Brain metastases and lung cancer: molecular biology, natural history, prediction of response and efficacy of immunotherapy

Brain metastases stemming from lung cancer represent a common and challenging complication that significantly impacts patients' overall health. The migration of these cancerous cells from lung lesions to the central nervous system is facilitated by diverse molecular changes and a specific environment that supports their affinity for neural tissues. The advent of immunotherapy and its varied combinations in non-small cell lung cancer has notably improved patient survival rates, even in cases involving brain metastases. These therapies exhibit enhanced penetration into the central nervous system compared to traditional chemotherapy. This review outlines the molecular mechanisms underlying the development of brain metastases in lung cancer and explores the efficacy of novel immunotherapy approaches and their combinations.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Trying to define “high tumor burden” in non-small cell lung cancer: A Delphi survey

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Background: High tumor burden (HTB) has been introduced in several solid tumors as clinical biomarker with negative prognostic value and has also been proposed as a clinical marker in patients with advanced non-small-cell lung cancer (NSCLC). There is no homogeneous definition for HTB in NSCLC and it is unknown whether is useful for guiding therapeutic decisions and how could be used by oncologists in real-world setting. Methods: A panel of 5 oncologists specialized in the management of NSCLC patients elaborated a questionnaire with 26 statements about HTB in advanced NSCLC using a modified Delphi method with a 9-point Likert scale of agreement for each statement. The aim was to define HTB concept and analyze its role in treatment decisions. Statements were grouped into 4 areas: clinical and pathological characteristics, metastatic involvement, clinical symptoms/scenarios and therapeutic implication. 66 Spanish oncologists with a minimum experience of 5 years treating at least 100 lung cancer patients per month were selected to participate. The questionnaire was fulfilled electronically by an internet specific website and all participants were asked to complete it twice: a first round (from December 2020 to February 2021) followed by a deliberation period about first results and then a second round (from June to August 2021). Results: 50 (76%) of the 66 selected experts fulfilled the questionnaire in the first round reaching consensus in 8 (31%) of the 26 statements. 33 (66%) of previous 50 experts fulfilled the questionnaire in the second round reaching consensus in 8 additional statements: 16 (61%) of the 26 statements in total. Consensus was reached in the following statements: HTB is relevant for the initial approach in advanced NSCLC; HTB is equivalent to aggressive disease; HTB is defined by a sum of the longest diameter of target lesions ≥10cm or a primary tumor with a diameter of ≥10 cm, an increase of LDH 2 ≥ ULN, hepatic involvement, lymphangitis, pericardial effusion, brain involvement that cannot be addressed with local techniques, or an oncological emergency; HTB is not defined by an elevation of tumor markers or symptomatic brain involvement; the threshold for the number of metastatic sites that defines HTB is 3; presence of HTB is important in selecting first and second-line treatment; and first treatment option to treat a patient with HTB is a combo of chemotherapy and immunotherapy regardless PDL1 status. On the other hand, consensus was not reached to define HTB by other important factors in clinical practice as high symptomatic burden, ECOG ≥2, weight loss > 10%, presence of pleural effusion or symptomatic bone metastases. Conclusions: Our Delphy survey results show there are only a few factors with a moderate strength of consensus about the definition and therapeutic implication of HTB concept and underscores the need to investigate its prognostic and predictive value as well as an involvement in therapeutic decisions.

Clinical-pathological and molecular characterization of long-term survivors with advanced non-small cell lung cancer

Objective: Long-term survivors (LS) of non-small cell lung cancer (NSCLC) without driver alterations, displaying an overall survival (OS) of more than 3 years, comprise around 10% of cases in several series treated with chemotherapy. There are classical prognosis factors for these cases [stage, Eastern Cooperative Oncology Group (ECOG), etc.], but more data are required in the literature. In this multi-center study, we focused on LS of advanced NSCLC with OS above 36 months to perform a clinical-pathological and molecular characterization.

Methods: In the first step, we conducted a clinical-pathological characterization of the patients. Afterwards, we carried out a genetic analysis by comparing LS to a sample of short-term survivors (SS) (with an OS less than 9 months). We initially used whole-genome RNA-seq to identify differentiating profiles of LS and SS, and later confirmed these with reverse transcription-polymerase chain reaction (RT-PCR) for the rest of the samples.

Results: A total of 94 patients were included, who were mainly men, former smokers, having adenocarcinoma (AC)-type NSCLC with an ECOG of 0–1. We obtained an initial differential transcriptome expression, displaying 5 over- and 33 under-expressed genes involved in different pathways: namely, the secretin receptor, surfactant protein, trefoil factor 1 (TFF1), serpin, Ca-channels, and Toll-like receptor (TLRs) families. Finally, RT-PCR analysis of 40 (20 LS/20 SS) samples confirmed that four genes (surfactant proteins and SFTP) were significantly down-regulated in SS compared to LS by using an analysis of covariance (ANCOVA) model: SFTPA1 (P = 0.023), SFTPA2 (P = 0.027), SFTPB (P = 0.02), and SFTPC (P = 0.047).

Conclusions: We present a sequential genetic analysis of a sample of NSCLC LS with no driver alterations, obtaining a differential RNA-seq/RT-PCR profile showing an abnormal expression of SF genes.

A multicenter analysis of the outcome of cancer patients with neutropenia and COVID-19 infection optionally treated with granulocyte colony-stimulating factor (G-CSF)

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Background: Infection by SARS-CoV-2 can turn into an acute respiratory infection. Approximately 15% of patients will develop a distress syndrome responsible in most cases of mortality. A host hyperinflammatory response induced by a cytokine storm, is the main cause of this severe complication. Chemotherapy myelosuppression is associated with higher risk of infections and mortality in cancer patients. There have been no previous reports about the clinical management of patients with neutropenia and concomitant COVID-19. Herein, we present a multicenter experience in several hospitals during COVID-19 outbreak in neutropenic cancer patients infected by SARS-Cov-2. Methods: Retrospective clinical data were collected from clinical reports. Protocol was approved by a Clinical Research Ethics Committee (HULP: PI-4194). Inclusion criteria were cancer patients with neutropenia (<1500 cells/mm3) and concomitant COVID-19 infection. Comorbidities, tumor type and stage, treatment, neutropenia severity, filgrastim (G-CSF), COVID-19 parameters and mortality were analyzed. Exploratory analysis included a description of all data collected and bivariate analyses among different pairs of variables, including their impact in mortality in this cohort. In addition, multivariable logistic regression was used to predict respiratory failure and death as a function of multiple variables. Results: Among 943 patients with cancer screened in 14 hospitals in Spain, eighty-three patients (8%) had a febrile neutropenia and COVID-19 infection. Lung (26%), breast (22%), colorectal (13%) and digestive non-colorectal (17%) cancers were the main locations and most patients had advanced disease (67%). Fifty-three (63%) of patients included died because respiratory failure. Neumonia was presented in 76% of patients, bilateral in 47% and 12% of all patients had thrombotic events. The median of neutrophils was 650cls/mm3 and 49% received G-CSF with a median of days on treatment around 4,5 days. Among all variables related with mortality in neutropenic cancer patients with COVID-19 infection, we found that the number of days with G-CSF showed a significant trend toward worse outcome and higher mortality. In particular, a logistic regression model was developed to predict respiratory failure, as a function of the number of days of G-CSF treatment. As adjusting covariates, sex, age, treatment purpose (palliative vs curative, to adjust for patient status), tumor type, and the lowest level of neutrophils in the patient (to adjust for neutropenic status) were used. A significant effect was obtained for the days of G-CSF treatment (OR = 1.4, 95% CI [1.03, 1.92], p-value = 0.01). Conclusions: Our findings suggest that a prolonged G-CSF treatment could be disadvantageous for these cancer patients with COVID-19, with a higher probability of worse outcome.

Molecular profiling by NGS upon progression disease in advanced stage NSCLC patients

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Background: Non-small cells lung cancer (NSCLC) patients treated with Tyrosine Kinase Inhibitors (TKI) at first-line ultimately develop disease progression after 10 to 14 months. Mechanisms underlying TKI-resistance are not complete understood. Tumor re-biopsy is often unfeasible for NSCLC patients and liquid biopsy is a suitable alternative in identify mechanism by which tumors progress. Methods: 113 plasma samples were collected from advanced stage EGFR positive NSCLC patients upon disease progression according to RECIST V1.1. cfDNA NGS profiling was carried out using the Oncomine™ Pan-Cancer Cell-Free Assay and sequenced on an Ion GeneStudio S5 Plus System. Variant calling and annotation were performed with Torrent Suite and Ion Reporter (v5.16) software, respectively. In addition, we developed a bioinformatic pipeline, using RStudio for variant filtering. Results: Overall, 344 somatic variants were detected with an average number of variants per patient of 2.32 and a median Mutant Allele Frequency (MAF) of 0.83%. Most mutated genes were EGFR (63.72%), TP53 (60.18%), APC (16.81%), MAP2K1 (11.50%), PIK3CA (10.62%), FGFR3 (7.08%), KRAS (7.08%) and BRAF (6.19%). As expected, SNPs were the most frequent mutation type (72.67%), following by INDELs (24.41%) and CNVs (2.91%). We found high co-occurrence between MYC-GNA11, MYC-CCND2, HRAS-AR and EGFR-TP53 genes using Jaccard’s score (0.5, 0.5, 0.5 and 0.46, respectively). Within EGFR-mutated patients, 40% had T790M resistance mutation. Finally, we found KRAS mutations and missense PIK3CA mutations were mutually exclusive. Conclusions: Molecular profiling of liquid biopsies collected upon disease progression using NGS help to identify molecular mechanisms underlying treatment failure.

Severe emphysematous cystitis: Outcome after seven days of antibiotics

We present the case of a 70-year-old woman with emphysematous cys- titis. She was a diabetic patient and she was on chemotherapy treatment for a breast  cancer. She complaint of severe asthenia and pain in her right lower extremity, but no fever or urinary symptoms. A computed tomography (CT) scan was suggestive of severe emphysematous cystitis. Emphysematous cystitis is a rare clinically entity, more commonly seen in diabetic, immunocompromised patients. A conservative  treatment approach using antibiotics and bladder catheterization is typically suc- cessful, with a complication rate less than 20%.

Clinical and molecular characteristics of the patients in the liquid biopsy study in mEGFR-NSCLC in a Spanish population (OPH-1)

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Background: The liquid biopsy (LB) is an important tool in the diagnostic and follow up of the patients with non-small cell lung cancer (NSCLC) and can provide big information about the mutational variability of the disease during of the treatment. Methods: We conducted a multicenter study with 200 patients with EGFR-mutated NSCLC, treated with first-line TKI therapy. We analyse the ctDNA by dPCR pre-treatment, at 8 weeks, at 7 months and at the progression of the disease (PD). Results: A total of 200 patients (60% women / 40% men) were included. The median of age was 68-year. The never smokers were 56% and 34% ex-smokers. 92% of the cases were adenocarcinomas. According to the stage of the disease, 52% were stage IVB, 38.5% stage IVA and 9.5% unknown. The first-line treatment was afatinib in 47.5%, erlotinib in 21.5% and gefitinib in 31%. According to the type of sensitivity mutation, 61.5% corresponded to Del19, 32% to L858R, 2.5% to G719X and 2.5% to L861Q. At the time of diagnosis, 63% had pulmonary metastatic involvement and 42.5% liver metastasis. At the time of data analysis, 66% of the patients had some progression of the disease (PD) and 37% died. 68% of the patients with Del19 received afatinib, while 20% of the patients with L858R received afatinib, 54.5% erlotinib and 32% gefitinib (p = 0.02). With a median follow-up of 20 months, progression-free survival was 11.8 months, without any differences according to the treatment (p = 0.93). The groups with worse PFS included: the squamous histology (HR 5.7; 95%CI 2.04-15.91, p = 0.001), the G719X mutation (HR 3.36; 95%CI 1.21-9.25, p = 0.019) and the liver metastasis (HR 1.65; 95%CI 1.01-2.68, p = 0.042). The sensitizing mutation was detected in the 80.8% of the patients in the LB by dPCR and the T790M in 2%. However, in the first control only was detectable in 18.5%. At the time of PD, the percentage of detection of T790M raised to 52.3%, and the sensitizing mutation 79.44%. At that moment, patients who developed T790M were mostly never smokers (66%, p = 0.006) and had Del19 (66%). Patients with bone progression developed T790M in 60.4% (p = 0.014) and hepatic 27% (p = 0.012). Conclusions: We concluded that the clinical characteristics of the patients of the OPH study are consistent with the previous reported in the Caucasian population and the subgroups with the worst prognosis include the squamous histology, the G719X mutation and the liver metastasis.

Prospective analysis of antinuclear antibodies prevalence in a pan-tumor sample

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Background: Antinuclear antibodies (ANAs) constitute a spectrum of autoantibodies targeted to nuclear and cytoplasmic components of the cells considered serological markers for different autoimmune disease. However, ANAs are also presented in different types of cancers. Here, we present an exploratory analysis of ANAs patterns detected in patients with a recent cancer diagnosis. Methods: We carried out a prospective analysis of patients recently diagnosed of cancer in two centers. All were tested for ANAs from January to December 2019. Clinical-pathological features were collected from clinical reports. Results: 190 patients were included with different tumors: Lung(56.3%); colon/rectum(16.3%); head-neck(10.5%); pancreas(3.6%); stomach(3.1%); sarcoma(3.1%); urothelial(2.6%) and others( 3.6%). Most of the patients (pts) had stage IV (65.7%) and III (26.8%). Several histologies were included: adenocarcinoma(55.7%); squamous (32.6%) and others (transitional, clear cells, small cell and mesotelial/sarcoma). Chemotherapy was the main treatment (73.6%pts) followed by immunotherapy (11.5%pts), targeted therapy (6.8%pts) and chemo-inmunotherapy (3.1%pts). Among all pts included, only 13 had autoimmune disease: polymyalgia rheumatica (1pt); psoriasis (4pts), bronchial hyperreactivity (2pts) and hypotiroidism (6pts). In this cohort, we found that 60/190, 31.5%pts, showed positive ANAs (+) titers by immunofluorescence analysis. Different patterns were described according to First International Consensus on Standardized Nomenclature of ANAs. The predominant was a speckled pattern presented in 26% pts; secondly, a nucleolar pattern in 16.6% pts and CENP-F AC14 was presented in 8.3%pts. More minoritary patterns were also described. Patients with advanced lung cancer included 56.6% of ANAs (+) cases followed by colorectal cancer (11.6%). Adenocarcinoma (73,3 % pts) and squamous carcinoma (16,6% pts) were the most common histologies among ANAs (+) cases but none of the small cell carcinoma were ANA(+). The majority of ANAs (+) patients were on chemotherapy (73.3 % pts) followed by immunotherapy (16.6% pts). On the other hand, 4/13 of patients with autoimmune diseases presented ANAs(+) titers (CENT-F, scl70 and AC3 patterns). The only patient who developed a severe inmune-related toxicity was ANA negative. Conclusions: In this study, we describe the prevalence of ANAs and their patterns in a cohort of cancer patients. A complementary description of relevant clinical-pathological features in ANAs(+) subgroup is also reported.

ctDNA levels before treatment predict survival in non-small cell lung cancer patients treated with a tyrosine kinase inhibitor

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Background: Currently there is an intense debate concerning therapeutic strategies in EGFR positive NSCLC patients with advance disease. Osimertinib is superior to standard EGFR Tyrosine Kinase Inhibitors (TKIs) as first line treatment. However, it is yet unclear whether this option is superior to sequential treatment of a 1st or 2nd generation TKI followed by osimertinib. In order to clarify this issue it is important to identify which patients are at high risk of progression disease. Methods: This is a prospective, multicentre, cross-sectional study promoted by Spanish Lung Cancer Group. 698 plasma samples from 196 advanced NSCLC patients with tumors harboring an EGFR activating mutation and treated with a first line TKI (afatinib, gefitinib, erlotinib or osimertinib) were analyzed. Plasma samples were prospectively collected before treatment (T0), after 3 months of treatment (T3), after 6 months of treatment (T6) and at first disease progression. EGFR mutations were analyzed by dPCR. Multivariate Cox proportional hazards analysis was used to determine the significance of ctDNA in the prediction of prognosis. Results: The median follow up was 19.8 months. At baseline patients with plasma EGFR sensitizing mutations at allele frequency (AF) ≥ 10% had worse OS and PFS than patients in which the opposite occurred (HR = 1.86; 95 %CI: 1.09-3.17, and HR = 1.65; 95 %CI: 1.07-2.58, respectively). Noteworthy, median OS and PFS time were 18.6 and 8.8 months respectively, in patients with plasma AF≥10% before treatment initiation compared to 37.9 and 12.4 months for patients with plasma AF < 10%. Similar results were obtained when a cutoff of AF≥ 5% was used (HR = 1.73; 95%CI: 1.02-2.94 for OS, and HR = 1.72; 95%CI: 1.13-2.61 for PFS). Patients who remained ctDNA-positive after 3 months of treatment exhibited also poorer outcomes (HR = 3.24; 95%CI: 1.77-5.94 for OS, and HR = 3.1; 95%CI: 1.91-5.03 for PFS). In the same way, detectable levels of ctDNA after 6 months of treatment predicted shorter OS and PFS (HR = 3.3; 95%CI: 1.53-7.13 and HR = 2.62; 95%CI: 1.62-4.25, respectively). Conclusions: ctDNA levels significantly predict survival. Moreover, ctDNA levels before treatment initiation can be useful to assess patient’s progression risk which is not possible to assess otherwise facilitating treatment decision making.

Analysis of lipid metabolism genes in advanced small cell lung cancer

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Background: Lung cancer is the leading cause of cancer death worldwide. Although most of the knowledge about metabolic dysregulation in cancer focuses on carbohydrates, the importance of alterations related to lipid metabolism is starting to be recognized. There is increasing data on lipid metabolism and non-small lung cancer, but much less is known about this in small cell lung cancer (SCLC). In order to improve our knowledge of these alterations we evaluated a genetic profile related to lipid metabolism and studied clinical outcomes. Methods: We performed a retrospective analysis of 22 genes related to lipid metabolism in 37 tumoral tissue samples of SCLC patients and evaluated clinical features and outcomes. Advanced SCLC patients enrolled from November 1, 2008 through December 31, 2015 were included in this analysis. Clinical data were collected from medical records at the time of enrollment. The study was approved by an Ethics Comittee and all patients signed an Informed Consent form. We used formalin-fixed, paraffin- embedded tumor tissue. Samples were deparaffinated and total RNA was extracted. A Taq-Man Low Density Array (Applied Biosystems) was specifically designed and gene-expression assays were performed in a HT-7900 Fast Real time PCR. RT-StatMiner software was used to detect and determine the quality control and differential expression analyses of data. Results: We included 37 patients, 73 % males and 27 % women, with a median age of 62. 29 patients (78%) had stage IV tumor and nearly all of them (92%) were treated with platinum- based chemotherapy. 11 % (4/37) received thoracic radiotherapy and 5% (2/37) received whole brain radiotherapy. 6 patients (16%) were on chronic treatment with metformin and 15 (40%) on statins. We performed a multivariable analysis and found that overexpression of two metabolic genes (a mitochondrial enzyme and a lipid metabolism regulator) led to longer overall survival. (HR 0.13 (0.04-0.42), p 0.0019, padjusted 0.04 and HR 0.11 (0.03-0.35) p 0.0006, padjusted 0.01, respectively). Conclusions: These genes contribute to normal functioning and regulation of lipid metabolism and could be considered as potential prognostic biomarkers. There is no previous evidence of association between levels of expression of these genes and overall survival in SCLC. Validation in a larger series of patients is ongoing.

How do patterns of progression influence treatment selection after chemohormonal therapy in patients with metastatic hormone sensitive prostate cancer?

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Background: In the CHAARTED and STAMPEDE clinical trials, Docetaxel combined with androgen-deprivation therapy (ADT) increased overall survival in mHSPC patients. Despite the increasing use of this strategy in clinical practice, there is a lack of information about the best treatment choice after progression. Methods: We retrospectively analyzed 96 patients with mHSPC treated with Docetaxel plus ADT in 18 Spanish centers (July 2014 to December 2016). The objectives of the study were to describe baseline and progression characteristics, as well as second-line treatment choice and its outcomes. Results: The median age was 66.7 years. 33.3% patients had visceral metastases at diagnosis and 81% had a Gleason Score 8-10. After a median follow-up of 12.2 months, 35.4% of patients developed castration-resistant prostate cancer (CRPC). The median time to CRPC was 15.4 months. 36.3% of patients had visceral progressive disease. 27 patients received subsequent treatment after progression: 9 (33.3%) were treated with chemotherapy (2 docetaxel, 6 cabazitaxel, 1 carboplatin-etoposide), and 18 (66.6%) received androgen receptor axis-targeted agents (12 enzalutamide, 6 abiraterone). Median progression-free survival was similar with hormonal therapies (4.3 months) than chemotherapy (3.5 months) as second line. Treatment choice was influenced by pattern of progression (visceral vs non visceral) and time to develop CRPC (≤ 12 vs > 12 months). Hormonal therapies were more frequent for non-visceral disease (75% vs 25%) or patients with longer time to develop CRPC (89% vs 11%). Chemotherapy was preferred in patients with visceral progressive disease (83.3% vs 16.7%). In patients with a time to CRPC less than 12 months both treatments were used equally (44.5 vs 55.5%). Conclusions: In our cohort, androgen receptor axis-targeted agents were used more frequently than chemotherapy after progression to chemo-hormonal therapy. Despite the low number of patients that received treatment at progression, our results suggest that the characteristics at the time of progression, such as pattern of progression and time to develop CRPC, could influence treatment choice.

Pazopanib in metastatic renal carcinoma (mRC): Experience of 31 centers in Spain in first, second, third, or subsequent lines in daily clinical practice

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Background: In clinical trials pazopanib (P) was superior to placebo, noninferior to sunitinib, and very well tolerated as 1st-line for mRC, but there is limited information in daily clinical practice. Methods: We retrospectively reviewed 159 patients (p) who received P in in 31 centers in Spain during the first 18 month after P approval, to evaluate the timing of use and its efficacy. Results: Mean age was 66 y, 64.8% were males, 81.1% clear-cell, 12% non-clear cell, and 6.9% unspecified. At diagnosis of mRC 73.6% had nephrectomy, 78.6% and 71.7% of p were of good-intermediate risk (MSKCC and Heng criteria respectively). Metastatic sites were lung (59.7%), lymph nodes (26.4%), bone (22.6%), skin/soft-tissues (17.6%), liver (11.9%), CNS (2.5%), and 31.4% others (adrenal, pancreas, etc.). Median follow-up since diagnosis of mRC was 16 months (m). P was given as 1st systemic treatment in 81 p, (50.9%), as 2nd line in 32 p (20.1%, most after sunitinib, 17 due to intolerance), or as ≥3r line (46 p, 29%). Median follow-up after P was 7 m in 1st line, and 10 m in 2nd or ≥ 3rd line. Toxicity was as expected. No toxic deaths were registered. At the time of analysis, 85 p have discontinued P (progression: 73 p, toxicity: 10 p, other causes: 2 p), and 35 p have died. The table shows time to treatment failure due to progression or toxicity (TTF), and overall survival (OS) since the 1st dose of P. There were statistically significant differences in 1st line TTF and OS between MSKCC subgroups. Conclusions: In p with mRC and good-intermediate prognosis, P appears to be as effective in daily clinical practice as it was in 1st line trials. P also showed efficacy in p with poor risk, in 2nd-line (particularly progression or intolerance to sunitinib), and after 2 or more TKIs. Updated analysis will be available in June 2013. [Table: see text]

Clinical profile and patterns of progression (PD) of patients (pts) with advanced nonsquamous non-small cell lung cancer (nsNSCLC) treated with first-line bevacizumab (B): AVVA study

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Background: B in combination with platinum doublets prolongs survival and delays PD in chemo-naïve pts with advanced nsNSCLC and its safety profile has been widely described in clinical trials. In this study we aim to evaluate the behavior, clinical profile and patterns of PD of real-life nsNSCLC pts treated with B in 44 Spanish institutions. Methods: AVVA is a multicenter, epidemiological study to define the clinical profile (gender, age, PS, histology, stage, comorbidities, tumor load, Tx, response and tolerability) and describe the patterns of PD. Pts diagnosed with advanced nsNSCLC and evidence of PD after treatment (Tx) with standard chemotherapy (CT) plus B up to 6 cycles followed by maintenance B were included. Results: Data of 158 pts are presented. Clinical profile was: median age 58 years (range 34-79); male 65%; stage IV 91%; adenocarcinoma 77%; ECOG PS 0/1/≥2 (%): 35/56/9; never/current/former smokers (%): 23/40/37. 64% of pts presented relevant concomitant disease at baseline (27% cardiovascular disease, 24% pulmonary disease). Tx received: B plus carboplatin-doublet/cisplatin-doublet/other (%) 70/25/5. Median no. of cycles for CT/B: 6/9. Patterns of PD: 44% presented high tumor load (tumor diameter ≥55mm and ≥5 lesions); 97% of pts presented intra-thoracic disease, 53% presented extra-thoracic disease and 13% only pulmonary disease. High tumor load was associated with extra-thoracic disease (p<0.05). ORR was 53% (95% CI: 45-61) and disease control rate was 85%. Best response was achieved after a median of 4 cycles (range 1-16). ECOG 0/1 at PD (%): 15/50. Median PFS was 7.7 months (95% CI: 7.3-8.1). No differences were found in ORR or PFS according to tumor load and intra/extra-thoracic disease. Grade 3/4 toxicities were: venous thrombosis (3.2%/0), proteinuria (0.6%/0), hemoptysis (0.6%/0), pulmonary embolism (0/0.6%) and mucositis (0.6%/0). Conclusions: B was effective in this real-life patients’ population, irrespective of tumor load and location of the disease. These results confirm the well-established safety profile and the efficacy of B as frontline Tx in nsNSCLC.

Genetic polymorphisms of SCNA9 as predictive markers of oxaliplatin-induced neuropathy

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Background: Oxaliplatin (OXL) is an active drug in digestive tumors. Oxaliplatin induced peripheral neuropathy (OIN) is the main dose limiting toxicity. Around 60-80% of patients developed a mild cold-induced neurotoxicity that used to disappear few days after but in 15% became a persistent neuropathy. The pathophysiology of oxaliplatin-induced neuropathy (OIN) remains unclear, preclinical studies suggest involvement of voltage Na channels. SCN9A gene codifies to Na channels α subunit highly expressed in nociceptive neurons. Mutations in SCN9A are involved in alterations in neuropatic pain perception. This study tried to identify if variants in SCN9A could be associated to a higher risk to OIN. Methods: Serum were obtained from 100 patients with digestive cancer (colorectal, gastric, pancreatic and bile duct) treated with OXL (adjuvant or advanced setting) in Infanta Sofía University Hospital. No diabetes or hypotiroidism were detected. Patients were divided in two groups according to the development of OIN: Arm A 50 patients diagnosed of grade 2-3 OIN after 6 courses and Arm B 50 with no OIN. The evaluation of severity of the OIN by a neurologist included a classification according to NCI-CTC and OSNS scales and conduction studies. Genomic DNA was isolated from serum and variants of SCN9A were analyzed by PCR-RFLP. The relation between SCN9A genotype and the development of severe OIN was the primary aim Results: One hundred patients were enrolled between May 2010-November 2011. 56 (56%) females and 44 (44%) males; mean age was 62; mean ECOG was 1; primary tumor were colorectal 81 pts (81%), gastric 10 (10%); 8 (8%) pancreto-biliar and anus 1(1%). Stage were classified in localized 65 (65%) and advanced (35%). The chemotherapy regimen included: 94 (94%) XELOX, 1 (1%) XELOX-Herceptin and 5 (5%) EOX regimen. The mean of cycles were 7 (1-14). Mean OXL dose intensity was 100mg/m2.The mean PFS was 23 months. High expression of SCN9A variants were detected in patients 26/50, 52% arm A and in 5/50, 10% arm B patients, suggesting a possible relationship beetwen the development of OIN and SCN9A genotype (p=0.04). Conclusions: SCN9A polimorphysms may help to identify those patients with a higher risk to develop oxaliplatin induced neuropathy.

On-line breath analysis of volatile organic compounds as a method for colorectal cancer detection

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Background: Analysis of exhaled volatile organic compounds (VOCs) in breath is an emerging approach for cancer diagnosis, but little is known about its potential use as a biomarker for colorectal cancer (CRC). We investigated whether a combination of VOCs could distinct CRC patients from healthy volunteers. Methods: In a pilot study, we prospectively analyzed breath exhalations of 38 CRC patient and 43 healthy controls all scheduled for colonoscopy, older than 50 in the average-risk category. The samples were ionized and analyzed using a Secondary ElectroSpray Ionization (SESI) coupled with a Time-of-Flight Mass Spectrometer (SESI-MS). After a minimum of 2 hours fasting, volunteers deeply exhaled into the system. Each test requires three soft exhalations and takes less than ten minutes. No breath condensate or collection are required and VOCs masses are detected in real time, also allowing for a spirometric profile to be analyzed along with the VOCs. A new sampling system precludes ambient air from entering the system, so background contamination is reduced by an overall factor of ten. Potential confounding variables from the patient or the environment that could interfere with results were analyzed. Results: 255 VOCs, with masses ranging from 30 to 431 Dalton have been identified in the exhaled breath. Using a classification technique based on the ROC curve for each VOC, a set of 9 biomarkers discriminating the presence of CRC from healthy volunteers was obtained, showing an average recognition rate of 81.94%, a sensitivity of 87.04% and specificity of 76.85%. Conclusions: A combination of cualitative and cuantitative analysis of VOCs in the exhaled breath could be a powerful diagnostic tool for average-risk CRC population. These results should be taken with precaution, as many endogenous or exogenous contaminants could interfere as confounding variables. On-line analysis with SESI-MS is less time-consuming and doesn’t need sample preparation. We are recruiting in a new pilot study including breath cleaning procedures and spirometric analysis incorporated into the postprocessing algorithms, to better control for confounding variables.

Comparison of breast cancer subtypes detected by mammography screening and tumors diagnosed with palpable masses

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Background: Recent studies have reported a greater mean breast density associated with estrogen receptor (ER)-positive disease than with ER-negative tumors, but controversial results have been published. The purpose of our study was to compare the difference in the distribution of breast cancer subtypes detected either by mammography screening or tumors diagnosed with clinically palpable masses in our centre. Methods: Between June 2008 and December 2011 157 patients with age between 40 and 70 years-old were diagnosed of early stage breast cancer. Tumors were classified in three major breast cancer subtypes by immunohistochemistry: TN (ie, ER, PR and Her2 negative), Her2-positive (ie, Her2 positive; ER and PR may be positive or negative), and ER-positive/Her2 negative (ie, ER positive, Her2 negative, PR may be positive or negative) types. Tumor characteristics and type of diagnosis (mammography screening or palpable masses) were obtained by retrospective chart review. Associations between categorical variables were evaluated with the X2 test. Results: Seventy patients (44.6%) were diagnosed of breast cancer with screening mammography, whereas 85 (54.1%) cases were detected by clinical suspected masses. Distribution according to molecular subtype defined by IHC were as follows: 123 (78.3%) ER-positive/Her2-negative tumors, 15 (9.6%) TN tumors, and 19 (12.1%) Her2-positive tumors. Less Her2-positive and TN tumors were significantly diagnosed with mammography screening (p=0.039 and p=0,020, respectively). No statistical differences were showed between ER-positive/Her2-negative tumors diagnosed with mammography screening and clinical palpable masses (p=0.78). Conclusions: The results presented in our study suggest that biologically aggressive subtypes of breast cancer are less frequently diagnosed with mammography screening in comparison with ER-positive/Her-2 negative tumors. Nevertheless, given the limited number of patients included and the bias related to retrospective studies these results must be interpreted with caution.

ERCC1 and topoisomerase I expression in small cell lung cancer: prognostic and predictive implications

Small cell lung cancer is the most aggressive lung cancer subtype. The standard treatment approach is based on cisplatin regimens. Although response rates to treatment are approximately 60-80%, the median survival is still very poor. Excision repair cross complementation group 1 (ERCC1) is an enzyme that removes cisplatin-induced DNA adducts and has been related with prognosis and cisplatin response. Topotecan is the standard treatment as second-line therapy and it is an inhibitor of topoisomerase I (TOP I). We selected 76 patients with small cell lung (SCLC) to analyze the ERCC1 and TOP I mRNA expression. ERCC1 was studied both by quantitative PCR and immunohistochemistry. A significant association was found between the inmunohistochemistry expression of ERCC1 and the lack of platinum response (p=0.001). Moreover, low levels of TOP I RNA were shown to be linked to cisplatin response (p=0.002). In the survival analysis, a significant correlation between a better PFS with a low TOP I RNA expression as well as a negative ERCC1 inmunostaining were found, in both cases with a significant p-value (p=0.02 and 0.009, respectively). In summary, our results suggest the use of ERCC1 immunohistochemistry and TOP I mRNA analysis to predict cisplatin response and prognosis in SCLC patients.

Severe emphysematous cystitis: Outcome after seven days of antibiotics

We present the case of a 70-year-old woman with emphysematous cystitis. She was a diabetic patient and she was on chemotherapy treatment for a breast cancer. She complaint of severe asthenia and pain in her right lower extremity, but no fever or urinary symptoms. A computed tomography (CT) scan was suggestive of severe emphysematous cystitis. Emphysematous cystitis is a rare clinically entity, more commonly seen in diabetic, immunocompromised patients. A conservative treatment approach using antibiotics and bladder catheterization is typically successful, with a complication rate less than 20%.

Strong lensing of gravitational waves as seen by LISA

We discuss strong gravitational lensing of gravitational waves from the merging of massive black hole binaries in the context of the LISA mission. Detection of multiple events would provide invaluable information on competing theories of gravity, evolution and formation of structures and, possibly, constraints on H0 and other cosmological parameters. Most of the optical depth for lensing is provided by intervening massive galactic halos, for which wave optics effects are negligible. Probabilities to observe multiple events are sizable for a broad range of formation histories. For the most optimistic models, up to ≲ 4 multiple events with a signal to noise ratio ≳ 8 are expected in a 5-year mission. Chances are significant even for conservative models with either light (≲ 60%) or heavy (≲ 40%) seeds. Because of lensing amplification, some intrinsically too faint signals are brought over threshold (≲ 2 per year).

Screening candidate targets by SAGE evaluation of rectal cancer transcriptome after chemoradiotherapy: Association of trefoil factor-family 3 (TFF3) expression with patients prognosis

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Background: Treatment resistance and the lack of reliable prognostic factors are major obstacles in rectal cancer (RC) management. A blind screening of RC transcriptome changes after chemoradiotherapy (CRT) could pinpoint proteins potentially involved in CRT resistance. Evaluation of their relation with disease outcome could help to identify novel therapeutic and prognostic candidates. Methods and Results: In a first stage we screened dynamic changes of RC transcriptome after CRT using blind and directed strategies. On one side, we selected fresh RC samples, before and after CRT, from three uT3N0 patients with poor response, as assessed by Dworak´s TRG2 and minimal downstaging (ypT2–3N0). Serial Analysis of Gene Expression (microSAGE) was conducted, six libraries were generated, sequencing around 30.000 tags. MonteCarlo analysis of dynamic “intra-patient” changes, and “inter-patient” comparisons revealed a set of 25 genes with shared significant changes. On another side, a collection of 29 genes was selected from the literature, In a second stage we evaluated dynamic changes in the mixed set of 54 genes in a cohort of 125 stage II-III RC patients treated with preopCRT. Samples from 74 patients assured sufficient tumor quality and quantity before and after CRT. mRNA dynamic changes of gene expression were evaluated by TaqMan Low Density Arrays (TLDAs), and statistical analysis done by Wilcoxon test with bootstrap and regulated genes selected for discriminant and Cox proportional-hazards regression analysis. Induction of mRNA TFF3, screened in the blind phase SAGE and exhibiting important tumor promotion and progression functions, was associated with tumor relapse and shorter survival. Also, analysis of TFF3 immunohistochemical expression in surgical samples revealed that an on/off pattern of intraluminal gland expression (PAS independent) strongly predicted tumor relapse. Conclusions: Upregulation of TFF3 after CRT, and an easily determined IHC pattern, predicted RC relapse in preoperatively treated patients. Confirmatory prognostic studies in independent series should be conducted, and its potential therapeutic merits as a candidate target evaluated.

No significant financial relationships to disclose.

Cardiac toxicity: old and new issues in anti-cancer drugs

Although rare, cardiotoxicity is a significant complication of cancer treatment. The incidence and severity of cardiovascular side effects are dependent on the type of drugs used, dose and schedule employed, and age of patients, as well as the presence of coexisting cardiac diseases and previous mediastinal irradiation. Classically, anthracyclines are among one of the most active agents in oncology, but their use is often hampered by their cumulative dose-limiting cardiotoxicity. In the past decade, combination therapy with new drugs such as taxanes or anti- EGFR, and Her-2 therapy as a single agent have also resulted in unexpected cardiotoxicity. Cardiac damage can be secondary to an alteration of cardiac rhythm, changes in blood pressure and ischaemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to being catastrophic, life-threatening and sometimes fatal. Knowledge of this toxicity can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient. In this work we present an exhaustive review of the cardiovascular side effects associated to new anticancer drugs, from new formulations of anthracyclines to tyrosine kinase inhibitors and monoclonal antibodies.

New screening method for lung cancer by detecting volatile organic compounds in breath

Lung cancer is a frequent cause of cancer-related deaths in the world. There is no valid screening process and this limits its detection to the late stages, with consequently high mortality rates. Volatile organic compounds (VOC) are chemical compounds (mainly the products of cell catabolism) found as gases in the human breath. Different methods have been developed to analyse VOCs and to compare them in healthy subjects and lung cancer patients. In this review, we summarise the different techniques used to analyse VOC. Many reports have been published with promising results similar to those achieved with accepted screening methods such as mammography. These methods show good perspectives on lung cancer screening.

Phospholipid hydroperoxide glutathione peroxidase (PHGPx) expression is downregulated in poorly differentiated breast invasive ductal carcinoma

Phospholipid Hydroperoxide Glutathione Peroxidase (PHGPx) is the only known enzyme able to reduce lipid peroxides bound to cell membranes. Moreover it has been involved in apoptosis and can influence intracellular signaling. To investigate the possible relationship between PHGPx and human cancer we have quantified PHGPx expression levels by real-time quantitative PCR and immunohistochemistry in tissue samples of human breast invasive ductal carcinoma from 34 patients compared with their own controls of benign breast tissue. PHGPx expression levels were compared with the clinical and pathological data of these patients. The results showed that PHGPx expression levels are downregulated in poorly differentiated (grade 3) breast invasive ductal carcinoma (P = 0.0043). PHGPx expression levels decreased gradually with tumor grade from grade 1 to grade 3. We also found a downregulation of PHGPx in cases that showed p53 accumulation compared with cases without p53 immunostaining (P = 0.0011). PHGPx was also downregulated in cases without progesterone receptors (PR) immunostaining compared with cases with PR immunostaining (P = 0.0165). Grade 3, p53 immunostaining and absence of PR immunostaining are poor prognostic factors. These results suggest that PHGPx downregulation could be related with a poorer prognosis in breast invasive ductal carcinoma.

Phase II study of a fixed dose-rate infusion of gemcitabine associated with erlotinib in advanced pancreatic carcinoma

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Background: The efficacy of gemcitabine in pancreatic cancer can be improved by its combination with erlotinib. Likewise, a fixed dose-rate infusion of gemcitabine seems to be superior to the conventional 30-minute infusion. Our objective was to evaluate the efficacy and toxicity of a fixed dose-rate infusion of gemcitabine associated with erlotinib in patients with advanced adenocarcinoma of the pancreas. Methods: From May 2005 to October 2006, 21 chemotherapy-naïve patients were included, median age 62 years (range 47 - 78), male/female 12/9. Five patients (24%) had locally advanced disease and 16 (76%) distant metastases. The Karnofsky score was 80–100 in 11 (52%), and 60–70 in 10 (48%). Treatment consisted of gemcitabine 1200 mg/m2 given as a 120-minute infusion on days 1, 8, 15, plus erlotinib 100 mg p.o daily. Cycles were repeated every 4 weeks. Results: A total of 80 cycles of chemotherapy were delivered with a median of 3.8 per patient (range 1- 8). There were five partial responses (24%, 95% CI: 8.4 - 47.6%), whereas seven patients had stable disease (33%) and 9 had a progression (43%). The median time to progression was 4 months. After a median follow-up of 6 months (1–14 months), the median overall survival has not been achieved. Toxicity was low. Grade 3- 4 WHO toxicities per patient were as follows: neutropenia in 5 (24%), thrombocytopenia in 1 (5%) and anaemia in 3 (14%). Grade 1–2 rash appeared in 8 (38%) and grade 3 in 3 (14%). Four patients (19%) had diarrhoea grade 1–2. Conclusions: These preliminary results suggest that a fixed dose-rate infusion of gemcitabine associated with erlotinib is active and well tolerated in patients with advanced pancreatic carcinoma.

No significant financial relationships to disclose.