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Pierret T, Toffart AC, Giaj Levra M, Moro-Sibilot D, Gobbini E. Advances and Therapeutic Perspectives in Extended-Stage Small-Cell Lung Cancer. Cancers (Basel) 2020; 12:E3224. [PMID: 33139612 PMCID: PMC7692868 DOI: 10.3390/cancers12113224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 01/13/2023] Open
Abstract
Extended small cell lung cancer (ED-SCLC) is a very aggressive disease, characterized by rapid growth and an early tendency to relapse. In contrast to non-small cell lung cancer, no therapeutic innovation has improved survival in patients with ED-SCLC over the past 20 years. Recently, immunotherapy has shown an important role in the management of these patients, emerging as the treatment of first choice in combination with chemotherapy and completely changing the therapeutic paradigm. However, patients' selection for this strategy is still challenging due to a lack of reliable predictive biomarkers. Conversely, the immunotherapy efficacy beyond the first line is pretty disappointing and innovative chemotherapies or target agents seem to be more promising in this setting. Some of them are also under evaluation as an upfront strategy and they will probably change the treatment algorithm in the next future. This proposal provides a comprehensive overview of available treatment strategies for ED-SCLC patients, highlighting their strengths and weaknesses.
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Affiliation(s)
- Thomas Pierret
- Thoracic Oncology Unit, CHU Grenoble-Alpes, 38700 Grenoble, France; (T.P.); (A.-C.T.); (M.G.L.); (D.M.-S.)
| | - Anne-Claire Toffart
- Thoracic Oncology Unit, CHU Grenoble-Alpes, 38700 Grenoble, France; (T.P.); (A.-C.T.); (M.G.L.); (D.M.-S.)
| | - Matteo Giaj Levra
- Thoracic Oncology Unit, CHU Grenoble-Alpes, 38700 Grenoble, France; (T.P.); (A.-C.T.); (M.G.L.); (D.M.-S.)
| | - Denis Moro-Sibilot
- Thoracic Oncology Unit, CHU Grenoble-Alpes, 38700 Grenoble, France; (T.P.); (A.-C.T.); (M.G.L.); (D.M.-S.)
| | - Elisa Gobbini
- Thoracic Oncology Unit, CHU Grenoble-Alpes, 38700 Grenoble, France; (T.P.); (A.-C.T.); (M.G.L.); (D.M.-S.)
- Cancer Research Center of Lyon, 69008 Lyon, France
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2
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Remon J, Passiglia F, Ahn MJ, Barlesi F, Forde PM, Garon EB, Gettinger S, Goldberg SB, Herbst RS, Horn L, Kubota K, Lu S, Mezquita L, Paz-Ares L, Popat S, Schalper KA, Skoulidis F, Reck M, Adjei AA, Scagliotti GV. Immune Checkpoint Inhibitors in Thoracic Malignancies: Review of the Existing Evidence by an IASLC Expert Panel and Recommendations. J Thorac Oncol 2020; 15:914-947. [PMID: 32179179 DOI: 10.1016/j.jtho.2020.03.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/29/2020] [Accepted: 03/06/2020] [Indexed: 02/07/2023]
Abstract
In the past 10 years, a deeper understanding of the immune landscape of cancers, including immune evasion processes, has allowed the development of a new class of agents. The reactivation of host antitumor immune response offers the potential for long-term survival benefit in a portion of patients with thoracic malignancies. The advent of programmed cell death protein 1/programmed death ligand-1 immune checkpoint inhibitors (ICIs), both as single agents and in combination with chemotherapy, and more recently, the combination of ICI, anti-programmed cell death protein 1, and anticytotoxic T-lymphocyte antigen 4 antibody, have led to breakthrough therapeutic advances for patients with advanced NSCLC, and to a lesser extent, patients with SCLC. Encouraging activity has recently emerged in pretreated patients with thymic carcinoma (TC). Conversely, in malignant pleural mesothelioma, pivotal positive signs of activity have not been fully confirmed in randomized trials. The additive effects of chemoradiation and immunotherapy suggested intriguing potential for therapeutic synergy with combination strategies. This has led to the introduction of ICI consolidation therapy in stage III NSCLC, creating a platform for future therapeutic developments in earlier-stage disease. Despite the definitive clinical benefit observed with ICI, primary and acquired resistance represent well-known biological phenomena, which may affect the therapeutic efficacy of these agents. The development of innovative strategies to overcome ICI resistance, standardization of new patterns of ICI progression, identification of predictive biomarkers of response, optimal treatment duration, and characterization of ICI efficacy in special populations, represent crucial issues to be adequately addressed, with the aim of improving the therapeutic benefit of ICI in patients with thoracic malignancies. In this article, an international panel of experts in the field of thoracic malignancies discussed these topics, evaluating currently available scientific evidence, with the final aim of providing clinical recommendations, which may guide oncologists in their current practice and elucidate future treatment strategies and research priorities.
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Affiliation(s)
- Jordi Remon
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal (HM-CIOCC), Hospital HM Delfos, HM Hospitales, Barcelona, Spain
| | - Francesco Passiglia
- Department of Oncology, University of Torino, AOU S. Luigi Gonzaga, Orbassano, Italy
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Fabrice Barlesi
- Multidisciplinary Oncology and Therapeutic Innovations Department, Aix Marseille University, CNRS, INSERM, CRCM, APHM, Marseille, France
| | - Patrick M Forde
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward B Garon
- David Geffen School of Medicine at University of California Los Angeles, Translational Research in Oncology US Network, Los Angeles, California
| | - Scott Gettinger
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Sarah B Goldberg
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Roy S Herbst
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Leora Horn
- Department of Hematology and Oncology, Vanderbilt Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee
| | - Kaoru Kubota
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shun Lu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Laura Mezquita
- Department of Cancer Medicine, Gustave Roussy Cancer Campus, Villejuif, France
| | - Luis Paz-Ares
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sanjay Popat
- Medical Oncology Department, The Royal Marsden Hospital, London, United Kingdom; Medical Oncology Department, The Institute of Cancer Research, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Kurt A Schalper
- Departments of Pathology and Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Ferdinandos Skoulidis
- Department of Thoracic and Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Martin Reck
- Lung Clinic Grosshansdorf, Airway Research Center North, German Center of Lung Research, Grosshansdorf, Germany
| | - Alex A Adjei
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Giorgio V Scagliotti
- Department of Oncology, University of Torino, AOU S. Luigi Gonzaga, Orbassano, Italy.
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3
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Ready NE, Ott PA, Hellmann MD, Zugazagoitia J, Hann CL, de Braud F, Antonia SJ, Ascierto PA, Moreno V, Atmaca A, Salvagni S, Taylor M, Amin A, Camidge DR, Horn L, Calvo E, Li A, Lin WH, Callahan MK, Spigel DR. Nivolumab Monotherapy and Nivolumab Plus Ipilimumab in Recurrent Small Cell Lung Cancer: Results From the CheckMate 032 Randomized Cohort. J Thorac Oncol 2020; 15:426-435. [PMID: 31629915 DOI: 10.1016/j.jtho.2019.10.004] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Nivolumab monotherapy is approved in the United States for third-line or later metastatic small cell lung cancer based on pooled data from nonrandomized and randomized cohorts of the multicenter, open-label, phase 1/2 trial of nivolumab ± ipilimumab (CheckMate 032; NCT01928394). We report updated results, including long-term overall survival (OS), from the randomized cohort. METHODS Patients with small cell lung cancer and disease progression after one to two prior chemotherapy regimens were randomized 3:2 to nivolumab 3 mg/kg every 2 weeks or nivolumab 1 mg/kg plus ipilimumab 3 mg/kg every 3 weeks for four cycles followed by nivolumab 3 mg/kg every 2 weeks. Patients were stratified by number of prior chemotherapy regimens and treated until disease progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) by blinded independent central review. RESULTS Overall, 147 patients received nivolumab and 96 nivolumab plus ipilimumab. Minimum follow-up for ORR/progression-free survival/safety was 11.9 months (nivolumab) and 11.2 months (nivolumab plus ipilimumab). ORR increased with nivolumab plus ipilimumab (21.9% versus 11.6% with nivolumab; odds ratio: 2.12; 95% confidence interval: 1.06-4.26; p = 0.03). For long-term OS, minimum follow-up was 29.0 months (nivolumab) versus 28.4 months (nivolumab plus ipilimumab); median (95% confidence interval) OS was 5.7 (3.8-7.6) versus 4.7 months (3.1-8.3). Twenty-four-month OS rates were 17.9% (nivolumab) and 16.9% (nivolumab plus ipilimumab). Grade 3 to 4 treatment-related adverse event rates were 12.9% (nivolumab) versus 37.5% (nivolumab plus ipilimumab), and treatment-related deaths were n =1 versus n = 3, respectively. CONCLUSIONS Whereas ORR (primary endpoint) was higher with nivolumab plus ipilimumab versus nivolumab, OS was similar between groups. In each group, OS remained encouraging with long-term follow-up. Toxicities were more common with combination therapy versus nivolumab monotherapy.
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Affiliation(s)
- Neal E Ready
- Duke University Medical Center, Durham, North Carolina.
| | | | - Matthew D Hellmann
- Memorial Sloan-Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | | | - Christine L Hann
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Filippo de Braud
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan; University of Milan, Milan, Italy
| | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Victor Moreno
- START Madrid - FJD, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Akin Atmaca
- Department of Oncology and Hematology, Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt, Germany
| | - Stefania Salvagni
- Policlinico S.Orsola-Malpighi, Azienda Ospedaliero Universitaria, Bologna, Italy
| | | | - Asim Amin
- Levine Cancer Institute, Atrium Healthcare System, Charlotte, North Carolina
| | | | - Leora Horn
- Vanderbilt Ingram Cancer Center, Nashville, Tennessee
| | - Emiliano Calvo
- START Madrid - CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Ang Li
- Bristol-Myers Squibb, Lawrenceville, New Jersey
| | | | | | - David R Spigel
- Sarah Cannon Research Institute/Tennessee Oncology Nashville, Nashville, Tennessee
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4
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Arnold SM, Chansky K, Baggstrom MQ, Thompson MA, Sanborn RE, Villano JL, Waqar SN, Hamm J, Leggas M, Willis M, Rosales J, Crowley JJ. Phase II Trial of Carfilzomib Plus Irinotecan in Patients With Small-cell Lung Cancer Who Have Progressed on Prior Platinum-based Chemotherapy. Clin Lung Cancer 2020; 21:357-364.e7. [PMID: 32173247 DOI: 10.1016/j.cllc.2020.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/23/2019] [Accepted: 01/20/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the efficacy and tolerability of carfilzomib plus irinotecan (C/I) in patients with relapsed small-cell lung cancer (SCLC). PATIENTS AND METHODS Patients with SCLC who progressed after 1 platinum-containing regimen for recurrent or metastatic disease were eligible. Patients were stratified as: sensitive (SS) (progressive disease > 90 days after chemotherapy) or refractory (RS) (progressive disease 30 to 90 days after chemotherapy) and received up to 6 cycles of C/I; imaging was performed every 2 cycles. The primary endpoint was 6-month overall survival (OS). RESULTS All 62 patients enrolled were evaluable for efficacy and adverse events. 6-month OS was 59% in the platinum SS and 54% in the platinum RS. The overall response rate was 21.6% (2.7% complete response, 18.9% partial response) in SS (n = 37) and 12.5% (all partial response) in RS (n = 25). The disease control rate was 68% (SS) and 56% (RS). Progression-free survival and OS were 3.6 months (95% confidence interval [CI], 2.6-4.6 months) and 6.9 months (95% CI, 4.3-12.3 months) in SS, and 3.3 months (95% CI, 1.8-3.9 months) and 6.8 months (95% CI, 4.1-11 months) in RS. Twenty-nine (47%) patients experienced ≥ grade 3 adverse events; 8 (12.9%) subjects had grade 4 toxicities. Three treatment-related deaths occurred: myocardial infarction (possible), lung infection (possible), and sepsis (probable). CONCLUSION In patients with relapsed SCLC, C/I was effective in the treatment of SS and RS. With 4.8% grade 5 toxicity, C/I is a viable option for relapsed patients with SCLC with performance status 0 to 1, particularly in platinum-resistant patients, or subjects who cannot receive immunotherapy.
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Affiliation(s)
- Susanne M Arnold
- University of Kentucky Markey Cancer Center, Lexington, KY; Division of Medical Oncology, Department of Medicine, University of Kentucky, Lexington, KY.
| | | | - Maria Q Baggstrom
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Rachel E Sanborn
- Division of Medical Oncology, Providence Cancer Center, Portland, OR
| | - John L Villano
- University of Kentucky Markey Cancer Center, Lexington, KY; Division of Medical Oncology, Department of Medicine, University of Kentucky, Lexington, KY
| | - Saiama N Waqar
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - John Hamm
- Norton Cancer Institute, Louisville, KY
| | - Markos Leggas
- University of Kentucky Markey Cancer Center, Lexington, KY; Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY
| | - Maurice Willis
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Joseph Rosales
- Department of Internal Medicine, Virginia Mason, Seattle, WA
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Chung HC, Piha-Paul SA, Lopez-Martin J, Schellens JHM, Kao S, Miller WH, Delord JP, Gao B, Planchard D, Gottfried M, Zer A, Jalal SI, Penel N, Mehnert JM, Matos I, Bennouna J, Kim DW, Xu L, Krishnan S, Norwood K, Ott PA. Pembrolizumab After Two or More Lines of Previous Therapy in Patients With Recurrent or Metastatic SCLC: Results From the KEYNOTE-028 and KEYNOTE-158 Studies. J Thorac Oncol 2019; 15:618-627. [PMID: 31870883 DOI: 10.1016/j.jtho.2019.12.109] [Citation(s) in RCA: 217] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/03/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Pembrolizumab has shown clinical benefit in patients with previously treated recurrent or metastatic SCLC in the phase 1b multicohort study KEYNOTE-028 (NCT02054806) and the phase 2 multicohort study KEYNOTE-158 (NCT02628067). We present a pooled analysis of patients from KEYNOTE-028 and KEYNOTE-158 who had received two or more lines of previous therapy for SCLC. METHODS Eligible patients were aged 18 years and above, had histologically or cytologically confirmed incurable recurrent or metastatic SCLC, had an Eastern Cooperative Oncology Group performance status of 1 and below, and had received two or more lines of previous therapy. Patients in KEYNOTE-028 were required to have a programmed death ligand 1 (PD-L1)-positive tumor. Patients received pembrolizumab (10 mg/kg every 2 weeks in KEYNOTE-028 or 200 mg every 3 weeks in KEYNOTE-158) for up to 2 years. The primary end point was objective response rate per Response Evaluation Criteria in Solid Tumors version 1.1, which is presented here per independent review. RESULTS Eighty-three patients who had received two or more lines of previous therapy (KEYNOTE-028, n = 19; KEYNOTE-158, n = 64) were included. Median follow-up duration was 7.7 (range, 0.5-48.7) months. Objective response rate was 19.3% (95% confidence interval: 11.4-29.4); two patients had complete response (one with a PD-L1-positive tumor), and 14 patients had partial response (13 with PD-L1-positive tumors). The median duration of response was not reached (range, 4.1‒35.8+ mo; plus sign indicates ongoing response); 61% of responders had responses lasting 18 months or longer. Fifty-one patients (61.4%) experienced any-grade treatment-related adverse events; eight patients (9.6%) had grade 3 or higher events. CONCLUSIONS Pembrolizumab exhibited durable antitumor activity in a subset of patients with recurrent or metastatic SCLC who had undergone two or more previous lines of therapy, regardless of PD-L1 expression. Pembrolizumab was well tolerated.
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Affiliation(s)
- Hyun Cheol Chung
- Department of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sarina A Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jose Lopez-Martin
- Department of Medical Oncology, 12 de Octubre University Hospital and Research Institute (i+12), Madrid, Spain
| | - Jan H M Schellens
- Division of Pharmacology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Steven Kao
- Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Wilson H Miller
- Segal Cancer Centre, Jewish General Hospital, Montreal, Quebec, Canada; Rossy Cancer Network, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Jean-Pierre Delord
- Department of Oncology, Institut Claudius Regaud Institut Universitaire du Cancer-Oncopole, Toulouse, France
| | - Bo Gao
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, New South Wales, Australia
| | - David Planchard
- Department of Medical Oncology, Thoracic Group, Gustave Roussy, Villejuif, France
| | | | - Alona Zer
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Shadia I Jalal
- Indiana University, Simon Cancer Center, Indianapolis, Indiana
| | - Nicolas Penel
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France
| | - Janice M Mehnert
- Developmental Therapeutics, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Ignacio Matos
- Department of Medical Oncology, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | | | - Dong-Wan Kim
- Seoul National University Hospital College of Medicine, Seoul, South Korea
| | - Lei Xu
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey
| | - Suba Krishnan
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey
| | - Kevin Norwood
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey
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Simeone E, Grimaldi AM, Festino L, Trojaniello C, Vitale MG, Vanella V, Curvietto M, Ascierto PA. Nivolumab for the treatment of small cell lung cancer. Expert Rev Respir Med 2019; 14:5-13. [PMID: 31622114 DOI: 10.1080/17476348.2020.1681977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Treatment of extensive-stage SCLC is still a challenge but immunotherapy with checkpoint inhibitors is showing promising results. Nivolumab alone or in combination with ipilimumab has demonstrated a benefit in terms of response and survival in patients with pre-treated extensive-stage disease and has been approved as third-line therapy after failure of chemotherapy. However, data from two phase III trials with nivolumab are negative. In the first trial, nivolumab was administered as a single agent compared to second-line chemotherapy, while in the second it was given alone or in combination with ipilimumab as maintenance treatment after platinum-based chemotherapy.Areas covered: Our review focuses on the role of immunotherapy, and in particular nivolumab, in the treatment of SCLC, describing the results of the main trials and its future perspectives, with reference to clinical trials with other checkpoint inhibitors.Expert opinion: The future of nivolumab in the treatment of SCLC needs to be clarified with further clinical trials, in which improved patient selection and a more specific setting and/or timepoint of the disease may be identified.
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Affiliation(s)
- Ester Simeone
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Antonio Maria Grimaldi
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Lucia Festino
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Claudia Trojaniello
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Maria Grazia Vitale
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Vito Vanella
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Marcello Curvietto
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Paolo Antonio Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
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Lum C, Alamgeer M. Technological and Therapeutic Advances in Advanced Small Cell Lung Cancer. Cancers (Basel) 2019; 11:E1570. [PMID: 31619019 PMCID: PMC6826371 DOI: 10.3390/cancers11101570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022] Open
Abstract
Small cell lung cancer (SCLC) accounts for approximately 10-15% of all lung cancers. The prognosis is poor with median survival in the advanced stage remaining at around 12 months. Despite applying every known therapeutic approach, no major breakthrough has improved the overall survival in the last 30 years. Historically, experiments performed on conventional cell lines may have limitations of not accurately reflecting the complex biological and genomic heterogeneity of this disease. However, additional knowledge gained from recently developed genetically engineered mouse models (GEMMs) and patient derived xenografts (PDXs) have made encouraging inroads. Whole genome sequencing (WGS) data reveals a high mutational burden and a number of genetic alterations but low frequency of targetable mutations. Despite several failures, considerable therapeutic opportunities have recently emerged. Potentially promising therapies include those targeting DNA damage repair, stem cell/renewal and drug resistant mechanisms. Modest success has also been achieved with immune checkpoint inhibitors while therapeutic exploration of various other components of the immune system is underway. However, the complex heterogeneities reflect the need for accurate bio-markers to translate novel discoveries into clinical benefit. Additionally, the molecular mechanisms that differentiate chemo-sensitive from chemo-refractory disease remain unknown. Obtaining reliable tumour samples by utilising novel techniques such as endobronchial ultrasound guided needle aspiration or adopting to liquid biopsies are becoming popular. This review will focus on recent technological and therapeutic advancements to surmount this recalcitrant disease.
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Affiliation(s)
- Caroline Lum
- Department of Medical Oncology, Monash Health and Monash University, Clayton, VIC 3168, Australia.
| | - Muhammad Alamgeer
- Department of Medical Oncology, Monash Health and Monash University, Clayton, VIC 3168, Australia.
- Centre for Cancer Research, Hudson Institute of Medical Research, Monash University, Clayton, VIC 3168, Australia.
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8
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Widick P, Gill RR, Mantia C, Costa DB, Rangachari D. Extensive-Stage Small-Cell Lung Cancer With Sustained Complete Response to Single-Agent Nivolumab and Immune-Related Dermatitis. Clin Lung Cancer 2019; 21:e6-e9. [PMID: 31640925 DOI: 10.1016/j.cllc.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/08/2019] [Accepted: 09/16/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Page Widick
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ritu R Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Charlene Mantia
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Daniel B Costa
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Deepa Rangachari
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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9
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Deneka AY, Boumber Y, Beck T, Golemis EA. Tumor-Targeted Drug Conjugates as an Emerging Novel Therapeutic Approach in Small Cell Lung Cancer (SCLC). Cancers (Basel) 2019; 11:cancers11091297. [PMID: 31484422 PMCID: PMC6769513 DOI: 10.3390/cancers11091297] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/25/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023] Open
Abstract
There are few effective therapies for small cell lung cancer (SCLC), a highly aggressive disease representing 15% of total lung cancers. With median survival <2 years, SCLC is one of the most lethal cancers. At present, chemotherapies and radiation therapy are commonly used for SCLC management. Few protein-targeted therapies have shown efficacy in improving overall survival; immune checkpoint inhibitors (ICIs) are promising agents, but many SCLC tumors do not express ICI targets such as PD-L1. This article presents an alternative approach to the treatment of SCLC: the use of drug conjugates, where a targeting moiety concentrates otherwise toxic agents in the vicinity of tumors, maximizing the differential between tumor killing and the cytotoxicity of normal tissues. Several tumor-targeted drug conjugate delivery systems exist and are currently being actively tested in the setting of SCLC. These include antibody-drug conjugates (ADCs), radioimmunoconjugates (RICs), small molecule-drug conjugates (SMDCs), and polymer-drug conjugates (PDCs). We summarize the basis of action for these targeting compounds, discussing principles of construction and providing examples of effective versus ineffective compounds, as established by preclinical and clinical testing. Such agents may offer new therapeutic options for the clinical management of this challenging disease in the future.
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Affiliation(s)
- Alexander Y Deneka
- Molecular Therapeutics Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
- Department of Biochemistry, Kazan Federal University, 420000 Kazan, Russia.
| | - Yanis Boumber
- Molecular Therapeutics Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
- Department of Biochemistry, Kazan Federal University, 420000 Kazan, Russia
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Tim Beck
- Cleveland Clinic, Cleveland, OH 44195, USA
| | - Erica A Golemis
- Molecular Therapeutics Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA.
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10
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Immune checkpoint blockade in small cell lung cancer. Lung Cancer 2019; 137:31-37. [PMID: 31525648 DOI: 10.1016/j.lungcan.2019.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Despite the highly immunogenic potential of small cell lung cancer (SCLC), progress in evaluating the therapeutic value of immune checkpoint agents has lagged behind that of non-small cell lung cancer. Results from a number of phase I-III clinical trials that specifically address the use of anti-PD-1, anti-PD-L1 and anti-CTLA-4 agents in SCLC have now been reported. This review will focus on the available evidence for immune checkpoint blockade in SCLC and review current biomarker strategies with the aim of providing perspective and interpretation of this data for clinical practice.
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11
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Wang S, Zimmermann S, Parikh K, Mansfield AS, Adjei AA. Current Diagnosis and Management of Small-Cell Lung Cancer. Mayo Clin Proc 2019; 94:1599-1622. [PMID: 31378235 DOI: 10.1016/j.mayocp.2019.01.034] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/05/2019] [Accepted: 01/31/2019] [Indexed: 12/25/2022]
Abstract
Small-cell lung cancer (SCLC) is an aggressive disease with distinct pathological, clinical, and molecular characteristics from non-small-cell lung cancer. SCLC has high metastatic potential, resulting in a clinically poor prognosis. Early concurrent chemo-radiation is the standard of care for limited-stage SCLC (LS-SCLC). Prophylactic cranial irradiation (PCI) is recommended for patients with LS-SCLC without progression of disease after initial therapy. A combination of etoposide and cisplatin or carboplatin remains the mainstay of first-line treatment for ES-SCLC, with the addition of atezolizumab, now becoming standard. Most SCLCs initially respond to therapy but almost invariably recur. Topotecan and amrubicin (in Japan) remain the primary chemotherapy options for relapsed SCLC. Immunotherapy, including nivolumab with or without ipilimumab, is now available for refractory disease. In general, the poor prognosis of SCLC has not improved significantly for more than 3 decades. Recently, next-generation molecular profiling studies have identified new therapeutic targets for SCLC. A variety of proapoptotic agents, compounds capitalizing on DNA-repair defects, immunotherapy agents, and antibody-drug conjugates are being evaluated in SCLC, with a number of them showing early promise.
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Affiliation(s)
- Shuhang Wang
- Peking University Cancer Hospital, Beijing, China
| | - Stefan Zimmermann
- Département d'Oncologie, service d'Immuno-Oncologie, CHUV, Lausanne, Switzerland
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12
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Ricciuti B, Kravets S, Dahlberg SE, Umeton R, Albayrak A, Subegdjo SJ, Johnson BE, Nishino M, Sholl LM, Awad MM. Use of targeted next generation sequencing to characterize tumor mutational burden and efficacy of immune checkpoint inhibition in small cell lung cancer. J Immunother Cancer 2019; 7:87. [PMID: 30922388 PMCID: PMC6437848 DOI: 10.1186/s40425-019-0572-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinically-available biomarkers to identify the fraction of patients with small cell lung cancer (SCLC) who respond to immune-checkpoint inhibitors (ICIs) are lacking. High nonsynonymous tumor mutational burden (TMB), as assessed by whole exome sequencing, correlates with improved clinical outcomes for patients with SCLC treated with ICIs. Whether TMB as assessed by targeted next generation sequencing (NGS) is associated with improved efficacy of ICIs in patients with SCLC is currently unknown. Here we determined whether TMB by targeted NGS is associated with efficacy of ICIs in patients with SCLC. METHODS We collected clinicopathologic data from patients with relapsed or refractory SCLC which underwent targeted NGS with TMB assessment by the Dana-Farber Cancer Institute OncoPanel platform. The relationship between TMB and clinical outcomes after treatment with ICIs was investigated. RESULTS Among the 52 patients treated with ICIs, we found no significant difference in the objective response rate (ORR) between patients with a TMB above the 50th percentile ("TMB high") and those with a TMB at or below the 50th percentile ("TMB low"). The median progression-free survival (mPFS) and median overall survival (mOS) were significantly longer in patients with a high TMB compared to those with a low TMB (mPFS: 3.3 versus 1.2 months, HR: 0.37 [95% CI: 0.20-0.69], P < 0.01; mOS: 10.4 versus 2.5 months, HR: 0.38 [95% CI: 0.19-0.77], P < 0.01). The one-year PFS and OS rates improved with increasing mutational load when TMB was divided into tertiles. CONCLUSIONS These findings show that targeted NGS, a readily available clinical diagnostic test, can be used to identify patients with SCLC who are most likely to benefit from treatment with immune checkpoint inhibitors.
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Affiliation(s)
- Biagio Ricciuti
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Sasha Kravets
- Department of Data Sciences, Division of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Suzanne E Dahlberg
- Department of Data Sciences, Division of Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Renato Umeton
- Department of Informatics, Dana-Farber Cancer Institute, Boston, MA, USA.,Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Adem Albayrak
- Department of Informatics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Safiya J Subegdjo
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Bruce E Johnson
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Mizuki Nishino
- Department of Radiology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Lynette M Sholl
- Department of Pathology, Brigham and Women's Hospital, Boston, Harvard Medical School, Boston, MA, USA
| | - Mark M Awad
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
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13
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Jin B, Chuang X, Liu Y. Remarkable Long-Term Efficacy of Nivolumab Immunotherapy in a Chinese Patient with Extensive-Disease Small Cell Lung Cancer. J Thorac Oncol 2018; 13:e174-e177. [PMID: 30166017 DOI: 10.1016/j.jtho.2018.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Bo Jin
- Department of Medical Oncology, The First Hospital, China Medical University, Shenyang, People's Republic of China.
| | - Xin Chuang
- Department of Medical Oncology, The First Hospital, China Medical University, Shenyang, People's Republic of China
| | - Yunpeng Liu
- Department of Medical Oncology, The First Hospital, China Medical University, Shenyang, People's Republic of China
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14
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Suzman DL, Pelosof L, Rosenberg A, Avigan MI. Hepatotoxicity of immune checkpoint inhibitors: An evolving picture of risk associated with a vital class of immunotherapy agents. Liver Int 2018; 38:976-987. [PMID: 29603856 DOI: 10.1111/liv.13746] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/21/2018] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICIs) block CTLA-4, PD-1 and PD-L1, or other molecules that control antitumour activities of lymphocytes. These products are associated with a broad array of immune-related toxicities affecting a variety of organs, including the liver. ICI-associated immune-mediated hepatitis (IMH) ranges in severity between mild and life-threatening and is marked by findings that bear both similarities as well as differences with idiopathic autoimmune hepatitis. Hepatotoxic events are often detected in clinical trials of ICIs that are powered for efficacy. Risk levels for ICI-induced liver injury may be impacted by the specific checkpoint molecule targeted for treatment, the ICI dose levels, and the presence of a pre-existing autoimmune diathesis, chronic infection or tumour cells which infiltrate the liver parenchyma. When patients develop liver injury during ICI treatment, a prompt assessment of the cause of injury, in conjunction with the application of measures to optimally manage the adverse event, should be made. Strategies to manage the risk of IMH include the performance of pretreatment liver tests with regular monitoring during and after ICI treatment and patient education. Using Common Terminology Criteria for Adverse Events developed at the National Cancer Institute to measure the severity level of liver injury, recommended actions may include continued ICI treatment with close patient monitoring, ICI treatment suspension or discontinuation and/or administration of corticosteroids or, when necessary, a non-steroidal immunosuppressive agent. The elucidation of reliable predictors of tumour-specific ICI treatment responses, as well as an increased susceptibility for clinically serious immune-related adverse events, would help optimize treatment decisions for individual patients.
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Affiliation(s)
- Daniel L Suzman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Lorraine Pelosof
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Amy Rosenberg
- Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mark I Avigan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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15
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Hellmann MD, Callahan MK, Awad MM, Calvo E, Ascierto PA, Atmaca A, Rizvi NA, Hirsch FR, Selvaggi G, Szustakowski JD, Sasson A, Golhar R, Vitazka P, Chang H, Geese WJ, Antonia SJ. Tumor Mutational Burden and Efficacy of Nivolumab Monotherapy and in Combination with Ipilimumab in Small-Cell Lung Cancer. Cancer Cell 2018; 33:853-861.e4. [PMID: 29731394 PMCID: PMC6750707 DOI: 10.1016/j.ccell.2018.04.001] [Citation(s) in RCA: 600] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/12/2018] [Accepted: 04/02/2018] [Indexed: 12/13/2022]
Abstract
Durable responses and encouraging survival have been demonstrated with immune checkpoint inhibitors in small-cell lung cancer (SCLC), but predictive markers are unknown. We used whole exome sequencing to evaluate the impact of tumor mutational burden on efficacy of nivolumab monotherapy or combined with ipilimumab in patients with SCLC from the nonrandomized or randomized cohorts of CheckMate 032. Patients received nivolumab (3 mg/kg every 2 weeks) or nivolumab plus ipilimumab (1 mg/kg plus 3 mg/kg every 3 weeks for four cycles, followed by nivolumab 3 mg/kg every 2 weeks). Efficacy of nivolumab ± ipilimumab was enhanced in patients with high tumor mutational burden. Nivolumab plus ipilimumab appeared to provide a greater clinical benefit than nivolumab monotherapy in the high tumor mutational burden tertile.
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Affiliation(s)
- Matthew D Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, and Parker Center for Cancer Immunotherapy, 885 2nd Avenue, New York, NY 10017, USA.
| | - Margaret K Callahan
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, and Parker Center for Cancer Immunotherapy, 885 2nd Avenue, New York, NY 10017, USA
| | - Mark M Awad
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Emiliano Calvo
- START Madrid, Centro Integral Oncológico Clara Campal, Medical Oncology Division, Hospital Universitario Madrid Norte Sanchinarro, Madrid 28050, Spain
| | - Paolo A Ascierto
- Unit of Melanoma, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori Fondazione G. Pascale, Naples 80131, Italy
| | - Akin Atmaca
- Department of Hematology and Oncology, Krankenhaus Nordwest, UCT-University Cancer Center, Frankfurt am Main 60488, Germany
| | - Naiyer A Rizvi
- Division of Hematology and Oncology, Columbia University Medical Center, New York, NY 10032, USA
| | - Fred R Hirsch
- Department of Medicine, Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Giovanni Selvaggi
- Clinical Development, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | | | - Ariella Sasson
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | - Ryan Golhar
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | - Patrik Vitazka
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | - Han Chang
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | - William J Geese
- Translational Medicine, Bristol-Myers Squibb, Princeton, NJ 08648, USA
| | - Scott J Antonia
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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16
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Karachaliou N, Rosell R. Science and biology drives the immune system to cure lung cancer patients: a revolution but not without challenges. Ther Adv Med Oncol 2018; 10:1758835918763723. [PMID: 29619092 PMCID: PMC5871042 DOI: 10.1177/1758835918763723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/15/2018] [Indexed: 12/26/2022] Open
Affiliation(s)
- Niki Karachaliou
- Instituto Oncológico Dr Rosell (IOR), University Hospital Sagrat Cor, QuirónSalud Group, Viladomat 288, 08029 Barcelona, Spain
| | - Rafael Rosell
- Instituto Oncológico Dr Rosell (IOR), Quirón-Dexeus University Institute, Barcelona, Spain; Institut d'Investigació en Ciències Germans Trias i Pujol, Badalona, Spain; Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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17
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Seeber A, Leitner C, Philipp-Abbrederis K, Spizzo G, Kocher F. What's new in small cell lung cancer – extensive disease? An overview on advances of systemic treatment in 2016. Future Oncol 2017; 13:1427-1435. [DOI: 10.2217/fon-2017-0046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Systemic therapy options for small cell lung cancer patients with extensive disease remain poor. After an initial response on first-line therapy, virtually all patients develop disease progression. For those who showed an initial response only few therapy options with low response rates are currently available. Until now, many experimental and targeted agents have failed to yield convincing clinical benefits, and new therapy options are clearly warranted for these patients. In this year's oncological congresses, several new therapy strategies, including checkpoint inhibition, showed promising results in ongoing trials. Furthermore, a potential benefit of new agents targeting DLL3, Aurora A kinase and PARP-inhibitor was reported. In this review we summarize new developments and critically highlight the most important and promising data in the relapsed small cell lung cancer disease.
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Affiliation(s)
- Andreas Seeber
- Department for Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Leitner
- Department for Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | | | - Gilbert Spizzo
- Department for Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Florian Kocher
- Department for Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
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