Clinical Characteristics of Liver Metastasis in Nivolumab-treated Patients with Non-small Cell Lung Cancer

Progress of immune checkpoint inhibitors therapy for non-small cell lung cancer with liver metastases

Nearly one-fifth of patients with non-small cell Lung Cancer (NSCLC) will develop liver metastases (LMs), and the overall treatment strategy of LMs will directly affect the survival of patients. However, some retrospective studies have found that patients receiving chemotherapy or targeted therapy have a poorer prognosis once LMs develop. In recent years, multiple randomised controlled trials (RCTS) have shown significant improvements in outcomes for patients with advanced lung cancer following the introduction of immune checkpoint inhibitors (ICIs) compared to conventional chemotherapy. ICIs is safe and effective in patients with LMs, although patients with LMs are mostly underrepresented in randomised clinical trials. However, NSCLC patients with LMs have a significantly worse prognosis than those without LMs when treated with ICIs, and the mechanism by which LMs induce systemic anti-tumour immunity reduction is unknown, so the management of LMs in patients with NSCLC is a clinical challenge that requires more optimised therapies to achieve effective disease control. In this review, we summarised the mechanism of ICIs in the treatment of LMs, the clinical research and treatment progress of ICIs and their combination with other therapies in patients with LMs from NSCLC.

The Impact of Prophylactic Cranial Irradiation and Consolidative Thoracic Radiation Therapy for Extensive Stage Small-Cell Lung Cancer in the Transition to the Chemo-Immunotherapy Era: A Single Institution Series

INTRODUCTION

Extensive-stage small-cell lung cancer (ES-SCLC) continues to have poor survival due to its aggressive behavior, despite improvements with incorporation of immunotherapy with standard chemotherapy. Controversy exists regarding the role of consolidative thoracic radiation therapy (TRT) and prophylactic cranial irradiation (PCI) in ES-SCLC due to high recurrence rates. We report our institutional result of the benefit of PCI and TRT in ES-SCLC.

METHODS

Patients with ES-SCLC without intracranial metastasis at diagnosis (N = 163) were included. All patients completed systemic therapy with or without immunotherapy based on time of standard of care. Cohorts were divided by systemic therapy use and further subdivided by treatment with PCI and TRT. Overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method with log-rank test for comparison. The effects of TRT and PCI were estimated by multivariable (MVA) Cox regression.

RESULTS

Seventy-four patients (45.4%) received TRT, and 33.1% (n = 54) received PCI. The median follow-up was 11 months (3-85 months). PCI improved median OS to 15 months from 10 months, P = .02) and median PFS to 8.5 months from 5 months (P = .02) which remained significant on MVA, P = .02 and P = .02, respectively. TRT improved OS on UVA (P = 0.002) but was not significant on MVA. TRT did not improve PFS.

CONCLUSION

This study including chemotherapy and chemo-immunotherapy suggests improved outcomes with addition of PCI in patients with ES-SCLC while TRT did not show benefit to either OS or PFS. A future trial is needed to evaluate the role of TRT and PCI in the era of chemo-immunotherapy.

Molecular Mechanisms of Colorectal Liver Metastases

The liver is the most frequently target for metastasis among patients with colorectal cancer mainly because of the portal vein circulation that directly connects the colon and rectum with the liver. The liver tumor microenvironment consists of different cell types each with unique characteristics and functions that modulate the antigen recognition and immune system activation. Primary tumors from other sites "prime" the liver prior to the seeding of cancer cells, creating a pre-metastatic niche. Following invasion into the liver, four different phases are key to the development of liver metastases: a microvascular phase in which cancer cells infiltrate and become trapped in sinusoidal vessels; an extravascular, pre-angiogenic phase; an angiogenic phase that supplies oxygen and nutrients to cancer cells; and a growth phase in which metastatic cells multiply and enlarge to form detectable tumors. Exosomes carry proteins, lipids, as well as genetic information that can create a pre-metastatic niche in distant sites, including the liver. The complexity of angiogenic mechanisms and the exploitation of the vasculature in situ by cancer cells have limited the efficacy of currently available anti-angiogenic therapies. Delineating the molecular mechanisms implicated in colorectal liver metastases is crucial to understand and predict tumor progression; the development of distant metastases; and resistance to chemotherapy, immunotherapy, and targeted treatment.

Effect and outcomes analysis of anlotinib in non-small cell lung cancer patients with liver metastasis: results from the ALTER 0303 phase 3 randomized clinical trial

PURPOSE

Liver metastasis (LM) is common in non-small cell lung cancer (NSCLC), and always predicted worse outcomes with no effective therapy. We aimed to evaluate the effects and prognosis in LM patients treated with anlotinib.

METHODS

The present study is a post hoc analysis based on a multicenter, double-blind, phase 3 randomized clinical trial which designed to evaluate the efficacy and safety of anlotinib in patients with advanced NSCLC. A total of 437 patients were enrolled in present study, and 78 patients with LM.

RESULTS

Patients with LM showed a worse outcome compared to those without LM (PFS median, 2.6 vs 4.2 months), and OS (median, 5.6 vs 9.4 months, both P < 0.0001). The anlotinib was associated with longer PFS (median, 3.0 months) compared with placebo (median, 0.9 months), with a hazard ratio (HR) of 0.23 (95%CI, 0.12-0.42; P < 0.0001). Furthermore, OS was marginally significantly better in anlotinib group (median 6.6 months), compared with placebo (median 4.0 months), HR 0.61 (95%CI, 0.36-1.02; P = 0.055). Multivariate analysis confirmed normal peripheral blood LDH/TBiL level predicted better PFS and OS, lower ECOG score acted as independently prognostic factor for superior OS. Anlotinib was more associated with hand-foot syndrome (7.7% vs 0) and serum TSH level rise (7.7% vs 3.8%) and well tolerated, all AEs were no more than grade 3.

CONCLUSION

Patients with LM had a dismal prognosis, anlotinib could lead to a better PFS in pretreated NSCLC patients, which suggested anlotinib is a potential third-line or further therapy in these patients.

Efficacy of PD-1/PD-L1 plus CTLA-4 inhibitors in solid tumors based on clinical characteristics: a meta-analysis

Aims: To clarify the relationship between the potency of dual blockade of PD-1 or its ligand (PD-L1) plus CTLA-4 and patients with different clinical characteristics with solid tumors, the authors performed this meta-analysis. Patients & methods: 12 randomized clinical trials containing 7056 patients were included after the literature was filtered. Results: Dual blockade substantially enhanced overall survival and progression-free survival compared with standard of care, especially in patients aged <65 years old, those 65-74 years old, those with a smoking history, members of the White population and those with a high tumor mutation burden. Conclusion: Dual blockade therapy significantly improved patient survival outcomes. Age, smoking history, race and tumor mutation burden might be used to predict the potency of dual blockade therapy in solid tumors.

Hepatotoxicity in immune checkpoint inhibitors: A pharmacovigilance study from 2014-2021

Adverse events(AEs) related to hepatotoxicity have been reported in patients treated with immune checkpoint inhibitors (ICIs). As the number of adverse events increases, it is necessary to assess the differences in each immune checkpoint inhibitor regimen. The purpose of this study was to examine the relationship between ICIs and hepatotoxicity in a scientific and systematic manner. Data were obtained from the FDA Adverse Event Reporting System database (FAERS) and included data from the first quarter of 2014 to the fourth quarter of 2021. Disproportionality analysis assessed the association between drugs and adverse reactions based on the reporting odds ratio (ROR) and information components (IC). 9,806 liver adverse events were reported in the FAERS database. A strong signal was detected in older patients (≥65 years) associated with ICIs. hepatic adverse events were most frequently reported with Nivolumab (36.17%). Abnormal liver function, hepatitis, and autoimmune hepatitis were most frequently reported, and hepatitis and immune-mediated hepatitis signals were generated in all regimens. In clinical use, patients should be alert to these adverse effects, especially in elderly patients, who may be aggravated by the use of ICI.

Choosing the optimal immunotherapeutic strategies for non-small cell lung cancer based on clinical factors

The treatment landscape of advanced non-small cell lung cancer (NSCLC) has changed dramatically since the emergence of immune checkpoint inhibitors (ICIs). Although some patients achieve long survival with relatively mild toxicities, not all patients experience such benefits from ICI treatment. There are several ways to use ICIs in NSCLC patients, including monotherapy, combination immunotherapy, and combination chemoimmunotherapy. Decision-making in the selection of an ICI treatment regimen for NSCLC is complicated partly because of the absence of head-to-head prospective comparisons. Programmed death-ligand 1 (PD-L1) expression is currently considered a standard biomarker for predicting the efficacy of ICIs, although some limitations exist. In addition to the PD-L1 tumor proportion score, many other clinical factors should also be considered to determine the optimal treatment strategy for each patient, including age, performance status, histological subtypes, comorbidities, status of oncogenic driver mutation, and metastatic sites. Nevertheless, evidence of the efficacy and safety of ICIs with some specific conditions of these factors is insufficient. Indeed, patients with poor performance status, oncogenic driver mutations, or interstitial lung disease have frequently been set as ineligible in randomized clinical trials of NSCLC. ICI use in these patients is controversial and remains to be discussed. It is important to select patients for whom ICIs can benefit the most from these populations. In this article, we review previous reports of clinical trials or experience in using ICIs in NSCLC, focusing on several clinical factors that are associated with treatment outcomes, and then discuss the optimal ICI treatment strategies for NSCLC.

Efficacy of Atezolizumab for Advanced Non-Small Cell Lung Cancer Based on Clinical and Molecular Features: A Meta-Analysis

Objective

Atezolizumab is becoming a significant therapy for non-small cell lung cancer (NSCLC), but its efficacy needs to be further improved. The aims of this study are to clarify the potency of atezolizumab-based therapy in advanced NSCLC patients with different clinical and molecular features, and to choose a better therapeutic regimen of atezolizumab to achieve more precise treatment in immunotherapy.

Methods

Randomized clinical trials (RCTs) in the Cochrane Library, PubMed, Embase Science Direct, and Google Scholar, together with major oncology conferences that compared atezolizumab with chemotherapy-based treatment for individuals with advanced NSCLC published prior to February 2022, were searched. Studies, bias risk assessment, and data extraction were selected by two independent authors. We extracted the basic features of the included studies, together with the 95% confidence interval (CI) and hazard ratios (HRs), from all patients and subgroups. The combined treatment data were assessed using the inverse variance weighting method.

Results

Seven RCTs including 4,859 patients were included. Our meta-analysis findings indicated that atezolizumab substantially enhanced OS (HR 0.82; 95% CI, 0.77–0.88; p < 0.00001) and PFS (HR 0.72; 95% CI, 0.61–0.85; p < 0.0001) in patients with advanced NSCLC compared with chemotherapy-based treatment. Atezolizumab substantially enhanced OS in patients aged <65 years old and 65–74 years old, those with wild-type EGFR, those without liver metastases, active or previous smokers, white patients and those with TC3 or IC3, TC2/3 or IC2/3, TC1/2/3 or IC1/2/3, and TC0 and IC0, but not in patients aged ≥75 years, never smokers, those with liver metastases, those with EGFR mutant, Asians, Black or African Americans, or those with TC1/2 or IC1/2. Patients with advanced NSCLC who received atezolizumab showed OS improvement regardless of sex (male or female), histological type (non-squamous or squamous NSCLC), performance status (0 or 1), and line of treatment (1st-line therapy or ≥2nd-line therapy). Subgroup analysis revealed that male individuals, those with non-squamous NSCLC, those with PS 1, active or previous smokers, and those with wild-type EGFR, TC3 or IC3, and TC1/2/3 or IC1/2/3 achieved OS benefit from atezolizumab treatment not related to the treatment line and treatment regimen.

Conclusions

Age group, smoking history, liver metastasis status, EGFR mutation status, race, and PD-L1 expression can be used to predict the potency of atezolizumab and provide a better treatment regimen for patients with advanced NSCLC to achieve accurate and personalized treatment.

Risk Assessment of Liver Metastasis in Pancreatic Cancer Patients Using Multiple Models Based on Machine Learning: A Large Population-Based Study

Background

A more accurate prediction of liver metastasis (LM) in pancreatic cancer (PC) would help improve clinical therapeutic effects and follow-up strategies for the management of this disease. This study was to assess various prediction models to evaluate the risk of LM based on machine learning algorithms.

Methods

We retrospectively reviewed clinicopathological characteristics of PC patients from the Surveillance, Epidemiology, and End Results database from 2010 to 2018. The logistic regression, extreme gradient boosting, support vector, random forest (RF), and deep neural network machine algorithms were used to establish models to predict the risk of LM in PC patients. Specificity, sensitivity, and receiver operating characteristic (ROC) curves were used to determine the discriminatory capacity of the prediction models.

Results

A total of 47,919 PC patients were identified; 15,909 (33.2%) of which developed LM. After iterative filtering, a total of nine features were included to establish the risk model for LM based on machine learning. The RF showed the most promising results in the prediction of complications among the models (ROC 0.871 for training and 0.832 for test sets). In risk stratification analysis, the LM rate and 5-year cancer-specific survival (CSS) in the high-risk group were worse than those in the intermediate- and low-risk groups. Surgery, radiotherapy, and chemotherapy were found to significantly improve the CSS in the high- and intermediate-risk groups.

Conclusion

In this study, the RF model constructed could accurately predict the risk of LM in PC patients, which has the potential to provide clinicians with more personalized clinical decision-making recommendations.

Clinical Efficacy of Immune Checkpoint Inhibitors in Non-small-cell Lung Cancer Patients with Liver Metastases: A Network Meta-Analysis of Nine Randomized Controlled Trials

Purpose

This network meta-analysis (NMA) was conducted to compare the efficacy of immune checkpoint inhibitors (ICIs) in advanced non-small cell lung cancer (NSCLC) patients with liver metastases.

Materials and Methods

English literature was retrieved from the PubMed, American Society of Clinical Oncology (ASCO), and European Society for Medical Oncology (ESMO) databases from January 2015 to January 2021. We pooled the overall survival (OS) and progression-free survival (PFS) hazard ratios (HRs) using a network meta-analysis and ranked treatments by the surface under the cumulative ranking curve (SUCRA). Publication bias was evaluated by Begg's and Egger's tests. STATA15.0 was used for the sensitivity analysis, and the remaining statistical analyses were performed using R 4.0.2.

Results

Nine eligible phase III randomized controlled trials (RCTs) were included, including 1,141 patients with liver metastases. Pembrolizumab + chemotherapy ranked highest, followed by atezolizumab + bevacizumab + chemotherapy and nivolumab. However, no significant difference in OS rates was observed across these three treatments (HR, 0.98; 95% CI: 0.43-2.22 for pembrolizumab + chemotherapy vs. atezolizumab + bevacizumab + chemotherapy; HR, 0.91; 95% CI: 0.52-1.57 for pembrolizumab + chemotherapy vs. nivolumab). Regarding the PFS rate, atezolizumab + bevacizumab + chemotherapy and pembrolizumab + chemotherapy ranked highest and no significant difference was observed between them (HR, 0.79; 95% CI: 0.36-1.70 for atezolizumab + bevacizumab + chemotherapy vs. pembrolizumab + chemotherapy).

Conclusion

Pembrolizumab + chemotherapy, atezolizumab + bevacizumab + chemotherapy, and nivolumab were superior to other treatments in NSCLC patients with liver metastases. These new findings may help clinicians better select therapeutic strategies for NSCLC patients with liver metastases.

Clinical Significance of CYFRA21-1, AFP, CA-153, CEA, and CA-199 in the Diagnosis of Lung Cancer Ocular Metastasis in Hypertension Population

Purpose: To detect lung metastases, we conducted a retrospective study to improve patient prognosis.

Methods: Hypertension patients with ocular metastases (OM group; n = 58) and without metastases (NM group; n = 1,217) were selected from individuals with lung cancer admitted to our hospital from April 2005 to October 2019. The clinical characteristics were compared by Student's t-test and chi-square test. Independent risk factors were identified by binary logistic regression, and their diagnostic value evaluated by receiver operating characteristic curve analysis.

Results: Age and sex did not differ significantly between OM and NM groups; There were significant differences in pathological type and treatment. Adenocarcinoma was the main pathological type in the OM group (67.24%), while squamous cell carcinoma was the largest proportion (46.43%) in the NM group, followed by adenocarcinoma (34.10%). The OM group were treated with chemotherapy (55.17%), while the NM group received both chemotherapy (39.93%) and surgical treatment (37.06%). Significant differences were detected in the concentrations of cancer antigen (CA)−125, CA-199, CA-153, alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), cytokeratin fraction 21-1 (CYFRA21-1), total prostate-specific antigen, alkaline phosphatase, and hemoglobin (Student's t-test). Binary logistic regression analysis indicated that CA-199, CA-153, AFP, CEA, and CYRFA21-1 were independent risk factors for lung cancer metastasis. AFP (98.3%) and CEA (89.3%) exhibited the highest sensitivity and specificity, respectively, while CYRFA21-1 had the highest area under the ROC curve value (0.875), with sensitivity and specificity values of 77.6 and 87.0%, respectively. Hence, CYFRA21-1 had the best diagnostic value.

FGF9/FGFR1 promotes cell proliferation, epithelial-mesenchymal transition, M2 macrophage infiltration and liver metastasis of lung cancer

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FGF9 induced cell proliferation, EMT, migration, and invasion of mouse Lewis lung cancer (LLC) cells, in vitro.

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FGF9 interacted with FGFR1 and activated FAK, AKT, and ERK/MAPK signal pathways, induced the expression of EMT key proteins (N-cadherin, vimentin, snail, MMP2, MMP3 and MMP13) and reduced the expression of E-cadherin.

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FGF9 promoted liver metastasis of subcutaneous inoculated LLC tumor with tumor growth, angiogenesis, EMT and M2-macrophage infiltration in the tumor microenvironment.

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The FGF9/LLC syngeneic animal model provides a useful tool for the mechanism studies of liver metastasis which is the worst prognostic factor for lung cancer patients with distant organ metastasis.

Fibroblast growth factors 9 (FGF9) modulates cell proliferation, differentiation and motility for development and repair in normal cells. Abnormal activation of FGF9 signaling is associated with tumor progression in many cancers. Also, FGF9 may be an unfavorable prognostic indicator for non-small cell lung cancer patients. However, the effects and mechanisms of FGF9 in lung cancer remain elusive. In this study, we investigated the FGF9-induced effects and signal activation profiles in mouse Lewis lung carcinoma (LLC) in vitro and in vivo. Our results demonstrated that FGF9 significantly induced cell proliferation and epithelial-to-mesenchymal transition (EMT) phenomena (migration and invasion) in LLC cells. Mechanism-wise, FGF9 interacted with FGFR1 and activated FAK, AKT, and ERK/MAPK signal pathways, induced the expression of EMT key proteins (N-cadherin, vimentin, snail, MMP2, MMP3 and MMP13), and reduced the expression of E-cadherin. Moreover, in the allograft mouse model, intratumor injection of FGF9 to LLC-tumor bearing C57BL/6 mice enhanced LLC tumor growth which were the results of increased Ki67 expression and decreased cleaved caspase-3 expression compared to control groups. Furthermore, we have a novel finding that FGF9 promoted liver metastasis of subcutaneous inoculated LLC tumor with angiogenesis, EMT and M2-macrophage infiltration in the tumor microenvironment. In conclusion, FGF9 activated FAK, AKT, and ERK signaling through FGFR1 with induction of EMT to stimulate LLC tumorigenesis and hepatic metastasis. This novel FGF9/LLC allograft animal model may therefore be useful to study the mechanism of liver metastasis which is the worst prognostic factor for lung cancer patients with distant organ metastasis.

Clinical decision support algorithm based on machine learning to assess the clinical response to anti-programmed death-1 therapy in patients with non-small-cell lung cancer

OBJECTIVE

Anti-programmed death (PD)-1 therapy confers sustainable clinical benefits for patients with non-small-cell lung cancer (NSCLC), but only some patients respond to the treatment. Various clinical characteristics, including the PD-ligand 1 (PD-L1) level, are related to the anti-PD-1 response; however, none of these can independently serve as predictive biomarkers. Herein, we established a machine learning (ML)-based clinical decision support algorithm to predict the anti-PD-1 response by comprehensively combining the clinical information.

MATERIALS AND METHODS

We collected clinical data, including patient characteristics, mutations and laboratory findings, from the electronic medical records of 142 patients with NSCLC treated with anti-PD-1 therapy; these were analysed for the clinical outcome as the discovery set. Nineteen clinically meaningful features were used in supervised ML algorithms, including LightGBM, XGBoost, multilayer neural network, ridge regression and linear discriminant analysis, to predict anti-PD-1 responses. Based on each ML algorithm's prediction performance, the optimal ML was selected and validated in an independent validation set of PD-1 inhibitor-treated patients.

RESULTS

Several factors, including PD-L1 expression, tumour burden and neutrophil-to-lymphocyte ratio, could independently predict the anti-PD-1 response in the discovery set. ML platforms based on the LightGBM algorithm using 19 clinical features showed more significant prediction performance (area under the curve [AUC] 0.788) than on individual clinical features and traditional multivariate logistic regression (AUC 0.759).

CONCLUSION

Collectively, our LightGBM algorithm offers a clinical decision support model to predict the anti-PD-1 response in patients with NSCLC.

Different prognostic implications of hepatic metastasis according to front-line treatment in non-small cell lung cancer: a real-world retrospective study

Background

Although liver metastasis occurs in approximately 15% of metastatic non-small cell lung cancer (NSCLC) patients with poor prognosis, its prognostic effect in patients who receive immunotherapy is unclear. This study aimed to verify the effects of liver metastasis on the prognosis of metastatic NSCLC patients according to their first-line treatment.

Methods

Patients who were initially diagnosed with stage 4 NSCLC from January 2015 to December 2019 were analyzed in this retrospective real-world data-based study. The patients were divided into three groups according to the type of first-line chemotherapy they received: cytotoxic, targeted, and immunotherapy. Prognosis was then compared depending on the presence of liver metastasis in each treatment group.

Results

Among the 1,470 patients, 723 (49.2%) received cytotoxic chemotherapy, 678 (46.1%) received targeted therapy, and 69 (4.7%) received immunotherapy as their first-line chemotherapy. A total of 234 (15.9%) patients had liver metastasis at the initial diagnosis. The mean patient age was 63.7 years, and 59.1% were male. There was no difference in overall survival (OS) in the immunotherapy group in patients with or without liver metastasis (11.7 vs. 13.0 months, P=0.968); however, patients with liver metastasis had worse outcomes in the cytotoxic and targeted therapy groups compared to patients without liver metastasis. Furthermore, in patients with liver metastasis, the immunotherapy group had a longer OS than the cytotoxic chemotherapy group (11.7 vs. 4.4 months, P<0.001). Liver metastasis was associated with poor outcomes (hazard ratio of 1.438), as were age, male sex, bone, adrenal gland, or soft tissue metastasis, and three or more metastatic sites; however, lymph node, brain, collateral lung, and pleura metastasis did not affect prognosis.

Conclusions

Although liver metastasis was associated with poor outcomes, it did not affect prognosis in patients who received immunotherapy.

Impact of concomitant medication on clinical outcomes in patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors: A retrospective study

Background

It has recently been suggested that concomitant medication may affect the clinical outcome of patients treated with immune checkpoint inhibitors (ICIs). However, only a few studies on the impact of concomitant medication on immune‐related adverse events (irAEs) have previously been reported. Here, we aimed to determine the impact of concomitant medication on the efficacy and safety of ICIs.

Methods

We retrospectively analyzed the data of 300 patients treated with nivolumab or pembrolizumab for advanced non‐small cell lung cancer (NSCLC) between January 2016 and July 2018. Multivariate logistic regression analysis was used to assess the effect of concomitant medication on treatment response or irAEs. A multivariate Cox proportional hazards model was used to evaluate concomitant medication‐related factors associated with time‐to‐treatment failure or overall survival (OS).

Results

A total of 70 patients responded to treatment and 137 experienced irAEs. The response rate and incidence of irAEs in patients treated with ICIs were not significantly associated with concomitant medication. Multivariate analysis showed that the use of opioids was an independent factor (time‐to‐treatment failure: hazard ratio 1.39, p = 0.021, OS: hazard ratio 1.54, p = 0.007).

Conclusions

The efficacy and safety of nivolumab or pembrolizumab in the treatment of patients with advanced NSCLC were not significantly influenced by concomitant medication. However, opioid usage might be associated with shorter OS in patients treated with these ICIs. Further mechanistic investigations should explore whether these associations are purely prognostic or contribute to ICI resistance.

Development and validation of a simple-to-use nomogram to predict liver metastasis in patients with pancreatic neuroendocrine neoplasms: a large cohort study

Background

Liver metastasis is an important prognostic factor for pancreatic neuroendocrine neoplasms (pNENs), but the relationship between the clinical features of patients with pNEN and liver metastasis remains undetermined. The aim of this study was to establish and validate an easy-to-use nomogram to predict liver-metastasis in patients with pNEN.

Methods

We obtained the clinicopathologic data of 2960 patients with pancreatic neuroendocrine neoplasms from the Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2016. Univariate and multivariate logistic regression were done to screen out independent influencing factors to establish the nomogram. The calibration plots and the area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of nomogram. Decision curve analysis (DCA) was applied to compare the novel model with the conventional predictive methods.

Results

A total of 2960 patients with pancreatic neuroendocrine neoplasms were included in the study. Among these, 1974 patients were assigned to the training group and 986 patients to the validation group. Multivariate logistic regression identified, tumor size, grade, other site metastasis, T stage and N stage as independent risk factors. The calibration plot showed good discriminative ability in the training and validation groups, with C-indexes of 0.850 for the training cohort and 0.846 for the validation cohort. The AUC values were 0.850 (95% CI 0.830–0.869) and 0.839 (95% CI 0.812–0.866), respectively. The nomogram total points (NTP) had the potential to stratify patients into low risk, medium risk and high risk (P < 0.001). Finally, comparing the nomogram with traditional prediction methods, the DCA curve showed that the nomogram had better net benefit.

Conclusions

Our nomogram has a good ability to predict liver metastasis of pancreatic neuroendocrine neoplasms, and it can guide clinicians to provide suitable prevention and treatment measures for patients with medium- and high-risk liver metastasis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01685-w.

Impact of different patterns of metastasis in non-small-cell lung cancer patients

Aim: The aim of this study was to evaluate the frequency and median time for the development of metastases and prognosis by metastatic site after the diagnosis of non-small-cell lung cancer (NSCLC). Patients & methods: This cohort study was conducted with 1096 patients diagnosed with NSCLC between 2006 and 2014. Results: The most prevalent site of NSCLC metastases was the respiratory system. The nervous and adrenal systems presented the longest median time for the development of metastases. The 6-month survival varied from 68.2% for liver to 79.9% for the nervous system. Bone metastases were associated with a higher risk of death. Conclusion: The respiratory system was the most prevalent site of metastases. OS and risk of death varied according to the metastatic site.

Efficacy of immune-checkpoint inhibitors in advanced non-small cell lung cancer patients with different metastases

Background

To investigate the significance of metastatic sites and their numbers to the efficacy of immune checkpoint inhibitors (ICIs) in patients with advanced non-small cell lung cancer (NSCLC).

Methods

A total of 232 patients who received ICI monotherapy or ICI-based combination therapy were retrospectively identified from January 2016 to February 2019. Six metastatic sites (brain, liver, bone, adrenal gland, contralateral lung, pleura) were included to analyze their significance to ICI efficacy. To explore the association between liver metastasis (LM) and tumor T cell infiltration, 46 patients with available tumor specimens were tested for PD-L1 expression, CD8+ tumor infiltrating lymphocytes (TILs) density. Overall survival (OS) and progression-free survival (PFS) were estimated by Kaplan-Meier curves.

Results

More metastatic organs involved were associated with significantly worse PFS (0–1 organ: 5.7 months, 2–3 organs: 3.5 months, ≥4 organs: 2.7 months, P<0.001) and lower ORR (36% vs. 29.8% vs. 18.2%, P<0.001). Patients with brain metastasis (BM) had shorter PFS and OS than those without (P=0.002, P=0.021; respectively). Notably, patients with LM had the shortest PFS (2.3 months, P=0.005) and numerically shortest OS (9.8 months, P=0.238) compared with those with other organ metastases. Multivariate analysis revealed that LM was independently associated with inferior PFS (P<0.001). Immunostaining showed that patients with LM tended to have lower proportions of PD-L1+CD8+TIL+ tumors compared with those without LM (0% vs. 30.8%, P=0.088). Interestingly, ICI-based combination therapy could effectively control LM with improved intrahepatic PFS (P=0.056) and ORR (41.7% vs. 6.7%, P=0.030).

Conclusions

More metastatic organs involved were associated with poorer response to ICIs. LM was a negative predictive factor for patients treated with ICI monotherapy and the combination strategy might effectively control LM.

Analysis of bevacizumab treatments and metastatic sites of lung cancer

INTRODUCTION

Liver metastasis has not been sufficiently evaluated in lung cancer so far. We retrospectively analyzed the distant metastasis of Non-squamous non-small cell lung cancer (NSQ-NSCLC), including liver metastasis, and association between prognosis and therapeutic effect of bevacizumab treatment.

PATIENTS AND METHODS

Clinical data were collected from 1954 patients with lung cancer admitted in our hospital between 1st April 2011 and 31 March 2019. Information is extracted from the electronic medical record. Main collection data was the age, gender, smoking history, performance status, histology and driver mutation, distant metastasis site. Efficacy data of treatment including treatment duration and survival time were obtained from medical record, image data and local registry.

RESULTS

Total 366 patients receiving any chemotherapy with NSQ-NSCLC were eligible for this study. Most frequent extrathoracic metastasis is bone (N = 59) followed by brain (37), liver (18), adrenal gland (23), and OS analysis showed liver metastasis was worse prognosis compared to brain and bone metastasis (median OS: 11.6, 18.9, 15.0, respectively). Bevacizumab treatment was tend to have favorable efficacy in patients with each metastatic sites, especially, induced significant longer OS for patients with liver metastasis. CONCLUSION;: Though this study was retrospective study for small sized metastatic patients, the study suggested that liver metastasis was refractory, and that bevacizumab treatment might improve the worse prognosis.

Metastatic sites as predictors in advanced NSCLC treated with PD-1 inhibitors: a systematic review and meta-analysis

BACKGROUND

Programmed cell death protein 1 (PD-1) inhibitors are the first-line treatment for advanced non-small-cell lung cancer (NSCLC) patients. However, their efficacy in metastatic NSCLC patients remains controversial.

AIM OF THE STUDY

The aim of our study was to evaluate the prognosis of advanced metastatic NSCLC patients treated with PD-1 inhibitors, and discuss the predictive effect of metastatic site on the long-term outcome.

METHODS

The Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, and PubMed databases were systematically screened up to February 10, 2020. Twenty-five eligible studies, involving 8,067 patients that assessed the impact of metastatic sites on survival outcome were incorporated in our study. Overall survival (OS) and progression-free survival (PFS) were described as hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Among the advanced NSCLC patients, the median proportion of brain, liver, bone, and adrenal gland metastases were 21%, 17%, 35%, and 21%, respectively. Patients with metastases to the brain, liver, and bone had worse OS compared to patients without these metastases when treated with PD-1 inhibitors. Similarly, patients with metastasis to the brain and liver were more likely to progress when treated with PD-1 inhibitors. Besides, patients with multiple metastatic sites had worse PFS compared to patients with one metastatic site, while no significant difference was found in terms of OS.

CONCLUSIONS

Based on the findings of our systematic review and meta-analysis, metastatic sites were independent predictors of the survival outcome for advanced NSCLC patients treated with PD-1 inhibitors.

Differential Efficacy of Pembrolizumab According to Metastatic Sites in Patients With PD-L1 Strongly Positive (TPS ≥ 50%) NSCLC

BACKGROUND

Pembrolizumab has shown significantly better efficacy than platinum doublet chemotherapy in patients with programmed cell death ligand 1 (PD-L1) strongly positive (tumor proportion score ≥ 50%) non-small-cell lung cancer (NSCLC). However, the predictors of response to pembrolizumab have not yet been fully elucidated for patients with PD-L1 strongly positive NSCLC.

PATIENTS AND METHODS

We retrospectively analyzed 145 patients who had been treated with pembrolizumab for PD-L1 strongly positive (TPS ≥ 50%) NSCLC without an EGFR (epidermal growth factor receptor) mutation or ALK rearrangement from February 2017 to March 2020. Various clinical characteristics, including Eastern Cooperative Oncology Group performance status, treatment line, PD-L1 expression, C-reactive protein level, neutrophil/lymphocyte ratio, and metastatic sites, and the clinical outcome of pembrolizumab treatment were examined.

RESULTS

Patients with higher PD-L1 expression (≥ 75%; n = 90) had a higher objective response rate (ORR) and longer progression-free survival (PFS) compared with those with lower expression (50%-74%; n = 55; ORR, 51% vs. 33%; P = .0305; median PFS, 13.9 months vs. 5.2 months; P = .0111). In addition, 15 patients with liver metastasis (LM) had a significantly lower ORR and shorter PFS than the 130 patients without LM (ORR, 20% vs. 47%; P = .0468; median PFS, 3.4 months vs. 9.4 months; P = .0018). A multivariate analysis indicated that PD-L1 expression and LM were significant predictors of PFS after pembrolizumab treatment (higher PD-L1 expression: hazard ratio, 0.58; 95% confidence interval, 0.38-0.91; P = .0183; presence of LM: hazard ratio, 2.05; 95% confidence interval, 1.03-3.82; P = .0420).

CONCLUSION

PD-L1 expression and LM status were predictors of the efficacy of pembrolizumab in patients with PD-L1 strongly positive NSCLC.

Prognostic factors for survival in patients with metastatic lung adenocarcinoma: An analysis of the SEER database

Background

Lung adenocarcinoma (ADC) is the main cause of death related to lung cancer. The aim of this study was to identify poor prognostic factors for overall survival (OS) in patients with stage IV lung ADC in real‐world clinical practice.

Methods

Patients were selected from the Surveillance Epidemiology and End Results (SEER) database. Chi‐square bivariate analysis was used for the association of binary qualitative variables. A multivariate Cox regression analysis was performed to determine the impact of these prognostic factors on OS.

Results

A total of 46 030 patients were included (51.3% men, mean age 67.03 ± 11.6), of whom 41.3% presented with metastases in bone, 28.9% in brain, 17.1% in liver and 31.8% in lung. Patients with liver metastases presented with two or more metastatic sites more frequently than patients without liver metastases (P < 0.001). Male sex (HR 0.78, 95% CI: 0.76–0.80), age ≥ 65 years (HR 1.37, 95% CI: 1.33–1.40), lack of family support (HR 0.80, 95% CI: 0.78–0.81) and presence of liver (HR 1.45, 95% CI: 1.40–1.50), bone (HR 1.21, 95% CI: 1.18–1.24) or brain metastases (HR 1.18, 95% CI: 1.15–1.21) were identified as poor prognostic factors for OS. Patients with liver metastasis showed the highest hazard ratio value (P < 0.001).

Conclusions

The presence of liver metastases was the worst prognostic factor for patients with metastatic lung ADC. This factor should be considered as a stratification factor for future studies evaluating new cancer treatments including immunotherapy.

Key points

Significant findings of the study

Regression analysis identified poor prognostic factors for overall survival. Factors were male sex, age ≥ 65 years, lack of family support and presence of liver, bone and brain metastases.

Patients with liver metastasis showed the highest HR (HR = 1.45 95% CI: 1.40–1.50).

This study included the highest number of adenocarcinoma patients analyzed so far (N = 46 030).

What this study adds

The presence of liver metastases should be considered as a stratification factor for future studies evaluating new cancer treatments including immunotherapy.

The prediction potential of neutrophil-to-lymphocyte ratio for the therapeutic outcomes of programmed death receptor-1/programmed death ligand 1 inhibitors in non-small cell lung cancer patients: A meta-analysis

BACKGROUND

Programmed death receptor-1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors have been demonstrated to improve the prognosis of patients with advanced non-small cell lung cancer (NSCLC) compared with chemotherapy. However, there were still some non-responders. Thus, how to effectively screen the responder may be an important issue. Recent studies revealed the immune-related indicator, neutrophil-lymphocyte ratio (NLR), may predict the therapeutic effects of anti-PD1/PD-L1 antibodies; however, the results were controversial. This study was to re-evaluate the prognostic potential of NLR for NSCLC patients receiving PD1/PD-L1 inhibitors by performing a meta-analysis.

METHODS

Eligible studies were identified by searching online databases of PubMed, EMBASE and Cochrane Library. The predictive values of NLR for overall survival, (OS), progression free survival (PFS) and overall response rate (ORR) were estimated by hazard ratio (HR) with 95% confidence interval (CI).

RESULTS

Twenty-four studies involving 2196 patients were included. The pooled analysis demonstrated that elevated NLR before PD-1/PD-L1 inhibitor treatment was a predictor of poor OS (HR = 2.17; 95% CI: 1.64 - 2.87, P < .001), PFS (HR = 1.54; 95% CI: 1.34 - 1.78, P < .001) and low ORR (HR = 0.64; 95% CI: 0.44 - 0.95, P = .027) in NSCLC patients. Subgroup analysis revealed the predictive ability of NLR for OS and PFS was not changed by ethnicity, sample size, cut-off, HR source, study design or inhibitor type (except the combined anti-PD-L1 group); while its association with ORR was only significant when the cut-off value was less than 5 and the studies were prospectively designed.

CONCLUSION

Our findings suggest patients with lower NLR may benefit from the use of PD-1/PD-L1 inhibitors to prolong their survival period.

Prognostic factors for patients with metastatic or recurrent thymic carcinoma receiving palliative-intent chemotherapy

BACKGROUND

Thymic malignancies are a model of rare cancer. However, little clinical data is available based on the large database. We aimed to clarify the prognostic factors, particularly the metastatic sites, for thymic malignancies using one of the largest, representative, multi-institutional databases, the NEJ023 database.

PATIENTS AND METHODS

Patients with Stage IVA/IVB or recurrent thymic carcinoma were enrolled between 1995 and 2014. Clinicopathologic information was evaluated, and the patients were subdivided according to the metastatic organs of involvement (serosal dissemination, liver, lymph node, pulmonary, and bone metastasis). A Kaplan-Meier analysis and multivariate Cox regression were used to evaluate survival.

RESULTS

Two hundred and seventy-nine patients with metastases and a predominantly squamous histology (66.7%) were included. Most patients (53.0%) had serosal dissemination, whereas 26.5%, 21.9%, 19.7%, and 15.8% had pulmonary, lymph node, bone and liver metastases, respectively. Over a median follow-up time of 21.5 months, the median overall survival (mOS) was 30.7 months. When the subjects were grouped according to involved metastatic sites, patients with more than 3 involved metastatic organs had the worst survival outcome. Among patients with isolated involvement, those with bone metastasis had the poorest survival, followed by patients with liver metastasis. Subjects with hypoalbuminemia also had poor survival outcomes. When patients treated with platinum and anthracycline-containing pharmacotherapy were compared with those treated with platinum and non-anthracycline-containing pharmacotherapy, no significant difference was observed. Bone metastasis (P = 0.0005), liver metastasis (P =  0.047), and hypoalbuminemia (P =  0.0021) were identified as prognostic factors in a multivariate analysis.

CONCLUSION

The site of metastatic involvement affects the survival outcomes of patients with thymic carcinoma, and this result may reflect the sensitivity of metastatic sites to pharmacotherapy. As a next step, controlling liver metastasis with pharmacotherapy could help to improve the prognosis of patients with thymic carcinoma.

Clinical features affecting survival in metastatic NSCLC treated with immunotherapy: A critical review of published data

Immune checkpoint inhibitors (ICIs) represent one of the main steps forward for the treatment of advanced or metastatic non-small-cell lung cancer (NSCLC), without oncogenic driver alterations. Despite this recent progress, only a minority of patients achieve a broad and durable benefit and another proportion report poor survival and sometimes fast disease progression, confirming the need to optimise the patient's selection. To date, several issues are unsolved about how to personalise the immunotherapy treatment for individual patients. In this review, analysing data from pivotal randomised clinical trials (RCTs), we discuss patient baseline clinical and demographic features, including sex, age, ECOG performance status, smoking habit and specific site of metastases (liver, bone and brain) that may influence the efficacy outcomes in patients treated with ICIs. The high performance of the ICIs blurred the vision on different efficacy-limiting factors, which require extensive evaluation to improve the understanding ofthe tumour-specificimmune response, in which clinical drivers could be useful for better patient stratification.

The unique immune microenvironment of liver metastases: Challenges and opportunities

Liver metastases from gastrointestinal and non-gastrointestinal malignancies remain a major cause of cancer-related mortality and a major clinical challenge. The liver has unique properties that facilitate metastatic expansion, including a complex immune system that evolved to dampen immunity to neoantigens entering the liver from the gut, through the portal circulation. In this review, we describe the unique microenvironment encountered by cancer cells in the liver, focusing on elements of the innate and adaptive immune response that can act as a double-edge sword, contributing to the elimination of cancer cells on the one hand and promoting their survival and growth, on the other. We discuss this microenvironment in a clinical context, particularly for colorectal carcinoma, and highlight how a better understanding of the role of the microenvironment has spurred an intense effort to develop novel and innovative strategies for targeting liver metastatic disease, some of which are currently being tested in the clinic.

Clinical Impact of Sarcopenia and Inflammatory/Nutritional Markers in Patients with Unresectable Metastatic Urothelial Carcinoma Treated with Pembrolizumab

Sarcopenia is a muscle loss syndrome known as a risk factor of various carcinomas. The impact of sarcopenia and sarcopenia-related inflammatory/nutritional markers in metastatic urothelial carcinoma (mUC) treated with pembrolizumab was unknown, so this retrospective study of 27 patients was performed. Psoas muscle mass index (PMI) was calculated by bilateral psoas major muscle area at the L3 with computed tomography. The cut-off PMI value for sarcopenia was defined as ≤6.36 cm²/m² for men and ≤3.92 cm²/m² for women. Neutrophil-to-lymphocyte ratio (NLR) ≥ 4.0 and sarcopenia correlated with significantly shorter progression-free survival (PFS) (hazard ratio (HR) 3.81, p = 0.020; and HR 2.99, p = 0.027, respectively). Multivariate analyses identified NLR ≥ 4.0 and sarcopenia as independent predictors for PFS (HR 2.89, p = 0.025; and HR 2.79, p = 0.030, respectively). Prognostic nutrition index < 45, NLR ≥ 4.0 and sarcopenia were correlated with significantly worse for overall survival (OS) (HR 3.44, p = 0.046; HR 4.26, p = 0.024; and HR 3.92, p = 0.012, respectively). Multivariate analyses identified sarcopenia as an independent predictor for OS (HR 4.00, p = 0.026). Furthermore, a decrease in PMI ≥ 5% in a month was an independent predictor of PFS and OS (HR 12.8, p = 0.008; and HR 6.21, p = 0.036, respectively). Evaluation of sarcopenia and inflammatory/nutritional markers may help in the management of mUC with pembrolizumab.

The effect of liver metastasis on efficacy of immunotherapy plus chemotherapy in advanced lung cancer

The present study aimed to evaluate the effect of liver metastases on the efficacy from the combination of PD-1/PD-L1 inhibitor with chemotherapy as first-line treatment in lung cancer using the meta-analysis. A total of 8 randomized controlled trials (RCTs) were included. In patients without liver metastases, PD-1/PD-L1 inhibitor plus chemotherapy could decrease the risk of progression by 40% and risk of death by 29% (HR = 0.60; 95%CI,0.55- 0.65 and HR = 0.71;95%CI,0.58-0.90 respectively). In patients with liver metastases, PD-1/PD-L1 inhibitor plus chemotherapy could decrease the risk of progression by 31% and risk of death by 21% (HR = 0.69;95%CI,0.58-0.81; and HR = 0.79; 95%CI,0.62-0.80, respectively). The pooled ratios of PFS-HRs and OS- HRs reported in lung cancer patients with liver metastases versus those without liver metastases were 1.11 (95%CI, 0.92-1.34) and 1.03 (95%CI, 0.80-1.35), respectively, suggesting that lung cancer patients with and without liver metastases could obtain comparable efficacy.

The efficacy of immune checkpoint inhibitors in advanced non-small-cell lung cancer with liver metastases

OBJECTIVES

Although liver metastasis has been known to be associated with poor prognosis, only a few studies have shown an association between liver metastasis and treatment outcomes with immune checkpoint inhibitors (ICI). Furthermore, factors associated with prognosis have remained unclear. The present study therefore evaluates the efficacy of nivolumab, pembrolizumab, and atezolizumab among patients with non-small cell lung cancer (NSCLC) who had liver metastasis and identifies factors correlated with prognosis.

MATERIALS AND METHODS

A total of 215 patients with advanced and recurrent NSCLC who received ICI therapy at a single center were retrospectively reviewed. A total of 41 patients (19.1%) had liver metastasis upon initiation of ICI therapy. Overall, 125, 64, and 26 patients were treated with nivolumab, pembrolizumab, and atezolizumab, respectively.

RESULTS

Among the included patients, those with liver metastasis had shorter overall survival (OS) [hazard ratio (HR), 2.04; 95% CI 1.33-3.13] and progression-free survival (PFS) (HR, 1.89; 95% CI 1.29-1.71) compared to those without the same. Patients with liver metastasis had a response rate (RR) of 22.5%. Among patients with liver metastasis, inferior OS was associated with low albumin, poor Eastern Cooperative Oncology Group performance status, driver mutation, and number of liver metastasis (≥ 5). Moreover, patients with liver metastasis who had good Royal Marsden Hospital (0-1) and Gustave Roussy Immune (0-1) scores showed significantly longer OS and PFS.

CONCLUSION

Despite the poor outcomes with ICI treatment in patients with advanced and recurrent NSCLC who had liver metastasis, some characteristics among patients with liver metastasis may be associated with prognosis.

Association between metastatic sites and first-line pembrolizumab treatment outcome for advanced non-small cell lung cancer with high PD-L1 expression: a retrospective multicenter cohort study

Associations between treatment outcomes of immune checkpoint inhibitors and metastatic sites in advanced non-small cell lung cancer (NSCLC) are not well known. Therefore, this multicenter retrospective study aimed to investigate the predictive factors of metastatic sites after first-line pembrolizumab treatment for advanced NSCLC with a PD-L1 tumor proportion score (TPS) ≥50%. We retrospectively analyzed advanced NSCLC patients with a PD-L1 TPS ≥50% who underwent first-line pembrolizumab therapy at 11 institutions between February 2017 and April 2018. Clinical data collected from medical records included metastatic sites at the time of pembrolizumab treatment. Treatment outcomes of pembrolizumab were assessed according to the Response Evaluation Criteria in Solid Tumors, version 1.1. In total, 213 patients were included in the study. The median age was 71 years (range 39-91 years). Of the 213 patients, 176 (83%) were men and 172 (81%) had an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of 0-1. The most common metastases were thoracic lymph node metastasis (77%), intrapulmonary metastasis (31%), bone metastasis (28%), and malignant pleural effusion (26%). On multivariate analysis, a poor ECOG-PS score (hazard ratio: 1.95, 95.0% confidence interval: 1.25-3.04; P = 0.003) and malignant pleural effusion (hazard ratio: 1.52, 95.0% confidence interval: 1.01-2.29; P = 0.043) were independent predictors of shorter progression-free survival in patients treated with pembrolizumab. For NSCLC patients with malignant pleural effusion, pembrolizumab monotherapy is not a suitable first-line treatment because of its insufficient effectiveness, even though their PD-L1 TPS was high.

Tissue-specific tumor microenvironments influence responses to immunotherapies

Objectives

Investigation of variable response rates to cancer immunotherapies has exposed the immunosuppressive tumor microenvironment (TME) as a limiting factor of therapeutic efficacy. A determinant of TME composition is the tumor location, and clinical data have revealed associations between certain metastatic sites and reduced responses. Preclinical models to study tissue‐specific TMEs have eliminated genetic heterogeneity, but have investigated models with limited clinical relevance.

Methods

We investigated the TMEs of tumors at clinically relevant sites of metastasis (liver and lungs) and their impact on αPD‐1/αCTLA4 and trimAb (αDR5, α4‐1BB, αCD40) therapy responses in the 67NR mouse breast cancer and Renca mouse kidney cancer models.

Results

Tumors grown in the lungs were resistant to both therapies whereas the same tumor lines growing in the mammary fat pad (MFP), liver or subcutaneously could be completely eradicated, despite greater tumor burden. Assessment of tumor cells and drug delivery in 67NR lung or MFP tumors revealed no differences and prompted investigation into the immune TME. Lung tumors had a more immunosuppressive TME with increased myeloid‐derived suppressor cell infiltration, decreased T cell infiltration and activation, and decreased NK cell activation. Depletion of various immune cell subsets indicated an equivalent role for NK cells and CD8⁺ T cells in lung tumour control. Thus, targeting T cells with αPD‐1/αCTLA4 or trimAb was not sufficient to elicit a robust antitumor response in lung tumors.

Conclusion

Taken together, these data demonstrate that tissue‐specific TMEs influence immunotherapy responses and highlight the importance in defining tissue‐specific response patterns in patients.

Impact of clinicopathological features on the efficacy of immune checkpoint inhibitors plus conventional treatment in patients with advanced lung cancer

Background

To investigate the impact of different immune checkpoint inhibitors (ICI), programmed-death ligand 1 (PD-L1) expression and clinical characteristics on clinical outcome of ICI plus conventional treatment in advanced lung cancer patients.

Methods

Randomized clinical trials that compared combination therapy versus control group were screened in PubMed, EMBASE, Web of Science, Cochrane Library and included. The pooled hazard ratio (HR) with a 95% confidence interval (95% CI) were used to estimate associations. Cochrane Collaboration tool was used for quality assessment.

Results

Thirteen clinical trials were included (n=9,241). The pooled results indicated that combination strategy based on ICI significantly improved PFS (HR =0.66, P<0.001) and OS (HR =0.77, P<0.001) in overall population. Greatest PFS improvement was seen in group of PD-1 based combination (HR =0.54, P<0.001), followed by PD-L1 based (HR =0.66, P<0.001) and CTLA-4 based combination (HR =0.86, P=0.002) (interaction: P<0.001).The improvement in PFS did proportionally differ by PD-L1 expression (interaction: P<0.001). OS HRs favored combination in patients with negative or strong positive group of PD-L1 expression not in the group of weak positive group (HR =0.77, P=0.12). Subgroup analysis demonstrated that OS benefit could be observed in male (HR =0.82, P=0.03), current or former smokers (HR =0.74, P=0.04), non-squamous (HR =0.71, P<0.001) and patients without driver mutations (HR =0.73, P<0.001). OS benefit rather than PFS benefit was appeared in patients with liver metastasis treated with ICI-based combination (HR =0.74, P=0.005).

Conclusions

ICI plus conventional treatment could significantly improve PFS and OS in overall advanced lung cancer patients. PD-1-based combination leads to the greatest improvement in both PFS and OS. More data are warranted to address the association of PD-L1 staining intensity with OS improvement. Male, current or former smokers, non-squamous and patients without driver mutations do benefit from ICI-based combination.

Prognostic role of pretreatment neutrophil-to-lymphocyte ratio in non-small cell lung cancer patients treated with systemic therapy: a meta-analysis

Background

Neutrophil-to-lymphocyte ratio (NLR) is related to prognosis in non-small cell lung cancer (NSCLC). However, no consensus on the relationship of pretreatment NLR and survival outcomes of systemic therapy in NSCLC exists. This meta-analysis investigated the prognostic role of pretreatment NLR during systemic therapy for NSCLC, including chemotherapy, immunotherapy and targeted therapy.

Methods

PubMed, Web of Science and Cochrane Library databases were systematically searched up to April 09, 2019. Hazard ratios (HRs) with their 95% confidence intervals (CIs) were pooled to investigate the association of pretreatment NLR with progression-free survival (PFS) and overall survival (OS).

Results

In total, 27 articles with 4,298 participants were selected. The pooled results showed that elevated pretreatment NLR was associated with inferior PFS (HR, 1.45, 95% CI, 1.28-1.66) and OS (HR, 1.63, 95% CI, 1.43-1.84) during systemic therapy. Subgroup analyses according to the treatment strategy suggested that higher pretreatment NLR was significantly associated with shorter survival in all therapies, including chemotherapy (PFS HR, 1.74, 95% CI, 1.39-2.17; OS HR, 1.73, 95% CI, 1.26-2.36), immunotherapy (PFS HR, 1.53, 95% CI, 1.27-1.84; OS HR, 2.50, 95% CI, 1.60-3.89) and targeted therapy (PFS HR, 1.53, 95% CI, 1.04-2.25; OS HR, 1.92, 95% CI, 1.14-3.24).

Conclusions

Pretreatment NLR is a promising prognostic indicator for NSCLC patients receiving systemic therapy, including chemotherapy, immunotherapy and targeted therapy.

Development and validation of a nomogram to predict liver metastasis in patients with pancreatic ductal adenocarcinoma: a large cohort study

Background: Few studies have explored the relationship between clinicopathological factors of patients with pancreatic ductal adenocarcinoma (PDAC) and liver metastasis. The aim of this study was to develop and validate a nomogram to predict liver metastasis in patients with PDAC. Patients and methods: Patients diagnosed with PDAC between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively collected. The nomogram was established based on a logistic regression model. The precision of the nomogram was evaluated and compared using concordance index (C-index), and the area under receiver operating characteristic curve (AUC). The clinical use of nomogram was evaluated by making use of a decision curve analysis (DCA). Results: A total of 12,644 eligible patients, which were randomly divided into training (n=9,483) and validation cohorts (n=3,161), were included in this study. The nomograms, which were established on the basis of independent predictors, were well calibrated, and demonstrated good discriminative ability, with C-indexes of 0.784 for the training cohort and 0.790 for validation cohort. The values of AUC for training and validation cohort were 0.792 and 0.800, respectively. When other sites of distant metastases were included into this predictive system, the new predictive model demonstrated a better discriminative ability and greater net benefit in predicting liver metastasis in patients with PDAC in both the training and validation cohorts. Conclusion: Nomograms were constructed to predict liver metastasis in patients with PDAC. Validation revealed excellent discrimination and calibration of the nomograms, suggesting that the nomograms were well calibrated and could serve to improve the prediction of the risks of liver metastasis which can be used to guide the management of patients with PDAC.

Gustave Roussy Immune Score and Royal Marsden Hospital Prognostic Score Are Biomarkers of Immune-Checkpoint Inhibitor for Non-Small Cell Lung Cancer

Background

The Gustave Roussy Immune Score (GRIm-Score) and the Royal Marsden Hospital prognostic score (RMH score) were recently developed in order to improve a better participant selection for phase I trials. The GRIm-Score is formed by combination of lactate dehydrogenase (LDH), serum albumin concentration, and neutrophil-to-lymphocyte ratio (NLR). The RMH score is calculated by LDH, albumin, and number of metastases. These two scores have been validated only in phase I trials. The purpose of this study was to assess whether these scores are useful for practical treatment of immune-checkpoint inhibitor (ICI) monotherapy in pretreated non-small cell lung cancer (NSCLC).

Methods

This was a retrospective and single-centered study of 76 NSCLC patients treated with ICI monotherapy between December 2015 and October 2018 at our hospital. We divided 76 patients into high and low GRIm-Score and RMH score groups. Comparison of overall survival (OS) and progression free survival (PFS) was performed by Kaplan-Meier curves and log-rank tests. Independent prognostic factors of OS and PFS were analyzed by multivariate Cox proportional hazard analyses.

Results

The OS of the high GRIm-Score group was significantly shorter than that of the low score group (low vs. high; median 19.9 vs. 3.2 months, P < 0.01), while no significant difference was observed in PFS (2.6 vs. 2.1 months, P = 0.13). The PFS of the high RMH score was significantly shorter than that of the low score group (low vs. high; 2.6 vs. 1.8 months, P = 0.01), while there was no significant difference in OS (16.0 vs. 10.4, P = 0.24). Multivariate analyses detected high GRIm-Score (hazard ratio (HR) 3.93, 95% confidence interval (CI) 2.04 - 7.58, P < 0.01), and high RMH score (HR 1.76, 95% CI 1.03 - 3.02, P = 0.04) as poor prognostic factors of OS and PFS, respectively.

Conclusions

Baseline GRIm-Score and RMH score were independent prognostic factors of OS and PFS of ICI monotherapy for pretreated NSCLC patients, respectively. These two scores are not only selection biomarkers for patients in experimental trials, but also useful prognostic biomarkers for NSCLC patients practically treated with ICI therapy.

Impact of sarcopenia in patients with advanced non-small cell lung cancer treated with PD-1 inhibitors: A preliminary retrospective study

The aim of this study was to investigate the clinical impact of sarcopenia on the efficacy of programmed death (PD)-1 inhibitors. We retrospectively reviewed the medical records of all patients treated with nivolumab or pembrolizumab between January 2016 and September 2018 for previously treated advanced non–small cell lung cancer (NSCLC). The cross-sectional area of the psoas muscle at the level of the third lumbar vertebra on baseline computed tomography was assessed to calculate the psoas muscle index (PMI). Sarcopenia was defined based on PMI cut-off values for Asian adults (6.36 cm²/m² for males and 3.92 cm²/m² for females). A total of 42 patients were analysed. The prevalence of sarcopenia was 52.4%. Sarcopenia was significantly associated with poorer progression-free survival (PFS) (median, 2.1 vs. 6.8 months, p = 0.004). Compared to patients with sarcopenia, those without sarcopenia had a higher overall response rate (40.0% vs. 9.1%, p = 0.025) and 1-year PFS rate (38.1% vs. 10.1%). In conclusion, sarcopenia at baseline as determined using computed tomography is a significant predictor of worse outcome in patients with advanced NSCLC receiving PD-1 blockade. Screening for sarcopenia may help identify patients more likely to achieve a long-term response in routine clinical practice.