Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other health care providers on integrative approaches to managing pain in patients with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included pain intensity, symptom relief, and adverse events. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 227 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Among adult patients, acupuncture should be recommended for aromatase inhibitor-related joint pain. Acupuncture or reflexology or acupressure may be recommended for general cancer pain or musculoskeletal pain. Hypnosis may be recommended to patients who experience procedural pain. Massage may be recommended to patients experiencing pain during palliative or hospice care. These recommendations are based on an intermediate level of evidence, benefit outweighing risk, and with moderate strength of recommendation. The quality of evidence for other mind-body interventions or natural products for pain is either low or inconclusive. There is insufficient or inconclusive evidence to make recommendations for pediatric patients. More research is needed to better characterize the role of integrative medicine interventions in the care of patients with cancer.Additional information is available at https://integrativeonc.org/practice-guidelines/guidelines and www.asco.org/survivorship-guidelines.

Clinic friendly estimation of muscle composition: Preoperative linear segmentation shows overall survival correlated with muscle mass in patients with nonmetastatic renal cell carcinoma

Purpose

Sarcopenia is associated with decreased survival and increased complications in patients with renal cell carcinoma. Readily identifying patients with low muscle composition that may experience worse outcomes or would benefit from preoperative intervention is of clinical interest. Traditional body composition analysis methods are resource intensive; therefore, linear segmentation with routine imaging has been proposed as a clinically practical alternative. This study assesses linear segmentation's prognostic utility in nonmetastatic renal cell carcinoma.

Materials and Methods

A single institution retrospective analysis of patients that underwent nephrectomy for nonmetastatic renal cell carcinoma from 2005-2021 was conducted. Linear segmentation of the bilateral psoas/paraspinal muscles was completed on preoperative imaging. Total muscle area and total muscle index associations with overall survival were determined by multivariable analysis.

Results

532 (388 clear cell) patients were analyzed, with median (IQR) total muscle index of 28.6cm²/m² (25.8-32.5) for women and 33.3cm²/m² (29.1-36.9) for men. Low total muscle index was associated with decreased survival (HR=1.96, 95% CI 1.32-2.90, p<0.001). Graded increases in total muscle index were associated with better survival (HR=0.95, 95% CI 0.92-0.99, p=0.006).

Conclusions

Linear segmentation, a clinically feasible technique to assess muscle composition, has prognostic utility in patients with localized renal cell carcinoma, allowing for incorporation of muscle composition analysis into clinical decision-making. Muscle mass determined by linear segmentation was associated with overall survival in patients with nonmetastatic renal cell carcinoma.

Neoadjuvant Nivolumab and Ipilimumab for Nonmetastatic Renal Cell Carcinoma with Tumor Thrombus

Renal cell carcinoma with level IV tumor thrombus is a condition necessitating aggressive surgical management. Many solid organ malignancies often benefit from neoadjuvant treatments for tumor debulking and improvement of surgical outcomes. However, neoadjuvant treatments for renal cell carcinoma have been limited by its resistance to traditional chemotherapy and radiation. Emerging treatment modalities, such as immunotherapies, are exciting new options that may be therapeutically effective. The combination of nivolumab and ipilimumab has exhibited success in managing metastatic renal cell carcinoma. Limited data exist for its use in nonmetastatic renal cell carcinoma with tumor thrombus. This case illustrates the use of nivolumab and ipilimumab combination therapy in delaying tumor growth, producing observable tumor thrombus histologic and radiologic treatment changes, and, most importantly, facilitating a less invasive surgical approach of a level IV renal cell carcinoma tumor thrombus.

Association of grit and overall survival in patients undergoing nephrectomy for renal cell carcinoma

Background

Quantifying grit with the Short Grit Scale (Grit-S) has shown ability to predict success in various academic and professional domains. Grit has yet to be analyzed in patients with cancer.

Methods

This study is a longitudinal analysis of prospectively distributed Grit-S surveys to patients undergoing radical or partial nephrectomy. Patients who completed a preoperative Grit-S survey with confirmed renal cell carcinoma (RCC) were included in the analysis. The relationship between preoperative grit scores and overall survival (OS) was determined using Cox proportional-hazard models and Kaplan-Meier analysis.

Results

A total of 323 patients with RCC that completed the Grit-S survey prior to nephrectomy were included in the study. Median Grit score was 3.9. Most patients were male (67.5%), White (69.3%), and greater than 60 years old (57.0%) with a median age of 62 at the time of surgery. Patients scoring above or below the median grit score had similar baseline characteristics. As a binary variable, lower preoperative grit was significantly associated with shorter OS [hazard ratio (HR) =2.02, 95% confidence interval (CI): 1.12-3.63, P=0.019] on multivariable analysis. Unit changes in grit were not significantly associated with OS (HR =0.77, 95% CI: 0.53-1.14, P=0.193).

Conclusions

Lower grit scores may predict decreased OS in RCC patients undergoing nephrectomy. The Grit-S survey may have utility in preoperative evaluation. Further research assessing grit in other malignancies and how to psychologically optimize patients prior to surgery are needed.

Utility of ultrasonography in preoperative assessment of tumor thrombi in kidney cancer

INTRODUCTION

This study examined the clinical accuracy of ultrasonography compared to magnetic resonance imaging (MRI) and intraoperative findings for evaluation of tumor thrombi level in patients with renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively identified 38 patients at our institution who underwent both ultrasonography and MRI before undergoing open radical nephrectomy with tumor thrombectomy between 2010 and 2019. We compared tumor thrombus level findings of both ultrasonography and MRI, as well as the diagnostic accuracy of each to intraoperative findings. Agreement between ultrasonography, MRI, and surgery was tested with kappa. Logistic regression models identified factors that predict a mismatched thrombus level between an imaging modality and surgical findings.

RESULTS AND CONCLUSIONS

Tumor thrombus levels determined by ultrasonography matched with MRI in 26 (68.4%) cases. Compared to operative findings, ultrasonography accurately identified the cephalad extent of thrombi in 30 (79.0%) cases, under-staged five (13.2%) cases, and over-staged three (7.9%). Magnetic resonance imaging agreed with operative findings in 30 (79.0%) cases, under-staged five (13.2%) and over-staged three (7.9%) cases. On univariable regression assessment, M1 stage was predictive of a mismatched result between MRI and surgery (OR: 6.0, 95% CI: 1.02-35.3, p = 0.047), but this association did not hold-up in a multivariable model. Ultrasonography and magnetic resonance imaging identified the preoperative tumor thrombus level at a rate of 79%. Ultrasonography is an effective preoperative imaging modality for evaluating tumor thrombi associated with kidney cancer, notably as an adjunct to magnetic resonance imaging.

Adjuvant atezolizumab versus placebo for patients with renal cell carcinoma at increased risk of recurrence following resection (IMmotion010): a multicentre, randomised, double-blind, phase 3 trial

BACKGROUND

The standard of care for locoregional renal cell carcinoma is surgery, but many patients experience recurrence. The objective of the current study was to determine if adjuvant atezolizumab (vs placebo) delayed recurrence in patients with an increased risk of recurrence after resection.

METHODS

IMmotion010 is a randomised, double-blind, multicentre, phase 3 trial conducted in 215 centres in 28 countries. Eligible patients were patients aged 18 years or older with renal cell carcinoma with a clear cell or sarcomatoid component and increased risk of recurrence. After nephrectomy with or without metastasectomy, patients were randomly assigned (1:1) to receive atezolizumab (1200 mg) or placebo (both intravenous) once every 3 weeks for 16 cycles or 1 year. Randomisation was done with an interactive voice-web response system. Stratification factors were disease stage (T2 or T3a vs T3b-c or T4 or N+ vs M1 no evidence of disease), geographical region (north America [excluding Mexico] vs rest of the world), and PD-L1 status on tumour-infiltrating immune cells (<1% vs ≥1% expression). The primary endpoint was investigator-assessed disease-free survival in the intention-to-treat population, defined as all patients who were randomised, regardless of whether study treatment was received. The safety-evaluable population included all patients randomly assigned to treatment who received any amount of study drug (ie, atezolizumab or placebo), regardless of whether a full or partial dose was received. This trial is registered with ClinicalTrials.gov, NCT03024996, and is closed to further accrual.

FINDINGS

Between Jan 3, 2017, and Feb 15, 2019, 778 patients were enrolled; 390 (50%) were assigned to the atezolizumab group and 388 (50%) to the placebo group. At data cutoff (May 3, 2022), the median follow-up duration was 44·7 months (IQR 39·1-51·0). Median investigator-assessed disease-free survival was 57·2 months (95% CI 44·6 to not evaluable) with atezolizumab and 49·5 months (47·4 to not evaluable) with placebo (hazard ratio 0·93, 95% CI 0·75-1·15, p=0·50). The most common grade 3-4 adverse events were hypertension (seven [2%] patients who received atezolizumab vs 15 [4%] patients who received placebo), hyperglycaemia (ten [3%] vs six [2%]), and diarrhoea (two [1%] vs seven [2%]). 69 (18%) patients who received atezolizumab and 46 (12%) patients who received placebo had a serious adverse event. There were no treatment-related deaths.

INTERPRETATION

Atezolizumab as adjuvant therapy after resection for patients with renal cell carcinoma with increased risk of recurrence showed no evidence of improved clinical outcomes versus placebo. These study results do not support adjuvant atezolizumab for treatment of renal cell carcinoma.

FUNDING

F Hoffmann-La Roche and Genentech, a member of the Roche group.

Resection of retroperitoneal tumors with inferior vena cava involvement without caval reconstruction

BACKGROUND AND OBJECTIVES

Retroperitoneal tumors with involvement of the inferior vena cava (IVC) often require resection of the IVC to achieve complete tumor removal. This study evaluates the safety and efficacy of IVC ligation without caval reconstruction.

METHODS

A retrospective chart review of patients who underwent IVC ligation (IVC-Ligation) and IVC resection with reconstruction (IVC-Reconstruction) at our institution between May 2004 and April 2021 was performed. Outcomes from the two surgical techniques were compared via univariate analysis using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables.

RESULTS

Forty-nine IVC-Ligation and six IVC-Reconstruction surgeries were identified. There were no differences in baseline demographics, tumor characteristics, complication rates, postoperative morbidity, or overall 5-year survival between groups. IVC-Reconstruction patients were more likely to require intensive care unit admission (83% vs. 33%; p = 0.0257) and the IVC-Ligation cohort had a tendency to present with nondebilitating postoperative lymphedema (35% vs. 0%; p = 0.1615), which resolved for most patients.

CONCLUSIONS

IVC-Ligation is a viable surgical option for select patients presenting with retroperitoneal tumors with IVC involvement and provides acceptable short- and medium-term outcomes.

Case report: Important considerations for a renal mass on a solitary kidney in an adult with history of childhood wilms tumor

Adult survivors of childhood Wilms tumor are at an increased risk of secondary malignant neoplasms. The presence of a solitary kidney further complicates clinical management in this population. Herein, we present the case of a 37 year old female with a history of childhood Wilms tumor presenting with a secondary renal neoplasm. We highlight important clinical considerations for renal function preservation and present a finding of predisposition to kidney stone formation due to urinary stasis from distorted ureter architecture secondary to tumor mass effect.

Combination Immune Checkpoint Blockade Regimens for Previously Untreated Metastatic Renal Cell Carcinoma: The Winship Cancer Institute of Emory University Experience

Introduction

There are three combination immune checkpoint inhibitor (ICI)-based regimens in the first-line setting for metastatic renal cell carcinoma (mRCC). Currently, there is limited real-world data for clinical outcomes and toxicity in mRCC patients treated with first-line ICI-based regimens.

Methods

We performed a retrospective review of 49 mRCC patients treated with ICI-based combination regimens in the standard of care setting at the Winship Cancer Institute of Emory University from 2015-2020. We collected baseline data from the electronic medical record including demographic information and disease characteristics. Immune-related adverse events (irAEs) were collected from clinic notes and laboratory values. The primary clinical outcomes measured were overall survival (OS), progression-free survival (PFS), and objective response rate (ORR).

Results

The median age was 65 years, and most patients (80%) were males. The majority were White (86%) and had clear cell RCC (83%). Most patients had an Eastern Cooperative Oncology Group (ECOG) performance status score of 0 (43%) or 1 (45%). Approximately one-half (49%) had at least three sites of distant metastatic disease. Most patients (88%) received nivolumab and ipilimumab. More than one-half (53%) of patients experienced an irAE, with 13 (27%) patients having treatment delayed and 18% discontinuing treatment for toxicity. The median OS was not reached, and the median PFS was 8.0 months per a Kaplan-Meier estimation. More than half of patients (53%) had a PFS > 6 months, and 22% had PFS > 1 year. The ORR was 33% for the entire cohort, and 7% of patients had a complete response.

Conclusion

We presented real-world efficacy and toxicity data for front-line ICI combination treatment regimens. The ORR and median PFS were lower in our cohort of patients compared to the available data in the clinical trial setting. This was likely because of more advanced disease in this study. Future studies should provide additional data that will allow comparisons between different ICI combination regimens for untreated mRCC.

Clinical outcome following checkpoint therapy in renal cell carcinoma is associated with a burst of activated CD8 T cells in blood

PURPOSE

Checkpoint therapy is now the cornerstone of treatment for patients with renal cell carcinoma (RCC) with advanced disease, but biomarkers are lacking to predict which patients will benefit. This study proposes potential immunological biomarkers that could developed for predicting therapeutic response in patients with RCC.

METHODS

Using flow cytometry, RNA sequencing, and T-cell receptor (TCR) sequencing, we investigated changes in T cells in the peripheral blood of patients with advanced RCC after receiving immunotherapy. We used immunofluorescence (IF) imaging and flow cytometry to investigate how intratumoral T cells in patients' tumors (resected months/years prior to receiving checkpoint therapy) predicted patient outcomes after immunotherapy.

RESULTS

We found that a small proportion of CD4 and CD8 T cells in the blood activate following checkpoint therapy, expressing the proliferation marker Ki67 and activation markers HLA-DR and CD38. Patients who had the highest increase in these HLA-DR +CD38+CD8 T cells after treatment had the best antitumor immune response and experienced clinical benefit. Using RNA sequencing, we found that while these cells expanded in most patients, their phenotype did not drastically change during treatment. However, when we analyzed the TCR repertoire of these HLA-DR +CD38+CD8+T cells, we found that only patients who clinically benefitted had a burst of new clonotypes enter this pool of activated cells. Finally, we found that abundant T cells in the untreated tumors predicted clinical benefit to checkpoint therapy on disease progression.

CONCLUSIONS

Together, these data suggest that having a strong pre-existing immune response and immediate peripheral T-cell activation after checkpoint therapy is a predictor of clinical benefit in patients with RCC.

Blood-Based Next-Generation Sequencing in Adrenocortical Carcinoma

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare and heterogeneous malignancy with poor prognosis. We aimed to evaluate the feasibility of next-generation sequencing (NGS) testing of circulating cell-free tumor DNA (ctDNA) in patients with ACC, to characterize the genomic landscape of alterations, and to identify potential clinically actionable mutations.

METHODS

Retrospective analysis of genomic data from 120 patients with ACC who had ctDNA testing between 12/2016 and 10/2021 using Guardant360 (Guardant Health, CA) was performed. ctDNA NGS analysis interrogated single nucleotide variants, fusions, indels, and copy number amplifications of up to 83 genes. The frequency of genomic alterations, landscape of co-occurring mutations, and pathogenic/likely pathogenic alterations with potential targeted therapies was identified. The prevalence of alterations identified in ctDNA was compared to those detected in tissue using a publicly available database (cBioPortal).

RESULTS

The median age of this cohort was 53 years (range 21-81), and 56% of patients were female. Ninety-six patients (80%) had ≥1 somatic alteration detected. TP53 (52%), EGFR (23%), CTNNB1 (18%), MET (18%), and ATM (14%) were found to be the most frequently altered genes in ACC samples. Pathogenic and/or likely pathogenic mutations in therapeutically relevant genes were observed in 56 patients (47%) and included EGFR, BRAF, MET, CDKN2A, CDK4/6, and ATM. The most frequent co-occurring mutations were EGFR + MET (9%), MET + CDK4 (7%), EGFR + CDK4 (7%), and BRAF + MET (7%). The frequencies of mutations detected in ctDNA were similar to those detected in tissue.

CONCLUSIONS

Utilizing blood-based NGS to characterize genomic alterations in advanced ACC is feasible in over 80% of patients. Almost half of the patients had actionable mutations with approved therapies in other cancers. This approach might inform the development of personalized treatment options or identify clinical trials available for this aggressive malignancy.

Autologous Dendritic Vaccine Therapy in Metastatic Kidney Cancer: The ADAPT Trial and Beyond

Autologous dendritic-cell vaccine therapy combined with systemic therapy may be of benefit in patients with metastatic renal cell cancer undergoing cytoreductive nephrectomy according to results from the large ADAPT trial. Combined retrospective analysis and correlative immunology research revealed that patients receiving everolimus may have derived a greater benefit. The currently enrolling phase 2 CoImmune trial is designed to test this hypothesis in patients undergoing cytoreductive nephrectomy and systemic therapy.

Sarcopenia and systemic inflammation are associated with decreased survival after cytoreductive nephrectomy for metastatic renal cell carcinoma

BACKGROUND

This study was aimed at assessing the associations of sarcopenia, muscle density, adiposity, and inflammation with overall survival (OS) after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma.

METHODS

In all, 158 patients undergoing CN from 2001 to 2014 had digitized preoperative imaging for tissue segmentation via Slice-O-Matic software (version 5.0) at the mid-L3 level. The skeletal muscle index was calculated with the skeletal muscle area (cm² ) normalized for height (m² ), and the skeletal muscle density (SMD) was calculated with average Hounsfield units. Adiposity was measured with the cross-sectional area (cm² ) of visceral, subcutaneous, and intramuscular adiposity compartments and was similarly normalized for height. The average fat density was obtained in Hounsfield units. OS was estimated with the Kaplan-Meier method. Associations between body composition, inflammation metrics, and relevant clinicopathology and OS were assessed with univariable and multivariate Cox analyses.

RESULTS

Seventy-six of the 158 patients (48%) were sarcopenic. Sarcopenia was associated with elevated neutrophil to lymphocyte ratios (NLRs; P = .02), increased age (P = .001), lower body mass indices (P = .009), greater modified Motzer scores (P = .019), and lower SMD (P = .006). The median OS was 15.0 and 29.4 months for sarcopenic and nonsarcopenic patients, respectively (P = .04). Elevated inflammation (NLR or C-reactive protein), in addition to sarcopenia, was independently associated with OS, with an elevated NLR ≥ 3.5 and sarcopenia associated with the poorest OS at 10.2 months. No associations were observed between measurements of muscle density or adiposity and OS.

CONCLUSIONS

Sarcopenia and measures of high systemic inflammation are additively associated with inferior OS after CN and may be of use in preoperative risk stratification.

LAY SUMMARY

Body composition and sarcopenia (a deficiency in skeletal musculature) have been shown to affect outcomes in cancer. We found that sarcopenic patients had poor survival in comparison with nonsarcopenic patients in the setting of metastatic renal cell carcinoma (mRCC). Patients with both elevated inflammation and sarcopenia had the poorest survival. Sarcopenia is an objective measure of nutrition that can assist in therapeutic counseling and decision-making for individualized treatment in mRCC.

Extramammary Paget's Disease of genitourinary origin

PURPOSE OF REVIEW

Extramammary Paget's Disease (EMPD) is an uncommon intra-epithelial malignancy, affecting primarily apocrine gland-bearing skin. EMPD is often considered an orphan diagnosis given its rarity. This review provides a contemporary overview of EMPD management.

RECENT FINDINGS

The mainstay of EMPD treatment centers around a high index of suspicion to allow for an early and accurate diagnosis, wide local or Mohs micrographic surgical excision with care paid toward the margin status, and thoughtful consideration for lymphadenectomy in patients with clinically positive regional disease. There is currently no consensus regarding adjuvant therapies or systemic therapies although with ongoing improvements in tumor biology and genomics, including molecular pathways and alterations specific to EMPD, targeted or combinatorial therapies may be on the horizon.

SUMMARY

Clinicians caring for patients with EMPD should seek consultation from or if feasible, consider referral to high-volume, experienced centers with patients counseled and provided with frequent and close follow-up for disease recurrence or progression. Collaboration with groups such as the Global Society for Rare Genitourinary Tumors, and especially patient groups will be vital to designing trials and collaborative databases.

The prognostic role of sarcopenia and albumin in locally advanced renal cell carcinoma with IVC tumor thrombus

387

Background: Indicators of body composition and nutritional status, such as lumbar skeletal muscle index (SMI, cm2/m2) and hypoalbuminemia, are associated with adverse outcomes following surgery for localized renal cell carcinoma (RCC) but have yet to be described in patients with RCC and venous tumor thrombus. We hypothesize that preoperative sarcopenia, a severe deficit in lean muscle mass, and hypoalbuminemia will be associated with decreased overall survival (OS) and cancer specific survival (CSS) in nonmetastatic RCC patients undergoing radical nephrectomy and tumor thrombectomy. Methods: We retrospectively analyzed 103 nonmetastatic RCC patients who underwent radical nephrectomy and tumor thrombectomy from 2005 to 2020. Optimally fit BMI (kg/m2) and sex-stratified sarcopenia thresholds were calculated (BMI<30: SMI<47 for males, SMI<38 for females; BMI≥30: SMI<54 for males, SMI<47 for females). Sarcopenia and albumin risk groups were created based on their individual hazard ratios on univariable analysis and defined as low-risk (non-sarcopenic, normal albumin), medium-risk (non-sarcopenic, hypoalbuminemia), high-risk (sarcopenic, normal albumin), and very high-risk (sarcopenic, hypoalbuminemia). Associations between independent and combined sarcopenia and hypoalbuminemia (albumin<3.5 g/dL) with OS and CSS were evaluated using multivariable and Kaplan-Meier analyses. Results: Prevalence of sarcopenia and hypoalbuminemia were 51.2% and 44.7%, respectively. Median follow up time was 24.8 months and median time from preoperative imaging to surgery was 21 days. Sarcopenia was an independent predictor of OS (p=0.003) and CSS (p=0.006) whereas hypoalbuminemia was not (OS: p=0.096; CSS: p=0.718). When analyzing sarcopenia and albumin in combination, the high and very high-risk groups were significantly associated with decreased OS (high-risk: p=0.011; very high-risk: p<0.001) and CSS (high-risk: p=0.011; very high-risk: p=0.017). Kaplan-Meier curves showed a stepwise decline in median OS (p=0.0071) and CSS (p=0.0068) times with increasing risk. Conclusions: Simultaneous sarcopenia and hypoalbuminemia were associated with nearly a seven-fold decrease in OS and CSS in patients undergoing surgery for nonmetastatic RCC with IVC tumor thrombus.[Table: see text]

Does presence of diabetes mellitus impact patient oncological outcomes in renal cell carcinoma: A multicenter analysis

325

Background: Diabetes mellitus (DM) has been hypothesized to be a risk factor for development of renal cell carcinoma (RCC). We evaluated impact of DM on survival outcomes in RCC. Methods: We performed a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC). The cohort was divided into three subgroups (patients with stage I vs. stage II vs. stage III RCC) for descriptive, survival and multivariable analysis of outcomes. Kaplan Meier Analysis (KMA) was used to compare diabetic and non-diabetic patients in the different stage subgroups to evaluate overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS). Cox Regression multivariable analysis (MVA) was used to elucidate independent risk factors for all-cause mortality (ACM). Results: 2,927 patients with stage I RCC (709-DM/ 2218 non-DM), 2,513 with stage II RCC (688 DM/1825 non-DM) and 460 with stage 3 RCC (355 DM/ 105 non-DM) were analyzed. MVA revealed DMII having no impact on CSM (p=0.118) or PFS (p=0.316) across all stages. MVA for ACM revealed age (HR 1.026, p<0.001), male sex (HR=1.425, p<0.001), hypertension (HR=1.693, p <0.001) and tumor size (HR=1.064, p<0.001) as independent risk factors. KMA identified increased ACM in stage I (p<0.001) and stage III (p<0.001) RCC patients with non-DM compared to diabetic patients. Conclusions: Our findings suggest that DM may have impact on survival of in RCC, but this impact is mostly driven by non-oncologic, as opposed to oncologic effects. Further investigation is requisite.

Differences in CRP and De Ritis ratio predictive abilities of cancer specific survival between ethnic groups

394

Background: Studies have discussed the prognostic use of C-reactive protein (CRP) and De Ritis ratio (AST/ALT or AAR) in the evaluation of renal malignant masses. Elevated pre-treatment CRP has been shown to be associated with non-cancer mortality. Additionally increased preoperative AAR has been found to be a prognostic factor for overall survival. With studies showing the ethnic disparities in mortality rate in certain underserved ethnic groups, there is a need for investigation into possible ethnic differences. Our aim is to evaluate the association between these elevated preoperative markers and all-cause mortality (ACM) and cancer specific mortality (CSM) among ethnic groups. Methods: Retrospective review of the International Marker Consortium for Renal Cancer (INMARC) was performed. Patients with renal malignancies who underwent partial or radical nephrectomy (PN, RN) were included. Patients were grouped according to ethnicity and African American (AA), White, Asian, and Hispanic ethnic groups were selected for descriptive, survival and multivariable analysis of outcomes. A Cox-regression multivariable analysis (MVA) was performed for each group. The primary outcome was overall survival and cancer specific survival from time of surgery to last follow-up, which was evaluated using Kaplan-Meyer Analysis (KMA). Results: A total of 4,810 patients were analyzed (627 AA, 2,344 White, 462 Hispanic, 1,094 Asian). Preoperative CRP and AAR were considered elevated if above 5 mg/L and 1.26, respectively. Descriptive analysis showed significant differences in age, diabetes mellitus status, hypertension status, tumor size, surgery type (PN vs. RN), preoperative CRP, preoperative AAR, ACM and CSM between ethnicities (p-value <0.001). MVA revealed elevated CRP to be predictive of ACM in AA (p<0.001, HR 2.830, 95% CI [1.728, 4.635]) and White (p<0.001, HR 2.933, 95% CI [2.272, 3.785]) patients. Elevated AAR was only predictive for all ACM in Asian (p=0.004, HR 2.546, 95% CI [1.358, 4.775]) patients. MVA showed similar results for CSM with elevated CRP found to be a significant independent risk factor for CSM in AA (p<0.001, HR 7.006, 95% CI [2.649, 18.531]) and White (p<0.001, HR 3.391, 95% CI [2.403, 4.784]) patients while elevated AAR is a significant independent risk factor for all CSM in Asian (p=0.041, HR 2.374, 95% CI [1.034, 5.448]) patients. KMA revealed statistically significant impact of elevated CRP on ACM and CSM in AA, White, and Asian patients (p<0.001). It also showed a statistically significant effect of elevated AAR in Asian patients (p<0.001). Conclusions: CRP has broad utilities in prognostic abilities for non-Asian ethnic sub-cohorts. However, AAR has predictive abilities in Asian patients. These results show the importance of using different lab markers for preoperative assessment in renal masses and the need for further research in ethnic differences in clinical presentation.

Adjuvant infigratinib as targeted therapy for patients with muscle-invasive urothelial carcinoma harboring susceptible FGFR3 genetic alterations: A randomized, double-blind, placebo-controlled, phase 3 trial (PROOF 302)

TPS580

Background: Radical surgery is the mainstay of treatment for muscle-invasive upper tract urothelial cancer (UTUC) and urothelial bladder cancer (UBC). However, even when surgery is combined with cisplatin‐based (neo)adjuvant chemotherapy, recurrence rates are high. Many patients (pts) are ineligible for, do not respond to, or refuse cisplatin-based chemotherapy because of toxicity concerns. Fibroblast growth factor receptor 3 ( FGFR3) genetic alterations occur in 21–38% of muscle-invasive UTUC, and in approx. 20% of invasive UBC. Infigratinib (BGJ398) is an ATP-competitive FGFR1–3 selective oral tyrosine kinase inhibitor that has clinical activity and tolerability in pts with advanced/metastatic urothelial carcinoma (UC) harboring susceptible FGFR3 alterations. PROOF 302 was designed to investigate the efficacy and safety of adjuvant infigratinib in pts with high-risk, muscle-invasive UC (85% UTUC) and susceptible FGFR3 alterations. Methods: PROOF 302 is a global, multicenter, randomized, double-blind, placebo-controlled, phase 3 trial (NCT04197986). Eligible pts have high-risk, muscle-invasive UTUC (85%) or UBC (15%) with susceptible FGFR3 alterations (mutations, gene fusions or rearrangements) confirmed by FoundationOne CDx test, and are ≤120 days following nephroureterectomy, distal ureterectomy, or cystectomy. The study protocol was amended to include pts with carcinoma in situ at surgical margins and those who refuse cisplatin-based chemotherapy (in addition to pts allowed to enroll if ineligible for perioperative cisplatin-based chemotherapy). Eligible pts are M0 and have either disease stage ≥ypT2 and/or yN+ after cisplatin-based neoadjuvant chemotherapy or ≥pT2 pN0–2 or pN+ (UTUC); and ≥pT3 or pN+ (UBC) if not treated with cisplatin-based neoadjuvant chemotherapy. Pts are randomized 1:1 to receive oral infigratinib 125 mg or placebo QD on days 1–21 of a 28-day cycle for up to 52 weeks (13 cycles) or until recurrence, unacceptable toxicity, or death. Primary endpoint: centrally reviewed disease-free survival (DFS) analyzed via stratified log-rank test and Cox model (hazard ratio). Secondary endpoints: investigator-reviewed DFS, metastasis-free survival, overall survival, safety/tolerability. Exploratory endpoints: quality of life, pharmacokinetics, determination of the prevalence of genomic alterations and correlation with features of UC, genomic and proteomic assessment of tumor tissue and cell-free DNA samples from baseline and at recurrence to identify the predictive/prognostic value of biomarkers. PROOF 302 is actively enrolling as of Sep 2021. A second Data Monitoring Committee meeting is planned for Dec 2021. The last pt is expected to complete treatment in 2024. Clinical trial information: NCT04197986.

Clinical outcomes in advanced urothelial cancer (UC) patients who experienced immune-related adverse events (irAEs) after immune checkpoint inhibitor monotherapy (ICI)

544

Background: Immune checkpoint inhibitors (ICIs) continue to demonstrate promise in treatment of advanced urothelial carcinoma (UC). Some patients undergoing ICIs experience immune related adverse events (irAEs) and may serve as a marker of response. We investigated the relationship between irAEs and clinical outcomes in UC patients treated with ICIs. Methods: A retrospective study of 70 UC patients treated with ICI monotherapies at Winship Cancer Institute from 2015-2020 was done. Overall survival (OS) and progression-free survival (PFS), defined as time from ICI initiation to death and clinical or radiographic progression, respectively as well as clinical benefit (CB), defined as best radiographic response of complete response, partial response, or stable disease for ≥ 6 months per RECIST v1.1, were used to measure clinical outcomes. Cox proportional hazards and multivariable analyses (MVA) were used to model associations with OS and PFS. Results: Most patients were male (70%) with a median age of 68.7 years (28.0-91.0). Most patients (95%) had urothelial carcinoma and most (81%) received at least 1 prior treatment. One third of patients had ECOG PS greater than or equal to 2. Of patients that experienced an irAE (35%), the most common were dermatologic (12.9%) and arthralgia (0.5%). In addition to significantly longer treatment duration, irAE patients had significantly increased OS (HR:0.38, 95% CI:0.18-0.79, p=0.009), significantly longer PFS (HR:0.27, 95% CI:0.14-0.53, p < 0.001), and significantly greater CB (OR:4.20, 95% CI:1.35-13.06, p=0.013). Patients who experienced dermatologic irAEs had significantly increased OS, PFS, and CB (Table). Conclusions: Our results demonstrate that UC patients undergoing ICI therapy who experience irAEs, especially dermatologic irAEs, had improved clinical outcomes. This suggests that irAEs may serve as a clinical biomarker of advantageous response in patients receiving ICI. Future prospective studies are needed for validation.[Table: see text]

Expression of Nectin-4 and PD-L1 in bladder cancer with variant histology

529

Background: Nectin-4, a cell adhesion molecule found in a frequently amplified region of the bladder cancer (BC) genome, has been recently used as target for the systemic treatment of locally advanced or metastatic BC. BC with variant histology (BCVH) is associated with poor clinical outcomes, and there is an unmet need for novel treatments in this population. Little is known about Nectin-4 expression and other targets. We investigated Nectin-4 and programmed death-ligand 1 (PD-L1) expression in BCVH. Methods: We performed a retrospective analysis of 117 patients with BCVH whose samples were collected at Winship Cancer Institute of Emory University from 2011-2021. Immunohistochemistry (IHC) was performed for Nectin-4 and PD-L1 expression on formalin-fixed, paraffin-embedded (FFPE) tissue. Nectin-4 staining was performed by Q2 Solutions using non-commercially available anti-Nectin-4 antibody (clone M22-312B41.1). Expression was measured using the H-score method (H-score = [% of strong positive tumor cells × 3] + [% of moderate positive tumor cells × 2] + [% of weak positive tumor cells × 1]). PD-L1 levels were assessed in tumor-infiltrating immune cells using DAKO 22C3 IHC to determine PD-L1 high, defined by a Combined Positive Score (CPS) of ≥10. Results: Median age was 70 years (mean=67.2, range 22-91), with 61.5% male, 54.7% white, and 32.5% black. Nearly all samples were taken from the bladder (95.7%), with 4.3% from sites of metastasis. The most common histologic variant was squamous cell carcinoma (26.5%), and the distribution of variants is summarized in table. Nectin-4 staining was successfully performed on 111 samples, and PD-L1 staining on 116. Nectin-4 expression was seen across different histological subtypes (mean H-score: 153.1, median [range]: 157 [0-300]), with highest expression in plasmacytoid and squamous, and lowest expression in small cell and sarcomatoid (Table). More than one-third (35.3%) were PD-L1 high, and greater in sarcomatoid and squamous cell histology (70.8% and 50% positivity, respectively). Only 5% of plasmacytoid samples were PD-L1 high. Conclusions: Although there is heterogeneity, our results showed expression of Nectin-4 and PD-L1 in this cohort of patients with BCVH. These findings highlight the therapeutic potential of antibody-drug conjugates against Nectin-4- and anti PD1/PD-L1-based therapy in this population. Additional analysis including clinical outcomes and genomic analyses are ongoing, and a prospective clinical trial is planned.[Table: see text]

Impact of age on functional decline following radical nephrectomy: Analysis of the International Marker Consortium for Renal Cancer (INMARC)

395

Background: Radical nephrectomy (RN) is a mainstay of management of localized renal cancer larger than 4 cm in size. RN is associated with renal functional decline, however impact of age on functional decline is unclear. We investigated impact of age on post RN function, focusing on decline to moderate and severe chronic kidney disease (CKD). Methods: This was a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC) registry of patients who underwent RN. Primary outcome was development of de novo CKD stage IIIB [estimated glomerular filtration rate (eGFR)<45 mL/min/1.73m2). Secondary outcomes included de novo CKD stage III (eGFR<60) and CKD Stage IV (eGFR>30). Patients clinical characteristics were stratified by age groups (<50, 50-70 and >70 years old). Multivariable logistic regression analysis (MVA) was utilized to identify risk factors with renal functional decline to different CKD stages. Kaplan-Meier analysis (KMA) was utilized to evaluate functional outcomes with respect to the different age groups. Results: Overall, 2,436 patients were analyzed (≤50 years, n=513; 50-70 years, n=1,344; >70, n=579; median follow up 31.9 months). On MVA, increasing age was independently associated with increased risk of development of CKD Stage IIIb [compared to ≤50 years (referent), 50-70 years, OR 3.35, p<0.001 and >70 years OR 7.7, p<0.001]. In addition, increasing BMI (OR 1.029, p=0.002), coronary artery disease (OR 1.70, p=0.01), diabetes mellitus (OR 1.37, p=0.029) and African American race (OR 1.6, p=0.01) were independent risk factors for CKD stage IIIb. Increasing age was also independently associated with an increased risk of development of CKD Stage III [compared to ≤50 years (referent), 50-70 years, OR 3.4 p<0.001 and >70 years OR 9.4, p<0.001]. Increasing BMI (OR 1.032, p=0.002) and coronary artery disease (OR 1.87, p=0.015) were also risk factors for CKD stage III. Age >70 years was independently associated with increased risk of development of CKD Stage IV [OR 1.96, p=0.027]. In addition, male (OR 1.49, p= 0.036), increasing BMI (OR 1.03, p=0.003), diabetes mellitus (OR 2.69, p <0.001), and African American race (OR 2.02, p=0.002) were risk factors for CKD stage IV. Kaplan-Meier Analyses demonstrated age associated declines in 5 year freedom from CKD Stage III (≤50 years 73.9%, 50-70 years 53.7%, and >70 years 37.06%, p<0.001), CKD Stage IIIb (age ≤50 years 92.7%, 50-70 years 71.8%, and >70 years 55.5%, p<0.001) and CKD Stage IV (age ≤50 years 93.7%, 50-70 years 89.8%, and >70 years 81.2%, p< 0.001). Conclusions: Increasing age is an independent risk factor for progressive and clinically significant renal functional decline after radical nephrectomy. Prioritization for nephron sparing management should be considered whenever safe and feasible in elderly patients to reduce potential risk of sequelae of functional decline.

Phase 2 study of neoadjuvant cabozantinib in patients with locally advanced non-metastatic clear cell renal cell carcinoma

340

Background: Cabozantinib is a small molecule inhibitor of the tyrosine kinases c-Met, AXL and VEGFR2 that has been shown to reduce tumor growth, metastasis, and angiogenesis. After the promising results from the METEOR, CABOSUN and Checkmate-9ER trials, cabozantinib was approved for use in patients with advanced renal cell carcinoma (RCC). The increased response rates with cabozantinib in metastatic RCC, along with the other neoadjuvant TKI data, support an expanded role for cabozantinib in the neoadjuvant setting. Methods: Patients with clinical stage ≥ T3Nx or TanyN+ or deemed unresectable by the surgeon with biopsy-proven clear cell RCC were eligible for this study, and received cabozantinib at a starting dose of 60 mg daily for 12 weeks. The primary outcome was objective response rate per RECIST v1.1 (complete and partial responses) at week 12 after the administration of cabozantinib as determined by independent radiologist review. Secondary outcomes included safety, tolerability, clinical outcome (DFS, OS), surgical outcome and quality of life. Results: As of 20 September 2021, 16 biopsy-proven clear cell RCC patients were treated with neoadjuvant cabozantinib. The median age was 56 years (range: 41-84 years) and 81.2% male. All patients completed 12 weeks of treatment, and 15 of them underwent surgery as planned without any delay after completion of 4 weeks wash-out. One patient refused to undergo surgery due to personal reasons and received further systemic treatment. Five patients (31.2%) experienced a partial response, and 11 patients had stable disease. There was no progression of disease while on cabozantinib. Median reduction of primary renal tumor size was 24% (range: 6-45%). The one patient who was deemed to be unresectable became resectable at the end of treatment. Two patients were converted from radical to partial nephrectomy. The most common AEs were diarrhea, nausea, fatigue, hypertension, anorexia, and palmar-plantar erythrodysesthesia syndrome. Intraoperatively, we did not experience any immediate complications. Postoperatively, no surgical complications related to the drug were noted. No treatment related grade 4 or 5 AEs related to cabozantinib or surgery occurred. Two patients had died at the time of analysis (1 due to COVID and 1 unknown cause). Conclusions: Cabozantinib was clinically active and safe in the neoadjuvant setting in patients with locally advanced non-metastatic clear cell RCC. Additional data will be reported including long term outcomes, correlative studies, quality of life, and frailty/sarcopenia indices. Clinical trial information: NCT04022343.

Sarcopenia as a predictor of perioperative morbidity in metastatic renal cell carcinoma patients undergoing radical nephrectomy and IVC tumor thrombectomy

388

Background: Preoperative sarcopenia, as determined by the lumbar skeletal muscle index (SMI), has shown potential value for predicting adverse survival outcomes in metastatic renal cell carcinoma (mRCC) patients undergoing cytoreductive surgery. However, its utility for predicting perioperative morbidity in mRCC patients with IVC involvement is poorly elucidated. We hypothesize that preoperative sarcopenia, a severe deficiency in lean muscle mass, will be associated with major surgical complications and longer lengths of hospital stay in mRCC patients managed with radical nephrectomy and tumor thrombectomy. Methods: We retrospectively analyzed 99 mRCC patients who underwent radical nephrectomy and tumor thrombectomy from 2005 to 2020. Sarcopenia was diagnosed using optimally fit body mass index (BMI) and sex-stratified thresholds. For patients with a BMI < 30 kg/m², sarcopenia was defined as a SMI < 47 cm2/m2 for males and SMI < 38 cm2/m2 for females and for those with a BMI≥30 kg/m², as a SMI < 54 cm2/m2 for males and SMI < 47 cm2/m2 for females. Outcome measures were the presence of any major complications within 90 days after surgery, major complications within 1 year after surgery, and length of hospital stay post-nephrectomy ≥7 days. Major complications were defined as grade ≥3a on the Clavien-Dindo classification system. Associations between sarcopenia and major surgical complications and length of hospital stay were evaluated using multivariable analysis. Multivariable models were adjusted for age, race, gender, BMI, Charlson comorbidity index, T and N staging, Fuhrman grade, ECOG Score, and extent of IVC tumor thrombus. Results: Median time from preoperative imaging to surgery was 22 days (IQR 15-29). Of the 57 (58%) patients with preoperative sarcopenia in our cohort, 19 (33%) and 20 (35%) patients experienced a major surgical complication within 3 and 12 months after surgery, respectively, and 34 (60%) patients had a length of stay ≥7 days. Preoperative sarcopenia was significantly associated with the occurrence of a major complication within 90 days (OR = 4.84, 95%CI: 1.30-18.06, p = 0.019) and 1 year (OR = 6.43, 95%CI: 1.66-24.89, p = 0.007) after surgery. The presence of sarcopenia did not significantly change the odds of staying in the hospital for more than 7 days post-nephrectomy (OR = 1.41, 95%CI: 0.45-4.41, p = 0.551). Conclusions: Preoperative sarcopenia was associated with major surgical complications occurring within 3 and 12 months among mRCC patients after radical nephrectomy and tumor thrombectomy. Screening for sarcopenia preoperatively may assist in identifying patients at high-risk for increased perioperative morbidity, which ultimately may permit the implementation of preventive therapeutic strategies. Future validation is needed.

Comprehensive genomic profiling of penile squamous cell carcinoma and impact of HPV status on immune-checkpoint inhibition-related biomarkers

4

Background: Penile squamous cell carcinoma (SCC) is a rare and aggressive malignancy with few treatments in the advanced setting and little success of immune-checkpoint inhibitions (ICI). Around half of penile SCC cases are linked to HPV infection. We aimed to report the landscape of somatic alterations and ICI-related biomarkers in penile SCC in the Caris Life Sciences dataset and to establish signatures for HPV-dependent and HPV-independent oncogenesis. Methods: Penile SCC tumors were analyzed using next-generation sequencing of DNA (TruSeq, 45 genes; NextSeq, 592 genes and NovaSeq, whole exome sequencing (WES)) and RNA (NovaSeq). PD-L1 expression was tested by IHC using SP142. Microsatellite instability (MSI) was tested by fragment analysis, IHC and NGS. Tumor mutational burden (TMB) was measured by counting all somatic mutations found per tumor (TMB-high: >10 mutations per MB). HPV16/18 status was determined using WES when available. Significance was determined using chi-square and Wilcoxon rank sum test and adjusted for multiple comparisons (q-value <0.05). Results: Among the entire cohort (N=108), the median age was 66 years and 79.6% of tumors were primary and 20.4% of tumors were metastatic. In the overall cohort, the most frequently detected mutations were TP53 (46%), CKDN2A (26%), PIK3CA (25%), TERT promoter (22%), KMT2C (16%) and NOTCH1 (14%), consistent with previous reports. Overall, 51% of tumors were PD-L1+ (SP142, >1%), 10.7% had high TMB, and 1.1% had dMMR/MSI-H. Of the 108 tumors, 29 had HPV status tested by WES (HPV16/18+, n=13 and HPV16/18-, n=16). KMT2C mutations (33% vs 0%) and FGF3 amplifications (30.8% vs 0%) were specific to HPV16/18+ tumors, while CDKN2A mutations (37.5% vs 0%) were exclusive to HPV16/18- tumors. HPV16/18+ tumors also had a trend towards decreased TP53 (7.7% vs 63%) and TERT promoter (25% vs 77%) alterations (Table). TMB-high were exclusively found in the HPV16/18+ group (30.8% vs 0%), while PD-L1 and dMMR/MSI-H status were comparable between the two groups. Conclusions: To our knowledge, our comprehensive NGS study of penile SCC somatic alterations is the largest to date. HPV16/18+ vs HPV16/18- penile SCC were molecularly distinct tumors, consistent with previous reports. Our finding that TMB-high was exclusive to patients with HPV16/18+ tumors requires confirmation in larger datasets and could be used for better patient stratification in ICI clinical trials.[Table: see text]

Risk Stratification of Prostatic Adenocarcinoma Metastatic to the Lymph Nodes

CONTEXT.—

The pathologic nodal staging of prostatic adenocarcinoma is binary for regional lymph nodes. Stages pN0 and pN1 indicate the absence or presence of regional nodal metastasis, respectively, whereas patients with metastasis to nonregional lymph nodes are staged as pM1a.

OBJECTIVE.—

To determine the risk of recurrence of pN1 prostatic adenocarcinoma patients based on the extent of nodal tumor burden.

DESIGN.—

We retrospectively reviewed pN1 patients with prostatic adenocarcinoma managed with radical prostatectomy seen between 2011 and 2019. Kaplan-Meier and Cox regression analyses were performed to compare disease-free survival.

RESULTS.—

Ninety-six patients were included (median [interquartile range] age, 62 years [57-67 years]; 70 of 96 [73%] white). On univariate analysis, age >65 years (P = .008), ≥2 positive regional lymph nodes (P < .001), and a maximum size of the tumor deposit ≥2 mm (P = .004) were significantly associated with an unfavorable outcome. Controlling for age, stage, metastatic deposit size, margin status, and the presence of extranodal extension, patients with ≥2 positive regional lymph nodes were 3.03 times more likely (95% confidence interval, 1.39-6.60; P = .005) to have an unfavorable outcome. Patients with pN1M1a stage showed a disease-free survival similar to that of pN1M0 patients, after controlling for the number of positive regional lymph nodes (P = .36).

CONCLUSIONS.—

Overall, pN1 patients with ≥2 positive regional lymph nodes are 3 times more likely to have an unfavorable outcome. The results suggest a benefit in further stratifying patients with metastatic prostatic adenocarcinoma to the lymph nodes into prognostically significant risk categories that could help the treating clinicians tailor subsequent patient follow-up and therapy.

Analysis of Toxicity and Clinical Outcomes in Full Versus Reduced Starting Dose Cabozantinib in Metastatic Renal Cell Carcinoma Patients

BACKGROUND

Full dose cabozantinib for metastatic renal cell carcinoma (mRCC) is 60 mg, but adverse events (AEs) may require dose reductions. Limited data exist comparing efficacy among cabozantinib doses. We compared AEs and clinical outcomes in mRCC patients treated with full vs. reduced starting cabozantinib dose.

METHODS

We performed a retrospective analysis of 87 mRCC patients treated with cabozantinib at Winship Cancer Institute from 2016 to 2019. Overall survival (OS), progression-free survival (PFS), and objective response (OR) rate measured clinical outcomes. AEs were collected from clinic notes and the most common were hypertension, mucositis/hand-foot skin reaction (HFSR), or gastrointestinal toxicity. Univariate analysis (UVA) between starting doses and AEs with clinical outcomes was performed using logistic regression model. Multivariable analysis was also performed using Cox proportional hazard model.

RESULTS

Most patients were men (71%) with clear-cell RCC (72%). The majority were IMDC intermediate (58%) or poor (35%) risk. One third received first-line cabozantinib and 64% had ≥3 baseline metastatic sites. Most patients (68%) required dose reduction from 60 mg or started at reduced dose without escalation. Reduced dose patients were more likely to have ≥3 distant metastatic sites (70% vs. 58%) and ≥2 prior lines of systemic therapy (50% vs. 40%) compared to full dose patients. UVA revealed a trend towards shorter OS (HR: 1.78, P = .095), PFS (HR: 1.50, P = .107), and lower chance of OR (HR:0.42, P = .149) among reduced dose patients. This trend did not hold in Multivariable analysis (OS HR: 1.20, P = .636; PFS HR: 1.23, P = .4662). Mucositis/HFSR and hypertension were significantly associated with improved outcomes in UVA.

CONCLUSIONS

Although we found a trend favoring full dose cabozantinib, this is likely due to worse baseline disease characteristics among patients starting on a reduced dose. Hypertension and mucositis/HFSR may be associated with improved outcomes. Larger studies are warranted to validate these findings.

Low free testosterone is associated with increased mortality in frail surgical patients

Background

Preoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied.

Methods

Preoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan–Meier and logistic regression analyses. Bivariate analysis was used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates.

Results

Median age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P = .044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68–14.46, P = .004).

Conclusion

We observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery.

•

Both frailty (P = .015) and low free testosterone (P = .005) were independently associated with 1-year mortality.

•

After stratifying our cohort into 4 composite groups based on frailty and testosterone status, frail patients with low free T had the shortest overall survival when compared to the reference group, with nearly a 5-fold higher risk of death.

Case Report: Exceptional Response to Nivolumab Plus Ipilimumab in a Young Woman With TFE3-SFPQ Fusion Translocation-Associated Renal Cell Carcinoma

Translocation-associated renal cell carcinoma (tRCC) is a rare, aggressive malignancy that primarily affects children and young adults. There is no clear consensus on the most effective treatment for tRCC and there are no biomarkers of response to treatments in these patients. We present a case of a 23 year-old female with metastatic tRCC to the lungs who was started on treatment with nivolumab and ipilimumab. She had a complete radiographic response to treatment and has been progression-free for over 18 months. Immunofluorescence imaging performed on the baseline primary tumor sample showed significant intratumoral immune infiltration. Importantly, these cells are present in niches characterized by TCF1+ CD8+ T cells. Histopathologic investigation showed the presence of lymphocytes in the fibrovascular septae and foci of lymphovascular invasion. Furthermore, lymphovascular invasion and intratumor niches with TCF1+ CD8+ T cells may predict a favorable response to treatment with nivolumab and ipilimumab. These findings have significant clinical relevance given that immune checkpoint inhibitors are approved for several malignancies and predictive biomarkers for response to treatment are lacking. Importantly, the identification of these TCF1+ CD8+ T cells may guide treatment for patients with tRCC, which is a rare malignancy without a consensus first-line treatment option.

Integrative surgical oncology: A model of acute integrative oncology

Integrative oncology has emerged as a recognized medical subspecialty because of growing interest in the use of integrative medicine in modern cancer care on behalf of both patients and providers. Acutherapy and mind-body techniques, such as meditation and yoga, have been shown to aid in symptom control and improve quality of life in oncologic patient populations, and the Society of Integrative Oncology and American Society of Clinical Oncology have recently endorsed a set of guidelines for the implementation of these techniques specifically in patients with breast cancer. Although the current guidelines focus largely on the management of chronic symptoms, there exists evidence to support the use of these techniques in acute symptom management as well. With surgical resection representing the backbone of many cancer treatment regimens, symptoms that arise during the perioperative period are prime examples of the acute symptomatology common among patients with cancer. Here, the authors provide a detailed literature review of the current evidence supporting the use of integrative techniques during the perioperative period and demonstrate their applicability for acute symptom management within oncologic and surgical populations. In doing so, the authors introduce a new paradigm of surgical practice they call integrative surgical oncology and integrative surgery.

Left renal vein nutcracker syndrome and concurrent IVC duplication: Surgical treatment

Multiple vascular anomalies may be encountered in patients with nutcracker syndrome; further compounding the surgical complexity in managing this condition. A 28-year-old male presented with persistent flank pain and hematuria. Imaging revealed narrowing of the left renal vein at the aortomesenteric junction, and a dilated vein consistent with the left gonadal vein. On surgical exploration, a duplicated IVC was found. The patient underwent a right caval-to-left caval bypass using a cryopreserved femoral vein homograft. The surgery was well tolerated and completely resolved the patient's symptoms.

Body Composition as an Independent Predictive and Prognostic Biomarker in Advanced Urothelial Carcinoma Patients Treated with Immune Checkpoint Inhibitors

BACKGROUND

Several immune checkpoint inhibitors (ICIs) are approved for the treatment of advanced urothelial carcinoma (UC). There are limited biomarkers for ICI-treated patients with UC. We investigated the association between body composition and clinical outcomes in ICI-treated UC patients.

MATERIALS AND METHODS

We conducted a retrospective analysis of 70 ICI-treated patients with advanced UC at Winship Cancer Institute from 2015 to 2020. Baseline computed tomography images within 2 months of ICI initiation were collected at mid-L3 and muscle and fat compartments (subcutaneous, intermuscular, and visceral) were segmented using SliceOMatic v5.0 (TomoVision, Magog, Canada). A prognostic body composition risk score (high: 0-1, intermediate: 2-3, or low-risk: 4) was created based on the β coefficient from the multivariate Cox model (MVA) following best-subset variable selection. Our body composition risk score was skeletal muscle index (SMI) + 2 × attenuated skeletal muscle (SM) mean + visceral fat index (VFI). Concordance statistics (C-statistics) were used to quantify the discriminatory magnitude of the predictive model.

RESULTS

Most patients (70%) were men and the majority received ICIs in the second- (46%) or third-line (21%) setting. High-risk patients had significantly shorter overall survival (OS; hazard ratio [HR], 6.72; p < .001), progression-free survival (HR, 5.82; p < .001), and lower chance of clinical benefit (odds ratio [OR], 0.02; p = .003) compared with the low-risk group in MVA. The C-statistics for our body composition risk group and myosteatosis analyses were higher than body mass index for all clinical outcomes.

CONCLUSION

Body composition variables such as SMI, SM mean, and VFI may be prognostic and predictive of clinical outcomes in ICI-treated patients with UC. Larger, prospective studies are warranted to validate this hypothesis-generating data.

IMPLICATIONS FOR PRACTICE

This study developed a prognostic body composition risk scoring system using radiographic biomarkers for patients with bladder cancer treated with immunotherapy. The study found that the high-risk patients had significantly worse clinical outcomes. Notably, the study's model was better at predicting outcomes than body mass index. Importantly, these results suggest that radiographic measures of body composition should be considered for inclusion in updated prognostic models for patients with urothelial carcinoma treated with immunotherapy. These findings are useful for practicing oncologists in the academic or community setting, particularly given that baseline imaging is routine for patients starting on treatment with immunotherapy.

Modified Glasgow Prognostic Score associated with survival in metastatic renal cell carcinoma treated with immune checkpoint inhibitors

BACKGROUND

The modified Glasgow Prognostic Score (mGPS) is a composite biomarker that uses albumin and C reactive protein (CRP). There are multiple immune checkpoint inhibitor (ICI)-based combinations approved for metastatic renal cell carcinoma (mRCC). We investigated the ability of mGPS to predict outcomes in patients with mRCC receiving ICI.

METHODS

We retrospectively reviewed patients with mRCC treated with ICI as monotherapy or in combination at Winship Cancer Institute between 2015 and 2020. Overall survival (OS) and progression-free survival (PFS) were measured from the start date of ICI until death or clinical/radiographical progression, respectively. The baseline mGPS was defined as a summary score based on pre-ICI values with one point given for CRP>10 mg/L and/or albumin<3.5 g/dL, resulting in possible scores of 0, 1 and 2. If only albumin was low with a normal CRP, no points were awarded. Univariate analysis (UVA) and multivariate analysis (MVA) were carried out using Cox proportional hazard model. Outcomes were also assessed by Kaplan-Meier analysis.

RESULTS

156 patients were included with a median follow-up 24.2 months. The median age was 64 years and 78% had clear cell histology. Baseline mGPS was 0 in 36%, 1 in 40% and 2 in 24% of patients. In UVA, a baseline mGPS of 2 was associated with shorter OS (HR 4.29, 95% CI 2.24 to 8.24, p<0.001) and PFS (HR 1.90, 95% CI 1.20 to 3.01, p=0.006) relative to a score of 0; this disparity in outcome based on baseline mGPS persisted in MVA. The respective median OS of patients with baseline mGPS of 0, 1 and 2 was 44.5 (95% CI 27.3 to not evaluable), 15.3 (95% CI 11.0 to 24.2) and 10 (95% CI 4.6 to 17.5) months (p<0.0001). The median PFS of these three cohorts was 6.7 (95% CI 3.6 to 13.1), 4.2 (95% CI 2.9 to 6.2) and 2.6 (95% CI 2.0 to 5.6), respectively (p=0.0216). The discrimination power of baseline mGPS to predict survival outcomes was comparable to the IMDC risk score based on Uno's c-statistic (OS: 0.6312 vs 0.6102, PFS: 0.5752 vs 0.5533).

CONCLUSION

The mGPS is prognostic in this cohort of patients with mRCC treated with ICI as monotherapy or in combination. These results warrant external and prospective validation.

Body Composition Variables as Radiographic Biomarkers of Clinical Outcomes in Metastatic Renal Cell Carcinoma Patients Receiving Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICI) have revolutionized the treatment of metastatic renal cell carcinoma (mRCC). Biomarkers for mRCC patients treated with ICI are limited, and body composition is underutilized in mRCC. We investigated the association between body composition and clinical outcomes in ICI-treated mRCC patients.

METHODS

We performed a retrospective analysis of 79 ICI-treated mRCC patients at Winship Cancer Institute from 2015-2020. Baseline CT images were collected at mid-L3 and segmented using SliceOMatic v5.0 (TomoVision). Density of skeletal muscle (SM), subcutaneous fat, inter-muscular fat, and visceral fat were measured and converted to indices by dividing by height(m)2 (SMI, SFI, IFI, and VFI, respectively). Total fat index (TFI) was defined as the sum of SFI, IFI, and VFI. Patients were characterized as high versus low for each variable at gender-specific optimal cuts using overall survival (OS) as the primary outcome. A prognostic risk score was created based on the beta coefficient from the multivariable Cox model after best subset variable selection. Body composition risk score was calculated as IFI + 2*SM mean + SFI and patients were classified as poor (0-1), intermediate (2), or favorable risk (3-4). Kaplan-Meier method and Log-rank test were used to estimate OS and PFS and compare the risk groups. Concordance statistics (C-statistics) were used to measure the discriminatory magnitude of the model.

RESULTS

Most patients were male (73%) and most received ICI as first (35%) or second-line (51%) therapy. The body composition poor-risk patients had significantly shorter OS (HR: 6.37, p<0.001), PFS (HR: 4.19, p<0.001), and lower chance of CB (OR: 0.23, p=0.044) compared to favorable risk patients in multivariable analysis. Patients with low TFI had significantly shorter OS (HR: 2.72, p=0.002), PFS (HR: 1.91, p=0.025), and lower chance of CB (OR: 0.25, p=0.008) compared to high TFI patients in multivariable analysis. The C-statistics were higher for body composition risk groups and TFI (all C-statistics ≥ 0.598) compared to IMDC and BMI.

CONCLUSIONS

Risk stratification using the body composition variables IFI, SM mean, SFI, and TFI may be prognostic and predictive of clinical outcomes in mRCC patients treated with ICI. Larger, prospective studies are warranted to validate this hypothesis-generating data.

Machine Learning-Enabled Renal Cell Carcinoma Status Prediction Using Multiplatform Urine-Based Metabolomics

Renal cell carcinoma (RCC) is diagnosed through expensive cross-sectional imaging, frequently followed by renal mass biopsy, which is not only invasive but also prone to sampling errors. Hence, there is a critical need for a noninvasive diagnostic assay. RCC exhibits altered cellular metabolism combined with the close proximity of the tumor(s) to the urine in the kidney, suggesting that urine metabolomic profiling is an excellent choice for assay development. Here, we acquired liquid chromatography-mass spectrometry (LC-MS) and nuclear magnetic resonance (NMR) data followed by the use of machine learning (ML) to discover candidate metabolomic panels for RCC. The study cohort consisted of 105 RCC patients and 179 controls separated into two subcohorts: the model cohort and the test cohort. Univariate, wrapper, and embedded methods were used to select discriminatory features using the model cohort. Three ML techniques, each with different induction biases, were used for training and hyperparameter tuning. Assessment of RCC status prediction was evaluated using the test cohort with the selected biomarkers and the optimally tuned ML algorithms. A seven-metabolite panel predicted RCC in the test cohort with 88% accuracy, 94% sensitivity, 85% specificity, and 0.98 AUC. Metabolomics Workbench Study IDs are ST001705 and ST001706.

Immune-Related Adverse Events as Clinical Biomarkers in Patients with Metastatic Renal Cell Carcinoma Treated with Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) are an important treatment for metastatic renal cell carcinoma (mRCC). These agents may cause immune-related adverse events (irAEs), and the relationship between irAEs and outcomes is poorly understood. We investigated the association between irAEs and clinical outcomes in patients with mRCC treated with ICIs.

METHODS

We performed a retrospective study of 200 patients with mRCC treated with ICIs at Winship Cancer Institute from 2015 to 2020. Data on irAEs were collected from clinic notes and laboratory values and grades were determined using Common Terminology Criteria in Adverse Events version 5.0. The association with overall survival (OS) and progression-free survival (PFS) was modeled by Cox proportional hazards model. Logistic regression models were used to define odds ratios (ORs) for clinical benefit (CB). Landmark analysis and extended Cox models were used to mitigate lead-time bias by treating irAEs as a time-varying covariate.

RESULTS

Most patients (71.0%) were male, and one-third of patients (33.0%) experienced at least one irAE, most commonly involving the endocrine glands (13.0%), gastrointestinal tract (10.5%), or skin (10.0%). Patients who experienced irAEs had significantly longer OS (hazard ratio [HR], 0.52; p = .013), higher chance of CB (OR, 2.10; p = .023) and showed a trend toward longer PFS (HR, 0.71; p = .065) in multivariate analysis. Patients who had endocrine irAEs, particularly thyroid irAEs, had significantly longer OS and PFS and higher chance of CB. In a 14-week landmark analysis, irAEs were significantly associated with prolonged OS (p = .045). Patients who experienced irAEs had significantly longer median OS (44.5 vs. 18.2 months, p = .005) and PFS (7.5 vs. 3.6 months, p = .003) without landmark compared with patients who did not.

CONCLUSION

We found that patients with mRCC treated with ICIs who experienced irAEs, particularly thyroid irAEs, had significantly improved clinical outcomes compared with patients who did not have irAEs. This suggests that irAEs may be effective clinical biomarkers in patients with mRCC treated with ICIs. Future prospective studies are warranted to validate these findings.

IMPLICATIONS FOR PRACTICE

This study found that early onset immune-related adverse events (irAEs) are associated with significantly improved clinical outcomes in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitors (ICIs). In this site-specific irAE analysis, endocrine irAEs, particularly thyroid irAEs, were significantly associated with improved clinical outcomes. These results have implications for practicing medical oncologists given the increasing use of ICIs for the treatment of mRCC. Importantly, these results suggest that early irAEs and thyroid irAEs at any time on treatment with ICIs may be clinical biomarkers of clinical outcomes in patients with mRCC treated with ICIs.

Racial Differences in Clinical Outcomes for Metastatic Renal Cell Carcinoma Patients Treated With Immune-Checkpoint Blockade

BACKGROUND

Immune-checkpoint-inhibitors (ICIs) have become the cornerstone of metastatic renal-cell-carcinoma (mRCC) therapy. However, data are limited regarding clinical outcomes by race. In this study, we compared the real-world outcomes between African American (AA) and Caucasian mRCC patients treated with ICIs.

METHODS

We performed a retrospective study of 198 patients with mRCC who received ICI at the Emory Winship Cancer Institute from 2015-2020. Clinical outcomes were measured by overall survival (OS), progression-free survival (PFS), and overall response rate (ORR) defined as a complete or partial response maintained for at least 6 months per response evaluation criteria in solid tumors version 1.1. Univariate and multivariable analyses were carried out for OS and PFS by Cox proportional-hazard model and ORR by logistical-regression model. Descriptive statistics compared rates of immune-related adverse events (irAEs) and non-clear-cell-RCC (nccRCC) histology were assessed using Chi-square test.

RESULTS

Our cohort was comprised of 38 AA and 160 Caucasian patients. Most were diagnosed with clear-cell-RCC (ccRCC) (78%) and more than half received (57%) PD-1/PD-L1 monotherapy. Most patients were intermediate or poor-risk groups (83%). Comparing to Caucasians, our AA cohort contained more females and nccRCC cases. Kaplan-Meier method showed AAs had no statistically different median OS (17 vs 25 months, p=0.368) and PFS (3.1 vs 4.4 months, p=0.068) relative to Caucasian patients. On multivariable analysis, AA patients had significantly shorter PFS (HR=1.52, 95% CI: 1.01-2.3, p=0.045), similar ORR (OR=1.04, 95% CI: 0.42-2.57, p=0.936) and comparable OS (HR=1.09, 95% CI: 0.61-1.95, p=0.778) relative to Caucasians.

CONCLUSIONS

Our real-world analysis of ICI-treated mRCC patients showed that AAs experienced shorter PFS but similar OS relative to Caucasians. This similarity in survival outcomes is reassuring for the use of ICI amongst real-world patient populations, however, the difference in treatment response is poorly represented in early outcomes data from clinical trials. Thus, the literature requires larger prospective studies to validate these findings.

Renal Cancer Without Primary Cancer in the Kidney: Extra-Renal TFE3 Translocation Associated Renal Cell Carcinoma

We report a case of an isolated para-aortic retroperitoneal renal cell carcinoma (RCC) in the absence of a primary cancer in the kidney. Single case reports in the literature have described extra-renal RCC in different locations with no evidence of primary renal tumor. We present the initial presentation, diagnostic imaging, surgical treatment, and pathologic evaluation. Immunohistochemistry demonstrated positivity for TFE3 and TFEB, both of which are Microphthalmia associated transcription factors (MiT) associated with translocation RCCs. We hypothesize these few cases of extra-renal RCC represent rare forms of translocation RCC.

18F-fluciclovine-PET/CT imaging versus conventional imaging alone to guide postprostatectomy salvage radiotherapy for prostate cancer (EMPIRE-1): a single centre, open-label, phase 2/3 randomised controlled trial

BACKGROUND

Molecular imaging is increasingly used to guide treatment decisions and planning in prostate cancer. We aimed to evaluate the role of ¹⁸F-fluciclovine-PET/CT in improving cancer control compared with conventional imaging (bone scan and either CT or MRI) alone for salvage postprostatectomy radiotherapy.

METHODS

In EMPIRE-1, a single-centre, open-label, phase 2/3 randomised controlled trial, patients with prostate cancer with detectable PSA after prostatectomy and negative conventional imaging (no extrapelvic or bone findings) were randomly assigned in a 1:1 ratio to radiotherapy directed by conventional imaging alone or to conventional imaging plus ¹⁸F-fluciclovine-PET/CT. Computer-generated randomisation was stratified by PSA concentration, adverse pathology indicators, and androgen deprivation therapy intent. In the ¹⁸F-fluciclovine-PET/CT group, radiotherapy decisions were rigidly determined by PET findings, which were also used for target delineation. The primary endpoint was 3 year event-free survival, with events defined as biochemical or clinical recurrence or progression, or initiation of systemic therapy, using univariate and multivariable analyses in patients who received radiotherapy. This trial is registered with ClinicalTrials.gov, NCT01666808 and is closed to new participants.

FINDINGS

From Sept 18, 2012, to March 4, 2019, 165 patients were randomly assigned, with median follow-up of 3·52 years (95% CI 2·98-3·95). PET findings resulted in four patients in the ¹⁸F-fluciclovine-PET/CT group having radiotherapy aborted; these patients were excluded from survival analyses. Median survival was not reached (95% CI 35·2-not reached; 33% of 81 patients had events) in the conventional imaging group compared with not reached (95% CI not reached-not reached; 20% of 76 patients) in the ¹⁸F-fluciclovine-PET/CT group, and 3 year event-free survival was 63·0% (95% CI 49·2-74·0) in the conventional imaging group versus 75·5% (95% CI 62·5-84·6) for ¹⁸F-fluciclovine-PET/CT (difference 12·5; 95% CI 4·3-20·8; p=0·0028). In adjusted analyses, study group (hazard ratio 2·04 [95% CI 1·06-3·93], p=0·0327) was significantly associated with event-free survival. Toxicity was similar in both study groups, with the most common adverse events being late urinary frequency or urgency (37 [46%] of 81 patients in the conventional imaging group and 31 [41%] of 76 in the PET group), and acute diarrhoea (11 [14%] in the conventional imaging group and 16 [21%] in the PET group).

INTERPRETATION

Inclusion of ¹⁸F-fluciclovine-PET into postprostatectomy radiotherapy decision making and planning significantly improved survival free from biochemical recurrence or persistence. Integration of novel PET radiotracers into radiotherapy decisions and planning for prostate cancer patients warrants further study.

FUNDING

National Institutes of Health/National Cancer Institute, Blue Earth Diagnostics, and Winship Cancer Institute of Emory University.

Clinical outcomes in metastatic renal cell carcinoma (mRCC) treated with combination of nivolumab and cabozantinib (nivo-cabo) in the salvage setting

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Background: The CheckMate 9ER trial showed that the combination of nivolumab and cabozantinib (nivo-cabo) in first line setting for treatment of mRCC was superior to sunitinib in terms of objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) and led to its FDA approval. We report outcomes of cohort of patients with mRCC treated with nivo-cabo in the salvage setting. Methods: We retrospectively reviewed 17 patients with mRCC treated at Winship Cancer Institute who progressed through at least one line of prior therapy. These patients were then treated with either sequences: [1] cabozantinib and then add nivolumab upon progression (n = 8) and [2] nivolumab/ipilimumab or nivolumab and then add cabozantinib upon progression (n = 9) with two with nivolumab and ipilimumab. Median PFS and OS rates, and clinical benefit (defined as complete response or partial response, or stable disease) were described. Results: Thirteen patients had clear cell histology and four patients had non-clear cell histology. For sequence [1], the mPFS for cabozantinib alone was 9.9 months and combination of nivolumab added to cabozantinib was 8.9 months. For sequence [2], the mPFS for nivolumab with or without ipilimumab was 5.9 months and combination of cabozantinib added to nivolumab was 10.4 months. The 12-month OS rate was 88% for sequence [1] and 89% for sequence [2]. The 24-month, OS rate was 50% for sequence [1] and 89% for sequence [2]. 5/8 (63%) patients in sequence [1] and 7/9 (78%) patients in sequence [2] had clinical benefit. 3/8 (37.5%) patients in sequence [1] and 2/9 (22%) patients in sequence [2] experienced immune-related adverse effects such as hypothyroidism (grade II for two patients), pneumonitis (grade II), hepatic transaminase elevations (grade II), and pancreatitis (grade III). No patients in sequence [1] needed dose reduction in cabozantinib once nivolumab was added. 3/9 (33%) patients had dose reduction in cabozantinib in sequence [2] due to diarrhea. Conclusions: Nivo-cabo demonstrates activity in the salvage setting but there is still need to understand the optimal sequencing of both agents in the treatment of mRCC. Outcomes from this combination treatment are to be further validated from ongoing phase III trial, PDIGREE (NCT03793166).

Circulating tumor DNA (ctDNA) in patients with advanced adrenocortical carcinoma

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Background: Adrenocortical Carcinoma (ACC) is a rare and aggressive malignancy with poor prognosis and limited treatments in the advanced setting. Molecular pathways with tumor suppressor genes (e.g. TP53, CDKN2A) and oncogenes (e.g. CTNNB1 and RAS) are implicated in oncogenesis. To our knowledge, the genomic landscape of ctDNA alterations for ACC has not been described in a large cohort. We report plasma-based ctDNA alterations in patients with advanced ACC. Methods: We retrospectively evaluated genomic data from 102 patients with ACC who had ctDNA testing between 12/2016 – 10/2020 using Guardant360 (Guardant Health, CA). ctDNA analysis interrogated single nucleotide variants (SNV), fusions, indels and copy number variations (CNV) of up to 83 genes. We evaluated the frequency of genomic alterations, the landscape of co-occurring mutations, and pathogenic or likely pathogenic alterations with potential targeted therapies. The prevalence of alterations identified in ctDNA were compared to those detected in tissue using a publicly available database (cBioPortal). Results: The median age was 54 years (range 24-81), and 55% of patients were male. Among the entire cohort, 84 pts (82.4%) had ≥1 somatic alteration detected. Mutations were most frequently detected in TP53 (52%), EGFR (23%), CTNNB1 (18%), MET (18%), and ATM (14%). The frequencies detected in ctDNA were similar to the results detected in tissue. Pathogenic and/or likely pathogenic mutations in therapeutically relevant alterations were observed in 36 patients (35%), including EGFR, BRAF, MET, CDKN2A, and CDK4/6 (Table 1). The most frequently co-occurring mutations were EGFR + TP53 (14%), EGFR + MET (11%), BRAF + MET (10%). Conclusions: Blood-based ctDNA profiling in advanced ACC provided comprehensive genomic data in most patients, with a similar profile to tumor tissue analyses. Over one third of patients had actionable mutations with approved therapies in other cancers. This approach might inform the development of personalized treatment options for this aggressive malignancy.[Table: see text]

Dissemination of validated health literacy videos: A tailored approach

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Background: Previously, we showed that chemotherapy and precision medicine terminology are remarkably difficult for patients to understand. Therefore, we developed short, animated videos explaining key terminology and demonstrated that they significantly improved understanding. These videos, though effective and published, including freely downloadable, will only be helpful if appropriately disseminated. In the past, even after a video-based educational tool for prostate cancer was proven effective for improving patient comprehension, no dissemination plan was implemented due to copyright issues. Therefore, in order to propel these validated health literacy videos from the academic community into clinic workflow, we aimed to determine the best dissemination method at two different hospitals with disparate populations just six miles apart: an underserved, inner-city hospital and a higher SES hospital. Methods: The dissemination interview was developed in collaboration with an expert Intervention Development, Dissemination, and Implementation team. The draft was cognitively tested with physicians and staff who were not oncologists and finalized. With consent, interviews were conducted with both Winship Cancer Institute and Grady Memorial Hospital providers (GMH). All interviews were audio recorded, transcribed and analyzed using a semantic content analysis method. Results: Eleven providers at GMH and 22 providers at Winship were interviewed, reaching saturation of themes. 72% (n = 8) of the GMH providers felt that the best place for patients to view the videos was in the clinic, compared to 27% (n = 6) of the Winship providers. 68% (n = 15) of the Winship providers stated an app would be the most useful format, compared to 27% (n = 3) at GMH. All agreed that it would be useful for the patient’s family or caregiver to view the videos (GMH = 100%, Winship = 72%), that translation of the videos to Spanish would be beneficial (GMH = 90%, Winship = 63%), and that a nurse would be best to introduce the videos (GMH = 81%, Winship = 68%). Conclusions: Educational materials explaining complicated oncology treatment terminology enhance patient-centered care, yet without proper dissemination these crucial educational tools may never reach the intended patient population. The hospitals examined in this study served significantly different patient populations and the dissemination recommendations were quite different. Providers believed that the underserved patients needed the videos accessible in the clinic whereas providers serving higher SES patients thought that a web-based app, requiring a smart device or internet access, was more appropriate. Our study shows that it is crucial to ensure that educational materials are accessible to all populations, not just those with more means. Without a location-specific dissemination plan, educational tools may only further exacerbate disparities, rather than alleviate them.

Baseline modified Glasgow prognostic score (mGPS) in patients with metastatic renal cell carcinoma (mRCC) treated with immune checkpoint inhibitors (ICI)

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Background: The IMDC and MSKCC risk models for mRCC were validated before the era of ICI. The mGPS incorporates albumin and C-reactive protein and reflects systemic inflammation. mGPS may be a useful prognostic biomarker of particular relevance in mRCC given the current, largely ICI-based treatment paradigm and hypothesis that systemic inflammation may contribute to ICI resistance. Methods: We retrospectively assessed mRCC patients treated with ICI (including anti-PD-1 and anti-PD-L1 agents) in any line of therapy at Winship Cancer Institute of Emory University from 2015-2018. Primary outcomes assessed included overall survival (OS) and progression-free survival (PFS). mGPS was calculated by giving 1 point for CRP > 10 mg/L and/or albumin < 3.5 g/dL with 0 points awarded for solitary low albumin. The relationship between mGPS and survival outcomes was assessed in UVA and MVA using Cox proportional hazard model and in Kaplan-Meier analysis. Results: We assessed 156 eligible patients. Median follow up was 24.2 months. Median age was 64 years, 69% were male, 20% were Black, and 78% had clear cell histology. 57.1% received anti-PD-1 monotherapy whereas all others received dual ICI or ICI combined with an antiangiogenic agent or experimental therapy in trial. Higher baseline mGPS was significantly associated with worse OS and PFS (Table). The median OS of patients with baseline mGPS of 0, 1 and 2 was 44.5 (CI 27.3, NA), 15.3 (CI 11, 24.2) and 10 (CI 4.6, 17.5) months, respectively (p<0.0001), while the median PFS of these three cohorts was 6.7 (CI 3.6, 13.1), 4.2 (CI 2.9, 6.2) and 2.6 (CI 2, 5.6) months, respectively (p=0.0216). Conclusions: A higher mGPS at the start of therapy was negatively prognostic in patients with mRCC receiving ICI. These results should be validated in a larger, prospective study. [Table: see text]