The Current Treatment Landscape of Malignant Pleural Mesothelioma and Future Directions

The incidence of malignant pleural mesothelioma is expected to increase globally. New treatment options for this malignancy are eagerly awaited to improve the survival and quality of life of patients. The present article highlights the results of recent advances in this field, analyzing data from several relevant trials. The heterogeneous tumor microenvironment and biology, together with the low mutational burden, pose a challenge for treating such tumors. So far, no single biomarker has been soundly correlated with targeted therapy development; thus, combination strategies are often required to improve outcomes. Locally applied vaccines, the expansion of genetically engineered immune cell populations such as T cells, the blockage of immune checkpoints that inhibit anti-tumorigenic responses and chemoimmunotherapy are among the most promising options expected to change the mesothelioma treatment landscape.

The journey of stage III and IV non-small cell lung cancer patients in the Brazilian private healthcare system: a retrospective study

Non-small cell lung cancer (NSCLC) is still diagnosed at late stages in Brazil. The availability of newer treatment options has changed patient management, however, few real-world data have been published since then. This is a population-based retrospective cohort study that aims to evaluate the characteristics of stage III/IV NSCLC patients and their journey in the Brazilian private healthcare system. Patients aged ≥18 years, residing in Brazil who had their first medical appointment between 2016 and 2018 were included in the study. The sociodemographic and clinical characteristics of the patients and time intervals of interest were described. A total of 10,394 patients were analyzed. The majority of the patients were male (58.5%) with a median age of 64.0 (IQR = 58.0 - 71.0) years. In relation to characteristics of the disease, most of the tumors were characterized as adenocarcinomas (52.3%) and diagnosed at stage IV (72.2%). Most patients arrived at the hospital with an established NSCLC diagnosis, while 45.7% were diagnosed at the first medical appointment in the hospital or later. For patients who were diagnosed at the first medical appointment or later, a median interval of 15.0 (IQR = 6.0 - 33.0) days was observed between the first medical appointment and the diagnosis. The first treatment was given after a median of 25.0 (IQR = 6.0 - 49.0) days after diagnosis for patients without a prior diagnosis, and 57.0 (IQR: 33.0 - 98.0) days for patients with a prior diagnosis. The most common treatments were chemotherapy alone (33.8%), chemotherapy combined with radiotherapy (21.5%), radiotherapy alone (13.1%), adjuvant or neoadjuvant treatment (9.3%), surgery (3.3%), and immunotherapy (0.7%; alone or combined). At the end of follow-up (September, 2020), 52.3% of the patients had died. Despite having more treatment options in the private sector, data show that there is a need to improve access to technologies.

Tumor-Infiltrating Lymphocytes in HER2-Low Breast Cancer

INTRODUCTION

Tumor-infiltrating lymphocytes (TIL) is a predictive and prognostic biomarker for breast cancer (BC) HER2-positive and triple negative, but its presence in HER2-low tumors is unknown. We aimed to determine TIL levels in HER2-low tumors and its correlation with other clinicopathologic features.

MATERIALS AND METHODS

We retrospectively analyzed all the pathology reports of breast surgeries of a tertiary hospital in Sao Paulo, Brazil, from January 2021 to March 2022. Inclusion criteria were stage I to III invasive BC, and exclusion criteria were nonmalignancies and neoadjuvant therapy. We assumed HER2 categories according to ASCO/CAP guidelines. TILs were defined as absent (0), low (1%-10%), intermediate (11%40%) and high (≥ 41%). Ki-67 levels were categorized as low (up to 19%) and high (≥ 20%).

RESULTS

From 272 patients, 198 met the inclusion criteria. Histological grade 3 was found in 10, 19 and 47% of HER2-0, low, and positive tumors (P < .001). HER2-positive tumors had 82.6% of high Ki-67 levels, while HER2-negative and HER2-low showed 25.8% and 31.4% (P = .005). TILs in HER2-0, low, and positive tumors were, respectively, absent in 16.1%, 17.6%, and 8.7%; low in 70.2%, 52.9% and 34.8%; intermediate in 11.3%, 25.5% and 47.8%; and high in 2.4%, 3.9% and 8.7%. There was a statistically significant difference in TILs between HER2-negative versus HER2-positive groups (P < .001), but not between HER2-negative versus HER2-low, or HER2-low versus HER2-positive.

CONCLUSION

TILs in HER2-low are marginally higher than HER2-negative, but significantly lower than HER2-positive levels. HER2-low tumors do not seem to significantly differ biologically from HER2-negative tumors.

Abstract P1-04-11: Tumor Infiltrating Lymphocytes in initial HER2-Low breast cancer

Rationale Human Epidermal Growth Factor Receptor 2 (HER2)-positive breast cancer (BC) represents a distinct subgroup of patients (pts) that derives significant benefits from anti-HER2 therapy. More recently, patients with metastatic BC that were previously considered HER2-Negative but with low positivity by immunohistochemistry (IHC) and a negative in situ hybridization (ISH) (HER2 1+, or 2+ with negative ISH) derived benefit from treatment with trastuzumab-deruxtecan (T-Dxd), an antibody-drug conjugate that targets HER2 receptor. This novel subgroup, termed HER2-Low (H-Low), represents nearly 60% of BCs. Tumor infiltrating-lymphocytes (TILs) are a biomarker that can be easily analyzed without additional stains, and that tend to be higher in tumors with more aggressive features. High levels of TILs can predict better outcomes in triple-negative (TN) and HER2-Positive (H-Pos) tumors. To date, there is no information about TILs levels in H-Low tumors. Objectives This work aims to determine TILs levels in HER2-Low tumors and their correlation with clinicopathologic features. Methods We retrospectively analyzed tissue from breast surgical products in a tertiary hospital in Sao Paulo, Brazil, from January 2021 to March 2022. Inclusion criteria were stage I to III invasive BC and available data for TILs, HER2, estrogen receptor (ER), progesterone receptor (PR) by IHC, and ISH, when applicable. Exclusion criteria was neoadjuvant therapy. We extracted clinical, histopathologic, and IHC parameters. HER2 subtypes were defined as follows: HER2-Negative (H-Neg) when HER2 0+ in IHC; H-Low when IHC 1+, or 2+ with ISH negative; and H-Pos when IHC 3+ or 2+ with ISH positive. TILs were defined as absent (0), low (1 to 9%), intermediate (10 to 39%) and high (&gt;40%). Ki-67 levels were divided as low (up to 19%) and high (≥20%). Results We included 202 eligible pts. 128 were H-Neg, 51 were H-Low (35 IHC 1+ and 16 IHC 2+ with ISH negative), and 23 were H-Pos. Four pts were TN in H-Neg and none in H-Low group. The mean ages for H-Neg, H-Low and H-Pos were 57, 51, and 57 years, respectively. ER and PR were negative in 3.1% and 11.7% of H-Neg, 0 and 7.8% of H-Low, and 52.4% and 56.5% of H-Pos. Ki-67 levels were high in 27.3% of H-Neg, 31.4% of H-Low and 82.6% of H-Pos. Nodal stages and multifocality were similar. Ductal histology had 89 (69.5%), 45 (88.2%), and 21 (91.3%) cases for H-Neg, H-Low, and H-Pos. Lobular carcinoma was found in 30 (23,4%) in H-Neg, 4 (7.8%) in H-Low, and none in the H-Pos group. Nuclear grade (NG) 2 was seen in 64.8% of H-Neg and 62% of H-Low. Nuclear grade 3 seen was in 82.6% of H-Pos. Histologic grade 1 was present in H-Neg and H-Low, with 29.7% and 25.5%; grade 2 was seen in 56.3% and 56.9%, respectively. In H-Pos grade 3 was found in 47.8%. Angiolymphatic invasion and perineural invasion were present in 26.6%, 35.3%, and 17.4%; and 26.6%, 35.3%, and 13% of H-Neg, H-Low and H-Pos respectively. TILs in H-Neg, H-Low, and H-Pos were, respectively, absent in 16.4%, 17.6%, and 8.7%; low in 69.5%, 52.9% and 34.8%; intermediate in 11.7%, 25.5% and 47.8%; and high in 2.3%, 3.9% and 8.7%. We divided samples into TILs levels to look at the distribution of HER2 subtypes. Absent, low, intermediate, and high TILs had respectively 32, 124, 39, and 7 cases. There were more H-Neg in low TILs and H-Pos in high TILs, with, respectively, 65.6% and 6.3% of absent; 71.8% and 6.5% of low; 38.5% and 28.2% of intermediate; and 42.9% and 28.6% of high TILs. Conversely, H-Low showed stability among the groups, with 28.1%, 21.8%, 33.3%, and 28.6% in absent, low, intermediate, and high TILs, respectively. Complete data and statistical analysis will be presented at the meeting. Conclusion TILs in H-Low are similar to H-Neg. Both had lower TILs compared to H-Pos pts. In our study, only 25% were defined as H-Low, which demonstrates that a better comprehension about prevalence or pathology concordance between HER2 IHC 0 and 1+ is warranted. TILs may not play a role as a biomarker in H-Low tumors.

Citation Format: Italo Fernandes, Eduarda Damasceno, Rafael Kaliks, Marcus Corpa, Gustavo Schvartsman. Tumor Infiltrating Lymphocytes in initial HER2-Low breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-04-11.

Abstract P4-10-05: Safety and efficacy of low dose topical testosterone for sexual function improvement in women with breast cancer under treatment with ovarian suppression and aromatase inhibitor

Background: Premenopausal, high-risk, hormone receptor-positive breast cancer patients areoften treated with ovarian suppression in combination with aromatase inhibitors (AI). Thiscombination results in important adverse effects, particularly in sexual function, such as vaginaldryness and loss of libido. Vaginal estrogen is effective but may elevate serum estradiol levelsand, theoretically, may increase recurrence risk. Vaginal testosterone is also commonlyprescribed to ameliorate symptoms, though its safety remains uncertain, with limited availabledata. In our study, we aimed to determine the safety and efficacy, particularly regarding sexualfunction, of a low-dose, topical testosterone gel administration.Methods: This is a pilot, single-center study, designed to evaluate the efficacy of topicaltestosterone gel (3 mg/ml/per day) in improving sexual function in 30 premenopausal patientson ovarian suppression in combination with an AI. The primary safety endpoint was todetermine serum estradiol, measured by liquid chromatography mass spectrometry (E2) on amonthly a basis for 3 consecutive months. The primary efficacy endpoint was assessed by meansof the Female Sexual Function Index (FSFI) questionnaire, that include various domains of sexualfunction such as libido, sexual satisfaction and vaginal lubrication. The score can range from 2to 36, being 2 the lowest and 36 the highest sexual satisfaction. Patients had to have a baselineE2 of less than 2.7 pg/ml prior to study entry.Results: Herein, we report the preliminary results on the first 20 patients. The mean age was39.3 years, 85% had early or locally advanced disease and 15% had metastatic disease. Tenpatients completed the 3-month treatment, while five are still on therapy. Four of the 20discontinued treatment, mainly due to logistical difficulties during the follow-up visits. Onepatient had a localized allergic reaction and, also, discontinued treatment. A total of 15 patientsmaintained the value of E2 of less than 2,7 pg/ml during the 3-month treatment in all 3measurements. We observed an improvement in FSFI measures over the visits, with an increasefrom a mean of 10.2 at baseline to 19.4 at the third month (P&lt;0.001), with the greatestimprovement observed between the second and third months.Conclusion: Our preliminary findings suggest that topical testosterone appears safe andeffective in improving sexual function in patients on ovarian suppression and aromataseinhibitor. Further studies are clearly warranted.

Citation Format: Patrícia Taranto, Diogo de Brito Sales, Luciano de Melo Pompei, Alessandro Leal, Gustavo Schvartsman, Antonio Carlos Buzaid. Safety and efficacy of low dose topical testosterone for sexual function improvement in women with breast cancer under treatment with ovarian suppression and aromatase inhibitor [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-10-05.

Pseudoprogression with Neoadjuvant Immunotherapy for Cutaneous Melanoma

Immune checkpoint inhibitors (ICI) have drastically changed the landscape of metastatic melanoma management, thus significantly improving survival. Clinically, assessing treatment response may be challenging in a portion of cases due to a massive influx of immune cells into the tumor microenvironment, causing a transient increase in the target lesion size. This phenomenon, coined pseudoprogression, can occur in 5-10% of metastatic patients, and it is commonly followed by a tumor regression. Its incidence, however, may be underestimated, given its ephemeral nature and often being documented in visceral metastatic lesions, which are only assessed by imaging scans every 2-3 months. More recently, ICI has been studied in the neoadjuvant setting, yielding durable pathological responses in patients with cutaneous melanoma. Here, we report a case of a large retroauricular melanoma mass with regional lymph node involvement treated with ipilimumab and nivolumab combination therapy that developed pseudoprogression. Initially documented as an increase in size along with inflammatory features, followed by a dramatic clinical improvement. A complete regression was pathologically documented after 3 months and the patient remains disease-free for 14 months after treatment initiation. In conclusion, we document a pseudoprogression case during neoadjuvant ICI treatment and raise the question of whether the incidence of this phenomenon is higher when observed in superficial lesions, which can be assessed by routine physical exam.

The tumor immune contexture of salivary duct carcinoma

BACKGROUND

Salivary duct carcinoma (SDC) is a rare and aggressive malignancy. Recently, biomarker studies found promising targetable alterations. In this study, we provide a descriptive analysis of tumor and immune biomarkers and survival associations.

METHODS

We extracted clinical data and performed immunohistochemistry for AR, AR-V7, HER-2, PD-L1, LAG-3, and tumor-infiltrating immune cells.

RESULTS

We included 17 patients. Age ranged from 42 to 85 years old; HER-2 was overexpressed or amplified in 65%. AR was positive in 88% of patients, while AR-V7 was positive in 13% by IHC. We found low scores of immune infiltration and a PD-L1 expression in 53%. We found no clinically significant association between biomarkers and survival outcomes.

CONCLUSION

In this small series of SDC, biomarkers do not seem to correlate with disease biology, although they provide additional treatment options. SDC may harbor a different immune profile compared to other subtypes, with an indication of T-cell dysfunction.

Salivary Gland Carcinoma: Novel Targets to Overcome Treatment Resistance in Advanced Disease

Salivary gland carcinomas (SGCs) account for <5% of head and neck malignant neoplasms, further subcategorized in over 20 histological subtypes. For the most part, treatment for advanced disease is guided by morphology. SGCs in general respond poorly to a wide array of standard chemotherapy, with short durability, and significant toxicity. More recently, next-generation sequencing provided significant input on the molecular characterization of each SGC subtype, not only improving diagnostic differentiation between morphologically similar tumor types but also identifying novel driver pathways that determine tumor biology and may be amenable to targeted therapy. Among the most common histological subtype is adenoid cystic carcinoma, which often harbors a chromosome translocation resulting in an MYB-NFIB oncogene, with various degrees of Myb surface expression. In a smaller subset, NOTCH1 mutations occur, conferring a more aggressive pattern and potential sensitivity to Notch inhibitors. Salivary duct carcinomas may overexpress Her-2 and androgen receptors, with promising clinical outcomes after exposure to targeted therapies approved for other indications. Secretory carcinoma, previously known as mammary analog secretory carcinoma, is distinguished by an ETV6-NTRK3 fusion that can both help differentiate it from its morphologically similar acinar cell carcinoma and make it susceptible to Trk inhibitors. In the present article, we discuss the molecular abnormalities, their impact on tumor biology, and therapeutic opportunities for the most common SGC subtypes and review published and ongoing clinical trials and future perspectives for this rare disease.

Establishing recurrence indicators and stratifying pancreatic ductal adenocarcinoma based on routine laboratory exams. Is it time to incorporate these parameters in daily clinical practice?

PURPOSE

Systemic inflammation plays a crucial role in carcinogenesis and progression of pancreatic cancer, due to its influence on tumor angiogenesis, invasion and metastasis. The association of CA 19-9, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) can identify patients with different prognoses.

METHODS

We reviewed 148 pancreatic cancer patients' charts diagnosed from January 2006 to December 2018 in a tertiary hospital. Cox proportional survival models were used to evaluate the impact of each factor on recurrence-free and overall survival (OS).

RESULTS

When assessing risk of relapse, the presence of angiolymphatic invasion was associated with an 80% chance of recurrence in 5 years. Among other factors associated with OS, the estimated risk of death in patients with CA 19-9>300 U/mL was 2.37-fold higher compared to lower values. In addition, the risk of death was 60% and 76% higher in patients with NLR>3 and PLR>150, respectively. Patients within these 3 categories had a median OS of only 7.5 months, lower than all-comer patients with stage IV disease, with median OS estimated at 9.84 months.

CONCLUSION

The laboratory variables CA 19-9, NLR and PLR together can contribute to a better stratification of patients with pancreatic adenocarcinoma beyond conventional staging. Prospective initiatives using these factors together can demonstrate different subgroups of patients who benefit from new treatment strategies.

Incidence, patterns of progression, and outcomes of preexisting and newly discovered brain metastases during treatment with anti-PD-1 in patients with metastatic melanoma

BACKGROUND

Melanoma brain metastases (MBM) occur in up to 50% of patients with metastatic melanoma (MM) and represent a frequent site of systemic treatment failure for targeted therapies. However, to the authors' knowledge, little is known regarding the incidence, patterns of disease progression, and outcomes of MBM in patients treated with anti-PD-1 immunotherapy.

METHODS

A total of 320 patients with MM who were treated with anti-PD-1 at The University of Texas MD Anderson Cancer Center in Houston were reviewed. Analyses were performed to identify factors associated with brain metastasis-free survival and overall survival (OS) using Cox regression models.

RESULTS

The median age of the patients was 63.3 years. OS from the initiation of anti-PD-1 therapy was not significantly different between patients without MBM prior to anti-PD-1 compared with patients with prior MBM (P = .359). Among patients without prior MBM, 21 patients (8.6%) developed MBM during anti-PD-1 therapy, 12 of whom (4.9%) presented with disease progression in the central nervous system (CNS) only. Developing MBM during or after therapy with anti-PD-1 (hazard ratio, 4.70; 95% CI, 3.18-6.93) was associated with shorter OS. Among patients with MBM prior to anti-PD-1 treatment, 15 (20.0%) progressed in the CNS only and 19 (25.3%) progressed both intracranially and extracranially; at the time of the last data cutoff, 27 patients (36.0%) had not developed disease progression. Radiation necrosis occurred in 11.3% of patients (7 of 62 patients) in the group with a prior MBM who received stereotactic radiosurgery.

CONCLUSIONS

Anti-PD-1 therapy may change the natural history of patients with preexisting MBM. However, CNS failure during treatment with anti-PD-1 is predictive of a worse prognosis compared with extracranial progression. The results of the current study support the activity of anti-PD-1 in patients with MBM, although routine CNS imaging during therapy is warranted.

Management of metastatic cutaneous melanoma: updates in clinical practice

In recent years, several drugs have been approved for the treatment of patients with metastatic cutaneous melanoma, completely reshaping the landscape of this aggressive disease. Immune therapy with cytotoxic T-lymphocyte antigen 4 and programmed cell death-1 inhibitors yielded significant and durable responses, achieving long-term disease control in up to 40% of the patients. BRAF inhibitors (BRAFi), in combination with MEK inhibitors, also resulted in improved overall survival compared with single-agent BRAFi in patients with BRAFV600-mutated metastatic melanoma. The optimized sequencing and duration of treatment, however, is yet to be found. In this article, we thoroughly review current data and discuss how to best sequence the various treatment modalities available at present, based on four distinct clinical presentations commonly seen in clinic. In addition, we review treatment options beyond checkpoint inhibitors and targeted therapy, which may be required by patients failing such effective treatments.

Salivary gland tumors: Molecular characterization and therapeutic advances for metastatic disease

Salivary gland cancers represent a rare group of tumors composed by over 20 histological subtypes. Initially treated as one single disease, its diagnosis, prognosis, and treatment are currently being stratified based on morphology. More recently, insight has been provided on the molecular characterization of each subtype, further improving diagnostic accuracy and paving the way for personalized therapy. In this article, we provide a comprehensive review of recent breakthroughs, preliminary results of novel therapy, and future directions on the treatment of these complex malignancies.

Association between weight gain during adjuvant chemotherapy for early-stage breast cancer and survival outcomes

Obese and overweight women have an increased risk of breast cancer and worse outcomes at the time of diagnosis. Women tend to gain weight after breast cancer diagnosis and during chemotherapy for early‐stage disease, which may in turn increase risk for worse outcomes. We examined if weight gained during adjuvant chemotherapy was associated with worse survival outcomes. We queried our database for data on patients who received adjuvant third‐generation chemotherapy for early‐stage breast cancer. Univariate and multivariate analyses by Cox regression were performed for survival outcomes across three categories according to BMI variation from start to end of chemotherapy: >0.5 kg/m² loss or gain and stable BMI (±0.5 kg/m²). We included 1998 patients in this study. Women over 50 years old and postmenopausal were more likely to lose weight during adjuvant chemotherapy, whereas women under 30 years old gained more weight (P < 0.001). At 1 year postchemotherapy, patients tended to return to their original weight (ρ = −0.3, P < 0.001). On multivariate analysis, BMI increase of >0.5 kg/m² compared to maintaining BMI was marginally associated with increased locoregional recurrence risk (HR: 2.53; 95% CI, 1.18–5.45; P = 0.017), adjusting for grade, stage, and radiation delivery. Weight variation during adjuvant chemotherapy for early‐stage breast cancer may occur as both weight gain and weight loss in a balanced manner. Furthermore, this variation seems to be transient in nature and does not appear to significantly influence recurrence rates and overall survival.

Could Objective Tests Be Used to Measure Fatigue in Patients With Advanced Cancer?

CONTEXT

Assessment of cancer-related fatigue is currently based on patient-reported outcomes. We asked whether objective assessments, such as muscle strength and nutritional markers, can be used as surrogate measures of cancer-related fatigue.

OBJECTIVE

We examined the association among three fatigue scales, muscle strength, and nutritional markers in patients with advanced cancer.

METHODS

In this prospective study, we enrolled hospitalized cancer patients who had been seen in palliative care consultation at MD Anderson Cancer Center. We assessed fatigue using three fatigue scales-the Brief Fatigue Inventory (BFI), the Edmonton Symptom Assessment System (ESAS), and the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30)-and determined their association with objective assessments, including handgrip strength, maximal inspiratory pressure, lean body mass, phase angle, and albumin. Spearman's correlation test was used to assess associations.

RESULTS

Among 222 patients, the mean age was 55 years; 59% were women. The median overall survival was 106 days. The total BFI score had weak association with handgrip strength (ρ = -0.18, P = 0.007) and no association with the remaining objective measures. ESAS fatigue and EORTC fatigue showed similar findings. Total BFI had moderate-to-strong association with ESAS (ρ = 0.54, P < 0.0001) and EORTC (ρ = 0.60, P < 0.0001) fatigue.

CONCLUSION

Our study showed that subjective assessment of fatigue based on patient-reported outcomes correlates only weakly with muscle strength and nutritional markers; thus, patient-reported outcomes remain the gold standard for fatigue assessment.

Safe and effective administration of T-VEC in a patient with heart transplantation and recurrent locally advanced melanoma

BACKGROUND

Immunotherapy plays a key role in the treatment of metastatic melanoma. Patients with autoimmune conditions and/or on immunosuppressive therapy due to orthotropic transplants, however, are systematically excluded from clinical trials. Talimogene laherparepvec (T-VEC) is the first oncolytic virus to be approved by the FDA for cancer therapy. To our knowledge, this is the first report of T-VEC being administered in the setting of an organ transplant recipient.

CASE PRESENTATION

Here we present the case of a patient with recurrent locally advanced cutaneous melanoma receiving salvage T-VEC therapy in the setting of orthotropic heart transplantation. After 5 cycles of therapy, no evidence of graft rejection has been observed to date, and the patient achieved a complete remission, and is currently off therapy.

CONCLUSION

This case advocates for further investigation on the safety and efficacy of immunotherapeutic approaches, such as T-VEC, in solid organ transplant recipients.

Incidence, patterns of progression and outcomes of melanoma brain metastasis (MBM) during programmed-death 1 inhibitor (PD1i) therapy

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Background: MBM are common in patients (pts) with metastatic melanoma (MM) and represent a frequent site of treatment failure with current therapies. Little is known, however, about the incidence, patterns of progression and outcomes of MBM pts treated with PD1i and in conjunction with central nervous system (CNS) focused therapy. Methods: Outcomes of mm pts treated with PD1i at MD Anderson from 01/12 to 07/16 were reviewed. The association between clinical variables and development of MBM and overall survival (OS) were assessed using logistic regression and Cox regression analyses. Results: We identified 324 mm pts, including 77 pts (24%) who had MBM prior to first dose of PD1i. Median follow-up from start of therapy was 16.3 months, median OS for pts without MBM at the start of PD1i 3.37 years, as compared to 2.85 years in pts with prior MBM (p = 0.268). Of the 247 pts without prior MBM, 64 (26%) developed MBM after exposure to PD1i. Of those, 21 pts (8.5%) developed MBM during therapy or within 30 days of discontinuation, with 12 (4.5%) having CNS-only progression, while 9 (3.6%) had both systemic and CNS progression. Pts with MBM prior to PD1i (n = 77) had CNS-only progression in 22 pts (28.6%) during therapy. Progression occurred in systemic and systemic plus CNS in 12 pts (15.6%) and 19 pts (24.7%), respectively. 24 pts (31.2%) had stable disease (SD). On multivariate analysis, pts with lung metastases (OR, 2.16; 95% CI, 1.25 - 3.78; p = 0.006) and NRAS-mutated tumors (OR, 2.17; 95% CI, 1.14 - 4.18; p = 0.02) were more likely to develop MBM; pts who had liver metastases at the start of PD1i (HR, 1.77; 95% CI, 1.09 - 2.87; p = 0.002) and those who developed MBM during PD1i (HR, 4.81; 95% CI, 3.00 - 7.71; p < 0.0001) had increased risk of death. Conclusions: We found a 26% incidence of MBM after PD1i exposure. Pts that develop MBM are still at higher risk of death despite advances in systemic and local CNS therapy. CNS-only progression was substantially higher in patients with MBM prior to PD1i, supporting a change in the natural history of the disease after PD1i. These findings support the use of CNS imaging to monitor disease during PD1i therapy.

Response to single-agent (SA) chemotherapy (CTx) after immunotherapy exposure in non-small cell lung cancer (NSCLC)

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Background: Overall response rates (ORR) to 2nd-line SACTx in NSCLC have consistently not exceeded 15%. Exploratory analysis of clinical trials in various tumor types have demonstrated potential improvements in ORR to CTx after exposure to vaccine-based immunotherapy. The objective of this retrospective study was to determine if SACTx (3rd-line or beyond) would yield improved ORR when given after exposure to programmed-death-(ligand)1 inhibitors (PD1i) in metastatic NSCLC. Methods: Eligibility criteria - patients registered in the Thoracic GEMINI database of MD Anderson treated between 06/12 and 11/16 who received at least one SACTx as 3rd-line or beyond, following progression after platinum-based CTx and PD1i. We computed efficacy outcomes to each therapy, including ORR by RECIST v1.1, progression-free survival (PFS) and overall survival (OS). Results: Of 306 PD1i-treated patients registered in the database, 28 met eligibility criteria - 54% were male, median age 66 years, 82% adenocarcinoma, 29% never smokers. The PD1i and SACTx most commonly used were nivolumab (82%) and docetaxel (54%). ORR to SACTx after exposure to PD1i was 39% (11/28 patients, 8 confirmed). In contrast, ORR to 1st-line CTx in this cohort was 30% (Table). Liver metastasis and pembrolizumab as the PD1i of choice were the only factors associated with response to SACTx on univariate analysis (p < 0.05). Conclusions: In NSCLC patients, ORR to SACTx after immunotherapy exposure was higher compared to historical data from the pre-PD1i era, and approached ORR to 1st-line platinum-based CTx. Further investigation of a possible chemosensitization effect by immunotherapy is warranted. [Table: see text]

Association between weight gain during adjuvant chemotherapy (CTx) for early-stage breast cancer (BC) and survival outcomes

e12057

Background: Obese and overweight women have an increased risk of BC and worse outcomes at the time of diagnosis compared to those at normal weight. Studies suggest that women tend to gain weight after BC cancer diagnosis and during CTx for early-stage disease, which may in turn increase risk for worse outcomes. We examined if weight gained during adjuvant CTx was associated with worse outcomes. Methods: We queried the prospectively maintained UT MD Anderson Cancer Center Breast Cancer (UTMDACC) Database for data on patients (pts) who received adjuvant third-generation CTx for early-stage BC cancer, including: demographics; tumor characteristics; and, body mass index (BMI) at diagnosis, pre- and post-CTx and one year after completion of treatment. Univariate and multivariate analysis (MA) by Cox regression were performed for survival outcomes across 3 categories according to BMI variation from start to end of CTx: >0.5-point loss or gain and stable BMI (± 0.5). Results: We included 1998 pts in this study. Women over 50 years old and post-menopausal were more likely to lose weight during adjuvant CTx, whereas women under 30 years old gained more weight (p<0.0001). At one year post-CTx, all pts tended to return to their original weight (ρ=0.3, p<0.0001). On MA, a BMI increase of 0.5 points was o associated with increased loco regional recurrence risk for both the entire cohort (HR 2.4; 95% CI, 1.122-5.166; p=0.0241) adjusting for grade and stage and for post-menopausal women (HR 3.774, 95% CI 1.241-11.447, p=0.0193) adjusting for Her2 status. Age <30 years old (HR, 2.52; 95% CI, 1.009-6.293; p=0.0478) and tumor stage 3 comparing to 1 (HR, 4.598; 95% CI, 2.754-7.677; p<0.0001) were associated with increased risk of death and tumor grade 2 (vs 3; HR, 0.547; 95% CI, 0.353-0.847; p=0.0069) was a protective factor on MA for the entire cohort. Conclusions: Weight gain during adjuvant CTx was associated with increased loco regional recurrence for the entire cohort and post-menopausal women, including pts who at year 1 returned to their normal weight. The effect of increased BMI during CTx on breast stroma, molecular profile and how it affects local recurrence is intriguing and needs to be further evaluated.

Checkpoint inhibitors in lung cancer: latest developments and clinical potential

Lung cancer is the leading cause of cancer death in the United States. The vast majority of patients are diagnosed with metastatic disease with a 5-year survival rate of less than 5%. After first-line chemotherapy or biomarker-matched targeted therapy, only suitable for a small group of patients, further systemic therapy options rendered very limited, if any, benefit until recently. Checkpoint inhibitors have significantly improved outcomes in patients with metastatic non-small cell lung cancer (NSCLC) and are currently an established second-line therapeutic option. In this manuscript, we review the mechanism of action of checkpoint inhibitors, present the available data with approved and experimental agents, discuss the progress that has already been made in the field, as well as toxicity awareness, and future perspectives.

Serum soluble-Fas is a predictor of red blood cell transfusion in critically ill patients

Objective:

To investigate the relation between the need for red blood cell transfusion and serum levels of soluble-Fas, erythropoietin and inflammatory cytokines in critically ill patients with and without acute kidney injury.

Methods:

We studied critically ill patients with acute kidney injury (n=30) and without acute kidney injury (n=13), end-stage renal disease patients on hemodialysis (n=25) and healthy subjects (n=21). Serum levels of soluble-Fas, erythropoietin, interleukin 6, interleukin 10, iron status, hemoglobin and hematocrit concentration were analyzed in all groups. The association between these variables in critically ill patients was investigated.

Results:

Critically ill patients (acute kidney injury and non-acute kidney injury patients) had higher serum levels of erythropoietin than the other groups. Hemoglobin concentration was lower in the acute kidney injury patients than in other groups. Serum soluble-Fas levels were higher in acute kidney injury and end-stage renal disease patients. Critically ill patients requiring red blood cell transfusions had higher serum levels of soluble-Fas (5,906±2,047 and 1,920±1,060; p<0.001), interleukin 6 (518±537 and 255+502; p=0.02) and interleukin 10 (35.8±30.7 and 18.5±10.9; p=0.02), better iron status and higher mortality rates in the first 28 days in intensive care unit. Serum soluble-Fas levels were independently associated with the number of red blood cell units transfused (p=0.02). Serum soluble-Fas behaved as an independent predictor of the need for red blood cell transfusion in critically ill patients (p=0.01).

Conclusions:

Serum soluble-Fas level is an independent predictor of the need for red blood cell transfusion in critically ill patients with or without acute kidney injury. Further studies are warranted to reconfirm this finding.

May titanium spiral tacks contribute to intra-abdominal adhesion formation?

PURPOSE

To verify if titanium spiral tacks may contribute to intra-abdominal adhesion formation in rabbits.

METHODS

Ten New Zealand white rabbits were used. Through videolaparoscopic surgery two titanium spiral tacks (ProTack(®), Covidien(®)) were applied in the right flank. After 30 days the animals were submitted to evaluate peritoneal cavity by videolaparoscopy.

RESULTS

No adhesion was found where the titanium spiral tacks were placed.

CONCLUSION

Titanium spiral tacks for fixation do not cause adhesions in rabbits.