Clinical and genomic landscape of RAS mutations in gynecologic cancers

BACKGROUND

We aimed to describe RAS mutations in gynecologic cancers as they relate to clinicopathologic and genomic features, survival, and therapeutic implications.

METHODS

Gynecologic cancers with available somatic molecular profiling data at our institution between February 2010 and August 2022 were included and grouped by RAS mutation status. Overall survival was estimated by Kaplan-Meier method, and multivariable analysis was performed using Cox proportional-hazards model.

RESULTS

Of 3328 gynecologic cancers, 523 (15.7%) showed any RAS mutation. Patients with RAS-mutated tumors were younger (57 vs 60 years non-mutated), had higher prevalence of endometriosis (27.3% vs 16.9%), and lower grades (grade 1/2, 43.2% vs 8.1%, all p<0.0001). Highest prevalence of KRAS mutation was in mesonephric-like endometrial (100%, n=9/9), mesonephric-like ovarian (83.3%, n=5/6), mucinous ovarian (60.4%), and low-grade serous ovarian (44.4%) cancers. After adjustment for age, cancer type, and grade, RAS mutation was associated with worse overall survival (HR=1.3, p=0.001). Specific mutations were in KRAS (13.5%), NRAS (2.0%), and HRAS (0.51%), most commonly KRAS G12D (28.4%) and G12V (26.1%). Common co-mutations were PIK3CA (30.9%), PTEN(28.8%), ARID1A (28.0%), and TP53 (27.9%), of which 64.7% were actionable. RAS+MAPK pathway-targeted therapies were administered to 62 patients with RAS-mutated cancers. While overall survival was significantly higher with therapy (8.4 years [95%CI 5.5-12.0] vs 5.5 years [95%CI 4.6-6.6], HR=0.67, p=0.031), this effect did not persist in multivariable analysis.

CONCLUSION

RAS mutations in gynecologic cancers have a distinct histopathologic distribution and may impact overall survival. PIK3CA, PTEN, and ARID1A are potentially actionable co-alterations. RAS pathway-targeted therapy should be considered.

RAF inhibitor re-challenge therapy in BRAF-aberrant pan-cancers: the RE-RAFFLE study

Previous studies have shown the clinical benefit of rechallenging the RAF pathway in melanoma patients previously treated with BRAF inhibitors. 44 patients with multiple tumors harboring RAF alterations were rechallenged with a second RAF inhibitor, either as monotherapy or in combination with other therapies, after prior therapy with a first RAF inhibitor. This retrospective observational study results showed that rechallenging with RAFi(s) led to an overall response rate of 18.1% [PR in thyroid (1 anaplastic; 3 papillary), 1 ovarian, 2 melanoma, 1 cholangiocarcinoma, and 1 anaplastic astrocytoma]. The clinical benefit rate was 54.5%; more than 30% of patients had durable responses with PR and SD lasting > 6 months. The median progression-free survival on therapy with second RAF inhibitor in the rechallenge setting either as monotherapy or combination was shorter at 2.7 months (0.9-30.1 m) compared to 8.6 months (6.5-11.5 m) with RAF-1i. However, the median PFS with RAF-2i responders (PFS-2) improved at 12.8 months compared to 11.4 months with RAF-1i responders. The median OS from retreatment with RAF-2i was 15.5 months (11.1-30.8 m). Further prospective studies are needed to validate these results and expand targeted therapy options for RAF-aberrant cancers.

Strategies for mitigating adverse events related to selective RET inhibitors in patients with RET-altered cancers

The US Food and Drug Administration (FDA) approval of the selective RET inhibitors selpercatinib and pralsetinib has led to a paradigm change in the treatment of RET-altered lung and thyroid cancers through a higher response rate and a more tolerable safety and toxicity profile than multi-kinase inhibitors. Recently, selpercatinib has received a tissue-agnostic FDA approval for all RET-fusion-positive cancers, and pralsetinib has shown pan-cancer activity as well. Given the anticipated increase in the use of both drugs across multiple tumor types, it is crucial to recognize the possible side effects and approaches for their optimal management in order to maximize the clinical benefit for treated patients. In this review, we underscore potential toxicities associated with selective RET inhibitors and discuss strategies to mitigate them.

Safety and Efficacy of Immune Checkpoint Inhibitors in Patients with Cancer and Viral Hepatitis: The MD Anderson Cancer Center Experience

BACKGROUND

Despite the clinical benefit of immune checkpoint inhibitors (ICIs), patients with a viral hepatitis have been excluded from clinical trials because of safety concerns. The purpose of this study was to determine the incidence rate of adverse events (AEs) in patients with viral hepatitis who received ICIs for cancer treatment.

MATERIALS AND METHODS

We conducted a retrospective study in patients with cancer and concurrent hepatitis B or C, who had undergone treatment with ICI at MD Anderson Cancer Center from January 1, 2010 to December 31, 2019.

RESULTS

Of the 1076 patients screened, we identified 33 with concurrent hepatitis. All 10 patients with HBV underwent concomitant antiviral therapy during ICI treatment. Sixteen of the 23 patients with HCV received it before the initiation of ICI. The median follow-up time was 33 months (95% CI, 23-45) and the median duration of ICI therapy was 3 months (IQR, 1.9-6.6). Of the 33 patients, 12 (39%) experienced irAEs (immune-related adverse events) of any grade, with 2 (6%) having grade 3 or higher. None of the patients developed hepatitis toxicities.

CONCLUSION

ICIs may be a therapeutic option with an acceptable safety profile in patients with cancer and advanced liver disease.

Histological transformation to gliosarcoma with combined BRAF/MEK inhibition in BRAF V600E mutated glioblastoma

The identification of BRAF V600 mutation in multiple cancers beyond melanoma and the development of combined BRAF and MEK targeting agents have altered the landscape of tissue-agnostic precision oncology therapies with an impact on survival outcomes. Despite initial efficacy, resistance emerges, and it is pertinent to identify putative resistance mechanisms. We report a case of recurrent glioblastoma (GBM) harboring BRAF V600E alteration who initially responded to combined BRAF + MEK inhibition and subsequently developed treatment resistance by histological transformation to gliosarcoma and acquisition of oncogenic KRAS ^G12D and an NF1 ^L1083R mutation. This documented case represents an initial evidence of a developing phenomenon in cancer research as it provides the first evidence of an emergent KRAS G12D/NF1 L1083R aberration with histological transformation occurring concurrently with primary BRAF V600E-altered glioblastoma as a previously unrecognized acquired mechanism of resistance in the setting of combined BRAF and MEK inhibition. This novel finding not only sheds new light on the RAS/MAPK pathway but also highlights the potential for morphological transformation to gliosarcoma, underscoring the critical need for further investigation in this area.

Abstract 2764: Safety and efficacy of CAR T and TCR therapies in solid tumors: A systematic review and meta-analysis, including a comparison with five phase II trials in hematologic malignancies used for the first FDA approvals of these agents

Background: Adoptive cellular therapies (ACT) have met with significant success in hematologic malignancies. The number of ACT trials in solid tumors has been increasing, however data are limited on the overall safety and efficacy of ACT in this population. We aimed to conduct a systematic review and meta-analysis looking specifically at TCR and CAR-T in solid tumors and rates of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) relative to the current approved agents in hematologic malignancies.

Methods: We conducted a systematic review of published studies/abstracts from January 2015 up to and including July 2021, selecting those that included ≥ 5 patients. Endpoints included rates and differences in CRS and ICANS. Response rates were evaluated. Statistical tests in the pooled data included χ2 and multivariable logistic regression.

Results: This meta-analysis included a total of 1,250 patients [566 patients with solid tumors who had received ACT in phase I, II or I/II clinical trials; a comparison was made with five phase 2 clinical trials in hematologic malignancies used for the first FDA approvals of these agents (JULIET, ZUMA-1, ZUMA-2, TRANSCEND and KARMMA), encompassing 684 heme malignant patients]. Rates of CRS of any grade, CRS ≥ grade 3, ICANS of any grade, and ICANS ≥ grade 3 in solid tumors were 33.0%, 3.8%, 2.3% and 2.1%, respectively. Fever, hypotension, and hypoxia were experienced by 37.4%, 18.5%, and 8.5% of solid tumor patients, respectively. CRS, ICANS, fever and hypoxia in solid tumor patients did not differ by whether the ACT received was TCR or CAR T. Objective response (ORR = CR + PR) in patients with solid tumors was higher with TCR compared with CAR-T [odds ratio (OR) = 3.1, P=0.001] and with NY-ESO-1 than other targets (OR=2.0, P=0.031). Compared to hematologic patients treated with ACT, solid tumor patients treated with adoptive cellular therapies were significantly less likely to experience CRS of any grade (62.4% vs. 33.0%, P&lt;0.001), CRS ≥ grade 3 (7.3% vs. 3.8%, P=0.043), fever (50.3% vs. 37.4%, P=0.001), hypoxia (34.1% vs. 8.5%, P&lt;0.001) or hypotension (29.5% vs. 18.5%, P=0.006), ICANS of any grade (29.7% vs. 2.3%, P&lt;0.001), or ICANS ≥ grade 3 (13.9% vs. 2.1%, P&lt;0.001). However, objective response (20.1% vs. 75.4%, P&lt;0.001) and clinical benefit (CBR = CR + PR + SD) (62.6% vs. 90.9%, P&lt;0.001) rates for ACT were lower in patients with solid tumors than in patients with hematologic malignancies.

Conclusions: CRS and ICANs were less prevalent in solid tumor cellular therapies. Based on this analysis, T-cell therapies in solid tumors are relatively safe, but further studies with larger populations and longer follow up are needed to address the role of these treatments in cancer.

Citation Format: Mirella Nardo, Ji Y. Son, Goldy G. George, David S. Hong. Safety and efficacy of CAR T and TCR therapies in solid tumors: A systematic review and meta-analysis, including a comparison with five phase II trials in hematologic malignancies used for the first FDA approvals of these agents [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2764.

Spectrum of Immune Checkpoint Inhibitor Anemias: Results From a Single Center, Early-Phase Clinical Trials Case Series Experience

Immune checkpoint inhibitor anemias (ICI-A) are a rare entity which can be potentially life-threatening without prompt identification. The goal of the study is to characterize the presentation, evaluation, and outcomes of ICI therapy in early phase clinical trial setting to guide future research and to develop standardized care guidelines. Retrospective chart review of 333 patients who participated in early phase clinical trials at the University of Texas MD Anderson Cancer Center revealed four cases with ICI-A between 2016 and 2020. We identified a spectrum of four cases which included ICI-related autoimmune hemolytic anemias, hemophagocytic lymphohistiocytosis and thrombotic microangiopathy as a result of combinatory investigational therapies involving ICI. Patient presentation, evaluation, bone marrow pathology, interventions, and clinical course were reviewed. The median time to onset of hematological immune-related adverse events (heme-irAEs) in this retrospective series was 3.5 weeks (2 - 6 weeks). One patient had pre-existing untreated chronic lymphocytic leukemia. Glucocorticoids are an effective first-line treatment in most patients although most patients were not rechallenged but successfully had complete recovery and pursued further non-immunotherapy-based therapies. Cognizance of ICI-A in clinical trial setting is paramount to early recognition of heme-irAEs. Further research is needed to identify and stratify risk factors during clinical trial enrollment and optimal management strategies for immune-mediated hematologic toxicities.

CA209-9JC: A phase II study of first-line nivolumab (NIVO) in patients (pts) with locally advanced or metastatic cutaneous squamous cell carcinoma

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Background: Cutaneous squamous cell carcinoma (cSCC) is among the most frequent malignancies worldwide, and an increasing incidence has been documented over the past decades. For those not amenable to treatment with curative intent, immune checkpoint blockade (ICP) with anti-PD-1 monoclonal antibodies emerged as a novel therapeutic option, supported by evidences of high mutational burden and expression of PD-L1. In this single-arm study, we sought in investigate the activity of NIVO in pts with advanced cSCC (AcSCC). Methods: We conducted a Simon two-stage, open-label, phase II study to evaluate the safety/efficacy of NIVO for up to 24 systemic-treatment-naïve pts with metastatic and/or locaally advanced cSCC. NIVO at 3mg/kg was administered intravenously every 2 weeks (w) until disease progression, unacceptable toxicity or 12 months of treatment. The primary endpoint was the best objective response rate (bORR) at 24w as per RECIST criteria. Tumor measurements were performed every 12w. Secondary endpoints included safety/tolerability, progression-free survival (PFS) and overall survival (OS). Results: Between October 2018 and October 2019, 24 pts with AcSCC were enrolled, with a median age of 74 years (range 48-93) and a male/female ratio of 1.4:1. Most frequent primary sites were head/neck (42%), trunk (29%) and extremities (25%); identified risk factors included chronic sun exposure or burn scars in 66 % and 12.5 %, respectively. Upon enrolment, the proportions of patients with locally advanced, locoregional (regional lymph node involvement) and metastatic disease were 16.6%, 66.6% and 16.6%, respectively. At data cut off (median number of doses of NIVO: 15), 15 pts (62.5%) remain on treatment and 6 pts have progressed and/or died. Three pts completed 12 months of treatment and entered surveillance. Among 22 pts evaluable for response (n = 2 have not reached 12w of treatment), the bORR was 54.5% (12/22), and disease control (stable disease or objective response) was achieved in 77% (17/22). Median duration of response, PFS and OS have not been reached. Grade ≥3 treatment-related adverse events occurred in 21% of the pts, and 1 patient discontinued NIVO due to toxicities. Conclusions: NIVO resulted in robust antitumor activity and good tolerability in systemic treatment-naïve pts with AcSCC. There were no new safety signals, despite the inclusion of individuals at advanced ages. These data provide further evidence to support the use of ICP as the standard treatment option for pts with AcSCC. Clinical trial information: NCT03834233.

Real-world evidence on first-line treatment for metastatic renal cell carcinoma with non-clear cell and sarcomatoid histologies: are sunitinib and pazopanib interchangeable?

Introduction

Non-clear cell renal cell carcinoma (nccRCC) and sarcomatoid renal cell carcinoma (sRCC) are underrepresented in clinical trials. Treatment approaches are frequently extrapolated from data of clear cell renal cell carcinoma, in which pazopanib is non-inferior to sunitinib. We aim to compare the effectiveness of first-line sunitinib and pazopanib for nccRCC and sRCC.

Methods

We evaluated a retrospective cohort of patients with metastatic nccRCC and sRCC treated with first-line sunitinib or pazopanib at an academic cancer centre. Overall survival (OS), progression-free survival (PFS) and response rate were measured. Kaplan–Meier and log-rank analyses were used for time-to-event data. Cox regression was used for prognostic factors.

Results

Fifty-three patients were included; 16 (30.1%) treated with sunitinib and 37 (69.9%) with pazopanib. Forty-six (86.8%) patients had nccRCC and 7 (13.2%) had sRCC. The majority had intermediate or poor International Metastatic Renal-Cell Carcinoma Database Consortium risk (93%).

Median PFS was 6.6 months with sunitinib and 4.9 months with pazopanib (HR 1.75; P = 0.078). Treatment with pazopanib was associated with inferior OS in comparison with sunitinib (median OS: 30.4 months versus 8.7 months; HR 2.71, 95% CI 1.31–5.58, P = 0.007). These results were confirmed in subgroup analysis of patients with papillary, chromophobe and MiT family translocation histologies (median OS: 38.7 months versus 14.7 months; HR 3.16, 95% CI 1.20–8.29, P = 0.019). Unclassified and sarcomatoid histologies had inferior OS (median: 6.9 and 1.1 months, respectively) regardless of the treatment used.

Conclusion

In this patient cohort, pazopanib was associated with inferior OS in comparison with sunitinib for metastatic nccRCC. Larger trials are ideally warranted to confirm these results.

Primary splenic angiosarcoma: a rare entity often associated with rupture and hemoperitoneum

Primary splenic angiosarcoma (PSA) is a rare neoplasm of vascular origin associated with aggressive behavior and poor prognosis. The clinical presentation is usually non-specific and is mostly characterized by a wasting disease with anemia and splenomegaly, mimicking a wide range of entities. The authors present the case of an 80-year-old woman with cardiovascular comorbidities with a 6-month history of weight loss, fatigue, weakness, pallor, and abdominal pain. The physical examination showed massive splenomegaly and pallor. After a thorough evaluation that ruled out lymphoproliferative diseases, the working diagnosis was a myelodysplastic disorder. A few days after discharge, she returned to the emergency room with severe abdominal pain, worsening fatigue, and a remarkable pallor. Point-of-care ultrasound showed free intraperitoneal fluid. Spleen rupture was confirmed by abdominal computed tomography (CT) scan, and an emergency laparotomy with splenectomy was performed. The postoperative period was uneventful, and the patient recovered in a few days. The histopathology confirmed the diagnosis of PSA and the patient was referred to an oncological center. Two months later staging CT demonstrated liver and peritoneal metastases, and despite the chemotherapy she died 6 months after the diagnosis.

Analysis of Efficacy and Toxicity Profile of First-Line Sunitinib or Pazopanib in Metastatic Clear Cell Renal Cell Carcinoma in the Brazilian Population

Purpose

Sunitinib and pazopanib are multitargeted tyrosine kinase inhibitors (TKIs) that act against vascular endothelial growth factor receptors and are standard first-line treatment options for metastatic clear cell renal cell carcinoma (ccRCC). The Brazilian public health system diverges from the randomized clinical trials in the availability of first and subsequent lines of treatment and in clinical and demographic characteristics of patients. Therefore, it is essential to describe the history of advanced ccRCC during and after TKI treatment in this population.

Methods

We performed a retrospective analysis of patients with advanced ccRCC treated with a first-line TKI (either sunitinib or pazopanib) between February 2009 and March 2017 in a single academic Brazilian cancer center (Instituto do Câncer do Estado de São Paulo).

Results

Of the 222 patients, 109 were treated with sunitinib and 113 with pazopanib. The median duration of treatment and overall survival (OS) were 6.4 and 15.2 months for sunitinib and 6.7 and 14.2 months for pazopanib, respectively. Discontinuation of treatment occurred secondarily to progressive disease or death in 64.2% of patients using sunitinib and in 54.8% of patients using pazopanib. Adverse events were responsible for discontinuation of treatment in 28.4% of patients in the sunitinib group and in 22.1% in the pazopanib group. According to Memorial Sloan-Kettering Cancer Center risk categories, the OS was 32.9 months, 15.9 months, and 8.1 months for low risk, intermediate risk, and poor risk, respectively (hazard ratio, 1.72; 95% CI, 1.13 to 2.26; P < .001).

Conclusion

The use of TKI inhibitors as first-line treatment of metastatic RCC is effective and feasible in the Brazilian public health. However, the median OS of our population is considerably lower compared with the prospective trials that evaluated the same drugs.

Preoperative variables associated with transfusion requirements in orthotopic liver transplantation

BACKGROUND

Patients with end-stage chronic liver disease (CLD) and submitted to orthotopic liver transplantation (OLT) usually require blood transfusion during the procedure or in the post-operative period due to hemorrhage. Risk factors for transfusion need are not fully known. This study aimed to identify the factors associated with blood components requirements.

METHODS

In this retrospective study a total of 166 consecutive patients submitted to OLT with the piggyback technique, between 2001 and 2011, were evaluated for number of blood components transfused during surgical procedure and the four subsequent days (total of 5 days). We evaluated the association between the number of units transfused and clinical variables, such as: Child-Turcotte-Pugh (CTP) and MELD scores, hemoglobin concentration (Hb), INR, serum creatinine, bilirubin and albumin concentrations, and total, hypothermic and normothermic time of graft ischemia.

RESULTS

152 (91.6%) Patients were transfused (median of 24 units of blood components). Risk factors for higher blood transfusion requirements were CTP, INR, Hb and total time of graft ischemia. The group with CTP-A score received less blood components than CTP-B/C (11.5 vs 27; P=0.002). The group with Hb<10 required a higher number of blood units (34.5 vs 23; P=0.003). The group with INR<1.5 received less blood units (20.5 vs 31; P=0.012). The group transplanted with a graft exposed to less than the median of 555 min of ischemia received less transfusion (21 vs 27; P=0.03). MELD score and the other factors were not associated with blood requirements.

CONCLUSION

These results demonstrate that CTP, but not MELD score, hemoglobin concentration, INR, and total time of graft ischemia are preoperative variables associated with blood requirements during OLT and in the subsequent days.