Osimertinib treatment based on plasma T790M monitoring in patients with EGFR-mutant non-small cell lung cancer (NSCLC): EORTC Lung Cancer Group 1613 APPLE phase II randomized clinical trial

BACKGROUND

The APPLE trial aimed to evaluate the feasibility of longitudinal plasma EGFR T790M monitoring for the best sequencing strategy of gefitinib and osimertinib.

METHODS

APPLE is a randomized, non-comparative, phase II study in patients with common EGFR-mutant, treatment-naïve NSCLC including 3-arms: Arm A (osimertinib upfront until RECIST progression, PD), Arm B (gefitinib until emergence of circulating tumor DNA EGFR T790M mutation by cobas EGFR Test v2 or RECIST PD) and Arm C (gefitinib until RECIST PD), and then switch to osimertinib in both arms. The primary endpoint is the progression-free survival rate "on osimertinib" at 18 months (PFSR-OSI-18) after randomization in Arm B (H₀: PFSR-OSI-18 of ≤40%). Secondary endpoints include response rate, overall survival (OS) and brain PFS (BPFS). We report the results of Arms B and C.

RESULTS

From November 2017 to February 2020, 52 and 51 patients were randomized into Arms B and C. Most patients were females (70%) and had EGFR Del19 (65%); one-third had baseline brain metastases. In Arm B, 17% of patients (8/47) switched to osimertinib based on the emergence of ct-DNA T790M mutation before RECIST PD, with a median time to molecular PD of 266 days. The study met its primary endpoint of PFSR-OSI-18 by 67.2% (84% CI: 56.4-75.9%) in Arm B vs. 53.5% (84% CI 42.3-63.5%) in Arm C, with a median PFS of 22.0 months vs. 20.2 months, respectively. The median OS was not reached in Arm B vs. 42.8 months in Arm C. Median BPFS in Arms B and C were 24.4 months and 21.4 months, respectively.

CONCLUSIONS

The serial monitoring of ct-DNA T790M-status in advanced EGFR-mutant NSCLC during treatment with first-generation EGFR inhibitors was feasible, and a molecular progression before RECIST PD led to an earlier switch to osimertinib in 17% of patients with satisfactory PFS and OS outcomes.

IFCT-1502 CLINIVO: real-world evidence of long-term survival with nivolumab in a nationwide cohort of patients with advanced non-small-cell lung cancer

BACKGROUND

Immunotherapy using inhibitors targeting immune checkpoint programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) is currently the standard of care in patients with advanced non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

We carried out a nationwide cohort retrospective study of consecutive patients with advanced, refractory NSCLC who received nivolumab as second to later lines of treatment as part of the expanded access program. Key objectives were to assess the efficacy and safety of nivolumab and the efficacy of first post-nivolumab treatment.

RESULTS

Nine hundred and two patients were enrolled: 317 (35%) with squamous cell carcinoma and 585 (65%) with non-squamous cell carcinoma. Median age was 64 years; there were 630 (70%) men, 795 (88%) smokers, 723 (81%) patients with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0/1, 197 (22%) patients with brain metastases, and 212 (27%) with liver metastases. Best response was partial response for 16.2% and stable disease (SD) for 30.5%. Progression-free survival and overall survival (OS) rates at 2, 3, and 5 years were 8% and 25%, 6% and 16%, and 4% and 10%, respectively. At multivariate analysis, ECOG PS ≥2 [hazard ratio (HR) = 2.13, 95% confidence interval (95% CI) 1.78-2.55, P < 0.001], squamous histology (HR = 1.17, 95% CI 1.01-1.36, P = 0.04), and presence of central nervous system metastases (HR = 1.29, 95% CI 1.08-1.54, P = 0.005) were significantly associated with lower OS. Four hundred and ninety-two patients received at least one treatment after discontinuation of nivolumab, consisting of systemic therapies in 450 (91%). Radiation therapy was delivered to 118 (24%) patients.

CONCLUSION

The CLINIVO cohort represents the largest real-world evidence cohort with the use of immune checkpoint inhibitor in advanced, metastatic NSCLC after failure of first-line chemotherapy, with long-term follow-up and analysis of subsequent therapies. Our data confirm the efficacy of nivolumab in a cohort larger than that reported in landmark clinical trials and identify prognostic factors, which reinforces the need for accurate selection of patients for treatment with immune checkpoint inhibitors. Our data indicate that oligoprogression is frequent after nivolumab exposure and provide a unique insight into the long-term survival.

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.

Proposals for managing patients with thoracic malignancies during COVID-19 pandemic

The objective of this document is to formalize a degraded mode management for patients with thoracic cancers in the context of the COVID-19 pandemic. The proposals are based on those of the French High Council for Public Health, on published data outside the context of COVID-19, and on a concerted analysis of the risk-benefit ratio for our patients by a panel of experts specialized on thoracic oncology under the aegis of the French-Language Society of Pulmonology (SPLF)/French-language oncology group. These proposals are evolving (10 April 2020) according to the situations encountered, which will enrich it, and are to be adapted to our institutional organisations and to the evolution of resources during the COVID-19 epidemic. Patients with symptoms and/or COVID-19+ are not discussed in this document and are managed within the framework of specific channels.

Somatic profile in lung cancers is associated to reproductive factors in never-smokers women: Results from the IFCT-1002 BioCAST study

BACKGROUND

Lung cancer in women is on the rise, with a higher proportion occurring in lifelong never-smokers. Lung cancer in never-smokers (LCINS) exhibits a high frequency of driver oncogene alterations. In this study, we aimed to investigate whether exposure to reproductive factors in women with LCINS may modulate the molecular pattern.

METHODS

All newly diagnosed LCINSs were included in a prospective, observational study (IFCT-1002 BioCAST). Each patient responded to a questionnaire including reproductive factors. Biomarker test results were also collected.

RESULTS

Two hundred and sixty women were included in this analysis, and 166 alterations were characterized. EGFR mutation frequency proved greater among patients with late menarche (74% in age>14 vs. 40% and 41% for 12-14 and ≤12 years, respectively; P=0.020) and tended to decrease with increasingly late age at menopause. In multivariate analysis, EGFR mutation frequency increased by 23% per increment of 1 year of age at menarche (P=0.048), and by 9% for each year at age at first birth (P=0.035). ALK alteration frequency was greater in women with high parity (50% in≥5 vs. 12% and 7% for 1-4 and nulliparity, respectively; P=0.021).

CONCLUSION

In a cohort of women LCINSs, female hormonal factors appear to impact molecular pattern.

Crizotinib in c-MET- or ROS1-positive NSCLC: results of the AcSé phase II trial

BACKGROUND

In 2013, the French National Cancer Institute initiated the AcSé program to provide patients with secure access to targeted therapies outside of their marketed approvals. Efficacy and safety was then assessed using a two-stage Simon phase II trial design. When the study design was designed, crizotinib was approved only as monotherapy for adults with anaplastic lymphoma kinase plus non-small-cell lung cancers (NSCLC).

PATIENTS AND METHODS

Advanced NSCLC patients with c-MET ≥6 copies, c-MET-mutated, or ROS-1-translocated tumours were enrolled in one of the three cohorts. Patients were treated with crizotinib 250 mg twice daily. Efficacy was assessed using the objective response rate (ORR) after two cycles of crizotinib as primary outcome. Secondary outcomes included disease control rate at four cycles, best ORR, progression-free survival, overall survival, and drug tolerance.

RESULTS

From August 2013 to March 2018, 5606 patients had their tumour tested for crizotinib targeted molecular alterations: 252 patients had c-MET ≥6 copies, 74 c-MET-mutation, and 78 ROS-1-translocated tumour. Finally, 25 patients in the c-MET ≥6 copies cohort, 28 in the c-MET-mutation cohort, and 37 in the ROS-1-translocation cohort were treated in the phase II trial. The ORR was 16% in the c-MET ≥6 copies cohort, 10.7% in the mutated, and 47.2% in the ROS-1 cohort. The best ORR during treatment was 32% in the c-MET-≥6 copies cohort, 36% in the c-MET-mutated, and 69.4% in the ROS-1-translocation cohort. Safety data were consistent with that previously reported.

CONCLUSIONS

Crizotinib activity in patients with ROS1-translocated tumours was confirmed. In the c-MET-mutation and c-MET ≥6 copies cohorts, despite insufficient ORR after two cycles of crizotinib, there are signs of late response not sufficient to justify the development of crizotinib in this indication. The continued targeting of c-MET with innovative therapies appears justified.

CLINICAL TRIAL NUMBER

NCT02034981.

Alectinib versus chemotherapy in crizotinib-pretreated anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer: results from the phase III ALUR study

Background

This is the first trial to directly compare efficacy and safety of alectinib versus standard chemotherapy in advanced/metastatic anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer (NSCLC) patients who have progressed on, or were intolerant to, crizotinib.

Patients and methods

ALUR (MO29750; NCT02604342) was a randomized, multicenter, open-label, phase III trial of alectinib versus chemotherapy in advanced/metastatic ALK-positive NSCLC patients previously treated with platinum-based doublet chemotherapy and crizotinib. Patients were randomized 2 : 1 to receive alectinib 600 mg twice daily or chemotherapy (pemetrexed 500 mg/m² or docetaxel 75 mg/m², both every 3 weeks) until disease progression, death, or withdrawal. Primary end point was investigator-assessed progression-free survival (PFS).

Results

Altogether, 107 patients were randomized (alectinib, n = 72; chemotherapy, n = 35) in 13 countries across Europe and Asia. Median investigator-assessed PFS was 9.6 months [95% confidence interval (CI): 6.9–12.2] with alectinib and 1.4 months (95% CI: 1.3–1.6) with chemotherapy [hazard ratio (HR) 0.15 (95% CI: 0.08–0.29); P < 0.001]. Independent Review Committee-assessed PFS was also significantly longer with alectinib [HR 0.32 (95% CI: 0.17–0.59); median PFS was 7.1 months (95% CI: 6.3–10.8) with alectinib and 1.6 months (95% CI: 1.3–4.1) with chemotherapy]. In patients with measurable baseline central nervous system (CNS) disease (alectinib, n = 24; chemotherapy, n = 16), CNS objective response rate was significantly higher with alectinib (54.2%) versus chemotherapy (0%; P < 0.001). Grade ≥3 adverse events were more common with chemotherapy (41.2%) than alectinib (27.1%). Incidence of AEs leading to study-drug discontinuation was lower with alectinib (5.7%) than chemotherapy (8.8%), despite alectinib treatment duration being longer (20.1 weeks versus 6.0 weeks).

Conclusion

Alectinib significantly improved systemic and CNS efficacy versus chemotherapy for crizotinib-pretreated ALK-positive NSCLC patients, with a favorable safety profile.

Trial registration

ClinicalTrials.gov NCT02604342; Roche study MO29750

[Immune-related adverse events after immune checkpoints inhibitors in 2019: An update]

Use of checkpoint inhibitors to treat cancer was one of the most important revolution these last years and an increasing number of new types of tumors is currently under investigation with these new treatments. However, immune-related adverse events associated with these agents frequently affect various organs, mimicking auto-immune or inflammatory diseases. Some of these effects can be severe, often requiring hospitalization and specialized treatment (immunosuppression). Most known agents are ipilimumab (anti-CTLA-4 antibody) nivolumab and pembrolizumab (anti-PD-1 antibodies). New molecules are now approved or in development as anti-PD-L1 antibodies, anti-LAG-3 or anti-TIM-3 antibodies, increasing the probability and new description of immune-related adverse events. With his experience in auto-immune diseases, the immunologist/internal medicine specialist has an important role in the management of these toxicities. The goal of this review is to focus on the incidence, diagnostic assessment and recommended management of the most relevant immune-related adverse events.

Lung cancer patients with HER2 mutations treated with chemotherapy and HER2-targeted drugs: results from the European EUHER2 cohort

BACKGROUND

HER2 mutations have been identified as oncogenic drivers in lung cancers and are found in 1-2% of lung adenocarcinomas. There is, to date, no standard of care for these patients. We thus aim to study the therapeutic outcomes of patients harboring HER2 mutations and establish the efficacy of various drug regimens.

PATIENTS AND METHODS

This retrospective cohort study in European centers assessed patients with advanced non-small-cell lung cancer (NSCLC), a known HER2 exon-20 insertion, treated with chemotherapy and/or HER2-targeted drugs.

RESULTS

We identified 101 eligible patients from 38 centers: median age 61 years (range: 30-87), 62.4% women, 60.4% never-smokers. All tumors were adenocarcinomas. Concomitant EGFR mutations, ALK translocations, and ROS translocations were observed in 5, 1, and 1 patients, respectively. The median number of treatment lines was 3 (range: 1-11). The median overall survival was 24 months. Overall response rate (ORR) and the median progression-free survival (PFS) with conventional chemotherapy (excluding targeted therapies) were 43.5% and 6 months in first-line (n = 93), and 10% and 4.3 months in second-line (n = 52) therapies. Sixty-five patients received HER2-targeted therapies: trastuzumab = 57, neratinib = 14, afatinib = 9, lapatinib = 5, T-DM1 = 1. ORR was 50.9% and PFS was 4.8 months with trastuzumab or T-DM1.

CONCLUSION

This series shows the chemosensitivity of HER2-driven NSCLC, and the potential interest of HER2-targeted agents. Our results should help to define the best therapeutic strategy for these patients and to orient future clinical trials.

Multicenter observational study of erlotinib therapy (OBSTAR) for non small-cell lung cancer: a GFPC study

CONTEXT

Erlotinib therapy for non small-cell lung cancer (NSCLC) has mainly been evaluated in randomized trials.

METHOD

OBSTAR was a multicenter, retrospective, observational study involving all patients treated with erlotinib in 18 French centers between June 2005 and September 2007. The analyses focused on the patients' characteristics, previous treatments, and treatment efficacy during a three-year follow-up period.

RESULTS

534 patients were included in this study. The median survival times were respectively 5.2 [3.7-7.4] and 4.7 [4.1-5.7] months, depending to whether erlotinib was used as second- (n=190), or ≥ third-line treatment (n=305). The disease control rate were 39.1% [30.2-48.7] and 29.9% [29.6-36.9] according to the line of treatment. Factors predictive of an objective response were gender, age, and smoking status. Factors predictive of progression were age, sex, smoking status, the line of treatment, and the number of metastases. Treatment had to be interrupted for toxicity in 8.5% of cases.

CONCLUSION

This study of erlotinib therapy in 2005-2007 confirms, in the general NSCLC patient population, the results of pivotal trials.

[Incidence and characteristics of bronchial colonisation in patient with lung cancer: a retrospective study of 388 cases]

INTRODUCTION

Bronchial colonisation is frequently reported in patients with lung cancer. These colonisations could influence patient therapeutic management and prognosis. The aim of our study is refine incidence and nature of bronchial colonisations in patients presenting with lung cancer.

METHODS

Three hundred and eighty-eight patients with lung cancer underwent a flexible bronchoscopy at the time of diagnosis. Among them, 216 patients had a bacteriological, mycobacteriological and fungal investigation. Type and frequency of these colonisations were analyzed.

RESULTS

Potential pathogens were found in 39.8% of samples, including mainly 39.8% of Gram-negative bacilli (Haemophilus influenzae, Enterobacter sp., Escherichia coli). In addition, we found 0.9% of mycobacteria and 13.9% of Candida albicans. Among these 216 patients where microbiological analysis was performed, patient features and tumor stage were not significantly correlated to microbial colonisation.

CONCLUSIONS

Colonisation of airways is frequently reported when a lung cancer is diagnosed. Our data suggest that bronchial colonisation should be prospectively collected due to its potential interest in the management of lung cancer patients.

[Radiofrequency ablation of primary lung cancer: a single centre experience]

INTRODUCTION

Radiofrequency ablation is a new interventional radiological technique for the treatment of primary or secondary lung tumors of small size (less than 3 cm) in inoperable patients or patients unsuitable for external radiotherapy. This procedure is already used in liver and renal cancers and metastases, and is now being evaluated in primary and secondary lung tumors.

METHODS

We have followed-up, by CT scanning, 12 consecutive patients with primary lung tumors treated by radiofrequency ablation in our institution between 2004 and 2008.

RESULTS

Our study shows that radiofrequency ablation is well-tolerated with few minor side effects (75% pneumothorax) and no major side effects. Moreover, it gives good local control (8.3% local progression).

CONCLUSIONS

Radiofrequency appears to be a valuable alternative to surgery for inoperable patients presenting with a small primary lung tumor.

[Stenting for superior vena cava obstruction associated with lung cancer: monocentric study]

INTRODUCTION

Superior vena cava obstruction is an urgent complication of lung cancer. Superior vena cava stent insertion can be considered to provide rapid relief of the symptoms.

METHODS

To estimate the efficiency and the complications of this procedure, we retrospectively analyzed 41 consecutive patients treated during the last 5 years by self-expanding nitinol stent insertion for superior vena cava obstruction due to lung cancer. It was combined with anticoagulation and corticosteroids.

RESULTS

41 patients benefited from this treatment (30 men and 11 women) with an average age of 59 years. Etiologies of the vena cava obstruction were: small cell carcinoma (11), adenocarcinoma (8), squamous cell carcinoma (9), large cell carcinoma (9) and others (4). All patients were symptomatic. The average period between the onset of symptoms and the vascular stenting was 14 days. Specific treatment was chemotherapy (18 patients), radiotherapy (1 patient), or both (14 patients), and no specific treatment for 6 patients. The procedure consisted of the insertion of 1 (73%) or 2 (27%) stents, with an average length and caliber of 7.5 cm and 14 mm respectively. No major complication was reported in short and long-term follow up. Symptomatic improvement was observed for all the patients within 48 hours. Median survival after the stenting was of 6.7 months.

CONCLUSION

In our study, vascular stenting for malignant superior cava vena obstruction allows a rapid improvement of the symptoms with very few complications, suggesting a possible role as first line treatment for chemo or radio-resistant tumours.

Pemetrexed in combination with cisplatin or carboplatin as adjuvant chemotherapy in early-stage NSCLC

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Background: Platinum based chemotherapy after complete resection of stage I-IIIa non-small cell lung cancer (NSCLC) has improved 5-yr survival by 4–15%. Pemetrexed (P) in combination with cisplatin (C) or carboplatin (Carb) has shown to be effective and safe in first-line Tx of advanced NSCLC, thus being a promising option in the adjuvant setting. Methods: Multicenter, open phase 2 in pts with resected stage Ib/II NSCLC. Pts were randomized to P (500 mg/m2)+C (75mg/m2) or P (500 mg/m2)+Carb (AUC5) d1 q3 wks, for 4 cycles; adequate organ function and ECOG PS 0–1 required. Primary endpoint was feasibility of the regimen defined as compliance to 4 Tx cycles with ≥ 95% of planned dose without ≥ Grade 3 toxicities (tox) at 30 d after last infusion. A regimen was deemed feasible if the rate (feasible pts/total pts) was >60%. Results: Please see Table for results. Conclusions: According to the strict definitions in this protocol neither regimen was feasible. The reason was poor compliance with at least one of the components that defined feasibility, but dose intensity and % pts completing cycle 4 was notably high, compared to other adjuvant trials. P+C was the more favourable regimen concerning feasibility and tolerability. In terms of tolerability pemetrexed could be combined with either platinum compound.

[Table: see text]

[Table: see text]

[Efficacy and tolerance of bevacizumab in non-small cell lung cancer: preliminary report]

INTRODUCTION

Bevacizumab is an antiangiogenic drug targeting VEGF. Its interest, in combination with chemotherapy, has been demonstrated in two recent trials in metastatic non-small cell lung cancer and its approval is awaited within few weeks. Due its original mechanism of action, bevacizumab has a very specific safety profile and radiological response patterns.

METHOD

Based upon selected observations reported from patients included in clinical trials and on recent literature, we bring some clue for a better and safer use of bevacizumab.

RESULTS

We report toxicity associated with bevacizumab, especially vascular side-effects and unusual radiological responses.

CONCLUSION

Bevacizumab use in NSCLC is associated with some unexpected side effects and responses that worth to be known by pulmonologists. Selections criteria should be rigorously followed.

Diagnostic value of bronchoscopy, CT and transbronchial biopsies in diffuse pulmonary lymphangiomatosis: case report and review of the literature

The authors present the case of a 48-year-old man with diffuse pulmonary lymphangiomatosis. This rare lymphatic disorder is characterized by proliferation of anastomosing lymphatic vessels varying in size. Clinical presentation and imaging findings are highly suggestive. Bronchoscopic examination of this patient showed, for the first time to our knowledge, vesicles disseminated throughout the bronchial tree. Histopathological examinations are necessary to differentiate lymphangiomatosis from lymphangiectasis. The diagnosis can be made by transbronchial biopsy without performing open lung biopsy which was, until now, considered necessary for diagnosis.