Adjuvant Osimertinib for Resected EGFR-Mutated Stage IB-IIIA Non-Small-Cell Lung Cancer: Updated Results From the Phase III Randomized ADAURA Trial

PURPOSE

The phase III ADAURA (ClinicalTrials.gov identifier: NCT02511106) primary analysis demonstrated a clinically significant disease-free survival (DFS) benefit with adjuvant osimertinib versus placebo in EGFR-mutated stage IB-IIIA non-small-cell lung cancer (NSCLC) after complete tumor resection (DFS hazard ratio [HR], 0.20 [99.12% CI, 0.14 to 0.30]; P < .001). We report an updated exploratory analysis of final DFS data.

METHODS

Overall, 682 patients with stage IB-IIIA (American Joint Committee on Cancer/Union for International Cancer Control, seventh edition) EGFR-mutated (exon 19 deletion/L858R) NSCLC were randomly assigned 1:1 (stratified by stage, mutational status, and race) to receive osimertinib 80 mg once-daily or placebo for 3 years. The primary end point was DFS by investigator assessment in stage II-IIIA disease analyzed by stratified log-rank test; following early reporting of statistical significance in DFS, no further formal statistical testing was planned. Secondary end points included DFS in stage IB-IIIA, overall survival, and safety. Patterns of recurrence and CNS DFS were prespecified exploratory end points.

RESULTS

At data cutoff (April 11, 2022), in stage II-IIIA disease, median follow-up was 44.2 months (osimertinib) and 19.6 months (placebo); the DFS HR was 0.23 (95% CI, 0.18 to 0.30); 4-year DFS rate was 70% (osimertinib) and 29% (placebo). In the overall population, DFS HR was 0.27 (95% CI, 0.21 to 0.34); 4-year DFS rate was 73% (osimertinib) and 38% (placebo). Fewer patients treated with osimertinib had local/regional and distant recurrence versus placebo. CNS DFS HR in stage II-IIIA was 0.24 (95% CI, 0.14 to 0.42). The long-term safety profile of osimertinib was consistent with the primary analysis.

CONCLUSION

These updated data demonstrate prolonged DFS benefit over placebo, reduced risk of local and distant recurrence, improved CNS DFS, and a consistent safety profile, supporting the efficacy of adjuvant osimertinib in resected EGFR-mutated NSCLC.

Health-Related Quality of Life Outcomes in Patients with Resected Epidermal Growth Factor Receptor-Mutated Non-Small Cell Lung Cancer Who Received Adjuvant Osimertinib in the Phase III ADAURA Trial

PURPOSE

In the phase III ADAURA trial, adjuvant treatment with osimertinib versus placebo, with/without prior adjuvant chemotherapy, resulted in a statistically significant and clinically meaningful disease-free survival benefit in completely resected stage IB-IIIA EGFR-mutated (EGFRm) non-small cell lung cancer (NSCLC). We report health-related quality of life (HRQoL) outcomes from ADAURA.

PATIENTS AND METHODS

Patients randomized 1:1 received oral osimertinib 80 mg or placebo for 3 years or until recurrence/discontinuation. HRQoL (secondary endpoint) was measured using the Short Form-36 (SF-36) health survey at baseline, 12, and 24 weeks, then every 24 weeks until recurrence or treatment completion/discontinuation. Exploratory analyses of SF-36 score changes from baseline until week 96 and time to deterioration (TTD) were performed in the overall population (stage IB-IIIA; N = 682). Clinically meaningful changes were defined using the SF-36 manual.

RESULTS

Baseline physical/mental component summary (PCS/MCS) scores were comparable between osimertinib and placebo (range, 46-47) and maintained to Week 96, with no clinically meaningful differences between arms; difference in adjusted least squares (LS) mean [95% confidence intervals (CI), -1.18 (-2.02 to -0.34) and -1.34 (-2.40 to -0.28), for PCS and MCS, respectively. There were no differences between arms for TTD of PCS and MCS; HR, 1.17 (95% CI, 0.82-1.67) and HR, 0.98 (95% CI, 0.70-1.39), respectively.

CONCLUSIONS

HRQoL was maintained with adjuvant osimertinib in patients with stage IB-IIIA EGFRm NSCLC, who were disease-free after complete resection, with no clinically meaningful differences versus placebo, further supporting adjuvant osimertinib as a new treatment in this setting. See related commentary by Patil and Bunn, p. 2204.

Postoperative Chemotherapy Use and Outcomes From ADAURA: Osimertinib as Adjuvant Therapy for Resected EGFR-Mutated NSCLC

INTRODUCTION

Adjuvant chemotherapy is recommended in patients with resected stage IIꟷIIIA (and select IB) NSCLC; however, recurrence rates are high. In the phase III, ADAURA study (NCT02511106), osimertinib demonstrated a highly statistically significant improvement in disease-free survival (DFS) in patients with resected stage IBꟷIIIA EGFRm NSCLC. Here, we report prespecified and exploratory analyses of adjuvant chemotherapy use and outcomes from ADAURA.

METHODS

Patients with resected stage IBꟷIIIA EGFRm NSCLC were randomized 1:1 to receive osimertinib or placebo for 3 years. Adjuvant chemotherapy before randomization was not mandatory, per physician and patient choice. DFS in the overall population (IBꟷIIIA), with/without adjuvant chemotherapy, was a prespecified analysis. Exploratory analyses included: adjuvant chemotherapy use by patient age, disease stage and geographical location; DFS by adjuvant chemotherapy use and disease stage.

RESULTS

Overall, 410/682 patients (60%) received adjuvant chemotherapy (osimertinib, n = 203; placebo, n = 207) for a median duration of 4.0 cycles. Adjuvant chemotherapy use was more frequent in patients: aged <70 years (338/509; 66%) versus ≥70 years (72/173; 42%); with stage II-IIIA disease (352/466; 76%) versus stage IB (57/216; 26%); enrolled in Asia (268/414; 65%) versus outside of Asia (142/268; 53%). A DFS benefit favoring osimertinib versus placebo was observed in patients with (DFS HR = 0.16, 95% CI: 0.10ꟷ0.26) and without adjuvant chemotherapy (HR = 0.23, 95% CI: 0.13ꟷ0.40), regardless of disease stage.

CONCLUSIONS

These findings support adjuvant osimertinib as an effective treatment for patients with stage IB-IIIA EGFRm NSCLC after resection, with or without prior adjuvant chemotherapy.

Effect of resected length in reconstructive surgery for tracheobronchial injury

Background

Mechanical injury to the trachea and bronchi may cause mild to severe stenosis requiring surgical intervention for reconstructing the damaged trachea. The location, length, and cause of injury are important factors affecting the surgical outcome.

Method

We conducted a retrospective study to evaluate the results of reconstructive surgery on noncancerous tracheobronchial lesions in 75 patients aged 5–55 years who had undergone reconstructive tracheobronchial surgery in our hospital from 2009 to 2018.

Results

The causes of tracheobronchial injury included blunt trauma in 38 patients, sharp penetrating trauma in 24, a postintubation lesion in 6, a post-tracheotomy lesion in 3, tuberculosis in 3, and an adult congenital lesion in one. In 59 cases of a lesion in the trachea, the length of missing segment before reconnection was 1–2 cm in 6 cases, 3 cm in 22, 4 cm in 18, 5 cm in 13, and >5.5 cm in 1 case. The length of the resected segment was <5.5 cm in all survivors, whereas one death occurred when the resected length was approximately 6 cm.

Conclusions

The length of the resected segment and precision of the surgery are crucial for determining the outcome of surgery.

Surgical reconstruction for congenital tracheal malformation and pulmonary artery sling

Background

Congenital tracheal malformations are less common than congenital cardiac diseases and surgical repair of these anomalies is complex. We sought to examine the surgical treatment and outcomes in cases of tracheal anomalies presenting with or without associated congenital malformations.

Methods

We retrospectively reviewed the demographic, clinical, and imaging data of 49 children who underwent surgery for congenital tracheal malformations between August 2013 and September 2017. Data were collected from the hospital records.

Results

In all, 49 patients (male, 30; female, 19) underwent surgeries at our center. The children were of ages between 3 and 36 months (average: 9.7 months). Associated congenital lesions included sling in31/49 (63%), vascularring: in 2/49; ventriculoseptaldefectin5/49; Fallot’s tetraology in 2/49 (4.1%), and imperforate anus in 3/49 (6.1%). The outcomes of surgery were excellent in 42(85.7%) cases, good in 3 cases, while mortality occurred in 4(8.1%) cases. All cases of tracheal stenosis without any change in tracheobronchial arborization, 10/12 cases of bridge carina, and all cases of tripod carina were reconstructed using the slide tracheoplasty technique. Antetracheal translocation was performed for correction of associated pulmonary sling, without reimplantation of the pulmonary artery.

Conclusions

Reconstructive surgery is a feasible treatment option for congenital tracheal malformations. Slide tracheoplasty can be safely applied in all cases for the correction of tracheal stenosis. Segment resection was not required for any portion of the trachea. Pulmonary artery translocation is safe and effective for patients with pulmonary artery sling, rather than reimplantation. Mortality was associated with severe cardiac complications.

Mechanical stress generated by orthodontic forces on apical root cementum: a finite element model

OBJECTIVES

1) To determine the mechanical stress generated at the root apex during different types of tooth movement using a finite element model of an ideal, human maxillary central incisor. 2) To determine the relationship of thickness of cementum and the magnitude of mechanical stress at the root apex.

DESIGN

Computer simulation.

SETTING AND SAMPLE POPULATION

Not applicable, computer simulation.

EXPERIMENTAL VARIABLES

Tooth and investing tissue layers (enamel, dentin, cementum, pulp, periodontal ligament, and alveolar bone).

OUTCOME MEASURE

Von Mises and maximum principal stresses.

RESULTS

Increasing the apical thickness of cementum increases the amount of mechanical stress.

CONCLUSION

A finite element model incorporating all layers of a human maxillary central incisor has been developed. This model was used to determine the location and magnitude of mechanical stress generated for all regions of the tooth, PDL, and enclosed alveolar bone, when orthodontic forces are applied to the tooth. Mechanical stresses were found to increase at the root apex with increasing thickness of apical cementum.

Infant mortality in Louisiana--identifying the risks

The state of Louisiana consistently has one of the five highest infant mortality rates in the nation and the racial disparity within the state is glaring. The purpose of this paper is to analyze the state's linked birth and death infant data set for the birth cohort of 1990-1998, and to identify the "at risk" population. We have analyzed data from the 1990 to 1998 birth and infant death cohort in Louisiana to determine mothers' characteristics that are associated with infant death. These include extremely young and old ages, unmarried marital status, lower levels of education, and prenatal care. A mother's race is also associated with higher future mortality for her infant, with black mothers and their infants being at greater risk than white ones. Because the infant mortality rate is higher for black infants than for white ones, Louisiana's higher infant mortality rate can be seen as a result of the higher proportion of black births. Main concerns in reducing infant mortality rates include reducing incidence of low birth weights specifically among black births primarily by providing adequate prenatal care.