Cobimetinib plus atezolizumab in BRAFV600 wild-type melanoma: primary results from the randomized phase III IMspire170 study

BACKGROUND

Emerging data suggest that the combination of MEK inhibitors and immunotherapeutic agents may result in improved efficacy in melanoma. We evaluated whether combining MEK inhibition and immune checkpoint inhibition was more efficacious than immune checkpoint inhibition alone in patients with previously untreated BRAF^V600 wild-type advanced melanoma.

PATIENTS AND METHODS

IMspire170 was an international, randomized, open-label, phase III study. Patients were randomized 1 : 1 to receive cobimetinib (60 mg, days 1-21) plus anti-programmed death-ligand 1 atezolizumab (840 mg every 2 weeks) in 28-day cycles or anti-programmed death-1 pembrolizumab (200 mg every 3 weeks) alone until loss of clinical benefit, unacceptable toxicity, or consent withdrawal. The primary outcome was progression-free survival (PFS), assessed by an independent review committee in the intention-to-treat population.

RESULTS

Between 11 December 2017, and 29 January 2019, 446 patients were randomized to receive cobimetinib plus atezolizumab (n = 222) or pembrolizumab (n = 224). Median follow-up was 7.1 months [interquartile range (IQR) 4.8-9.9] for cobimetinib plus atezolizumab and 7.2 months (IQR 4.9-10.1) for pembrolizumab. Median PFS was 5.5 months [95% confidence interval (CI) 3.8-7.2] with cobimetinib plus atezolizumab versus 5.7 months (95% CI 3.7-9.6) with pembrolizumab [stratified hazard ratio 1.15 (95% CI 0.88-1.50); P = 0.30]. Hazard ratios for PFS were consistent across prespecified subgroups. In exploratory biomarker analyses, higher tumor mutational burden was associated with improved clinical outcomes in both treatment arms. The most common grade 3-5 adverse events (AEs) were increased blood creatine phosphokinase (10.0% with cobimetinib plus atezolizumab versus 0.9% with pembrolizumab), diarrhea (7.7% versus 1.9%), rash (6.8% versus 0.9%), hypertension (6.4% versus 3.7%), and dermatitis acneiform (5.0% versus 0). Serious AEs occurred in 44.1% of patients with cobimetinib plus atezolizumab and 20.8% with pembrolizumab.

CONCLUSION

Cobimetinib plus atezolizumab did not improve PFS compared with pembrolizumab monotherapy in patients with BRAF^V600 wild-type advanced melanoma.

[Inky marks of memory]

An exhibition in the Special Collections Department of the Main Medical Library in Warsaw, the second in a series devoted to women's themes, presenting the correspondence of Polish women-doctors, the wives and fiansées of well-known physicians and the patients of the latter, complemented with photographic documentation.

[Localization of intraocular foreign bodies using computed tomography]

PURPOSE

To present the evaluation of computed tomography (CT) application for detecting the intraocular foreign bodies.

MATERIAL AND METHODS

Sixteen computed tomographies of orbit to localise a foreign body were performed in the 2nd Radiology Department at Lublin University School of Medicine from May 1995 to October 1998. During examination 2 mm computed tomography cuts were taken. In almost all cases fundus examination was not possible because of hazy media (cataract, vitreous haemorrhage, endophthalmitis). Pars plana vitrectomy was applied to remove foreign body in all cases.

RESULTS

In 14 cases a foreign body was localised inside the eye (3 of them were embedded in the wall of the eye) and in 2 cases a double perforation was noticed. With pars plana vitrectomy 12 of 14 intraocular foreign bodies were removed. Two foreign bodies deeply embedded in the wall of the eye were left. One of the two foreign bodies after double perforation was removed from the orbit and the second, which was localized deeply in the orbit, was left.

CONCLUSION

The localisation of the foreign bodies using the computed tomography is a very accurate and sensitive method, facilitating further surgery.

[Vitrectomy in the treatment of endophthalmitis]

PURPOSE

To present our experience with the surgical management of endophthalmitis.

MATERIAL AND METHODS

The results of 27 pars plana vitrectomies in 19 patients with clinical evidence of endophthalmitis were analysed. The endophthalmitis was considered as endogenous in 4 cases and exogenous in 15 cases.

RESULTS

With the use of vitrectomy good anatomical and functional results were obtained. Pre-operative visual acuity was worse than 1/50 in 16 patients and ranged from 1/50 to 4/50 in 3 patients. Postoperative visual acuity was worse than 1/50 in 7 patients, ranged from 1/50 to 4/50 in 3 patients and was better than 5/50 in 9 patients.

CONCLUSIONS

Pars plana vitrectomy in the management of endophthalmitis makes it possible to collect material for culture, removal of viable organisms and inflammatory products. In cases of posttraumatic endophthalmitis vitrectomy allows to prevent future complications.

In vivo evaluation of submicron emulsions with pilocarpine: the effect of pH and chemical form of the drug

Submicron emulsions containing 2.0% w/v pilocarpine as pilocarpine HCl, soybean oil (10% w/v) and egg lecithin (1.2% w/v) were formulated. Emulsions at pH 5.0, 6.5 and 8.5 were applied to the rabbit's eye, and the reduction in pupil diameter was measured for 6 h. The miotic effect was compared with that obtained with aqueous solutions at the same pH. A prolonged miotic effect was observed when the submicron emulsion was used as a vehicle. After application of emulsions at pH 5.0, 6.5 or 8.5, the time when 20% reduction of pupil diameter was still observed was 3.9 +/- 1.1 h, 4.3 +/- 1.3 h and 5.3 +/- 0.8 h, respectively, while, after application of a solution, this parameter was shorter by 30-40%. AUC(0-6h) values were larger after application of the submicron emulsions in comparison to aqueous solutions; however, statistically significant differences were only observed for emulsions at pH 6.5. Although the bioavailability of the drug is pH dependent, emulsions at higher pH cannot be considered for clinical use because of pilocarpine degradation which occurs with a similar rate as in aqueous solutions. Introduction of pilocarpine into the oily phase in the form of pilocarpine base or its oleate did not improve either the physicochemical or the pharmacological properties of the formulations. Irrespective of the pH and chemical form of pilocarpine used for emulsion preparation, practically all drug was found in the aqueous phase of the emulsion; thus, partitioning to the oily phase was negligible.

Etiology of uveitis in rural and urban areas of mid-eastern Poland

The aim of this study was to assess and compare the frequencies of uveitis etiology in inhabitants of rural and urban areas of mid-eastern Poland. We reviewed the cases of 563 patients (263 males, 300 females; aged 2-87) with uveitis, treated at the 1st Department of Ophthalmology at the Medical Academy in Lublin and at the District Ophthalmic Hospital in Kielce, Poland, from January 1996-December 2000. Anatomical classification of uveitis was used according to the International Uveitis Study Group and etiological classification including uveitis associated with trauma, infection, systemic disease, non-associated with a systemic disease and masquerade syndromes. Data regarding age, gender, place of residence, anatomical location and etiology of uveitis were obtained. Statistical analyses were performed using Pearson's chi-square test, Spearman's rank correlation test and logistic regression. Etiology of uveitis was established in 70.0% of cases. The most common cause of uveitis was infection. Patients from rural areas were significantly more likely to have uveitis of infectious origin whereas patients from urban areas significantly more likely to have uveitis associated with a systemic disease. In conclusion, the pattern of uveitis in mid-eastern Poland confirms the influence of environmental factors on the etiology of this heterogenous disease.

[Secondary glaucoma in the course of arterio-cavernous fistula: a case report]

PURPOSE

To present a case of 59-year-old woman with the symptoms of redness, proptosis of her left eye and temporary bruit in her head.

METHODS

Basic ophthalmological examination, measurement of proptosis, tonometry, visual field examination (Humphrey 30-2 threshold) CT, MRI and carotid angiography were performed.

CLINICAL SIGNS

Proptosis of the left eye, dilatation of the episcleral vessels, fundus examination--optic disc normal, enlarged and engorged venous vessels, intraretinal haemorrhages in posterior pole. Tonometry--13 mm Hg--right eye, 24 mm Hg--left eye. Perimetry--general reduction of sensitivity. CT scan--abnormal structure (0.9 x 0.4 cm) in the medial part of the left orbit, without enhancement after applying contrast. MRI examination--enlargement of extraocular muscles of the left eye. Carotid artery angiography revealed indirect carotid--cavernous fistula.

CONCLUSION

Special investigations like CT and MRI showed different picture, final diagnosis could be based upon the clinical picture and confirmed by angiography.

[Diode laser trans-scleral cyclo-photo-coagulation]

The purpose of this study is to present the results of treatment of refractory glaucoma with diode laser transscleral cyclophotocoagulation (DLCT). 88 patients (from 10 to 91 years old) were treated with diode laser. The follow up was 6 months. Mean intraocular pressure (IOP) before treatment was 38.2 mm Hg, 1 week after treatment--23.8 mm Hg, 1 month after treatment--21.3 mm Hg, after 6 months--19.0 mm Hg. We repeated treatment in 5 patients (5.6%). In 2 patients we observed hypotony--about 2 mm Hg. Diode laser cycloablation is a relatively safe and effective method in treatment of advanced refractory glaucoma.

[First women with physician's diploma on the Russian and Austrian occupation areas]

The first Polish women physicians started their work in Warsaw by the end of the 19th century. In view of the fact that no women were admitted to universities on the area of both occupying countries, they were graduates of Swiss universities. They often waited for the official recognition of their diplomas in the Russian colleges for a few years. In 1900 on the Polish area under the Austrian occupation women were given an access to the medical faculties at the Universities of Cracow and Lvov. Still, at that time the majority of doctors completed their studies abroad. Until the World War I the number of professionally active women physicians ranged from a few to a dozen in Warsaw, Cracow and Lvov. They had speciality mainly in gynecology and obstetrics as well as pediatrics. They frequently came from urban intelligentsia without much wealth, and were commonly the descendants of land owners. Nearly all of the women physicians at that time dealt with social work and participated in intellectual life of their cities.

[Solar retinopathy]

The purpose of this study is the present clinical evaluation of 21 patients (number of affected eyes--33), who watched eclipse of the sun on 12 October 1996. All patients had general ophthalmic examination with emphasis on visual acuity, visual field, Amsler test, fluorescein angiography and fundus appearance. Eleven out of 21 patients had at least one follow up examination (number of affected eyes--17). None of the patient received any treatment. All patients revealed tiny, central scotomata--positive Amsler test and decreased visual acuity on the first visit; reading Snellen chart could be improved in all patients by adequate head tilt or eye movement (improvement up to 3 Snellen chart lines). No signs of retinopathy were observed in two eyes with uncorrected refractive error and one amblyopic eye. After 7-8 weeks the visual acuity was decreased to 5/30 in two eyes and to 5/10 in ten eyes. In all those eyes persisted a tiny, central scotoma. Looking at the eclipse of the sun in spite of using primitive eye protection may cause irreversible retinal damage. Return of visual acuity to 5/5 does not always imply complete recovery because of persistent central scotoma.

[Histopathologic studies of the rabbit retina after use of perfluorodecalin]

PURPOSE

To investigate the retinal toxicity of a vitreous substitute perfluorodecalin (PFD) in the rabbit eye up to 2 weeks after injection.

MATERIAL AND METHODS

A space was created in the vitreous cavity by injecting 0.4 cc of perfluoropropane gas. After 3 days gas-fluid exchange was performed. Experimental eyes were injected with 1 cc of PFD and control eyes with 1 cc of Ringer solution. The eyes were enucleated 1, 3, 6 and 14 days after the procedure and histological studies were conducted.

RESULTS

Control samples showed almost normal histology. One day after PFD injection photoreceptor nuclei dropout and migration below the outer limiting membrane, pyknosis and occasional densification of cell bodies were observed. After 3 days glial cell hypertrophy and accumulation of macrophages above the inner limiting membrane was also noted. After 6 days necrosis was observed in the outer and inner retinal layers. Foci of cell death in the retina were also observed 14 days after PFD injection.

CONCLUSION

PFD induced degenerative changes in the rabbit retina within the first 24 hours after administration. Structural alterations in the inner and outer retina persisted within the two weeks of observation. Our results support the removal of PFD at the end of the primary surgical procedure.

[Intraretinal foreign bodies]

PURPOSE

To present our experience with the removal of intraretinal foreign bodies.

MATERIAL AND METHODS

9 intraretinal foreign bodies were removed by pars plana vitrectomy. Laser photocoagulation of the retina surrounding the foreign body was performed either before surgery or intraoperatively (endolaser). Pars plana vitrectomy with foreign body removal through the sclerotomy site with endomagnet and/or forceps was performed. In some cases fluid-gas exchange was done.

RESULTS

The average follow-up period was 6.2 months. Seven of nine foreign bodies were magnetic and two were nonmagnetic. Five of seven magnetic foreign bodies had negative magnetic traction as the first surgical procedure. In these 9 eyes, final visual acuity was below 1/50 in 2 eyes and over 5/50 in 7 eyes.

CONCLUSION

Pars plana vitrectomy should be the method of choice in removal of intraretinal foreign bodies.

[Retinitis due to cytomegalovirus in AIDS]

Clinical course of 4 AIDS patients suffering from CMV retinitis is presented. Two patients were treated with ganciclovir, one died before starting the treatment and one was vitrectomized with silicone oil injection. Of the two patients treated with ganciclovir one improved significantly when the other continued to deteriorate and died after 8 months of follow-up. Early diagnosis and treatment of patients with zone I involvement gives the best chances for improvement. Mean life expectancy in aids patients after diagnosis of CMV retinitis is 7-10 months.

[Case of subacute myelo-optico-neuropathy]

A 52-year-old female patient is reported in whom after taking of about 20 g Clioquinol blindness and paralysis of extremities with urinary incontinence developed. Complete cure ensued.

Warfarin elimination and responsiveness in patients with renal dysfunction

Plasma warfarin half-life was estimated in four patients with renal dysfunction and five normal control subjects. Hypoprothrombinemic responsiveness to a single oral dose of warfarin (0.75 mg/kg) was also evaluated for both groups. The mean warfarin half-life of 29.9+/-5.0 (S.E.M.) hours for renal patients was significantly shorter than the 44.8+/-6.0 hours half-life for normal controls (P less than 0.05). Additionally, a positive correlation was found between warfarin half-life and creatinine clearance. Pharmacologic responsiveness to warfarin was comparable for both groups. It therefore appears that patients with renal dysfunction do not possess an increased susceptibility, either pharmacokinetic or pharmacologic, to the hypoprothrombinemic effect of warfarin.

Influence of renal dysfunction on warfarin plasma protein binding

The in vitro plasma protein binding of warfarin was evaluated by ultrafiltration in plasma from seven normal subjects and seven patients with varying degrees of renal dysfunction. The unbound, or free, warfarin fraction was twice as high in the plasma samples withdrawn from patients with renal impairment than in the samples obtained from normal volunteers. Furthermore, there was a positive correlation between the extent of renal dysfunction and the magnitude of the free warfarin fraction when either creatinine clearance, plasma creatinine, or BUN was used to estimate renal function.