A tertiary care cancer center experience with carboplatin and pemetrexed in combination with pembrolizumab in comparison with carboplatin and pemetrexed alone in non-squamous non-small cell lung cancer

The safety and efficacy of anti-PD-1/PD-L1 monoclonal antibodies for lung cancer brain metastasis: a systematic review and meta-analysis on brain metastasis

Individuals with non-small cell lung cancer (NSCLC) who develop brain metastases face a poor prognosis and limited treatment options. Programmed cell death protein 1 (PD-1) inhibitors, such as pembrolizumab and nivolumab, have emerged as a promising immunotherapy for treating lung cancer with brain metastases. This systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and evaluate the safety and efficacy of anti-PD-1/PD-L1 monoclonal antibodies in treating lung cancer patients with brain metastases. A comprehensive literature search was conducted to identify relevant studies up to 27 August 2023. Data on overall survival (OS), progression-free survival, radiological response rates, and adverse events were extracted. All statistical analysis was performed using STATA v.17. Our literature search yielded 39 eligible studies involving 15,428 patients. The overall response rate for PD-1 inhibitors was substantial, with pooled rates of 39% for overall response, 7% for complete response (CR), 27% for partial response (PR), and 31% for stable disease (SD). The pooled 6-month OS rate was 77%, and the 1-year OS rate was 61%. Subgroup analyses revealed higher PD-L1 expression levels and the use of platinum-based chemotherapy alongside immunotherapy were associated with improved outcomes. PD-1/PD-L1 inhibitors have demonstrated promising efficacy and safety in treating lung cancer patients with brain metastases, as evidenced by significant improvements in OS, PFS, and response rates. Incorporating PD-1/PD-L1 inhibitors into the treatment regimen, particularly for patients with high PD-L1 expression, has the potential to improve clinical outcomes in this patient population.

Clinical Effect of Treatment with Metformin for Type 2 Diabetes on Non-Small Cell Lung Cancer Patients Undergoing Immunotherapy: A Retrospective Study

Purpose

To further identify the clinical impact of metformin on the prognosis of non-small cell lung cancer (NSCLC) with type 2 diabetes who received immunotherapy.

Methods

Stage IV NSCLC patients with type 2 diabetes receiving the immunotherapy from 2017 to 2021 were retrospectively enrolled and divided into the metformin group or non-metformin group according to the treatment strategy for type 2 diabetes (metformin vs other hypoglycemic medicines). The overall response rate (ORR) was primary endpoint, and overall survival (OS), progression-free survival (PFS) and disease control rate (DCR) were secondary endpoints. These outcomes were compared between two groups.

Results

A total of 34 patients were eventually enrolled, including 18 patients in the metformin group. No significant differences in the basic characteristics and incidence of adverse events were observed between two groups. In addition, there was no significant difference in ORR (44.4%, 8/18 vs 25.0%, 4/16, P = 0.236) and DCR (77.8%, 14/18 vs 75.0%, 12/16, P > 0.999) between the metformin and non-metformin groups. Kaplan-Meier survival curve (P = 0.039) and Cox regression analysis indicated that the use of metformin was an independent factor for OS (HR: 0.310, 95% CI: 0.113-0.845, P = 0.022), but not for PFS (Cox regression analysis: P = 0.145).

Conclusion

For NSCLC patients with type 2 diabetes, the combination of metformin and immunotherapy may contribute to OS benefits. However, more high-quality prospective studies with big sample sizes are needed to further clarify the effect of metformin use on the efficacy of immunotherapy in advanced NSCLC patients with diabetes.

Comparative Efficacy and Safety of Immunotherapy on Non-Small Cell Lung Cancer Patients With Brain Metastases: A Systematic Review and Network Meta-Analysis

BACKGROUND

Growing evidence suggests that immunotherapy has a positive effect on non-small cell lung cancer (NSCLC) patients with brain metastases (BMs). However, it remains unclear which type of immunotherapy is more efficient. The aim of this network meta-analysis (NMA) was to compare the efficacy and safety of different immunotherapy types and determine the optimal option.

METHOD

Four databases (PubMed, Cochrane Library databases, Embase, and Web of Science) and ClinicalTrial.gov were searched from inception until January 26, 2023. Randomized controlled trials (RCTs), prospective nonrandomized trials, or observational studies investigating NSCLC patients with BMs treated by immunotherapy were included. The quality of the included studies was evaluated using the Cochrane risk of bias (ROB) tool and the Newcastle-Ottawa Scale (NOS). The efficacy of immunotherapy on NSCLC patients with BMs was evaluated using frequentist random-effects NMA.

RESULT

Eleven studies from 1560 citations, encompassing 1437 participants, were included in this NMA. Statistical analysis showed that pembrolizumab (SMD = 4.35, 95% CI [2.21, 6.60]) and nivolumab+ipilimumab (SMD = 3.81, 95% CI [1.21, 6.40]) could improve overall survival (OS). Pembrolizumab (SMD = 3.32, 95% CI [2.75, 3.90]) demonstrated better effects in improving the overall response rate (ORR). No significant difference in adverse event (AE) was observed between immunotherapy and chemotherapy.

CONCLUSION

Our findings indicated that pembrolizumab was the most promising immunotherapy for NSCLC patients with BMs. Nivolumab+ipilimumab might be an alternative choice to improve OS.

LIMITATION

Inconsistency tests were not performed because of the scarcity of direct comparison. Besides, high heterogeneity was observed in our NMA.

Brain metastases and lung cancer: molecular biology, natural history, prediction of response and efficacy of immunotherapy

Brain metastases stemming from lung cancer represent a common and challenging complication that significantly impacts patients' overall health. The migration of these cancerous cells from lung lesions to the central nervous system is facilitated by diverse molecular changes and a specific environment that supports their affinity for neural tissues. The advent of immunotherapy and its varied combinations in non-small cell lung cancer has notably improved patient survival rates, even in cases involving brain metastases. These therapies exhibit enhanced penetration into the central nervous system compared to traditional chemotherapy. This review outlines the molecular mechanisms underlying the development of brain metastases in lung cancer and explores the efficacy of novel immunotherapy approaches and their combinations.

Clinical benefit of pembrolizumab in treatment of first line non-small cell lung cancer: a systematic review and meta-analysis of clinical characteristics

OBJECTIVE

Pembrolizumab has become an integral first line therapeutic agent for non-small cell lung cancer (NSCLC), but its potential predictive role in clinical and molecular characteristics remains to be clarified. Accordingly, we performed a systematic review and meta-analysis to evaluate the clinical benefit of pembrolizumab in treatment of first line NSCLC and to select individuals with the greatest potential benefit from pembrolizumab therapy, in order to obtain a more accurate treatment of NSCLC in immunotherapy.

METHODS

Mainstream oncology datasets and conferences were searched for randomized clinical trials (RCTs) published before August 2022. RCTs involved individuals with first line NSCLC treated with pembrolizumab monotherapy or in combination with chemotherapy. Two authors independently selected the studies, extracted data, and assessed the risk of bias. The basic characteristics of the included studies were recorded, along with 95 percent confidence intervals (CI) and hazard ratios (HR) for all patients and subgroups. The primary endpoint was overall survival (OS), and secondary endpoints was progression-free survival (PFS). Pooled treatment data were estimated using the inverse variance-weighted method.

RESULTS

Five RCTs involving 2,877 individuals were included in the study. Pembrolizumab-based therapy significantly improved OS (HR 0.66; CI 95%, 0.55-0.79; p < 0.00001) and PFS (HR 0.60; CI 95%, 0.40-0.91; p = 0.02) compared with chemotherapy. OS was substantially enhanced in individuals aged < 65 years (HR 0.59; CI 95%, 0.42-0.82; p = 0.002), males (HR 0.74; CI 95%, 0.65-0.83; p < 0.00001), with a smoking history (HR 0.65; CI 95%, 0.52-0.82; p = 0.0003), with PD-L1 tumor proportion score (TPS) < 1% (HR 0.55; CI 95%, 0.41-0.73; p < 0.0001) and TPS ≥ 50% (HR 0.66; CI 95%, 0.56-0.76; p < 0.00001), but not in individuals aged ≥ 75 years (HR 0.82; CI 95%, 0.56-1.21; p = 0.32), females (HR 0.57; CI 95%, 0.31-1.06; p = 0.08), never smokers (HR 0.57; CI 95%, 0.18-1.80; p = 0.34), or with TPS 1-49% (HR 0.72; CI 95%, 0.52-1.01; p = 0.06). Pembrolizumab significantly prolonged OS in NSCLC patients, regardless of histology type (squamous or non-squamous NSCLC), performance status (PS) (0 or 1), and brain metastatic status (all p < 0.05). Subgroup analysis revealed that pembrolizumab combined with chemotherapy had more favorable HR values than pembrolizumab monotherapy in improving the OS of individuals with different clinical and molecular features.

CONCLUSION

Pembrolizumab-based therapy is a valuable option for first line treating advanced or metastatic NSCLC. Age, sex, smoking history and PD-L1 expression status can be used to predict the clinical benefit of pembrolizumab. Cautiousness was needed when using pembrolizumab in NSCLC patients aged ≥ 75 years, females, never smokers, or in patients with TPS 1-49%. Furthermore, pembrolizumab in combination with chemotherapy may be a more effective treatment regimen.

Efficacy of different therapies for brain metastases of non-small cell lung cancer: a systematic review and meta-analysis

Background

As one of the most common causes of death in advanced non-small cell lung cancer (NSCLC), brain metastases (BM) have attracted attention and debate about treatment options, especially for patients with negative driver genes or resistance to targeted agents. Therefore, we conducted a meta-analysis to investigate the potential benefit of different therapeutic regimens for intracranial lesions in non-targeted therapy NSCLC patients.

Methods

A comprehensive search was conducted in databases including PubMed, Embase, and the Cochrane Library. The primary endpoints included the intracerebral objective response rate (icORR) and intracerebral progression-free survival (iPFS) in patients with BM.

Results

Thirty-six studies involving 1,774 NSCLC patients with baseline BM were included in this meta-analysis. Antitumor agents plus radiotherapy (RT) showed the most significant synergistic effects; the highest pooled icORR that appeared in the combination of immune checkpoint inhibitor (ICI) and RT was 81% [95% confidence interval (CI): 16-100%], and the median iPFS was 7.04 months (95% CI: 2.54-11.55 months). The pooled icORR and median iPFS of RT plus chemotherapy were 46% (95% CI: 34-57%) and 5.7 months (95% CI: 3.90-7.50 months), respectively. The highest median iPFS in nivolumab plus ipilimumab plus chemotherapy was 13.5 months (95% CI: 8.35-18.65 months). ICI plus chemotherapy also showed potent antitumor activity in BM, with a pooled icORR of 56% (95% CI: 29-82%) and a median iPFS of 6.9 months (95% CI: 3.20-10.60 months). Notably, the subgroup analysis indicated that the pooled icORR of patients in programmed cell death-ligand 1 (PD-L1) (≥50%) who received ICI was 54% (95% CI: 30-77%), and that of patients who received first-line ICI was 69.0% (95% CI: 51-85%).

Conclusions

ICI-based combination treatment provides a long-term survival benefit for non-targeted therapy patients, with the most significant benefits observed in improving icORR and prolonging overall survival (OS) and iPFS. In particular, patients who received first-line treatment or who were PD-L1-positive had a more significant survival benefit from aggressive ICI-based therapies. For patients with a PD-L1-negative status, chemotherapy plus RT led to better clinical outcomes than other treatment regimens. These innovative findings could help clinicians to better select therapeutic strategies for NSCLC patients with BM.

Efficacy and safety of sintilimab plus docetaxel in patients with previously treated advanced non-small cell lung cancer: a prospective, single-arm, phase II study in China

PURPOSE

Although immune checkpoint inhibitor monotherapy has been used as a second-line treatment in advanced non-small cell lung cancer (NSCLC), the improvement in progression-free survival (PFS) remains unsatisfactory. We investigated the feasibility of sintilimab plus chemotherapy as a second-line treatment in advanced NSCLC.

METHODS

This was a phase II, single-arm, prospective study in advanced NSCLC patients who had failed standard platinum-based chemotherapy (ChiCTR1900027634, Registered 22 November 2019). Eligible patients received docetaxel 75 mg/m² (day 1) plus sintilimab 200 mg (day 3) Q3W. Those did not progress after 4-6 cycles received sintilimab 200 mg Q3W as maintenance treatment. The primary endpoint was PFS.

RESULTS

Forty patients were enrolled between October 2019 and October 2020. With a median follow-up of 12.2 months, the median PFS was 5.8 months, and the PFS rates at 6 and 12 months were 48% and 30%, respectively. The median overall survival (OS) was 12.6 months, with a 12-month OS rate of 62.0%. The overall response rate was 32.4%, and the disease control rate was 89.2%. The incidence of all and ≥ grade 3 treatment-related adverse events (TRAEs) were 65% (26/40) and 17.5% (7/40), respectively. No TRAEs-related permanent treatment discontinuation or death occurred. bTMB reduction at 6 weeks was associated with a longer PFS (NR vs 3.0 months, P < 0.0001).

CONCLUSION

This prospective phase II study in China suggested that sintilimab plus docetaxel might improve PFS and tumor response with good tolerability for Chinese patients with previously treated advanced NSCLC. bTMB reduction at 6 weeks could serve as a potential predictive biomarker for this regimen.

Effectiveness and safety of pembrolizumab for patients with advanced non-small cell lung cancer in real-world studies and randomized controlled trials: A systematic review and meta-analysis

Background

Several randomized controlled trials (RCTs) have confirmed the favorable clinical benefit of pembrolizumab in advanced non-small cell lung cancer (NSCLC). However, considering the strict inclusion and exclusion criteria in clinical research, there are certain differences between patients in the real-world, it is unclear whether the findings of clinical trials are fully representative of the treatment efficacy in patients who will eventually use it. Therefore, to further comprehensively assess the efficacy and safety of pembrolizumab in NSCLC, we conducted a systematic review and meta-analysis based on the latest RCTs and real-world studies (RWSs).

Methods

We systematically searched PubMed, Embase, The Cochrane Library, The Web of Science, and clinical trials.gov as of December 2021. RCTs and RWSs of patients receiving pembrolizumab monotherapy or in combination with chemotherapy for advanced NSCLC were included.

Results

The meta-analysis ultimately included 11 RCTs and 26 RWSs with a total of 10,695 patients. The primary outcomes of this study were overall survival (OS), progression-free survival (PFS), objective response rate (ORR), serious adverse events (SAEs), the incidence of severe pneumonia reactions, and drug-related mortality. Direct meta-analysis results showed that in RCTs, pembrolizumab in combination with chemotherapy was superior to chemotherapy in terms of OS (HR=0.60, 95%CI:0.50-0.73), PFS (HR=0.47, 95%CI:0.38-0.58) and ORR (OR=3.22, 95%CI:2.57-4.03); pembrolizumab monotherapy was superior to chemotherapy in terms of OS (HR=0.73, 95%CI:0.66-0.80) and ORR (OR=1.90, 95%CI:1.17-3.09), but comparable to chemotherapy in terms of PFS (HR=0.83, 95%CI:0.66-1.04). The ORR values in retrospective single-arm studies were 45% (40%-51%).

Conclusion

In RCTs, pembrolizumab monotherapy or in combination with chemotherapy is more effective and safer than chemotherapy for advanced NSCLC. In RWSs, ECOG PS 0-1 was shown to correlate with PFS and OS for patients with NSCLC.

The Strategies and Mechanisms of Immune Checkpoint Inhibitors for Brain Metastases in NSCLC

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.

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

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.

Tumor Immune Microenvironment and Immunotherapy in Brain Metastasis From Non-Small Cell Lung Cancer

Brain metastasis (BM), a devastating complication of advanced malignancy, has a high incidence in non-small cell lung cancer (NSCLC). As novel systemic treatment drugs and improved, more sensitive imaging investigations are performed, more patients will be diagnosed with BM. However, the main treatment methods face a high risk of complications at present. Therefore, based on immunotherapy of tumor immune microenvironment has been proposed. The development of NSCLC and its BM is closely related to the tumor microenvironment, the surrounding microenvironment where tumor cells live. In the event of BM, the metastatic tumor microenvironment in BM is composed of extracellular matrix, tissue-resident cells that change with tumor colonization and blood-derived immune cells. Immune-related cells and chemicals in the NSCLC brain metastasis microenvironment are targeted by BM immunotherapy, with immune checkpoint inhibition therapy being the most important. Blocking cancer immunosuppression by targeting immune checkpoints provides a suitable strategy for immunotherapy in patients with advanced cancers. In the past few years, several therapeutic advances in immunotherapy have changed the outlook for the treatment of BM from NSCLC. According to emerging evidence, immunotherapy plays an essential role in treating BM, with a more significant safety profile than others. This article discusses recent advances in the biology of BM from NSCLC, reviews novel mechanisms in diverse tumor metastatic stages, and emphasizes the role of the tumor immune microenvironment in metastasis. In addition, clinical advances in immunotherapy for this disease are mentioned.

Inhibitors of PD-1 in Non-Small Cell Lung Cancer: A Meta-Analysis of Clinical and Molecular Features

Objective

PD-1 inhibitors have become an indispensable treatment in Non-Small Cell Lung Cancer (NSCLC), but the potential predictive value of clinical and molecular features need to be clarified. The objective of the study was to study the potency of PD-1 inhibitors in patients with NSCLC in contexts of both clinical and molecular features, and to aid identification of patients for choice of type of PD-1 inhibitor therapy in order to acquire more accurate NSCLC treatment in immunotherapy.

Method

PubMed, Google Scholar, Embase Science Direct, the Cochrane library, and major oncology conferences were searched for randomized clinical trials (RCTs) that were published prior to December 2021. RCTs that had PD-1 inhibitor alone or in combination with chemotherapy with non-PD-1 inhibitor for the treatment of NSCLC patients were selected. Two authors independently selected studies, data extraction and bias risk assessment. Basic characteristics of included studies, and also the 95% confidence interval and hazard ratios of the overall patients and subgroups were recorded. The inverse variance weighted method was used to estimate pooled treatment data.

Result

A total of eleven RCTs including 5,887 patients were involved. PD-1 inhibitors-based therapy substantially enhanced OS compared with non-PD-1 inhibitor therapy in patients with age group <65 years, 65-74 years, active or previous smokers, without brain metastases, liver metastases, EGFR wild-type patients, individuals in East Asia and U.S./Canada, but not in patients with age group ≥75 years, never smokers, brain metastases, EGFR mutant patients or individuals in Europe. OS was improved in patients with NSCLC who received PD-1 inhibitors regardless of their gender (male or female), histomorphological subtypes (squamous or non-squamous NSCLC), performance status (0 or 1), and PD-L1 tumor proportion score (TPS) (<1%, ≥1%, 1-49%, or ≥50%). An analysis of subgroups revealed that, patients with age group <65 years old, male, non squamous cell carcinoma, PS 1, TPS ≥1%, and TPS ≥50% benefited from pembrolizumab treatment not related with treatment line and treatment regimen.

Conclusion

Age group, smoking history, metastasis status/site, EGFR mutation status, and region can be used to predict the potency of PD-1 inhibitors, and to be individualized to choose different types of PD-1 inhibitors, and treatment regimen for NSCLC patients.

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

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.

Research Progress and Challenges in the Treatment of Central Nervous System Metastasis of Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is one of the most common malignant tumors and has high morbidity and mortality rates. Central nervous system (CNS) metastasis is one of the most frequent complications in patients with NSCLC and seriously affects the quality of life (QOL) and overall survival (OS) of patients, with a median OS of untreated patients of only 1-3 months. There are various treatment methods for NSCLC CNS metastasis, including surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy, which do not meet the requirements of patients in terms of improving OS and QOL. There are still many problems in the treatment of NSCLC CNS metastasis that need to be solved urgently. This review summarizes the research progress in the treatment of NSCLC CNS metastasis to provide a reference for clinical practice.

Outcomes With Pembrolizumab Plus Platinum-Based Chemotherapy for Patients With Non-Small-Cell Lung Cancer and Stable Brain Metastases: Pooled Analysis of KEYNOTE-021, 189, and 407

INTRODUCTION

This exploratory analysis retrospectively evaluated outcomes in patients with advanced NSCLC to determine whether baseline brain metastases influenced the efficacy of first-line pembrolizumab plus chemotherapy versus chemotherapy alone.

PATIENTS AND METHODS

We pooled data for patients with advanced NSCLC in KEYNOTE-021 cohort G (nonsquamous), KEYNOTE-189 (nonsquamous), and KEYNOTE-407 (squamous). Patients were assigned to platinum-doublet chemotherapy with or without the addition of 35 cycles of pembrolizumab 200 mg every 3 weeks. All studies permitted enrollment of patients with previously treated or untreated (KEYNOTE-189/KEYNOTE-407 only) stable brain metastases. Patients with previously treated brain metastases were clinically stable for ≥2 weeks (≥4 weeks in KEYNOTE-021 cohort G), had no evidence of new or enlarging brain metastases, and had no steroid use ≥3 days before dosing. Patients with known untreated asymptomatic brain metastases required regular imaging of the brain.

RESULTS

1298 patients were included, 171 with and 1127 without baseline brain metastases. Median (range) durations of follow-up at data cutoff were 10.9 (0.1‒35.1) and 11.0 (0.1‒34.9) months, respectively. Hazard ratios (pembrolizumab plus chemotherapy/chemotherapy) were similar for patients with and without brain metastases for overall survival (0.48 [95% CI, 0.32‒0.70] and 0.63 [95% CI, 0.53‒0.75], respectively) and progression-free survival (0.44 [95% CI, 0.31‒0.62] and 0.55 [95% CI, 0.48‒0.63], respectively). In patients with brain metastases, median overall survival was 18.8 months with pembrolizumab plus chemotherapy and 7.6 months with chemotherapy, and median progression-free survival was 6.9 months and 4.1 months, respectively. Objective response rates were higher and duration of response longer with pembrolizumab plus chemotherapy versus chemotherapy regardless of brain metastasis status. Incidences of treatment-related adverse events with pembrolizumab plus chemotherapy versus chemotherapy were 88.2% versus 82.8% among patients with brain metastases and 94.5% versus 90.6% in those without.

CONCLUSION

With or without brain metastasis, pembrolizumab plus platinum-based histology-specific chemotherapy improved clinical outcomes versus chemotherapy alone across all PD-L1 subgroups, including patients with PD-L1 tumor proportion score <1%, and had a manageable safety profile in patients with advanced NSCLC. This regimen is a standard-of-care treatment option for treatment-naïve patients with advanced NSCLC, including patients with stable brain metastases.

Immunotherapy in Non-Small Cell Lung Cancer Patients with Brain Metastases: Clinical Challenges and Future Directions

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.

Immune checkpoint inhibitors for brain metastases in non-small-cell lung cancer: from rationale to clinical application

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.

[Research Progress in the Treatment of Brain Metastases from Non-small Cell Lung Cancer]

Lung cancer is the leading cause of cancer-related deaths worldwide. The most common pathological type of lung cancer is non-small cell lung cancer (NSCLC). The incidence of brain metastases caused by NSCLC has been on the rise. Brain metastasis seriously affects the patient's cognitive function, survival time and quality of life, and the prognosis is extremely poor. The natural course of the disease is about 1 mon-3 mon. After treatment, the median survival time is only 3 mon-6 mon, the one year survival rate is 14%, and the two years survival rate is only 7.6%. The location, number, and size of brain metastases are related to their symptoms and survival. Patients with central nervous system symptoms have a worse prognosis. The goal of brain metastasis treatment is to optimize overall survival and quality of life, and to prioritize the preservation of neurocognitive functions. At present, the main treatments for brain metastases in NSCLC include radiotherapy, surgery, chemotherapy, molecular targeting, and immunotherapy. Clinically, it is necessary to conduct a multidisciplinary assessment of the best treatment methods for patients according to the heterogeneity of patients (clinical characteristics, pathological types, tissue types, etc). This article aims to review the research progress of current treatment methods.
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Immune Checkpoint Inhibitors with or without Radiotherapy in Non-Small Cell Lung Cancer Patients with Brain Metastases: A Systematic Review and Meta-Analysis

This study aimed to evaluate the radiologic response and adverse event rates of immune checkpoint inhibitor (ICI) therapy with or without radiotherapy for the treatment of non-small cell lung cancer (NSCLC) brain metastases. A systematic literature search was performed up to January 3, 2020. Studies evaluating the intracranial objective response rates (ORR) and/or disease control rates (DCR) of ICI with or without radiotherapy for treating NSCLC brain metastases were included. Consequently, twelve studies satisfied inclusion criteria. ICI combined with radiotherapy (pooled ORR, 95%; DCR, 97%) showed better local efficacy compared to ICI monotherapy (pooled ORR, 24%; DCR, 44%; p < 0.01 for both ORR and DCR). Grade 3 or 4 central nervous system (CNS)-related adverse event rates were not different (5% vs. 4%; p = 0.93). In conclusion, ICI combined with radiotherapy showed better intracranial efficacy than ICI monotherapy for treating NSCLC brain metastases. CNS-related grade 3 or 4 adverse event rate was not statistically different between the two groups. Several prospective trials are needed to compare the efficacy of ICI combined with radiotherapy and ICI monotherapy.

PD-1/PD-L1 Blockers in NSCLC Brain Metastases: Challenging Paradigms and Clinical Practice

Immune checkpoint inhibitors (ICI) have revolutionized the management of advanced non-small cell lung cancer (NSCLC). However, most pivotal phase III trials systematically excluded patients with active brain metastases, precluding the generalization of the results. Although theoretically restricted from crossing the blood-brain barrier, the novel pharmacokinetic/pharmacodynamic profiles of anti-PD-1/PD-L1 drugs have prompted studies to evaluate their activity in patients with NSCLC with active central nervous system (CNS) involvement. Encouraging results have suggested that ICI could be active in the CNS in selected patients with driver-negative advanced NSCLC with high PD-L1 expression and low CNS disease burden. Single-agent CNS response rates around 30% have been reported. Beyond this particular setting, anti-PD-1/PD-L1 antibodies have been evaluated in patients receiving local therapy for brain metastases (BM), addressing concerns about potential neurologic toxicity risks associated with radiotherapy, more specifically, radionecrosis (RN). Accordingly, a variety of clinical and imaging strategies are being appropriately developed to evaluate tumor response and to rule out pseudoprogression or radionecrosis. Our purpose is to critically summarize the advances regarding the role of systemic anti-PD-1/PD-L1 antibodies for the treatment of NSCLC BM. Data were collected from the PubMed database, reference lists, and abstracts from the latest scientific meetings. Recent reports suggest anti-PD-1/PD-L1 agents are active in a subset of patients with NSCLC with BM showing acceptable toxicity. These advances are expected to change soon the management of these patients but additional research is required to address concerns regarding radionecrosis and the appropriate sequencing of local and systemic therapy combinations.

Therapy With Carboplatin and Anti-PD-1 Antibodies Before Surgery Demonstrates Sustainable Anti-Tumor Effects for Secondary Cancers in Mice With Triple-Negative Breast Cancer

Patients with triple-negative breast cancer (TNBC) suffer an unfavorable prognosis. Carboplatin (CBDCA) as a cytotoxic reagent has been widely administered to patients with cancer including TNBC. Programmed cell death protein 1 (PD-1) is an immune checkpoint, blockade of which unleashes T cell functions that kill cancer cells. However, the efficacy of CBDCA combined with anti-PD-1 antibodies in TNBC has not been determined. Patient-derived xenografts (PDX) were implanted to immune-deficient mice. Three mouse TNBC cell lines (4T1, EMT6, and E0771) were seeded to immune-competent mice. Tumor volumes and survival rates were monitored. CBDCA and anti-PD-1 antibodies were administered by intra-peritoneal injection at designated time points. Total CD8⁺ T cells, memory CD8⁺ T cells, and CD103⁺ dendritic cells (DC) in the tumor were measured by flow cytometry. Tumor-specific CD8⁺ T cells were quantified by the ELISpot assay. Administration of CBDCA to PDX-bearing mice induced increased levels of tumor cell necrosis and reduced tumor size. Treatment with CBDCA and anti-PD-1 antibodies reduced TNBC tumor volumes and slightly improved survival rates. More importantly, therapy with CBDCA and anti-PD-1 antibodies before surgery showed a remarkably improved, sustainable protection against a secondary tumor after surgery by a CD8⁺- T-cell-dependent manner, which required CCL4 expressed in the tumor and subsequently CD103⁺ DC recruited to the tumor microenvironment. Immunochemotherapy with CBDCA and anti-PD-1 antibodies before surgery improves the outcome of a secondary tumor after surgery via increasing the number of tumor-specific CD8⁺ T cells in the tumor microenvironment of murine TNBC. These results highlight the possibility to utilize this regimen in clinical practice.

Use of Programmed Death Receptor-1 and/or Programmed Death Ligand 1 Inhibitors for the Treatment of Brain Metastasis of Lung Cancer

The central nervous system (CNS) is regarded as an immune privileged environment; however, changes in the neuroimmunology paradigm have led to an increased interest in systematic immunotherapy in lung cancer therapy. The presence of the lymphatic system in the CNS as well as the physiological and biochemical changes in the blood–brain barrier in the tumor microenvironment suggests that immunocytes are fully capable of entering and exiting the CNS. Emerging clinical data suggest that inhibitors of programmed death receptor-1/programmed death ligand 1 (PD-1/PD-L1) can stimulate surrounding T cells and thus have antitumor effects in the CNS. For example, PD-1 antibody (pembrolizumab) monotherapy has displayed a 20–30% encephalic response rate in patients with brain metastases from malignant melanoma or non-small cell lung cancer. Combined application of nivolumab and ipilimumab anti-PD-1 and anti-cytotoxic T-lymphocyte-associated protein 4 showed an encephalic response rate of 55% in patients with brain metastases of melanoma. Further evidence is required to verify these response rates and identify the mechanisms of curative effects and drug tolerance. While regional treatments such as whole-brain radiosurgery, stereotactic radiosurgery, and brain surgery remain the mainstream, PD-1/PD-L1 inhibitors display potential decreased neurotoxic effects. To date, five drugs have been approved for use in patients with encephalic metastases of lung carcinoma: the anti-PD-1 drugs, pembrolizumab and nivolumab, and the anti-PD-L1 agents, atezolizumab, durvalumab, and avelumab. In recent years, clinical trials of inhibitors in combination with other drugs to treat brain metastasis have also emerged. This review summarizes the biological principles of PD-1/PD-L1 immunotherapy for brain metastasis of lung cancer, as well as ongoing clinical trials to explore unmet needs.

[Basis of Tumor Microenvironment Relevant to Immunotherapies for Brain Metastases of NSCLC]

脑是非小细胞肺癌(non-small cell lung cancer, NSCLC)最常见的远处转移部位，脑转移也是晚期肺癌致残致死的主要原因。近年来，小分子酪氨酸激酶抑制剂的应用和疗效奠定了驱动基因突变阳性的NSCLC脑转移的治疗基础。随着程序性死亡受体1(programmed cell death protein 1, PD-1)/程序性死亡受体配体1(programmed cell death protein ligand 1, PD-L1)抑制剂及相应联合疗法的不断发展，免疫治疗已成为驱动基因突变泛阴性的NSCLC脑转移患者的重要选择，相关生物标志物的价值也日益凸显。由于NSCLC脑转移肿瘤及其微环境的免疫病理特征具有一定的特殊性，本文旨在回顾相关研究进展，并为免疫治疗联合策略的探索与新型免疫疗法的开发提供参考。

Clinical outcomes in non-small-cell lung cancer patients receiving concurrent metformin and immune checkpoint inhibitors

Aim:

To study the clinical benefits of concurrent metformin and immune checkpoint inhibitors (ICIs) in non-small-cell lung cancer patients.

Materials & methods:

This is a retrospective review of 50 non-small-cell lung cancer patients receiving ICIs with metformin (cohort A) or without metformin (cohort B). Patients were also stratified by ICIs as second-/third-line therapy.

Results:

Overall response rate and disease control rate were higher in cohort A (41.1 vs 30.7%, p = 0.4 and 70.5 vs 61.6%, p = 0.5, respectively). Median overall survival and progression-free survival were also higher in cohort A (11.5 vs 7.6 months, p = 0.5 and 4.0 vs 3.0 months, p = 0.6, respectively). On subset analysis (second-/third-line ICIs), overall response rate, disease control rate, median overall survival, progression-free survival were also higher in cohort A.

Conclusion:

Despite the small-sample size, we observed improved clinical outcomes in patients who received ICIs in combination with metformin.

From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC

Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.