Immune checkpoint inhibitors versus second line chemotherapy for patients with lung cancer refractory to first line chemotherapy

PURPOSE

Anti Programmed Death-ligand (PD1/PD-L1) directed immune-checkpoint-inhibitors (ICI) are widely used to treat patients with advanced non-small cell lung cancer (NSCLC) who progress after first line chemotherapy. The best strategy after early progression under first line has not been specifically studied.

PATIENTS AND METHODS

We conducted a multicenter, retrospective study including all consecutive NSCLC patients progressing within the first 3 months following introduction of first-line chemotherapy and being treated with second line ICI monotherapy or chemotherapy between March 2010 and November 2017. We analysed the clinicopathological data and outcome under second line chemotherapy vs. second line ICI: objective response rate (ORR), progression-free survival (PFS), overall survival (OS.

RESULTS

We identified 176 patients with refractory disease, 99 who received subsequent immunotherapy and 77 undergoing chemotherapy. The 2 populations were comparable regarding the main prognostic criteria, median age was 60, main histology was adenocarcimoma (68.2%). PFS was not significantly different between both treatments 1.9 [1.8-2.1] versus 1.6 month [1.4-2.0] (P=0.125). Compared to chemotherapy, ICI treated patients had a superior OS (P=0.03) (Median [95% CI] OS 4.6 [2.8-6.7] versus 4.2 months [3.4-5.9] and a non-significant improvement in ORR (17.2% versus 7.9%, respectively, P=0.072). Poor performance status (ECOG PS≥2) and a higher number of metastatic sites (≥3) were associated with poorer prognosis. KRAS-mutated patients did not seem to benefit more from ICI than chemotherapy.

CONCLUSIONS

ICI appears to be the preferred second-line treatment for patients who are refractory to first line chemotherapy.

Pulmonary embolism revealed on helical CT angiography: comparison with ventilation-perfusion radionuclide lung scanning

OBJECTIVE

We compared helical CT angiography and ventilation-perfusion radionuclide lung scanning as initial tests in the diagnosis of acute pulmonary embolism.

SUBJECTS AND METHODS

Two hundred sixteen consecutive patients who were clinically suspected of having acute pulmonary embolism underwent helical CT angiography, ventilation-perfusion radionuclide lung scanning, and Doppler sonography of the veins of the legs. On the basis of concordance of the results for ventilation-perfusion radionuclide lung scanning and helical CT angiography and on the degree of clinical suspicion, certain patients underwent pulmonary angiography. Patients without pulmonary embolism at initial evaluation in whom no treatment was instituted were followed up for at least 3 months to determine the potential recurrence of thromboembolic disease.

RESULTS

Of the 216 patients, 37 (17%) were excluded because of insufficient data to assess the initial event. Final diagnosis for the 179 remaining patients was pulmonary embolism in 68 (37.9%) and no pulmonary embolism in 111 (62.0%), based on pulmonary angiography in 23 patients (12.8%) and concordant imaging findings and outcome in the remaining patients. Statistically significant differences (p < 0.05) were found between sensitivity, specificity, positive predictive value, and negative predictive value for helical CT angiography and ventilation-perfusion radionuclide lung scanning (94.1% versus 80.8%; 93.6% versus 73.8%; 95.5% versus 82%; and 96.2% versus 75.9%, respectively). Interobserver agreement was excellent for helical CT angiography (kappa = 0.72) and moderate for ventilation-perfusion radionuclide lung scanning (kappa = 0.22).

CONCLUSION

Helical CT angiography could replace ventilation-perfusion radionuclide lung scanning as the initial test for screening patients who are clinically suspected of having pulmonary embolism.