Molecular correlates of response to capmatinib in advanced non-small-cell lung cancer: clinical and biomarker results from a phase I trial

BACKGROUND

Dysregulation of receptor tyrosine kinase MET by various mechanisms occurs in 3%-4% of non-small-cell lung cancer (NSCLC) and is associated with unfavorable prognosis. While MET is a validated drug target in lung cancer, the best biomarker strategy for the enrichment of a susceptible patient population still remains to be defined. Towards this end we analyze here primary data from a phase I dose expansion study of the MET inhibitor capmatinib in patients with advanced MET-dysregulated NSCLC.

PATIENTS AND METHODS

Eligible patients [≥18 years; Eastern Cooperative Oncology Group (ECOG) performance status ≤2] with MET-dysregulated advanced NSCLC, defined as either (i) MET status by immunohistochemistry (MET IHC) 2+ or 3+ or H-score ≥150, or MET/centromere ratio ≥2.0 or gene copy number (GCN) ≥5, or (ii) epidermal growth factor receptor wild-type (EGFRwt) and centrally assessed MET IHC 3+, received capmatinib at the recommended dose of 400 mg (tablets) or 600 mg (capsules) b.i.d. The primary objective was to determine safety and tolerability; the key secondary objective was to explore antitumor activity. The exploratory end point was the correlation of clinical activity with different biomarker formats.

RESULTS

Of 55 patients with advanced MET-dysregulated NSCLC, 40/55 (73%) had received two or more prior systemic therapies. All patients discontinued treatment, primarily due to disease progression (69.1%). The median treatment duration was 10.4 weeks. The overall response rate per RECIST was 20% (95% confidence interval, 10.4-33.0). In patients with MET GCN ≥6 (n = 15), the overall response rate by both the investigator and central assessments was 47%. The median progression-free survival per investigator for patients with MET GCN ≥6 was 9.3 months (95% confidence interval, 3.8-11.9). Tumor responses were observed in all four patients with METex14. The most common toxicities were nausea (42%), peripheral edema (33%), and vomiting (31%).

CONCLUSIONS

MET GCN ≥6 and/or METex14 are suited to predict clinical activity of capmatinib in patients with NSCLC (NCT01324479).

Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

[Pedicled vascularized iliac bone graft for treatment of osteonecrosis of the femoral head]

OBJECTIVE

Illustration of a nowadays only rarely performed operative procedure for the treatment of osteonecrosis of the femoral head to prevent or at least delay advanced arthrosis and the need for a total hip replacement. The pedicled vascularized iliac bone graft is raised without the need for special microsurgical techniques and has less vascular complications often seen in free vascularized grafts.

INDICATIONS

Early stages of osteonecrosis of the femoral head stages II and III according to the Association Research Circulation Osseous (ARCO) up to the detection of fracture lines (crescent sign) but without mechanical insufficiency.

CONTRAINDICATIONS

Osteonecrosis of the femoral head with collapse of the femoral head (ARCO stage ≥IIIB) and mechanical insufficiency. Patients who are noncompliant or a not able to take the weight off the operated leg. Patients who had radiotherapy or an operation on ipsilateral inguinal lymph nodes and patients who have vascular anomalies or severe arteriosclerosis.

SURGICAL TECHNIQUE

Debridement of the femoral head osteonecrosis and implantation of a pedicled vascularized iliac bone graft.

POSTOPERATIVE MANAGEMENT

Free movement of the hip joint 4 weeks after surgery. Outward rotation of the hip joint allowed after 3 months and restriction of weight load on the operated leg for at least 3-6 months postoperatively depending on the bony consolidation.

RESULTS

Vascularized bone grafts for the treatment of femoral head necrosis show better clinical and radiological results than avascular bone grafts. Nevertheless, after 5 years follow-up approximately 25% of the operated hips formerly in stage II show further progression of radiological necrosis. In stage III all hips eventually show progress of femoral head collapse and the need of a total hip replacement. Concerning the outcome of a free vascularized bone graft (fibula flap) compared to the pedicled vascularized graft from the iliac crest for treatment, the anatomically demanding area and a higher complication rate should be considered even though the cancellous bone of the iliac crest is biologically ideal. Nowadays a free vascularized fibular graft is the most frequently used bone graft for treatment of femoral head necrosis.

Cisplatin and 5-fluorouracil with or without epidermal growth factor receptor inhibition panitumumab for patients with non-resectable, advanced or metastatic oesophageal squamous cell cancer: a prospective, open-label, randomised phase III AIO/EORTC trial (POWER)

BACKGROUND

Palliative chemotherapy of advanced oesophageal squamous cell cancer (ESCC) consists of cisplatin/5-fluorouracil (CF) to target epidermal growth factor receptor (EGFR) with panitumumab (P); chemotherapy enhanced overall survival (OS) in advanced colorectal or squamous cell head and neck cancers. With prospective serum and tumour biomarkers, we tested if P added to CF (CFP) improved OS in advanced ESCC.

PATIENTS AND METHODS

Eligible patients with confirmed ESCC that was not curatively resectable or did not qualify for definitive radiochemotherapy, were randomised 1 : 1 to receive CF [cisplatin (C) 100 mg/m² i.v., day 1; 5-fluorouracil (F) 1000 mg/m² i.v., days 1-4] or CF plus P (9 mg/kg, i.v., day 1, each q3-week cycle) until progressive disease or unacceptable toxicity. Safety was reviewed by the Data Safety Monitoring Board after 40, 70 and 100 patients who completed at least one cycle. After 53 enrolled patients, cisplatin was reduced from 100 mg/m² to 80 mg/m².

RESULTS

The trial was stopped early based on interim efficacy results triggered by the third safety analysis: median OS (mOS) favoured CF over CFP, regardless of cisplatin dose [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.06-2.98; P = 0.028]. In the final analysis, mOS was 10.2 versus 9.4 months for CF versus CFP, respectively (HR 1.17, 95% CI 0.79-1.75; P = 0.43). One hundred (70.4%) of 142 patients in the safety population died, 51 (51.0%) with CFP. Most deaths were related to disease progression [44/49 (90%) deaths in CF versus 34/51 (67%) deaths in CFP]; objective responses [27/73 (37.0%)] were identical. The most common serious adverse events were kidney injury [3 (4.3%) versus 7 (9.7%)], general health deterioration [5 (7.1%) versus 5 (6.9%)] and dysphagia [4 (5.7%) versus 4 (5.6%)] in CF versus CFP, respectively. There were three (4.3%) and 17 (23.6%) common terminology criteria for adverse events (CTCAE) grade 5 events in CF versus CFP, respectively. Low soluble (s)EGFR levels were associated with better progression-free survival; sEGFR was induced under CFP.

CONCLUSION

EGFR inhibition added to CF did not improve survival in unselected advanced ESCC patients. The results support further liquid biopsy studies.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01627379) and EudraCT (2010-020606-15).

Advance care planning in the palliative phase of people with intellectual disabilities: analysis of medical files and interviews

BACKGROUND

Advance care planning (ACP) is a process in which professionals, patients and their relatives discuss wishes and options for future care. ACP in the palliative phase reduces the chance that decisions have to be taken suddenly and can therefore improve the quality of life and death. The primary aim of this study is to explore how ACP takes place in cases of people with intellectual disabilities (ID).

METHOD

Medical files were analysed, and interviews were held in six care organisations for people with mild to severe ID. The data concerned people with ID (n = 30), 15 in the palliative phase, identified using the 'surprise question', and 15 who had died after an identifiable period of illness. Additional pre-structured telephone interviews were conducted with their relatives (n = 30) and professionals (n = 33).

RESULTS

For half of the people with ID who had died, the first report in their file about palliative care (needs) was less than 1 month before their death. Professionals stated that ACP was started in response to the person's deteriorating health situation. A do-not-attempt-resuscitation order was recorded for nearly all people with ID (93%). A smaller group also had other agreements between professionals and relatives documented in their files, mainly about potentially life-sustaining treatments (43%) and/or hospitalisation admissions (47%). Relatives and professionals are satisfied with the mutual cooperation in ACP in the palliative phase. Cognitive and communication disabilities were most frequently mentioned by relatives and professionals as reasons for not involving people with ID in ACP.

CONCLUSIONS

Advance care planning in the palliative phase of people with ID focuses mainly on medical issues at the end of life. Specific challenges concern a proactive identification of changing needs, fear to initiate ACP discussions, documentation of ACP in medical files and the involvement of people with ID in ACP. It is recommended that relatives and professionals should be informed about the content of ACP and professionals should be trained in communicating in advance about wishes for future care.

Imagining the Future of the International Cancer Screening Network: Responding to Needs and Engagement in Cancer Screening Globally

Background: Over the past three decades, much evidence has been generated in high-income countries (HIC) for effective implementation of cervical, breast and colorectal cancer screening programs and their contribution to reducing mortality. However, translation of cancer screening programs to low- and middle-income countries (LMIC) continues to be a challenge. For 30 years, the US National Cancer Institute's International Cancer Screening Network (ICSN) has gathered cancer screening researchers, implementers and evaluators at the ICSN biennial scientific meeting, provided expert assistance and facilitated working groups that advance research on cancer screening, via standardization of definitions, metrics, and measures, and cross-national comparative studies. For many years, this group has been comprised largely of participants from HICs, with limited participation by individuals from LMICs. However, in recent years, cancer screening has been adopted in an increasing number of LMICs. There is now a critical need to understand how to translate cancer screening delivery, program implementation, documentation, and research to LMICs. Aim: To gather insights from ICSN participants on the translatability of cancer screening knowledge between high and low-resource settings to advance the field of cancer screening globally. Methods: In 2018, ICSN conducted an evaluation research study to assess the outcomes and impacts of the ICSN to date and inform future ICSN activities, including engagement of individuals working in LMICs. Data collection consisted of a survey to our listserv, which has 666 subscribers. Results: There were 266 network members who responded to the survey, including 244 advanced who completed the full survey. The majority (58.7%) have been working in the field of cancer screening for 15 or fewer years, although 27.8% have 20 or more years of experience. Most respondents work in government agencies (32.7%) and academic institutions (37.2%), and dedicate most of their time to conducting cancer screening research. ICSN members predominantly work in organized cancer screening programs (72.6%). In addition, 80.5% work primarily in HICs and 10.9% in upper middle-income countries. Of those who attended the 2017 ICSN biennial meeting (56.1%), 78.8% agreed that it enabled them to learn from cancer screening in higher resource settings while 66.4% agreed that it enabled them to learn from cancer screening in lower resource settings. Conclusion: With 30 years of experience facilitating the advancement of cancer screening research, implementation and evaluation in HICs, the ICSN has many lessons to offer to countries that are considering establishing cancer screening programs. Findings suggest the relevance of ICSN activities to advancing cancer screening in both HICs and LMICs. ICSN is currently engaged in and developing additional approaches to advance cancer screening in LMICs, including technical assistance, workshops, and regional meetings.

A novel cytochrome P450 mono-oxygenase from Streptomyces platensis resembles activities of human drug metabolizing P450s

Cytochrome P450 mono-oxygenases (P450) are versatile enzymes which play essential roles in C-source assimilation, secondary metabolism, and in degradations of endo- and exogenous xenobiotics. In humans, several P450 isoforms constitute the largest part of phase I metabolizing enzymes and catalyze oxidation reactions which convert lipophilic xenobiotics, including drugs, to more water soluble species. Recombinant human P450s and microorganisms are applied in the pharmaceutical industry for the synthesis of drug metabolites for pharmacokinetics and toxicity studies. Compared to the membrane-bound eukaryotic P450s, prokaryotic ones exhibit some advantageous features, such as high stability and generally easier heterologous expression. Here, we describe a novel P450 from Streptomyces platensis DSM 40041 classified as CYP107L that efficiently converts several commercial drugs of various size and properties. This P450 was identified by screening of actinobacterial strains for amodiaquine and ritonavir metabolizing activities, followed by genome sequencing and expression of the annotated S. platensis P450s in Escherichia coli. Performance of CYP107L in biotransformations of amodiaquine, ritonavir, amitriptyline, and thioridazine resembles activities of the main human metabolizing P450s, namely CYPs 3A4, 2C8, 2C19, and 2D6. For application in the pharmaceutical industry, an E. coli whole-cell biocatalyst expressing CYP107L was developed and evaluated for preparative amodiaquine metabolite production.

Interferon-free therapy of chronic hepatitis C with direct-acting antivirals does not change the short-term risk for de novo hepatocellular carcinoma in patients with liver cirrhosis

BACKGROUND

Hepatitis C virus (HCV) clearance with IFN-based therapies reduces the incidence of hepatocellular carcinoma (HCC). There has been some debate if IFN-free therapy with direct-acting antivirals alters the risk for HCC.

AIM

To investigate the HCC incidence in cirrhotic HCV patients who cleared HCV with direct-acting antivirals vs untreated controls.

METHODS

We prospectively monitored 373 patients with chronic hepatitis C who received IFN-free therapies with direct-acting antiviral after January 2014. A retrospective control cohort of untreated cirrhotic patients was recruited out of 3715 HCV patients who were followed at our centre between 2007 and 2013, with similar HCC screening protocols.

RESULTS

158 direct-acting antiviral-treated and 184 control patients with liver cirrhosis were included in this analysis. The groups did not differ in gender and genotype distribution, severity of liver disease and prevalence of diabetes mellitus. Patients were followed up for a median of 440 (range 91-908) and 592 (range 90-1000) days. HCCs developed in 6 and 14 patients during follow-up, resulting in an incidence of 2.90 vs 4.48 HCCs per 100 person-years. In the direct-acting antiviral-treated group, there was no new case of HCC later than 450 days after treatment initiation. In multivariate analysis, higher MELD-Scores and AFP-levels were independently associated with HCC development. Transplant-free patient survival was similar in both groups.

CONCLUSIONS

IFN-free direct-acting antiviral therapy of chronic hepatitis C does not alter the short-term risk for HCC in patients with liver cirrhosis. A reduced HCC incidence may become evident after more than 1.5 years of follow-up.