FASTOCH: Feasibility of Electronic Patient-Reported Outcomes in Older Patients With Cancer-A Multicenter Prospective Study

PURPOSE

Multiple studies have demonstrated that electronic patient-reported outcomes (ePROs) improve overall survival and quality of life in cancer care. However, there are no specific prospective data on remote ePRO monitoring in the older population, although they represent a significant proportion of patients with cancer.

PATIENTS AND METHODS

From February 2021 to April 2022, patients age 75 years and older under active anticancer treatment were consecutively recruited in six institutions. Remote ePRO feasibility was determined in intention-to-test (ITT) on the basis of the number of active users in the overall population. Primary failure applied to patients who had no Internet access or declined to test ePROs, while the other patients were assigned to the ITT population. Feasibility was also determined per-protocol on the basis of the number of active patients in the ITT population.

RESULTS

Of the 473 patients included, primary failure applied to 288 patients (233 of whom had no Internet access). Among the 185 patients in ITT, 122 used ePROs, leading to a 26% feasibility in ITT and a 66% feasibility per protocol. In a multivariate analysis, the intent to test population was from a higher socioprofessional category (P = .009) and felt in better general condition in the Geriatric 8-score evaluation (P = .002). Active patients significantly differed from the inactive on their self-assessment of a better general condition (P < .001) only.

CONCLUSION

Our multicenter study showed a limited feasibility rate (26%) of remote ePROs monitoring for older patients with cancer, mainly because of technology barriers. Yet, among the patients who did have Internet access, most of them indeed used ePROs (66%). Given the expected benefit of ePROs, the technology barriers therefore need to be lifted to improve cancer care in older patients.

Pemigatinib for patients with previously treated, locally advanced or metastatic cholangiocarcinoma harboring FGFR2 fusions or rearrangements: A joint analysis of the French PEMI-BIL and Italian PEMI-REAL cohort studies

BACKGROUND

Pemigatinib is approved for patients with pretreated, locally advanced or metastatic CCA harboring FGFR2 rearrangements or fusions. We aim to assess the effectiveness and safety of pemigatinib in real-world setting.

MATERIAL AND METHODS

A joint analysis of two multicentre observational retrospective cohort studies independently conducted in France and Italy was performed. All consecutive FGFR2-positive patients affected by CCA and treated with pemigatinib as second- or further line of systemic treatment in clinical practice, within or outside the European Expanded Access Program, were included.

RESULTS

Between July 2020 and September 2022, 72 patients were treated with pemigatinib in 14 Italian and 25 French Centres. Patients had a median age of 57 years, 76% were female, 81% had ECOG-PS 0-1, 99% had intrahepatic CCA, 74% had ≥ 2 metastatic sites, 67% had metastatic disease at diagnosis, while 38.8% received ≥ 2 previous lines of systemic treatment. At data cut-off analysis (April 2023), ORR and DCR were 45.8% and 84.7%, respectively. Median DoR was 7 months (IQR: 5.8-9.3). Over a median follow-up time of 19.5 months, median PFS and 1-year PFS rate were 8.7 months and 32.8%. Median OS and 1-year OS rate were 17.1 months and 60.6%. Fatigue (69.4%), ocular toxicity (68%), nail toxicities (61.1%), dermatologic toxicity (41.6%) hyperphosphataemia (55.6%), stomatitis (48.6%), and diarrhea (36.1%) were the most frequent, mainly G1-G2 AEs. Overall incidence of G3 AEs was 22.2%, while no patient experienced G4 AE. Dose reduction and temporary discontinuation were needed in 33.3% and 40.3% of cases, with 1 permanent discontinuation due to AEs.

CONCLUSIONS

These results confirm the effectiveness and safety of pemigatinib in a real-world setting.

Case Report of Probable DRESS Syndrome Associated with Ribociclib

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but known and potentially severe side effect of drugs. The recent development of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors, such as ribociclib, has considerably improved the management of hormone receptor positive (HR+) and HER2 negative (HER2-) advanced breast cancer. Here, we present the case of an 83-year-old patient who developed a probable DRESS syndrome induced by ribociclib, presenting with fever, eosinophilia, rash, and hepatic cytolysis. The RegiSCAR score was 4. The symptomatology evolved favorably with topical and systemic corticosteroids, without any sequel. Another CDK4/6 inhibitor, palbociclib, was introduced later without any cross-toxicity and with an excellent therapeutic response for more than 3 years.

Immune tumor microenvironnement (iTME) post-neoadjuvant chemotherapy, beyond PD-L1: Novel immune targets in ovarian cancer, data from the CHIVA trial, a GINECO/GINEGEPS study

5554

Background: Antibodies targeting PDL1 or PD1 have been disappointing so far in the treatment of ovarian cancer (OC). A greater understanding of the complex iTME and of the impact of chemotherapy on immune features could uncover promising immune targets. We previously reported that neoadjuvant chemotherapy (NACT) increased CD4+ and CD8+ immune cells (IC) and depleted FOXP3+ suppressive T-regs in OC iTME. Here we aimed to describe the expression of PDL1 as well as other co-regulatory molecules in OC and their changes under NACT. Methods: Tumor samples and clinical data were prospectively collected from patients (pts) in the randomized CHIVA trial of NACT +/- nintedanib. Samples were evaluable for immune profiling for 116-124 pts at diagnosis and 89-107 at surgery after 3 cycles of NACT. IC stained for CD4, CD8 were scored as number of IC+/mm². Expression of immune co-regulatory molecules PDL1, TIM3, LAG3 and IDO was scored as percentage of positive cells, and tumors were classified as PDL1/TIM3/IDO/LAG3 positive if > 1% of IC and/or tumor cells (TC) were positive. Highly sensitive pts, defined as objective response to NACT and prolonged median progression-free survival (mPFS > 24months), were compared to refractory pts (progressing during or within 3mo of platinum). Results: As expected, about one third (36%) of tumors were PDL1+ at diagnosis. In contrast, the prevalence of other co-regulatory molecules was higher with 52%, 54% and 93% of tumors being positive for IDO, LAG3 and TIM3, respectively. There was no significant change in PDL1 expression with NACT. However, in paired samples NACT significantly increased IDO and LAG3 expression (p < 0.05), such that 60% and 66% of tumors post-NACT were positive for IDO and LAG3, respectively. TIM3 expression remained high post-NACT with 92% of positive tumors. Highly sensitive tumors (vs refractory tumors) had significantly higher IC expression of TIM3 after NACT (24% vs 6%, p = 0.005), and were significantly more infiltrated by CD4+ (441 vs 228 cells/mm2, p = 0.04) and CD8+ (460 vs 225 cells/mm2, p = 0.045) T cells. Conclusions: Other immune targets beyond PDL1 are highly expressed in OC. In addition NACT appears to prime the iTME by increasing effector T cell infiltration and the expression of other relevant co-regulatory molecules (LAG3, TIM3 and IDO). Future studies could be performed by priming the iTME with NACT and testing novel immune therapies based on target expression in samples obtained at interval debulking surgery.

Covid-19 à Mayotte : profil épidémiologique d’une année de crise

Introduction

Le 13/03/20, Mayotte déclare son premier cas de Covid-19. Le contexte socio-économique précaire rend inconcevable l’application des recommandations de prévention. Bien que la moitié de la population ait moins de 18 ans ; chez les adultes, la prévalence des facteurs de risque de formes graves fait redouter une saturation de l’unique hôpital de l’île : 38 % d’HTA, 12 % de diabète tandis que l’IMC moyen est de 26,9 kg/m².

Matériels et méthodes

Afin de comprendre la dynamique et la sévérité du Covid-19 à Mayotte, plusieurs dispositifs de surveillance ont été mis en place. Ce travail décrit l’évolution épidémique du 9/03/20 au 14/03/21 en distinguant deux vagues différentes du fait de l’émergence de variants: 2020 (9/03/20-31/12/20) versus 2021 (01/01/21-14/03/21).

Résultats

L’épidémie a débuté en mars 2020 avec un pic en mai (taux d’incidence (TI) de 133/100000 hbts). L’âge médian des cas était de 36 ans et la plupart d’entre eux était sans activité professionnelle. Le TI a diminué pour passer début juillet, sous le seuil d’alerte, suggérant une accalmie durant l’hiver austral. Cette première vague s’est avérée relativement peu sévère avec un maximum de cas hospitalisés en S21 : 51 patients hospitalisés dont 11 en réanimation. La circulation virale a continué sans impact sanitaire majeur jusqu’en décembre 2020 où l’Afrique du Sud a signalé l’émergence du variant 501Y.V2. Quelques semaines après les Comores, Mayotte enregistrait une dégradation rapide et intense de la situation: doublement du TI, triplement du taux de positivité Sars-Cov-2 (TP) entre mi-décembre et mi-janvier, y compris chez les 0-14 ans. En S6-2021, le TI a atteint un pic (894/100000 hbts) tout comme le TP culminant à 28 %. Deux enquêtes flash en février ont montré la part majoritaire d’un variant avec la mutation 501Y, représentant 87 % (150/172) des échantillons analysés par criblage. Les indicateurs hospitaliers témoignaient de la sévérité de cette nouvelle vague avec un pic atteint en S18-2021 : 148 patients hospitalisés dont 27 en réanimation, majoritairement des formes oxygéno-requérentes. En 2021, 149 cas ont été admis en réanimation contre 104 en 2020 (sex ratio H/F = 1,9). Parmi les patients présentant une forme pulmonaire, le profil des cas admis en réanimation en 2021 a changé par rapport à 2020 : ils étaient significativement plus jeunes (57 vs 62 ans) et présentaient un profil de comorbidités différent. Au total, en un an, 18899 cas ont été confirmés biologiquement et 253 patients admis en réanimation: ils correspondaient à 203 cas de formes pulmonaires, 46 cas de portage asymptomatique et 14 cas de syndrome inflammatoire multi-systématique associé à une infection par le Sars-Cov-2. En 2021, 88 patients sont décédés contre 55 en 2020; âges médians respectifs de 73 et 64 ans.

Conclusion

Le confinement de février 2021 s’est suivi d’une inversion de la tendance épidémique. Fin mars, l’épidémie se poursuit avec un TI de 63/100000 hbts. Alors que moins de 5000 personnes ont été vaccinées à deux doses, la vigilance est de mise pour ce territoire vulnérable.

CA-125 ELIMination Rate Constant K (KELIM) Is a Marker of Chemosensitivity in Patients with Ovarian Cancer: Results from the Phase II CHIVA Trial

PURPOSE

In patients with ovarian cancer receiving neoadjuvant chemotherapy, the first-line treatment success will depend on both the tumor-primary chemosensitivity and the completeness of interval debulking surgery (IDS). The modeled CA-125 ELIMination rate constant K (KELIM), calculated with the CA-125 longitudinal kinetics during the first 100 chemotherapy days, is a validated early marker of tumor chemosensitivity. The objective was to investigate the role of the chemosensitivity relative to the success of first-line medical-surgical treatment.

EXPERIMENTAL DESIGN

The CA-125 concentrations were prospectively measured in the randomized phase II trial CHIVA (NCT01583322, carboplatin-paclitaxel regimen ± nintedanib, and IDS, n = 188 patients). The KELIM predictive value regarding the tumor response rate, likelihood of complete IDS, risk of subsequent platinum-resistant relapse (PtRR), progression-free survival (PFS), and overall survival (OS) was assessed using univariate and multivariate tests.

RESULTS

The data from 134 patients were analyzed. KELIM was an independent and major predictor of subsequent PtRR risk, and of survivals. The final logistic regression model, including KELIM [OR = 0.13; 95% confidence interval (CI), 0.03-0.49] and complete IDS (no vs. yes, OR = 0.30; 95% CI, 0.11-0.76) highlights the preponderant role of chemosensitivity on the success of the first-line treatment. In patients with highly chemosensitive diseases, the patient prognosis was driven more by the chemotherapy-induced antitumor effects than by the surgery.

CONCLUSIONS

The tumor-primary chemosensitivity, assessed by the modeled CA-125 KELIM calculated during neoadjuvant chemotherapy (http://www.biomarker-kinetics.org/CA-125-neo), may be a major parameter to consider for decision-making regarding IDS attempt, and selecting patients for treatments meant to reverse the primary chemoresistance.See related commentary by May and Oza, p. 4432.

Olaparib plus Bevacizumab as First-Line Maintenance in Ovarian Cancer

BACKGROUND

Olaparib has shown significant clinical benefit as maintenance therapy in women with newly diagnosed advanced ovarian cancer with a BRCA mutation. The effect of combining maintenance olaparib and bevacizumab in patients regardless of BRCA mutation status is unknown.

METHODS

We conducted a randomized, double-blind, international phase 3 trial. Eligible patients had newly diagnosed, advanced, high-grade ovarian cancer and were having a response after first-line platinum-taxane chemotherapy plus bevacizumab. Patients were eligible regardless of surgical outcome or BRCA mutation status. Patients were randomly assigned in a 2:1 ratio to receive olaparib tablets (300 mg twice daily) or placebo for up to 24 months; all the patients received bevacizumab at a dose of 15 mg per kilogram of body weight every 3 weeks for up to 15 months in total. The primary end point was the time from randomization until investigator-assessed disease progression or death.

RESULTS

Of the 806 patients who underwent randomization, 537 were assigned to receive olaparib and 269 to receive placebo. After a median follow-up of 22.9 months, the median progression-free survival was 22.1 months with olaparib plus bevacizumab and 16.6 months with placebo plus bevacizumab (hazard ratio for disease progression or death, 0.59; 95% confidence interval [CI], 0.49 to 0.72; P<0.001). The hazard ratio (olaparib group vs. placebo group) for disease progression or death was 0.33 (95% CI, 0.25 to 0.45) in patients with tumors positive for homologous-recombination deficiency (HRD), including tumors that had BRCA mutations (median progression-free survival, 37.2 vs. 17.7 months), and 0.43 (95% CI, 0.28 to 0.66) in patients with HRD-positive tumors that did not have BRCA mutations (median progression-free survival, 28.1 vs. 16.6 months). Adverse events were consistent with the established safety profiles of olaparib and bevacizumab.

CONCLUSIONS

In patients with advanced ovarian cancer receiving first-line standard therapy including bevacizumab, the addition of maintenance olaparib provided a significant progression-free survival benefit, which was substantial in patients with HRD-positive tumors, including those without a BRCA mutation. (Funded by ARCAGY Research and others; PAOLA-1 ClinicalTrials.gov number, NCT02477644.).

Modeled CA-125 kinetics during neoadjuvant chemotherapy for predicting the likelihood of optimal interval debulking surgery in ovarian cancer patients: Data from CHIVA trial (a GINECO study)

5546

Background: A pre-operative predictive biomarker of CC0 interval debulking surgery (IDS) likelihood would be helpful. The modeled CA125 elimination rate constant KELIM predicts OS in 1st line setting (You et al. Clin Cancer Res 2019). The predictive/prognostic values of KELIM regarding CC scores at IDS, and survivals, during neo-adjuvant chemotherapy were assessed. Methods: The data of the CHIVA randomized phase II trial, comparing carboplatin-paclitaxel +/- nintedanib before IDS (NCT01583322), were used. A semi-mechanistic model was built to describe CA125 longitudinal kinetics during the first 100 treatment days. The relationships between KELIM and IDS CC scores, PFS & OS, were assessed with other major prognostic factors (grade, histology, GCIG CA125 response, FIGO stage, and arm) using multivariate logistic regression (logit), C-index & survival tests. Results: The longitudinal kinetics of 529 CA125 values, assessed every 3 weeks during neo-adj chemotherapy, were modeled in 133 patients (out of 188). KELIM (as a continuous covariate) was the only significant predictive factor of CC0 IDS likelihood using multivariate analyses (OR = 12.37, 95% CI [4.32-39.67]). CC0 IDS probability can be estimated with patient KELIM: ≥ 90 % if standardized KELIM ≥ 0.12. Non-parametric survival models confirmed the independent predictive values of KELIM categorized by terciles regarding PFS & OS (Table). The parametric model linking KELIM (as a continuous covariate) with OS allows to predict the patient survivals (months) based on their estimated KELIM (HR = 0.20, [0.10-0.39]). Conclusions: The prognostic & predictive values of the modeled CA125 KELIM are also confirmed regarding CC0 IDS likelihood, PFS and OS with neo-adjuvant chemotherapy. Patient KELIM is calculable online, based on observed CA125 values, on http://www.biomarker-kinetics.org/ . Clinical trial information: 2011-006288-23. [Table: see text]

Impact of adding nintedanib to neoadjuvant chemotherapy (NACT) for advanced epithelial ovarian cancer (EOC) patients: The CHIVA double-blind randomized phase II GINECO study

5512

Background: Nintedanib, an oral inhibitor of VEGF-FGF-PDGF receptors, has been shown to prolong progression-free survival (PFS) when added to adjuvant chemotherapy after primary surgery (duBois A, Lancet Oncol 2015). CHIVA trial explored the role of nintedanib in combination with NACT. Methods: Patients (pts) with FIGO stage IIIC-IV chemotherapy-naive AEOC considered as unresectable after laparoscopic evaluation were randomized (2:1) to be treated with 3 to 4 cycles (cy) of carboplatin (AUC 5 mg/mL/min) and paclitaxel (175 mg/m²) (CP) before interval debulking surgery (IDS) followed by 2 to 3 cy of CP for a total of 6 cy, plus either 200 mg of Nin (armA) or placebo (armB) twice daily on days 2–21 q3week at cy 1&2, 5&6 and maintenance therapy for up to 2 years. The primary endpoint was PFS. Results: Between Jan. 2013 and May 2015, 188 pts were included (124 arm A, 64 arm B) with a median Peritoneal Cancer Index of 22 (range 19-27). Pts characteristics were well balanced between both arms. Median PFS was 14.4 mos (95%CI 12.2-15.4) and 16.8 (13.3-21.4) in arm A and B respectively (HR:1.50, p=0.02). Median OS was 37.7 mos (29.8-41.0) and 44.1 (32.7-not reached) in arm A and B respectively (HR:1.54, p=0.053). Arm A was associated with more toxicity compared to arm B respectively (Grade 3&4 adverse events: 92 versus 71%), with increased early treatment discontinuation before the 3rd cy (14.5 vs 6.2%) & CP dose reduction (12% vs 0%). Pts in Arm A reported inferior RECIST ORR to pre-IDS therapy compared to Arm B (35.1 vs 55.9%). IDS was performed significantly less frequently in arm A (58.1%) vs arm B (76.6%). However among pts who underwent IDS, complete surgical cytoreduction rate (76%) and peri/postoperative complication rate (11.2%) were similar in both arms. Conclusions: The addition of nintedanib to NACT increases toxicity and compromise chemotherapy efficacy leading to a reduced rate of IDS and worse PFS and OS for advanced EOC patient. Clinical trial information: 2011-006288-23.

Morbidity of rectosigmoid resection in cytoreductive surgery for ovarian cancer. Risk factor analysis

AIM

Rectosigmoid resection is often performed during cytoreductive surgery for ovarian cancer, to achieve the goal of no residual tumour. Here, we evaluated the morbidity associated with rectosigmoid resection and the underlying risk factors.

METHODS

We retrospectively assessed consecutive patients managed with rectosigmoid resection during cytoreductive surgery for ovarian cancer at our centre in Paris, France, between 2005 and 2013. All previously identified risk factors were analysed. Major complications were defined as grade III-IV in the Clavien-Dindo classification.

RESULTS

Of 228 patients, 116 had primary and 112 interval surgery; 43/228 [18.9%]; experienced major complications, and these were more common after primary surgery [24.1% vs. 13.4%, p = .04]. The 69 patients who had rectosigmoid resection [33 primary vs. 36 interval surgery, p = .32] had a higher morbidity rate compared to the other patients [30.4% vs. 14.6%, p = .006]. The anastomotic leakage rate was 2.89%. By multivariate logistic regression, independent risk factors for morbidity were postmenopausal status [adjusted odds ratio (aOR), 13.7; 95% confidence interval (95%CI), 1.2;161.9], surgery after neoadjuvant chemotherapy [aOR, 4.4; 95%CI, 1.1;18.8], and peritoneal stripping of the left; paracolic gutter [aOR, 11.3; 95%CI, 2.3;54.3].

CONCLUSION

The morbidity of rectosigmoid resection during cytoreductive surgery for ovarian cancer seems acceptable. Ileostomy does not seem associated with a lower risk of major complications or adjuvant bevacizumab with a higher complication rate.

Recurrent ovarian cancer

Recurrence still occurs in a majority of patients with advanced ovarian cancer. However, progress in the management has allowed a significant prolongation of survival for relapsing disease. These last years, the field of interest has moved from chemotherapy to targeted therapy which is dominated by anti-angiogenic and anti-PARP agents. It is assumed that platinum-free interval will not remain the main prognostic and predictive criterion in the future, and will be replaced by a multi-factorial approach. This trend for personalization of therapy has highlighted important neglected fields for clinical research such as multi-line (≥3) relapse, frail patients including elderly and symptomatic and supportive measures.

Tim-3 Expression on Tumor-Infiltrating PD-1+CD8+ T Cells Correlates with Poor Clinical Outcome in Renal Cell Carcinoma

Inhibitory receptors expressed by T cells mediate tolerance to tumor antigens, with coexpression of these receptors exacerbating this dysfunctional state. Using the VectraR automated multiparametric immunofluorescence technique, we quantified intratumoral CD8⁺ T cells coexpressing the inhibitory receptors PD-1 and Tim-3 from patients with renal cell carcinoma (RCC). A second validation cohort measured the same parameters by cytometry. The percentage of tumor-infiltrating CD8⁺ T cells coexpressing PD-1 and Tim-3 correlated with an aggressive phenotype and a larger tumor size at diagnosis. Coexpression of PD-1 and Tim-3 above the median conferred a higher risk of relapse and a poorer 36-month overall survival. Notably, other CD8⁺T-cell subsets did not exert a similar effect on overall survival. Moreover, only the PD-1⁺Tim-3⁺ subset of CD8⁺ T cells exhibited impaired function after stimulation. Our findings establish intratumoral Tim-3⁺PD1⁺CD8⁺ T cells as critical mediators of an aggressive phenotype in RCC. Use of the Vectra tool may be useful to identify similarly critical prognostic and predictive biomarkers in other tumor types and their response to immunotherapy. Cancer Res; 77(5); 1075-82. ©2016 AACR.

Base-Position Error Rate Analysis of Next-Generation Sequencing Applied to Circulating Tumor DNA in Non-Small Cell Lung Cancer: A Prospective Study

BACKGROUND

Circulating tumor DNA (ctDNA) is an approved noninvasive biomarker to test for the presence of EGFR mutations at diagnosis or recurrence of lung cancer. However, studies evaluating ctDNA as a noninvasive "real-time" biomarker to provide prognostic and predictive information in treatment monitoring have given inconsistent results, mainly due to methodological differences. We have recently validated a next-generation sequencing (NGS) approach to detect ctDNA. Using this new approach, we evaluated the clinical usefulness of ctDNA monitoring in a prospective observational series of patients with non-small cell lung cancer (NSCLC).

METHODS AND FINDINGS

We recruited 124 patients with newly diagnosed advanced NSCLC for ctDNA monitoring. The primary objective was to analyze the prognostic value of baseline ctDNA on overall survival. ctDNA was assessed by ultra-deep targeted NGS using our dedicated variant caller algorithm. Common mutations were validated by digital PCR. Out of the 109 patients with at least one follow-up marker mutation, plasma samples were contributive at baseline (n = 105), at first evaluation (n = 85), and at tumor progression (n = 66). We found that the presence of ctDNA at baseline was an independent marker of poor prognosis, with a median overall survival of 13.6 versus 21.5 mo (adjusted hazard ratio [HR] 1.82, 95% CI 1.01-3.55, p = 0.045) and a median progression-free survival of 4.9 versus 10.4 mo (adjusted HR 2.14, 95% CI 1.30-3.67, p = 0.002). It was also related to the presence of bone and liver metastasis. At first evaluation (E1) after treatment initiation, residual ctDNA was an early predictor of treatment benefit as judged by best radiological response and progression-free survival. Finally, negative ctDNA at E1 was associated with overall survival independently of Response Evaluation Criteria in Solid Tumors (RECIST) (HR 3.27, 95% CI 1.66-6.40, p < 0.001). Study population heterogeneity, over-representation of EGFR-mutated patients, and heterogeneous treatment types might limit the conclusions of this study, which require future validation in independent populations.

CONCLUSIONS

In this study of patients with newly diagnosed NSCLC, we found that ctDNA detection using targeted NGS was associated with poor prognosis. The heterogeneity of lung cancer molecular alterations, particularly at time of progression, impairs the ability of individual gene testing to accurately detect ctDNA in unselected patients. Further investigations are needed to evaluate the clinical impact of earlier evaluation times at 1 or 2 wk. Supporting clinical decisions, such as early treatment switching based on ctDNA positivity at first evaluation, will require dedicated interventional studies.

Analysis of Base-Position Error Rate of Next-Generation Sequencing to Detect Tumor Mutations in Circulating DNA

BACKGROUND

Detecting single-nucleotide variations and insertions/deletions in circulating tumor DNA is challenging because of their low allele frequency. The clinical use of circulating tumor DNA to characterize tumor genetic alterations requires new methods based on next-generation sequencing.

METHODS

We developed a method based on quantification of error rate of each base position [position error rate (PER)]. To identify mutations, a binomial test was used to compare the minor-allele frequency to the measured PER at each base position. This process was validated in control samples and in 373 plasma samples from patients with lung or pancreatic cancer.

RESULTS

Minimal mutated allele frequencies were 0.003 for single-nucleotide variations and 0.001 for insertions/deletions. Independent testing performed by droplet digital PCR (n = 231 plasma samples) showed strong agreement with the base-PER method (κ = 0.90).

CONCLUSIONS

Targeted next-generation sequencing analyzed with the base-PER method represents a robust and low cost method to detect circulating tumor DNA in patients with cancer.

Sustained response to vemurafenib in a low grade serous ovarian cancer with a BRAF V600E mutation

Low-grade serous ovarian adenocarcinomas (LGSOC) make up approximately 10 % of serous ovarian carcinomas. While rarely aggressive, this slow-growing tumor is well known to respond poorly to chemotherapy. Specific treatments for this ovarian subtype are lacking, with the same global approaches used for high grade cases being applied for LGSOC patients. LGSOCs have been reported to have a specific genetic profile, with notable implication of the MAPK pathway. This has opened up opportunities for novel therapeutic strategies, with in particular the use of targeted therapies. We report here the case of a heavily pretreated unresectable BRAF p.V600E-mutated LGSOC, which we treated vemurafenib, a BRAF inhibitor specific for V600E mutations. We saw impressive efficacy, with a long-term partial response along with CA125 reductions and symptom relief. Although this mutation is present in LGSOC at very a low incidence, we recommend routine testing for BRAF and other targetable mutations in this patient population, along with further evaluation in the increasingly popular basket trial approach.

Trial Watch: Therapeutic vaccines in metastatic renal cell carcinoma

Despite the renaissance of cancer immunotherapy, no novel immunotherapy has been approved for the treatment of renal cell cancer (RCC) since the availability of recombinant cytokines (interleukin-2, interferon-α). All vaccine trials have failed to meet their endpoints although they have highlighted potential predictive biomarkers (e.g., pre-existing immune response, hematological parameters, tumor burden). Recent advances in immunomodulatory therapies have prompted the study of combination treatments targeting the tumor immunosuppressive microenvironment consisting of regulatory T-cells (Treg), myeloid suppressor cells, and cytokines. Approaches under investigation are use of inhibitors to curb the overexpression of immune checkpoint ligands by tumor cells (e.g., anti-CTLA-4, anti-PD-1/PD-L1) and exploiting the immunomodulatory effects of anti-angiogenic agents that are the current standard of metastatic RCC care. Phase III trials are focusing on the possible synergy between therapeutic vaccines (e.g., IMA-901 and AGS-003) and anti-angiogenic agents.

VEGF-A modulates expression of inhibitory checkpoints on CD8+ T cells in tumors

Immune escape is a prerequisite for tumor development. To avoid the immune system, tumors develop different mechanisms, including T cell exhaustion, which is characterized by expression of immune inhibitory receptors, such as PD-1, CTLA-4, Tim-3, and a progressive loss of function. The recent development of therapies targeting PD-1 and CTLA-4 have raised great interest since they induced long-lasting objective responses in patients suffering from advanced metastatic tumors. However, the regulation of PD-1 expression, and thereby of exhaustion, is unclear. VEGF-A, a proangiogenic molecule produced by the tumors, plays a key role in the development of an immunosuppressive microenvironment. We report in the present work that VEGF-A produced in the tumor microenvironment enhances expression of PD-1 and other inhibitory checkpoints involved in CD8(+) T cell exhaustion, which could be reverted by anti-angiogenic agents targeting VEGF-A-VEGFR. In view of these results, association of anti-angiogenic molecules with immunomodulators of inhibitory checkpoints may be of particular interest in VEGF-A-producing tumors.

VEGF-A modulates expression of inhibitory checkpoints on CD8+ T cells in tumors

VEGF-A production in the tumor microenvironment enhances expression of PD-1 and other inhibitory checkpoints involved with CD8⁺ T cell exhaustion, which can be reversed with anti-VEGF/VEGFR treatment.

Immune escape is a prerequisite for tumor development. To avoid the immune system, tumors develop different mechanisms, including T cell exhaustion, which is characterized by expression of immune inhibitory receptors, such as PD-1, CTLA-4, Tim-3, and a progressive loss of function. The recent development of therapies targeting PD-1 and CTLA-4 have raised great interest since they induced long-lasting objective responses in patients suffering from advanced metastatic tumors. However, the regulation of PD-1 expression, and thereby of exhaustion, is unclear. VEGF-A, a proangiogenic molecule produced by the tumors, plays a key role in the development of an immunosuppressive microenvironment. We report in the present work that VEGF-A produced in the tumor microenvironment enhances expression of PD-1 and other inhibitory checkpoints involved in CD8⁺ T cell exhaustion, which could be reverted by anti-angiogenic agents targeting VEGF-A–VEGFR. In view of these results, association of anti-angiogenic molecules with immunomodulators of inhibitory checkpoints may be of particular interest in VEGF-A-producing tumors.

Rechallenge with mTOR inhibitors in metastatic renal cell carcinoma patients who progressed on previous mTOR inhibitor therapy

OBJECTIVE

To determine if mammalian target of rapamycin (mTOR) inhibitor (everolimus or temsirolimus) rechallenge in the third- or fourth-line setting after sequential use of a vascular endothelial growth factor receptor (VEGF)-targeted agent and an mTOR inhibitor is a feasible and effective treatment strategy in patients with metastatic renal cell carcinoma (mRCC).

METHODS

Patients who received a VEGF-targeted agent, an mTOR inhibitor and rechallenge with a second mTOR inhibitor at 2 institutions (Hôpital Européen Georges-Pompidou and Vienna Medical School) between 30 March 2001 and 15 September 2011 were included. Analyses of radiographic images were performed according to the Response Evaluation Criteria in Solid Tumors, version 1.0, to determine the objective response rate and treatment duration (TD).

RESULTS

Twelve patients met the inclusion criteria. Following 1 or 2 VEGF receptor-tyrosine kinase inhibitors, 7 patients firstly received everolimus and 5 patients received temsirolimus. Irrespective of treatment sequence, 6 of 12 patients (50%) responded to everolimus and 4 of 12 patients (33%) responded to temsirolimus; 3 patients (25%) did not respond to either. Median TDs (95% confidence interval) for everolimus → temsirolimus and temsirolimus → everolimus sequences were 10.3 months (8.8-19.2 months) and 5.8 months (2.9-19.3 months), respectively.

CONCLUSIONS

Despite the limited number of patients, this highlights the feasibility of utilizing mTOR rechallenge as an integral part of sequential treatment strategies in mRCC.

Metastatic renal cell carcinoma treated sequentially with multiple VEGF receptor-targeted inhibitors--a case report

Six targeted agents [sorafenib, sunitinib, temsirolimus, bevacizumab (plus interferon), everolimus and pazopanib] have been approved for the treatment of patients with metastatic renal cell carcinoma. As disease progression is inevitable, most patients will receive several lines of treatment. However, the choice regarding which sequence of drugs to use remains unclear, particularly concerning the drug class, i.e. those targeting the vascular endothelial growth factor (receptor) [VEGF(R)] pathway versus those acting on the mammalian target of rapamycin pathway. There appears to be no absolute crossresistance between tyrosine kinase inhibitors (TKIs) acting on the VEGF(R) pathway, and there have been numerous reports of two TKIs being successfully used in sequence. We report the case of a 63-year-old woman who responded for 24 months to three successive lines of treatment with different TKIs (sunitinib, axitinib and sorafenib). This suggests that TKIs targeting VEGFR should be considered as individual drugs and not as a single class.

Molecular characterization of rotavirus strains circulating among children with acute gastroenteritis in Madagascar during 2004-2005

A survey was undertaken of the etiology of acute gastroenteritis in children <16 years of age in Antananarivo, Madagascar, from May 2004 through May 2005. With use of electron microscopy of fecal specimens, 104 (36%) of 285 children were found to be infected with rotavirus. Rotavirus strain characterization was undertaken using enzyme-linked immunosorbent assay, electropherotyping, reverse-transcription polymerase chain reaction genotyping, and nucleotide sequencing. The predominant group A rotavirus strain types identified were P[4]G2 (62%) and P[8]G9 (23%). Nucleotide sequence analysis of the VP7 genes of selected Malagasy G2 and G9 strains demonstrated similarity with those of other recently identified African rotavirus strains belonging to the same genotype.

Cryptosporidium species causing acute diarrhoea in children in Antananarivo, Madagascar

A 13-month study of children presenting with acute diarrhoeal disease at hospitals and rehydration clinics in Antananarivo, Madagascar, was undertaken between May 2004 and May 2005. Cryptosporidiosis accounted for diarrhoea in 12 (5.6%) of the 215 children investigated. Cases of cryptosporidiosis were detected only in the rainy season, and the median age of cases was 13.5 months (range=1 day-27 months). As 11 of the cases of cryptosporidiosis were caused by Cryptosporidium hominis and only one by C. parvum, most of the cases were probably the result of anthroponotic transmission. GP60/45/15 gene polymorphisms indicated that the causative pathogens were of subtypes Ia, Id, Ie and IIc.

[Diagnosis of malaria in Antananarivo City: examination of the results obtained at the Institut Pasteur de Madagascar from 2001 to 2004]

Malaria diagnosis is part of the daily activities of the Clinical Biology Center (CBC) of the Institut Pasteur de Madagascar in Antananarivo. Over a period of four years (2001-2004), regardless the methods being used, out of 6537 blood samples examined, 159 (2.43%) tests were positive. All four species of Plasmodium infecting human. were detected with a high prevalence of P. falciparum (87.2%). 49/159 patients were foreigners, but their files did not allow us to distinguish imported from locally acquired malaria cases. Also, among Malagasy patients, there was no possibility to recognize introduced malaria cases (contracted in coastal areas). In Madagascar malaria remains a public health problem. But fever and recent history of fever are often considered and treated as malaria. Our results demonstrated that confirmed malaria rate was very low. Reporting malaria on the basis of clinical signs overestimates malaria cases at the national level. The importance of malaria biological diagnosis is discussed in this article.

HIV-1-related morbidity in adults, Abidjan, Côte d'Ivoire: a nidus for bacterial diseases

We studied mortality and morbidity in 270 HIV-1-infected adults (60% women, median age 31 years, mean baseline CD4 count 331/mm(3) ) observed in a follow-up that lasted a median 10 months in Côte d'Ivoire. Survival and probability of remaining free from any episode of morbidity at 12 months were 0.80 and 0.50, respectively. Baseline CD4 count <200/mm(3) was the only variable associated with global morbidity and mortality, with hazard ratios of 2.50 and 7.57, respectively. The most frequent causes of morbidity were severe bacterial infections (incidence rate: 26.1 per 100 person-years [py]), followed by oral candidiasis (22.3% py), unexplained weight loss over 10% of baseline body weight (13.3% py), tuberculosis (10.1% py), unexplained chronic diarrhea (9.7% py), and isosporiasis (5.1% py). Nontyphoid Salmonella accounted for 37% of isolated strains during severe bacterial infections, followed by Streptococcus pneumoniae (34%), Escherichia coli (15%), and Shigella species (7%). A significant part of bacterial morbidity occurred in patients with baseline CD4 count > or = 200/mm(3), in whom the incidence rate of bacterial diseases was 21.3% py and the probability of remaining free from any bacterial infection at 12 months was 0.80 (vs. 36.4% py and 0.71 in patients with baseline CD4 count <200/mm(3); p =.07).

[Causes of fever in adults infected by HIV-1. Ambulatory follow-up in the ANRS 059 trial in Abidjan, Ivory Coast]

OBJECTIVE

Describe the causes of fever in HIV-1 infected adults in Abidjan, Ivory Coast.

METHODS

Exhaustive analysis of all the morbid episodes with raise in temperature to above 37.5 degrees C in patients followed-up prospectively, within the framework of the ANRS 059 study from April 1996 to March 1998.

RESULTS

One hundred and four patients presented 269 episodes of fever. At the start of these episodes, the mean CD4 count was of 311/mm3, fever had lasted a mean of 3.4 days and mean body temperature was 38.7 degrees C. The 269 episodes lead to 288 diagnoses: 152 specific etiologic diagnoses and 136 non-specific syndrome diagnoses. Community bacterial infections represented 55% of the specific diagnoses, followed by malaria (16%) and tuberculosis (12%). The mean CD4 count during the bacterial episodes was 208/mm3, in malaria 384/mm3 and in tuberculosis 245/mm3. Non-typhi salmonella, pneumococci and Escherischia coli represented 37%, 32%, and 15% respectively of the bacteria isolated. The mean duration between the first and last day of fever was 8.4 days. This time lapse was superior or equal to 30 days in 22 episodes (8%), 50% of which were mycobacterioses (36% tuberculosis and 14% atypic mycobacterioses). Nineteen episodes (7%) lead to death within a mean delay of 58 days. The first cause of death was atypic mycobacteriosis (26%). Death was significantly associated with a CD4 count < 200/mm3 and to prolongation of fever for more than 30 days.

CONCLUSION

Other than the frequently described role of tuberculosis in HIV morbidity in sub-Saharian Africa, the role of bacterial diseases, responsible for early death, potentially severe, but curable should be underlined. The diffusion of antibiotic treatment algorithms adapted to the principle clinical syndromes encountered, might improve the treatment of adults infected by HIV consulting in sub-Saharian Africa.

Spontaneous pneumothorax: pragmatic management and long-term outcome

We prospectively considered 65 patients admitted for a spontaneous pneumothorax (SP) to describe the pragmatic management of SP, the first recurrence-free interval after medical therapeutic procedure and to specify the first recurrence risk factors over a 7-year period in these patients treated medically. The treatment options were observation alone (9%), needle aspiration (6%), small calibre chest tube (Pleurocatheter) drainage (28%) or thoracic tube drainage (49%), and pleurodesis with video-assisted thoracic surgery procedure (8%). Duration of the drainage and length of hospital stay were shorter in the Pleurocatheter group than in the thoracic tube group (P < 0.01). Among the 47 patients (72%) with a first SP and treated medically, nine patients (19%) had a first homolateral recurrence (FHR) during a mean follow-up of 84+/-13 months. Recurrence-free intervals ranged from 1 to 24 months (mean +/- SD: 9.3+/-8.4 months). FHR cases were more frequent in the Pleurocatheter group (P < 0 04). Analysis of potential risk factors showed that the patient's height and a previous homolateral SP episode are independent recurrence risk factors.

Hepatitis B and C infections, human immunodeficiency virus and other sexually transmitted infections among women of childbearing age in Côte d'Ivoire, West Africa

Few studies have been conducted in developing countries to estimate the prevalence of hepatitis C virus (HCV) infection and its association with human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). We have screened for hepatitis B virus (HBV) and HCV markers 200 HIV-1-positive, 23 HIV-2-positive and 206 HIV-negative women attending gynaecology clinics in 1995/96 in Abidjan, Côte d'Ivoire, a sample selected among 2198 consecutive consultants. Taking into account the prevalence of 21.7% for HIV in this population, the overall prevalence of anti-HBV core antibody was 81.6%, that for hepatitis B surface antigen was 9.9% and for HCV antibody was 3.3%. HIV infection and other STDs were not associated with HBV or HCV markers. Moreover, HBV and HCV markers were not statistically associated. Our results confirm the high prevalence of HIV in Abidjan and the endemic situation of HBV infection. Furthermore, HCV infection is not infrequent in this developing country setting, not explained by sexual transmission.

What is the meaning of repeated isolation of Mycobacterium africanum?

Mycobacterium africanum is a member of the tuberculosis complex, together with M. tuberculosis and M. bovis. Its morphological growth is quite different from that of M tuberculosis. It is a causative agent of the same tuberculosis disease, and its precise identification seems important only for epidemiological purposes. We report here the repetitive isolation of 17 M. africanum strains (among 321 TB complex strains) during a national primary resistance survey in C te d'Ivoire in 1995. All of the M. africanum strains were isolated in four regions located in the same geographical area. They showed biochemical heterogeneity yielding three patterns, none of which was specific to one region. Molecular analysis by RFLP for 14 strains showed identical patterns for four strains, two by two, and a clustering of 62-77% homology for eight of the 14 strains (57%). This report confirms that M. africanum is less frequent than M. tuberculosis. Its repeated isolation may reflect inter-human transmission. Biochemical similarities between strains may not always be associated with a common geographical origin.