Adverse Events Associated with Encorafenib Plus Cetuximab in Patients with BRAFV600E-mutant Metastatic Colorectal Cancer: An in-depth Analysis of the BEACON CRC Study

BACKGROUND

The BRAF inhibitor encorafenib in combination with cetuximab was recently approved for patients with BRAF^V600E-mutated (BRAF^V600Emut) metastatic colorectal cancer (mCRC). Approval was based on positive results from the phase 3 BEACON CRC study in BRAF^V600Emut mCRC patients who had progressed after 1-2 previous regimens. This analysis provides a detailed examination of the adverse events (AEs) of interest (AEIs) with encorafenib+cetuximab in the BEACON study to aid gastrointestinal oncologists, given the limited experience with this combination.

MATERIALS AND METHODS

AEIs, including dermatological AEs, arthralgia/myalgia, nausea/vomiting, diarrhea, abdominal pain, fatigue/asthenia and nephrotoxicity, were examined in the doublet therapy group. Clinical characteristics associated with these AEs, AE grade, time to onset and time to resolution were also studied.

RESULTS

Safety analysis included 216/220 patients randomized to doublet therapy. The most commonly occurring AEI was dermatological toxicity (75.5%), followed by arthralgia/myalgia (56.0%) and fatigue/asthenia (56.0%). Other than nephrotoxicity (7 patients; 5/7 with Grade 3 or 4), most AEs were Grade 1 or 2. Most AEs were more common in women than men (nausea/vomiting, diarrhea, abdominal pain, dermatological AEs, and arthralgia/myalgia). Nausea/vomiting, abdominal pain and fatigue/asthenia were more common in patients aged ≥70 years. Most AEs developed early, within the first 1-2 months of treatment, and resolved within 1-2 weeks. In addition, survival outcomes were better in patients experiencing arthralgia/myalgia or dermatological toxicities.

CONCLUSION

This analysis indicated that, except for rare cases of nephrotoxicity, encorafenib+cetuximab is well tolerated in most patients, with most AEIs being mild-to-moderate in severity, occurring early and resolving rapidly.

CLINICAL TRIAL REGISTRATION

the BEACON study (ClinicalTrials.gov, NCT02928224; EudraCT, 2015-005805-35).

Safety and Effectiveness of Aflibercept + Fluorouracil, Leucovorin, and Irinotecan (FOLFIRI) for the Treatment of Patients with Metastatic Colorectal Cancer (mCRC) in Current Clinical Practice: OZONE Study

For patients with metastatic colorectal cancer (mCRC) that have failed a first-line oxaliplatin-based regimen, the preferred treatment option is an irinotecan-based regimen. This prospective, observational, noncomparative, post-authorization safety study (OZONE) evaluated the safety and effectiveness of aflibercept plus fluorouracil, leucovorin, and irinotecan (FOLFIRI) in patients with mCRC treated in daily practice after failure of an oxaliplatin-based regimen. Patients were grouped by age, renal impairment, hepatic impairment, race, number, and type of prior anticancer therapy. Of 766 treated patients enrolled, 59.5% were male, 94.8% had an Eastern Cooperative Oncology Group performance status of 0–1, all received previous chemotherapy (97.8% including oxaliplatin), and 58.6% had prior exposure to bevacizumab. At least one grade ≥ 3 treatment-emergent adverse event (TEAE) was reported in 68.3% of patients. Neutropenia, hypertension, diarrhea, and asthenia were the most frequently occurring grade ≥ 3 TEAEs. Antivascular endothelial growth factor class events were infrequent. Subgroup analyses did not reveal major differences in the safety profile according to age, renal and hepatic status, race, or prior anticancer therapy. For the total population, median overall survival was 12.5 months, median progression-free survival was 6.1 months, and overall response rate was 16.3%. Aflibercept in combination with FOLFIRI is a safe and efficacious regimen administered in current clinical practice to patients with mCRC previously treated with oxaliplatin. The study results, conducted in real-world clinical practice with a less selected patient population, are aligned with the VELOUR (NCT00561470) trial and no new safety issues were identified.

Post hoc safety and effectiveness analysis of aflibercept + FOLFIRI for patients with metastatic colorectal cancer (mCRC) previously treated with antiepidermal growth factor receptor (EGFR) therapy in OZONE

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Background: Anti-EGFR therapies are frequently given as first-line therapy for patients with mCRC, while anti-angiogenic therapies may be suitable at any line. Despite improving outcomes for patients with mCRC, there is still an unmet need regarding the optimal treatment sequence. In this post hoc analysis, the safety and effectiveness of aflibercept + FOLFIRI was evaluated for patients with mCRC based on their prior anti-EGFR therapy use. Methods: OZONE is a prospective, multicenter, observational, non-comparative study evaluating patients receiving aflibercept + FOLFIRI in the clinical setting, for 24 months from aflibercept initiation or until death. Patients were retrospectively assessed according to prior use of anti-EGFR therapy (defined as patients who received cetuximab and/or panitumumab as previous anti-cancer therapy). Overall survival (OS) and progression-free survival (PFS) were analyzed by hazard ratios (HR) and 95% confidence intervals (CI); overall response rate (ORR) was analyzed by odds ratios (OR) and 95% CI. Results: Among the overall treated population (N = 766), 19.2% (n = 147) received prior anti-EGFR therapy. Prior anti-EGFR therapy had no significant impact on the median OS (11.47 vs 12.58 months; HR [95% CI] 1.112 [0.889–1.390]), median PFS (5.29 vs 6.24 months; HR [95% CI] 1.022 [0.830–1.260]), or ORR (14.96% vs 18.75%; OR [95% CI] 0.597 [0.332–1.071]) of patients vs those who did not receive prior anti-EGFR therapy. Rates of grade ≥ 3 treatment-emergent adverse events (TEAEs) were similar between patients who did vs did not receive prior anti-EGFR therapy (70.7% vs 67.7%). The most frequently reported grade ≥ 3 TEAEs for patients who did vs did not receive prior anti-EGFR therapy were neutropenia (12.2% vs 15.0%), hypertension (8.8% vs 10.3%), and diarrhea (10.2% vs 9.4%). Conclusions: This post hoc analysis of the OZONE study did not reveal major differences in safety and effectiveness according to prior anti-EGFR therapy. Clinical trial information: ENCEPP/SDPP/4836.

Randomized phase II study on the influence of BRAF and PIK3CA mutations on the efficacy of FOLFIRI plus bevacizumab (Bev) or cetuximab (Cet), as first line therapy of patients (pts) with RAS wild-type metastatic colorectal carcinoma (mCRC) and <3 baseline circulating tumor cells (bCTCs)

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Background: The outcome for mCRC has changed since the introduction of new chemotherapy schedules and targeted therapies, however new predictive biomarkers are needed. bCTCs and BRAF / PIK3CA mutations have been studied as a potential predictive biomarkers. The primary endpoint was progression-free survival (PFS) in pts WT KRAS and <3 bCTCs, according to BRAF/ PIK3CA status. Methods: This is an open, multicentric, randomized phase II trial and included wildtype KRAS mCRC pts (RAS after approval of protocol amendment), younger than ≤70 with <3 bCTCs, ECOG 0-1 and available tissue for molecular analyses. Pts were stratified per number of metastatic organs involved (1 vs >1) and mutation status of BRAF and/or PIK3CA (WT vs MUT) and randomized to group A (FOLFIRI+Bev) or group B (FOLFIRI+Cet). Results: 240 pts (196 WT and 44 MUT: 6 BRAF, 12 PIK3CA and 6 BRAF + PIK3CA) were included. General characteristics per mutation status (WT vs MUT): Mean age (59 vs 61 years), gender (Male/Female 68/32 vs 70/30%), ECOG 0/1 (57/43 vs 66/34%), primary tumor unresected (48 vs 64%), RAS MUT in 12 pts (11 and 1 pts, respectively), previous chemotherapy (12 vs 9%). Overall response rate (ORR) was 52 and 41% in the WT and MUT groups, respectively. PFS and overall survival (OS) are presented in the table. Conclusions: In the low risk mCRC pts according to bCTCs, BRAF and/or PIK3CA MUT have a negative impact in OS and a trend to worse PFS in the ITT population. The impact of treatment is under evaluation and will be provided during the meeting. Clinical trial information: 2012-000840-90. [Table: see text]

Prognostic models in advanced gastric cancer in first and second line chemotherapy treatment in Spanish population

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Background: No globally accepted prognostic score has been developed in advanced gastric cancer (AGC). The purpose of this study is to explore baseline host or tumor related prognostic factors in spanish AGC patients in first and second line chemotherapy treatment. In addition we compare our scores with previously published scores in asian and european population. Methods: A total of 166 patients with AGC treated in our institution between 2012 and 2016 were screened. 119 received first line chemotherapy (CT) and 47 of them also received second line CT and were included in the analysis. Prognostic factors were evaluated using the Cox proportional hazard model. We use as comparators four first line and three second line scores published in literature. Results: The overal survival (OS) in first line and second line patients were 9 and 5 months. To construct first line CT score we selected four risk factors: ECOG≥2, Her2 negative, Irinotecan based CT and albumin < 3,6mg/dl. OS were 23 months in low risk group, who had zero or one risk points, 15 months for patients in the moderate risk group, who had two or three risk points, and 5 months for patients in the high risk group, who had all four risk points. In the second line CT score we included four risk factors: ECOG ≥2, albumin < 3.6mg/dl, Hb < 11.5mg/dl and CA19.9 reduction less than 30% after 2 CT cycles. OS were 30 months in low risk group, who had zero or one risk points, 16 months for patients in the moderate risk group, who had two or three risk points, and 3 months for patients in the high risk group, who had all four risk points. Conclusions: In the present study, we propose two new prognostic scores for patients with AGC developed in the same cohort and including HER2 status. This prognostic model could help clinicians choose and applicable treatment based on the stimated prognosis. [Table: see text]

Impact of vascular endothelial growth factor (VEGF) and hypoxia-inductible factor-1 alpha (HIF-1) expression on the prognosis of locally advanced cervical carcinoma (LACC) treated with radiochemotherapy

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Background: Combination of radiotherapy plus platinum-based chemotherapy (RT-CT) is considered the standard treatment in LACC. The risk of recurrence after local treatment is around 50-70%. The role of angiogenesis in tumor progression has been shown in large series. The aim of this study was to determinate the impact of the expression of VEGF and HIF-1 on disease-free survival (DFS) and overall survival (OS) in patients with LACC receiving RT-CT. Methods: Expression of VEGF and HIF–1 was assessed by an immunohistochemistry (IHC) assay in 115 cases. Inmunostainning was considered negative (< 10% of cells), slightly positive (< 25%), moderate (26%-50%) and strongly positive (> 50%). A univariate analysis was carried out for each variable using the log-rank test. Subsequently, a multivariate analysis was performed employing Cox’s proportional hazards model. Results: 115 patients (p) with LACC were included and received RT-CT between January/2003 and December/2012. IHC revealed absence of expression of VEGF in 12 (10,4%) cases, slightly positive in 34 (29,6%), moderate in 30 (26,1%) and strongly positive in 39 (33,9%). The expression of HIF-1 was negative in 63 (54,8%) cases and positive (weak or moderate) in 52 (45,2%). 76p (66,1%) showed a complete clinical response (CR), 26p (22,6%) partial response and 13p (11,3%) stable disease or progression. The median follow–up was 35 months (1-140). 56p (48,7%) relapsed. Univariate analysis indicate that ECOG > 1, tumor size ≥ 4,5 cm, FIGO stage III-IVA, lymph nodes positive, non CR, CA125 post-treatment ≥ 35 U/mL, hemoglobin levels <11 mg/dl (basal, nadir and post-treatment), strong expression VEGF and positive expression of HIF – 1 were all associated with a significant lower OS and DFS. In multivariate analysis strong expression of VEGF remained statistically significant, as tumor size, non CR and hemoglobin level post-treatment < 11g/dL. Conclusions: IHC-assessed strong expression of VEGF was independent prognostic factor of shorter OS and DFS in patients with LACC treated with RT-CT. IHC determination of VEGF could be useful in clinical practice.

Aflibercept (Z) in combination with FOLFIRI for second-line treatment of patients (pts) with metastatic colorectal cancer (mCRC): Safety and quality of life (QoL) data from the Spanish subgroup of the Aflibercept Safety and Quality-of-Life Program (ASQoP)

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Background: In the VELOUR trial, adding Z to FOLFIRI improves OS, PFS and RR in mCRC pts progressing after oxaliplatin ±biologic agents. The ASQoP trial (NCT01571284) was designed to gather safety and QoL data from mCRC in real-life setting. We report data collected by the Spanish investigators. Methods: ASQoP is single-arm, open-label trial evaluating safety and QoL of Z in mCRC pts as 2nd line. Eligible pts received Z (4mg/kg) q2wks on day 1/cycle, followed by FOLFIRI (dosing was at physician’s discretion) until disease progression, unacceptable toxicity, death, or investigator/pt decision. The EQ-5D was used for utility index (UI) measure and the EORTC QLQ-C30 as generic cancer instrument. QoL population consisted of pts completing the questionnaire at baseline and ≥1 assessment post-baseline and received ≥1 part of 1 dose of study treatment. Results: The safety population comprised 77 pts with ≥1 completed cycle of treatment. Grade (G)3/4 AEs were reported in 72.7% of pts (vs 83.5% in VELOUR), being G3 most commonly reported. There was no G4 hypertension, stomatitis, or proteinuria. G4 Diarrhea was found in 1.3% of pts. Mean baseline UI was 0.7 (95% CI, 0.63-0.78) in 51 pts, and remained relatively stable at cycles 3 (n=39) and 7 (n=24), with a mean (±SD) change from baseline of 0.03 (±0.26) and -0.06 (±0.35), respectively. Mean baseline global health status score was 63.1 (95% CI, 55.8-70.4) in 54 pts, and remained stable up to cycle 9 with a mean (±SD) change from baseline of 4.17 (±38). Conclusions: Thisanalysis has identified no new safety signals and suggests an acceptable toxicity profile with a relatively stable UI and QoL in Spanish mCRC pts in the real-life setting. [Table: see text]

Application of solid phase microextraction to the determination of strychnine in blood

A simple and rapid method based on solid phase microextraction (SPME) via direct immersion followed by gas chromatography coupled with electron impact ionization/mass spectrometry (GC/EI-MS) was developed for the determination of strychnine in blood. Papaverine was used as internal standard (I.S.). Two types of fibre coating were tested, 100 microm polydimethylsiloxane and 65 microm Carbowax/Divinylbenzene, the latter giving higher recoveries of the compound. The main factors affecting the SPME process, such as sample dilution (1:10), adsorption and desorption times (20 and 10 min, respectively), carry-over effect (not observed), pH and salt addition (no modifications on pH or salt concentration) were optimized. The procedure was validated in terms of linearity (r(2)=0.9992 for concentrations ranging from 0.10 to 5.00 microg/mL), intra and interday precision (0.93 and 4.62%, respectively at 0.50 microg/mL; 3.33 and 8.06%, respectively at 2.50 microg/mL), sensitivity (6.83 and 8.91 ng/mL for LOD and LOQ, respectively) and extraction recovery (0.54 and 0.39% at 0.50 and 2.50 microg/mL, respectively). The developed procedure was found suitable for forensic investigations and was considered a good alternative to the liquid-liquid extraction methods normally used for the determination of this compound in biological media.

Training in medical informatics: combining onsite and online instruction

The Internet is promoting active exchange of teaching materials and discussion among geographically distant collaborators. We envision that training in medical informatics can be better achieved if both onsite and online instruction are combined, provided that cultural and technological barriers are anticipated and the training program is prepared accordingly. We describe our Brazil/USA program in medical informatics, which includes components of on-site and online education, and discuss lessons learned during its ongoing implementation. Three onsite courses and one workshop have been planned, and two online courses are being developed.

Analytical method for the determination of strychnine in tissues by gas chromatography/mass spectrometry: two case reports

This paper describes an analytical method for strychnine determination in biological samples by gas chromatography/mass spectrometry and their application in the investigation of two cases involving strychnine ingestion: A fatal case and a clinical one. The strychnine is isolated from biological samples using a liquid-liquid extraction procedure. The clean-up procedure is performed using an acid solution. Papaverine is used as internal standard in the quantification of strychnine. In the analysed specimens, the limits of quantification were 0.1 microg/ml or 0.1 microg/g. The recovery rate ranged from 75.0% to 98.7% and the coefficients of variation ranged from 4.8% to 10.5%.

[Progression to IDDM and islet cell antibodies (ICA; ICA-CF)]

We have followed eight first-degree relatives of IDDM patients (insulin-dependent, type I diabetes) attending the outpatient diabetes clinic at the State University of Rio de Janeiro for three years, all of them with positive islet cell antibodies (ICA and/or ICA-CF). Three out of eight relatives less than fifteen years old have subsequently progressed to overt Insulin-Dependent Diabetes Mellitus (IDDM) 12, 21 and 8 months after the first positive autoantibodies detection. Four relatives have remained with ICA and/or ICA-CF positive, and in another one the reaction became negative during the observation period. A positive correlation has been found between high titles of ICA (> or = 1/16) and development of IDDM. We have concluded from our prospective study during three years that of our antibody-positive relatives, 37.5 % have developed overt diabetes, all of them being less than fifteen years old, with high titles of ICA and ICA-CF positive.

[Analysis of various epidemiological parameters in patients with diabetes mellitus type I in the city of Rio de Janeiro, Brazil]

The authors analyzed epidemiological data of 157 type I diabetes patients living in the city of Rio de Janeiro, Brazil. The mean age at the time of study 16 +/- 8.1 years (arithmetic mean +/- standard deviation) and the age at the time of the diagnosis was 12.5 +/- 7.4 years. The diabetes history span was 3.1 +/- 4.3 years and the interval between appearance of symptoms and diagnosis was 30.7 +/- 30.4 days. Neither seasonal nor sex dependent differences were observed, but there was an inverse correlation between the average monthly temperature in Rio de Janeiro and the number of newly diagnosed cases. A first grade family history was positive in 15.9% of patients (11% of type I diabetes). The autoimmunity history was positive in 4.1% of patients (mainly thyroid disease). An infectious disease history was positive in 7% of patients (mainly mumps). Our data suggests that some epidemiological aspects, observed among type I brazilian diabetic patients of a mixed genetic background, are similar to those observed in other populational groups of different ethnic origins.