A meta-analysis and real-world cohort study on the sex-related differences in efficacy and safety of immunotherapy for hepatocellular carcinoma

Background & Aims

Sex-related differences in the immune pathogenesis of hepatocellular carcinoma (HCC), particularly related to oestrogen-dependent secretion of pro-tumourigenic cytokines, are well-known. Whether sex influences the efficacy and safety of immunotherapy is not known.

Methods

We performed a restricted maximum likelihood random effects meta-analysis of five phase III trials that evaluated immune checkpoint inhibitors (ICIs) in advanced HCC and reported overall survival (OS) hazard ratios (HRs) stratified by sex to evaluate sex-related differences in OS. In a real-world cohort of 840 patients with HCC from 22 centres included between 2018 and 2023, we directly compared the efficacy and safety of atezolizumab + bevacizumab (A+B) between sexes. Radiological response was reported according to RECIST v1.1. Uni- and multivariable Cox regression analyses were performed for OS and progression-free survival (PFS).

Results

In the meta-analysis, immunotherapy was associated with a significant OS benefit only in male (pooled HR 0.79; 95% CI 0.73-0.86) but not in female (pooled HR 0.85; 95% CI 0.70-1.03) patients with HCC. When directly comparing model estimates, no differences in the treatment effect between sexes were observed. Among 840 patients, 677 (81%) were male (mean age 66 ± 11 years), and 163 (19%) were female (mean age 67 ± 12 years). Type and severity of adverse events were similar between the two groups. OS and PFS were comparable between males and females upon uni- and multivariable analyses (aHR for OS and PFS: 0.79, 95% CI 0.59-1.04; 1.02, 95% CI 0.80-1.30, respectively). Objective response rates (24%/22%) and disease control rates (59%/59%) were also similar between sexes.

Conclusion

Female phase III trial participants experienced smaller OS benefit following ICI therapy for advanced HCC, while outcomes following A+B treatment were comparable between sexes in a large real-world database. Based on the ambiguous sex-related differences in survival observed here, further investigation of sex-specific clinical and biologic determinants of responsiveness and survival following ICIs are warranted.

Impact and implications

While immune checkpoint inhibitors have emerged as standard of care for the treatment of hepatocellular carcinoma, there are conflicting reports on whether the efficacy of cancer immunotherapy differs between females and males. Our study suggests ambiguous sex-related differences in outcomes from immunotherapy in hepatocellular carcinoma. Further investigation of sex-specific clustering in clinicopathologic and immunologic determinants of responsiveness to immune checkpoint inhibitor therapy should be prioritised.

Systematic review registration

PROSPERO CRD42023429625.

PD-L1, brain metastases, and survival among patients with metastatic non-small cell lung cancer treated with immune checkpoint inhibitors

e21655

Background: PD-L1 expression is predictive of response to treatment with PD-1/PD-L1 immune checkpoint inhibitors (ICI) among patients with metastatic non-small cell lung cancer (mNSCLC). Brain metastases (BM) are common in patients with mNSCLC and carry significant morbidity. While the use of ICI has significantly improved survival for mNSCLC, it is unclear if patients with brain metastases have the same survival benefit. Methods: In this retrospective study, we reviewed data from all patients treated at our center with mNSCLC who had PD-L1 testing from 2015-2019. Patients with another active malignancy were excluded. Descriptive statistics were calculated using proportions and means using SAS v9.4. We examined the relationship between PD-L1 level ( < 50% vs ≥50%) and BM at diagnosis among patients with mNSCLC using chi-square analysis. We then compared overall survival (OS) and progression free survival (PFS) among mNSCLC patients with and without BM at diagnosis treated with ICI using Kaplan-Meier plots followed by log rank tests. Results: 141 mNSCLC patients with PD-L1 results were identified. 71 (50.4%) were female. Mean age was 63. 71 (50.4%) were current smokers, 53 (37.6%) were former smokers. Histology included 111 (78.7%) adenocarcinoma, 19 (13.5%) squamous cell carcinoma, and 11 (7.8%) other or mixed types. 19 (13.5%) had KRAS mutation, 13 (9.2%) had EGFR mutation, 1 had ALK rearrangement, 3 had ROS1 rearrangement, and 2 had BRAF mutations. 86 (61.0%) were PD-L1 high (≥50%). 57 (40.4%) had BM at diagnosis. Patients with high PD-L1 had a higher rate of BM at diagnosis (47.3% vs 36.0%), but this trend was not statistically significant (p = 0.18). There were significantly more current smokers among those with BM at diagnosis than those without BM (p = 0.01). Among patients treated with first line ICI (n = 78), median OS was 26.5 months for those without BM and 12.2 months for those with BM at diagnosis, although this difference was not significant (p = 0.11). Median PFS was 8.9 months for patients without BM and 8.6 for those with BM (p = 0.58). Conclusions: While a higher proportion of patients with high PD-L1 had BM at the time of metastatic diagnosis, this trend was not significant. Among patients treated with ICI, survival for those with or without BM at the time of diagnosis was not significantly different. Our observations may be limited by the number of patients.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

[A case of renal cell carcinoma in childhood]

We report a case of renal cell carcinoma in a 6-year-old girl. The child had the chief complaints of gross hematuria and abdominal pain. An examination using ultrasound, computerized tomography scans and angiography showed a left renal tumor. Left side radical nephrectomy with lymphadenectomy was performed. Histopathological examination revealed renal cell carcinoma of clear cell type with metastasis to the hilar lymph node. She received postoperative therapy with interferon. Now, 3 years since the operation, she is living without evident recurrence. We reviewed 89 Japanese cases of renal cell carcinoma in children including this case and have discussed symptoms, differential diagnosis and treatments.

[Clinical and pathological evaluations of methotrexate, vinblastine, adriamycin and cisplatin (M-VAC) chemotherapy for advanced urothelial cancers]

Fifteen patients with advanced transitional cell carcinoma of the urothelial tract were treated with methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) chemotherapy. Eleven patients were treated to metastatic lesions after surgical resection of primary cancers. One out of 15 patients died of chemotherapy. Of the remaining 14 patients, CR was achieved in one and PR was achieved in seven, clinically. The response rate was 57.1% and the median response duration was 12.6 months. In the patients who had been resected their primary lesions, the response rate was 70% and the duration was 14.1 months. Six patients, including five PRs and one NC, underwent surgical resection and re-staging of the residual tumors after chemotherapy. Clinical response coincided with pathological one in all 6 cases. Three patients were observed the decrease of the lung metastasis, which rate was more than 90%. Two out of 3 who did not show any invasion into the lymph channels in the resected residual tumors, have been free of a recurrence through-out the course of at 47 or at 42 months. However, another patient with lymph channel invasion died of metastasis of the mediastinal and paraaortic lymph nodes. Regarding the frequency of side effects, it seemed to be no significant difference between full and 80% doses administration. In the effectual cases, the residual tumors should be resected surgically and re-staged pathologically.

[Clinical analysis of renal cell carcinoma with extension into the inferior vena cava]

We performed clinical analysis of 12 patients with renal cell carcinomas associated with tumor thrombosis in the inferior vena cava. Eleven cases were men, and one was a woman; their ages range from 48 to 76 years old with a mean of 58 years. Nine tumors were observed on the right side, the other 3 tumors were observed on the left side. In five cases, the distant metastases of the disease were noticed at the first visiting to our hospital. Lung metastases were found in five and bone or liver in each one. Chief complaints were macroscopic hematuria in 8 cases (67%), and were weight loss or general fatigue. The symptoms of obstruction of the inferior vena cava, such as venous dilatation of abdominal wall, edema of lower extremities and varicocele of the testes, were seen in 6 cases. The level of the tumor thrombosis was preoperatively determined by CT, echography, cavography or MRI. The level was near the right atrium in one, near the hepatic vein in 8 and near the renal vein in 3, although there was no case extending into the right atrium. Transperitoneal nephrectomy and thrombectomy in the inferior vena cava were performed in 9 cases. Surgery could not be performed in the other 3 patients of their poor general condition or severe heart disease. One patient died because of massive hemorrhage during the operation. The other complications were transient renal failure in 3 cases and postoperative bleeding in one case. In 4 patients without distant metastases or regional lymph nodes metastasis, two died of multiple metastasis of renal cell carcinomas and diabetic coma. The other two cases are alive without disease for 4 and 40 months after operation. For renal cell carcinoma extending into the inferior vena cava without metastasis, nephrectomy and thrombectomy should be performed using the extracorporeal circulation.

[Clinical evaluation of M-VAC chemotherapy (methotrexate, vinblastine, adriamycin and cisplatin) for advanced urothelial cancer]

Combination chemotherapy with methotrexate, vinblastine, adriamycin and cisplatin (M-VAC regimen) was administered to 12 patients with advanced epithelial cancer of the urinary tract in a clinical trial undertaken to assess clinical efficacy of this multiagent therapy. This series comprised 11 males and 1 female ranging in age from 46 to 76 years (mean age: 63), with performance status (PS) being rated 0 in 2, 1 in 5, 2 in 2, 3 in 2 and 4 in 1 of these 12 patients. The site of primary lesion was bladder in 8, renal pelvis in 3 and ureter in 1. Histologically, these tumors were all identified as transitional cell carcinoma (grade 3) with the exception of 1 mixed type (transitional cell carcinoma plus squamous carcinoma). Nine of the patients had already their primary tumor resected surgically while the remaining 3 had undergone only biopsy. The site of metastasis was lung in 7, bone in 4 and lymph nodes in 3. In consideration of the patients' general condition, the dosages of the chemotherapeutic agents were set at 80% of those recommended by Sternberg. Of the 9 patients with primary tumor resected, 1 died of chemotherapy; of the remaining 9 patients, the M-VAC regimen brought about CR in 1 and PR in 4, hence with a response rate of 62.5%. The 4 patients showing PR underwent surgical resection of residual tumor and 2 of them achieved CR and have been free of a recurrence during a 33- or 29-month period of the chemotherapeutic regimen.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of basic fetoprotein in testicular cancer

We attempted to determine the efficacy of basic fetoprotein as a marker in testicular cancer. The levels of serum basic fetoprotein were studied in 58 patients (31 with seminoma and 27 with nonseminoma). Elevated levels were observed in 22 seminoma (71 per cent) and 15 nonseminoma (56 per cent) patients, while the levels of other markers (beta-subunit of human chorionic gonadotropin, alpha-fetoprotein and lactic dehydrogenase) remained normal in 6 seminoma (19 per cent) and 2 nonseminoma (7 per cent) patients. The levels of basic fetoprotein changed in relation to the clinical courses and they elevated again in 3 of 4 patients with recurrence. The concentration of basic fetoprotein in testicular cancer tissue was significantly higher than in the normal testis. Histological localization of basic fetoprotein in testicular cancer tissue was demonstrated immunohistochemically. Thus, basic fetoprotein was considered to be a useful serum marker for testicular cancer.

[A case of bilateral renal cell carcinoma]

A case of asynchronous bilateral renal cell carcinoma is reported. A 52-year-old man with the chief complaint of asymptomatic gross hematuria visited our hospital on November 16, 1981. Intravesicular pyelography showed poor secretion of the left kidney, compression of its pelvis and calyces and normal visualization of the right kidney. On computer tomographic (CT) scanning, abdominal aortogram and left selective renal angiogram, a round tumor lesion on the left kidney was recognized. Under the diagnosis of left renal tumor, radical left nephrectomy was performed in December, 1981. Histological diagnosis was clear cell carcinoma of the left kidney. He was administered medroxyprogesterone acetate. In December, 1985, CT showed a space-occupying lesion laterally on the right kidney and another suspected tumorous lesion. On the right selective renal angiogram, a round hypervascular lesion about 3 cm in diameter was found on the upper portion of the right kidney. On February 10, 1986 simple surgical enucleation of the 2 renal tumors was performed. Histological diagnosis was the same as that of the left kidney. Postoperative course was uneventful. He is well without recurrence or metastasis 8 months after operation.

CT findings in multicentric glioblastoma: diagnostic-pathologic correlation

Computerized cranial tomography (CCT) and angiographic findings in three cases of multicentric glioblastoma are reported. Differentiation of multicentric glioblastoma from diffuse metastatic deposits or multiple abscesses can be difficult with CCT. Apart from demonstrating a mass effect in one case and tumor neovascularity in the second case, angiography did not provide additional helpful information. The pathological diagnoses of these lesions were confirmed by biopsy and subsequent autopsy. Pathological differentiation of the multifocal or multicentric nature of the glioblastoma can be made only at autopsy.

Case report. Tandem lesions: chromophobe adenoma and meningioma

A number of cases of multiple primary intracranial neoplasms have been reported, including tumors of neuroepithelial and mesenchymal origin. The presence of meniogioma has been reported in association with glioblastoma, oligodendroglioma, astrocytoma, and eosinophilic adenoma. This case represents a unique example of adjacent chromophobe adenoma and meningioma. The usefulness of computed tomography in the diagnosis of concomitant lesions with different density attenuations is discussed.

Coronal head scans by computed tomography with patient in sitting position

Coronal scans of any region of the head as well as of the craniocervical region may be obtained with the patient in sitting position. The Hitachi tomograph is used for this purpose.