Impact of Locoregional Therapies for Brain Lesions on Survival in Patients With Non-small Cell Lung Cancer With Multiple Extrathoracic Metastases

BACKGROUND/AIM

The treatment of brain metastases in patients with non-small cell lung cancer (NSCLC) typically involves surgery, irradiation, and chemotherapy (single or combination therapy). However, the impact of these therapies on the survival of patients with NSCLC with multiple extrathoracic metastases has not yet been determined. Therefore, in the present study, we examined the prognostic effect of multimodal treatment for brain metastases in patients with NSCLC with multiple extrathoracic metastases in the absence of driver mutations.

PATIENTS AND METHODS

Patients with NSCLC with multiple extrathoracic metastases (including at least one brain metastasis), who visited Saitama Medical Center, Saitama Medical University from January 1, 2010 to December 31, 2016, were enrolled in this study; follow-up was conducted until December 31, 2021.

RESULTS

A total of 56 patients were enrolled, including 12 and 44 patients with single and multiple brain metastases, respectively. The median overall survival (OS) for all patients was 4.9 months, and did not differ significantly between patients with single and multiple brain metastases (3.0 vs. 4.9 months, respectively). The selection of locoregional treatment for brain metastases did not depend on Karnofsky performance status (p=0.0862). Among patients with multiple brain metastases, the OS for those who underwent craniotomy followed by whole brain radiation therapy (WBRT), those who received only WBRT, and those treated without locoregional therapy was 47.7, 3.9, and 15.9 months, respectively (p=0.00382).

CONCLUSION

Surgical resection followed by radiation therapy is an effective treatment option for brain metastases in patients with multiple metastases. However, WBRT alone did not improve prognosis.

Efficacy and Safety of Prasugrel vs Clopidogrel in Thrombotic Stroke Patients With Risk Factors for Ischemic Stroke Recurrence: A Double-blind, Phase III Study (PRASTRO-III)

AIM

To examine the efficacy and safety of prasugrel vs clopidogrel in thrombotic stroke patients at risk of ischemic stroke.

METHODS

This multicenter, active-controlled, randomized, double-blind, double-dummy, parallel group study enrolled thrombotic stroke patients aged ≥ 50 years at risk of ischemic stroke. Patients received prasugrel (3.75 mg/day) or clopidogrel (75 or 50 mg/day) for 24-48 weeks; other antiplatelet drugs were prohibited. The primary efficacy endpoint was the composite incidence of ischemic stroke, myocardial infarction (MI), and death from other vascular causes from the start to 1 day after treatment completion or discontinuation. Secondary efficacy endpoints included the incidences of ischemic stroke, MI, death from other vascular causes, ischemic stroke and transient ischemic attack, and stroke. Safety endpoints included bleeding events and adverse events (AEs).

RESULTS

In the prasugrel (N=118) and clopidogrel (N=112; all received 75 mg) groups, the primary efficacy endpoint composite incidence (95% confidence interval) was 6.8% (3.0%-12.9%) and 7.1% (3.1%-13.6%), respectively. The risk ratio (prasugrel/clopidogrel) was 0.949 (0.369-2.443). Secondary efficacy endpoints followed a similar trend. The combined incidences of life-threatening, major, and clinically relevant bleeding were 5.0% and 3.5% in the prasugrel and clopidogrel groups, respectively. The incidences of all bleeding events and AEs were 19.2% and 24.6% and 76.7% and 82.5% in the prasugrel and clopidogrel groups, respectively. No serious AEs were causally related to prasugrel.

CONCLUSIONS

We observed a risk reduction of 5% with prasugrel vs clopidogrel, indicating comparable efficacy. There were no major safety issues for prasugrel.

Phase I/II study of nedaplatin and nab-paclitaxel for patients with previously untreated advanced squamous cell lung cancer: Kanto Respiratory Disease Study Group (KRSG) 1302

BACKGROUND

Nedaplatin and nab-paclitaxel are each efficacious in the treatment of squamous cell lung cancer.

PATIENTS AND METHODS

Eligibility criteria were: no prior chemotherapy, advanced squamous cell lung cancer; performance status 0-1, age > 20 years but < 75 years, and adequate hematologic, hepatic and renal function. Patients received escalating doses of nab-paclitaxel under a fixed dose of nedaplatin (100 mg/m², day 1) every 3 weeks in phase I. The initial nab-paclitaxel dose was 100 mg/m² on days 1 and 8 (level 1), and the next dose was 100 mg/m² on days 1, 8, and 15 (level 2). In phase II, patients received the recommended doses. The primary endpoint was tumor response rate.

RESULTS

In phase I, three patients at level 1 experienced no dose-limiting toxicities (DLTs) and two patients at level 2 experienced DLTs. Level 1 was thus determined as the recommended dose. Twenty-three patients were enrolled in phase II. The 3 patients in level 1 and 23 patients in phase II were included together for analyses. Three of these 26 patients were excluded from response analysis due to pneumonia and patient refusal. Response rate was 91.3% (95% confidence interval, 72.0-98.9%). Toxicities observed during all cycles were tolerable.

CONCLUSIONS

The recommended dose for this combination was nedaplatin at 100 mg/m² on day 1 and nab-paclitaxel at 100 mg/m² on days 1 and 8 every 3 weeks. The combination of nedaplatin and nab-paclitaxel appears safe and efficacious in patients with untreated advanced squamous cell lung cancer.

Nintedanib induces gene expression changes in the lung of induced-rheumatoid arthritis–associated interstitial lung disease mice

Nintedanib is a multi-tyrosine kinase inhibitor widely used to treat progressive fibrosing interstitial lung diseases because it slows the reduction in forced vital capacity. However, the prognosis for patients treated with nintedanib remains poor. To improve nintedanib treatment, we examined the effects of nintedanib on gene expression in the lungs of induced-rheumatoid arthritis–associated interstitial lung disease model mice, which develop rheumatoid arthritis and subsequent pulmonary fibrosis. Using next-generation sequencing, we identified 27 upregulated and 130 downregulated genes in the lungs of these mice after treatment with nintedanib. The differentially expressed genes included mucin 5B and heat shock protein 70 family genes, which are related to interstitial lung diseases, as well as genes associated with extracellular components, particularly the myocardial architecture, suggesting unanticipated effects of nintedanib. Of the genes upregulated in the nintedanib-treated lung, expression of regulatory factor X2, which is suspected to be involved in cilia movement, and bone morphogenetic protein receptor type 2, which is involved in the pathology of pulmonary hypertension, was detected by immunohistochemistry and RNA in situ hybridization in peripheral airway epithelium and alveolar cells. Thus, the present findings indicate a set of genes whose expression alteration potentially underlies the effects of nintedanib on pulmonary fibrosis. It is expected that these findings will contribute to the development of improved nintedanib strategies for the treatment of progressive fibrosing interstitial lung diseases.

Prognostic Implication of PD-L1 Expression on Osimertinib Treatment for EGFR-mutated Non-small Cell Lung Cancer

BACKGROUND/AIM

Real-world data on the clinical outcomes of first-line osimertinib treatment for non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations is lacking. This study aimed to reveal the treatment outcomes and prognostic factors of osimertinib as first-line therapy in clinical practice settings.

PATIENTS AND METHODS

We retrospectively evaluated clinical outcomes of patients with EGFR-mutated NSCLC treated with osimertinib as first-line therapy across 12 institutions in Japan between August 2018 and March 2020.

RESULTS

Among 158 enrolled patients, the objective response rate (ORR) was 68%, and the estimated median progression-free survival (PFS) was 17.1 months [95% confidence interval (CI)=14.5-19.7]. Subgroup analysis showed that PFS in the group with high programmed death-ligand 1 (PD-L1) expression was significantly shorter than that in groups with low or no PD-L1 expression (10.1 vs. 16.1 vs. 19.0 months; p=0.03). Univariate and multivariate analyses demonstrated that high PD-L1 expression was the only independent adverse prognostic factor of osimertinib outcome related to PFS (hazard ratio=2.71; 95%CI=1.26-5.84; p=0.01). In terms of anti-tumor response, there was no statistically significant correlation between PD-L1 expression and the ORR (67% vs. 76% vs. 65%; p=0.51). No significant correlation was also found between PD-L1 and the incidence of de novo resistance to osimertinib (p=0.39).

CONCLUSION

Although PD-L1 expression was not associated with either the ORR or frequency of de novo resistance, high PD-L1 expression could be an independent adverse prognostic factor related to PFS in osimertinib treatment.

Multiple Endocrine Neoplasia Type 1 with Functional Parathyroid Cysts

A 51-year-old woman was admitted because of hypercalcemia. Neck ultrasonography and computed tomography revealed the presence of parathyroid cysts on both sides. After primary hyperparathyroidism was diagnosed by technetium-99m-methoxyisobutylisonitrile scintigraphy, the patient was successfully treated with total parathyroidectomy and autotransplantation. She also had a non-functioning pancreatic neuroendocrine tumor, prolactinoma, and adrenal tumors with subclinical Cushing's syndrome. Given these clinical features and her family history, multiple endocrine neoplasia type 1 (MEN1) was suspected, and germline DNA sequencing revealed a missense mutation (c.1013T>C, [corrected] p.Leu338Pro) in exon 7 of MEN1. This case demonstrates the phenotypic and genetic diversity of MEN1.

Clinical Significance of Tumor Markers for Advanced Thymic Carcinoma: A Retrospective Analysis from the NEJ023 Study

Simple Summary

Advanced thymic carcinoma (ATC) is rare. Owing to its rarity, there is limited information on the prognostic factors, and the optimal serum tumor markers are also unknown. We conducted a multi-institutional retrospective study of patients with ATC. In this study, we collected data on patient characteristics, progression-free survival (PFS), overall survival (OS), and tumor marker values, and investigated the relationship between tumor marker values and PFS/OS. We found that the neuron-specific enolase (NSE) level may be a useful prognostic tumor marker for ATC, regardless of histology. The findings of the analysis limited to squamous cell carcinoma suggested that the NSE and squamous cell carcinoma antigen levels may be useful prognostic factors.

Abstract

The optimal tumor marker for predicting the prognosis of advanced thymic carcinoma (ATC) remains unclear. We conducted a multi-institutional retrospective study of patients with ATC. A total of 286 patients were treated with chemotherapy. Clinicopathological information, including serum tumor markers, was evaluated to determine the overall survival (OS) and progression-free survival (PFS). The carcinoembryonic antigen, cytokeratin-19 fragment, squamous cell carcinoma (SCC) antigen, progastrin-releasing peptide, neuron-specific enolase (NSE), and alpha-fetoprotein levels were evaluated. In the Kaplan–Meier analysis, the OS was significantly shorter in the patients with elevated NSE levels than in those with normal NSE levels (median, 20.3 vs. 36.8 months; log-rank test p = 0.029; hazard ratio (HR), 1.55; 95% confidence interval (CI), 1.05–2.31 (Cox proportional hazard model)); a similar tendency regarding the PFS was observed (median, 6.4 vs. 11.0 months; log-rank test p = 0.001; HR, 2.04; 95% CI, 1.31–3.18). No significant differences in the OS and PFS were observed among the other tumor markers. In both univariate and multivariate analyses of the patients with SCC only, the NSE level was associated with the OS and PFS. Thus, the NSE level may be a prognostic tumor marker for thymic carcinoma, regardless of histology.

Differential effects of dexamethasone and roflumilast on asthma in mice with or without short cigarette smoke exposure

Appropriate drug treatment for smoking asthmatics is uncertain because most smokers with asthma are less sensitive to treatment with glucocorticoids compared with non-smokers with asthma. We hypothesized that roflumilast (Rof), a selective phosphodiesterases-4 inhibitor regarded as an add-on therapy for chronic obstructive pulmonary disease, might be more effective than glucocorticoids for improving asthma in smokers. To investigate this hypothesis, we compared the therapeutic effects of dexamethasone (Dex) and Rof in a mouse model of ovalbumin-induced asthma with or without concurrent cigarette smoke (CS) exposure for 2 weeks. We found that recurrent asthma attacks increased lung tissue resistance. CS exposure in asthmatic mice decreased the central airway resistance, increased lung compliance, and attenuated airway hyper-responsiveness (AHR). CS exposure in asthmatic mice also increased the number of neutrophils and macrophages in the bronchoalveolar fluid. Treatment with Dex in asthmatic mice without CS exposure reduced airway resistance, AHR and airway eosinophilia. In asthmatic mice with CS exposure, however, Dex treatment unexpectedly increased lung tissue resistance and restored AHR that had been otherwise suppressed. Dex treatment in asthmatic mice with CS exposure inhibited eosinophilic inflammation but conversely exacerbated neutrophilic inflammation. On the other hand, treatment with Rof in asthmatic mice without CS exposure reduced airway resistance and airway eosinophilia, although the inhibitory effect of Rof on AHR was unremarkable. In asthmatic mice with CS exposure, Rof treatment did not exacerbate lung tissue resistance but modestly restored AHR, without any significant effects on airway inflammation. These results suggest that CS exposure mitigates sensitivity to both Dex and Rof. In asthmatic mice with CS exposure, Dex is still effective in reducing eosinophilic inflammation but increases lung tissue resistance, AHR and neutrophilic inflammation. Rof is ineffective in improving lung function and inflammation in asthmatic mice with CS exposure. This study did not support our initial hypothesis that Rof might be more effective than glucocorticoids for improving asthma in smokers. However, glucocorticoids may have a detrimental effect on smoking asthmatics.

A case of nonislet cell tumor hypoglycemia associated with malignant mesothelioma requiring a multifaceted approach for optimal glycemic control

Nonislet tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome characterized by refractory hypoglycemia, which often requires multifaceted therapy. We reported a case of a patient with pleural malignant mesothelioma and developed NICTH, for which chemotherapy, glucocorticoids, and nutrition were given to achieve optimal glycemic control.

Differential diagnosis of relapsing polychondritis from asthma by 18-fluoro-2-deoxyglucose positron emission tomography and computed tomography

About a half of all patients with relapsing polychondritis show airway involvement, which is a major cause of morbidity and mortality from this disease. FDG-PET/CT is useful in the differential diagnosis of relapsing polychondritis from asthma.

Anti-cancer strategy targeting the energy metabolism of tumor cells surviving a low-nutrient acidic microenvironment

OBJECTIVE

Tumor cells experience hypoxia, acidosis, and hypoglycemia. Metabolic adaptation to glucose shortage is essential to maintain tumor cells' survival because of their high glucose requirement. This study evaluated the hypothesis that acidosis might promote tumor survival during glucose shortage and if so, explored a novel drug targeting metabolic vulnerability to glucose shortage.

METHODS

Cell survival and bioenergetics metabolism were assessed in lung cancer cell lines. Our in-house small-molecule compounds were screened to identify those that kill cancer cells under low-glucose conditions. Cytotoxicity against non-cancerous cells was also assessed. Tumor growth was evaluated in vivo using a mouse engraft model.

RESULTS

Acidosis limited the cellular consumption of glucose and ATP, causing tumor cells to enter a metabolically dormant but energetically economic state, which promoted tumor cell survival during glucose deficiency. We identified ESI-09, a previously known exchange protein directly activated by cAMP (EAPC) inhibitor, as an anti-cancer compound that inhibited cancer cells under low-glucose conditions even when associated with acidosis. Bioenergetic studies showed that independent of EPAC inhibition, ESI-09 was a safer mitochondrial uncoupler than a classical uncoupler and created a futile cycle of mitochondrial respiration, leading to decreased ATP production, increased ATP dissipation, and fuel scavenging. Accordingly, ESI-09 exhibited more cytotoxic effects under low-glucose conditions than under normal glucose conditions. ESI-09 was also more effective than actively proliferating cells on quiescent glucose-restricted cells. Cisplatin showed opposite effects. ESI-09 inhibited tumor growth in lung cancer engraft mice.

CONCLUSIONS

This study highlights the acidosis-induced promotion of tumor survival during glucose shortage and demonstrates that ESI-09 is a novel potent anti-cancer mitochondrial uncoupler that targets a metabolic vulnerability to glucose shortage even when associated with acidosis. The higher cytotoxicity under lower-than-normal glucose conditions suggests that ESI-09 is safer than conventional chemotherapy, can target the metabolic vulnerability of tumor cells to low-glucose stress, and is applicable to many cancer cell types.

Age-based efficacy and safety of nivolumab for recurrent or metastatic head and neck squamous cell carcinoma: A multicenter retrospective study

AIM

This study retrospectively investigated the efficacy and safety of nivolumab for patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) classified using age <65 years as the cutoff.

METHODS

Overall, 88 patients with R/M HNSCC treated with nivolumab were classified into the young group (<65 years; n = 39) and elderly group (≥65 years; n = 49). Efficacy was evaluated using overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and disease control rate (DCR). Safety was evaluated considering immune-related adverse events (irAEs).

RESULTS

The median OS was 9.7 and 8.6 months in the young and elderly groups, respectively. The 1-year OS rate was 42.0% and 29.4% in the young and elderly groups, respectively. The median PFS was 3.0 and 4.2 months in the young and elderly groups, respectively. The 1-year PFS rate was 30.0% and 27.9% in the young and elderly groups, respectively. In the young group, the ORR was 10.3% and DCR was 33.3%. In the elderly group, the ORR was 18.4% and DCR was 53.1%. There were no significant differences in OS, PFS, ORR, and DCR (P = 0.36, 0.53, 0.29 and 0.06, respectively). Interstitial lung disease (ILD) as an irAE occurred in the young group at a significantly higher rate (20.5% vs 4.1%; P = 0.02).

CONCLUSIONS

There were no significant differences in OS, PFS, ORR, and DCR between the young and elderly groups. DCR tended to be better in the elderly group (P = 0.06). ILD occurred at a significantly higher rate in the young group.

Pulmonary mucoepidermoid carcinoma arising in a patient with Kartagener syndrome

Background

Kartagener syndrome, an autosomal recessive disorder with a triad of chronic sinusitis, bronchiectasis, and situs inversus, is characterized by recurrent respiratory tract infections and chronic inflammation of the lung. Information on comorbidities other than infections in patients with Kartagener syndrome is currently limited.

Case presentation

A 39-year-old, non-smoking female was diagnosed with Kartagener syndrome and admitted to Saitama Medical Center, Jichi Medical University, Japan. Computed tomography revealed an endobronchial massive shadow at the ostial site of the right upper lobe bronchus with atelectasis of the right upper lobe. The mass was surgically resected and pathologically diagnosed as mucoepidermoid carcinoma. The lesion had no vascular invasions and no metastases to the lungs or lymph nodes. The surgical margin was negative for carcinoma. Following surgery, the patient has been in good condition.

Conclusions

The present case showed different clinicopathological characteristics from those previously reported in cases of Kartagener syndrome complicated by carcinoma. To the best of our knowledge, this is the first reported case of a young, non-smoking female with comorbid Kartagener syndrome and pulmonary mucoepidermoid carcinoma. This case report may provide a new perspective on the complications of Kartagener syndrome.

Serum C-Reactive Protein Level Predicts Clinical Outcomes in Patients With Non-Small Cell Lung Cancer Harboring EGFR Mutations

The aim of this study was to assess the association of serum C-reactive protein (CRP) levels with outcomes in 81 patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). Patients with high serum CRP levels had lower therapeutic responses to EGFR-tyrosine kinase inhibitors (43.8%), and shorter time to treatment failure (TTF; 5.8 months) and overall survival (OS; 14.2 months) than those with low CRP levels. In multivariate analysis, serum CRP level was associated with TTF (hazard ratio [HR] 4.86) and OS (HR 49.42). High serum CRP levels may predict poor outcomes in patients with EGFR-mutated NSCLC.

Efficacy and safety of nivolumab in 100 patients with recurrent or metastatic head and neck cancer - a retrospective multicentre study

Background: No large-scale retrospective studies have examined the efficacy and safety of nivolumab. Objective: This retrospective study aimed to investigate the efficacy and safety of nivolumab administered to patients in multiple facilities. Material and methods: The primary endpoint was overall response rate (ORR) and secondary endpoints were progression-free survival (PFS) and overall survival (OS). For safety, adverse event occurrence rates by grade, deaths and severe adverse events were investigated. OS and PFS were also examined according to whether immune-related adverse events (irAEs) appeared. Statistical analysis was conducted using log-rank testing, with values of p < .05 considered significant. Results: Nivolumab was administered to 100 patients with a history of receiving platinum-based drugs. ORR was 13.5% and disease control rate was 49.0%. Median PFS was 3.7 months. Median OS was 9.6 months. For all grades, irAEs occurred in 30 patients. The 1-year survival rate in the subgroup without irAEs was 34.0%, compared to 52.6% with irAEs (p = .041). Conclusions and significance: The 1-year survival rate was better in patients who developed irAEs. This is a new finding for head and neck cancer. Appearance of irAEs could also be used as an indicator of expected therapeutic effect in head and neck cancer.

Idiopathic pulmonary fibrosis in small cell lung cancer as a predictive factor for poor clinical outcome and risk of its exacerbation

Objective

Lung cancer frequently co-exists with idiopathic interstitial pneumonia (IIP), which can be subdivided into idiopathic pulmonary fibrosis (IPF) and IIP other than IPF (other IIP). Although chemotherapy in small cell lung cancer (SCLC) patients with IIP may result in the exacerbation of IIP, these patients commonly receive chemotherapy. This study aimed to assess the risks and benefits of chemotherapy in SCLC patients with IIP.

Methods

We retrospectively analyzed the medical records of 122 patients with SCLC who received chemotherapy. Patients with secondary interstitial lung disease (ILD) of known etiology were excluded. Eligible patients were divided into two groups: SCLC with and without IIP. The former group was subdivided into those with IPF and other IIP.

Results

Of the 47 (39.2%) SCLC patients with IIP, 20 had IPF and 27 had other IIP. The frequency of chemotherapy-induced ILD development or IIP exacerbation was higher in patients with IPF (40.0%) than in those with other IIP (3.7%) and non-IIP (1.4%). Logistic regression analysis demonstrated that ILD development or IIP exacerbation was independently associated with IPF (P = 0.007). Time to treatment failure (P < 0.001) and overall survival (P = 0.001) were different among the groups., Cox proportional hazard model revealed that IPF was independently associated with time to treatment failure (P = 0,017) and overall survival (P = 0.006). Other IIP had no impact on time to treatment failure or overall survival. Development of ILD or exacerbation of IIP independently reduced time to treatment failure and overall survival.

Conclusions

Comorbid IPF can be an independent, negative prognostic indicator and at high risk of ILD development or IIP exacerbation in SCLC patients. Early diagnosis and intervention for chemotherapy-induced IIP exacerbation will be beneficial for SCLC patients with IPF, who need close monitoring for its onset.

Abstract 766: Mutual negative regulation of EZH2 and miR-4448 for tumor progression via epithelial mesenchymal transition in small cell lung cancer

Enhancer of zeste homolog 2 (EZH2) is a catalytic component of polycomb repressive complexes, promotes tumor progression and metastasis. Expression levels of EZH2 are associated with clinical outcomes in a variety of tumors. High expression levels of EZH2 have been reported in cell lines and tissues of small cell lung cancer (SCLC), which is characterized by its invasiveness and metastatic potentials. Epithelial-mesenchymal transition (EMT) is well recognized to contribute to aggressiveness of SCLC, and microRNA (miRNA) is known to be associated with both EMT and the biological characteristics of SCLC. The aim of this study was to identify a novel miRNA defining EZH2-assciated EMT and tumor aggressiveness in SCLC. Immunohistochemistry and quantitative PCR showed that EZH2 expressions levels were decreased in three types of SCLC cell lines and tumor tissues from 34 patients with SCLC. Small interfering RNA (siRNA) against EZH2 suppressed its expression and EMT in SBC3 and SBC5 cell lines, both of which had high EZH2 expression levels as SCLC cell lines. Comprehensive miRNA expression analysis was used to compare changes of miRNA expression between EZH2 siRNA-transfected cells and mock-transfected cells. As a result, miR-4448 expression was significantly decreased in

SBC3 and SBC5 cells transfected with EZH2 siRNA. Cell growth assay and cell invasion assay revealed that overexpression of miR-4448 inhibited cellular proliferation and invasion potential. Furthermore, we confirmed that overexpression of miR-4448 abrogated EMT and decreased EZH2 expression. In conclusion, EZH2 and miR-4448 mutually suppressed these expressions and functions, which was associated with tumor progression via EMT in SCLC. The findings of this study suggest that miR-4448 may play a crucial role in the biological characteristics of SCLC.

Citation Format: Nobuyuki Koyama, Yuichi Ishikawa, Yuki Iwai, Kazutetsu Aoshiba, Hiroyuki Nakamura, Koichi Hagiwara. Mutual negative regulation of EZH2 and miR-4448 for tumor progression via epithelial mesenchymal transition in small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 766.

Abstract 800: ESI-09 and HJC0197, known EPAC inhibitors, sensitize lung cancer cells to glucose starvation by uncoupling mitochondrial electron transport, leading to bioenergetic crisis

Cancer cells utilize aerobic glycolysis and proliferate continuously beyond the capacity of their blood supply, leading to microenvironmental stresses such as hypoxia, nutrient (glucose) deprivation and extracellular acidosis. We have previously showed that extracellular acidosis prevents glucose starvation-induced death of lung cancer cells by reducing glycolytic energy production and de novo protein/RNA synthesis that consume ATP (AACR 2018). This acidosis-dependent, glucose starvation-resistant, and ATP-saving phenotype is thought to serve as an adaptive response to glucose deprivation in cancer cells to survive an energy-restricted tumor microenvironment. In the present study, we screened small-molecule inhibitors to explore therapeutic reagents that can exert cytotoxicity against the glucose starvation-resistant phenotype in the lung cancer cell lines, A549 and H1299 cells. Among the various inhibitors tested, we found that ESI-09 and HJC0197, known as inhibitors of the exchanger protein directly activated by cAMP (EPAC), reduced the cellular ATP levels and survival under glucose deprivation stress under both acidic (pH 6.8) and neutral (pH 7.4) conditions. Interestingly, the ATP-reducing effect of ESI-09 and HJC0197 was not due to inhibition of the EPAC function, because the effect cannot be reproduced with other EPAC inhibitors, such as CE3F4, EPAC5376753 and ESI-05. Rather, the effect of ESI-09 and HJC0197 was attributed to their previously unknown action of uncoupling the mitochondrial electron transport chain (ETC). We found that ESI-09 and HJC0197 induced mitochondrial proton leak, causing ATP deficiency and cell death via the following three mechanisms: 1) decreased mitochondrial ATP production due to ETC uncoupling, 2) increased ATP consumption resulting from reversal of F0/F1-ATPsynthase/ATPase to maintain the mitochondrial membrane potential, and 3) glucose deficiency as a result of increased glucose consumption due to a compensatory stimulation of glycolytic ATP production. The energy-saving phenotype of cancer cells is thought to serve as an adaptive strategy that allows cell survival in an energy-restricted, acidic tumor microenvironment. Our results suggest that ESI-09 and HJC0197 disrupt bioenergetic tumor metabolism for energy homeostasis in both acidic and neutral microenvironment, and may exert a therapeutic effect against the starvation-resistant phenotype of cancer cells.

The complete chemical structures of ESI-09 and HJC0197 will be divulged at the time of the presentation at the meeting.

Citation Format: Yuki Iwai, Ryota Kikuchi, Hiroyuki Nakamura, Nobuyuki Koyama, Koichi Hagiwara, Kazutetsu Aoshiba. ESI-09 and HJC0197, known EPAC inhibitors, sensitize lung cancer cells to glucose starvation by uncoupling mitochondrial electron transport, leading to bioenergetic crisis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 800.

Effectiveness of nanoparticle albumin-bound paclitaxel plus carboplatin in non-small lung cancer patients with malignant pleural effusion

Malignant pleural effusion (MPE) is a common complication occurring in cancer patients, and its management affects the prognosis of these patients. Preclinical and clinical studies have reported that treatment with nanoparticle albumin-bound paclitaxel (nab-paclitaxel) plus carboplatin (CBDCA) is effective against intraperitoneal malignant tumors. To investigate the effectiveness of nab-paclitaxel plus CBDCA therapy for MPEs arising in patients with non-small cell lung cancer (NSCLC), we retrospectively analyzed the clinicopathological characteristics of 40 patients with stage IIIb or IV NSCLC who were treated with nab-paclitaxel plus CBDCA from 2013 to 2016. Out of 26 patients with MPEs who were treated with nab-paclitaxel plus CBDCA in this study, 21 patients (80.8%) had effective responses in MPEs; 6 of 21 patients exhibited complete responses (23.1%) and 15 of 21 had partial responses (57.7%). Kaplan-Meier survival curves and log-rank tests to evaluate the effectiveness of nab-paclitaxel plus CBDCA therapy against MPEs showed longer median progression-free survival (323 days vs. 26 days; p=0.009) and overall survival (not reached vs. 199 days; p=0.047) in patients with complete responses compared with those who achieved no response. There were no statistical differences between therapeutic effects on MPEs and those on systemic lesions. Nab-paclitaxel plus CBDCA therapy may be a preferred therapeutic option for patients with NSCLC who experience MPEs, and its effectiveness in treatment of MPEs may need to be evaluated separately from its therapeutic responses in systemic lesions.

Simultaneous metastasized primary unknown signet ring cell carcinoma of the cervical lymph node and mucoepidermoid carcinoma of the parotid gland as double cancers

Lymph node metastasis from signet ring cellcarcinoma (SRCC) primary unknown is extremely rare. We here report a case of primary-unknown SRCC that metastasized to the cervical lymph nodes, co-existing with mucoepidermoid carcinoma (MEC) of the parotid gland as a simultaneous double cancer. A 68-year-old female patient with right swollen cervical lymph nodes consulted our medical center. A diagnosis of bilateral cervical lymph node metastasis and a right parotid tumor was made. After bilateral neck dissection and right parotidectomy, the pathological diagnosis was SRCC of primary unknown with metastasis to the cervical lymph node and MEC of the parotid gland. Examination of the CRTC1/3-MAML2 fusion gene showed no relation between SRCC of primary unknown with metastasis to the cervical lymph node and MEC of the parotid gland. Ten months after the first treatment, there was recurrence in the left neck lymph node, and left neck dissection was performed. Fourteen months after the first treatment, the patient is alive and cancer-free. This case is the fourth report of SRCC with lymph node metastasis, and highlights the value of fusion gene detection to determine relatedness between simultaneous cancers. Moreover, such cases should be closely monitored for the subsequent appearance of distant metastases.

Hypercapnic tumor microenvironment confers chemoresistance to lung cancer cells by reprogramming mitochondrial metabolism in vitro

The tumor microenvironment has previously been reported to be hypercapnic (as high as ~84 mmHg), although its effect on tumor cell behaviors is unknown. In this study, high CO₂ levels, ranging from 5% to 15%, protected lung cancer cells from anticancer agents, such as cisplatin, carboplatin and etoposide, by suppressing apoptosis. The cytoprotective effect of a high CO₂ level was independent of acidosis and was due to mitochondrial metabolic reprogramming that reduced mitochondrial respiration, as assessed by oxygen consumption, oxidative phosphorylation, mitochondrial membrane and oxidative potentials, eventually leading to reduced reactive oxidant species production. In contrast, high CO₂ levels did not affect cisplatin-mediated DNA damage responses or the expression of Bcl-2 family proteins. Although high CO₂ levels inhibited glycolysis, this inhibition was not mechanistically involved in high CO₂-mediated reductions in mitochondrial respiration, because a high CO₂ concentration inhibited isolated mitochondria. A cytoprotective effect of high CO₂ levels on mitochondria DNA-depleted cells was not noted, lending support to our conclusion that high CO₂ levels act on mitochondria to reduce the cytotoxicity of anticancer agents. High CO₂-mediated cytoprotection was also noted in a 3D culture system. In conclusion, the hypercapnic tumor microenvironment reprograms mitochondrial respiratory metabolism causing chemoresistance in lung cancer cells. Thus, tumor hypercapnia may represent a novel target to improve chemosensitivity.

Advanced Lung Adenocarcinoma with Nivolumab-associated Dermatomyositis

We herein report a 42-year-old man with advanced lung adenocarcinoma and nivolumab-associated dermatomyositis. Nivolumab, an anticancer drug that is classified as an immune checkpoint inhibitor, often induces immune-related adverse events (irAEs). However, there have so far been no reports regarding nivolumab-associated dermatomyositis. This patient was diagnosed with dermatomyositis due to the presence of proximal muscle weakness with abnormal electromyography and magnetic resonance imaging findings; skin lesions, such as heliotrope rash, shawl sign, and periungual erythema; and an elevated serum aldolase level after nivolumab administration. It is important to consider drug-associated dermatomyositis in the differential diagnosis of patients presenting with skin lesions and muscle weakness after nivolumab treatment.

Abstract 2407: Extracellular acidosis inhibits glucose starvation-induced lung cancer cell death by suppressing overall metabolic rate

Bioenergetic tumor metabolism is essential to meet ATP requirements for energy homeostasis. Cancer cells utilize aerobic glycolysis and proliferate continuously beyond the capacity of blood supply. These phenotypic alterations lead to various microenvironmental stresses, such as hypoxia, nutrient (glucose) deprivation, and extracellular acidosis, to which cancer cells must metabolically adapt in order to survive and proliferate. However, compared to hypoxia, relatively little is known about the metabolic adaptations in response to glucose deprivation and acidosis. In the present study, we explored the effects of extracellular acidosis on cancer metabolism under glucose deprivation stress, as extracellular acidosis and insufficient glucose supply usually co-exist in the tumor microenvironment. To this aim, A549 lung cancer cells were treated with acidosis, glucose deprivation, or a combination. Then, cell survival, total cellular ATP turnover, relative glycolytic and mitochondrial dependency and capacity, and de novo rRNA and protein synthesis were determined. We found that acidosis (pH 6.8) inhibited ATP depletion and cell death induced by glucose deprivation. The cytoprotective effect of acidosis against glucose deprivation-induced cell death was mediated by two distinct mechanisms. First, acidosis shifted cellular ATP production from glycolysis to OXPHOS that became independent of glucose uptake but dependent on glutaminolysis and fatty acid β-oxidation. Second, acidosis reduced ATP consumption by inhibiting de novo rRNA and protein synthesis that utilizes ATP. In contrast, the protective effect of acidosis on glucose starvation-induced cell death was independent of AMPK, PI3K, ERK, and p38 MAPK. Based on this mechanistic knowledge of acidosis-dependent metabolic alterations, we tested the effect of the mitochondrial complex I inhibitor metformin on death of lung cancer cells. Metformin and a combination of rotenone and AICAR mimicking an action of metformin induced ATP depletion and cell death in glucose-free medium, but under acidosis the cytotoxic effect of metformin was significantly attenuated because overall ATP turnover was reduced under low pH. These results suggest that during acidosis, cells are forced to a reduced glycolytic energy production, but the decrease in protein synthesis and ATP requirement serves as an adaptive response to glucose deprivation stress. This acidosis-dependent, glucose starvation-resistant phenotype may provide an adaptive strategy in an energy-restricted tumor microenvironment. Our findings highlight the importance of considering the two factors, acidosis and nutrient starvation in combination to understand their contributions to tumor metabolism.

Citation Format: Yuki Iwai, Ryota Kikuchi, Yasutaka Watanabe, Nobuyuki Koyama, Koichi Hagiwara, Hiroyuki Nakamura, Kazutetsu Aoshiba. Extracellular acidosis inhibits glucose starvation-induced lung cancer cell death by suppressing overall metabolic rate [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2407.

Pre-existing interstitial lung disease as a risk factor for pneumonitis associated with ramucirumab and paclitaxel in patients with gastric cancer: The impact of usual interstitial pneumonia

OBJECTIVE

Combination treatment with ramucirumab and paclitaxel shows significant efficacy in patients with advanced gastric cancer as a second-line standard therapy. However, limited information is available about the development of pneumonitis associated with this treatment in clinical practice. This study aimed to characterize this form of pneumonitis and identify the risk factors for its onset.

METHODS

We retrospectively analyzed the medical records of 44 patients with gastric cancer who received combination treatment with ramucirumab and paclitaxel from 2016 to 2017. Then, the clinicopathological characteristics of patients who developed treatment-related pneumonitis were evaluated and further compared with those of patients who did not.

RESULTS

Six patients (13.6%) developed pneumonitis within five treatment cycles, and in five cases, remission was observed after cessation of combination treatment alone. The onset of pneumonitis was independently associated with pre-existing interstitial lung disease (ILD) (p = 0.025; odds ratio = 206.4). Patients with pneumonitis showed reduced time to treatment failure (median 56 vs. 138 days; p = 0.008), as compared with those without pneumonitis. Most patients with pre-existing ILD with a usual interstitial pneumonia (UIP) pattern developed pneumonitis.

CONCLUSIONS

In clinical practice, pneumonitis associated with the combination treatment of ramucirumab and paclitaxel was generally mild, but common. Patients with gastric cancer with pre-existing ILD, particularly those presenting with a UIP pattern, undergoing this combination treatment, should be carefully monitored for the development of treatment-related pneumonitis.

Prognostic Factors and Efficacy of First-Line Chemotherapy in Patients with Advanced Thymic Carcinoma: A Retrospective Analysis of 286 Patients from NEJ023 Study

BACKGROUND

The prognostic factors and the efficacy of first-line chemotherapy remain unclear in patients with advanced thymic carcinoma.

MATERIALS AND METHODS

We conducted a multi-institutional retrospective study named NEJ023 for patients with advanced thymic carcinoma. All patients without any indication of curative treatment were treated with chemotherapy from 1995 to 2014 at 40 institutions of the North East Japan Study Group.

RESULTS

A total of 286 patients with advanced thymic carcinoma were analyzed. First-line chemotherapy included platinum-based doublets in 62.2% of the patients, monotherapy in 3.5%, and other multidrug chemotherapy (e.g., cisplatin, doxorubicin, vincristine, and cyclophosphamide [ADOC]) in 34.3%. The median follow-up period was 55.5 months, and the median overall survival (OS) from the start of first-line chemotherapy was 30.7 months (95% confidence interval, 25.9-35.9 months). There was no significant difference in OS among different first-line chemotherapy regimens (e.g., between carboplatin/paclitaxel and ADOC, median OS: 27.8 vs. 29.9 months). Masaoka-Koga stage IVa and volume reduction surgery were favorable prognostic factors for OS in the multivariate analysis using the Cox proportional hazards model.

CONCLUSION

The efficacy of each first-line chemotherapy regimen for advanced thymic carcinoma did not vary significantly. Our results might support the adequacy of the use of carboplatin/paclitaxel as first-line chemotherapy for these patients.

IMPLICATIONS FOR PRACTICE

Because of its rarity, there is limited information about prognostic factors and efficacy of chemotherapy in patients with advanced thymic carcinoma. This is the largest data set for those patients treated with chemotherapy. This study suggests there is no significant difference in efficacy between carboplatin/paclitaxel and cisplatin/doxorubicin/vincristine/cyclophosphamide for advanced thymic carcinoma. This result can support the adequacy of the selection of platinum doublets as treatment for those patients, rather than anthracycline-based multidrug regimen.

Circulatory CNP Rescues Craniofacial Hypoplasia in Achondroplasia

Achondroplasia is the most common genetic form of human dwarfism, characterized by midfacial hypoplasia resulting in occlusal abnormality and foramen magnum stenosis, leading to serious neurologic complications and hydrocephalus. Currently, surgery is the only way to manage jaw deformity, neurologic complications, and hydrocephalus in patients with achondroplasia. We previously showed that C-type natriuretic peptide (CNP) is a potent stimulator of endochondral bone growth of long bones and vertebrae and is also a potent stimulator in the craniofacial region, which is crucial for midfacial skeletogenesis. In this study, we analyzed craniofacial morphology in a mouse model of achondroplasia, in which fibroblast growth factor receptor 3 (FGFR3) is specifically activated in cartilage ( Fgfr3^ach mice), and investigated the mechanisms of jaw deformities caused by this mutation. Furthermore, we analyzed the effect of CNP on the maxillofacial area in these animals. Fgfr3^ach mice exhibited midfacial hypoplasia, especially in the sagittal direction, caused by impaired endochondral ossification in craniofacial cartilage and by premature closure of the spheno-occipital synchondrosis, an important growth center in craniomaxillofacial skeletogenesis. We crossed Fgfr3^ach mice with transgenic mice in which CNP is expressed in the liver under the control of the human serum amyloid-P component promoter, resulting in elevated levels of circulatory CNP ( Fgfr3^ach/SAP-Nppc-Tg mice). In the progeny, midfacial hypoplasia in the sagittal direction observed in Fgfr3^ach mice was improved significantly by restoring the thickness of synchondrosis and promoting proliferation of chondrocytes in the craniofacial cartilage. In addition, the foramen magnum stenosis observed in Fgfr3^ach mice was significantly ameliorated in Fgfr3^ach/SAP-Nppc-Tg mice due to enhanced endochondral bone growth of the anterior intraoccipital synchondrosis. These results clearly demonstrate the therapeutic potential of CNP for treatment of midfacial hypoplasia and foramen magnum stenosis in achondroplasia.

Distinct Benefit of Overall Survival between Patients with Non-Small-Cell Lung Cancer Harboring EGFR Exon 19 Deletion and Exon 21 L858R Substitution

BACKGROUND

Exon 19 deletion (Del19) and exon 21 L858R substitution (L858R), which account for 90% of epidermal growth factor receptor (EGFR) mutations as common mutations, are associated with favorable outcomes with EGFR-tyrosine kinase inhibitors (TKIs) compared with other uncommon EGFR mutations in non-small-cell lung cancer (NSCLC). However, whether there are differences in overall survival (OS) between patients with these common EGFR mutations remains controversial.

METHODS

The subjects studied were 74 NSCLC patients with common EGFR mutations treated with gefitinib or erlotinib. Using univariate and multivariate analyses, we retrospectively compared the clinicopahological characteristics of patients harboring Del19 with those harboring L858R.

RESULTS

Compared with patients harboring L858R, EGFR-TKIs provided a significant OS benefit in patients harboring Del19 (p = 0.024), as well as favorable therapeutic responses (p = 0.045) and progression-free survival (PFS) benefits (p = 0.031). In multivariate analyses, Del19 was independently associated with PFS (p = 0.029) and OS (p = 0.009), whereas no parameters other than pleural dissemination at the initial treatment were associated with EGFR mutation types.

CONCLUSION

Del19 and L858R have distinct prognostic implications and may require individual therapeutic strategies.

Treatments and outcomes of advanced/recurrent non-small cell lung cancer harboring the EGFR T790M mutation: a retrospective observational study of 141 patients in Japan

BACKGROUND

The epidermal growth factor receptor (EGFR) T790M mutation is considered the major mechanism of acquired resistance to EGFR tyrosine kinase inhibitors (EGFR-TKIs) in non-small cell lung cancer (NSCLC) patients with EGFR-sensitizing mutations. Although chemotherapy is commonly used for those patients under the condition without T790M-targeted therapy, the clinical outcomes are poorly defined. Therefore, we aimed to reveal the treatment patterns and clinical outcomes in patients with T790M-positive NSCLC.

METHODS

We conducted a retrospective observational study at 23 sites in Japan, and 141 patients with T790M-positive advanced/recurrent NSCLC were identified from January 2008 to December 2014. Their records were studied to understand treatment patterns after detection of a T790M mutation and to assess the objective response rate (ORR) and median survival time (MST) to specific treatment modalities.

RESULTS

Of 141 patients, 24 had de novo T790M-positive tumors and 117 had acquired T790M-positive tumors, with MSTs (95% CI) of 21.4 (12.4-36.7) and 9.1 (6.4-13.9) months, respectively. The most common regimen was platinum-based doublet chemotherapy ± bevacizumab, which was associated with an ORR/MST of 25.0%/29.1 months, respectively, in patients with de novo T790M mutations, and 22.2%/15.3 months, respectively, in patients with acquired T790M mutations.

CONCLUSIONS

This study reveals the treatment patterns and outcomes of NSCLC patients in Japan after detection of the T790M mutation. The most common treatment following detection of the T790M mutation was platinum-based doublet chemotherapy ± bevacizumab. Platinum-based doublet chemotherapy ± bevacizumab was moderately effective, indicating the need for targeted therapies for patients with T790M mutation-positive NSCLC.

Clinical and biological significance of erlotinib therapy after pemetrexed in non-small cell lung cancer with wild-type EGFR

Pemetrexed is a multi-targeted anti-folate agent that confers favorable benefits to patients with non-small cell lung cancer (NSCLC). However, the optimal use including treatment schedule of pemetrexed and other drugs in clinical practice remains to be determined, particularly for NSCLC with wild-type epidermal growth factor receptor (EGFR). The present study investigated a potential therapeutic strategy for NSCLC patients with wild-type EGFR who were treated with pemetrexed. To identify factors associated with a survival, medical record data from 130 patients were retrospectively reviewed, using the Kaplan-Meier method with log-rank test. Factors identified in the clinical analysis were further investigated within in vitro studies. Patients who underwent the treatment schedule of erlotinib at the time of progression after pemetrexed-based chemotherapy prolonged overall survival, compared to those treated with other schedules (p=0.010; hazard ratio, 0.418). This survival benefit was also observed in the treatment schedule of pemetrexed monotherapy and subsequent erlotinib (p=0.008; hazard ratio, 0.220). As a treatment at the time of progression after pemetrexed-based chemotherapy, erlotinib conferred a survival benefit when compared to docetaxel (p=0.024; hazard ratio, 0.377). The cell growth assay confirmed that treatment with pemetrexed followed by erlotinib significantly inhibited proliferation of NSCLC cells regardless of EGFR mutation status. In conclusion, use of erlotinib at the time of progression after pemetrexed therapy confers a survival benefit in NSCLC patients with wild-type EGFR. The result of this study provides an important clue to the optimal treatment schedule for NSCLC.

Abstract 103: Abundant expression of enhancer of zeste homolog 2 in small cell lung cancer

Background: Enhancer of Zeste Homolog 2 (EZH2) is a catalytic component of polycomb repressive complexes and functions as a histon methyltransferase for H3 lysine 27 residues. EZH2 overexpression promotes tumor progression and metastasis, leading to a poor prognosis. Small cell lung cancer (SCLC) is characterized by highly invasive and metastatic potentials compared with non-small cell lung cancer (NSCLC), whereas these are very limited information about whether EZH expression is associated with clinical and biological differences between both tumor types. The objective of the current study is to elucidate the role of EZH2 in the phenotypic characteristics of SCLC

Method: EZH2 expressions in staging-matched tumor samples from 34 patients with SCLC and NSCLC consisting of adenocarcinoma (Ad) and squamous cell carcinoma (SCC) were evaluated using immunohistochemistry. The extent and location of immunohistochemical staining for EZH2 was assessed according to the immunoreactive score (IRS) evaluating the proportion of cells that express EZH2 protein and the intensity of its staining. Percentage of the cancer area stained in high-power fields was measured. Staining intensity was graded as 0 (negative), 1 (weak), 2 (moderate), and 3 (strong); percentage of positive cells was scored as 0 (negative), 2 (from 11 to 50%), 3 (from 51 to 80%), and 4 (&gt; 80%). The IRS taken from the multiplication of these two scores (values from 0-12) was defined as follows: 0 as negative, values 1-3 as weak, values 4, 6 as positive, and multiplication values 8, 9, 12 as strongly positive.

Results:Thirty-four patients analyzed contained, 16 (47%) of surgical stage I, 10 (29%) of Stage II, 7 (21%) of Stage III, and one (3%) of Stage IV. The patient's clinical characteristic among three groups (SCLC, Ad, and SCC group) are summarized. Sex (M/F) = (27/7, 20/14, and 31/3). Mean Age = (68.2, 65.3, and 70.4). Mean Smoking Index (the number of cigarettes per day×smoking years) = (1236, 526, and 1222). Negative staining was noted in one SCLC, five Ads, and four SCCs, weakly positive in 0 SCLC, 17 Ads, and 15 SCCs, positive in 8 SCLCs, 2 Ads, and 9 SCCs and strongly positive in 25 SCLCs, 10 Ads, and 6 SCCs. Mean IRS was 9.5 in SCLCs, 4.5 in Ads, and 3.8 in SCCs. The immunohistochemical analysis of EZH2 expression levels based on the staining intensity and the percentage of positive cells was significantly higher with SCLC (p&lt;0.001).

Conclusion:EZH2 expression may determine the clinical and biological characteristics of SCLC.

Citation Format: Yasutaka Watanabe, Nobuyuki Koyama, Yuki Iwai, Chihiro Miwa, Shinichiro Koyama. Abundant expression of enhancer of zeste homolog 2 in small cell lung cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 103. doi:10.1158/1538-7445.AM2015-103

Adverse cardiovascular events predict survival benefit in non-small lung cancer patients treated with bevacizumab

BACKGROUND

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor (VEGF) that provides a survival benefit to patients with non-small cell lung cancer (NSCLC). However, the treatment is sometimes accompanied by life-threatening bleeding events, and studies have not yet identified factors that can predict outcomes for NSCLC patients receiving bevacizumab.

METHODS

To identify prognostic factors for patients with NSCLC who are undergoing bevacizumab therapy, this study retrospectively investigated 34 consecutive patients with NSCLC treated with bevacizumab-containing chemotherapy.

RESULTS

Adverse cardiovascular events, including hypertension and bleeding events, during bevacizumab therapy were observed in 18 patients (53%). Kaplan-Meier survival analyses and log-rank tests revealed that median overall survival was significantly better in patients who experienced adverse cardiovascular events than those who did not (442 versus 304 days; P=0.012). In the multivariate Cox proportional hazard model, the onset of adverse cardiovascular events was independently associated with a better overall survival.

CONCLUSIONS

The onset of adverse cardiovascular events during bevacizumab therapy may be a favorable prognostic factor for patients with NSCLC. The results of this retrospective study warrant further large-scale prospective trials.

Clinical significance of erlotinib monotherapy for gefitinib-resistant non-small cell lung cancer with EGFR mutations

BACKGROUND

The efficacy of the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) erlotinib is difficult to be accurately assessed in patients with non-small cell lung cancer (NSCLC) because it is commonly employed after failure of another EGFR-TKI, gefitinib.

PATIENTS AND METHODS

Medical records from 104 patients with NSCLC treated with erlotinib were retrospectively reviewed.

RESULTS

There were no significant differences in erlotinib efficacy between EGFR-mutated NSCLC with gefitinib resistance and NSCLC with wild-type EGFR. A therapeutic response of disease control (DC) and the onset of skin rash prolonged the progression-free survival (PFS), whereas the onset of interstitial lung disease shortened both PFS and overall survival (OS). The DC group also experienced prolonged OS.

CONCLUSION

Erlotinib may be a therapeutic option for EGFR-mutated NSCLC with gefitinib resistance, as well as for NSCLC with wild-type EGFR. Therapeutic response of DC and the onset of the described adverse events may be practical predictors of survival in erlotinib treatment.

Phase 1 study of lenvatinib combined with carboplatin and paclitaxel in patients with non-small-cell lung cancer

BACKGROUND

This dose-finding study evaluated lenvatinib, an oral multitargeted receptor tyrosine kinase inhibitor, in combination with carboplatin/paclitaxel in chemotherapy-naïve non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Patients received lenvatinib twice daily (BID) with carboplatin (area under the curve 6 mg ml(-1) min(-1), day 1)/paclitaxel (200 mg m(-2), day 1) every 3 weeks. The initial dose of lenvatinib was 6 mg BID. The primary end point was maximum tolerated dose (MTD) of lenvatinib. At the MTD, the cohort was expanded by 16 patients. Safety, pharmacokinetics, pharmacodynamics, and antitumor effects were evaluated.

RESULTS

Twenty-eight patients were treated. At 6 mg BID, dose-limiting toxicities (DLTs) included febrile neutropenia/gingival infection (n=2). No DLTs occurred with 4 mg BID, the recommended MTD for the expansion. Common grade 3/4 toxicities included neutropenia, leukopenia, hypertension, and thrombocytopenia. The combination had no significant impact on individual drug pharmacokinetics. Response rate and median progression-free survival were 68% and 9.0 months, respectively, with 4 mg BID. In the plasma biomarker analysis, stromal cell-derived factor 1α, stem cell factor, and granulocyte colony-stimulating factor correlated with antitumor activity.

CONCLUSION

The MTD for lenvatinib with carboplatin/paclitaxel is 4 mg BID in advanced NSCLC patients. This regimen demonstrated manageable tolerability and encouraging antitumor activity.