Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer

Background

Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments.

Patients and methods

The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted.

Results

Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis.

Conclusion

Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

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From 2013 to 2018, 3.9% of the 46 829 patients diagnosed with a first cancer presented with an SPC.

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Treatment of the first cancer with ICIs was associated with a major reduction of SPC.

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CC given for an FPC was also associated with a lower magnitude of reduction of SPC.

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There were no SPC in cancer patients treated with ICIs in the localized phase of their first cancer.

Expansion of the TLO gene family enhances the virulence of Candida species

The TLO genes are a family of subtelomeric ORFs in the fungal pathogens Candida albicans and C. dubliniensis encoding a subunit of the Mediator complex homologous to Med2. The more virulent pathogen C. albicans has 15 copies of the gene whereas the less pathogenic species C. dubliniensis has only two. To investigate if expansion of the TLO repertoire in C. dubliniensis has an effect on phenotype and virulence we expressed three representative C. albicans TLO genes (TLOβ2, TLOγ11 and TLOα12) in a wild type C. dubliniensis background, under the control of either their native or the ACT1 promoter. Expression of TLOβ2 resulted in a hyperfilamentous phenotype, while overexpression of TLOγ11 and TLOα12 resulted in enhanced resistance to oxidative stress. Expression of all three TLO genes from the ACT1 promoter resulted in increased virulence in the Galleria infection model. In order to further investigate if individual TLO genes exhibit differences in function we expressed six representative C. albicans TLO genes in a C. dubliniensis Δtlo1/Δtlo2 double mutant. Differences were observed in the ability of the expressed CaTLOs to complement the various phenotypes of the mutant. All TLO genes with the exception of TLOγ7 could restore filamentation, however only TLOα9, γ11 and α12 could restore chlamydospore formation. Differences in the ability of CaTLO genes to restore growth in the presence of H₂O₂, calcofluor white, Congo red and at 42°C were observed. Only TLOα3 restored wild-type levels of virulence in the Galleria infection model. These data show that expansion of the TLO gene family in C. dubliniensis results in gain of function and that there is functional diversity amongst members of the gene family. We propose that this expansion of the TLO family contributes to the success of C. albicans as a commensal and opportunistic pathogen.

Telomeric ORFs (TLOs) in Candida spp. Encode mediator subunits that regulate distinct virulence traits

The TLO genes are a family of telomere-associated ORFs in the fungal pathogens Candida albicans and C. dubliniensis that encode a subunit of the Mediator complex with homology to Med2. The more virulent pathogen C. albicans has 15 copies of the gene whereas the less pathogenic species C. dubliniensis has only two (CdTLO1 and CdTLO2). In this study we used C. dubliniensis as a model to investigate the role of TLO genes in regulating virulence and also to determine whether TLO paralogs have evolved to regulate distinct functions. A C. dubliniensis tlo1Δ/tlo2Δ mutant is unable to form true hyphae, has longer doubling times in galactose broth, is more susceptible to oxidative stress and forms increased levels of biofilm. Transcript profiling of the tlo1Δ/tlo2Δ mutant revealed increased expression of starvation responses in rich medium and retarded expression of hypha-induced transcripts in serum. ChIP studies indicated that Tlo1 binds to many ORFs including genes that exhibit high and low expression levels under the conditions analyzed. The altered expression of these genes in the tlo1Δ/tlo2Δ null mutant indicates roles for Tlo proteins in transcriptional activation and repression. Complementation of the tlo1Δ/tlo2Δ mutant with TLO1, but not TLO2, restored wild-type filamentous growth, whereas only TLO2 fully suppressed biofilm growth. Complementation with TLO1 also had a greater effect on doubling times in galactose broth. The different abilities of TLO1 and TLO2 to restore wild-type functions was supported by transcript profiling studies that showed that only TLO1 restored expression of hypha-specific genes (UME6, SOD5) and galactose utilisation genes (GAL1 and GAL10), whereas TLO2 restored repression of starvation-induced gene transcription. Thus, Tlo/Med2 paralogs encoding Mediator subunits regulate different virulence properties in Candida spp. and their expansion may account for the increased adaptability of C. albicans relative to other Candida species.

Addition of Bevacizumab to Temsirolimus in Kidney Cancer Patients

Treatment of metastatic kidney cancer has changed dramatically in the past years with the use of VEGF-targeted therapies and mTOR inhibitors. However, resistance occurs. We report here two cases of patients who benefited, both on disease control and side effects, from the addition of bevacizumab to temsirolimus, after progression on the mTOR inhibitor alone.

Major prognostic value of modeled AUChCG-AFP, a dynamic kinetic marker characterizing tumor marker decline of nonseminomatous germ cell tumors (NSGCT) intermediate-poor-risk patients according to the IGCCCG

5085

Background: The level of human chorionic gonadotrophin (hCG) and alpha-foetoprotein (AFP) serum tumor marker is well established in NSGCT as prognostic factor, the relevance of marker kinetic analysis under treatment is still unclear. This may be due to the inaccuracy of methods employed so far, simplifying complex exponential decrease curves by a median half-life (HL). We propose to model patient's AFP and hCG decline profiles in order to calculate area under the curve of marker concentrations versus time (AUChCG-AFP) and to test its prognostic value. Methods: Our retrospective study involved 65 pts treated by 4 cycles of bleomycin-etoposide-cisplatin (BEP) regimen for an intermediate-poor-risk group NSGCT in the same center between 1997 and 2008. A kinetic population approach with NONMEM software was used to model equations of hCG and AFP individual decrease profiles between day 7 (D7) and D42 after the first BEP cycle. AUChCG and AUCAFP were calculated between day D0 and D42 as: AUC0–42=AUC0–7+AUC7–42 where AUC0–7 = trapezium area between D0 and D7 while AUC7–42=integral of modeled equation. Survival univariate and multivariate analyses tested the prognostic value of AUChCG-AFP regarding PFS. Results: Mono-exponential models best fitted AFP and hCG decreases: CAFP (t) = 381*e - 0.14 *t +3.27 and ChCG (t) = 1230*e - 0.25 *t +1.22. Three prognostic groups (AUChCG-AFP) were determined according to AUCAFP median and AUChCG terciles: good if AUCAFP<=11729.4 and AUChCG0–42<=6670; intermediate if AUCAFP>11729 and/or if 6670<=AUChCG<18178 and poor risk if AUChCG>18178 whatever AUCAFP. AUChCG-AFP was a significant prognostic factor in the univariate analysis on the 2 year PFS (100% vs 73.8% vs 67.7%, p = 0.035) as well as IGCCCG score (poor/intermediate risk groups), primary site (mediastinal/other) and HLhCG-AFP. Yet AUChCG-AFP was the only significant independent factor in the multivariate Cox model (HR = 3.3, 95%CI = [1.2–9.2], p = 0.032). Conclusions: Modeled AUChCG-AFP is a dynamic kinetic marker characterizing NSGCT patient marker decline during BEP treatment. These results must be validated in a prospective cohort. It may be a major prognostic factor.

No significant financial relationships to disclose.

ET 743 is an effective agent against sarcoma

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Background: ET-743 has shown clinical activity in soft tissue sarcoma after failure of anthracyclines and ifosfamide. We propose to assess these results in our institution. Methods: We reviewed the patients treated (in phase II studies or on a compassionate basis) until June 2006 Results: Median age of the 99 patients was 53 years (18–82, with 20% leiomyosarcomas, 18% other spindle cell sarcomas, 12% liposarcomas, 9% osteosarcomas and 4% Ewing's sarcomas. The initial tumor was in the lower limbs in 31% of cases, and 70% had lung metastases. Patients had received anthracyclines (72%) or ifosfamide (61%), but 12% received ET-743 as their 1st chemotherapy. Most patients received ET-743 as a single agent, but 7 received it in combination with doxorubicin. After a median of 4 cycles (1–25), 50% of patients responded: 0 CR, 12 patients with PR, 4 MR (minor response), 34 SD and 49 progressed. Median time to progression for patients with a clinical benefit (PR+MR+SD) was 7 months (1.5 to 66 months). Among the 29 patients who didn't progress in the first six months, 10 had leiomyosarcomas and 8 spindle cell sarcomas. Grade3/4 toxicity, mainly hematological (42% neutropenia, 16% anemia, 11% thrombocytopenia) and hepatic (33%), was noted in 69 patients (28 needed a dose reduction). Main cause of treatment discontinuation was progression (70%) but 7 patients had to stop treatment because of toxicity. Conclusions: ET- 743 can benefit some patients with sarcomas, especially leiomyosarcomas, even pretreated. Some patients have long lasting responses. Grade ¾ toxicity is frequent but rarely leads to treatment discontinuation

No significant financial relationships to disclose.

Characterization and identification of black alder ectomycorrhizas by PCR/RFLP analyses of the rDNA internal transcribed spacer (ITS)

The identity of black alder (Alnus glutinosa (L.) Gaertn.) ectomycorrhizas was investigated using PCR/RFLP analysis of the ITS region from 16 morphotypes sampled at a 60-yr-old black alder stand. A comparison was made with restriction patterns from sporocarps of 28 mycobionts, of which 16 originated from the same stand, the remaining 12 came from two geographically distant alder stands. Eight of the mycorrhizal types could thus be identified, whereas eight mycorrhizal types remained unidentified. The identified mycorrhizas belonged to the genera Russula, Lactarius, Naucoria and Cortinarius. Four of the identified ectomycorrhizal types had identical PCR/RFLP profiles to corresponding fruit bodies from all investigated stands with no detectable intraspecific variation, despite the geographical distance of c.300 km between the sampling locations. By contrast, intraspecific variation between sporocarps from the different locations was detected in Paxillus rubicundulus, mycorrhizas of which were not found. The diversity of fruiting alder mycobionts at the main experimental plot only partly matched the diversity observed from mycorrhizas when comparing their PCR/RFLP profiles. The results are discussed regarding sampling techniques, PCR/RFLP analyses and ecological aspects.

The use of an LHRH agonist, buserelin, in the long-term management of premenstrual syndromes

Buserelin, an LHRH agonist, was given by nasal spray to 20 women with premenstrual syndrome. In 10 women benefits were such that they continued treatment for periods varying from 5 to 15 months. There were significant improvements in mood and physical symptoms, and side-effects such as hot flushes were mild. The remaining 10 women were all made worse by the spray and stopped it within 2 months. Ovulation was blocked in all women though six showed evidence of ovulation during the first treatment month, and two women later in treatment. Of the long-term group, six eventually became amenorrhoeic, and four continued to menstruate. There was a significant improvement in symptoms during treatment in the long-term group. Physical symptoms continued to be worse before any menstrual bleeding. Mood change lost its relationship to menstruation. The adverse effects in the short-term group were sometimes severe and it is necessary to identify the characteristics of the woman who are likely to show such reactions before recommending this treatment for more general use.

Intranasal treatment with luteinising hormone releasing hormone agonist in women with endometriosis

An agonist analogue of luteinising hormone releasing hormone (buserelin) was successfully used to treat women with endometriosis. A dose of 200 micrograms administered intranasally thrice daily was found to be effective in five patients, in whom the endometriotic lesions resolved after six months' treatment. Failure occurred in a sixth patient, who received only 400 micrograms once daily. Anovulation was induced in all subjects together with suppression of menstruation after the first month of treatment. Symptoms of abdominal pain, dysmenorrhoea, and dyspareunia were relieved during treatment, and one previously infertile patient conceived within two months of stopping treatment. No side effects were reported with this dosage, and the results suggest a new form of treatment for patients with endometriosis.

Fertility after childbirth: pregnancy associated with breast feeding

During studies on the resumption of fertility postpartum in 12 breast feeding mothers who were using no contraception, eight pregnancies occurred. In seven cases these pregnancies occurred while the mothers continued to breast feed while in one it occurred within 2 weeks of weaning. In two cases pregnancy occurred prior to first postpartum menstruation but followed an abrupt decline in suckling frequency and duration resulting in resumption of follicular development and ovulation. In the remaining six cases, pregnancy was preceded by between 1 and 7 menstrual cycles, the majority of which (13/19) had deficient luteal phases or were anovular (4/19). In all mothers a significant decrease in the suckling frequency and duration observed during lactational amenorrhoea had occurred prior to the resumption of ovulation and conception. No mother conceived with a suckling frequency of greater than three times per day although some mothers ovulated without conceiving when suckling four times per day. The results suggests that if a breast feeding mother wishes to rely upon the infertility associated with lactational amenorrhoea, she must suckle at least five times per day with a total suckling duration of more than 65 min per day (more than 10 min per feed). Any reduction below either of these limits may result in a return of fertility.

Fertility after childbirth: adequacy of post-partum luteal phases

Normal ranges of urinary pregnanediol and total urinary oestrogen were determined from weekly estimations in twenty-seven cycles from seven normally menstruating control women and compared with the levels in the cycles of twenty-seven breast feeding and ten bottle feeding mothers. During lactation, the luteal phase pregnanediol levels were within normal limits in thirteen of forty-nine (27%) cycles, the remainder of the luteal phases being deficient (31%) or absent (42%). The proportion of normal luteal phases remained low during first cycles after lactation in six of twenty-three (26%) but rose to twenty-four of thirty-one (77%) in subsequent cycles. In bottle feeding mothers, the luteal phases of first post-partum cycles were deficient in two of ten (20%) and absent in eight of ten (80%). In second post-partum cycles, the majority of luteal phases were deficient (eight of ten, 80%) and it was not until third post-partum cycles that seven of eight (88%) had luteal phase pregnanediol levels in the normal range. Cycles during lactation and first cycles after lactation had significantly lower mean urinary pregnanediol and total urinary oestrogen levels than both the control cycles and the later cycles after lactation. Similarly, first post-partum cycles in bottle feeders had lower urinary pregnanediol and total urinary oestrogen levels than controls. This study shows an increased frequency of abnormal luteal phases during the early post-partum menstrual cycles of both breast and bottle feeding mothers which may be associated with defective development of the follicle.

Fertility after childbirth: infant feeding patterns, basal PRL levels and post-partum ovulation

The infant feeding patterns at the time of first ovulation after childbirth were determined in a longitudinal study of twenty-seven mothers who chose to breast feed their babies. Fourteen mothers suppressed ovulation throughout lactation and thirteen ovulated while still breast feeding. Those who ovulated while breast feeding had all introduced two or more supplementary feeds/day, reduced suckling frequency to less than six times/day and reduced suckling duration to less than 60 min/day at the time of first ovulation. Basal PRL levels had fallen to below 600 microunits/l in all but one of the mothers at first ovulation. Those mothers who suppressed ovulation for more than 40 weeks post-partum (late ovulation group) were compared with those who ovulated between 30 and 40 weeks post-partum (middle group) and with those who ovulated before 30 weeks post-partum (early group). The late ovulation group breast-fed for longest, suckled most intensively, maintained night feeds for longest and introduced supplementary feeds most gradually. This study suggests suckling may be the most important factor inhibiting the return of ovulation during lactation and that policies which encourage increased suckling frequency and duration will maximize the contraceptive effects of breast feeding.

Effect of supplementary food on suckling patterns and ovarian activity during lactation

Patterns of infant feeding, basal prolactin concentrations, and ovarian activity were studied longitudinally in 27 breast-feeding mothers from delivery until first ovulation. Suckling frequency (6.1 feeds/day) and suckling duration (122 mins/day) reached peak values four weeks post partum and remained relatively constant until the introduction of supplementary food at a mean of 16 weeks post partum. There were subsequently sharp declines in both the frequency and duration of suckling, both of which correlated closely with basal prolactin concentrations. None of the 27 mothers ovulated during unsupplemented breast-feeding, but within 16 weeks of introducing supplements ovarian follicular development had returned in 20 and ovulation in 14 mothers. The mothers who ovulated within 16 weeks of giving supplements had reduced frequency and duration of suckling more quickly and weaned more abruptly than those who continued to suppress ovulation. These data suggest that the introduction of supplementary food may exert an important and hitherto unrecognised effect on the timing of first ovulation by reducing the frequency and duration of suckling episodes.

Persistence of symptoms of premenstrual tension in hysterectomized women

Daily symptom ratings were recorded in seven women with premenstrual tension syndrome for one month before and for up to two months after hysterectomy. Ovarian activity was monitored after operation by twice weekly measurements of total oestrogen and pregnanediol in 12-hour urine samples. Cyclical changes in mood persisted following hysterectomy with the greatest mental and physical symptoms occurring during the late luteal phase of the cycle. In contrast there was a marked decrease in activity and vigour ratings during the late luteal phase of the cycle and during menstruation. There was a small but significant improvement in symptoms in most women following hysterectomy. These results demonstrate that neither the presence of the uterus nor the occurrence of menstruation are necessary for the manifestation of the premenstrual tension syndrome and support the view that it has a hormonal basis.

Hormone changes in relation to the time of fetal death after prostaglandin-induced abortion

The changes in unconjugated estradiol-17beta and estriol, progesterone and chorionic somatomammotropin (HCS) in peripheral plasma have been studied in 18 women at 30-minute intervals following intra-uterine prostaglandin E2 administration for therapeutic termination of second trimester pregnancy. The hormonal changes were related to the time of fetal death detected by the disappearance of fetal heart pulsations. Prostaglandin E2 was given by the intra-amniotic route with urea (5 patients) or with intravenous oxytocin (5 patients), or by the extra-amniotic route with intravenous oxytocin (8 patients). Fetal death occurred rapidly with intra-amniotic PGE2, but usually at a late stage with extra-amniotic PGE2. Three fetuses in the extra-amniotic group died at or just before abortion. A variety of fetal heart changes were noted and the time of fetal death did not appear to influence the time of abortion within each treatment subgroup. Estradiol and estriol showed a sligh but persistent fall over 24 hours prior to induction of abortion. A more rapid fall usually occurred after induction, with a consistent fall around the time of fetal death. Progesterone and HCS usually fell much less before and immediately after fetal death. A marked rise in estradiol sometimes occurred before fetal death, particularly in the intraamniotic PGE2 and urea subgroup. Estriol levels declined more rapidly before than after fetal death, whereas fetal death had less consistent effects on the other hormones. All hormones had usually fallen considerably at the time of abortion, and in some individuals marked fluctuations in hormone levels were seen.