CDK4/6 Inhibitors in Advanced HR+/HER2 - Breast Cancer: A Multicenter Real-World Data Analysis

Purpose

CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy are considered standard-of-care for first-line therapy of patients with hormone receptor positive, HER2 negative, advanced breast cancer (HR+/HER2- ABC). Superiority of combination therapy over endocrine monotherapy has been demonstrated in a multitude of randomized controlled trials (RCTs) in phase III and IV. However, RCTs reflect clinical reality only to a limited extent, as narrow inclusion criteria lead to a selected patient collective. Here, we present real-world data (RWD) on CDK4/6i treatment in patients with HR+/HER2- ABC at four certified German university breast cancer centers.

Methods

Patients diagnosed with HR+/HER2- ABC who were treated in clinical routine with CDK4/6i between November 2016 and December 2020 at four certified German university breast cancer centers (Saarland University Medical Center, University Medical Center Charité Berlin, University Medical Center Bonn, and University Medical Center Hospital Schleswig-Holstein, Campus Kiel) were identified and enrolled in this retrospective study. Clinicopathological characteristics and clinical outcomes were recorded with particular emphasis on CDK4/6i therapy course [progression-free survival (PFS) following treatment initiation, toxicity, dose reduction, therapy discontinuation, prior and subsequent therapy line].

Results

Data from n = 448 patients were evaluated. The mean patient age was 63 (±12) years. Of these patients, n = 165 (36.8%) were primarily metastasized, and n = 283 (63.2%) had secondary metastatic disease. N = 319 patients (71.3%) received palbociclib, n = 114 patients (25.4%) received ribociclib, and n = 15 patients (3.3%) received abemaciclib, respectively. Dose reduction was performed in n = 132 cases (29.5%). N = 57 patients (12.7%) discontinued the treatment with CDK4/6i due to side effects. N = 196 patients (43.8%) experienced disease progression under CDK4/6i treatment. The median PFS was 17 months. Presence of hepatic metastases and prior therapy lines were associated with shorter PFS, whereas estrogen positivity and dose reduction due to toxicity were positively associated with PFS. Presence of bone and lung metastases, progesterone positivity, Ki67 index, grading, BRCA1/2 and PIK3CA mutation status, adjuvant endocrine resistance, and age did not significantly impact on PFS.

Conclusion

Our RWD analysis on CDK4/6i treatment in Germany supports data from RCTs regarding both treatment efficacy and safety of CDK4/6i for treatment of patients with HR+/HER2- ABC. In comparison to data from the pivotal RCTs, median PFS was lower but within the expected range for RWD, which could result from inclusion of patients with more advanced diseases (i.e., higher therapy lines) to our dataset.

[Results of surgical treatment of patients with internal carotid artery kinking depending on methods of its reconstruction]

It was analyzed the results of surgical treatment of 60 patients with internal carotid artery kinking operated in the department of vascular surgery of acad. B.V. Petrovsky Russian Scientific Center of Surgery of RAN. Indications for surgery included symptoms of cerebrovascular insufficiency (CVI) and instrumentally confirmed hemodynamically significant kinking of ICA. Criteria for surgical treatment were linear flow velocity gradient more than 2 and turbulent blood flow in the kinking segment diagnosed by ultrasonic scanning. All patients were divided into 2 groups depending on methods of surgery. The first group included 36 (60%) patients who underwent resection of ICA with orifice bringing down. The second group included 8 (13%) patients after ICA replacement and 16 (27%) cases with eversion endarterectomy, resection of ICA and orifice bringing down. The analysis of immediate surgery results did not reveal significant differences in dynamics of CVI and velocity parameters in reconstructed ICA (p>0.05). The index "stroke+mortality from stroke" was higher in the second group (p<0.05). Thrombosis of ICA reconstruction area has been developing more frequent (p<0.05) after ICA replacement (8%) in comparison with resection of ICA with orifice bringing down (0) and eversion endarterectomy, resection of ICA and orifice bringing down (0). Our data show that resection of ICA with orifice bringing down is preferable for surgical treatment of ICA kinking. ICA replacement is associated with significantly more frequent complications. Eversion endarterectomy with resection of ICA is optimal in case of combination of kinking with stenosis of ICA.

[Assessment of efficacy of reconstructive operations on carotid arteries in combination of stenosis and pathological tortuosity]

OBJECTIVE

The purpose of this study was to assess efficacy of reconstructive operations on carotid arteries in patients presenting with stenosis of the internal carotid artery (ICA) combined with its pathological tortuosity.

MATERIAL AND METHODS

We analysed our experience in surgical treatment of 84 patients with pathological tortuosity of the ICA combined with atherosclerotic stenosis. The study included patients with ICA stenosis ≥60% (any type of the atherosclerotic plaque) and with any degree of cerebrovascular insufficiency (CVI), or with ICA stenosis <60% (type I-III atherosclerotic plaque) with degree II-IV CVI in a combination with either S- or C-shaped tortuosity of the ICA, kinking or coiling, with the linear blood flow rate ≥110 cm/s and turbulence of blood flow. Only six (7.1%) patients of the 84 (100%) presented with no clinical signs of CVI and were found to have a past medical history free from episodes of cerebral circulation impairments. The ratio of asymptomatic/symptomatic patients was as follows: in group 1 - 12 (58.7%)/19 (61.3%), in group 2 - 27 (81.8%)/6 (18.2%), and in group 3 - 10 (50%)/10 (50%).

RESULTS

Six months after surgery, the asymptomatic/symptomatic patients ratio was as follows: in group 1 - 22 (70.9%)/9 (29.1%), in group 2 - 28 (84.8%)/5 (15.2%), p=0.045, and in group 3 - 9 (45%)/11 (55%), p=0.024. In group 3, one (5%) patient developed thrombosis of the reconstruction zone with the development of ischaemic-type acute cerebral circulation impairment. Twelve months after surgery the ratio in the groups did not change. Of twelve patients with degree IV chronic CVI, four (33.3%) were found to have partial regression of the focal neurological symptomatology.

CONCLUSION

Surgical method of treatment of patients with ICA stenos combined with pathological tortuosity proved efficient and safe both for asymptomatic patients and patients with clinical manifestations of CVI. Significantly better results were observed in the group subjected to eversion carotid endarterectomy with resection of the excessive ICA, with brining down and reimplantation into the ostium as compared with carotid endarterectomy with a patch and as compared with ICA resection with prosthetic repair.

[Immediate and remote results of surgical treatment of patients presenting with pathological tortuosity of internal carotid arteries and accompanying ocular ischaemic syndrome]

The article deals with the data concerning the efficacy of reconstructive operations and conservative treatment in patients presenting with pathological tortuosity of internal carotid arteries. The study included a total of 63 patients. The diagnostic algorithm was as follows: studying the haemodynamics of the internal carotid arteries, assessing the neurological status, and the methods of examining the eye. The patients were subdivided into two groups: Group One consisted of operated on patients (n=37) and Group Two comprising patients treated conservatively (n=26). The patients according to the neurological status were subdivided as follows: an asymptomatic course in 25 (39.7%) patients, transitory ischaemic attacks in 18 (28.6%) patients, dyscirculatory encephalopathy in 12 (19 %) patients, and stroke in 8 (12.7%) patients. Ophthalmological symptomatology was predominantly manifested by fits of amaurosis fugax in 19 (30.2%) patients and processes of maculodystrophy in 49 (77.8 %) patients. We assessed the immediate (day 30) and remote (1 year) results of conservative and surgical treatment. Group One patients demonstrated cessation of the amaurosis fugax attacks, improvement of the acuity of vision by 0.1 and more, enlargement of the borders of the field of vision, disappearance of scotomas, as well as arrest of the processes of maculodystrophy. Patients with transitory ischaemic attacks and dyscirculatory encephalopathy changed to the category of asymptomatic patients. In Group Two patients the dynamics of the neurological status was negative and the patients continued to experience fits of amaurosis fugas. The dynamics of the opthalmological symptomatology was weakly pronounced.

[Comparative analysis of the outcomes of surgical and conservative treatment of patients with pathological kinking of carotid arteries]

OBJECTIVE

The study was aimed at comparatively analysing the results of surgical and conservative treatment of patients with pathological kinking of carotid arteries in order to determine the indications for operative treatment of patients presenting with the pathology concerned.

PATIENTS AND METHODS

Analysed herein are the outcomes of managing a total of 75 patients presenting with pathological kinking of the internal carotid artery. Of these, 43 (57,4%) patients were operated on, with a total of 48 interventions performed. A further 32 (42,6%) patients underwent conservative treatment. In the group of operated patients (Group I), an asymptomatic course of pathological tortuosity was encountered in 19 (44,2%) patients, and 24 (35,8%) patients were found to have various-degree cerebrovascular insufficiency. The group of non-operated patients (Group II) consisted of 15 (46,8%) asymptomatic and 17 (53,2%) symptomatic patients. Also discussed are variants of reconstruction of the deformed carotid arteries.

RESULTS

The immediate outcomes were studied within the terms of 30 days. Positive dynamics of the neurological status was observed in both groups. In Group One, 38 (88,3%) patients (p < 0,05) of the 43 followed-up patients became symptom-free, and in Group Two, out of the 32 patients, twenty-four (75%) were found to have an asymptomatic course. However, in the remote period (the follow-up term varying from 12 months, 3 and 5 years), positive dynamics of the neurological status was observed in 33 (80,4%) of 41 patients within the follow-up terms up to 5 years), whereas in the Group of non-operated patients it was seen only in 11 (42,3%) of 26 patients (within the follow-up terms up to 5 years) (p < 0,05).

CONCLUSION

Surgical management of patients for pathological kinking of the internal carotid artery is an effective method of preventing progression of cerebrovascular insufficiency in the carotid basin in initially asymptomatic and symptomatic patients, which has been confirmed by the obtained short- and long-term outcomes of the operations in patients with the pathology concerned.

[Lumbar sympathectomy in treatment of obliterating diseases of lower limbs: state of the art]

The article deals with analysing examination and surgical treatment of 80 patients with predominant lesions to the distal arterial bed of the lower extremities, who were operated on at the RRSC from 1996 to 2003 with various degree on the background of chronic obliterating diseases of lower limbs arteries. All the patients were subdivided into two groups according to the outcomes of the epidural block: Group I -- with positive outcomes consisted of 36 (45 %) patients, and Group II -- with a negative outcome -- included 44 (55 %) patients. The patients from the both groups underwent the following operations: lumbar sympathectomy combined with direct and indirect methods of revascularisation, as well as lumbar sympathectomy as an independent therapeutic method. To solve the problem concerning feasibility of either done, or concomitant lumbar sympathectomy, we devised assessment of microcirculation state (alterations in volumetric blood flow indices in epidural block in relation to the indices at rest, as well as in the immediate or remote postoperative period) and peripheral haemocirculation (dynamics of the onkle brachial index values on the background of epidural block test, nitroglycerine test in relation to the ARI at rest both in the short-, and long-term postoperative period) by data of scintigraphy and dopplerography of the lower limbs.

[A present-day variant of intermitttent replacement renal therapy in patients with multiple organ failure after cardiovascular surgery]

The efficiency of "semi-prolonged" replacement renal therapy (RRT) was assessed in patients with multiple organ dysfunction (MOD) after cardiovascular surgery. The results of semiprolonged RRT are analyzed in 65 patients (36-69 years, mean age 52.4 +/- 15.7 years, body weight 57-105 kg, mean 79.4 +/- 21.6 kg) operated on at A. N. Bakulev Cardiovascular Surgery Center, Russian Academy of Medical Sciences. Bicarbonate hemodialysis (BHD) was carried out in 50 patients, on-line hemodiafiltration (HDF) in the rest patients. Interventions on the heart and vessels of different complexity were carried out. The results indicate that semiprolonged SRT in complex with intensive care measures notably reduced the mortality of patients with MOD and improved the survival rate in this category of patients. Semiprolonged RRT is an effective method, which can and should be used in critical patients. This method meets all the requirements to modern RRT and ensures adequate filtration of nitrous metabolism products, corrects water-electrolyte and acid base balance, allows infusion/transfusion therapy and parenteral nutrition, and has no negative impact on the hemodynamic values, which is particularly important after cardiovascular interventions.

[Surgical treatment of inveterate injuries of peripheral nerves of the forearm and hand]

In the article is described the method of application of the wrapping epineural suture, proposed by the authors. There are demonstrated the advantages of the given suture in relation to the ordinary epineural one in comparative aspect. Moreover, there is proposed the method of autoneuroplasty at injuries of the median and ulnar nerves with regard to the direction of transplants in the "cable". 18 patients have been operated on according to the proposed method of autoneuroplasty . The positive effect has been detected when studying the remote results. The operated nerve function restores much quicker due to the application of the local hyperthermia of a limb beginning from the 6th post-operative day during 2-3 months. The comparative evaluation of the results of treatment demonstrated the efficiency of the proposed methods.