Unexpected "Lazarus response" to single-agent bevacizumab in heavily pretreated patients with HER2-positive breast cancer

Early clinical trials aimed to halt cancer progression by inhibiting the growth of new blood vessels in tumors through single-agent targeted therapy with bevacizumab. These trials largely proved unsuccessful. However, bevacizumab turned out to be efficient when administered in combination with other anticancer drugs. The efficacy of this approach is explained by the ability of bevacizumab to eliminate immature blood vessels thus normalizing intratumoral blood flow and improving the delivery of cytotoxic or targeted agents. This report describes four cases of heavily pretreated patients with metastatic HER2-positive breast cancer, who had no meaningful treatment options left, and who received single-agent bevacizumab as an empirical last-resort therapy. Three of these patients had severe complaints, and they demonstrated striking symptomatic relief within the first day of this treatment. In addition to the observed "Lazarus response", which was likely attributed to the bevacizumab-driven resolution of edema, some evidence of a direct antitumor effect was observed. These data may call for the reconsideration of bevacizumab monotherapy in patients with HER2-associated breast cancer, and perhaps in some other categories of cancer patients.

Is single versus combination therapy problematic in the treatment of cutaneous melanoma?

Introduction: The development of immunotherapies and targeted therapies has changed the treatment approach in resectable, nonresectable, and metastatic melanoma. Because of their different pharmacological profiles, immunotherapies and/or targeted therapies have been studied in various combinations. Areas covered: We reviewed PubMed for most important clinical trials investigating efficacy and tolerability of combinatorial and single-agent approaches for the treatment of melanoma that were published up to June 2019. We discuss the most promising therapy approaches and highlight challenges of melanoma treatment. Expert opinion: Combinatorial approaches seem to be very promising in the treatment of resectable and advanced melanoma. Currently, dual immune checkpoint inhibition (ICI) with nivolumab and ipilimumab offers the best first-line treatment option for patients with BRAF-wt and -mutated, advanced melanoma. It is therapy of choice in younger patients with good ECOG performance status and poor prognostic features, whereas ICI monotherapy should be preferred in elderly patients with advanced melanoma. Benefit-risk ratio, patient's QoL and expectations, as well as treatment costs have to be considered in the choice of treatment. However, to elucidate mechanisms of resistance, biomarkers of response and to better define personalized strategies in the treatment of cutaneous melanoma, larger clinical trials comparing combined versus sequential therapies are necessary.

Bevacizumab and ovarian cancer

Bevacizumab is a recombinant humanized monoclonal IgG1 antibody that targets vascular endothelial growth factor-A, and is indicated in the treatment of various tumors (colon, lung, renal, and glioblastoma). It has been recently approved for the treatment of ovarian cancer in various countries. This review summarizes the activity and toxicity of bevacizumab in the treatment of ovarian cancer, both as single-agent drug and in combination with cytotoxic chemotherapy. As a single-agent drug, it has shown response rates of 16-21% in the treatment of recurrent ovarian cancer. Two phase III randomized trials have been published evaluating the addition of bevacizumab to standard chemotherapy as front-line treatment of advanced ovarian cancer. In addition, trials evaluating the combination with chemotherapy in recurrent ovarian cancer (platinum-sensitive and platinum-resistant disease) have also been reported. All these trials showed a statistically significant improvement in progression-free survival although no improvement in overall survival has been reported. The main adverse event is hypertension. Other serious, but uncommon adverse events include gastrointestinal perforation as well as renal and central nervous system toxicity.