Efficacy of sonic hedgehog inhibitors rechallenge, after initial complete response in recurrent advanced basal cell carcinoma: a retrospective study from the CARADERM database

BACKGROUND

Smoothened (SMO) inhibitors, blocking the sonic hedgehog pathway, have been approved for advanced basal cell carcinoma (aBCC). Safety analyses reveal a high rate of adverse events (AEs) and, most of the time, vismodegib is most commonly stopped when the best overall response is reached. The long-term evolution of aBCC after vismodegib discontinuation is poorly described. The aim of this study is to evaluate the efficacy and safety of the SMO inhibitors (SMOis) available (vismodegib and sonidegib) following rechallenge after complete response (CR) following an initial treatment by vismodegib.

MATERIALS AND METHODS

This real-life, retrospective, multicenter and descriptive study is based on an extraction from the CARADERM accredited database, including 40 French regional hospitals, of patients requiring BCC systemic treatment.

RESULTS

Of 303 patients treated with vismodegib, 110 achieved an initial CR. The vast majority of these patients (98.2%) stopped vismodegib, notably due to poorly tolerated AEs. The CARADERM database provided a median follow-up of 21 months (13.5-36.0 months) after CR. Of the 110 patients, 48.1% relapsed after a median relapse-free survival of 24 months (13.0-38.0 months). Among them, 35 patients were retreated by an SMOi and the overall response rate was 65.7% (34.3% of CR and 31.4% of partial response). The median duration of retreatment was 6.0 months (4.0-9.5 months).

CONCLUSION

Our real-life study, carried out on patients with complex clinical pictures, shows that after treatment discontinuation, 48.1% of patients achieved CR relapse within an average of 24 months (13.0-38.0 months). It emphasized that even though rechallenge can be considered as a therapeutic option, efficacy seems to decrease, suggesting the development of resistance mechanisms.

COVID-19 et lymphomes cutanés

Introduction

La gravité de la coronavirus disease-2019 (COVID-19) est liée à l’âge, au sexe masculin et à la présence de comorbidités (obésité, pathologies pulmonaires et cardiovasculaires, diabète et cancers). Les patients atteints de lymphome cutané T (LCT) ou B (LCB), surtout à un stade évolué et recevant un traitement immunosuppresseur sont considérés comme à risque de forme sévère de COVID-19. Notre objectif était d’analyser les cas de COVID-19 identifiés au sein du Groupe français d’étude des lymphomes cutanés (GFELC) en 2020.

Matériel et méthodes

Étude rétrospective du GFELC avec recueil standardisé des données concernant le lymphome et son traitement, les caractéristiques de la COVID-19 et son évolution.

Résultats

Sept patients, suivis en région parisienne (n = 6) ou en Bourgogne (n = 1), pour un LCT (2 syndromes de Sézary, 3 mycosis fongoïde de stade IB à IIIA) ou un LCB (1 centrofolliculaire, 1 leg type), ont développé une COVID-19 entre février et juin 2020. Six patients avaient plus de 65 ans et 6 présentaient d’autres facteurs péjoratifs (obésité, antécédents cardiovasculaires ou respiratoires, diabète, dialyse). Tous recevaient un traitement systémique (médiane 4 lignes [1–14]). Cinq patients étaient symptomatiques avec le plus souvent des signes respiratoires fébriles et un scanner thoracique évocateur. Le contage était hospitalier chez 2 patients. La PCR nasopharyngée était positive chez tous. Alors que l’infection était grave chez 3 patients (2 critiques [présence d’une défaillance respiratoire ou d’un choc] décédés dont 1 traité par R-mini-CHOP ; 1 sévère [présence d’une hypoxie, d’une atteinte scannographique > 50 % ou d’une dyspnée] avec une embolie pulmonaire recevant du R-CHOP), elle était bénigne chez 4 autres. Le LC a progressé pendant la période d’infection chez un patient dont le traitement du LCT était suspendu en raison de l’infection.

Discussion

La survenue de COVID-19 chez des patients atteints de LCT ou LCB paraît être un événement rare sans pouvoir éliminer une sous-estimation des cas. Ils sont survenus dans des régions impactées par l’épidémie. Selon les critères publiés en mars 2020, ces patients recevaient tous un traitement systémique à risque intermédiaire ou élevé de COVID et présentaient un LCT/LCB à risque intermédiaire haut à élevé de COVID-19 dans 6/7 cas. La fréquence élevée des cas sévères/critiques dans cette petite série (42 %) avec 5 hospitalisations et 2 décès suggère que le bénéfice/risque des traitements systémiques doit être discuté en période épidémique comme suggéré par les recommandations américaines et européennes.

En conclusion, cette première série de patients atteints de LCT/LCB développant une infection par le SARS-Cov-2 montre un nombre relativement faible de cas, mais suggère que ces patients ont un risque élevé de formes sévères qui doit être connu par les dermatologues.

Epidemiological changes in cutaneous lymphomas: an analysis of 8593 patients from the French Cutaneous Lymphoma Registry

BACKGROUND

Primary cutaneous lymphomas (PCLs) are a heterogeneous group of T-cell (CTCL) and B-cell (CBCL) malignancies. Little is known about their epidemiology at initial presentation in Europe and about potential changes over time.

OBJECTIVES

The aim of this retrospective study was to analyse the frequency of PCLs in the French Cutaneous Lymphoma Registry (GFELC) and to describe the demography of patients.

METHODS

Patients with a centrally validated diagnosis of primary PCL, diagnosed between 2005 and 2019, were included.

RESULTS

The calculated incidence was unprecedently high at 1·06 per 100 000 person-years. The number of included patients increased yearly. Most PCL subtypes were more frequent in male patients, diagnosed at a median age of 60 years. The relative frequency of rare CTCL remained stable, the proportion of classical mycosis fungoides (MF) decreased, and the frequency of its variants (e.g. folliculotropic MF) increased. Similar patterns were observed for CBCL; for example, the proportion of marginal-zone CBCL increased over time.

CONCLUSIONS

Changes in PCL frequencies may be explained by the emergence of new diagnostic criteria and better description of the entities in the most recent PCL classification. Moreover, we propose that an algorithm should be developed to confirm the diagnosis of PCL by central validation of the cases.

Update of survival and cost of metastatic melanoma with new drugs: Estimations from the MelBase cohort

PURPOSE

Since 2011, significant progress was observed in metastatic melanoma (MM), with the commercialisation of seven immunotherapies or targeted therapies, which showed significant improvement in survival. In France, in 2004, the cost of MM was estimated at €1634 per patient; this cost has not been re-estimated since. This study provided an update on survival and cost in real-life clinical practice.

METHODS

Clinical and economic data (treatments, hospitalisations, radiotherapy sessions, visits, imaging and biological exams) were extracted from the prospective MelBase cohort, collecting individual data in 955 patients in 26 hospitals, from diagnosis of metastatic disease until death. Survival was estimated by the Kaplan-Meier method. Costs were calculated from the health insurance perspective using French tariffs. For live patients, survival and costs were extrapolated using a multistate model, describing the 5-year course of the disease according to patient prognostic factors and number of treatment lines.

RESULTS

Since the availability of new drugs, the mean survival time of MM patients has increased to 23.6 months (_95%confidence interval [CI] :21.2;26.6), with 58% of patients receiving a second line of treatment. Mean management costs increased to €269,682 (_95%CI:244,196;304,916) per patient. Drugs accounted for 80% of the total cost.

CONCLUSION

This study is the first that evaluated the impact of immunotherapies and targeted therapies both on survival and cost in real-life conditions. Alongside the introduction of breakthrough therapies in the first and subsequent lines, MM has been associated with a significant increase in survival but also in costs, raising the question of financial sustainability.

French updated recommendations in Stage I to III melanoma treatment and management

As knowledge continues to develop, regular updates are necessary concerning recommendations for practice. The recommendations for the management of melanoma stages I to III were drawn up in 2005. At the request of the Société Française de Dermatologie, they have now been updated using the methodology for recommendations proposed by the Haute Autorité de Santé in France. In practice, the principal recommendations are as follows: for staging, it is recommended that the 7th edition of AJCC be used. The maximum excision margins have been reduced to 2 cm. Regarding adjuvant therapy, the place of interferon has been reduced and no validated emerging medication has yet been identified. Radiotherapy may be considered for patients in Stage III at high risk of relapse. The sentinel lymph node technique remains an option. Initial examination includes routine ultrasound as of Stage II, with other examinations being optional in stages IIC and III. A shorter strict follow-up period (3 years) is recommended for patients, but with greater emphasis on imaging.

Clinical evaluation of a dressing with poly absorbent fibres and a silver matrix for managing chronic wounds at risk of infection: a non comparative trial

OBJECTIVE

To assess the efficacy, safety and acceptability of a new silver poly absorbent dressing (UrgoCleanAg) in the local management of exudative chronic wounds at risk of infection, with inflammatory signs suggesting heavy bacterial load.

METHOD

This prospective, multicentre, non-comparative clinical trial was conducted in French hospital wards (dermatology and vascular medicine) or specialised private-practice physicians. Patients were considered at high-risk of infection when presenting with at least three of five selected inflammatory clinical signs, suggesting a heavy bacterial load (pain between two dressing changes, erythema, oedema, malodorous wound and presence of a heavy exudate). They were treated for a maximum period of four weeks, and followed by the physician on a weekly basis, including a clinical examination, area tracings and photographs. The primary efficacy criterion of the trial was the relative wound surface area reduction at the end of the four weeks of treatment. Acceptability was documented by the nursing staff at each dressing change between the weekly evaluations.

RESULTS

We recruited 37 patients with chronic wounds. Wound surface area, mostly covered by sloughy tissue, was reduced by 32.5% at the end of the treatment (median value), while the clinical score (maximum value of 5, based on inflammatory clinical signs) decreased from 4.0 to 2.0. Effective debridement properties were documented (62.5% relative reduction of sloughy tissue at week 4; 58.8% of debrided wounds at week 4) and improvement of the periwound skin status was noted (healthy for 28.6% of the patients at week 4 versus 2.7% at baseline). In addition, the tested wound dressing presented a good safety profile associated to a high level of acceptability, noted by both patients and nursing staff.

CONCLUSION

These clinical data support that the tested dressing is a credible therapeutic alternative for the management of chronic wounds at risk of infection with inflammatory signs suggesting heavy bacterial load.