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Benzekry S, Schlicke P, Mogenet A, Greillier L, Tomasini P, Simon E. Computational markers for personalized prediction of outcomes in non-small cell lung cancer patients with brain metastases. Clin Exp Metastasis 2024; 41:55-68. [PMID: 38117432 DOI: 10.1007/s10585-023-10245-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023]
Abstract
Intracranial progression after curative treatment of early-stage non-small cell lung cancer (NSCLC) occurs from 10 to 50% and is difficult to manage, given the heterogeneity of clinical presentations and the variability of treatments available. The objective of this study was to develop a mechanistic model of intracranial progression to predict survival following a first brain metastasis (BM) event occurring at a time [Formula: see text]. Data included early-stage NSCLC patients treated with a curative intent who had a BM as the first and single relapse site (N = 31). We propose a mechanistic mathematical model able to derive computational markers from primary tumor and BM data at [Formula: see text] and estimate the amount and sizes of (visible and invisible) BMs, as well as their future behavior. These two key computational markers are [Formula: see text], the proliferation rate of a single tumor cell; and [Formula: see text], the per day, per cell, probability to metastasize. The predictive value of these individual computational biomarkers was evaluated. The model was able to correctly describe the number and size of metastases at [Formula: see text] for 20 patients. Parameters [Formula: see text] and [Formula: see text] were significantly associated with overall survival (OS) (HR 1.65 (1.07-2.53) p = 0.0029 and HR 1.95 (1.31-2.91) p = 0.0109, respectively). Adding the computational markers to the clinical ones significantly improved the predictive value of OS (c-index increased from 0.585 (95% CI 0.569-0.602) to 0.713 (95% CI 0.700-0.726), p < 0.0001). We demonstrated that our model was applicable to brain oligoprogressive patients in NSCLC and that the resulting computational markers had predictive potential. This may help lung cancer physicians to guide and personalize the management of NSCLC patients with intracranial oligoprogression.
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Affiliation(s)
- Sébastien Benzekry
- COMPutational Pharmacology and Clinical Oncology Department, Inria Sophia Antipolis - Méditerranée, Faculté de Pharmacie, Cancer Research Center of Marseille, Inserm UMR1068, CNRS UMR7258, Aix Marseille University UM105, 27 Boulevard Jean Moulin, 13005, Marseille, France.
| | - Pirmin Schlicke
- Department of Mathematics, TUM School of Computation, Information and Technology, Technical University of Munich, Garching (Munich), Germany
| | - Alice Mogenet
- Multidisciplinary Oncology and Therapeutic Innovations Department, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
| | - Laurent Greillier
- Multidisciplinary Oncology and Therapeutic Innovations Department, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
- Aix Marseille University, CNRS, INSERM, CRCM, Marseille, France
| | - Pascale Tomasini
- Multidisciplinary Oncology and Therapeutic Innovations Department, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
- Aix Marseille University, CNRS, INSERM, CRCM, Marseille, France
| | - Eléonore Simon
- Multidisciplinary Oncology and Therapeutic Innovations Department, Assistance Publique - Hôpitaux de Marseille, Aix Marseille University, Marseille, France
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Zhang C, Zhou W, Zhang D, Ma S, Wang X, Jia W, Guan X, Qian K. Treatments for brain metastases from EGFR/ALK-negative/unselected NSCLC: A network meta-analysis. Open Med (Wars) 2023; 18:20220574. [PMID: 36820064 PMCID: PMC9938645 DOI: 10.1515/med-2022-0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 02/16/2023] Open
Abstract
More clinical evidence is needed regarding the relative priority of treatments for brain metastases (BMs) from EGFR/ALK-negative/unselected non-small cell lung cancer (NSCLC). PubMed, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov databases were searched. Overall survival (OS), central nervous system progression-free survival (CNS-PFS), and objective response rate (ORR) were selected for Bayesian network meta-analyses. We included 25 eligible randomized control trials (RCTs) involving 3,054 patients, investigating nine kinds of treatments for newly diagnosed BMs and seven kinds of treatments for previously treated BMs. For newly diagnosed BMs, adding chemotherapy, EGFR-TKIs, and other innovative systemic agents (temozolomide, nitroglycerin, endostar, enzastaurin, and veliparib) to radiotherapy did not significantly prolong OS than radiotherapy alone; whereas radiotherapy + nitroglycerin showed significantly better CNS-PFS and ORR. Surgery could significantly prolong OS (hazard ratios [HR]: 0.52, 95% credible intervals: 0.41-0.67) and CNS-PFS (HR: 0.32, 95% confidence interval: 0.18-0.59) compared with radiotherapy alone. For previously treated BMs, pembrolizumab + chemotherapy, nivolumab + ipilimumab, and cemiplimab significantly prolonged OS than chemotherapy alone. Pembrolizumab + chemotherapy also showed better CNS-PFS and ORR than chemotherapy. In summary, immune checkpoint inhibitor (ICI)-based therapies, especially ICI-combined therapies, showed promising efficacies for previously treated BMs from EGFR/ALK-negative/unselected NSCLC. The value of surgery should also be emphasized. The result should be further confirmed by RCTs.
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Affiliation(s)
- Chengkai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Wenjianlong Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Dainan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Shunchang Ma
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing100071, China
| | - Xi Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing100071, China,Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing100071, China
| | - Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 West Road, Beijing100071, China
| | - Ke Qian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 West Road, Beijing100071, China
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The role of immune checkpoint inhibitors in patients with intracranial metastatic disease. J Neurooncol 2023; 161:469-478. [PMID: 36790654 DOI: 10.1007/s11060-023-04263-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Intracranial metastatic disease (IMD) complicates the course of nearly 2-4% of patients with systemic cancer. The prevalence of IMD has been increasing over the past few decades. Historically, definitive treatment for brain metastases (BM) has been limited to radiation therapy or surgical resection. Chemotherapies have not typically proven valuable in the treatment of IMD, with the exception of highly chemotherapy-sensitive lesions. Recent data have supported a role for systemic targeted therapies and immune checkpoint inhibitors (ICIs) in the treatment of select patients with IMD. There remains, however, a clear clinical need for further investigation to delineate the role of ICIs in patients with BM. In this review, we outline and describe recent and current efforts to identify the efficacy of ICI therapy in patients with IMD.
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Feng HM, Zhao Y, Yan WJ, Li B. Genomic and immunogenomic analysis of three prognostic signature genes in LUAD. BMC Bioinformatics 2023; 24:19. [PMID: 36650426 PMCID: PMC9843910 DOI: 10.1186/s12859-023-05137-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Searching for immunotherapy-related markers is an important research content to screen for target populations suitable for immunotherapy. Prognosis-related genes in early stage lung cancer may also affect the tumor immune microenvironment, which in turn affects immunotherapy. RESULTS We analyzed the differential genes affecting lung cancer patients receiving immunotherapy through the Cancer Treatment Response gene signature DataBase (CTR-DB), and set a threshold to obtain a total of 176 differential genes between response and non-response to immunotherapy. Functional enrichment analysis found that these differential genes were mainly involved in immune regulation-related pathways. The early-stage lung adenocarcinoma (LUAD) prognostic model was constructed through the cancer genome atlas (TCGA) database, and three target genes (MMP12, NFE2, HOXC8) were screened to calculate the risk score of early-stage LUAD. The receiver operating characteristic (ROC) curve indicated that the model had good prognostic value, and the validation set (GSE50081, GSE11969 and GSE42127) from the gene expression omnibus (GEO) analysis indicated that the model had good stability, and the risk score was correlated with immune infiltrations to varying degrees. Multi-type survival analysis and immune infiltration analysis revealed that the transcriptome, methylation and the copy number variation (CNV) levels of the three genes were correlated with patient prognosis and some tumor microenvironment (TME) components. Drug sensitivity analysis found that the three genes may affect some anti-tumor drugs. The mRNA expression of immune checkpoint-related genes showed significant differences between the high and low group of the three genes, and there may be a mutual regulatory network between immune checkpoint-related genes and target genes. Tumor immune dysfunction and exclusion (TIDE) analysis found that three genes were associated with immunotherapy response and maybe the potential predictors to immunotherapy, consistent with the CTR-DB database analysis. CONCLUSIONS From the perspective of data mining, this study suggests that MMP12, NFE2, and HOXC8 may be involved in tumor immune regulation and affect immunotherapy. They are expected to become markers of immunotherapy and are worthy of further experimental research.
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Affiliation(s)
- Hai-Ming Feng
- grid.411294.b0000 0004 1798 9345Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University Second Clinical Medical College, 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu People’s Republic of China
| | - Ye Zhao
- grid.411634.50000 0004 0632 4559Department of Radiotherapy, Gansu Provincial People’s Hospital, Lanzhou City, 730030 China
| | - Wei-Jian Yan
- grid.411294.b0000 0004 1798 9345Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University Second Clinical Medical College, 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu People’s Republic of China
| | - Bin Li
- grid.411294.b0000 0004 1798 9345Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou University Second Clinical Medical College, 82 Cuiyingmen, Chengguan District, Lanzhou, 730030 Gansu People’s Republic of China
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Efficacy and safety of immune checkpoint inhibitors plus anlotinib in small cell lung cancer with brain metastases: a retrospective, multicentre study. J Neurooncol 2022; 160:631-642. [DOI: 10.1007/s11060-022-04182-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/22/2022] [Indexed: 11/11/2022]
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Zhou S, Ren F, Meng X. Efficacy of immune checkpoint inhibitor therapy in EGFR mutation-positive patients with NSCLC and brain metastases who have failed EGFR-TKI therapy. Front Immunol 2022; 13:955944. [PMID: 36238280 PMCID: PMC9552846 DOI: 10.3389/fimmu.2022.955944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Few treatment options are available for brain metastases (BMs) in EGFR-mutant non-small cell lung cancer (NSCLC) that progress with prior EGFR tyrosine kinase inhibitor (EGFR-TKI) therapy. This study aimed to evaluate the efficacy of immune checkpoint inhibitor (ICI) therapy in these patients. Methods NSCLC patients with confirmed sensitive EGFR mutations and BMs were retrospectively reviewed. All patients experienced failure of EGFR-TKI therapy and were divided into two cohorts based on subsequent treatment. Cohort 1 included patients who received ICI therapy, while cohort 2 included patients treated with chemotherapy. Overall and intracranial objective response rates (ORRs) were used to evaluate the treatment response. Overall and intacranial progression-free survival (PFS) were calculated by Kaplan−Meier analysis and compared with the log-rank test. Univariate and multivariate Cox analyses were used to identify prognostic factors. Results A total of 53 patients treated with ICI therapy and 40 patients treated with chemotherapy were included in cohorts 1 and 2, respectively. In cohort 1, the overall ORR was 20.8%, with a median overall PFS of 4.2 months. The median intracranial PFS was 5.1 months. Of the 38 patients with measurable intracranial lesions, the intracranial ORR was 21.0%. Patients who received ICI combined with chemotherapy had the highest intracranial ORR of 37.5%. Compared to patients treated with chemotherapy in cohort 2, patients receiving ICI combined with chemotherapy had both longer intracranial PFS (6.4 vs. 5.1 months, p = 0.110) and overall PFS (6.2 vs. 4.6 months, p = 0.054), and these differences approached statistical significance. Univariate and multivariate Cox analyses demonstrated that high disease burden (p = 0.019), prior third-generation EGFR-TKI therapy (p = 0.019), and a poor lung immune prognostic index (LIPI) (p = 0.012) were independent negative predicators of overall PFS and that multiple BMs were negatively correlated with intracranial PFS among patients treated with ICI therapy. Conclusions Our results suggested that ICI combined with chemotherapy had potent intracranial efficacy and may be a promising treatment candidate in EGFR-mutant NSCLC patients with BMs for whom prior EGFR-TKI therapy failed.
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Affiliation(s)
- Shujie Zhou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Fei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Xiangjiao Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
- *Correspondence: Xiangjiao Meng,
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Xu L, Zou C, Zhang S, Chu TSM, Zhang Y, Chen W, Zhao C, Yang L, Xu Z, Dong S, Yu H, Li B, Guan X, Hou Y, Kong FM. Reshaping the systemic tumor immune environment (STIE) and tumor immune microenvironment (TIME) to enhance immunotherapy efficacy in solid tumors. J Hematol Oncol 2022; 15:87. [PMID: 35799264 PMCID: PMC9264569 DOI: 10.1186/s13045-022-01307-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
The development of combination immunotherapy based on the mediation of regulatory mechanisms of the tumor immune microenvironment (TIME) is promising. However, a deep understanding of tumor immunology must involve the systemic tumor immune environment (STIE) which was merely illustrated previously. Here, we aim to review recent advances in single-cell transcriptomics and spatial transcriptomics for the studies of STIE, TIME, and their interactions, which may reveal heterogeneity in immunotherapy responses as well as the dynamic changes essential for the treatment effect. We review the evidence from preclinical and clinical studies related to TIME, STIE, and their significance on overall survival, through different immunomodulatory pathways, such as metabolic and neuro-immunological pathways. We also evaluate the significance of the STIE, TIME, and their interactions as well as changes after local radiotherapy and systemic immunotherapy or combined immunotherapy. We focus our review on the evidence of lung cancer, hepatocellular carcinoma, and nasopharyngeal carcinoma, aiming to reshape STIE and TIME to enhance immunotherapy efficacy.
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Affiliation(s)
- Liangliang Xu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China
| | - Chang Zou
- Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, 518020, China.,Shenzhen Public Service Platform on Tumor Precision Medicine and Molecular Diagnosis, Shenzhen, Guangdong, 518020, China.,Key Laboratory of Medical Electrophysiology of Education Ministry, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, 646100, China
| | - Shanshan Zhang
- Department of Chemical Biology, School of Life and Marine Sciences, Shenzhen University, Shenzhen, Guangdong, 518000, China
| | - Timothy Shun Man Chu
- Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Yan Zhang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China
| | - Weiwei Chen
- Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Caining Zhao
- Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Li Yang
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China
| | - Zhiyuan Xu
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China
| | - Shaowei Dong
- Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, 518020, China
| | - Hao Yu
- Chinese Academy of Sciences Shenzhen Institutes of Advanced Technology, Shenzhen, Guangdong, 518055, China
| | - Bo Li
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, Scientific Research Center, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, 518107, China
| | - Xinyuan Guan
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China. .,Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China. .,Advanced Energy Science and Technology Guangdong Laboratory, Huizhou, Guangdong, 528200, China.
| | - Yuzhu Hou
- Department of Pathogenic Microbiology and Immunology, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, China.
| | - Feng-Ming Kong
- Department of Clinical Oncology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, 518053, China. .,Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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Li J, Wang M, Xu S, Li Y, Li J, Yu J, Zhu H. The Strategies and Mechanisms of Immune Checkpoint Inhibitors for Brain Metastases in NSCLC. Front Pharmacol 2022; 13:841623. [PMID: 35656295 PMCID: PMC9152109 DOI: 10.3389/fphar.2022.841623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/08/2022] [Indexed: 11/26/2022] Open
Abstract
Brain metastases are more and more common among patients with non-small cell lung cancer (NSCLC). TKI therapy could provide ideal outcomes for patients harboring epidermal growth factor receptor or ALK mutations. For wild-type patients, however, survival is poor because there are few effective treatments other than radiotherapy. Immune checkpoint inhibitors (ICIs) have changed the management of advanced NSCLC. However, the exclusion of patients with active brain metastasis (BM) from most ICI trials precludes the generalization of results. Accordingly, a variety of appropriate real-world studies and clinical trials are being developed to evaluate tumor response. Increasingly encouraging results have suggested that ICIs could be active in the central nervous system (CNS) in select patients with high PD-L1 expression and low CNS disease burden. With the extensive use of ICIs in NSCLC patients with BM, many important questions have emerged concerning issues such as the clinical response to a single ICI, use of ICIs combined with chemotherapy or radiation, the biological mechanism and appropriate sequencing of local and systemic therapy combinations, and safety and toxicity. The present review summarizes the advances in systemic ICIs for the treatment of NSCLC patients with BM, discusses factors associated with efficacy and toxicity, and explores future directions.
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Affiliation(s)
- Ji Li
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Min Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Shuhui Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yuying Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jiatong Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinming Yu
- Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong University, Jinan, China
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Chu X, Niu L, Xiao G, Peng H, Deng F, Liu Z, Wu H, Yang L, Tan Z, Li Z, Zhou R. The Long-Term and Short-Term Efficacy of Immunotherapy in Non-Small Cell Lung Cancer Patients With Brain Metastases: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:875488. [PMID: 35693805 PMCID: PMC9175180 DOI: 10.3389/fimmu.2022.875488] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Background Although immunotherapy has been widely used, there is currently no research comparing immunotherapy for non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). This meta-analysis addresses a gap in the comparison of immunotherapy efficacy, including immune checkpoint inhibitors (ICIs), chemotherapy (CT), radiotherapy (RT), and ICI combined CT or RT. Methods A search of Pubmed, Cochrane, EMBASE, and ClinicalTrial.gov was conducted to identify studies which enrolled NSCLC patients with BM treated with ICIs. The outcomes consisted of intracerebral overall response rate (iORR), intracerebral disease control rate (iDCR), extracranial overall response rate (EORR), distant brain failure (DBF), local control (LC), progression-free survival (PFS), and overall survival (OS). Results A total of 3160 participants from 46 trials were included in the final analysis. Patients treated with immunotherapy were associated with a longer PFS (0.48, 95%CI: 0.41-0.56), and a longer OS (0.64, 95%CI: 0.60-0.69) compared with immunotherapy-naive patients. In prospective studies, dual ICI combined CT and ICI combined CT achieved a better OS. The hazard ratio (HR) of dual ICI combined CT versus dual ICI was 0.61, and the HR of ICI combined CT versus ICI monotherapy was 0.58. Moreover, no statistical difference in PFS, OS, EORR, iORR, iDCR, and EDCR was found between patients with ICI monotherapy and ICI combined cranial radiotherapy. Concurrent ICI combined RT was shown to decrease the rate of DBF (OR = 0.15, 95% CI: 0.03-0.73) compared with RT after ICI. Patients treated with WBRT might have an inferior efficacy than those with SRS because the iORR of SRS was 0.75 (0.70, 0.80) and WBRT was 0. Furthermore, no obvious difference in PFS and OS was observed among the three different types of ICI, which targets PD-1, PD-L1, and CTLA-4, respectively. Conclusions Patients treated with ICI got superior efficacy to those without ICI. Furthermore, dual ICI combined CT and ICI combined CT seemed to be optimal for NSCLC patients with BM. In terms of response and survival, concurrent administration of SRS and ICI led to better outcomes for patients with BMs than non-concurrent or non-SRS. Importance of the Study In the new era of immunotherapy, our meta-analysis validated the importance of immunotherapy for non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). By comparing the long-term and short-term impacts of various regimens, all immunotherapy treatments had superior efficacy to immunotherapy-naive. At the same time, through pairwise comparison in immunotherapy, our findings can help clinicians to make treatment decisions for NSCLC patients with BMs. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=269621, identifier CRD42021269621.
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Affiliation(s)
- Xianjing Chu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lishui Niu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Gang Xiao
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Haiqin Peng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Fuxing Deng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiyuan Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Honghua Wu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Lei Yang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhuguilong Tan
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhanzhan Li
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Rongrong Zhou, ; Zhanzhan Li,
| | - Rongrong Zhou
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Rongrong Zhou, ; Zhanzhan Li,
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10
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Sheng J, Li H, Yu X, Yu S, Chen K, Pan G, Xie M, Li N, Zhou Z, Fan Y. Efficacy of PD-1/PD-L1 inhibitors in patients with non-small cell lung cancer and brain metastases: A real-world retrospective study in China. Thorac Cancer 2021; 12:3019-3031. [PMID: 34596346 PMCID: PMC8590903 DOI: 10.1111/1759-7714.14171] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There is only limited knowledge of the treatment responses and clinical outcomes of immune checkpoint inhibitors (ICIs) in driver gene-negative non-small cell lung cancer (NSCLC) patients with brain metastases (BM). This study aims to assess the efficacy of immunotherapy in these patients in a real world setting. METHODS NSCLC-BM patients without driver gene mutations who received ICIs were retrospectively identified between July 2017 and December 2019. The primary observation endpoint was intracranial objective response rate (iORR), and secondary objectives were objective response rate (ORR), intracranial and systemic progression-free survival (iPFS, PFS), and overall survival (OS). RESULTS We reviewed 1578 patients with lung cancer and BM. According to the exclusion criteria, 41 patients were finally enrolled. Among these 41 patients, iORR was 36.6% (95% confidence interval [CI] = 21.2%-52.0%), whereas iPFS was 6.8 (95% CI = 3.32-10.35) months. Additionally, ORR, PFS, and OS were 24.4% (95% CI = 10.7%-38.1%), 6.2 (95% CI = 4.57-7.83) months and 13.7 (95% CI = 11.20-16.26) months, respectively. ICIs combined with concurrent radiotherapy group exhibited preferred iORR (p = 0.030) compared with no radiotherapy group, and ICIs plus chemotherapy showed improved OS (p = 0.024) compared to ICI monotherapy. Moreover, the lines of ICI treatment ≥2 (p = 0.005) and derived neutrophil-to-lymphocyte ratio (dNLR) ≥3 (p = 0.010) were independently negative factors for OS. CONCLUSION In NSCLC-BMs patients lacking driver genes, ICIs exhibited an effective drug regime. A combination of ICIs with concurrent radiotherapy showed a better intracranial response, whereas ICIs plus chemotherapy were associated with superior OS.
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Affiliation(s)
- Jiamin Sheng
- The First Clinical Medical College of Wenzhou Medical UniversityWenzhouChina
| | - Hui Li
- Department of Medical Oncology, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Xiaoqing Yu
- Department of Medical Oncology, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Sizhe Yu
- Department of Medical Oncology, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Kaiyan Chen
- Department of Medical Oncology, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
| | - Guoqiang Pan
- The First Clinical Medical College of Wenzhou Medical UniversityWenzhouChina
| | - Mingying Xie
- The Second Clinical Medical College of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Na Li
- The First Clinical Medical College of Wenzhou Medical UniversityWenzhouChina
| | - Zichao Zhou
- The Second Clinical Medical College of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Yun Fan
- Department of Medical Oncology, the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital)Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of SciencesHangzhouChina
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11
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Mansfield AS, Herbst RS, de Castro G, Hui R, Peled N, Kim DW, Novello S, Satouchi M, Wu YL, Garon EB, Reck M, Robinson AG, Samkari A, Piperdi B, Ebiana V, Lin J, Mok TS. Outcomes With Pembrolizumab Monotherapy in Patients With Programmed Death-Ligand 1-Positive NSCLC With Brain Metastases: Pooled Analysis of KEYNOTE-001, 010, 024, and 042. JTO Clin Res Rep 2021; 2:100205. [PMID: 34590048 PMCID: PMC8474394 DOI: 10.1016/j.jtocrr.2021.100205] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction We retrospectively evaluated outcomes in patients with programmed death-ligand 1 (PD-L1)–positive non–small-cell lung cancer (NSCLC) to determine whether baseline (i.e., at study enrollment) brain metastases were associated with the efficacy of pembrolizumab versus chemotherapy. Methods We pooled data for patients with previously treated or untreated PD-L1‒positive (tumor proportion score [TPS], ≥1%) advanced or metastatic NSCLC in KEYNOTE-001 (NCT01295827), KEYNOTE-010 (NCT01905657), KEYNOTE-024 (NCT02142738), and KEYNOTE-042 (NCT02220894). Patients received pembrolizumab (2 mg/kg, 10 mg/kg, or 200 mg every 3 wk or 10 mg/kg every 2 wk); chemotherapy was a comparator in all studies except KEYNOTE-001. All studies included patients with previously treated, stable brain metastases. Results A total of 3170 patients were included, 293 (9.2%) with and 2877 (90.8%) without baseline brain metastases; median (range) follow-up at data cutoff was 12.9 (0.1‒43.7) months. Pembrolizumab improved overall survival versus chemotherapy in patients with or without baseline brain metastases: benefit was seen in patients with PD-L1 TPS ≥50% (0.67 [95% confidence intervals (CI): 0.44‒1.02] and 0.66 [95% CI: 0.58‒0.76], respectively) and PD-L1 TPS ≥1% (0.83 [95% CI: 0.62‒1.10] and 0.78 [95% CI: 0.71‒0.85], respectively). Progression-free survival was improved, objective response rates were higher, and duration of response was longer with pembrolizumab versus chemotherapy regardless of brain metastasis status. The incidence of treatment-related adverse events with pembrolizumab versus chemotherapy was 66.3% versus 84.4% in patients with brain metastases and 67.2% versus 88.3% in those without. Conclusions Pembrolizumab monotherapy improved outcomes and was associated with fewer adverse events than chemotherapy in patients with treatment-naive and previously treated PD-L1‒positive advanced/metastatic NSCLC regardless of the presence of baseline treated, stable brain metastases.
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Affiliation(s)
- Aaron S. Mansfield
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
- Corresponding author. Address for correspondence: Aaron S. Mansfield, MD, Division of Medical Oncology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905.
| | - Roy S. Herbst
- Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | | | - Rina Hui
- Westmead Hospital and the University of Sydney, Sydney, Australia
| | - Nir Peled
- Soroka Cancer Center, Ben Gurion University, Beer Sheva, Israel
| | - Dong-Wan Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Silvia Novello
- Azienda Ospedaliero-Universitaria San Luigi Gonzaga, University of Turin, Orbassano, Italy
| | | | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital and Guangdong Academy of Medical Sciences, Guangdong, China
| | - Edward B. Garon
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - Martin Reck
- Lung Clinic Grosshansdorf, Airway Research Center North, German Center of Lung Research, Grosshansdorf, Germany
| | - Andrew G. Robinson
- Cancer Centre of Southeastern Ontario at Kingston General Hospital, Kingston, Ontario, Canada
| | | | | | | | | | - Tony S.K. Mok
- State Key Laboratory of Translational Oncology, Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
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12
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Pathak R, Amini A, Hill A, Massarelli E, Salgia R. Immunotherapy in Non-Small Cell Lung Cancer Patients with Brain Metastases: Clinical Challenges and Future Directions. Cancers (Basel) 2021; 13:3407. [PMID: 34298620 PMCID: PMC8303291 DOI: 10.3390/cancers13143407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
Immune checkpoint inhibitors have revolutionized the treatment landscape for patients with non-small cell lung cancers. Existing treatment paradigms for brain metastases in lung cancer patients leave patients with adverse neurocognitive function, poor quality of life, and dismal prognosis, thus highlighting the need to develop more effective systemic therapies. Although data are limited, emerging knowledge suggests promising activity and safety of immune checkpoint inhibitors in brain metastases in non-small cell lung cancer patients. This review aims to summarize the current data, highlight the challenges of incorporating immune checkpoint inhibitors in treating these patients, and identify areas for future research.
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Affiliation(s)
- Ranjan Pathak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (A.H.); (E.M.); (R.S.)
| | - Arya Amini
- Department of Radiation Oncology, City of Hope, Duarte, CA 91010, USA;
| | - Addie Hill
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (A.H.); (E.M.); (R.S.)
| | - Erminia Massarelli
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (A.H.); (E.M.); (R.S.)
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (A.H.); (E.M.); (R.S.)
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13
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Xiao G, Liu Z, Gao X, Wang H, Peng H, Li J, Yang L, Duan H, Zhou R. Immune checkpoint inhibitors for brain metastases in non-small-cell lung cancer: from rationale to clinical application. Immunotherapy 2021; 13:1031-1051. [PMID: 34231370 DOI: 10.2217/imt-2020-0262] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Brain metastases (BM) is common in non-small-cell lung cancer (NSCLC) patients. Immune checkpoint inhibitors (ICIs) have gradually become a routine treatment for NSCLC BM patients. Currently, three PD-1 inhibitors (pembrolizumab, nivolumab and cemiplimab), one PD-L1 inhibitor (atezolizumab) and one CTLA-4 inhibitor (ipilimumab) have been approved for the first-line treatment of metastatic NSCLC. It is still controversial whether PD-L1, tumor infiltrating lymphocytes, and tumor mutation burden can be used as predictive biomarkers for immune checkpoint inhibitors in NSCLC patients with BM. In addition, clinical data on NSCLC BM were inadequate. Here, we review the theoretical basis and clinical data for the application of ICIs in the therapy of NSCLC BM.
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Affiliation(s)
- Gang Xiao
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zhiyuan Liu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Xuan Gao
- Geneplus-Beijing, Beijing, 102205, China
| | - Han Wang
- Geneplus-Beijing, Beijing, 102205, China
| | - Haiqin Peng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Jiahui Li
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Lei Yang
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Hexin Duan
- Department of Oncology Xiangxi Autonomous Prefecture People's Hospital, Jishou, 416000, China
| | - Rongrong Zhou
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, 410008, China.,Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, 410008, China
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14
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Sudmeier L, Tian S, Higgins KA. Multidisciplinary Management of Brain Metastases from Non-Small Cell Lung Cancer in the Era of Immunotherapy. Curr Treat Options Oncol 2021; 22:77. [PMID: 34213649 DOI: 10.1007/s11864-021-00871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Brain metastases from non-small cell lung cancer often cause neurologic symptoms which lead to initial diagnosis or identification of recurrence. In other patients, they are identified on surveillance imaging or when a patient undergoing treatment develops neurological symptoms. Patients with symptomatic lesions should be started on dexamethasone and evaluated by a neurosurgeon as soon as possible. If feasible, surgery should be offered to decrease intracranial pressure, alleviate symptoms, and prevent irreversible neurological damage. Postoperative stereotactic radiosurgery (SRS) to the resection cavity and any additional brain metastases should follow within 4 weeks of surgery, as early as 2 weeks post-op. Tissue from surgery is used to confirm the diagnosis and test for targetable oncogenic driver mutations. Treatment response and surveillance for development of additional lesions is assessed with MRI of the brain 1 month after SRS and every 3 months thereafter. Patients who are not surgical candidates or who have small, asymptomatic brain metastases should proceed with SRS, the preferred treatment, or sometimes whole-brain radiation therapy (WBRT) if multifocal disease requires more extensive treatment, such as for leptomeningeal spread of disease. The number of brain metastases that warrants use of WBRT over SRS is controversial and a topic of ongoing investigation, and is discussed in this review. When possible, SRS is preferred over WBRT due to reduce morbidity and cognitive side effects. When patients are already on systemic therapy at time of brain metastases diagnosis, systemic therapy should continue, with radiation therapy occurring between cycles. Regarding systemic therapy for new diagnosis at time of brain metastases presentation, molecular testing will guide treatment choice, when available. If there is no neurosurgical intervention, biopsy of another site of disease may provide tissue for molecular testing. If there are no targetable oncogenic driver mutations, concurrent immune checkpoint blockade (ICB) and chemotherapy is preferable for patients who can tolerate it. Single-agent ICB is an alternative option for patients who cannot tolerate chemotherapy. Systemic therapy should start as soon as possible. In some patients with poor performance status, best supportive care may be the most appropriate choice. Treatment decisions should always incorporate patients' goals of care and in many cases should be discussed in a multidisciplinary setting.
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Affiliation(s)
- Lisa Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Road, Atlanta, GA, 30322, USA.
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15
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Li S, Zhang H, Liu T, Chen J, Dang J. The Effect of Asymptomatic and/or Treated Brain Metastases on Efficacy of Immune Checkpoint Inhibitors in Metastatic Non-Small Cell Lung Cancer: A Meta-Analysis. Front Oncol 2021; 11:702924. [PMID: 34249764 PMCID: PMC8267413 DOI: 10.3389/fonc.2021.702924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/08/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND To assess the effect of asymptomatic and/or treated brain metastases (BMs) on the efficacy of immune checkpoint inhibitors (ICIs) in metastatic non-small cell lung cancer (NSCLC). PATIENTS AND METHODS PubMed, Embase, Cochrane Library, Web of Science, and recent meetings were searched for randomized controlled trials (RCTs). The primary outcomes of interest were overall survival (OS) and progression-free survival (PFS). RESULTS Seventeen articles reporting 15 RCTs with 10,358 patients (1,199 with and 9,159 without BMs) were eligible. ICIs were associated with longer OS and PFS than those in chemotherapy either in patients with (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.51-0.82 and HR, 0.60; 95% CI, 0.45-0.79) or without BMs (HR, 0.74; 95% CI, 0.70-0.78 and HR, 0.70; 95% CI, 0.57-0.86); no significant difference in the pooled HRs for OS (Pinteraction = 0.29) and PFS (Pinteraction = 0.37) was observed between the two patient populations. Subgroup analyses revealed that either ICI monotherapy or combination therapy significantly improved OS and PFS compared with those in chemotherapy both for patients with and without BMs. Superior OS benefit from ICI combination therapy than that in monotherapy was observed in patients with BMs (HR, 0.49 vs. 0.81, Pinteraction = 0.005) but not in patients without BMs (HR, 0.71 vs. 0.76, Pinteraction = 0.27). CONCLUSION There was no compelling statistical evidence that the efficacy of ICIs in metastatic NSCLC was modified by the presence of asymptomatic and/or treated BMs. Patients with BMs were likely to obtain more OS benefit from ICI combination therapy than that from monotherapy.
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Affiliation(s)
- Sihan Li
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hongwei Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Tingting Liu
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Chest Hospital, Shenyang, China
| | - Jun Dang
- Department of Radiation Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
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16
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Fares J, Ulasov I, Timashev P, Lesniak MS. Emerging principles of brain immunology and immune checkpoint blockade in brain metastases. Brain 2021; 144:1046-1066. [PMID: 33893488 PMCID: PMC8105040 DOI: 10.1093/brain/awab012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022] Open
Abstract
Brain metastases are the most common type of brain tumours, harbouring an immune microenvironment that can in principle be targeted via immunotherapy. Elucidating some of the immunological intricacies of brain metastases has opened a therapeutic window to explore the potential of immune checkpoint inhibitors in this globally lethal disease. Multiple lines of evidence suggest that tumour cells hijack the immune regulatory mechanisms in the brain for the benefit of their own survival and progression. Nonetheless, the role of the immune checkpoint in the complex interplays between cancers cells and T cells and in conferring resistance to therapy remains under investigation. Meanwhile, early phase trials with immune checkpoint inhibitors have reported clinical benefit in patients with brain metastases from melanoma and non-small cell lung cancer. In this review, we explore the workings of the immune system in the brain, the immunology of brain metastases, and the current status of immune checkpoint inhibitors in the treatment of brain metastases.
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Affiliation(s)
- Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ilya Ulasov
- Group of Experimental Biotherapy and Diagnostics, Institute for Regenerative Medicine, World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Peter Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, Moscow 119991, Russia
| | - Maciej S Lesniak
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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17
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Zhou S, Xie J, Huang Z, Deng L, Wu L, Yu J, Meng X. Anti-PD-(L)1 immunotherapy for brain metastases in non-small cell lung cancer: Mechanisms, advances, and challenges. Cancer Lett 2021; 502:166-179. [PMID: 33450361 DOI: 10.1016/j.canlet.2020.12.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/01/2020] [Accepted: 12/26/2020] [Indexed: 12/25/2022]
Abstract
The brain is one of the most common metastatic sites in non-small cell lung cancer (NSCLC), which is associated with an extremely poor prognosis. Despite the availability of several therapeutic options, the treatment efficacy remains unsatisfactory for NSCLC brain metastases. Anti-programmed cell death-1 (PD-1) and its ligand (PD-L1) monoclonal antibodies have reshaped therapeutic strategies in advanced NSCLC. Preliminary evidence has shown that anti-PD-(L)1 monotherapy is also effective in NSCLC patients with brain metastases. However, the traditional view asserted that these therapeutic antibodies were incapable of crossing the blood-brain barrier (BBB) with large molecular size, thus most patients with brain metastases were excluded from most studies on anti-PD-(L)1 immunotherapy. Therefore, the efficacy and its mechanisms of action of anti-PD-(L)1 immunotherapy against brain metastases in NSCLC have not been clarified. In this review, we will survey the underlying mechanisms and current clinical advances of anti-PD-(L)1 immunotherapy in the treatment of brain metastases in NSCLC. The trafficking of activated cytotoxic T cells that are mainly derived from the primary tumor and deep cervical lymph nodes is critical for the intracranial response to anti-PD-(L)1 immunotherapy, which is driven by interferon-γ (IFN-γ). Additionally, promising combined strategies with the rationale in the treatment of brain metastases will be presented to provide future directions for clinical study design. Several significant challenges in the preclinical and clinical studies of brain metastases, as well as potential solutions, will also be discussed.
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Affiliation(s)
- Shujie Zhou
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jingjing Xie
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Liufu Deng
- Shanghai Institute of Immunology; Department of Immunology and Microbiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Leilei Wu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jinming Yu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Xiangjiao Meng
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
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18
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Veccia A, Kinspergher S, Dipasquale M, Caffo O. Management of brain metastases from lung cancer in the era of immunotherapy: a review of the literature. Future Oncol 2021; 17:597-609. [PMID: 33401981 DOI: 10.2217/fon-2020-0701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The brain is one of the most frequent sites of metastases in lung cancer patients, whose prognosis is related to the histological, biomolecular and clinical features of the disease. Over the years, the survival has improved significantly with the introduction of immune checkpoint inhibitors (ICIs), but there are limited data concerning their efficacy in patients with brain metastases. The aim of this review is to describe the biological mechanisms supporting the use of immunotherapy for brain metastases and the outcomes experienced by lung cancer patients with brain involvement enrolled in Phase III registration trials of ICIs. We also review retrospective data on ICIs alone or combined with brain radiotherapy, and indicate future directions for preclinical and clinical research.
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Affiliation(s)
- Antonello Veccia
- Medical Oncology, Santa Chiara Hospital, Largo Medaglie d'Oro 1, 38122, Trento, Italy
| | - Stefania Kinspergher
- Medical Oncology, Santa Chiara Hospital, Largo Medaglie d'Oro 1, 38122, Trento, Italy
| | | | - Orazio Caffo
- Medical Oncology, Santa Chiara Hospital, Largo Medaglie d'Oro 1, 38122, Trento, Italy
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19
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Gal O, Dudnik E, Rotem O, Finkel I, Peretz I, Zer A, Mandel J, Amiel A, Siegal T, Bar J, Lobachov A, Yust S. Tyrosine Kinase Inhibitors as a Treatment of Symptomatic CNS Metastases in Oncogene-Driven NSCLC. JOURNAL OF ONCOLOGY 2020; 2020:1980891. [PMID: 32963526 PMCID: PMC7486631 DOI: 10.1155/2020/1980891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/12/2020] [Accepted: 08/25/2020] [Indexed: 12/25/2022]
Abstract
Central nervous system (CNS) metastases occur frequently in oncogene-driven non-small cell lung cancer (NSCLC). Standard treatment approaches can potentially delay systemic treatment (surgical intervention) or result in neurocognitive impairment (radiotherapy). Recently, next-generation tyrosine kinase inhibitors (TKIs) have demonstrated remarkable intracranial activity. However, most clinical trials did not enroll patients suffering neurological symptoms. Our study aimed to assess the CNS activity of targeted therapies in this patient population. We present a case series of nine NSCLC patients with either EGFR mutation or ALK rearrangement and symptomatic CNS metastases that were treated with TKIs. Clinicopathological characteristics, treatment, and outcomes were analyzed. Most patients presented with symptomatic CNS metastases at time of metastatic disease presentation (6/9). Additionally, the majority of patients had leptomeningeal disease (6/9) and multiple parenchymal metastases. Patients presented with a variety of CNS symptoms with the most common being nausea, vomiting, headache, and confusion. Most patients (6/9) responded rapidly both clinically and radiographically to the targeted treatment, with a marked correlation between systemic and intracranial radiographic response. In conclusion, upfront use of next-generation TKIs in patients with oncogene-driven NSCLC with symptomatic CNS metastases is associated with reasonable intracranial activity and represents a valuable treatment option.
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Affiliation(s)
- Omer Gal
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
| | - Elizabeth Dudnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Ofer Rotem
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Inbar Finkel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Idit Peretz
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Alona Zer
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Cancer Service, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Jacob Mandel
- Baylor College of Medicine, 7200 Cambridge Suite 9a, Houston, Texas 77030, USA
| | - Alexandra Amiel
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
| | - Tali Siegal
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Jair Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Oncology, Institute of Oncology, Sheba Medical Center, Tel HaShomer, Ramat Gan 5262000, Israel
| | - Anastasiya Lobachov
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Thoracic Oncology, Institute of Oncology, Sheba Medical Center, Tel HaShomer, Ramat Gan 5262000, Israel
| | - Shlomit Yust
- Neuro-Oncology Unit, Davidoff Cancer Center, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
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20
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Vilariño N, Bruna J, Bosch-Barrera J, Valiente M, Nadal E. Immunotherapy in NSCLC patients with brain metastases. Understanding brain tumor microenvironment and dissecting outcomes from immune checkpoint blockade in the clinic. Cancer Treat Rev 2020; 89:102067. [PMID: 32682248 DOI: 10.1016/j.ctrv.2020.102067] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/01/2020] [Accepted: 06/26/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Brain metastases are frequent complications in patients with non-small-cell lung cancer (NSCLC) associated with significant morbidity and poor prognosis. Our goal is to give a global overlook on clinical efficacy from immune checkpoint inhibitors in this setting and to review the role of biomarkers and molecular interactions in brain metastases from patients with NSCLC. METHODS We reviewed clinical trials reporting clinical outcomes of patients with NSCLC with brain metastases as well as publications assessing the tumor microenvironment and the complex molecular interactions of tumor cells with immune and resident cells in brain metastases from NSCLC biopsies or preclinical models. RESULTS Although limited data are available on immunotherapy in patients with brain metastases, immune checkpoint inhibitors alone or in combination with chemotherapy have shown promising intracranial efficacy and safety results. The underlying mechanism of action of immune checkpoint inhibitors in the brain niche and their influence on tumor microenvironment are still not known. Lower PD-L1 expression and less T CD8+ infiltration were found in brain metastases compared with matched NSCLC primary tumors, suggesting an immunosuppressive microenvironment in the brain. Reactive astrocytes and tumor associated macrophages are paramount in NSCLC brain metastases and play a role in promoting tumor progression and immune evasion. CONCLUSIONS Discordances in the immune profile between primary tumours and brain metastases underscore differences in the tumour microenvironment and immune system interactions within the lung and brain niche. The characterization of immune phenotype of brain metastases and dissecting the interplay among immune cells and resident stromal cells along with cancer cells is crucial to unravel effective immunotherapeutic approaches in patients with NSCLC and brain metastases.
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Affiliation(s)
- N Vilariño
- Department of Medical Oncology, Catalan Institute of Oncology, Hospital Duran i Reynals, Avinguda de la Gran Via de l'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research in Solid Tumors (CReST) Group, Molecular Mechanisms and Experimental Therapeutics in Cancer (Oncobell). IDIBELL, Avinguda de la Gran Via de l'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - J Bruna
- Neuro-Oncology Unit, Bellvitge University Hospital-ICO (IDIBELL), Avinguda de la Gran Via de l'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - J Bosch-Barrera
- Department of Medical Oncology, Catalan Institute of Oncology, Doctor Josep Trueta University Hospital, Avinguda França-Sant Ponç, 0, 17007 Girona, Spain.
| | - M Valiente
- Brain Metastases Group, Spanish National Cancer Research Centre (CNIO), Calle Melchor Fernández Almagro, 3, 28029 Madrid, Spain.
| | - E Nadal
- Department of Medical Oncology, Catalan Institute of Oncology, Hospital Duran i Reynals, Avinguda de la Gran Via de l'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research in Solid Tumors (CReST) Group, Molecular Mechanisms and Experimental Therapeutics in Cancer (Oncobell). IDIBELL, Avinguda de la Gran Via de l'Hospitalet, 199-203, L'Hospitalet de Llobregat, Barcelona, Spain.
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Henon C, Remon J, Hendriks LE. Combination treatments with immunotherapy in brain metastases patients. Future Oncol 2020; 16:1691-1705. [PMID: 32412817 DOI: 10.2217/fon-2020-0156] [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] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized the treatment of many advanced cancers. However, in most pivotal trials, patients with brain metastases (BM) were either excluded, or only selected patients were allowed. Therefore, there are still some concerns about the safety/efficacy ratio of ICI in patients with BM. In this special report we will provide an overview on the biological rationale for using ICI in the treatment of BM, the reported BM-related outcomes of clinical trials with a focus on ICI plus chemotherapy and ICI plus ICI combinations. Last, we will provide future challenges with this strategy, as well as directions for future research.
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Affiliation(s)
- Clemence Henon
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, Villejuif, France
| | - Jordi Remon
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal (HM CIOCC), Hospital HM Delfos, HM Hospitales, Barcelona, Spain
| | - Lizza El Hendriks
- Department of Pulmonary Diseases, GROW - School for Oncology & Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
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22
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Prelaj A, Ferrara R, Rebuzzi SE, Proto C, Signorelli D, Galli G, De Toma A, Randon G, Pagani F, Viscardi G, Brambilla M, Trevisan B, Ganzinelli M, Martinetti A, Gallucci R, Di Mauro RM, Molino G, Zilembo N, Torri V, de Braud FM, Garassino MC, Lo Russo G. EPSILoN: A Prognostic Score for Immunotherapy in Advanced Non-Small-Cell Lung Cancer: A Validation Cohort. Cancers (Basel) 2019; 11:E1954. [PMID: 31817541 PMCID: PMC6966664 DOI: 10.3390/cancers11121954] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Beyond programmed death ligand 1 (PD-L1), no other biomarkers for immunotherapy are used in daily practice. We previously created EPSILoN (Eastern Cooperative Oncology Group performance status (ECOG PS), smoking, liver metastases, lactate dehydrogenase (LDH), neutrophil-to-lymphocyte ratio (NLR)) score, a clinical/biochemical prognostic score, in 154 patients treated with second/further-line immunotherapy. This study's aim was to validate EPSILoN score in a different population group. METHODS 193 patients were included at National Cancer Institute of Milan (second-line immunotherapy, 61%; further-line immunotherapy, 39%). Clinical/laboratory parameters such as neutrophil-to-lymphocyte ratio and lactate dehydrogenase levels were collected. Kaplan-Meier and Cox hazard methods were used for survival analysis. RESULTS Overall median progression-free survival and median overall survival were 2.3 and 7.6 months, respectively. Multivariate analyses for Progression-Free Survival (PFS) identified heavy smokers (hazard ratio (HR) 0.71, p = 0.036) and baseline LDH < 400 mg/dL (HR 0.66, p = 0.026) as independent positive factors and liver metastases (HR 1.48, p = 0.04) and NLR ≥ 4 (HR 1.49, p = 0.029) as negative prognostic factors. These five factors were included in the EPSILoN score which was able to stratify patients in three different prognostic groups, high, intermediate and low, with PFS of 6.0, 3.8 and 1.9 months, respectively (HR 1.94, p < 0.001); high, intermediate and low prognostic groups had overall survival (OS) of 24.5, 8.9 and 3.4 months, respectively (HR 2.40, p < 0.001). CONCLUSIONS EPSILoN, combining five baseline clinical/blood parameters (ECOG PS, smoking, liver metastases, LDH, NLR), may help to identify advanced non-small-cell lung cancer (aNSCLC) patients who most likely benefit from immune checkpoint inhibitors (ICIs).
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Affiliation(s)
- Arsela Prelaj
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Roberto Ferrara
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Sara Elena Rebuzzi
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genova, Italy;
| | - Claudia Proto
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Diego Signorelli
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Giulia Galli
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Alessandro De Toma
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Giovanni Randon
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Filippo Pagani
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Giuseppe Viscardi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Marta Brambilla
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Benedetta Trevisan
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Monica Ganzinelli
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Antonia Martinetti
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Rosaria Gallucci
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Rosa Maria Di Mauro
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Giuliano Molino
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Nicoletta Zilembo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Valter Torri
- Pharmacological Research Institute IRCSS Mario Negri, Via La Masa 19, 20156 Milan, Italy;
| | - Filippo Maria de Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Marina Chiara Garassino
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
| | - Giuseppe Lo Russo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy; (R.F.); (C.P.); (D.S.); (G.G.); (A.D.T.); (G.R.); (F.P.); (G.V.); (M.B.); (B.T.); (M.G.); (A.M.); (R.G.); (R.M.D.M.); (G.M.); (N.Z.); (F.M.d.B.); (M.C.G.); (G.L.R.)
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