Progression pattern and post-progression survival following atezolizumab and bevacizumab treatment in advanced hepatocellular carcinoma

BACKGROUND

Although the combination of atezolizumab and bevacizumab (ATZ + BEV) is a standard treatment for advanced hepatocellular carcinoma (HCC), strategies for addressing treatment failure and prognostic factors of post-progression survival (PPS) remain unestablished.

METHODS

We conducted a multicentre retrospective study to evaluate PPS following ATZ + BEV treatment in patients with advanced HCC. We classified the patients into three groups: BCLC stage B and BCLC stage C without or with new extrahepatic lesions (BCLCp-C1 and BCLCp-C2, respectively) at the time of progression.

RESULTS

Of the 204 patients who started ATZ + BEV treatment between October 2020 and September 2022, 110 showed disease progression, with 33, 55 and 22 showing the BCLCp-B, BCLCp-C1 and BCLCp-C2 stages of the disease, respectively. Specifically, patients with the BCLCp-B stage of the disease showed better overall survival than those with the BCLCp-C1 and BCLCp-C2 stages (hazard ratios: 1.93 [95% confidence interval, CI, 1.06-3.51] and 2.64 [95% CI, 1.32-5.30] for HCC stages BCLCp-C1 and BCLCp-C2, respectively). Via multivariable analysis, we identified the BCLCp-C1 and BCLCp-C2 stages, as well as performance status, Child-Pugh class and alpha-fetoprotein as poor prognostic factors for PPS.

CONCLUSIONS

BCLCp-B1 stage was identified as a better prognostic factor for PPS following ATZ + BEV treatment compared with BCLCp-C1 and BCLCp-C2 stages. This may help in making decisions regarding subsequent treatment after ATZ + BEV.

Liposomal irinotecan plus fluorouracil/leucovorin in older patients with advanced pancreatic cancer: a single-center retrospective study

BACKGROUND

The global phase 3 NAPOLI -1 trial of patients with pancreatic ductal adenocarcinoma (PDAC) demonstrated an overall survival (OS) benefit from using liposomal irinotecan and 5-fluorouracil/leucovorin (nal-IRI + 5-FU/LV) after treatment with gemcitabine (GEM) compared to 5-FU/LV alone. However, the efficacy and safety of this regimen in older patients are not well studied.

METHODS

We conducted a single-center retrospective study to compare the therapeutic efficacy of nal-IRI + 5-FU/LV between older and younger patients with cutoff ages of 70 and 75 years, respectively. We included patients with a prior history of one or more GEM-based regimens for locally advanced or metastatic PDAC and were treated with nal-IRI + 5-FU/LV.

RESULTS

Of the 115 patients, 54 (47.0%) and 24 (20.9%) were aged ≥ 70 and ≥ 75 years, respectively. The median OS and progression-free survival (PFS) of the entire cohort were 8.5 and 3.6 months, respectively. No significant differences were observed in OS and PFS hazard ratios using age cutoffs of 70 (P = 0.90 and 0.99, respectively) and 75 (P = 0.90 and 0.76, respectively) years. Additionally, no significant differences were found in the incidence of treatment-related adverse events (trAEs) between patients aged ≥ 70 and < 70 years or those aged ≥ 75 and < 75 years. Other than hematological toxicity, no trAEs higher than Grade 4 were observed in either age group.

CONCLUSION

The efficacy and safety of nal-IRI + 5-FU/LV for patients with PDAC are not significantly different for those aged ≥ 70 years compared to younger patients.

Risk factors for early recurrence in patients with pancreatic ductal adenocarcinoma who underwent curative resection

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers, and surgical resection is the only potentially curative approach. However, the rate of recurrence remains high, particularly within the first 6 months, and is associated with a poor prognosis. The present study evaluated the clinical characteristics and risk factors for early recurrence in pancreatic ductal adenocarcinoma (PDAC) patients who underwent curative resection, regardless of the use of neoadjuvant chemotherapy, to identify predictive factors associated with early recurrence and poor outcomes as well as to determine the optimal treatment strategy for patients at high risk of early recurrence after surgical resection.

METHODS

Patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2021 were included in this study. We investigated the clinicopathological features of patients in groups: those with recurrence within 6 months, recurrence between 6 and 12 months, and recurrence beyond 12 months or no recurrence. A logistic regression analysis identified covariates associated with early recurrence at 6 and 12 months.

RESULTS

The study included 403 patients with a median follow-up of 25.7 months. Recurrence was observed in 279 patients, with 14.6% recurring within 6 months, 23.3% within 6-12 months, and 62% after 12 months or not at all. The preoperative CA19-9 level, modified Glasgow prognostic score (mGPS), and positive peritoneal cytology were significant risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant risk factors for recurrence within 12 months. For patients who received preoperative chemotherapy or chemoradiotherapy, the preoperative CA19-9 level, mGPS, and positive peritoneal cytology were significant independent risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant independent risk factors for recurrence within 12 months. The study concluded that the overall survival after surgical resection for potentially resectable PDAC worsened according to the number of risk factors present in the patient.

CONCLUSIONS

We clarified that preoperative CA19-9, positive peritoneal cytology, and the lack of adjuvant chemotherapy were consistent predictors for early recurrence within 6 and 12 months. In addition, an increased number of risk factors affecting the patient was associated with a poorer overall survival after potentially curable resection. Calculating the number of risk factors for early recurrence may be an essential predictive factor when considering treatment strategies.

Impact of body composition for patients with hepatocellular carcinoma who received atezolizumab plus bevacizumab therapy

OBJECTIVE

To investigate the association between body composition and prognosis in patients with advanced hepatocellular carcinoma treated with atezolizumab plus bevacizumab.

METHODS

This cohort study analysed 119 patients who received atezolizumab plus bevacizumab for unresectable hepatocellular carcinoma. We investigated the association between body composition and progression-free survival and overall survival. Body composition was quantified by the visceral fat index, subcutaneous fat index, and skeletal muscle index. A high or low index score was defined as that above or below the median of these indices.

RESULTS

Poor prognosis was observed in the low visceral fat index and low subcutaneous fat index groups. The mean progression-free survival in the low visceral fat index and low subcutaneous fat index groups vs. the other groups were 194 and 270 days, respectively [95% confidence interval (CI), 153-236 and 230-311 days, respectively; P = 0.015], while the mean overall survival was 349 vs. 422 days, respectively (95% CI, 302-396 and 387-458 days, respectively; P = 0.027). In the multivariate analysis, both a low subcutaneous fat index and low visceral fat index were statistically associated with lower progression-free and overall survival rates [hazard ratio (HR) 1.721; 95% CI, 1.101-2.688; P = 0.017; and HR 2.214; 95% CI, 1.207-4.184; P = 0.011, respectively].

CONCLUSION

Low visceral fat index and subcutaneous fat index scores were independent predictors of poor prognosis in patients with unresectable hepatocellular carcinoma treated with atezolizumab plus bevacizumab.

A Phase I Study to Investigate the Safety, Tolerability and Pharmacokinetics of Napabucasin Combined with Sorafenib in Japanese Patients with Unresectable Hepatocellular Carcinoma

BACKGROUND AND OBJECTIVE

For patients with advanced hepatocellular carcinoma (HCC), the standard of care for many years has been sorafenib. Preliminary data have suggested that the combination of the NAD(P)H:quinone oxidoreductase 1 bioactivatable agent napabucasin plus sorafenib may improve clinical outcomes in patients with HCC. In this phase I, multicenter, uncontrolled, open-label study, we evaluated napabucasin (480 mg/day) plus sorafenib (800 mg/day) in Japanese patients with unresectable HCC.

METHODS

Adults with unresectable HCC and an Eastern Cooperative Oncology Group performance status of 0 or 1 were enrolled in a 3 + 3 trial design. The occurrence of dose-limiting toxicities was assessed through 29 days from the start of napabucasin administration. Additional endpoints included safety, pharmacokinetics, and preliminary antitumor efficacy.

RESULTS

In the six patients who initiated treatment with napabucasin, no dose-limiting toxicities occurred. The most frequently reported adverse events were diarrhea (83.3%) and palmar-plantar erythrodysesthesia syndrome (66.7%), all of which were grade 1 or 2. The pharmacokinetic results for napabucasin were consistent with prior publications. The best overall response (per Response Evaluation Criteria in Solid Tumors [RECIST] version 1.1) was stable disease in four patients. Using Kaplan-Meier methodology, the 6-month progression-free survival rate was 16.7% per RECIST 1.1 and 20.0% per modified RECIST for HCC. The 12-month overall survival rate was 50.0%.

CONCLUSIONS

These findings confirm the viability of napabucasin plus sorafenib treatment, and there were no safety or tolerability concerns in Japanese patients with unresectable HCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02358395, registered on 9 February 2015.

Association Between Immune-Related Adverse Events and Survival in Patients with Hepatocellular Carcinoma Treated With Atezolizumab Plus Bevacizumab

BACKGROUND

Immune checkpoint inhibitors (ICIs) are effective for advanced hepatocellular carcinoma (HCC). However, there are few reports on the correlation between the clinical efficacy of ICIs and the development of immune-related adverse events (irAEs) in patients with HCC. The aim of this study was to investigate the association between irAE development and survival in patients with HCC treated with atezolizumab plus bevacizumab.

PATIENTS AND METHODS

We enrolled 150 patients with advanced HCC treated with atezolizumab plus bevacizumab between October 2020 and October 2021 at 5 territorial institutions. We compared the efficacy of atezolizumab plus bevacizumab between patients who experienced irAEs (irAE group) and those who did not (non-irAE group).

RESULTS

Thirty-two patients (21.3%) developed irAEs of any grade. Grade 3/4 irAEs were observed in 9 patients (6.0%). The median progression-free survivals (PFS) in the irAE and non-irAE groups were 273 and 189 days, respectively (P = .055). The median overall survivals (OS) in the irAE and non-irAE groups were not reached and 458 days, respectively (P = .036). Grade 1/2 irAEs significantly prolonged PFS (P = .014) and OS (P = .003). Grade 1/2 irAEs were significantly associated with PFS (hazard ratio [HR], 0.339; 95% confidence interval [CI], 0.166-0.691; P = .003) and OS (HR, 0.086; 95% CI, 0.012-0.641; P = .017) on multivariate analysis.

CONCLUSION

The development of irAEs was associated with increased survival in a real-world population of patients with advanced HCC treated with atezolizumab plus bevacizumab. Grade 1/2 irAEs were strongly correlated with PFS and OS.

FOLFOX regimen after failure of fluorouracil and leucovorin plus nanoliposomal-irinotecan therapy for advanced pancreatic cancer: a retrospective observational study

BACKGROUND

Fluorouracil, leucovorin (5FU/LV), and nanoliposomal-irinotecan (nal-IRI) combination therapy has been established as the second-line treatment for advanced pancreatic ductal adenocarcinoma. Oxaliplatin with 5FU/LV (FOLFOX) is often used as a subsequent treatment, although its efficacy and safety are yet to be fully elucidated. We aimed to evaluate the efficacy and safety of FOLFOX as a third- or later-line treatment for patients with advanced pancreatic ductal adenocarcinoma.

METHODS

We conducted a single-centre, retrospective study that enrolled 43 patients who received FOLFOX after failure of gemcitabine-based regimen followed by 5FU/LV + nal-IRI therapy between October 2020 and January 2022. FOLFOX therapy consisted of oxaliplatin (85 mg/m²), levo-leucovorin calcium (200 mg/m²) and 5-FU (2400 mg/m²) every 2 weeks per cycle. Overall survival, progression-free survival, objective response, and adverse events were evaluated.

RESULTS

At the median follow-up time of 3.9 months in all patients, the median overall survival and progression-free survival were 3.9 months (95% confidence interval [CI], 3.1-4.8) and 1.3 months (95% CI, 1.0-1.5), respectively. Response and disease control rates were 0 and 25.6%, respectively. The most common adverse event was anaemia in all grades followed by anorexia; the incidence of anorexia and grades 3 and 4 was 21 and 4.7%, respectively. Notably, grades 3-4 peripheral sensory neuropathy was not observed. Multivariable analysis revealed that a C-reactive protein (CRP) level of > 1.0 mg/dL was a poor prognostic factor for both progression-free survival and overall survival: hazard ratios were 2.037 (95% CI, 1.010-4.107; p = 0.047) and 2.471 (95% CI, 1.063-5.745; p = 0.036), respectively.

CONCLUSION

FOLFOX as a subsequent treatment after failure of second-line treatment with 5FU/LV + nal-IRI is tolerable, although its efficacy is limited, particularly in patients with high CRP levels.

Clinical therapeutic effects of neoadjuvant chemotherapy in resectable pancreatic cancer

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Background: Results from the phase III Prep-02/JSAP-05 trial demonstrated the efficacy and safety of gemcitabine plus S-1 as neoadjuvant chemotherapy for resectable pancreatic cancer. However, consensus on neoadjuvant chemotherapy for pancreatic cancer has not yet been established, and the effects of neoadjuvant therapy on clinical features of the tumor and improvement in prognosis have not been fully investigated. We aimed to investigate the effect of neoadjuvant chemotherapy on resectable pancreatic cancer. Methods: Between 2013 and 2021, 291 patients who underwent curative resection for resectable pancreatic cancer at our hospital were enrolled. The patients were categorized into groups of those who received neoadjuvant chemotherapy (NAC group: n = 91) and those who received up-front surgery (US group: n = 200). Prognostic predictors were examined in (i) all patients, (ii) US group, and (iii) NAC group. Statistical significance was considered at p < 0.05. Results: The median follow-up periods were 20.7 and 33.2 months in the NAC and US groups, respectively. In the NAC group, 84 of the 91 patients (94.5%) received gemcitabine-based chemotherapy, and three (3.3%) received chemoradiotherapy. There was no difference in overall survival (OS) and recurrence free survival (RFS) between the two groups. In the background, the NAC group had lower preoperative CA19-9 levels, lower lymph node ratio (LNR), and smaller tumor size than in the US group. During multivariable analysis of OS, preoperative CA19-9 levels, LNR, modified Glasgow prognostic score (mGPS), resection margin, and tumor size were identified as possible prognostic predictors in all patients and in the US group, whereas LNR and mGPS were identified in the NAC group. Conclusions: The prognostic significance of preoperative CA19-9 level, tumor size, and LNR were counteracted in the NAC group. These findings may indicate the effect of neoadjuvant chemotherapy for resectable pancreatic cancer.

Cabozantinib in Japanese patients with advanced hepatocellular carcinoma: Final results of a multicenter phase II study

AIM

Cabozantinib showed a favorable benefit-risk profile in Japanese patients with advanced hepatocellular carcinoma (HCC) in an open-label, phase II study (NCT03586973). This analysis presents cumulative data to final database lock.

METHODS

Patients with previously treated, advanced HCC received cabozantinib 60 mg/day. Progression-free survival (PFS) and tumor response rates in prior-sorafenib and sorafenib-naïve cohorts were assessed by independent radiology committee (IRC) and an investigator. Liver function was evaluated by albumin-bilirubin (ALBI) score.

RESULTS

Median cabozantinib exposure was 5.6 months. In the prior-sorafenib cohort (n = 20), median PFS was 7.4 months per IRC assessment and 5.6 months per investigator assessment. In the sorafenib-naïve cohort (n = 14), median PFS was 3.6 and 4.4 months per IRC and investigator assessment, respectively. Six-month PFS rate per IRC and investigator assessment in the prior-sorafenib cohort was 59.8% and 49.5%, respectively, and in the sorafenib-naïve cohort was 16.7% and 35.7%, respectively. Disease control rate by both IRC and investigator assessment was 85.0% in the prior-sorafenib cohort and 64.3% in the sorafenib-naïve cohort. Median overall survival (Kaplan-Meier estimate) was 19.3 and 9.9 months in the prior-sorafenib and sorafenib-naïve cohort, respectively. Mean ALBI score remained relatively constant in patients able to continue treatment. The most frequent adverse events were palmar-plantar erythrodysesthesia syndrome, diarrhea, hypertension, and decreased appetite. No new safety concerns were identified.

CONCLUSIONS

Cabozantinib showed efficacy and a manageable safety profile in Japanese patients with advanced HCC.

Prognostic significance of sarcopenia as determined by bioelectrical impedance analysis in patients with advanced pancreatic cancer receiving gemcitabine plus nab‑paclitaxel: A retrospective study

Sarcopenia often affects patients with various types of cancer, and has been reported to affect patient prognosis and therapeutic effects. However, to the best of our knowledge, there are no reports on the relationship between gemcitabine plus nab-paclitaxel combination therapy (GnP) and sarcopenia in patients with unresectable pancreatic cancer. The present study analyzed the relationship between overall survival (OS), progression-free survival (PFS), response rate, disease control rate, adverse events (AEs) and sarcopenia in patients with pancreatic cancer treated with GnP. A total of 121 consecutive patients with advanced pancreatic cancer who received GnP as first-line chemotherapy between January 2015 and December 2017 were retrospectively analyzed. GnP consisted of 1,000 mg/m² gemcitabine and 125 mg/m² nab-paclitaxel, which were administered on days 1, 8 and 15 every 4 weeks. The skeletal muscle index (SMI) was calculated using bioimpedance analysis (BIA) as an index of sarcopenia prior to GnP. The patients were divided into sarcopenia (n=41) and non-sarcopenia (n=80) groups using cutoff values of 8.87 and 6.42 kg/m² for male and female patients, respectively. The sarcopenia and non-sarcopenia groups had a median OS of 8.1 and 13.9 months, respectively [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.53-1.20], and a median PFS of 4.3 and 6.3 months, respectively (HR 0.63; 95% CI 0.42-0.95). The response and disease controls rate were not statistically different between the groups (20 vs. 32%, P=0.20; 81 vs. 80%, P=1.0). In addition, comparison of common grade 3 and 4 AEs between the two groups revealed no statistically significant differences. In conclusion, the results of the present study indicated that SMI obtained by BIA may be a predictor of treatment response and prognosis in patients with advanced pancreatic cancer who undergo GnP.

Nal-IRI/5-FU/LV versus modified FOLFIRINOX and FOLFIRI as second-line chemotherapy for unresectable pancreatic cancer: A single center retrospective study

BACKGROUND

The preferred regimen for unresectable pancreatic cancer following gemcitabine-based chemotherapy is not well-established. This study compared the efficacy of (ⅰ) liposomal irinotecan (nal-IRI) plus 5-fluorouracil (5-FU)/leucovorin (LV) (nal-IRI/5-FU/LV) versus modified FOLFIRINOX (mFFX) and (ⅱ) nal-IRI/5-FU/LV versus FOLFIRI, respectively, and the safety of the three regimens each other, as second-line chemotherapies for unresectable pancreatic cancer.

METHODS

This was a retrospective single-center analysis of all patients who were administered nal-IRI/5-FU/LV, mFFX, or FOLFIRI from December 2014 to July 2021 as second-line chemotherapy for pancreatic cancer. The primary endpoint was the overall survival (OS) of all patients, excluding those with locally advanced pancreatic cancer. Regarding safety, we assessed the incidence of grade ≥3 adverse events of interest in all patients.

RESULTS

A total of 137 patients (nal-IRI/5-FU/LV, n = 55; mFFX, n = 39; FOLFIRI, n = 43) were included. The median OS in the nal-IRI/5-FU/LV group, the mFFX group, and the FOLFIRI group was 7.4, 11.8, and 8.4 months, respectively. Compared with the nal-IRI/5-FU/LV group, the mFFX and FOLFIRI groups displayed a hazard ratio of 0.66 [95% confidence interval 0.40-1.08] and 0.87 [95% confidence interval 0.55-1.39], respectively. In the FOLFIRI group, the incidence of grade ≥3 treatment-related adverse events tended to be low among all three groups.

CONCLUSIONS

Given the trend toward longer OS in the mFFX group and the lower incidence of adverse events in the FOLFIRI group, both mFFX and FOLFIRI, as well as nal-IRI/5-FU/LV, can be treatment options for second-line chemotherapy for unresectable pancreatic cancer.

A case of pancreatic mucinous cystadenocarcinoma with malignant ascites without recurrence for more than 8 years after surgery

Mucinous cystadenocarcinoma (MCAC) with malignant ascites is rare. We report a case of a 28-year-old woman who presented with epigastric pain. The ascites in the Douglas fossa was identified at a nearby gynecology clinic. Computed tomography showed a multiloculated cystic lesion (9.5 × 6.4 cm) in the tail of the pancreas, which was diagnosed as mucinous cystic neoplasm on imaging. Staging laparoscopy was performed, and rapid cytology of ascites revealed adenocarcinoma, leading to a diagnosis of unresectable MCAC. Subsequently, combination chemotherapy with gemcitabine plus S-1 was initiated. Although there were no remarkable changes in the imaging findings, the peritoneal dissemination node was not consistently recognized in any of the imaging findings, and distal pancreatectomy was performed. A peritoneal dissemination node was not observed in the laparotomy findings, but the peritoneal lavage cytology was positive. The postoperative pathological result was non-invasive MCAC, and the ascites was suspected to be caused by cyst rupture. The patient has been recurrence-free, including the reappearance of ascites, for > 8 years after adjuvant therapy with S-1. Although careful follow-up will be required in the future, the very good prognosis in this case suggests that MCAC with malignant ascites without obvious peritoneal dissemination should be considered for surgical resection.

Impact of psoas muscle index assessed by a simple measurement method on tolerability and duration of continued treatment with sorafenib in hepatocellular carcinoma patients

BACKGROUND

In this study, we investigated the impact of simple measurement of psoas muscle index (PMI) on the tolerability of sorafenib treatment of switch from sorafenib to regorafenib.

METHOD

This retrospective study enrolled 109 patients with Child-Pugh A hepatocellular carcinoma (HCC) treated with sorafenib. Pretreatment PMI was calculated by measuring and multiplying the greatest anterior/posterior and transverse diameters of the psoas muscles on axial computed tomography images at the L3 vertebral level, and normalizing the sum of bilateral psoas muscle areas by the square of the height in meters. We, then, statistically analyzed the association between PMI and adverse events (AEs) to treatment, tolerability of sorafenib, time to treatment failure (TTF), and prognosis in patients stratified according to PMI.

RESULT

Patients were divided into high PMI (n = 41) and low PMI (n = 68) groups based on the cutoff PMI values (men: 7.04 cm2/m2; women: 4.40 cm2/m2) determined by receiver operating characteristic curve analysis to determine sorafenib tolerability. Frequencies of all types of severe AEs were higher in the low PMI group (50.0%) than in the high PMI group (29.3%; P = 0.045). The high PMI group (51.2%) had greater tolerance to sorafenib than the low PMI group (25.0%; P = 0.007). Moreover, in multivariable analysis, PMI was associated with sorafenib tolerability (odds ratio 0.26; P = 0.008) and was a prognostic factor affecting TTF (hazard ratio 1.77; P = 0.021).

CONCLUSION

PMI might be a predictive marker of tolerance to treatment and TTF in HCC patients receiving sorafenib treatment.

AB0401 THE BASELINE SERUM SOLUBLE TNF RECEPTOR LEVELS ARE ASSOCIATED WITH THE RESPONSE OF RHEUMATOID ARTHRITIS PATIENTS TO JAKinibs

Background

Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the multiple joints.

The elucidation of the pathogenesis of RA has progressed dramatically in recent decades, and among the many cytokines involved in the pathogenesis of RA, interleukin (IL)-6 and TNF-α are known to be the major pro-inflammatory cytokines that are abundant in the bloodstream and synovial tissue. JAK inhibitors (JAKinibs) such as tofacitinib and baricitinib are used in the treatment of RA by inhibiting JAK, which in turn inhibits the signaling of various cytokines including IL-6. However, predictors of the response to JAKinibs are still required.

Objectives

We aimed to combine soluble TNF receptor (sTNFR) I, sTNFR II, IL-6, soluble IL-6R (sIL-6R) and soluble gp130 (sgp130) levels to identify groups of JAKinibs responses in RA patients.

Methods

This research is a retrospective study. We reviewed medical records of RA patients initiating JAKinibs between July 2013 and July 2021 in our hospital. The Simplified Disease Activity Index (SDAI) was evaluated at baseline and 3, 6 months after JAKinibs administration. Clinical remission was defined when SDAI decreased ≤ 3.3. Of the 125 patients treated with JAKinibs, 89 patients with 6 months follow-up, valid SDAI and serum available were enrolled. Serum samples were tested for IL-6 (Human IL-6 Quantikine ELISA Kit, R&D systems), sIL-6R (Human soluble IL-6R alpha Quantikine ELISA Kit, R&D systems) and sgp130 (Human soluble gp130 Quantikine ELISA Kit, R&D systems), sTNFR I (Human TNF RI/TNFRSF1A Quantikine ELISA Kit DRT100) and sTNFR II (Human sTNF RII/TNFRSF1B Quantikine ELISA Kit DRT200) using specific ELISAs according to the manufacturer’s instructions. The statistical analyses were performed with EZR 1.55, and p values less than 0.05 were considered significant.

Results

The median age of patients was 62 (IQR: 51 - 72) years and the median of disease duration was 6.0 (2.0 - 16.0) years. Twenty-seven (30.3%) patients were biologics and Jakinibs naive. The baseline SDAI was median 18.9 (12.7 - 27.9). When comparing SDAI-remission group (clinical remission: CR) and non-remission group, there were no significant differences in any of the baseline clinical parameters. There was no significant difference in the serum levels of IL-6, sIL-6R and sgp130 between the CR and non-CR groups, but the serum levels of sTNFR I and sTNFR II in the CR group were significantly lower than non-CR group. Univariate logistic regression analysis suggested Biologics and JAKinibs naive (odds ratio (OR) 3.58, p = 0.015), baseline Log sTNFR II levels (OR 0.013, P=0.034) as predictors of SDAI remission treated with JAKinibs at 6 months. Although not significant, Stage IV (OR 0.211, P=0.082) and baseline Log sTNFR I serum levels (OR 0.013, P=0.065) were associated with clinical remission.

Conclusion

RA patients could be easily stratified prior to JAKinibs intervention with serum sTNFR II and sTNFR I levels, not but IL-6 axis cytokines (IL-6, sIL-6R and sgp130).

Univariate logistic regression analysis for clinical remission in patients treated with JAKinibs.　Odds Ratio[95% C.I.]P ValueAge, year0.973[0.942 - 1.010]0.104Female (%)0.820[0.231 - 2.910]0.759BMI0.968[0.847 - 1.110]0.627Duration, year0.952[0.897 - 1.010]0.110StageIreferrenceII0.857[0.218 - 3.370]0.825III0.444[0.072 - 2.740]0.382IV0.211[0.036 - 1.220]0.082Biologic/JAKi naïve3.580[1.280 - 9.950]0.015JAKi Drug-Baricitinibreferrence-Tofacitinib1.780[0.659 - 4.800]0.256MTX use1.640[0.532 - 5.30]0.390PSL use0.476[0.176 - 1.290]0.143SASP use0.783[0.268 - 2.290]0.654IGU use0.328[0.039 - 2.750]0.304BUC use0.436[0.051 - 3.760]0.450TAC use0.233[0.029 - 1.910]0.1750W IL-6, pg/mL0.991[0.977 - 1.000]0.1980W sIL-6R, ng/mL0.983[0.947 - 1.02]0.3690W sgp130, ng/mL0.998[0.994 - 1.000]0.4440W sTNFR II/I ratio0.808[0.222 - 2.940]0.7460W Log sTNFR II, pg/mL0.002[0.0000653 - 0.634]0.0340W Log sTNFR I, pg/mL0.013[0.000126 - 1.300]0.065

Disclosure of Interests

None declared

Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma

INTRODUCTION

Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection.

METHODS

A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition.

RESULTS

A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy.

CONCLUSIONS

POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.

AB0362 NEUTROPHIL COUNT REDUCTION 1 MONTH AFTER INITIATING SARILUMAB AND BASELINE SERUM SOLUBLE gp130 LEVELS CAN INDEPENDENTLY PREDICT CLINICAL REMISSION WITHIN 3 MONTH IN RHEUMATOID ARTHRITIS PATIENTS

Background

IL-6 contributes significantly to the chronic inflammatory process of rheumatoid arthritis (RA) and is elevated in serum and synovial fluid of RA patients.

Sarilumab (SRL), a human anti-human IL-6 receptor alpha monoclonal antibody that blocks the signaling originated by the IL-6/IL-6R complex like tocilizumab (TCZ),is an effective treatment. Recently, an association between the therapeutic effect of TCZ and neutropenia after TCZ initiation was reported[1]. Neutropenia is a common adverse event of SRL in patients with RA, but the relationship between reduced neutrophil count and clinical response to SRL is still inconclusive. In EULAR 2020, we reported the association between serum soluble gp130 levels before SRL treatment and the efficacy of SRL[2]. It is also unclear whether there is a relationship between IL-6 axis cytokines and SRL-induced neutropenia.

Objectives

The purpose of this study was to determine whether neutropenia at 1 month by SRL predicts clinical remission within 3 months and whether there is an association between IL-6 axis cytokines levels and SRL-induced neutropenia.

Methods

This research is a retrospective study. We reviewed medical records of RA patients initiating SRL between February 2018 and August 2021 in our hospital. The Clinical Disease Activity Index (CDAI) was evaluated at baseline (before initiating SRL) and 3 months after administration. Clinical remission was defined when CDAI decreased ≤ 2.8. Of the 66 patients treated with SRL, 42 patients with 3 months follow-up, valid CDAI and serum available were enrolled. The ratio of neutrophil counts 1 month after initiating SRL to those at baseline (neutrophil ratio) was also calculated. Serum samples were tested for IL-6 (Human IL-6 Quantikine ELISA Kit, R&D systems), sIL-6R (Human soluble IL-6R alpha Quantikine ELISA Kit, R&D systems) and sgp130 (Human soluble gp130 Quantikine ELISA Kit, R&D systems) using specific ELISAs according to the manufacturer’s instructions. The statistical analyses were performed with EZR 1.55, and p values less than 0.05 were considered significant.

Results

The median age of patients was 69.0 (IQR: 59.3 - 73.8) years and the median of disease duration was 9.0 (3.0 - 16.0) years. Eighteen (42.9%) patients were biologics and Jakinibs naive. The baseline CDAI was median 16.7 (11.5 - 25.8). When comparing CDAI-remission group (clinical remission: CR) and non-CR group, Patients in the CR group had significantly shorter disease duration, were more Biologic and JAKinib naive, and had greater neutropenia 1 month after starting SRL (0.71 vs 0.94, P=0.0252). There was no significant difference in the baseline serum levels of IL-6, sIL-6R between the CR and non-CR groups, but baseline serum sgp130 levels in the CR group tended to be higher than in the non-CR group (264.9 vs 234.2 ng/mL, P=0.0592). Univariate logistic regression analysis suggested Biologics and JAKinibs naive (odds ratio (OR) 6.68, p = 0.0317), baseline serum sgp130 levels (OR 8.608, P=0.0312) as predictors of CDAI remission treated with SRL at 3 months. Although not significant, neutrophil ratio ≤ 0.8 was associated with achieving remission (OR 6.67, P=0.0537). Univariate logistic regression for neutrophil ratio ≤ 0.8 did not show any relevant factors, including higher baseline serum sgp130 levels (OR 1.25, P=0.782).

Conclusion

A 20% or greater decrease in neutrophil count after 1 month of SRL treatment and a high baseline serum sgp130 level independently predict clinical remission within 3 months.

References

[1]Nakajima T, Watanabe R, Hashimoto M, Murata K, Murakami K, Tanaka M, et al. Neutrophil count reduction 1 month after initiating tocilizumab can predict clinical remission within 1 year in rheumatoid arthritis patients. Rheumatol Int. 2021;1rin

[2]Yoshikawa T, Furukawa T, Tamura M, Hashimoto T, Morimoto M, Azuma N, et al. FRI0113 THE BASELINE SOLUBLE GP130 IS ASSOCIATED WITH THE RESPONSE OF RHEUMATOID ARTHRITIS PATIENTS TO SARILUMAB. Ann Rheum Dis. 2020;79(Suppl 1):637.1-637.

Disclosure of Interests

None declared

A prospective observational cohort study of lenvatinib as initial treatment in patients with BCLC-defined stage B hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) is the standard treatment for intermediate stage hepatocellular carcinoma (HCC) (Barcelona Clinic Liver Cancer [BCLC] B). However, it often leads to a poor prognosis and decreased hepatic function especially in patients with BCLC substage B2. Lenvatinib (LEN) was demonstrated to be efficacious in these patients in the REFLECT phase 3 trial. We therefore aimed to evaluate the efficacy and safety of LEN as a first-line treatment for the patients with HCC at BCLC substage B2.

Methods

This prospective observational study used LEN in TACE-naïve patients with HCC at BCLC substage B2 and preserved hepatic function. The primary endpoint was overall survival. A one-year survival rate threshold of 60% and an expected survival rate of 78%, based on previous reports of TACE, was assumed for setting the sample size. With a one-sided α-type error of 5% and 70% detection power, 25 patients were required over a 2-year enrollment period and 10-month follow-up period.

Results

Thirty-one patients were enrolled in this study from June 2018 to June 2020. The 1-year survival rate was 71.0% (90% confidence interval, 68.4–73.6%). Median overall and progression-free survival periods were 17.0 and 10.4 months, and the objective response rates according to Response Evaluation Criteria in Solid Tumor (RECIST) version 1.1 and modified RECIST criteria were 22.6% and 70.0%, respectively. Common adverse events (AEs) were fatigue (68%), hypertension (65%), anorexia (61%), palmar-plantar erythrodysesthesia (39%), and thrombocytopenia (32%) of any grade; aspartate aminotransferase increased (23%), alanine aminotransferase increased (16%), and grade ≥ 3 proteinuria (13%). Treatment interruption and dose reduction were required in 61% and 81% of patients, respectively. LEN was discontinued in 29 patients due to disease progression (n = 17), AEs (n = 9), conversion to curative treatments (n = 2), and sudden death (n = 1), whereas post-LEN treatments were administered in 18 patients, including systemic chemotherapy (n = 11), TACE (n = 6), transarterial infusion (n = 1) and clinical trial (n = 1).

Conclusions

The results suggest that LEN provides treatment benefits as an initial therapeutic in patients with BCLC substage B2 HCC with a safety profile comparable to that previously reported.

Identification of CT Values That Could Be Predictive of Necrosis (N-CTav) in Hepatocellular Carcinoma after Lenvatinib Treatment

Purpose: To assess the utility of measurement of the computed tomography (CT) attenuation value (CTav) in predicting tumor necrosis in hepatocellular carcinoma (HCC) patients who achieve a complete response (CR), defined using modified Response Evaluation Criteria in Solid Tumors (mRECIST), after lenvatinib treatment. Method: We compared CTav in arterial phase CT images with postoperative histopathology in four patients who underwent HCC resection after lenvatinib treatment, to determine CTav thresholds indicative of histological necrosis (N-CTav). Next, we confirmed the accuracy of the determined N-CTav in 15 cases with histopathologically proven necrosis in surgical specimens. Furthermore, the percentage of the tumor with N-CTav, i.e., the N-CTav occupancy rate, assessed using Image J software in 30 tumors in 12 patients with CR out of 571 HCC patients treated with lenvatinib, and its correlation with local recurrence following CR were examined. Results: Receiver operating characteristic (ROC) curve analysis revealed an optimal cut-off value of CTav of 30.2 HU, with 90.0% specificity and 65.0% sensitivity in discriminating between pathologically identified necrosis and degeneration, with a CTav of less than 30.2 HU indicating necrosis after lenvatinib treatment (N30-CTav). Furthermore, the optimal cut-off value of 30.6% for the N30-CTav occupancy rate by ROC analysis was a significant indicator of local recurrence following CR with 76.9% specificity and sensitivity (area under the ROC curve; 0.939), with the CR group with high N30-CTav occupancy (≥30.6%) after lenvatinib treatment showing significantly lower local recurrence (8.3% at 1 year) compared with the low (<30.6%) N30-CTav group (p < 0.001, 61.5% at 1 year). Conclusion: The cut-off value of 30.2 HU for CTav (N30-CTav) might be appropriate for identifying post-lenvatinib necrosis in HCC, and an N30-CTav occupancy rate of >30.6% might be a predictor of maintenance of CR. Use of these indicators have the potential to impact systemic chemotherapy for HCC.

Safety and efficacy of atezolizumab plus bevacizumab in patients with unresectable hepatocellular carcinoma in early clinical practice: A multicenter analysis

PURPOSE

To assess the impact of clinical factors on the safety and efficacy of atezolizumab plus bevacizumab (ATZ + BV) treatment in patients with unresectable hepatocellular carcinoma (u-HCC).

METHOD

Ninety-four u-HCC patients who were treated with ATZ + BV at multiple centers were enrolled. We defined Child-Pugh (CP)-A patients who received ATZ + BV treatment as a first line therapy as the 'meets the broad sense of the IMbrave150 criteria' group (B-IMbrave150-in, n = 46), and patients who received ATZ + BV treatment as a later line therapy or CP-B patients (regardless of whether ATZ + BV was a first line or later line therapy) as the B-IMbrave150-out group (n = 48). Patients were retrospectively analyzed for adverse events (AEs) and treatment outcomes according to their clinical characteristics, including neutrophil lymphocyte ratio (NLR) at baseline.

RESULTS

The overall incidence of AEs was 87.2% (82/94 patients). The frequency of interruption of ATZ + BV treatment due to fatigue was higher in CP-B than CP-A patients (p = 0.030). Objective response (OR) rates of the B-IMbrave150-in group (28.3%, 39.1%) were significantly higher than those of the B-IMbrave150-out group (8.3%, 18.8%; p = 0.0157, 0.0401) using Response Evaluation Criteria in Solid Tumors (RECIST) and modified RECIST, respectively. In multivariate analysis, NLR (hazard ratio (HR), 4.591; p = 0.0160) and B-IMbrave150 criteria (HR, 4.108; p = 0.0261) were independent factors associated with the OR of ATZ + BV treatment using RECIST.

CONCLUSION

In real-world practice, ATZ + BV treatment might offer significant benefits in patients who meet B-IMbrave150 criteria or have low NLR.

A prospective observational study of lenvatinib as an initial treatment for patients with intermediate-stage hepatocellular carcinoma

412

Background: The standard treatment for intermediate stage hepatocellular carcinoma (HCC) has been transarterial chemoembolization (TACE); however, it might not be suitable for patients (pts) beyond the up-to-7 criteria because of its insufficient efficacy and decline of liver function. Conversely, lenvatinib has shown a good response rate in the phase III trial REFLECT and was considered promising as an initial treatment for patients with BCLC stage B2 HCC. Methods: We conducted a multicenter prospective observational study to evaluate the efficacy of lenvatinib as an initial treatment for pts aged 20 years or older, diagnosed with BCLC stage B2 HCC, naive to TACE, and with preserved organ function. The primary endpoint was a 1-year survival rate, with a threshold of 60% and an expected survival rate of 78% based on previous reports of TACE. With a one-sided alpha error of 5% and a power of 70%, 25 pts were recruited over an enrollment period of 2 years and a follow-up period of 10 months. Results: Enrollment began in June 2018 and was closed with 31 eligible pts enrolled by June 2020. Data cut-off was done in April 2021. Patient characteristics are as follows: the median age was 77 years (range: 57–86); 94% of the pts were male; the etiology of chronic liver disease was hepatitis B virus, hepatitis C virus, alcohol abuse, and others in 3, 6, 9, and 10 pts, respectively; 20 and 11 pts had a Child-Pugh score of 5 and 6 points, respectively; the median maximum tumor diameter was 36 mm (range: 10–135); the number of pts with a tumor number of ≥10 was 8; and the median AFP level was 52.1 ng/mL (range: 2.4–49800). The 1-year survival rate was 71.0% (90% confidence interval [CI]: 68.4–73.6) and the primary endpoint was met. The median overall and progression-free survival was 17.0 months (95% CI, 15.3–19.2) and 10.4 months (95% CI, 6.6–13.8), respectively; the 2-year survival rate was 32.3%. The objective response rate according to RECIT1.1 and mRECIST was 22.6% and 70.0%, respectively. The common adverse events (AEs) were fatigue (68%), hypertension (65%), and anorexia (61%) in any grade, AST increased (23%), ALT increased (16%), and proteinuria (13%) in grade 3 or worse. Treatment interruption and dose reduction was required in 61% and 81% of the pts, respectively. The median relative dose intensity was 61.8% (range: 7.5–100). At the time of analysis, out of 24 pts, 17 (55%), nine (29%), and two (6%) discontinued lenvatinib due to disease progression, AEs, and conversion to curative treatments, respectively. One patient who showed partial response suddenly died during treatment due to unknown reasons. Systemic chemotherapy, TACE, and transarterial infusion therapy was administered in 11 (38%), six (21%) and one (3%) as a post study treatment, respectively. Conclusions: Our study indicates that initial treatment using lenvatinib prolongs the survival of pts with BCLC stage B2 HCC.

Sarcopenia: Prognostic Value for Unresectable Pancreatic Ductal Adenocarcinoma Patients Treated With Gemcitabine Plus Nab-Paclitaxel

OBJECTIVE

The aim of the study was to clarify the association of skeletal muscle mass and the prognosis of unresectable pancreatic ductal adenocarcinoma (PDAC) treated with gemcitabine plus nab-paclitaxel (GnP).

METHODS

We included 124 unresectable PDAC patients who received GnP chemotherapy. Skeletal muscle mass of the third lumbar vertebrae (L3) level was measured by computed tomography immediately before GnP initiation, and the skeletal muscle index (L3-SMI) was calculated. Sarcopenia was defined as L3-SMI less than 42 cm2/m2 in male patients and less than 38 cm2/m2 in female patients.

RESULTS

Sarcopenia was found in 63 patients (50.8%). There was no significant difference in overall survival (OS) between sarcopenia and nonsarcopenia patients; however, in elderly patients (>70 years), the OS of sarcopenia patients was significantly poorer than that of nonsarcopenia patients (390 vs 631 days, respectively; hazard ratio, 2.64; 95% confidence interval, 1.33-5.23). Multivariate analyses in elderly patients revealed that sarcopenia and tumor stage were independent poor prognostic factors. Despite the short OS of elderly sarcopenia patients, there were no significant differences in progression-free survival or response rate.

CONCLUSIONS

Sarcopenia diagnosed by L3-SMI is a prognostic factor in elderly patients who receive GnP for unresectable PDAC. However, GnP exhibits a certain efficacy in sarcopenia and nonsarcopenia patients.

Modified FOLFIRINOX versus sequential chemotherapy (FOLFIRI/FOLFOX) as a second-line treatment regimen for unresectable pancreatic cancer: A real-world analysis

BACKGROUND

Although second-line treatment for pancreatic cancer has been proven to have survival benefit, it is not clear which is the most preferred regimen. This study compared the efficacy and safety of modified FOLFIRINOX (mFOLFIRINOX) and sequential chemotherapy (FOLFIRI/FOLFOX) as a second-line treatment regimen for unresectable pancreatic cancer.

METHOD

This was a retrospective single-center analysis of all patients who initiated treatment with mFOLFIRINOX or sequential chemotherapy from December 2014 to May 2019 as a second-line treatment for unresectable pancreatic cancer. The sequential chemotherapy group included all patients who initiated sequential chemotherapy. For efficacy analysis, the primary endpoint was overall survival (OS) of all patients, excluding those with locally advanced pancreatic cancer. For safety analysis, we assessed the incidence of grade ≥3 adverse events in all patients.

RESULTS

Seventy-four patients (mFOLFIRINOX group, n = 44; sequential chemotherapy group, n = 30) were included. OS tended to be slightly prolonged in the mFOLFIRINOX group than in the sequential chemotherapy group (median 10.6 [95% confidence interval {CI} 5.9-13.8] vs. 8.5 [95% CI 5.0-12.2] months; hazard ratio 1.40 [95% CI 0.71-2.71]). The objective response rate and disease control rate were 8.1% and 64.9%, respectively, in the mFOLFIRINOX group and 3.8% and 42.3%, respectively, in the sequential chemotherapy group. In safety analysis, the grade ≥3 rates of neutropenia, febrile neutropenia, and anorexia were 40.9%, 6.8%, and 18.2%, respectively, in the mFOLFIRINOX group and 3.3%, 0%, and 3.3%, respectively, in the sequential chemotherapy group.

CONCLUSIONS

Whereas efficacy tended to be slightly better in the mFOLFIRINOX group than in the sequential chemotherapy group, given the higher incidence of grade ≥3 adverse events with mFOLFIRINOX than with sequential chemotherapy, sequential chemotherapy is a regimen with better risk-benefit balance than mFOLFIRINOX, and can be considered a second-line treatment option for patients with unresectable pancreatic cancer.

Comparative study between sorafenib and lenvatinib as the first-line therapy in the sequential treatment of unresectable hepatocellular carcinoma in a real-world setting

Aims

There is a paucity of comparative data on the use of sorafenib and lenvatinib for unresectable hepatocellular carcinoma. We assessed the real‐world treatment outcomes between using sorafenib and lenvatinib for unresectable hepatocellular carcinoma in the multiple molecular‐targeted therapy era.

Methods and Results

We enrolled 386 patients treated with sorafenib or lenvatinib as the first‐line therapy for unresectable hepatocellular carcinoma at multiple centers. Propensity score matching was performed to adjust for differences in baseline and tumor characteristics between the two groups. Propensity score matching identified 110 patients in each treatment group. The median overall survival was similar between lenvatinib and sorafenib (14.8 and 13.0 months, respectively; P = 0.352). The median progression‐free survival was longer with lenvatinib than with sorafenib (7.6 and 3.9 months, respectively; P < 0.001). The overall response rate (P < 0.001) and disease control rate (P = 0.015), as defined by the modified Response Evaluation Criteria in Solid Tumors, were significantly better with lenvatinib than with sorafenib. The median overall survival was longer in patients who received subsequent treatment than in those who did not in the sorafenib group (23.1 and 5.7 months, respectively; P < 0.001), whereas the median overall survival with or without subsequent treatment did not differ significantly in the lenvatinib group (17.8 and 14.7 months, respectively; P = 0.439).

Conclusion

Overall survival with sorafenib and lenvatinib was not significantly different. However, patients who received subsequent treatments had longer overall survival than those who received only first‐line treatment with sorafenib, whereas lenvatinib did not show this effect.

The age-adjusted Charlson comorbidity index is an independent prognostic factor in pancreatic cancer patients who receive curative resection followed by adjuvant chemotherapy

Background

We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on the pancreatic cancer survival and recurrence after curative surgery followed by adjuvant chemotherapy.

Patients and Methods

This study included 155 patients who underwent curative surgery followed by adjuvant chemotherapy for pancreatic cancer between 2005 and 2014. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified.

Results

An ACCI of 8 was regarded as the optimum critical point of classification considering the 1-, 3- and 5-year survival rates. The OS rates at 3 and 5 years after surgery were 25.7% and 19.0% in the ACCI-low group, respectively, and 7.6% and 0% in the ACCI-high group, which amounted to a statistically significant difference (P = 0.019). The RFS rates at 3 and 5 years after surgery were 17.3% and 13.8% in the ACCI-low group, respectively, and 7.1% and 0% in the ACCI-high group, which amounted to a marginally statistically significant difference (P = 0.104). A multivariate analysis showed that the ACCI was a significant independent risk factor for both the OS and RFS.

Conclusions

The ACCI was a risk factor for the OS in patients who underwent curative surgery followed by adjuvant chemotherapy for pancreatic cancer. An effective plan is needed for determining the optimum surgical strategy according to the ACCI.

Therapeutic results of Denver percutaneous peritoneovenous shunt in cancer patients with malignant ascites

Background

Intractable ascites secondary to malignant disease deteriorates patients' quality of life. The purpose of this study was to evaluate the safety and efficacy of percutaneous peritoneovenous (Denver) shunt in treating intractable malignant ascites in cancer patients.

Materials and Methods

Thirty-five patients who had undergone Denver peritoneovenous shunt for the treatment of ascites associated with malignant tumor from October 2014 to 2017 were retrospectively analyzed. The demographic characteristics, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analyses were performed.

Results

The sites of primary tumor were pancreatic cancer in 19 patients, bile duct cancer in 8, gallbladder cancer in 5, breast cancer in 2, and peritoneal malignant mesothelioma in 1. Palliation of abdominal distention was achieved in 29 patients (82.9%). Postoperative complications of Grade 2 or higher were seen in 11 patients (31.4%), and Grade 5 complications were observed in three patients (8.6%). Patients with a high American Society of Anesthesiologists (ASA) grade and high ascites drainage volume had a significantly higher incidence of postoperative complications than a low ASA grade and low ascites drainage volume, and a multivariate logistic analysis showed that the intraoperative ascites drainage volume was an independent risk factor for all complications.

Conclusions

The Denver shunt for malignant ascites is useful for improving patients' quality of life if the indications are selected properly. Drainage of intraoperative ascites was a risk factor for postoperative complications after the Denver shunt technique in cancer patients with malignant ascites. Further experience and discussion are necessary to establish the patient selection criteria.

Ramucirumab for Patients with Intermediate-Stage Hepatocellular Carcinoma and Elevated Alpha-Fetoprotein: Pooled Results from Two Phase 3 Studies (REACH and REACH-2)

BACKGROUND

Intermediate-stage hepatocellular carcinoma (HCC), as defined by Barcelona Clinic Liver Cancer (BCLC) stage B, is heterogeneous in terms of liver function and tumor burden. REACH and REACH-2 investigated ramucirumab in patients with HCC after prior sorafenib, with REACH-2 enrolling only patients with baseline α-fetoprotein (AFP) ≥400 ng/mL. An exploratory analysis of outcomes by BCLC stage was performed.

METHODS

A pooled meta-analysis of independent patient data (stratified by study) from REACH (AFP ≥ 400 ng/mL) and REACH-2 was performed. All patients had Child-Pugh A, Eastern Cooperative Oncology Group performance status 0-1, prior sorafenib treatment, and either HCC BCLC stage B (refractory/not amenable to locoregional therapy) or BCLC stage C. Patients were randomized to ramucirumab 8 mg/kg or placebo every 2 weeks. Median overall survival (OS) and progression-free survival were estimated by the Kaplan-Meier method. Treatment effects in BCLC stage B and C were evaluated by Cox proportional-hazards model; prognosis of BCLC staging for OS was evaluated by multivariate Cox proportional-hazards model. Tumor responses were evaluated according to Response Evaluation in Solid Tumors v1.1. Liver function was assessed with albumin-bilirubin score.

RESULTS

Baseline characteristics were generally balanced between treatment arms in each BCLC stage. BCLC staging trended as an independent prognostic factor for OS (B vs. C; hazard ratio [HR] 0.756 [95% CI 0.546-1.046]). Consistent treatment benefit was observed for ramucirumab versus placebo across BCLC stages. Median OS for ramucirumab versus placebo was 13.7 versus 8.2 months; HR (95%): 0.43 (0.23-0.83) and 7.7 versus 4.8 months; HR (95%): 0.72 (0.59-0.89) for BCLC stage B and C, respectively. Adverse events (AEs) were consistent with observations from both studies; hypertension was the most frequent grade ≥3 AE. Liver function was preserved throughout the study and similar between treatment arms in both BCLC stages.

CONCLUSIONS

Ramucirumab provided a better survival benefit irrespective of BCLC stage and was well tolerated without compromising liver function during treatment.

Repeated Lusutrombopag Treatment for Thrombocytopenia in Patients with Chronic Liver Disease

BACKGROUND/AIMS

Lusutrombopag, a small-molecule thrombopoietin receptor agonist, is used to treat thrombocytopenia based on the results of a phase 3 trial, including data for single-use administration in patients with chronic liver disease (CLD) undergoing invasive procedures. We aimed to evaluate the efficacy and safety of repeated lusutrombopag use.

METHODS

Lusutrombopag was administered repeatedly in patients undergoing multi-cycle invasive procedures at intervals >1 month.

RESULTS

Data from 8 patients (median platelet count at baseline, 44.0 [range, 35-49] × 109/L) and 25 cycles of invasive procedures, including 2 cycles in 3 patients, 3 cycles in 4 patients, and 7 cycles in 1 patient, were retrospectively evaluated. The procedures included 18 transarterial chemoembolizations, 5 radiofrequency ablations, and 2 liver needle biopsies. Platelet counts increased significantly compared with baseline, and median changes in platelet counts were 46.0 × 109/L (p = 0.012) in cycle 1, 44.0 × 109/L (p = 0.012) in cycle 2, and 42.0 × 109/L (p = 0.008) in cycles 3-7. No severe adverse events, including portal vein thrombus or bleeding, were observed.

CONCLUSIONS

Repeated use of lusutrombopag might be safe and effective against thrombocytopenia in patients with CLD undergoing multi-cycle invasive procedures, although long-term data from more patients are required.

Tissue factor and its procoagulant activity on cancer-associated thromboembolism in pancreatic cancer

Pancreatic cancer frequently involves cancer-associated thromboembolism, which is strongly associated with poor prognosis. Tissue factor, a blood coagulation factor largely produced in cancer patients as a component of extracellular vesicles, plays a key role in the incidence of cancer-associated thromboembolism in patients with pancreatic cancer. However, no prospective studies have been published on the relationship between tissue factor and cancer-associated thromboembolism or patient clinical characteristics, including recent chemotherapy regimens. Thus, we aimed to address this in a Japanese cohort of 197 patients and 41 healthy volunteers. Plasma tissue factor levels were measured by ELISAs preevaluated by tissue factor specificity. Multivariable analysis was used to identify independent predictors of cancer-associated thromboembolism. We found that the cancer-associated thromboembolism rate in the patient cohort was 6.6% (4.6%, venous thromboembolism; 2.0%, arterial thromboembolism). Tissue factor levels of 100 pg/mL or higher at patient registration were predictive of cancer-associated thromboembolism, with positive and negative predictive values of 23.1% and 94.6%, respectively. Multivariable analysis showed that plasma tissue factor levels were an independent predictive factor for cancer-associated thromboembolism, with a risk ratio of 5.54 (95% confidence interval, 1.02-30.09). Unlike in healthy volunteers and patients without cancer-associated thromboembolism, tissue factor levels were highly correlated with extracellular vesicles' procoagulant activity in patients developing cancer-associated thromboembolism. Taken together, our data show that the tissue factor levels at patient registration were a predictive factor for cancer-associated thromboembolism in this cohort of patients with pancreatic cancer.

AB0311 INCREASED LEVELS OF SERUM WISTERIA FLORIBUNDA AGGLUTININPOSITIVE MAC-2 BINDING PROTEIN IN RHEUMATIC DISEASES INCLUDING SLE

Background:

Mac-2 binding protein is a cell-adhesive glycoprotein of the extracellular matrix secreted as a ligand of galectin-3 (Mac-2). Recently, a Wisteria floribunda agglutinin positive-M2BP (M2BP) assay developed using a lectin-antibody sandwich immunoassay has shown promise as a new fibrotic marker in liver fibrosis and interstitial lung disease (ILD) to detect unique fibrosis-related glycoalteration.

Objectives:

The aim of this study is to evaluate the utility of serum Mac-2 binding protein glycosylation isomer (M2BPGi) levels in patients with rheumatic diseases (RD).

Methods:

We retrospectively measured serum M2BPGi levels in 68 patients with RD and 16 healthy controls (HC). There were no patients of cirrhosis and active hepatitis. Serum levels of M2BPGi were measured using HISCL M2BP glycosylation isomer Assay Kit. We examined the relationship between serum M2BPGi levels and clinical parameters in patients with RD.

Results:

In patients with RD, the median age was 62.0 years and 79.4% of them were female.

Serum M2BPGi levels were significantly higher in patients with RD than in HC (median 0.98 cutoff index [COI], 0.32 COI, respectively; P < 0.00001). Patients with SLE tended to have higher serum M2BPGi levels than other rheumatic diseases.

In patients with RD, a significant correlation was not found between serum M2BP levels and inflammation markers such as CRP or ferritin. However, serum M2BPGi levels were significantly correlated with B cell activation markers such as immunoglobulin free light chain and IgG (r = 0.588, 0.504) and T cell activation marker such as sIL-2R (r = 0.408).

Conclusion:

Most of the rheumatic diseases in this study were considered to be type I interferonopathy diseases such as rheumatoid arthritis, Sjogren’s syndrome, inflammatory myositis, scleroderma and SLE.

Serum M2BPGi was reported to have a significant correlation with SLE disease activity [SS Ahn et al. Lupus. 2018; 27: 771], and also to have a significant correlation with Gakectin-9, a novel biomarker for IFN signiture [Lucas L van den Hoogen et al. Ann Rheum Dis. 2018; 77: 1810].

So, it was suggested that serum M2BPGi may be a novel biomarker that indirectly indicates how much IFN is activated in rheumatic diseases.

Disclosure of Interests:

None declared

Association between time to stent dysfunction and the anti-tumour effect of systemic chemotherapy following stent placement in patients with pancreaticobiliary cancers and malignant gastric outlet obstruction: a retrospective cohort study

Background

Malignant gastric outlet obstruction (MGOO) occasionally occurs due to pancreaticobiliary cancer. Endoscopic duodenal stenting (DS) is a common treatment for MGOO. However, it has been reported that DS does not have sufficient patency time for it to be used in patients who have a potentially increased lifespan. Nowadays, systemic chemotherapy for pancreaticobiliary cancer has developed, and its anti-tumour effect would make time to stent dysfunction longer.

Therefore, we retrospectively evaluated the association between objective response to systemic chemotherapy, followed by DS and time to stent dysfunction in patients with advanced pancreaticobiliary cancer.

Methods

This retrospective study included 109 patients with advanced pancreaticobiliary cancer who received systemic chemotherapy after DS. Patients who showed complete or partial response were defined as responders. The rest were defined as non-responders. Time to stent dysfunction was compared between responders and non-responders using the landmark analysis at 2 months after DS. Death without recurrence of MGOO was considered as a competing risk for time to stent dysfunction.

Results

Combination and monotherapy regimens were adopted for 46 and 63 patients, respectively. Median progression-free survival and overall survival were 3.2 months (95% confidence interval [CI], 2.4–4.0) and 6.0 months (95% CI, 4.6–7.3). Objective response was observed in 21 patients (19.3%). Median time to stent dysfunction was 12.5 months (95% CI, 8.4–16.5) in the entire cohort. In 89 patients, responders had a lower cumulative incidence of stent dysfunction than non-responders: 9.5 and 19.1% at 6 months, and 19.0 and 27.9% at 1-year, respectively. There was difference of time to stent dysfunction between responders and non-responders among patients who received combination regimen as the first-line treatment with p-value of 0.009: cumulative incidence was 0 and 42.9% at 6 months, and 9.3 and 57.1% at 1-year, respectively.

Conclusions

Longer time to stent dysfunction is expected when systemic chemotherapy following DS suppresses tumour progression; DS is slated to be a standard treatment for MGOO even in patients with pancreaticobiliary cancer and a long lifespan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08336-z.

Repeated transarterial chemoembolization with epirubicin-loaded superabsorbent polymer microspheres vs. conventional transarterial chemoembolization for hepatocellular carcinoma

The aim of the present study was to evaluate the long-term outcomes and the impact of repeated conventional transarterial chemoembolization (C-TACE) and transarterial chemoembolization with epirubicin-loaded superabsorbent polymer embolics (SAP-TACE) on liver function in TACE-naïve patients with unresectable hepatocellular carcinoma (HCC). Overall, 155 consecutive patients with HCC received either C-TACE or SAP-TACE. The first cohort (n=71), treated between 2011 and 2014, received C-TACE; the second cohort (n=84), treated between 2014 and 2016, received SAP-TACE. Overall survival and deterioration of liver function were compared between the two cohorts. The 1-, 2- and 3-year overall survival rates and median survival times were 74, 50, 35% and 26 months in the C-TACE cohort and 75, 60, 39% and 28 months in the SAP-TACE cohort, respectively. There were no significant differences between the two groups (P=0.289). Age <70 years, Child-Pugh class A, alpha-fetoprotein <400 ng/ml and des-gamma-carboxy prothrombin <1,000 mAU/ml were identified as favorable prognostic factors in multivariate analysis. In the subgroup of patients with a Child-Pugh score of 5, survival was 29 months for C-TACE vs. 55 months for SAP-TACE (P<0.05). In the C-TACE cohort, the median Child-Pugh score was 6 after 3 cycles and 7 after 5 cycles of TACE, and the score worsened significantly (before vs. 3 cycles, P<0.05; before vs. 5 cycles, P<0.05). In the SAP-TACE cohort, the median Child-Pugh score was 6 after 3 and 5 cycles of TACE, and the score did not worsen during the treatment cycles. There were no differences in overall survival between repeated C-TACE and SAP-TACE in TACE-naïve patients with HCC. However, liver function deterioration was more evident in patients treated with C-TACE than in those treated with SAP-TACE.

Sofosbuvir-based therapies associated with regression of liver fibrosis in patients with hepatitis C virus infection: A prospective observational study

Oral direct-acting antiviral (DAA) treatment leads to >95% sustained virological response (SVR) and could be clinically useful in regression of liver fibrosis in chronic hepatitis C virus (HCV) infection. We evaluated if ledipasvir/sofosbuvir or sofosbuvir + ribavirin is associated with regression of fibrosis in HCV patients who achieved SVR.In this prospective cohort study performed at 3 sites in Japan, patients with genotype 1 and genotype 2 were given standard treatment of ledipasvir 90 mg/sofosbuvir 400 mg and sofosbuvir 400 mg + 200-1000 mg/day ribavirin, respectively, for 12 weeks. Liver fibrosis was assessed using Mac-2-binding protein glycosylation isomer (M2BPGi) and other fibrosis markers (platelet count, Fib-4 index, liver stiffness measurement [LSM]) in patients who achieved SVR.A total of 98.1% of (n = 101/103) patients in genotype 1 cohort and 100% (n = 16/16) in the genotype 2 cohort achieved SVR12. Based on per-protocol analysis, M2BPGi levels showed a significant decrease (-2.2  cut-off index [COI], P < .0001) at week 48 after treatment initiation. Forty-three patients showed a significant decrease in Fib-4 index (-1.2, P < .0001), and 44 patients showed improvement in LSM (-5.9 kPa, P < .0001).Achievement of SVR after antiviral therapy was associated with fibrosis regression. M2BPGi correlated well with LSM at week 48 after treatment initiation, supporting the sustainable benefit of HCV therapy.

Analysis of efficacy of lenvatinib treatment in highly advanced hepatocellular carcinoma with tumor thrombus in the main trunk of the portal vein or tumor with more than 50% liver occupation: A multicenter analysis

AIMS

To assess the safety, efficacy, and prognostic impact of clinical factors associated with lenvatinib treatment in highly advanced hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein trunk (VP4) or tumor with more than 50% liver occupation (tm50%LO).

METHODS

A total of 61 highly advanced HCC patients (41 patients with tm50%LO and 20 patients with VP4) who were treated with lenvatinib at multicenter were enrolled and retrospectively analyzed for treatment outcomes according to their clinical status, including tumor morphology.

RESULTS

The most frequent grade ≥3 adverse event in tm50%LO HCC was elevated aspartate aminotransferase (17.1%). Objective response rates were 37.5% and 0% in tm50%LO HCC patients with Child-Pugh grade (CP)-A and CP-B, respectively, and 26.7% and 0% in VP4 HCC patients with CP-A and CP-B, respectively. Estimated median progression-free survival and overall survival were 132 days and 229 days, and 101 days and 201 days in patients with tm50%LO and VP4, respectively. In multivariate analysis, modified albumin-bilirubin grade (hazard ratio 0.372, 95% CI 0.157-0.887; p = 0.0241) and tumor morphology (hazard ratio 0.322, 95% CI 0.116-0.889; p = 0.0287) were independently associated with progression-free survival in patients with tm50%LO HCC. In VP4 HCC, median progression-free survival was worse in CP-B (57 days) than in CP-A patients (137 days, p = 0.0462).

CONCLUSIONS

Lenvatinib treatment offers a benefit in highly advanced HCC (tm50%LO or VP4) patients with good liver function or nodular-type tumor. The various characteristics identified in this study might be useful as indicators of lenvatinib treatment in highly advanced HCC with tm50%LO or VP4, which are considered very refractory cancers.

Phase I study of BI 754091 plus BI 754111 in Asian patients with gastric/gastroesophageal junction or esophageal cancer

212

Background: Dual blockade of immune checkpoint molecules, PD-1 and LAG-3, has been proposed to restore T-cell function and thus enhance antitumor responses. This Phase I trial evaluated BI 754091 (anti-PD-1) with BI 754111 (anti-LAG-3) antibodies in Asian pts with advanced solid tumors (NCT03433898). Here, we present results from pts with anti-PD-(L)1 inhibitor-naïve gastric/gastroesophageal junction or esophageal cancer (Cohorts A and B). Methods: In Parts 1 and 2 (dose escalation), the recommended dose for the combination was determined as BI 754091 240 mg + BI 754111 600 mg IV Q3W. In Part 3, the combination was assessed in expansion cohorts including pts with gastric/gastroesophageal junction cancer (Cohort A) and esophageal cancer (Cohort B). Eligible pts had received ≥1 line of prior systemic therapy but no prior anti-PD-(L)1 therapy. The primary endpoint in Part 3 was objective response (OR; confirmed complete response or partial response [PR]) per RECIST 1.1. Results: In Cohort A/B, 36/37 pts were treated:26/31 (72/84%) male, median age 60/63 years. Patients were enrolled in Taiwan (1/7 pts, 3/19%), Japan (12/27 pts, 33/73%) or Korea (23/3 pts, 64/8%). The median number of regimens of prior systemic therapy was 2/2 (Cohorts A/B, range: 1–6/1–4). All pts in Cohort B had squamous cell carcinoma. At the time of analysis, pts in Cohort A/B had undergone a median of 84/73 days on treatment (range: 31–346/8–325), from the start of treatment until the date of snapshot, death or discontinuation. Confirmed OR (PR) was observed in 4/7 pts in Cohorts A/B; overall response rate (ORR) was 11% and 19%. Stable disease (SD) was observed in 10/8 (28/22%) pts in Cohorts A/B and overall disease control rate was 39/41%. In Cohorts A/B, adverse events (AEs) and treatment-related AEs were experienced by 30/34 (83/92%) and 12/22 (33/59%) pts, respectively. The most commonly reported AEs were pyrexia (25/19%), decreased appetite (17/19%), increased aspartate aminotransferase (11/14%), anemia (11/11%) and nausea (6/14%). In Cohort A/B, 9/15 (25/41%) pts experienced immune-related AEs, most commonly rash in Cohort A (4 pts; 11%) and hyperthyroidism in Cohort B (4 pts; 11%). In Cohorts A/B, 2/6 (6/16%) patients experienced AEs leading to discontinuation of treatment. Conclusions: Treatment was well tolerated and preliminary antitumor activity was seen. Addition of LAG3 did not improve ORR beyond that expected for an anti-PD-1 monotherapy in gastric and esophageal cancer without patient selection. Clinical trial information: NCT03433898. [Table: see text]

Randomized Phase II Study of Gemcitabine Monotherapy vs. Gemcitabine with an EPA-Enriched Oral Supplement in Advanced Pancreatic Cancer

BACKGROUND

Pancreatic cancer is often associated with cachexia. It had been reported that eicosapentaenoic acid (EPA) improve cachexia. This study aimed to evaluate the efficacy and safety of gemcitabine with an EPA-enriched oral supplement in patients with advanced pancreatic cancer.

METHODS

This open-label phase II study consisted of patients (pts) who were randomly categorized into the EPA group (1,000 mg/m² gemcitabine was administered on day 1, 8, and 15, every 4 weeks while an EPA-enriched oral supplement (prosure®, EPA 1.056 mg per pack) was taken daily at the maximum of two packs or the gemcitabine monotherapy group with an allocation ratio of 2:1. The primary endpoint was the evaluation of the 1-year survival estimating 10% addition.

RESULTS

Randomized 68 pts were examined (EPA: 45, gemcitabine: 23). The 1-year survival probability of the EPA group was 35% while the gemcitabine group was 19%. The median survival times were 8.2 and 9.7 mo, respectively. The hazard ratio for EPA group was 0.79 [95% CI 0.46-1.37]; (P = 0.40). The toxicities were mild and insignificant in both groups. More beneficial effects of EPA in survival were observed in men, pancreatic body-tail and low C-reactive protein patients.

CONCLUSION

An EPA-enriched oral supplement may be effective in advanced pancreatic cancer.

Cabozantinib in Japanese patients with advanced hepatocellular carcinoma: a phase 2 multicenter study

BACKGROUND

To evaluate the efficacy and safety of cabozantinib in Japanese patients with advanced hepatocellular carcinoma (HCC) who had progressed following one or two lines of systemic therapy including sorafenib. An exploratory evaluation in sorafenib-naïve patients was performed.

METHODS

In this open-label, single-arm, phase 2 trial, patients received oral cabozantinib 60 mg once daily. The primary endpoint was progression-free survival (PFS) rate at Week 24. Secondary endpoints included PFS, overall survival (OS), objective response rate (ORR, best response of complete/partial response), disease control rate (DCR, objective response or stable disease) and safety.

RESULTS

Thirty-four patients received cabozantinib across 17 centers (prior sorafenib cohort, n = 20; sorafenib-naïve cohort, n = 14). PFS rate at 24 weeks was 59.8% [90% confidence interval (CI) 36.1-77.2%] in the prior sorafenib cohort, 16.7% (90% CI 4.0-36.8%) in the sorafenib-naïve cohort and 40.1% (90% CI 24.8-55.0%) overall. Median PFS was 7.4 months for the prior sorafenib cohort, 3.6 months for the sorafenib-naïve cohort, and 5.6 months overall. OS rate at 6 months was 100.0%, 78.6% and 91.1%, respectively; DCR was 85.0%, 64.3% and 76.5%, respectively. The ORR was 0.0% for both cohorts. All patients required dose modifications due to adverse events, the most common of these were palmar-plantar erythrodysesthesia syndrome and diarrhea. Three patients (8.8%) discontinued due to adverse events other than disease progression.

CONCLUSIONS

Cabozantinib 60 mg/day has a favorable benefit/risk profile for Japanese patients with advanced HCC who have previously received one or two lines of systemic anticancer therapy including sorafenib. (Clinical trial registration: NCT03586973).

Multicenter Phase II Trial of Axitinib Monotherapy for Gemcitabine-Based Chemotherapy Refractory Advanced Biliary Tract Cancer (AX-BC Study)

LESSONS LEARNED

Axitinib exhibited marginal activity against gemcitabine-refractory unselected biliary tract cancer. Pretreated soluble vascular endothelial growth factor receptor-2 may be a useful biomarker for axitinib treatment outcome. Ascites should be carefully monitored in patients receiving anti-vascular endothelial growth factor receptor therapy including axitinib in advanced biliary tract cancer.

BACKGROUND

There are no clear options for second-line treatment in patients with gemcitabine (GEM)-refractory biliary tract cancer (BTC). We conducted a multicenter, single-arm, phase II trial to confirm the efficacy and safety of axitinib, a potent selective inhibitor of vascular endothelial growth factor receptor (VEGFR)-1/2/3, in patients with GEM-refractory BTC.

METHODS

Patients refractory or intolerant to GEM-based chemotherapy were enrolled. Axitinib was administered orally at an initial dose of 5 mg twice daily. The primary endpoint was progression-free survival (PFS), and the threshold and expected values were set at 2 and 3 months, respectively. The target sample size was 32 patients.

RESULTS

Nineteen patients were enrolled. The trial was interrupted for a total of 13 months for the evaluation of adverse events. Thirteen patients were previously treated with ≥2 regimens. The median PFS was 2.8 months (95% confidence interval [CI]: 2.1-4.1). The median overall survival was 5.8 months (95% CI: 3.3-9.7). The response rate was 5.3% (95% CI: 0.0-15.3). Grade 3 ascites occurred in two patients. Baseline soluble VEGFR-2 levels were significantly associated with PFS.

CONCLUSION

Axitinib exhibited marginal activity against GEM-refractory BTC. Ascites should be carefully monitored in axitinib-treated patients with advanced BTC.

Safety and Efficacy of Lenvatinib Treatment in Child-Pugh A and B Patients with Unresectable Hepatocellular Carcinoma in Clinical Practice: A Multicenter Analysis

Purpose

To assess the safety, efficacy and prognostic impact of clinical factors related to lenvatinib treatment in Child-Pugh class A (CP-A) and class B (CP-B) patients with unresectable hepatocellular carcinoma (u-HCC).

Methods

Patients with u-HCC who were treated with lenvatinib at multiple centers in Japan were retrospectively analyzed for treatment outcomes according to their respective CP status. Radiological objective response (OR) was assessed using modified response evaluation criteria in solid tumors (mRECIST) guidelines.

Results

Baseline demographic parameters were comparable between 126 (69.6%) patients with CP-A disease and 55 patients (30.4%) with CP-B disease. Frequency of lenvatinib-related adverse events, including decreased appetite (P=0.034), diarrhea (P=0.040), elevated serum bilirubin (P=0.016) and vomiting (P=0.009), were higher in CP-B than in CP-A patients. Relative dose intensity (RDI) was significantly higher in CP-A (0.69) than CP-B patients (0.50, P <0.001). Furthermore, OR rate (44.0%) was markedly higher in CP-A5 patients as compared to CP-A6 (25.5%), CP-B7 (22.2%), and CP-B8 patients (5.3%), respectively (P=0.002). In multivariable analysis, performance status (0 vs 1, 2, P=0.026), CP class (A vs B, P=0.045) and RDI (≥0.7 vs <0.7, P=0.034) were identified as factors associated with response to lenvatinib treatment. Overall survival (OS) at 12 months was significantly different between CP-A (66.3%) and CP-B patients (30.0%, P=0.002), and between CP 5-7 (59.2%) and CP 8 patients (34.8%, P=0.003). In multivariable analysis, CP class (A vs B, P=0.007) and Barcelona clinic liver cancer (BCLC) stage (B vs C, P=0.002) were associated with OS following lenvatinib treatment.

Conclusion

Lenvatinib treatment offers significant benefits in patients with good liver function in real-world practice. The various characteristics identified in this study might be helpful as clinical predictors of response to lenvatinib and survival in clinical practice. Further studies are required to address eligibility for lenvatinib treatment in CP 7 patients.

A randomized, double-blind, placebo-controlled, phase 3 study of tivantinib in Japanese patients with MET-high hepatocellular carcinoma

A previous randomized phase 2 study of hepatocellular carcinoma revealed that the c‐Met inhibitor tivantinib as second‐line treatment significantly prolonged progression‐free survival in a subpopulation whose tumor samples highly expressed c‐Met (MET‐high). Accordingly, this phase 3 study was conducted to evaluate the efficacy of tivantinib as a second‐line treatment for Japanese patients with MET‐high hepatocellular carcinoma. This randomized, double‐blind, placebo‐controlled study was conducted at 60 centers in Japan. Hepatocellular carcinoma patients with one prior sorafenib treatment and those with MET‐high tumor samples were eligible for inclusion. Registered patients were randomly assigned to either the tivantinib or placebo group at a 2:1 ratio and were treated with twice‐a‐day oral tivantinib (120 mg bid) or placebo until the discontinuation criteria were met. The primary endpoint was progression‐free survival while the secondary endpoints included overall survival and safety. Between January 2014 and June 2016, 386 patients provided consent, and 195 patients were randomized to the tivantinib (n = 134) or placebo (n = 61) group. Median progression‐free survival was 2.8 (95% confidence interval: 2.7‐2.9) and 2.3 (1.5‐2.8) mo in the tivantinib and placebo groups, respectively (hazard ratio = 0.74, 95% confidence interval: 0.52‐1.04, P = .082). Median overall survival was 10.3 (95% confidence interval: 8.1‐11.6) and 8.5 (6.2‐11.4) mo in the tivantinib and placebo group, respectively (hazard ratio = 0.82, 95% confidence interval: 0.58‐1.15). The most common tivantinib‐related grade ≥3 adverse events were neutropenia (31.6%), leukocytopenia (24.8%), and anemia (12.0%). This study did not confirm the significant efficacy of tivantinib as a second‐line treatment for Japanese patients with MET‐high hepatocellular carcinoma. (NCT02029157).

Ramucirumab in elderly patients with hepatocellular carcinoma and elevated alpha-fetoprotein after sorafenib in REACH and REACH-2

BACKGROUND & AIMS

Limited data on treatment of elderly patients with hepatocellular carcinoma (HCC) increase the unmet need. REACH and REACH-2 were global phase III studies of ramucirumab in patients with HCC after prior sorafenib, where patients with alpha-fetoprotein (AFP) ≥400 ng/mL showed an overall ssurvival (OS) benefit for ramucirumab. These post-hoc analyses examined efficacy and safety of ramucirumab in patients with HCC and baseline AFP ≥ 400 ng/mL by three prespecified age subgroups (<65, ≥65 to <75 and ≥75 years).

METHODS

Individual patient data were pooled from REACH (baseline AFP ≥400 ng/mL) and REACH-2. Kaplan-Meier and Cox proportional hazards regression methods (stratified by study) assessed OS, progression-free survival (PFS), time to progression (TTP) and patient-reported outcomes (Functional Hepatobiliary System Index-8 [FHSI-8] score).

RESULTS

A total of 542 patients (<65 years: n = 302; ≥65 to <75 years: n = 160; ≥75 years: n = 80) showed similar baseline characteristics between ramucirumab and placebo. Older subgroups had higher hepatitis C and steatohepatitis incidences, and lower AFP levels, than the <65 years subgroup. Ramucirumab prolonged OS in patients <65 years (hazard ratio [HR], 0.753; 95% CI 0.581-0.975), ≥65 to <75 years (0.602; 0.419-0.866) and ≥75 years (0.709; 0.420-1.199), PFS and TTP irrespective of age. Ramucirumab showed similar overall safety profiles across subgroups, with a consistent median relative dose intensity ≥97.8%. A trend towards a delay in symptom deterioration in FHSI-8 with ramucirumab was observed in all subgroups.

CONCLUSIONS

In this post-hoc analysis, ramucirumab showed a survival benefit across age subgroups with a tolerable safety profile, supporting its use in advanced HCC with elevated AFP, irrespective of age, including ≥75 years.

Genome-wide association meta-analysis identifies GP2 gene risk variants for pancreatic cancer

Pancreatic cancer is the fourth leading cause of cancer-related deaths in Japan. To identify risk loci, we perform a meta-analysis of three genome-wide association studies comprising 2,039 pancreatic cancer patients and 32,592 controls in the Japanese population. Here, we identify 3 (13q12.2, 13q22.1, and 16p12.3) genome-wide significant loci (P < 5.0 × 10⁻⁸), of which 16p12.3 has not been reported in the Western population. The lead single nucleotide polymorphism (SNP) at 16p12.3 is rs78193826 (odds ratio = 1.46, 95% confidence interval = 1.29-1.66, P = 4.28 × 10⁻⁹), an Asian-specific, nonsynonymous glycoprotein 2 (GP2) gene variant. Associations between selected GP2 gene variants and pancreatic cancer are replicated in 10,822 additional cases and controls of East Asian origin. Functional analyses using cell lines provide supporting evidence of the effect of rs78193826 on KRAS activity. These findings suggest that GP2 gene variants are probably associated with pancreatic cancer susceptibility in populations of East Asian ancestry.

Previous genome-wide association studies have identified risk loci for pancreatic cancer but were centered on individuals of European ancestry. Here the authors identify GP2 gene variants associated with pancreatic cancer susceptibility in populations of East Asian ancestry.

FRI0113 THE BASELINE SOLUBLE GP130 IS ASSOCIATED WITH THE RESPONSE OF RHEUMATOID ARTHRITIS PATIENTS TO SARILUMAB

Background:

IL-6 contributes significantly to the chronic inflammatory process of rheumatoid arthritis (RA). Sarilumab (SRL), a human anti-human IL-6 receptor alpha monoclonal antibody that blocks the signaling originated by the IL-6/IL-6R complex like tocilizumab,is an effective treatment. However, predictors of the response to sarilumab are still required.

Objectives:

We aimed to combine IL-6, soluble IL-6R (sIL-6R) and gp130 (sgp130) levels to identify groups of sarilumab responses.

Methods:

This research is a retrospective study. a total of 32 RA patients with SRL therapy in our department from February 1 in 2018 to December 31 in 2019 were included. Serum and clinical data from 32 RA patients were collected before treatment and until the last visit. Follow-up period was up to one year after starting SRL treatment. Serum were tested for IL-6 (Human IL-6 Quantikine ELISA Kit, R&D systems), sIL-6R (Human soluble IL-6R alpha Quantikine ELISA Kit, R&D systems) and sgp130 (Human soluble gp130 Quantikine ELISA Kit, R&D systems), using specific ELISAs according to the manufacturer’s instructions. Hierarchical cluster analysis (JMP14.3.0) was used to establish the relationship between IL-6, sIL-6R and sgp130. We evaluated the efficacy of SRL treatment on the last visit using European League Against Rheumatism (EULAR) response criteria in the groups of patients. The other statistical analyses were performed with EZR 1.41, and p Values less than 0.05 were considered significant.

Results:

The median age of patients was 70.5 (IQR: 66.5-74.3) years and the median of disease duration was 7.3 (1.7-15.3) years. Nine (28.1%) patients were biologics and Jakinibs naive. the median follow-up periods were 24 (12-26) weeks. The baseline DAS28 was median 4.39 (3.77 - 5.43), and CDAI was 21.1 (11.7-29.5). When comparing responders and non-responders, there were no significant differences in any of the baseline parameters and cytokines. Four statistical significant clusters of RA patients (i.e., Group1, Group2, Group3 and tocilizumab use group before SRL) were defined by serum concentrations of IL-6, sIL-6R and spg130 at baseline. The levels of IL-6 expressed as median in Group1 patients were 25.6 (14.4–72.2) pg/ml, in Group2 5.9 (3.3–11.3) pg/ml, and in Group3 70.2 (45.4–86.1) pg/ml (p < 0.002, significant difference only between Group2 and Group3). The levels of sIL-6R expressed as median in Group1 patients were 38.7 (34.7-45.1) ng/ml, in Group2 35.1 (24.8-41.9) ng/ml, and in Group3 35.7 (34.2-39.8) ng/ml (p = 0.5477). The levels of sgp130 expressed as median in Group1 patients were 272.6 (263.0-277.2) ng/ml, in Group2 223.1 (221.0-228.0) ng/ml, and in Group3 204.6 (192.0-207.6) ng/ml (p < 0.00003, significant difference between the three groups respectively). There were no significant differences in any of the baseline clinical features and laboratory findings between the three groups. Out of the 8 patients in Group1 had a good or moderate response to SRL. Conversely, the percentage of patients with no response to SRL was higher in Group3 than in Group1 and Group2.

Conclusion:

RA patients could be easily stratified prior to the rapeutic intervention with sgp130 related to the IL-6 signal reguration. Group1 patients, who had the best response to SRL, had the highest level of sgp130.

Table 1.

Comparison of baseline serum IL-6, sIL-6R and sgp130 of each groups of patients

TCZ use before SRLGroup 1Group 2Group 3P valuen=3N=9N=8N=9IL-6,pg/mL69.8,77.6,592.6Median[IQR]25.6[14.4-72.2]5.9[3.3-11.3]70.2[45.4-86.1]<0.002csIL-6R,ng/mL390.5,413.2,481.7Median[IQR]38.7[34.7-45.1]35.1[24.8-41.9]35.7[34.2-39.8]0.547sgp130,ng/mL205.6,219.2,239.8Median[IQR]273[263-277]223[221-228]205[192-208]<0.001abc

*a, b and c mean that statically significant difference between subgroups as a: group1 vs. 2, b: group 1 vs. 3, c: group 2 vs. 3.

Disclosure of Interests:

Takahiro Yoshikawa: None declared, Tetsuya Furukawa: None declared, Masao Tamura: None declared, Teppei Hashimoto: None declared, Mai Morimoto: None declared, Naoto Azuma: None declared, Kiyoshi Matsui Grant/research support from: Asahi Kasei Pharma, Astellas Pharma (research grants), Speakers bureau: Bristol-Myers Squibb (lecture fees)

Ramucirumab after prior sorafenib in patients with advanced hepatocellular carcinoma and elevated alpha-fetoprotein: Japanese subgroup analysis of the REACH-2 trial

BACKGROUND

The global, randomized, phase 3 REACH-2 study (ClinicalTrials.gov identifier: NCT02435433) found significantly longer overall survival (OS) for second-line ramucirumab versus placebo (hazard ratio [HR]: 0.710, 95% confidence interval [CI] 0.531-0.949, P = 0.0199) in patients with advanced hepatocellular carcinoma (HCC) and alpha-fetoprotein (AFP) ≥ 400 ng/mL. This prespecified subgroup analysis evaluated the efficacy and safety of ramucirumab in the Japanese patients enrolled in the study.

METHODS

Patients with advanced HCC and AFP ≥ 400 ng/mL after first-line sorafenib were randomized 2:1 to ramucirumab (8 mg/kg intravenously) or placebo every 2 weeks. Hazard ratios for progression-free survival (PFS) and OS (primary endpoint of the overall study) were estimated using the stratified Cox regression model. We also pooled individual patient data from REACH-2 with data from REACH (NCT01140347) for patients with AFP ≥ 400 ng/mL.

RESULTS

In the Japanese REACH-2 subpopulation, there were improvements for ramucirumab (n = 41) versus placebo (n = 18) in PFS (HR 0.282, 95% CI 0.144-0.553) and OS was numerically prolonged (HR 0.599, 95% CI 0.303-1.187), consistent with the significant benefit seen in the overall REACH-2 study population. In the ramucirumab and placebo arms, respectively, the objective response rate was 7.3% and 0%, and the disease control rate was 70.7% and 33.3%. The most frequently reported grade ≥ 3 treatment-emergent adverse event was hypertension (ramucirumab: 15%; placebo: 11%).

CONCLUSIONS

Ramucirumab after prior sorafenib improved PFS and OS compared with placebo, with a manageable safety profile, in the Japanese REACH-2 subpopulation, consistent with the overall REACH-2 study results. Ramucirumab is the first agent to demonstrate clinical benefit for Japanese patients with HCC in the second-line setting.

0570 Apnea-Hypopnea Index is Positively Correlated with Mood Disturbance

Introduction

The prevalence of mood disorders such as depression is higher in individuals with obstructive sleep apnea (OSA). Previous studies have found no significant correlation between the apnea-hypopnea index (AHI) and measures of mood and have only included participants who met diagnostic criteria for OSA. The current analysis sought to determine whether mood correlated with AHI in individuals with any AHI values including those that did not meet diagnostic criteria for OSA.

Methods

31 volunteers were studied (BMI=29.2±1.0 kg/m2, mean±SE), free from medication and without psychiatric illness or chronic medical conditions with the exception of untreated OSA, uncomplicated hypertension (BP&lt;160/100), or obesity. Following 1-3 weeks of an 8h habitual at home sleep schedule, participants completed the POMS-Brief questionnaire (POMS-B) to assess mood after undergoing overnight polysomnography to determine AHI. Total mood disturbance (TMD) scores were calculated by adding the scores on the POMS-B for each mood state subscale and subtracting the score for vigor-activity.

Results

The average AHI was 15.3±3.1 (range of 1.1-74.1) events per hour. The average POMS-B TMD score was 21±1.5 (range of 4-46). There was a significant correlation between the POMS-B TMD score and AHI (p=0.037, r2=0.14). This result was also seen in only those individuals with AHI scores &gt;5 (p=0.002, r2=0.4).

Conclusion

In this sample, individuals with higher AHI values displayed higher TMD scores. These results differ from previous data that showed no significant correlation between AHI and TMD. This is the first analysis to demonstrate a correlation between TMD and AHI while including individuals who didn’t meet diagnostic criteria for OSA. However, the relationship between AHI and TMD was also significant in those with AHI&gt;5. More data on these measures with larger sample sizes and a more equal representation of AHI values should be gathered to provide additional evidence for this relationship.

Support: Support

NIH R01-HL125893; CTSA UL1TR000128, R21HL140377

An open-label, phase I trial of BI 754091 alone and in combination with BI 754111 in Asian patients (pts) with advanced solid tumors

3054

Background: Dual blockade of immune checkpoint molecules, PD-1 and LAG-3, may enhance the anti-tumor response versus PD-1 blockade alone. This Phase I trial investigated BI 754091, an anti-PD-1 antibody, as monotherapy and in combination with BI 754111, an anti-LAG-3 antibody, in Asian pts with advanced solid tumors. Methods: This trial comprised 3 parts. Parts 1 and 2 (dose escalation) were in pts with unresectable/metastatic solid tumors. In Part 1, pts received BI 754091 240 mg intravenously (iv), every 3 weeks (q3w); in Part 2, pts received BI 754091 240 mg in combination with BI 754111 (400 mg, 600 mg or 800 mg iv, q3w). Dose escalation was guided by a Bayesian logistic regression model, with overdose control. The primary endpoint in Parts 1 and 2 was maximum tolerated dose (MTD) of BI 754091 alone or in combination with BI 754111, based on dose-limiting toxicities (DLTs) in Cycle 1. In Part 3, BI 754091 240 mg plus BI 754111 600 mg q3w was assessed in 4 expansion cohorts. Cohorts A–C included pts with: A) gastric/esophagogastric junction cancer; B) esophageal cancer; C) hepatocellular cancer; all had received ≥1 line of prior systemic therapy and no prior anti-PD-(L)1 therapy. Cohort D included pts who had received prior anti-PD-(L)1 therapy for the tumor types in Cohorts A–C. The primary endpoint in Part 3 was objective response (confirmed complete response or partial response [PR] per RECIST 1.1). Results: In Part 1, 6 pts received BI 754091 240 mg. In Part 2, 9 pts received BI 754091 240 mg plus BI 754111 (400 mg/600 mg/800 mg; n = 3 per cohort). No DLTs were reported in Parts 1 and 2. In Part 3, 121 pts were treated (97 [80%] male, median age 61 years [range 23–80]); Cohorts A/B/C/D included 33/33/20/35 pts. All-grade adverse events (AEs) and treatment-related AEs (TRAEs) were experienced by 96 (79%) and 47 (39%) pts, respectively. The most commonly reported AEs (all/≥G3) were pyrexia (21%/0%), decreased appetite (17%/2%), anemia (11%/6%), and nausea (9%/0%). 36 (30%) pts reported immune-related AEs, most commonly hypothyroidism, in 7 (6%) pts. Confirmed PR was observed in 6 pts (5%; Cohort A/B, n = 4/2) and 35 (29%) pts had stable disease (Cohort A/B/C/D, n = 9/11/10/5). Conclusions: MTD was not reached for BI 754091 monotherapy or for BI 754091 in combination with BI 754111. The recommended dose for the combination was determined as BI 754091 240 mg plus BI 754111 600 mg q3w. Treatment was well tolerated and consistent with that observed in the global trial. Preliminary anti-tumor activity was seen. Clinical trial information: NCT03433898 .