表皮生长因子-酪氨酸激酶抑制剂（epidermal growth factor receptor tyrosine kinase inhibitors, EGFR-TKIs）治疗具有EGFR基因突变的晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）疗效显著，但患者的无进展生存时间（progression free survival, PFS）可有较大差异。既往研究表明一些临床因素可能与疗效相关，本研究旨在探讨影响EGFR-TKI疗效的临床预测因素。

方法

收集203例存在EGFR基因敏感突变且一线接受EGFR-TKI治疗的晚期NSCLC患者的人口学及临床资料并进行回顾性分析。

结果

截至随访结束时203例患者中共有139例发生病情进展，63例死亡。中位随访时间为21.1个月，中位PFS为14.3个月。接受治疗患者疾病部分缓解（partial response, PR）127例（66.1%），疾病稳定（stable disease, SD）55例（28.6%）。与PFS相关的单因素分析结果显示，ECOG评分≥2分（5.1个月 vs 16个月，P=0.033）、最佳疗效为SD（9.5个月 vs 17.9个月，P=0.030）、合并胸腔外远处转移（11.7个月 vs 27.5个月，P=0.004）、肝转移（4.1个月 vs 16.0个月，P=0.000）、骨转移（13.3个月 vs 21.5个月，P=0.027）和同时并发肺栓塞（5.5个月 vs 16.6个月，P=0.005）的患者PFS明显缩短。多因素Cox回归结果显示合并肝转移（HR=1.694, 95%CI: 1.146-5.756, P=0.022）、最佳治疗反应仅达到SD（HR=1.825, 95%CI: 1.107-3.008, P=0.018）是独立的疗效预测因素。

结论

对于EGFR突变阳性的晚期NSCLC患者，一线应用EGFR-TKI治疗效果良好。治疗的最佳疗效以及基线肝转移是PFS的独立临床预测因素。

Best Response According to RECIST During First-line EGFR-TKI Treatment Predicts Survival in EGFR Mutation-positive Non-Small-cell Lung Cancer Patients

INTRODUCTION

The association between the response to first-line epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and survival in EGFR mutation-positive non-small-cell lung cancer (NSCLC) remains unclear. We studied the association between the response to first-line EGFR-TKIs and survival using Response Evaluation Criteria In Solid Tumors (RECIST) and maximal tumor shrinkage.

MATERIALS AND METHODS

We analyzed data from patients with advanced EGFR mutation-positive NSCLC enrolled in first-line gefitinib and afatinib trials. A total of 98 patients who achieved a response or stable disease and had ≥ 1 measurable target lesion were included. The association between the best response by RECIST or maximal tumor shrinkage and survival was analyzed in Kaplan-Meier and Cox regression models with the landmark method. The specified landmark time points were 8 weeks, the median time to maximal tumor shrinkage (16.5 weeks), and median progression-free survival (PFS; 56 weeks).

RESULTS

A total of 76 patients (77%) responded to gefitinib or afatinib. Of these 76 patients, 49 (64%) and 75 (99%) had achieved a response at 8 and 16.5 weeks, respectively. All responders had achieved a response by 56 weeks. The responders had a significantly longer PFS and overall survival (OS) compared with those with stable disease at 16.5 weeks (PFS, P = .003; OS, P < .001) and 56 weeks (PFS, P = .026; OS, P = .016) but not at 8 weeks (PFS, P = .104; OS, P = .313). Among the responders, greater tumor shrinkage was not associated with longer PFS or OS.

CONCLUSION

Those with a response to first-line gefitinib or afatinib had more favorable PFS and OS compared with those with stable disease. A sufficient observation period was required for the response to occur and predict outcomes. Greater maximal tumor shrinkage in the responders was not predictive of survival.

Prognostic value of tumor volume for patients with advanced lung cancer treated with chemotherapy

BACKGROUND AND OBJECTIVE

We aim to develop a reference system utilizing computed tomography to calculate changes in tumor volume of lung cancer patients after chemotherapy to assist physicians in clinical treatment and evaluation.

METHODS

Image processing techniques were used to analyze the computed tomography of lung cancer, locate the tumor, and calculate the tumor volume. The medical indicator was then evaluated and analyzed. We examined the correlation between reduced tumor volume and survival duration of 88 patients after chemotherapy at Tri-Service General Hospital, Taiwan. The innovative survival prediction index was obtained by four statistical methods: receiver operating characteristic curve, Youden index, Kaplan-Meier method, and log rank test.

RESULTS

From the image processing techniques, tumor volume from each patient were obtained within an average of 7.25 seconds. The proposed method was shown to achieve rapid positioning of lung tumors and volume reconstruction with an estimation error of 1.92% when calibrated with an irregularly shaped stone. In medical indicator evaluation and analysis, the area below the receiver operating characteristic curve is greater than 0.8, indicating good predictability of the medical index used herein. The Youden index spotted the best cut-off point of volume, and the correlation between the volume's cut-off point and survival time was confirmed again by Kaplan-Meier and log rank test. The p-values were all less than 0.05, presenting a high degree of correlation between the two, indicating that this medical indicator is highly reliable.

CONCLUSIONS

The proposed techniques can automatically find the location of tumors in the lung, reconstruct the volume, and calculate changes in volume before and after treatment, thus obtaining an innovative survival prediction index. This will help facilitate early and accurate predictions of disease outcomes during the course of therapy, and categorize patient stratification into risk groups for more efficient therapies.

Optimal tumor shrinkage predicts long-term outcome in advanced nonsmall cell lung cancer (NSCLC) treated with target therapy: Result from 3 clinical trials of advanced NSCLC by 1 institution

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are used as standard therapies for advanced nonsmall cell lung cancer (NSCLC) patients with EGFR mutation positive. Because these targeted therapies could cause tumor necrosis and shrinkage, the purpose of the study is to search for a value of optimal tumor shrinkage as an appropriate indicator of outcome for advanced NSCLC.A total of 88 NSCLC enrollees of 3 clinical trials (IRESSA registration clinical trial, TRUST study and ZD6474 study), who received Gefitinib (250 mg, QD), Erlotinib (150 mg, QD), and ZD6474 (100 mg, QD), respectively, during December 2003 and October 2007, were retrospectively analyzed. The response evaluation criteria in solid tumors (RECIST) were used to identify responders, who had complete response (CR) or partial responses (PR) and nonresponders who had stable disease (SD) or progressive disease (PD). Receiver operating characteristics (ROC) analysis was used to find the optimal tumor shrinkage as an indicator for tumor therapeutic outcome. Univariate and multivariate Cox regression analyses were performed to compare the progression-free survival (PFS) and overall survival (OS) between responders and nonresponders stratified based on radiologic criteria.Among the 88 NSCLC patients, 26 were responders and 62 were nonresponders based on RECIST 1.0. ROC indicated that 8.32% tumor diameter shrinkage in the sum of the longest tumor diameter (SLD) was the cutoff point of tumor shrinkage outcomes, resulting in 46 responders (≤8.32%) and 42 nonresponders (≥8.32%). Univariate and multivariate Cox regression analyses indicated that (1) the responders (≤8.32%) and nonresponders (≥ -8.32%) were significantly different in median PFS (13.40 vs 1.17 months, P < 0.001) and OS (19.80 vs 7.90 months, P < 0.001) and (2) -8.32% in SLD could be used as the optimal threshold for PFS (hazard ratio [HR], 8.11, 95% CI, 3.75 to 17.51, P < 0.001) and OS (HR, 2.36, 95% CI, 1.41 to 3.96, P = 0.001).However, 8.32% tumor diameter shrinkage is validated as a reliable outcome predictor of advanced NSCLC patients receiving EGFR-TKIs therapies and may provide a practical measure to guide therapeutic decisions.

The effectiveness of RECIST on survival in patients with NSCLC receiving chemotherapy with or without target agents as first-line treatment

We analyzed the correlation between survival and antitumor effect evaluated by RECIST in advanced NSCLC patients with chemotherapy plus target therapy or not as first-line treatment, to examine the applicability of RECIST in this population. The patients were screened from 4 clinical trials (12621, 12006, FASTACT-I, and FASTACT-II), and those who received chemotherapy plus target therapy or chemotherapy alone were eligible. Among the 59 enrolled patients, 29 received combination therapy, while the other 30 received chemotherapy only. In the combination therapy group, patients with PR or SD had longer overall survival (OS) than those with PD (P < 0.001 and P = 0.002, respectively). However, in the chemotherapy alone group, compared with PD patients, either PR or SD group had no significant overall survival benefit (P = 0.690 and P = 0.528, respectively). In summary, for advanced NSCLC patients receiving chemotherapy plus target therapy as first-line treatment and evaluated by RECIST criteria, SD has the same overall survival benefit as PR, suggesting that antitumor effective evaluation by RECIST criteria cannot be translated to overall survival benefit especially for this kind of patients. Therefore, developing a more comprehensive evaluation method to perfect RECIST criteria is thus warranted for patients received target therapy in NSCLC.

New strategy for monitoring targeted therapy: molecular imaging

Targeted therapy is becoming an increasingly important component in the treatment of cancer. How to accurately monitor targeted therapy has been crucial in clinical practice. The traditional approach to monitor treatment through imaging has relied on assessing the change of tumor size by refined World Health Organization criteria, or more recently, by the Response Evaluation Criteria in Solid Tumors. However, these criteria, which are based on the change of tumor size, show some limitations for evaluating targeted therapy. Currently, genetic alterations are identified with prognostic as well as predictive potential concerning the use of molecularly targeted drugs. Conversely, considering the limitations of invasiveness and the issue of expression heterogeneity, molecular imaging is better able to assay in vivo biologic processes noninvasively and quantitatively, and has been a particularly attractive tool for monitoring treatment in clinical cancer practice. This review focuses on the applications of different kinds of molecular imaging including positron emission tomography-, magnetic resonance imaging-, ultrasonography-, and computed tomography-based imaging strategies on monitoring targeted therapy. In addition, the key challenges of molecular imaging are addressed to successfully translate these promising techniques in the future.