Unexpected favorable outcome to sintilimab plus bevacizumab in an EGFR-mutated non-small cell lung cancer patient: A case report

Efficacy and safety of anti-programmed cell death protein 1 antibody combination therapy in patients with advanced experienced epidermal growth factor receptor-tyrosine kinase inhibitor-resistant lung adenocarcinoma: a retrospective cohort study

Background

The effectiveness of combining anti-programmed cell death protein 1 (PD-1) and chemotherapy has been evaluated as superior to that of chemotherapy alone in the patients with advanced epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI)-resistant non-small cell lung cancer (NSCLC). In this study the efficacy and safety of anti-PD-1 combination therapy were evaluated retrospectively in patients who experienced EGFR-TKI-resistant with advanced lung adenocarcinoma (LUAD), with the goal of providing helpful guidance for clinical application.

Methods

The clinical results of patients with incurable LUAD who received anti-PD-1 antibody combined with or without anti-angiogenic or chemotherapy after EGFR-TKI therapy failure were collected. The efficacy was calculated based on the objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). The efficacy of the regimes was compared according to treatment groups and programmed cell death ligand 1 (PD-L1) expression.

Results

The final analysis included a total of 43 patients with advanced EGFR-mutant LUAD. The overall cohort had an ORR of 23.3%, median PFS (mPFS) of 6.5 months, and median OS (mOS) of 10.6 months. No notable distinction was observed in mPFS and mOS among patients receiving three types of anti-PD-1 antibody combination therapies. Patients with positive PD-L1 expression showed a longer mPFS compared to patients with negative PD-L1 expression. No statistical difference was detected in terms of mPFS between the use of immune combination chemotherapy and immune combination anti-angiogenic therapy in the PD-L1 positive subgroup, and PFS was prolonged regardless of the PD-L1 expression status being positive or negative in the population receiving immune combination chemotherapy. Treatment-related adverse events (TRAEs) of grade 3 or higher were observed in 16.3% of patients, including chemotherapy-containing immunotherapy. No deaths resulting from immune-related adverse events (irAEs) were reported, and only 1 patient receiving immunotherapy plus chemotherapy had to discontinue treatment due to irAEs.

Conclusions

Combination immunotherapy is feasible in post-TKI resistant individuals with LUAD harboring EGFR mutations. Immune combination chemotherapy and immune combination anti-angiogenic therapy have equivalent efficacy in the PD-L1 positive population. PD-L1 expression can be used as a reference for screening candidates for combination immunotherapy.

[Research Progress of Anti-PD-1/PD-L1 Therapy for Non-small Cell Lung Cancer with EGFR Mutation]

The use of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the first line treatment for EGFR-mutant advanced non-small cell lung cancer (NSCLC), but drug resistance will be acquired within 1-2 years, and the following treatment efficacy is poor. The invention of programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors has dramatically changed the situation of tumor treatment. PD-1/PD-L1 inhibitors are less effective in patients with NSCLC harboring EGFR mutation. It is a challenge to make patients with EGFR-mutated advanced NSCLC benefit from anti-PD-1/PD-L1 therapy. In this paper, the research progress on the impact of EGFR mutation on the immune status of NSCLC and related clinical studies in recent 5 years are reviewed.
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Immunotherapy-based combination strategies for treatment of EGFR-TKI-resistant NSCLC

The rapid development of molecular targeted therapy brings hope to patients with advanced non-small-cell lung cancer (NSCLC). However, drug resistance inevitably occurs during treatment with EGFR-tyrosine kinase inhibitors (TKIs). Osimertinib, a third-generation EGFR-TKI, shows a favorable prognosis in T790M-positive NSCLC. Unfortunately, acquired resistance is still a challenge for both patients and clinicians. There is still no consensus on the optimal treatment. PD-1 and its ligand receptor 1 (PD-L1) inhibitors have yielded great progress, especially in patients with no actionable mutations. In this review, the authors take stock of the relationship between EGFR mutations and PD-L1 expression and summarize the important clinical studies on immunotherapy-inhibitor-based treatment in patients with EGFR-TKI-resistant NSCLC.

Upper Gastrointestinal Tract IrAEs: A Case Report About Sintilimab-Induced Acute Erosive Hemorrhagic Gastritis

INTRODUCTION

Immune checkpoint inhibitors (ICIs) have now become the standard therapy for malignancies like non-small cell lung cancer and classical Hodgkin's lymphoma. ICIs are associated with unique immune-related adverse events (irAEs) caused by dysregulated immune activation. Treatment of lower gastrointestinal (GI) tract irAEs, such as colitis, is more common. However, for upper gastrointestinal tract irAEs, there is a lack of consensus in terms of globally standardized disease classification and treatment guidelines. Here, we report a case of sintilimab-induced acute erosive hemorrhagic gastritis.

CASE PRESENTATION

A 54-year-old man with metastatic NSCLC (PT2N2M1 stage IV) underwent treatment with eight courses of sintilimab + bevacizumab, followed by maintenance therapy with sintilimab alone. However, he presented with epigastric pain and melena at the end of the first sintilimab treatment, and the symptoms occurred repeatedly after regular treatment with acute erosive hemorrhagic gastritis. Repeat esophagogastroduodenoscopy (EGD) showed severe hemorrhagic gastritis; symptomatic relief and improvement in EGD images were noted for as long as he was being treated with steroids, methylprednisolone sodium.

CONCLUSION

As far as we are aware, we here describe the first case of sintilimab-associated acute erosive hemorrhagic gastritis, an upper gastrointestinal toxicity event. Throughout the treatment progression, differential diagnosis, multidisciplinary discussion, and the use of immunosuppressants were instrumental in clarifying the diagnosis and were crucial to the prognosis of the patient and continued treatment with ICIs.

Severe immune-related hyperthermia followed by immune-related pneumonitis with PD-1 inhibitor (sintilimab) in small cell lung cancer: A case report

Immune checkpoint inhibitors (ICIs) have achieved prominent efficacy in the treatment of numerous cancers, which is the most significant breakthrough in cancer therapy in recent years. However, ICIs are associated with a series of immune-related adverse events (irAEs). Pneumonitis is an uncommon but potentially fatal irAE. In the case reported here, a patient with advanced small cell lung cancer (SCLC) had rapid progression of disease following chemotherapy and received ICIs. The patient experienced severe immune-related hyperthermia followed by immune-related pneumonitis. Fortunately, a good clinical response was achieved after the patient received corticosteroids and tocilizumab.

The Efficacy and Safety of Anlotinib Combined With PD-1 Antibody for Third-Line or Further-Line Treatment of Patients With Advanced Non-Small-Cell Lung Cancer

Background

Both anlotinib and programmed death 1 (PD-1) monoclonal antibody (mAb) have been approved for the third line treatment of metastatic non-small cell lung cancer (NSCLC). However, the combination of these two standard therapies has not been investigated in third-line or further-line treatment of patients with advanced NSCLC.

Methods

We reviewed 22 patients with NSCLC who received anlotinib combined with PD-1 mAb therapy from July 2018 to October 2019 at Sir Run Run Shaw Hospital. Based on the baseline characteristics, PD-L1 expression and EGFR mutation status, we retrospectively analyzed the efficacy and safety of this combination therapy by RESIST 1.1 and CTCAE 5.0.

Results

The combination treatment of anlotinib and PD-1 mAb in 22 NSCLC patients gained a median PFS of 6.8 months and a median OS of 17.3 months. The disease control rate (DCR) was 90.9%, and the objective response rate (ORR) was 36.4%, where 1 (4.6%) patient achieved complete response (CR) and 7 (31.8%) patients achieved partial response (PR). The median time to response was 3.9 months, and the median duration of the response was 6.8 months. The common grades 1–2 adverse events were fatigue 10/22 (45.5%), decreased appetite 9/22 (40.9%), hypertension 10/22 (45.5%); the common grades 3–4 adverse events were hypertension 2/22 (9.1%) and mouth ulceration 2/22 (9.1%).

Conclusion

Anlotinib combined with PD-1 mAb showed promising efficacy in third-line or further-line treatment of NSCLC, and its adverse effects is tolerable.

Recent updates on Sintilimab in solid tumor immunotherapy

In recent years, there have been advancements in traditional patterns of tumor therapy with the adoption of immunotherapy. Its application with or without other combined regimens has attracted attention from clinicians. Sintilimab (Tyvyt®), a highly selective fully human IgG4 monoclonal antibody, blocks the binding site of programmed cell death protein 1 (PD-1), thereby, inhibiting the interaction between PD-1 and its ligands (PD-L1/2) to restore the endogenous anti-tumor T cell responses. Sintilimab has been proven to be clinically beneficial in multiple solid tumor therapies. Combination therapy and monotherapy have shown potential and encouraging anti-tumor efficacy with controllable and acceptable toxicities. The combination therapy is more likely to be a novel and promising therapeutic option. This study provides an overview of the status of sintilimab-based clinical trials in various solid tumors.

Sintilimab: A Promising Anti-Tumor PD-1 Antibody

Sintilimab (Tyvyt®) is a monoclonal antibody against programmed cell death protein 1 (PD-1). It could block the interaction between PD-1 and its ligands and help the anti-tumor effect of T-cells to recover. Sintilimab is developed by Innovent Biologics and Eli Lilly and Company and has been approved to treat relapsed or refractory classical Hodgkin lymphoma in patients who have undergone two or more lines of systemic chemotherapy by the National Medical Products Administration of China. Recently, sintilimab has been reported in plenty of literature and shows satisfying anti-tumor effect. Meanwhile, there are some reports showing its side effects. Overall, sintilimab has similar anti-tumor effects and a better safety profile compared to nivolumab and pembrolizumab in Hodgkin lymphoma, natural killer/T cell lymphoma and advanced non-small cell lung cancer. In this review, we aim to briefly describe the mechanisms, pharmacological characteristics, anti-tumor effects, predictive parameters of efficacy and side effects of sintilimab, providing valuable information of sintilimab for decision-making in the treatment of tumors in the future.