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Yegya-Raman N, Berman AT, Ciunci CA, Friedes C, Berlin E, Iocolano M, Wang X, Lai C, Levin WP, Cengel KA, O'Reilly SE, Cohen RB, Aggarwal C, Marmarelis ME, Singh AP, Sun L, Bradley JD, Plastaras JP, Simone CB, Langer CJ, Feigenberg SJ. Phase 2 Trial of Consolidation Pembrolizumab After Proton Reirradiation for Thoracic Recurrences of Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 119:56-65. [PMID: 37652303 DOI: 10.1016/j.ijrobp.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/08/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Reirradiation (reRT) with proton beam therapy (PBT) may offer a chance of cure while minimizing toxicity for patients with isolated intrathoracic recurrences of non-small cell lung cancer (NSCLC). However, distant failure remains common, necessitating strategies to integrate more effective systemic therapy. METHODS AND MATERIALS This was a phase 2, single-arm trial (NCT03087760) of consolidation pembrolizumab after PBT reRT for locoregional recurrences of NSCLC. Four to 12 weeks after completion of 60 to 70 Gy PBT reRT, patients without progressive disease received pembrolizumab for up to 12 months. Primary endpoint was progression-free survival (PFS), measured from the start of reRT. Secondary endpoints were overall survival (OS) and National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 toxicity. RESULTS Between 2017 and 2021, 22 patients received PBT reRT. Median interval from prior radiation end to reRT start was 20 months. Most recurrences (91%) were centrally located. Most patients received concurrent chemotherapy (95%) and pencil beam scanning PBT (77%), and 36% had received prior durvalumab. Fifteen patients (68%) initiated consolidation pembrolizumab on trial and received a median of 3 cycles (range, 2-17). Pembrolizumab was discontinued most commonly due to toxicity (n = 5; 2 were pembrolizumab-related), disease progression (n = 4), and completion of 1 year (n = 3). Median follow-up was 38.7 months. Median PFS and OS were 8.8 months (95% CI, 4.2-23.7) and 22.8 months (95% CI, 6.9-not reached), respectively. There was only one isolated in-field failure after reRT. Grade ≥3 toxicities occurred in 10 patients (45%); 2 were pembrolizumab-related. There were 2 grade 5 toxicities, an aorto-esophageal fistula at 6.9 months and hemoptysis at 46.8 months, both probably from reRT. The trial closed early due to widespread adoption of immunotherapy off-protocol. CONCLUSIONS In the first-ever prospective trial combining PBT reRT with consolidation immunotherapy, PFS was acceptable and OS favorable. Late grade 5 toxicity occurred in 2 of 22 patients. This approach may be considered in selected patients with isolated thoracic recurrences of NSCLC.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine A Ciunci
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cole Friedes
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Iocolano
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ching Lai
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon E O'Reilly
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melina E Marmarelis
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aditi P Singh
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lova Sun
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- New York Proton Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Corey J Langer
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Sun L, Handorf EA, Zhou Y, Borghaei H, Aggarwal C, Bauman J. Outcomes in patients treated with frontline immune checkpoint inhibition (ICI) for advanced NSCLC with KRAS mutations and STK11/KEAP1 comutations across PD-L1 levels. Lung Cancer 2024; 190:107510. [PMID: 38432028 DOI: 10.1016/j.lungcan.2024.107510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION In patients with advanced NSCLC (aNSCLC), the impact of KRAS mutations (m) and comutations with STK11 and KEAP1 on outcomes across different PD-L1 levels remains incompletely understood. We aimed to investigate the frequency of KRAS mutations and comutations across PD-L1 levels, and the association between these mutations and survival, stratified by PD-L1 expression. METHODS We conducted a nationwide cohort study of patients diagnosed with aNSCLC between 2016 and 2021 treated with frontline (chemo)immunotherapy, who underwent molecular genotyping including KRAS, STK11, and KEAP1. Real-world overall survival (OS) and progression-free survival (rwPFS) were estimated using Kaplan-Meier methodology. Cox multivariable regressions were used to evaluate the association between KRASm and survival across different PD-L1 strata, and to assess whether the association between KRASm and survival differed by PD-L1 level. Finally, within subgroups defined by PD-L1 expression, we used interaction terms to assess whether co-mutations with STK11 and KEAP1 moderated the association between KRAS mutation and survival. RESULTS Of our 2593-patient cohort, 982 (37.9 %) were KRASm and 1611 (62.1 %) KRASwt. KRASm were enriched in the PD-L1 ≥50 % cohort (334/743, 45 %), but within patients with KRASm, co-mutations with STK11 and KEAP1 were enriched in the PD-L1 0 % cohort. KRASm was associated with significantly worse OS in the PD-L1 0 % cohort compared to the PD-L1 ≥50 % cohort (P for interaction = 0.008). On adjusted analyses stratified by PD-L1, KRASm was associated with worse survival only in the PD-L1 0 % group (OS HR 1.46, p = 0.001). KEAP1 and STK11 comutations were most strongly associated with worse OS in the PD-L1 0 % subgroup; patients with triple KRASm/KEAPm/STK11m PD-L1 0 % NSCLC experienced the worst outcomes. CONCLUSIONS KRASm are associated with worse overall survival in PD-L1 negative NSCLC; however, this association is largely driven by comutations with STK11 and KEAP1, which are enriched in PD-L1 negative tumors.
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Affiliation(s)
- Lova Sun
- Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Yunyun Zhou
- Fox Chase Cancer Center, Philadelphia, PA, USA
| | | | - Charu Aggarwal
- Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Yegya-Raman N, Friedes C, Lee SH, Iocolano M, Duan L, Wang X, Li B, Aggarwal C, Cohen RB, Su W, Doucette A, Levin WP, Cengel KA, DiBardino D, Teo BKK, O'Reilly SE, Sun L, Bradley JD, Xiao Y, Langer CJ, Feigenberg SJ. Pneumonitis Rates Before and After Adoption of Immunotherapy Consolidation in Patients With Locally Advanced Non-Small Cell Lung Cancer Treated With Concurrent Chemoradiation. Int J Radiat Oncol Biol Phys 2024; 118:1445-1454. [PMID: 37619788 DOI: 10.1016/j.ijrobp.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/24/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE We hypothesized that after adoption of immune checkpoint inhibitor (ICI) consolidation for patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving concurrent chemoradiation therapy (cCRT), rates of symptomatic pneumonitis would increase, thereby supporting efforts to reduce lung radiation dose. METHODS AND MATERIALS This single institution, multisite retrospective study included 783 patients with LA-NSCLC treated with definitive cCRT either before introduction of ICI consolidation (pre-ICI era cohort [January 2011-September 2017]; N = 448) or afterward (ICI era cohort [October 2017-December 2021]; N = 335). Primary endpoint was grade ≥2 pneumonitis (G2P) and secondary endpoint was grade ≥3 pneumonitis (G3P), per Common Terminology Criteria for Adverse Events v5.0. Pneumonitis was compared between pre-ICI era and ICI era cohorts using the cumulative incidence function and Gray's test. Inverse probability of treatment weighting (IPTW)-adjusted Fine-Gray models were generated. Logistic models were developed to predict the 1-year probability of G2P as a function of lung dosimetry. RESULTS G2P was higher in the ICI era than in the pre-ICI era (1-year cumulative incidence 31.4% vs 20.1%; P < .001; IPTW-adjusted multivariable subdistribution hazard ratio, 2.03; 95% confidence interval, 1.53-2.70; P < .001). There was no significant interaction between ICI era treatment and either lung volume receiving ≥20 Gy (V20) or mean lung dose in Fine-Gray regression for G2P; however, the predicted probability of G2P was higher in the ICI era at clinically relevant values of lung V20 (≥24%) and mean lung dose (≥14 Gy). Cut-point analysis revealed a lung V20 threshold of 28% in the ICI era (1-year G2P rate 46.0% above vs 19.8% below; P < .001). Among patients receiving ICI consolidation, lung V5 was not associated with G2P. G3P was not higher in the ICI era (1-year cumulative incidence 7.5% vs 6.0%; P = .39; IPTW-adjusted multivariable subdistribution hazard ratio, 1.12; 95% confidence interval, 0.63-2.01; P = .70). CONCLUSIONS In patients with LA-NSCLC treated with cCRT, the adoption of ICI consolidation was associated with an increase in G2P but not G3P. With ICI consolidation, stricter lung dose constraints may be warranted.
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Affiliation(s)
| | | | | | | | | | | | - Bolin Li
- Departments of Radiation Oncology
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - David DiBardino
- Section of Interventional Pulmonology and Thoracic Oncology, Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Lova Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Corey J Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Friedes C, Iocolano M, Lee SH, Li B, Duan L, Levin WP, Cengel KA, Sun LL, Aggarwal C, Marmarelis ME, Doucette A, Cohen RB, Xiao Y, Langer CJ, Bradley J, Feigenberg SJ, Yegya-Raman N. Patterns of Failure, Low-Volume Relapse, and Subsequent Ablative Management in Locally Advanced Non-Small Cell Lung Cancer Treated With Definitive Chemoradiation and Consolidation Immune Checkpoint Inhibitors. Int J Radiat Oncol Biol Phys 2024; 118:1435-1444. [PMID: 37866762 DOI: 10.1016/j.ijrobp.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE The objective of this study was to describe the patterns of failure, frequency of low-volume relapse (LVR), and candidacy for ablative therapy at time of disease progression (PD) after chemoradiation and consolidative immunotherapy (CRT + ICI) in patients with stage III non-small cell lung cancer. METHODS AND MATERIALS We identified 229 consecutive patients with stage III non-small cell lung cancer treated with CRT + ICI between October 2017 and December 2021 at a single institution. PD was classified as isolated locoregional failure (LRF), isolated distant failure (DF), or synchronous LRF + DF. Any LRF was subclassified as in-field failure, marginal failure, or out-of-field failure. LVR was defined as 3 or fewer sites of PD in any number of organs. Ablative candidates were defined as having 5 or fewer sites of PD radiographically amenable to high-dose radiation or surgery. Time-to-event data were calculated using cumulative incidence analysis and Kaplan-Meier methods. Multivariable Cox modeling was used to examine the correlations between characteristics of relapse and postprogression survival. RESULTS Of the 229 patients, 119 (52%) had PD. Of these 119 patients, 20 (21%) had isolated LRF, 28 (24%) had synchronous LRF + DF, and 71 (60%) had isolated DF. Of the 48 patients with any LRF, 28 (58%) had in-field failure, 10 (21%) marginal failure, and 10 (21%) out-of-field failure. The cumulative incidence of LRF and DF was 13% (95% CI, 9.2%-18%) and 32% (95% CI, 26%-38%) at 1 year and 19% (95% CI, 14%-24%) and 39% (95% CI, 33%-46%) at 2 years, respectively. Overall, 64 patients (54%) were considered to have LVR. At time of PD, 60 patients (50%) were eligible for ablative therapy. Patients with LVR had longer median survival versus with high-volume relapse (37.4 vs 15.2 months, P < .001). On multivariable analysis, LVR (hazard ratio, 0.32; 95% CI, 0.18-0.56; P < .001) was associated with improved postprogression survival. CONCLUSIONS After CRT + ICI, approximately half of patients experience LVR at time of PD and are candidates for ablative therapies. Prospective trials are needed to validate the optimal treatment strategy for LVR.
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Affiliation(s)
- Cole Friedes
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sang Ho Lee
- Division of Physics, Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Bolin Li
- Division of Physics, Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lian Duan
- Division of Physics, Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lova L Sun
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Melina E Marmarelis
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Abigail Doucette
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ying Xiao
- Division of Physics, Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Corey J Langer
- Department of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey Bradley
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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5
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Marmarelis ME, Scholes DG, McGrath CM, Priore SF, Roth JJ, Feldman M, Morrissette JJD, Litzky L, Deshpande C, Thompson JC, Doucette A, Gabriel PE, Sun L, Singh AP, Cohen RB, Langer CJ, Carpenter EL, Aggarwal C. Brief Report: Impact of Reflex Testing on Tissue-Based Molecular Genotyping in Patients With Advanced Non-Squamous Non-Small Cell Lung Cancer. Clin Lung Cancer 2024:S1525-7304(24)00037-8. [PMID: 38582618 DOI: 10.1016/j.cllc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Melina E Marmarelis
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Dylan G Scholes
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Cindy M McGrath
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Salvatore F Priore
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Jacquelyn J Roth
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Michael Feldman
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | | | - Leslie Litzky
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Charu Deshpande
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey C Thompson
- Department of Pulmonary Medicine and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Peter E Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA; Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lova Sun
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aditi P Singh
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Erica L Carpenter
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA.
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Aggarwal C, Ahmed H, Sharma P, Reddy ES, Nayak K, Singla M, Maheshwari D, Chawla YM, Panda H, Rai RC, Gunisetty S, Priyamvada L, Bhaumik SK, Ahamed SF, Vivek R, Bhatnagar P, Singh P, Kaur M, Dixit K, Kumar S, Gottimukkala K, Saini K, Bajpai P, Sreekanth GP, Mammen S, Rajan A, Verghese VP, Abraham AM, Shah P, Alagarasu K, Yu T, Davis CW, Wrammert J, Ansari A, Antia R, Kabra SK, Medigeshi GR, Ahmed R, Lodha R, Shet A, Chandele A, Murali-Krishna K. Severe disease during both primary and secondary dengue virus infections in pediatric populations. Nat Med 2024; 30:670-674. [PMID: 38321219 DOI: 10.1038/s41591-024-02798-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/02/2024] [Indexed: 02/08/2024]
Abstract
Dengue is a global epidemic causing over 100 million cases annually. The clinical symptoms range from mild fever to severe hemorrhage and shock, including some fatalities. The current paradigm is that these severe dengue cases occur mostly during secondary infections due to antibody-dependent enhancement after infection with a different dengue virus serotype. India has the highest dengue burden worldwide, but little is known about disease severity and its association with primary and secondary dengue infections. To address this issue, we examined 619 children with febrile dengue-confirmed infection from three hospitals in different regions of India. We classified primary and secondary infections based on IgM:IgG ratios using a dengue-specific enzyme-linked immunosorbent assay according to the World Health Organization guidelines. We found that primary dengue infections accounted for more than half of total clinical cases (344 of 619), severe dengue cases (112 of 202) and fatalities (5 of 7). Consistent with the classification based on binding antibody data, dengue neutralizing antibody titers were also significantly lower in primary infections compared to secondary infections (P ≤ 0.0001). Our findings question the currently widely held belief that severe dengue is associated predominantly with secondary infections and emphasizes the importance of developing vaccines or treatments to protect dengue-naive populations.
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Affiliation(s)
- Charu Aggarwal
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Hasan Ahmed
- Department of Biology, Emory University, Atlanta, GA, USA
| | - Pragati Sharma
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Elluri Seetharami Reddy
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
- Kusuma School of Biological Sciences, Indian Institute of Technology, New Delhi, India
| | - Kaustuv Nayak
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Mohit Singla
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Maheshwari
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Yadya M Chawla
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Harekrushna Panda
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Ramesh Chandra Rai
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Sivaram Gunisetty
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
- Department of Pediatrics, Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Lalita Priyamvada
- Department of Pediatrics, Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Siddhartha Kumar Bhaumik
- Department of Pediatrics, Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Syed Fazil Ahamed
- Division of Infectious Diseases, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, India
| | - Rosario Vivek
- Division of Infectious Diseases, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, India
- The University of Trans-Disciplinary Health Sciences & Technology, Bengaluru, India
| | - Priya Bhatnagar
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
- TERI school of advanced studies, New Delhi, India
| | - Prabhat Singh
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Manpreet Kaur
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Kritika Dixit
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Sanjeev Kumar
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Kamal Gottimukkala
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Keshav Saini
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Prashant Bajpai
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Gopinathan Pillai Sreekanth
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Shobha Mammen
- Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Anand Rajan
- Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Valsan Philip Verghese
- Pediatric Infectious Diseases, Department of Pediatrics, Christian Medical College, Vellore, India
| | - Asha Mary Abraham
- Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Paresh Shah
- Department of Molecular Virology, National Institute of Virology, Pune, India
| | - Kalichamy Alagarasu
- Department of Molecular Virology, National Institute of Virology, Pune, India
| | - Tianwei Yu
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Shenzhen Research Institute of Big Data, School of Data Science, The Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | - Carl W Davis
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Jens Wrammert
- Department of Pediatrics, Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Aftab Ansari
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Rustom Antia
- Department of Biology, Emory University, Atlanta, GA, USA
| | - Sushil Kumar Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Guruprasad R Medigeshi
- Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, India
| | - Rafi Ahmed
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| | - Anita Shet
- Division of Infectious Diseases, St. John's Research Institute, St. John's National Academy of Health Sciences, Bengaluru, India.
- International Vaccine Access Centre, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Anmol Chandele
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.
| | - Kaja Murali-Krishna
- ICGEB Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.
- Department of Pediatrics, Division of Infectious Disease, Emory University School of Medicine, Atlanta, GA, USA.
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA, USA.
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7
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Iocolano M, Yegya-Raman N, Friedes C, Wang X, Kegelman T, Lee SH, Duan L, Li B, Levin WP, Cengel KA, Konski A, Langer CJ, Cohen RB, Sun L, Aggarwal C, Doucette A, Xiao Y, Kevin Teo BK, O'Reilly S, Zou W, Bradley JD, Simone CB, Feigenberg SJ. Acute hospitalizations after proton therapy versus intensity-modulated radiotherapy for locally advanced non-small cell lung cancer in the durvalumab era. Cancer 2024. [PMID: 38294959 DOI: 10.1002/cncr.35230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/25/2023] [Accepted: 12/05/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION It was hypothesized that use of proton beam therapy (PBT) in patients with locally advanced non-small cell lung cancer treated with concurrent chemoradiation and consolidative immune checkpoint inhibition is associated with fewer unplanned hospitalizations compared with intensity-modulated radiotherapy (IMRT). METHODS Patients with locally advanced non-small cell lung cancer treated between October 2017 and December 2021 with concurrent chemoradiation with either IMRT or PBT ± consolidative immune checkpoint inhibition were retrospectively identified. Logistic regression was used to assess the association of radiation therapy technique with 90-day hospitalization and grade 3 (G3+) lymphopenia. Competing risk regression was used to compare G3+ pneumonitis, G3+ esophagitis, and G3+ cardiac events. Kaplan-Meier method was used for progression-free survival and overall survival. Inverse probability treatment weighting was applied to adjust for differences in PBT and IMRT groups. RESULTS Of 316 patients, 117 (37%) received PBT and 199 (63%) received IMRT. The PBT group was older (p < .001) and had higher Charlson Comorbidity Index scores (p = .02). The PBT group received a lower mean heart dose (p < .0001), left anterior descending artery V15 Gy (p = .001), mean lung dose (p = .008), and effective dose to immune circulating cells (p < .001). On inverse probability treatment weighting analysis, PBT was associated with fewer unplanned hospitalizations (adjusted odds ratio, 0.55; 95% CI, 0.38-0.81; p = .002) and less G3+ lymphopenia (adjusted odds ratio, 0.55; 95% CI, 0.37-0.81; p = .003). There was no difference in other G3+ toxicities, progression-free survival, or overall survival. CONCLUSIONS PBT is associated with fewer unplanned hospitalizations, lower effective dose to immune circulating cells and less G3+ lymphopenia compared with IMRT. Minimizing dose to lymphocytes may be warranted, but prospective data are needed.
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Affiliation(s)
- Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cole Friedes
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Xingmei Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Timothy Kegelman
- Department of Radiation Oncology, Delaware Radiation Oncology Associates, Christiana Care Health Systems, Newark, Delaware, USA
| | - Sang Ho Lee
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lian Duan
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bolin Li
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andre Konski
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corey J Langer
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lova Sun
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Charu Aggarwal
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ying Xiao
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shannon O'Reilly
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Wei Zou
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Bleiberg BA, Aggarwal C. Concurrent Circulating Tumor DNA and Tissue Genotyping-Ready for Prime Time? JAMA Netw Open 2024; 7:e2351679. [PMID: 38252442 DOI: 10.1001/jamanetworkopen.2023.51679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Affiliation(s)
- Benjamin A Bleiberg
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Penn Center for Cancer Care Innovation, Philadelphia, Pennsylvania
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9
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Friedes C, Yegya-Raman N, Zhang S, Iocolano M, Cohen RB, Aggarwal C, Thompson JC, Marmarelis ME, Levin WP, Cengel KA, Ciunci CA, Singh AP, D'Avella C, Davis CW, Langer CJ, Feigenberg SJ. Patterns of Failure in Metastatic NSCLC Treated With First Line Pembrolizumab and Use of Local Therapy in Patients With Oligoprogression. Clin Lung Cancer 2024; 25:50-60.e6. [PMID: 37813713 DOI: 10.1016/j.cllc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/14/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION The patterns of failure (POF) for metastatic non-small-cell lung cancer (mNSCLC) treated with immunotherapy are not well established. METHODS We conducted a retrospective cohort study of mNSCLC that received first-line pembrolizumab with or without chemotherapy at a single academic center from 2015 to 2021. We defined POF with 2 classifications: 1) local, regional, or distant failure, or 2) failure in existing lesions, new lesions, or a combination. Oligoprogression was defined as disease progression (PD) in ≤3 sites of failure. Overall survival (OS) was measured via Kaplan-Meier and modelled with Cox regression. RESULTS Of 298 patients identified, 198 had PD. Using POF classification 1, most failures were distant (43.9%) or a combination of locoregional and distant (34.4%). For POF classification 2, failures occurred in a combination of new and existing lesions (45.0%), existing lesions alone (33.3%), or in new lesions only (21.7%). Oligoprogression occurred in 39.9% (n = 79) cases. Median OS was higher in the following: PD in existing lesions vs. new or new + existing lesions (28.7 vs. 20.2 vs. 13.9 months, P < .001) and oligoprogression vs. polyprogression (35.1 vs. 12.2 months, P < .001). In oligoprogression, median OS was better for those who received radiation to all sites of PD (62.2 months) than for those who changed systemic therapy (22.9 months, P = .007). On multivariable analysis, radiation for oligoprogression (HR 0.35, 95% CI: 0.20-0.62, P < .001) was associated with improved OS. CONCLUSIONS In mNSCLC treated with pembrolizumab, oligoprogression is relatively common. Randomized data are needed to define the benefits of radiation in oligoprogressive mNSCLC.
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Affiliation(s)
- Cole Friedes
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Siqi Zhang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey C Thompson
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Melina E Marmarelis
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christine A Ciunci
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Aditi P Singh
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher D'Avella
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christiana W Davis
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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10
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Friedes C, Iocolano M, Lee SH, Duan L, Li B, Doucette A, Cohen RB, Aggarwal C, Sun LL, Levin WP, Cengel KA, Kao G, Teo BKK, Langer CJ, Xiao Y, Bradley J, Feigenberg SJ, Yegya-Raman N. The effective radiation dose to immune cells predicts lymphopenia and inferior cancer control in locally advanced NSCLC. Radiother Oncol 2024; 190:110030. [PMID: 38008414 DOI: 10.1016/j.radonc.2023.110030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE To explore the association of the effective dose to immune cells (EDIC) with disease control, lymphopenia, and toxicity in patients with non-small cell lung cancer (NSCLC) and identify methods to reduce EDIC. METHODS We abstracted data from all patients with locally advanced NSCLC treated with chemoradiation with or without consolidative immunotherapy over a ten-year period. Associations between EDIC and progression-free survival (PFS) and overall survival (OS) were modeled with Cox proportional hazards and Kaplan-Meier method. Logistic regression was used to model predictors of lymphopenia and higher EDIC. Analyses were performed with EDIC as a continuous and categorical variable. Lymphopenia was graded per CTCAE v5.0. RESULTS Overall, 786 patients were included (228 of which received consolidative immunotherapy); median EDIC was 4.7 Gy. Patients with EDIC < 4.7 Gy had a longer median PFS (15.3 vs. 9.0 months; p < 0.001) and OS (34.2 vs. 22.4 months; p < 0.001). On multivariable modeling, EDIC correlated with inferior PFS (HR 1.08, 95 % CI 1.01-1.14, p = 0.014) and OS (HR 1.10, 95 % CI 1.04-1.18, p = 0.002). EDIC was predictive of grade 4 lymphopenia (OR 1.16, 95 % CI 1.02-1.33, p = 0.026). EDIC ≥ 4.7 Gy was associated with increased grade 2 + pneumonitis (6-month incidence: 26 % vs 20 %, p = 0.04) and unplanned hospitalizations (90-day incidence: 40 % vs 30 %, p = 0.002). Compared to protons, photon therapy was associated with EDIC ≥ 4.7 Gy (OR 5.26, 95 % CI 3.71-7.69, p < 0.001) in multivariable modeling. CONCLUSIONS EDIC is associated with inferior disease outcomes, treatment-related toxicity, and the development of severe lymphopenia. Proton therapy is associated with lower EDIC. Further investigations to limit radiation dose to the immune system appear warranted.
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Affiliation(s)
- Cole Friedes
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Sang Ho Lee
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Lian Duan
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Bolin Li
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Abigail Doucette
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Roger B Cohen
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Charu Aggarwal
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Lova L Sun
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Gary Kao
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Corey J Langer
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ying Xiao
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Jeffrey Bradley
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
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11
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Barsouk A, Friedes C, Iocolano M, Doucette A, Cohen RB, Robinson KW, D'Avella CA, Marmarelis ME, Kosteva JA, Singh AP, Ciunci CA, Levin WP, Cengel KA, Bradley JD, Feigenberg SJ, Sun L, Aggarwal C, Langer CJ, Yegya-Raman N. Plunging Into the PACIFIC: Outcomes of Patients With Unresectable KRAS-Mutated Non-Small Cell Lung Cancer Following Definitive Chemoradiation and Durvalumab Consolidation. Clin Lung Cancer 2023:S1525-7304(23)00266-8. [PMID: 38195320 DOI: 10.1016/j.cllc.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) consolidation following concurrent chemoradiotherapy (CRT) substantially improved progression free survival (PFS) and overall survival (OS) in the PACIFIC trial becoming the standard of care in locally-advanced, unresectable NSCLC. KRAS mutation may influence response to ICI. METHODS In this single-institution, retrospective analysis, we compared treatment outcomes for patients with unresectable KRAS mutated (KRAS-mt) and wild-type (KRAS-wt) NSCLC treated with CRT between October 2017 and December 2021. Kaplan-Meier analysis was conducted comparing median progression free survival and median overall survival from completion of radiotherapy in all KRAS-mt patients and KRAS-G12C-mutated patients. Outcomes were also compared with and without ICI consolidation. RESULTS Of 156 patients, 42 (26.9%) were KRAS-mt and 114 (73.1%) were KRAS-wt. Baseline characteristics differed only in histology; KRAS-mt NSCLC more likely to be adenocarcinoma. KRAS-mt patients had worse PFS (median 6.3 vs. 10.7 months, P = .041) but similar OS (median 23.1 vs. 27.3 months, P = .237). KRAS-mt patients were more likely to not receive ICI due to rapid disease progression post-CRT (23.8% vs. 4.4%, P = .007). Among patients who received ICI (n = 114), KRAS-mt was not associated with inferior PFS (8.1 vs. 11.9 months, P = .355) or OS (30.5 vs. 31.7 months, P = .692). KRAS-G12C patients (n = 22) had similar PFS and OS to other KRAS-mt. CONCLUSION In one of the largest post-CRT KRAS-mt cohort published, KRAS-mt was associated with inferior PFS, largely due to rapid progression prior to ICI consolidation, but did not affect OS. Among those who received ICI consolidation, outcomes were comparable regardless of KRAS-mt status.
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Affiliation(s)
- Adam Barsouk
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Cole Friedes
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michelle Iocolano
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Abigail Doucette
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kyle W Robinson
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christopher A D'Avella
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Melina E Marmarelis
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John A Kosteva
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Aditi P Singh
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christine A Ciunci
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William P Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lova Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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12
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Thompson JC, Scholes DG, Carpenter EL, Aggarwal C. Molecular response assessment using circulating tumor DNA (ctDNA) in advanced solid tumors. Br J Cancer 2023; 129:1893-1902. [PMID: 37789101 PMCID: PMC10703899 DOI: 10.1038/s41416-023-02445-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/05/2023] Open
Abstract
The therapeutic landscape for patients with advanced malignancies has changed dramatically over the last twenty years. The growing number of targeted therapies and immunotherapeutic options available have improved response rates and survival for a subset of patients, however determining which patients will experience clinical benefit from these therapies in order to avoid potential toxicities and reduce healthcare costs remains a clinical challenge. Cell-free circulating tumor DNA (ctDNA) is shed by tumor cells into systemic circulation and is already an integral part of routine clinical practice for the non-invasive tumor genotyping in advanced non-small cell lung cancer as well as other malignancies. The short half-life of ctDNA offers a unique opportunity to utilize early on-treatment changes in ctDNA for real-time assessment of therapeutic response and outcome, termed molecular response. Here, we provide a summary and review of the use of molecular response for the prediction of outcomes in patients with advanced cancer, including the current state of science, its application in clinic, and next steps for the development of this predictive tool.
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Affiliation(s)
- Jeffrey C Thompson
- Division of Pulmonary, Allergy and Critical Care Medicine, Thoracic Oncology Group, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Abramson Cancer Center, Philadelphia, PA, USA.
| | - Dylan G Scholes
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Philadelphia, PA, USA
| | - Erica L Carpenter
- Abramson Cancer Center, Philadelphia, PA, USA
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Charu Aggarwal
- Abramson Cancer Center, Philadelphia, PA, USA
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Philadelphia, PA, USA
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13
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Singh P, Bajpai P, Maheshwari D, Chawla YM, Saini K, Reddy ES, Gottimukkala K, Nayak K, Gunisetty S, Aggarwal C, Jain S, Verma C, Singla P, Soneja M, Wig N, Murali-Krishna K, Chandele A. Functional and transcriptional heterogeneity within the massively expanding HLADR +CD38 + CD8 T cell population in acute febrile dengue patients. J Virol 2023; 97:e0074623. [PMID: 37855600 PMCID: PMC10688317 DOI: 10.1128/jvi.00746-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/17/2023] [Indexed: 10/20/2023] Open
Abstract
IMPORTANCE CD8 T cells play a crucial role in protecting against intracellular pathogens such as viruses by eliminating infected cells and releasing anti-viral cytokines such as interferon gamma (IFNγ). Consequently, there is significant interest in comprehensively characterizing CD8 T cell responses in acute dengue febrile patients. Previous studies, including our own, have demonstrated that a discrete population of CD8 T cells with HLADR+ CD38+ phenotype undergoes massive expansion during the acute febrile phase of natural dengue virus infection. Although about a third of these massively expanding HLADR+ CD38+ CD8 T cells were also CD69high when examined ex vivo, only a small fraction of them produced IFNγ upon in vitro peptide stimulation. Therefore, to better understand such functional diversity of CD8 T cells responding to dengue virus infection, it is important to know the cytokines/chemokines expressed by these peptide-stimulated HLADR+CD38+ CD8 T cells and the transcriptional profiles that distinguish the CD69+IFNγ+, CD69+IFNγ-, and CD69-IFNγ- subsets.
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Affiliation(s)
- Prabhat Singh
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Prashant Bajpai
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Deepti Maheshwari
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Yadya M. Chawla
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Keshav Saini
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Elluri Seetharami Reddy
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
- Kusuma School of Biological Sciences, Indian Institute of Technology Delhi, New Delhi, India
| | - Kamalvishnu Gottimukkala
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Kaustuv Nayak
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Sivaram Gunisetty
- Department of Pediatrics, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Charu Aggarwal
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Shweta Jain
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chaitanya Verma
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Paras Singla
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kaja Murali-Krishna
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
- Department of Pediatrics, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
- Emory Vaccine Center, Emory University, Atlanta, Georgia, USA
| | - Anmol Chandele
- ICGEB-Emory Vaccine Center, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
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Simone CB, Yegya-Raman N, Manjunath S, Verma V, Shabason JE, Xu L, Cengel KA, Levin WP, Berman AT, Christodouleas JP, Aggarwal C, Cohen RB, Langer CJ, Pechet TT, Singhal S, Kucharczuk JC, Rengan R, Feigenberg SJ. Prospective Feasibility and Phase 1/2 Trial of Preoperative Proton Beam Therapy With Concurrent Chemotherapy for Resectable Stage IIIA or Superior Sulcus Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2023; 117:683-689. [PMID: 37201756 DOI: 10.1016/j.ijrobp.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Charles B Simone
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; New York Proton Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shwetha Manjunath
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vivek Verma
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jacob E Shabason
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee Xu
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; New York Proton Center, New York, New York
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Christodouleas
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corey J Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Taine T Pechet
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C Kucharczuk
- Division of Thoracic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Yegya-Raman N, Lee SH, Friedes C, Iocolano M, Kim KN, Duan L, Li B, Sun L, Cohen R, Cengel KA, Levin WP, Langer C, Aggarwal C, Ky B, O'Quinn RP, Zou W, Teo K, Deasy JO, Xiao Y, Feigenberg SJ. Association of Cardiac Dose with Cardiac Events and Survival for Locally Advanced Non-Small Cell Lung Cancer (LA-NSCLC) Treated with Concurrent Chemoradiotherapy (cCRT) in the Era of Immune Checkpoint Inhibitor (ICI) Consolidation. Int J Radiat Oncol Biol Phys 2023; 117:S169-S170. [PMID: 37784421 DOI: 10.1016/j.ijrobp.2023.06.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To assess the association of cardiac dose with post-cCRT cardiac events and survival among patients (pts) with LA-NSCLC after adoption of ICI consolidation, modern radiotherapy (RT) techniques, and data-driven cardiac constraints. MATERIALS/METHODS This single-institution, multi-site retrospective study included 335 pts with LA-NSCLC treated with definitive cCRT (60-70 Gy) from October 2017 to December 2021. Pts were evaluated for ICI consolidation. Cardiac dose constraints included heart volume receiving ≥50 Gy (V50) <25% and mean heart dose (MHD) <20 Gy. Heart, left anterior descending artery (LAD), and left ventricle were autocontoured, manually reviewed, and edited. 21 dosimetric parameters (mean dose, max dose, and min dose to the hottest x% volume [Dx%(Gy); x from 5-95 in 5% intervals]) for each were extracted, as well as LAD V15. Baseline cardiovascular disease (bCVD) was defined as heart failure (HF), coronary artery disease, peripheral vascular disease, or cerebrovascular disease. Primary endpoint was post-cCRT major adverse cardiac events (MACE), defined as acute coronary syndrome, HF hospitalization/urgent visit, coronary revascularization, or cardiac death. Secondary endpoints were grade ≥3 cardiac events (CTCAE v5.0), overall survival (OS), cancer specific mortality (CSM), and other cause mortality (OCM). Competing risk regression was used for MACE and grade ≥3 cardiac events, and Cox regression for OS, CSM, and OCM. RESULTS Median age was 68 years, 139 (41%) had bCVD, and 225 (67%) received consolidation ICI. Proton therapy was used in 117 (35%), intensity-modulated RT in 199 (59%), and 3D conformal RT in 19 (6%). Median MHD was 8.7 Gy (IQR 4.6-14.4) and median LAD V15 1.4% (IQR 0-22). Median follow-up was 39.5 months. 35 MACE events occurred; 1- and 2-year cumulative incidence (CI) were 4.2% and 9.5%. No cardiac dosimetric parameter associated with MACE after adjusting for bCVD and age (e.g., MHD sHR 0.98/Gy, 95% CI 0.93-1.03, p = 0.43) or within the following 3 subgroups: no bCVD, photon therapy, and ICI consolidation. 87 grade ≥3 cardiac events occurred; 1- and 2- year CI were 12.6% and 20.4%. Heart dose was not associated with grade ≥3 cardiac events after adjusting for bCVD, ECOG, and BMI (e.g., MHD sHR 1.00/Gy, 95% CI 0.97-1.03, p = 0.85) or within the 3 aforesaid subgroups. 183 OS events occurred, including 125 CSM and 58 OCM events. Multiple cardiac dosimetric parameters associated with worse OS on multivariable analysis (e.g., LAD V15 HR 1.01/%, 95% CI 1.00-1.02, p = 0.003), driven by associations with CSM (LAD V15 HR 1.02/%, p<0.001) but not OCM (LAD V15 HR 1.00/%, p = 0.73). Median OS was worse for LAD V15 ≥10% (22.2 vs 35.1 months, p = 0.004). CONCLUSION Among pts with LA-NSCLC treated with cCRT after adoption of ICI consolidation, modern RT techniques, and cardiac constraints, post-cCRT cardiac events were common but showed no association with cardiac dose. Cardiac dose associated with OS, driven by an association with CSM and not OCM, which may not reflect cardiac toxicity.
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Affiliation(s)
- N Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S H Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Friedes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - M Iocolano
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K N Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Duan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - B Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Sun
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - R Cohen
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - K A Cengel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - W P Levin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Langer
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Aggarwal
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - B Ky
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - R P O'Quinn
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
| | - W Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - J O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Y Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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16
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Iocolano M, Yegya-Raman N, Wang X, Friedes C, Lee SH, Duan L, Li B, Levin WP, Cengel KA, Langer C, Cohen R, Sun L, Aggarwal C, Doucette A, Xiao Y, Teo K, O'Reilly SE, Zou W, Simone CB, Feigenberg SJ. Proton Beam Therapy (PBT) Versus Intensity-Modulated Radiotherapy (IMRT) for Locally Advanced Non-Small Cell Lung Cancer (LA-NSCLC) in the Era of Immune Checkpoint Inhibitor (ICI) Consolidation: A Retrospective Cohort Study. Int J Radiat Oncol Biol Phys 2023; 117:e26. [PMID: 37784996 DOI: 10.1016/j.ijrobp.2023.06.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Patients (pts) with LA-NSCLC treated with concurrent chemoradiation (cCRT) and ICI consolidation are at high risk for treatment-related toxicities and subsequent hospitalization. We hypothesized that PBT is associated with a reduction in acute unplanned hospitalizations as compared to IMRT in the era of ICI consolidation. MATERIALS/METHODS This single institution, multi-site retrospective study included consecutive pts with LA-NSCLC treated with definitive cCRT with either PBT or IMRT from October 2017 to December 2021. Pts were evaluated for consolidative ICI. Primary endpoint was unplanned treatment-related hospitalization within 90 days of first radiation (RT) treatment. Secondary endpoints included grade 3+ pneumonitis, grade 3+ esophagitis, PFS and OS. Logistic regression was used to assess associations with 90-day hospitalization. Competing risk regression was used for grade 3+ pneumonitis and esophagitis, and Cox regression for PFS and OS. RESULTS A total of 316 pts were included: 117 (37%) received PBT and 199 (63%) IMRT. Median age was 68.5 yrs; median RT dose 66.6 Gy (IQR 65.9-70.0). PBT group was older (median 71.1 vs 67.2 yrs, p<0.005) and had a higher Charlson comorbidity index (CCI) (median 4 vs 3, p = 0.02). There was no significant difference in ECOG, smoking pack-years, T stage, N stage, target volume size, or receipt of ICI consolidation (66.7% vs 68.3%, p = 0.76). PBT group had lower mean heart dose (5.9 vs 10.8 Gy, p<0.001), LAD V15 (0 vs 6 %, p = 0.001), mean lung dose (14.7 vs 15.7 Gy, p <0.008) and effective dose to immune circulating cells (median 3.7 vs 4.9 Gy, p<0.001) but not mean esophagus dose. PBT was associated with fewer unplanned 90-day hospitalizations (23.9% vs 34.7%); which persisted on multivariable analysis (OR 0.52, 95% CI 0.30-0.90, p = 0.02) after adjusting for CCI, smoking pack-years, T4 tumors and target volume. Reasons for hospitalization in PBT and IMRT groups included progression (1.7% vs 1.5%), definite/probable toxicity from cCRT (11.1% vs 18.6%), possible toxicity from cCRT (7.7% vs 12.6%) or unrelated to cCRT (3.4% vs 2.0%). There was no significant difference between PBT or IMRT groups in G3+ pneumonitis (1-year 6.0% vs 9.1%, p = 0.49), G3+ esophagitis (1-year 6.0% vs 6.5%, p = 0.71), PFS (median 14.4 vs 15.1 months, p = 0.69), or OS (median 34.2 vs 29.4 months, p = 0.41). CONCLUSION Among pts with LA-NSCLC treated with cCRT in the era of ICI consolidation, PBT was associated with fewer acute unplanned hospitalizations compared to IMRT. There was no difference in G3+ pneumonitis, G3+ esophagitis, PFS or OS.
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Affiliation(s)
- M Iocolano
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - N Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - X Wang
- University of Pennsylvania, Department of Biostatistics and Epidemiology, Philadelphia, PA
| | - C Friedes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S H Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Duan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - B Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - W P Levin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K A Cengel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Langer
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - R Cohen
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Sun
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Aggarwal
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - A Doucette
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Y Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K Teo
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S E O'Reilly
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - W Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | | | - S J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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17
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Friedes C, Yegya-Raman N, Iocolano M, Lee SH, Li B, Duan L, Levin WP, Cengel KA, Sun L, Aggarwal C, Marmarelis ME, Doucette A, Cohen R, Xiao Y, Langer C, Feigenberg SJ. Patterns of Failure, Volume of Disease Progression, and Subsequent Ablative Management in Locally Advanced Non-Small Cell Lung Cancer (LA-NSCLC) Treated with Definitive Chemoradiation and Consolidation Immune Checkpoint Inhibitors (ICI). Int J Radiat Oncol Biol Phys 2023; 117:e18-e19. [PMID: 37784800 DOI: 10.1016/j.ijrobp.2023.06.687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) For patients (pts) with LA-NSCLC treated with chemoradiation and consolidation ICI (CRT+ICI), the patterns of failure (POF) and volume of disease progression (PD) are not well characterized. The primary objective of this study was to classify POFs, the frequency of low volume relapse (LVR), and identify pts eligible for further ablative therapy. MATERIALS/METHODS We retrospectively identified pts with unresectable stage III NSCLC treated with CRT+ICI between October 2017 and December 2021 at a single institution. Site of first failure was classified as locoregional (LRF), distant (DF), or synchronous LRF + DF. Any LRF was subclassified as in field (IFF; PD within 90% isodose line), marginal (MF; within 50% isodose line) or out of field (OOF; outside of 50% isodose line). LVR was defined as < 3 discrete sites of PD in any number or location of organs. Pts with distant LVR were considered to have oligometastatic relapse. Ablative candidates were defined as pts with < 3 discrete sites of PD amenable to further RT or surgery. Cumulative incidence of PD was calculated with death as a competing risk. Progression free survival (PFS) and overall survival (OS) were calculated from the end of RT and assessed via Kaplan Meier. Multivariable Cox modeling was used to assess correlation of pt characteristics and time-to-event outcomes. Logistic regression was used to predict variables associated with LVR. RESULTS A total of 229 pts received CRT+ICI. Median follow up was 39 months and 119 pts experienced PD. Median PFS and OS were 18.4 and 34.5 months, respectively. Of pts with PD, 71 (60%) had DF, 28 (24%) had LRF+DF, and 20 (17%) had LRF. Of pts with any LRF, 28 (57%) had IFF, 10 (21%) had MF, and 10 (21%) had OOF. Estimated 1-year cumulative incidence of LRF, DF, and LRF+DF were 9.3% (95% CI 4.5-16), 39% (95% CI 31-48), and 19% (95% CI 12-27), respectively. A total of 63 (53%) pts had LVR. In pts with LVR, 19 (30%) had isolated thoracic relapse and 44 (69%) had oligometastatic relapse. Most oligometastatic disease was intracranial (22 metastases, 44%). Pts with LVR had a longer median OS vs pts with high volume relapse (37.4 vs 15.2 months, p<0.001). At time of PD, 56 (47%) pts were candidates for further ablative therapies. Subsequent anticancer therapies were local therapy alone (35%), local and systemic therapy (16%), systemic therapy alone (36%), or no therapy (13%). On multivariable analysis, LVR (HR 0.39; 95% CI 0.21-0.73, p = 0.003) and longer receipt of ICI (HR 0.96; 95% CI 0.95-0.98; p<0.001) were associated with improved survival while squamous histology (HR 2.26; 95% CI 1.18-4.32; p = 0.039) was associated with worse survival. Longer receipt of ICI was the only variable predictive for the development of LVR (OR 1.03; 95% CI 1.01-1.05; p = 0.004). CONCLUSION This is the largest real-world series reporting POF after CRT+ICI for stage III NSCLC. Approximately half of pts experience LVR and are candidates for further ablative therapy. Further data are needed to define optimal treatment strategies for pts with LVR after CRT+ICI.
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Affiliation(s)
- C Friedes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - N Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - M Iocolano
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S H Lee
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - B Li
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Duan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - W P Levin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K A Cengel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - L Sun
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Aggarwal
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - M E Marmarelis
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - A Doucette
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - R Cohen
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - Y Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Langer
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - S J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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18
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Cantor DJ, Aggarwal C. Targeting KRAS-Mutated NSCLC: Novel TKIs and Beyond. Clin Cancer Res 2023; 29:3563-3565. [PMID: 37466928 PMCID: PMC10530517 DOI: 10.1158/1078-0432.ccr-23-1658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/20/2023]
Abstract
KRAS-mutated non-small cell lung cancer (NSCLC) is the most common genetically altered subtype of NSCLC, yet targeted therapies remain limited. Multiple studies have investigated combinations of MEK inhibitors with chemotherapy without success. Here we discuss these studies and novel approaches to targeting KRAS-mutated NSCLC. See related article by Gadgeel et al., p. 3641.
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Affiliation(s)
- David J. Cantor
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
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19
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Aggarwal C, Liu SV. Zipalertinib in EGFR Exon 20-Mutant Non-Small-Cell Lung Cancer: Drug Development in a Rare but Crowded Setting. J Clin Oncol 2023; 41:4200-4203. [PMID: 37487151 DOI: 10.1200/jco.23.00958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/25/2023] [Accepted: 06/15/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Stephen V Liu
- Division of Hematology and Oncology, Department of Medicine, Georgetown University, Washington, DC
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20
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Tompkins WP, Hwang WT, Yang YX, Singh A, Ciunci C, D'Avella C, Aggarwal C, Cohen RB, Langer CJ, Mamtani R, Marmarelis ME. Brief Report: Second-line treatment outcomes in patients with advanced NSCLC previously treated with first-line immunotherapy regimens. Clin Lung Cancer 2023; 24:558-562.e2. [PMID: 37451933 DOI: 10.1016/j.cllc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023]
Abstract
CLINICAL PRACTICE POINTS In the United States of America, nearly all patients with advanced NSCLC, absent oncogenic drivers, receive some form of immunotherapy (IO) as part of initial treatment. Current national guidelines currently recommend against IO re-challenge if there is disease progression on IO in the first line, but re-treatment with IO is attractive given its favorable toxicity profile and descriptions of durable clinical benefit in a subset of patients treated beyond disease progression on initial IO (Gandara, J Thorac Oncol, 2018). Data in the non-clinical trial setting on the efficacy of IO in sequential lines of treatment after initial IO are lacking. In our large cohort study of patients with advanced NSCLC treated with immunotherapy regimens in the first-line setting, we find that outcomes after second-line treatment did not differ statistically by type of treatment used in the second line. While current prospective clinical trials are investigating several aspects of the utility of continuing immunotherapy and adding novel agents, our study offers data outside of a clinical trial. In addition, with the increased prevalence of adjuvant immunotherapy we urgently need to wrestle with whether to continue immunotherapy in the first-line metastatic setting if a patient experiences disease progression on adjuvant immunotherapy. While this analysis does not directly investigate that question, it does provide hypothesis-generating evidence for further evaluations.
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Affiliation(s)
- William P Tompkins
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Wei-Ting Hwang
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Yu-Xiao Yang
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Aditi Singh
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christine Ciunci
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Charu Aggarwal
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronac Mamtani
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Melina E Marmarelis
- Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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21
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Sun L, Bleiberg B, Hwang WT, Marmarelis ME, Langer CJ, Singh A, Cohen RB, Mamtani R, Aggarwal C. Association Between Duration of Immunotherapy and Overall Survival in Advanced Non-Small Cell Lung Cancer. JAMA Oncol 2023; 9:1075-1082. [PMID: 37270700 PMCID: PMC10240399 DOI: 10.1001/jamaoncol.2023.1891] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/03/2023] [Indexed: 06/05/2023]
Abstract
Importance For patients with advanced non-small cell lung cancer (NSCLC) treated with frontline immunotherapy-based treatment, the optimal duration of immune checkpoint inhibitor (ICI) treatment is unknown. Objective To assess practice patterns surrounding ICI treatment discontinuation at 2 years and to evaluate the association of duration of therapy with overall survival in patients who received fixed-duration ICI therapy for 2 years vs those who continued therapy beyond 2 years. Design, Setting, and Participants This retrospective, population-based cohort study included adult patients in a clinical database diagnosed with advanced NSCLC from 2016 to 2020, who received frontline immunotherapy-based treatment. The data cutoff was August 31, 2022; data analysis was conducted from October 2022 to January 2023. Exposures Treatment discontinuation at 2 years (between 700 and 760 days, fixed duration) vs continued treatment beyond 2 years (greater than 760 days, indefinite duration). Main Outcomes and Measures Overall survival from 760 days was analyzed using Kaplan-Meier methods. Multivariable Cox regression that adjusted for patient-specific and cancer-specific factors was used to compare survival beyond 760 days between the fixed-duration group and the indefinite-duration group. Results Of 1091 patients in the analytic cohort who were still on ICI treatment at 2 years after exclusion criteria for death and progression were applied, 113 patients (median [IQR] age, 69 [62-75] years; 62 [54.9%] female; 86 [76.1%] White) were in the fixed-duration group, and 593 patients (median [IQR] age, 69 [62-76] years; 282 [47.6%] female; 414 [69.8%] White) were in the indefinite-duration group. Patients in the fixed-duration group were more likely to have a history of smoking (99% vs 93%; P = .01) and be treated at an academic center (22% vs 11%; P = .001). Two-year overall survival from 760 days was 79% (95% CI, 66%-87%) in the fixed-duration group and 81% (95% CI, 77%-85%) in the indefinite-duration group. There was no statistically significant difference in overall survival between patients in the fixed-duration and indefinite-duration groups, either on univariate (hazard ratio [HR] 1.26; 95% CI, 0.77-2.08; P = .36) or multivariable (HR 1.33; 95% CI, 0.78-2.25; P = .29) Cox regression. Approximately 1 in 5 patients discontinued immunotherapy at 2 years in the absence of progression. Conclusions and Relevance In a retrospective clinical cohort of patients with advanced NSCLC who were treated with immunotherapy and were progression-free at 2 years, approximately only 1 in 5 discontinued treatment. The lack of statistically significant overall survival advantage for the indefinite-duration cohort on adjusted analysis provides reassurance to patients and clinicians who wish to discontinue immunotherapy at 2 years.
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Affiliation(s)
- Lova Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Benjamin Bleiberg
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Melina E. Marmarelis
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Corey J. Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Aditi Singh
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Roger B. Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ronac Mamtani
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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22
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Aggarwal C, Gong M, Kumar R. MEDI0457 Plus Durvalumab in HPV-associated HNSCC-Response. Clin Cancer Res 2023; 29:2736. [PMID: 37449358 DOI: 10.1158/1078-0432.ccr-23-1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/02/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Charu Aggarwal
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maozhen Gong
- Oncology R&D, AstraZeneca, Gaithersburg, Maryland
| | - Rakesh Kumar
- Oncology R&D, AstraZeneca, Gaithersburg, Maryland
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23
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Gutierrez M, Lam WS, Hellmann MD, Gubens MA, Aggarwal C, Tan DSW, Felip E, Chiu JWY, Lee JS, Yang JCH, Garon EB, Finocchiaro G, Ahn MJ, Luft A, Landers GA, Basso A, Ma H, Kobie J, Palcza J, Cristescu R, Fong L, Snyder A, Yuan J, Herbst RS. Biomarker-directed, pembrolizumab-based combination therapy in non-small cell lung cancer: phase 2 KEYNOTE-495/KeyImPaCT trial interim results. Nat Med 2023:10.1038/s41591-023-02385-6. [PMID: 37429923 DOI: 10.1038/s41591-023-02385-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/03/2023] [Indexed: 07/12/2023]
Abstract
Although pembrolizumab confers clinical benefit in non-small cell lung cancer (NSCLC), only a subset of patients will respond due to a heterogenous tumor microenvironment. KEYNOTE-495/KeyImPaCT is an ongoing biomarker-directed, adaptively randomized phase 2 study investigating first-line pembrolizumab (200 mg every 3 weeks) + lenvatinib (20 mg daily), anti-CTLA-4 quavonlimab (25 mg every 6 weeks) or anti-LAG-3 favezelimab (200 mg or 800 mg every 3 weeks) in advanced NSCLC. Patients were categorized by T-cell-inflamed gene expression profile (TcellinfGEP) and tumor mutational burden (TMB) status and randomly assigned 1:1:1 to receive pembrolizumab + lenvatinib, pembrolizumab + quavonlimab or pembrolizumab + favezelimab. The primary outcome was investigator-assessed objective response rate (ORR) per Response Evaluation Criteria in Solid Tumors version 1.1 using pre-specified efficacy thresholds for each biomarker-defined subgroup (>5% (TcellinfGEPlowTMBnon-high (group I)), >20% (TcellinfGEPlowTMBhigh (group II) and TcellinfGEPnon-lowTMBnon-high (group III)) and >45% (TcellinfGEPnon-lowTMBhigh (group IV))). Secondary outcomes were progression-free survival, overall survival and safety. At data cutoff, ORR ranges were 0-12.0% in group I, 27.3-33.3% in group II, 13.6-40.9% in group III and 50.0-60.0% in group IV. ORR with pembrolizumab + lenvatinib in group III met the pre-specified efficacy threshold. The safety profile of each treatment arm was consistent with the known safety profile of each combination. These data demonstrate the feasibility of prospective TcellinfGEP and TMB assessment to study the clinical activity of first-line pembrolizumab-based combination therapies in advanced NSCLC. ClinicalTrials.gov registration: NCT03516981 .
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Affiliation(s)
| | - Wei-Sen Lam
- Fiona Stanley Hospital and Western Australia Country Health Service, Perth, WA, Australia
| | - Matthew D Hellmann
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Oncology Research and Development, AstraZeneca, New York, NY, USA
| | - Matthew A Gubens
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Charu Aggarwal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Shao Weng Tan
- National Cancer Centre and SingHealth Duke NUS Academic Medical Centre, Singapore, Singapore
| | - Enriqueta Felip
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Joanne W Y Chiu
- University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong, China
| | - Jong-Seok Lee
- Seoul National University, Bundang Hospital, Seongnam, South Korea
| | - James Chih-Hsin Yang
- National Taiwan University Hospital and National Taiwan University Cancer Center, Taipei City, Taiwan
| | - Edward B Garon
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Myung-Ju Ahn
- Samsung Medical Center, Sungkyunkwan University of Medicine, Seoul, South Korea
| | - Alexander Luft
- Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | | | | | - Hua Ma
- Merck & Co., Inc., Rahway, NJ, USA
- Biostatistics, Pfizer, Collegeville, PA, USA
| | | | | | | | - Lawrence Fong
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Alexandra Snyder
- Merck & Co., Inc., Rahway, NJ, USA
- Generate Biomedicines, Somerville, MA, USA
| | | | - Roy S Herbst
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA.
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24
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Aggarwal C, Marmarelis ME, Hwang WT, Scholes DG, McWilliams TL, Singh AP, Sun L, Kosteva J, Costello MR, Cohen RB, Langer CJ, Doucette A, Gabriel PN, Shulman LN, Rendle KA, Thompson JC, Bekelman JE, Carpenter EL. Association Between Availability of Molecular Genotyping Results and Overall Survival in Patients With Advanced Nonsquamous Non-Small-Cell Lung Cancer. JCO Precis Oncol 2023; 7:e2300191. [PMID: 37499192 DOI: 10.1200/po.23.00191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE Current guidelines recommend molecular genotyping for patients newly diagnosed with metastatic nonsquamous (mNSq) non-small-cell lung cancer (NSCLC). The association between availability of molecular genotyping before first line (1L) therapy and overall survival (OS) is not known. METHODS We conducted a real-world cohort study using electronic health records in patients newly diagnosed with mNSq NSCLC. Cox proportional-hazards multivariable regression models were constructed to examine the association between OS and test result availability before 1L therapy, adjusting for covariates. Additional analyses were conducted to assess the consistency and strength of the relationship. Multivariable logistic regression models were used to examine the association between concurrent tissue and plasma testing (v tissue alone) and result availability. RESULTS Three hundred twenty-six patients were included, 80% (261/326) with results available before 1L (available testing group), and 20% (65/326) without results available (unavailable testing group). With 14.2-month median follow-up, patients in the available testing group had significantly longer OS relative to the unavailable testing group (adjusted hazard ratio, 0.43; 95% CI, 0.30 to 0.62; P < .0001). The adjusted odds of availability of results before 1L therapy was higher with concurrent tissue and plasma testing (v tissue testing alone; adjusted odds ratio, 2.06; 95% CI, 1.09 to 3.90; P = .026). CONCLUSION Among patients with mNSq NSCLC in a real-world cohort, availability of molecular genotyping results before 1L therapy was associated with significantly better OS. Concurrent tissue and plasma testing was associated with a higher odds of availability of results before 1L therapy. These findings warrant renewed attention to the completion of molecular genotyping before 1L therapy.
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Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Melina E Marmarelis
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Wei-Ting Hwang
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Dylan G Scholes
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Tara L McWilliams
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Aditi P Singh
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lova Sun
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - John Kosteva
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael R Costello
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Peter N Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Katharine A Rendle
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey C Thompson
- Department of Pulmonary Medicine and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin E Bekelman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Erica L Carpenter
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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Abstract
This Viewpoint describes the use of broad molecular marker testing in patients with early-stage non–small cell lung cancer
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Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Howard Jack West
- Department of Medical Oncology, City of Hope Cancer Center, Duarte, California
- AccessHope, Los Angeles, California
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26
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Grant MJ, Aredo JV, Starrett JH, Stockhammer P, van Alderwerelt van Rosenburgh IK, Wurtz A, Piper-Valillo AJ, Piotrowska Z, Falcon C, Yu HA, Aggarwal C, Scholes D, Patil T, Nguyen C, Phadke M, Li FY, Neal J, Lemmon MA, Walther Z, Politi K, Goldberg SB. Efficacy of Osimertinib in Patients with Lung Cancer Positive for Uncommon EGFR Exon 19 Deletion Mutations. Clin Cancer Res 2023; 29:2123-2130. [PMID: 36913537 PMCID: PMC10493186 DOI: 10.1158/1078-0432.ccr-22-3497] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/03/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE The uncommon EGFR exon 19 deletion (ex19del), L747_A750>P, demonstrates reduced sensitivity to osimertinib compared with the common ex19del, E746_A750del in preclinical models. The clinical efficacy of osimertinib in patients with non-small cell lung cancer harboring L747_A750>P and other uncommon ex19dels is not known. EXPERIMENTAL DESIGN The AACR GENIE database was interrogated to characterize the frequency of individual ex19dels relative to other variants, and a multicenter retrospective cohort was used to compare clinical outcomes for patients with tumors harboring E746_A750del, L747_A750>P, and other uncommon ex19dels who received osimertinib in the first line (1L) or in second or later lines of therapy and were T790M+ (≥2L). RESULTS ex19dels comprised 45% of EGFR mutations, with 72 distinct variants ranging in frequency from 28.1% (E746_A750del) to 0.03%, with L747_A750>P representing 1.8% of the EGFR mutant cohort. In our multi-institutional cohort (N = 200), E746_A750del was associated with significantly prolonged progression-free survival (PFS) with 1L osimertinib versus L747_A750>P [median 21.3 months (95% confidence interval, 17.0-31.7) vs. 11.7 months (10.8-29.4); adjusted HR 0.52 (0.28-0.98); P = 0.043]. Osimertinib efficacy in patients with other uncommon ex19dels varied on the basis of the specific mutation present. CONCLUSIONS The ex19del L747_A750>P is associated with inferior PFS compared with the common E746_A750del mutation in patients treated with 1L osimertinib. Understanding differences in osimertinib efficacy among EGFR ex19del subtypes could alter management of these patients in the future.
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Affiliation(s)
- Michael J Grant
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Jacqueline V Aredo
- Department of Medicine (Oncology), Stanford University, Stanford, California
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | | | - Paul Stockhammer
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
| | - Iris K van Alderwerelt van Rosenburgh
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Department of Pharmacology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Biology Institute, West Haven, Connecticut
| | - Anna Wurtz
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Andrew J Piper-Valillo
- Department of Medicine (Hematology/Oncology), Massachusetts General Hospital, Boston, Massachusetts
| | - Zofia Piotrowska
- Department of Medicine (Hematology/Oncology), Massachusetts General Hospital, Boston, Massachusetts
| | - Christina Falcon
- Department of Medicine (Thoracic Oncology), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Helena A Yu
- Department of Medicine (Thoracic Oncology), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charu Aggarwal
- Department of Medicine (Division of Hematology/Oncology), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Dylan Scholes
- Department of Medicine (Division of Hematology/Oncology), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Tejas Patil
- Department of Medicine (Division of Medical Oncology), University of Colorado School of Medicine, Aurora, Colorado
| | - Christina Nguyen
- Department of Medicine (Division of Medical Oncology), University of Colorado School of Medicine, Aurora, Colorado
| | - Manali Phadke
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Fang-Yong Li
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Joel Neal
- Department of Medicine (Oncology), Stanford University, Stanford, California
| | - Mark A Lemmon
- Department of Pharmacology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Biology Institute, West Haven, Connecticut
| | - Zenta Walther
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Katerina Politi
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Sarah B Goldberg
- Department of Medicine (Section of Medical Oncology), Yale School of Medicine, New Haven, Connecticut
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27
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Sun L, Marmarelis M, Aggarwal C. Re-Evaluating Real-World Evidence in RET Fusion-Positive NSCLC: Are Randomized Clinical Trials Needed? J Thorac Oncol 2023; 18:549-551. [PMID: 37087114 DOI: 10.1016/j.jtho.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Lova Sun
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melina Marmarelis
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Center for Precision Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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28
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Aggarwal C, Ben-Shachar R, Gao Y, Hyun SW, Rivers Z, Epstein C, Kaneva K, Sangli C, Nimeiri H, Patel J. Assessment of Tumor Mutational Burden and Outcomes in Patients With Diverse Advanced Cancers Treated With Immunotherapy. JAMA Netw Open 2023; 6:e2311181. [PMID: 37129893 PMCID: PMC10155064 DOI: 10.1001/jamanetworkopen.2023.11181] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Importance There are few studies assessing the association of tumor mutational burden (TMB) and clinical outcomes in a large cohort of patients with diverse advanced cancers. Objective To clinically validate a TMB biomarker from a next-generation sequencing targeted gene panel assay. Design, Setting, and Participants A prespecified cohort study using the deidentified clinicogenomic Tempus database of patients sequenced between 2018 and 2022, which contained retrospective, observational data originating from 300 cancer sites including 199 community sites and 101 academic sites. Patients with advanced solid tumors across 8 cancer types and more than 20 histologies, sequenced with Tempus xT who were treated with immune checkpoint inhibitors (ICIs) in the first-line or second-line setting were included. Data were analyzed from September 2018 to August 2022. Exposure Treatment with US Food and Drug Administration (FDA)-approved antiprogrammed cell death-1/programmed cell death-ligand 1 (PD-1/PD-L1) ICI and/or in combination with a cytotoxic T-lymphocyte-associated protein-4 ICI. Main Outcomes and Measures The primary outcome was the association of tumor mutational burden (TMB) binary category (high [≥10 mut/mb] vs low) with overall survival (OS) in patients treated with ICIs. Secondary outcomes were progression-free survival (PFS), and time to progression (TTP). Results In the evaluable cohort of 674 patients, the median (IQR) age was 69.4 (28.6-89.8) years, 271 patients (40.2%) were female, and 435 patients (64.5%) were White. The most common advanced cancers were non-small cell lung cancer (330 patients [49.0%]), followed by bladder cancer (148 patients [22.0%]), and head and neck squamous cell carcinoma (96 patients [14.8%]). Median (IQR) follow-up was 7.2 (3.2-14.1) months. High TMB (TMB-H) cancers (206 patients [30.6%]) were significantly associated with longer OS than low TMB (TMB-L) cancers (hazard ratio [HR], 0.72; upper confidence bound [UCB], 0.91; P = .01). In a prospective subset of 403 patients treated with ICIs after TMB testing, TMB-H cancers (135 patients [33.5%]) were significantly associated with longer OS (HR, 0.61; UCB, 0.84; P = .005), PFS (HR, 0.62; UCB, 0.82; P = .003), and TTP (HR, 0.67; UCB, 0.92; P = .02) than TMB-L cancers. An overall survival benefit was seen regardless of the type of ICI used (pembrolizumab, 339 patients; HR, 0.67; UCB, 0.94; P = .03), other ICIs (64 patients; HR, 0.37; UCB, 0.85; P = .03), and after adjusting for PD-L1 and microsatellite stability status (403 patients; HR = 0.67; UCB, 0.92; P = .02). Conclusions and Relevance In this cohort study of patients with advanced solid tumors treated with ICIs in diverse clinics, TMB-H cancers were significantly associated with improved clinical outcomes compared with TMB-L cancers.
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Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
- Abramson Cancer Center, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | | | | - Jyoti Patel
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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29
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Aggarwal C, Maity AP, Bauml JM, Long Q, Aleman T, Ciunci C, D'Avella C, Volpe M, Anderson E, Jones LMC, Sun L, Singh AP, Marmarelis ME, Cohen RB, Langer CJ, Amaravadi R. A Phase II Open-Label Trial of Binimetinib and Hydroxychloroquine in Patients With Advanced KRAS-Mutant Non-Small Cell Lung Cancer. Oncologist 2023:7143566. [PMID: 37186063 DOI: 10.1093/oncolo/oyad106] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/13/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND In RAS-mutant tumors, combined MEK and autophagy inhibition using chloroquine demonstrated synthetic lethality in preclinical studies. This phase II trial evaluated the safety and activity of the MEK inhibitor binimetinib combined with hydroxychloroquine (HCQ) in patients with advanced KRAS-mutant non-small cell lung cancer (NSCLC). METHODS Eligibility criteria included KRAS-mutant NSCLC, progression after first-line therapy, ECOG PS 0-1, and adequate end-organ function. Binimetinib 45 mg was administered orally (p.o.) bid with HCQ 400 mg p.o. bid. The primary endpoint was objective response rate (ORR). A Simon's 2-stage phase II clinical trial design was used, with an α error of 5% and a power β of 80%, anticipating an ORR of 30% to proceed to the 2-stage expansion. RESULTS Between April 2021 and January 2022, 9 patients were enrolled to stage I: median age 64 years, 44.4% females, 78% smokers. The best response was stable disease in one patient (11.1%). The median progression free survival (PFS) was 1.9 months, and median overall survival (OS) was 5.3 months. Overall, 5 patients (55.6%) developed a grade 3 adverse event (AE). The most common grade 3 toxicity was rash (33%). Pre-specified criteria for stopping the trial early due to lack of efficacy were met. CONCLUSION The combination of B + HCQ in second- or later-line treatment of patients with advanced KRAS-mutant NSCLC did not show significant antitumor activity. (ClinicalTrials.gov Identifier: NCT04735068).
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Affiliation(s)
- Charu Aggarwal
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Alisha P Maity
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, PA, USA
| | - Joshua M Bauml
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Qi Long
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Tomas Aleman
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Christine Ciunci
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Christopher D'Avella
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Melissa Volpe
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Evan Anderson
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Mc Cormick Jones
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Lova Sun
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Aditi P Singh
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Melina E Marmarelis
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Roger B Cohen
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Corey J Langer
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Ravi Amaravadi
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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30
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Natarajan J, Yegya-Raman N, Kegelman TP, Kallan MJ, Roshkovan L, Katz S, Ky B, Fradley M, Xiao Y, Lee SH, Zhang Z, Langer C, Aggarwal C, Cohen R, Cengel K, Levin W, Berman AT, Feigenberg SJ. Cardiovascular Substructure Dose and Cardiac Events following Proton- and Photon-Based Chemoradiotherapy for Non-Small Cell Lung Cancer. Adv Radiat Oncol 2023. [DOI: 10.1016/j.adro.2023.101235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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31
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Yegya-Raman N, Friedes C, Sun L, Iocolano M, Kim KN, Doucette A, Cohen RB, Robinson KW, Levin WP, Cengel KA, Lally B, Agarwal M, D'Avella CA, Marmarelis ME, Kosteva JA, Singh AP, Ciunci CA, Aggarwal C, Berman AT, Langer CJ, Feigenberg SJ. Utilization and factors precluding receipt of checkpoint inhibitor consolidation for stage III NSCLC in a large U.S. academic health system. Clin Lung Cancer 2023:S1525-7304(23)00054-2. [PMID: 37076396 DOI: 10.1016/j.cllc.2023.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES We sought to determine the proportion of patients with stage III non-small cell lung cancer (NSCLC) who initiate consolidation durvalumab or other immune checkpoint inhibitors (ICIs) after concurrent chemoradiotherapy (cCRT), as well as reasons for nonreceipt and prognostic implications. MATERIALS AND METHODS We retrospectively identified consecutive patients with unresectable stage III NSCLC treated with definitive cCRT between October 2017 and December 2021 within a large US academic health system. Patients either received consolidation ICIs (ICI group) or did not (no-ICI group). Baseline characteristics and overall survival (OS) of the groups were assessed. Factors predictive of ICI nonreceipt were evaluated using logistic regression. RESULTS Of 333 patients who completed cCRT, 229 (69%) initiated consolidation ICIs; 104 (31%) did not. Reasons for ICI nonreceipt included progressive disease post-cCRT (N = 31, 9%), comorbidity or intercurrent illness (N = 25, 8%), cCRT toxicity (N = 23, 7%; 19/23 pneumonitis), and EGFR/ALK alteration (N = 14, 4%). The no-ICI group had worse performance status and a higher rate of baseline pulmonary comorbidity. Larger planning target volume was associated with post-cCRT progressive disease, and higher lung radiation dose with cCRT toxicity. Median OS was 16 months in the no-ICI group and 34.4 months in the ICI group. In the no-ICI group, OS was superior among those with EGFR/ALK alterations (median 44.5 months) and worst among those with progressive disease (median 5.9 months, P < 0.001). CONCLUSION 31% of patients who completed cCRT for stage III NSCLC did not receive consolidation ICIs. Survival amongst these patients is poor, especially for those with progressive disease post-cCRT.
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Marmarelis ME, Sun L, Aggarwal C. Adjuvant Atezolizumab Should Be Administered to All Patients With Programmed Death-Ligand 1 Expressing Surgically Resected Stage II to III NSCLC After Chemotherapy: In Favor. J Thorac Oncol 2023; 18:265-267. [PMID: 36842810 DOI: 10.1016/j.jtho.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 02/28/2023]
Affiliation(s)
- Melina E Marmarelis
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lova Sun
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Center for Precision Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Yegya-Raman N, Kegelman TP, Ho Lee S, Kallan MJ, Kim KN, Natarajan J, Deek MP, Zou W, O'Reilly SE, Zhang Z, Levin W, Cengel K, Kao G, Cohen RB, Sun LL, Langer CJ, Aggarwal C, Singh AP, O'Quinn R, Ky B, Apte A, Deasy J, Xiao Y, Berman AT, Jabbour SK, Feigenberg SJ. Death without progression as an endpoint to describe cardiac radiation effects in locally advanced non-small cell lung cancer. Clin Transl Radiat Oncol 2023; 39:100581. [PMID: 36691564 PMCID: PMC9860414 DOI: 10.1016/j.ctro.2023.100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/03/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Background and purpose Prior studies have examined associations of cardiovascular substructure dose with overall survival (OS) or cardiac events after chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC). Herein, we investigate an alternative endpoint, death without cancer progression (DWP), which is potentially more specific than OS and more sensitive than cardiac events for understanding CRT toxicity. Materials and methods We retrospectively reviewed records of 187 patients with locally advanced or oligometastatic NSCLC treated with definitive CRT from 2008 to 2016 at a single institution. Dosimetric parameters to the heart, lung, and ten cardiovascular substructures were extracted. Charlson Comorbidity Index (CCI), excluding NSCLC diagnosis, was used to stratify patients into CCI low (0-2; n = 66), CCI intermediate (3-4; n = 78), and CCI high (≥5; n = 43) groups. Primary endpoint was DWP, modeled with competing risk regression. Secondary endpoints included OS. An external cohort consisted of 140 patients from another institution. Results Median follow-up was 7.3 years for survivors. Death occurred in 143 patients (76.5 %), including death after progression in 118 (63.1 %) and DWP in 25 (13.4 %). On multivariable analysis, increasing CCI stratum and mean heart dose were associated with DWP. For mean heart dose ≥ 10 Gy vs < 10 Gy, DWP was higher (5-year rate, 16.9 % vs 6.7 %, p = 0.04) and OS worse (median, 22.9 vs 34.1 months, p < 0.001). Ventricle (left, right, and bilateral) and pericardial but not atrial substructure dose were associated with DWP, whereas all three were inversely associated with OS. Cutpoint analysis identified right ventricle mean dose ≥ 5.5 Gy as a predictor of DWP. In the external cohort, we confirmed an association of ventricle, but not atrial, dose with DWP. Conclusion Cardiovascular substructure dose showed distinct associations with DWP. Future cardiotoxicity studies in NSCLC could consider DWP as an endpoint.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Timothy P. Kegelman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sang Ho Lee
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael J. Kallan
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kristine N. Kim
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jyotsna Natarajan
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew P. Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Wei Zou
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Shannon E. O'Reilly
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Zheng Zhang
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - William Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Keith Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Gary Kao
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Roger B. Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lova L. Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Corey J. Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aditi P. Singh
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rupal O'Quinn
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ying Xiao
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abigail T. Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Steven J. Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Kim KN, Heintz J, Yegya-Raman N, Cohen R, Kegelman T, Cengel K, Marmarelis M, Sun L, Langer C, Aggarwal C, Singh A, Singhal S, Kucharczuk J, Robinson K, Feigenberg S. Toxicities and Deaths From Intercurrent Disease Following Contemporary Postoperative Radiotherapy in Resected Non-Small-Cell Lung Cancer. Clin Lung Cancer 2023; 24:e78-e86. [PMID: 36628846 DOI: 10.1016/j.cllc.2022.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/04/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The role of postoperative radiotherapy (PORT) in patients with resected locally advanced non-small-cell lung cancer (NSCLC) remains controversial due to the radiation techniques used in randomized trials. We conducted a retrospective cohort study evaluating contemporary PORT techniques to evaluate the safety of PORT and risk of death from intercurrent disease . MATERIALS AND METHODS We analyzed consecutive patients with NSCLC treated in a single center that underwent PORT for pN2 disease and/or positive margin, with 3-dimensional conformal radiotherapy (3DRT), intensity modulated radiotherapy , or proton RT (PRT), between 2008 and 2019. Clinical details were collected including intercurrent deaths, defined as death without cancer recurrence. Kaplan-Meier and Cox-Proportional Hazards Models were used. RESULTS Of 119 patients, 21 (17.6%) received 3DRT, 47 (39.5%) intensity modulated radiotherapy, and 51 (42.9%) PRT. Median follow-up was 40 months (range 8-136) and median RT dose was 5040cGy. Most patients (65.5%) received sequential adjuvant chemoRT; 18.5% received concurrent chemoRT. The rate of grade 3 toxicities was 9.2%. There were 13 (10.9%) deaths from intercurrent diseases, including 6 from second primary cancers and 2 from cardiopulmonary diseases. There were 2 additional deaths from cardiopulmonary disease in patients with cancer progression at time of death. Mean, V5Gy, V30Gy heart doses and mean lung doses were significantly lower with PRT. Three-year OS and disease-free-survival were 70.1% and 49.9%. CONCLUSION PORT using contemporary techniques was well tolerated with acceptable toxicity and low rates of intercurrent deaths. Proton therapy significantly reduced heart and lung doses, but radiotherapy modality was not associated with differences in intercurrent disease.
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Affiliation(s)
- Kristine N Kim
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Jonathan Heintz
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Roger Cohen
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Timothy Kegelman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Keith Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Melina Marmarelis
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lova Sun
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Corey Langer
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Aditi Singh
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sunil Singhal
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John Kucharczuk
- Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kyle Robinson
- Division of Hematology Oncology, Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Steven Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Febrinanto FG, Xia F, Moore K, Thapa C, Aggarwal C. Graph Lifelong Learning: A Survey. IEEE COMPUT INTELL M 2023. [DOI: 10.1109/mci.2022.3222049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Feng Xia
- Federation University Australia, AUSTRALIA
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Aggarwal C, Saba NF, Algazi A, Sukari A, Seiwert TY, Haigentz M, Porosnicu M, Bonomi M, Boyer J, Esser MT, Cheng LI, Agrawal S, Jennings EC, Durham NM, Fraser K, Lissa D, Gong M, Ceaicovscaia N, Gascó Hernández A, Kumar R. Safety and Efficacy of MEDI0457 plus Durvalumab in Patients with Human Papillomavirus-Associated Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma. Clin Cancer Res 2023; 29:560-570. [PMID: 36455147 PMCID: PMC9890138 DOI: 10.1158/1078-0432.ccr-22-1987] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/06/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Tumoral programmed cell death ligand-1 (PD-L1) expression is common in human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC). We assessed whether a DNA vaccine targeting HPV-16/18 E6/E7 with IL12 adjuvant (MEDI0457) combined with the PD-L1 inhibitor durvalumab could enhance HPV-specific T-cell response and improve outcomes in recurrent/metastatic HPV-16/18-associated HNSCC. PATIENTS AND METHODS In this phase Ib/IIa study, immunotherapy-naïve patients with ≥1 previous platinum-containing regimen (neoadjuvant/adjuvant therapy or for recurrent/metastatic disease) received MEDI0457 7 mg intramuscularly with electroporation on weeks 1, 3, 7, and 12, then every 8 weeks, plus durvalumab 1,500 mg intravenously on weeks 4, 8, and 12, then every 4 weeks, until confirmed progression and/or unacceptable toxicity. Coprimary objectives were safety and objective response rate (ORR; H0: ORR ≤ 15%); secondary objectives included 16-week disease control rate (DCR-16), overall survival (OS), and progression-free survival (PFS). RESULTS Of 35 treated patients, 29 were response evaluable (confirmed HPV-associated disease; received both agents). ORR was 27.6% [95% confidence interval (CI), 12.7-47.2; four complete responses, four partial responses]; responses were independent of PD-L1 tumor-cell expression (≥25% vs. <25%). DCR-16 was 44.8% (95% CI, 26.5-64.3). Median PFS was 3.5 months (95% CI, 1.9-9.0); median OS was 29.2 months (15.2-not calculable). Twenty-eight (80.0%) patients had treatment-related adverse events [grade 3: 5 (14.3%); no grade 4/5], resulting in discontinuation in 2 (5.7%) patients. HPV-16/18-specific T cells increased on treatment; 4 of 8 evaluable patients had a >2-fold increase in tumor-infiltrating CD8+ T cells. CONCLUSIONS MEDI0457 plus durvalumab was well tolerated. While the primary efficacy endpoint was not reached, clinical benefit was encouraging.
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Affiliation(s)
- Charu Aggarwal
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nabil F. Saba
- Winship Cancer Institute, Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Alain Algazi
- Department of Medicine: Hematology/Oncology, University of California, San Francisco, San Francisco, California
| | - Ammar Sukari
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Tanguy Y. Seiwert
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Missak Haigentz
- Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | | | - Jean Boyer
- Inovio Pharmaceuticals, Philadelphia, Pennsylvania
| | - Mark T. Esser
- Vaccines & Immune Therapies, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Lily I. Cheng
- Pathology, Oncology Safety, AstraZeneca, Gaithersburg, Maryland
| | - Sonia Agrawal
- Oncology Data Science, Research and Early Development, Oncology R&D, AstraZeneca, Gaithersburg, Maryland
| | - Emily C. Jennings
- Oncology Data Science, Research and Early Development, Oncology R&D, AstraZeneca, Gaithersburg, Maryland
| | - Nicholas M. Durham
- Oncology R&D Translational Medicine, AstraZeneca, Gaithersburg, Maryland
| | - Karl Fraser
- Oncology R&D, AstraZeneca, Gaithersburg, Maryland
| | - Delphine Lissa
- Early Oncology Clinical Science, AstraZeneca, Cambridge, United Kingdom
| | - Maozhen Gong
- Oncology R&D, AstraZeneca, Gaithersburg, Maryland
| | | | | | - Rakesh Kumar
- Oncology R&D, AstraZeneca, Gaithersburg, Maryland
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Shukla R, Ahuja R, Beesetti H, Garg A, Aggarwal C, Chaturvedi S, Nayyar K, Arora U, Lal AA, Khanna N. Sinococuline, a bioactive compound of Cocculus hirsutus has potent anti-dengue activity. Sci Rep 2023; 13:1026. [PMID: 36658277 PMCID: PMC9852271 DOI: 10.1038/s41598-023-27927-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
Dengue virus (DENV) infection has increased worldwide, with over 400 million infections annually, and has become a serious public health concern. Several drug candidates, new and repurposed, have failed to meet the primary efficacy endpoints. We have recently shown that Aqueous Extract of the stem of Cocculus hirsutus (AQCH) was effective in vitro and in vivo against DENV and was safe in humans. We now report that an active ingredient of AQCH, Sinococuline, protects against the antibody-mediated secondary-DENV infection in the AG129 mouse model. DENV infection markers were assessed, viz. serum viremia and vital organs pathologies-viral load, proinflammatory cytokines and intestinal vascular leakage. The treatment with Sinococuline at 2.0 mg/kg/day; BID (twice a day), was the most effective in protecting the severely DENV-infected AG129 mice. Also, this dose effectively reduced serum viremia and tissue-viral load and inhibited the elevated expression levels of proinflammatory cytokines (TNF-α and IL-6) in several vital organs. Based on these findings, it could be explored further for pre-clinical and clinical developments for the treatment of dengue.
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Affiliation(s)
- Rahul Shukla
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.,Division of Virus Research and Therapeutics, CSIR-Central Drug Research Institute, Lucknow, India
| | - Richa Ahuja
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.,Sun Pharmaceutical Industries Limited, Gurugram, India
| | - Hemalatha Beesetti
- Sun Pharmaceutical Industries Limited, Gurugram, India.,Virology Division, Foundation for Neglected Disease Research, 20A, KIADB Industrial Area Veerapura, Doddaballapur, Bengaluru, Karnataka, 561203, India
| | - Amit Garg
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Charu Aggarwal
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Shivam Chaturvedi
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | | | - Upasana Arora
- Sun Pharmaceutical Industries Limited, Gurugram, India
| | - Altaf A Lal
- Sun Pharmaceutical Industries Limited, Gurugram, India
| | - Navin Khanna
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India. .,Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, India.
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Aggarwal C, Leighl NB. Next-generation ctDNA-driven clinical trials in precision immuno-oncology. J Immunother Cancer 2023; 11:jitc-2022-006397. [PMID: 36657816 PMCID: PMC9853228 DOI: 10.1136/jitc-2022-006397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aggarwal C, Ramasamy V, Garg A, Shukla R, Khanna N. Cellular T-cell immune response profiling by tetravalent dengue subunit vaccine (DSV4) candidate in mice. Front Immunol 2023; 14:1128784. [PMID: 36926350 PMCID: PMC10011089 DOI: 10.3389/fimmu.2023.1128784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
While most vaccines aim to develop a solid humoral and neutralizing antibody response against the pathogen, an effective vaccine candidate should be able to stimulate both the B-cell mediated humoral immunity, and T-cell mediated cellular immunity. The focus of vaccinology is rapidly gaining to generate T cell responses, which can mediate pathogen clearance and help B cells leading to protective antibody responses. Here we evaluate the cellular immune response of the pre-clinical tetravalent dengue subunit vaccine candidate, DSV4, in mice. While we have shown previously that DSV4 induces type-specific neutralizing antibody responses in mice, in this study, we show that the vaccine candidate DSV4 well induces dengue-specific T- cell responses evaluated by their ability to produce IFN-γ. In addition to IFN-γ secretion by both CD4+ and CD8+ T-cells in immunized mice, we observed that DSV4 also induces a higher frequency and cytokine functions of follicular CD4+ helper T-cells (TFH). These cytokines lead to an efficient germinal center reaction and potent B cell antibody response. Apart from TFH response, DSV4 stimulated Type 1 T helper cells (TH1) which is characteristic of a viral infection leading to secretion of pro-inflammatory cytokines and phagocyte-dependent protective immune responses. Our study highlights that DSV4 can mediate both arms of adaptive immunity-humoral and cell-mediated immunity in mice. By elucidating vaccine-specific T cell response, our work has implications in showing DSV4 as an effective, type-specific and safe dengue vaccine candidate.
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Affiliation(s)
- Charu Aggarwal
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Viswanathan Ramasamy
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Amit Garg
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Rahul Shukla
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.,Division of Virus Research and Therapeutics, CSIR-Central Drug Research Institute, Lucknow, India
| | - Navin Khanna
- Translational Health, Molecular Medicine Division, International Centre for Genetic Engineering and Biotechnology, New Delhi, India.,Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad, India
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Yegya-Raman N, Kegelman T, Lee S, Kim K, Natarajan J, Kallan M, Levin W, Cengel K, Kao G, Langer C, Cohen R, Aggarwal C, Singh A, Adusumalli S, O'Quinn R, Ky B, Apte A, Deasy J, Xiao Y, Feigenberg S. Association Between Cardiovascular Substructure Dose and Death Without Progression after Chemoradiation for Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yeung V, Sackstein P, Grant NN, Krochmal R, Gandhi N, Aggarwal C, Halmos B, Reuss JE, Liu SV, Kim C. Use of Erdafitinib in FGFR3-Mutated Recurrent Respiratory Papillomatosis. JCO Precis Oncol 2022; 6:e2200435. [DOI: 10.1200/po.22.00435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Vincent Yeung
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Paul Sackstein
- Department of Internal Medicine, Georgetown University, Washington, DC
| | | | - Rebecca Krochmal
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Georgetown University, Washington, DC
| | | | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Balazs Halmos
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Joshua E. Reuss
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Stephen V. Liu
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Chul Kim
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
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Mountzios G, Aggarwal C. Pembrolizumab Administration Frequency, Dose Exposure, and Toxicity: Is Switching Safe? J Thorac Oncol 2022; 17:1155-1157. [PMID: 36192075 DOI: 10.1016/j.jtho.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Giannis Mountzios
- Fourth Oncology Department and Clinical Trials Unit, Henry Dunant Hospital Center, Athens, Greece.
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Philadelphia, Pennsylvania
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Aggarwal C, Carpenter EL, Scholes DG, Hwang WT, McWilliams T, Singh AP, Sun L, Kosteva JA, Costello MR, Doucette A, Gabriel PE, Roy M, Martella AO, Thompson JC, Cohen RB, Langer CJ, Shulman LN, Marmarelis ME. Improving comprehensive genotyping in patients with newly diagnosed non-squamous NSCLC: Results from a prospective trial of a behavioral nudge intervention. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
362 Background: Despite current guidelines, less than 50% of patients with metastatic (m) non-squamous (NSq) NSCLC undergo comprehensive molecular genotyping. At our institution, based on improved comprehensiveness of genotyping with use of concurrent tissue (T) and plasma (P) next generation sequencing (NGS), we designed an electronic medical record (EMR)-based nudge intervention to auto-generate an order for P NGS at the time of initial consultation, while T NGS was carried out reflexively based on institutional pathways. Methods: A prospective study was conducted at the Abramson Cancer Center and 2 community sites within the University of Pennsylvania Health System after IRB approval. A provider team-focused EMR-based nudge intervention was designed to order P NGS at the time of new patient consultation. Eligible patients for the nudge were identified using an EMR based checklist, that included 3 criteria i. newly diagnosed, ii. treatment naïve, iii. mNSq NSCLC. Results from the intervention period (4/2021-12/2021) were compared to baseline data from similar patients treated at our institution between 01/2019 and 03/2021. Categories of NCCN guideline recommended molecular genotyping were defined as: i) comprehensive: EGFR, ALK, BRAF, ROS1, MET, RET, NTRK testing, and ii) incomplete or no testing performed. The proportion of patients with comprehensive molecular genotyping prior to 1st-line therapy were compared in the pre- and post-intervention groups using the chi-square test. Results: 526 patients with mNSq NSCLC were included in this analysis: 381 in the pre-intervention cohort, 145 in the post-intervention cohort. After implementation of the EMR-based nudge, a higher proportion of patients underwent concurrent T+P testing resulting in improved comprehensive molecular genotyping. In addition, a greater proportion of patients had comprehensive genotyping available prior to 1st-line therapy in the post-intervention vs pre-intervention cohort (Table). Conclusions: Across 3 practice sites, a provider team-focused EMR-based nudge intervention was associated with a significantly higher proportion of patients with mNSq NSCLC undergoing comprehensive molecular genotyping, both overall and prior to 1st-line therapy. These findings demonstrate that behavioral, EMR-based nudges can promote guideline concordant diagnostic testing at both community and academic sites and should be studied further as a tool to improve rates of molecular testing in NSCLC.[Table: see text]
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Affiliation(s)
| | | | | | - Wei-Ting Hwang
- University of Pennsylvania, Department of Biostatistics and Epidemiology, Philadelphia, PA
| | - Tara McWilliams
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | | | - Lova Sun
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Megan Roy
- Abramson Cancer Center, Philadelphia, PA
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Barlesi F, Goldberg S, Mann H, Gopinathan A, Newton M, Aggarwal C. P1.10-01 Phase 3 Study of Durvalumab Combined with Oleclumab or Monalizumab in Patients with Unresectable Stage III NSCLC (PACIFIC-9). J Thorac Oncol 2022. [DOI: 10.1016/j.jtho.2022.07.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Vega DM, Nishimura KK, Zariffa N, Thompson JC, Hoering A, Cilento V, Rosenthal A, Anagnostou V, Baden J, Beaver JA, Chaudhuri AA, Chudova D, Fine AD, Fiore J, Hodge R, Hodgson D, Hunkapiller N, Klass DM, Kobie J, Peña C, Pennello G, Peterman N, Philip R, Quinn KJ, Raben D, Rosner GL, Sausen M, Tezcan A, Xia Q, Yi J, Young AG, Stewart MD, Carpenter EL, Aggarwal C, Allen J. Changes in Circulating Tumor DNA Reflect Clinical Benefit Across Multiple Studies of Patients With Non-Small-Cell Lung Cancer Treated With Immune Checkpoint Inhibitors. JCO Precis Oncol 2022; 6:e2100372. [PMID: 35952319 PMCID: PMC9384957 DOI: 10.1200/po.21.00372] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 03/15/2022] [Accepted: 06/14/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE As immune checkpoint inhibitors (ICI) become increasingly used in frontline settings, identifying early indicators of response is needed. Recent studies suggest a role for circulating tumor DNA (ctDNA) in monitoring response to ICI, but uncertainty exists in the generalizability of these studies. Here, the role of ctDNA for monitoring response to ICI is assessed through a standardized approach by assessing clinical trial data from five independent studies. PATIENTS AND METHODS Patient-level clinical and ctDNA data were pooled and harmonized from 200 patients across five independent clinical trials investigating the treatment of patients with non-small-cell lung cancer with programmed cell death-1 (PD-1)/programmed death ligand-1 (PD-L1)-directed monotherapy or in combination with chemotherapy. CtDNA levels were measured using different ctDNA assays across the studies. Maximum variant allele frequencies were calculated using all somatic tumor-derived variants in each unique patient sample to correlate ctDNA changes with overall survival (OS) and progression-free survival (PFS). RESULTS We observed strong associations between reductions in ctDNA levels from on-treatment liquid biopsies with improved OS (OS; hazard ratio, 2.28; 95% CI, 1.62 to 3.20; P < .001) and PFS (PFS; hazard ratio 1.76; 95% CI, 1.31 to 2.36; P < .001). Changes in the maximum variant allele frequencies ctDNA values showed strong association across different outcomes. CONCLUSION In this pooled analysis of five independent clinical trials, consistent and robust associations between reductions in ctDNA and outcomes were found across multiple end points assessed in patients with non-small-cell lung cancer treated with an ICI. Additional tumor types, stages, and drug classes should be included in future analyses to further validate this. CtDNA may serve as an important tool in clinical development and an early indicator of treatment benefit.
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Affiliation(s)
| | | | | | - Jeffrey C. Thompson
- Division of Pulmonary, Allergy and Critical Care Medicine, Thoracic Oncology Group, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Antje Hoering
- Cancer Research And Biostatistics (CRAB), Seattle, WA
| | | | | | - Valsamo Anagnostou
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan Baden
- Translational Medicine, Bristol Myers Squibb, Princeton, NJ
| | - Julia A. Beaver
- Oncology Center of Excellence, Food and Drug Administration (FDA), Silver Spring, MD
| | - Aadel A. Chaudhuri
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
- Department of Genetics, Washington University School of Medicine, St Louis, MO
- Department of Computer Science and Engineering, Washington University, St Louis, MO
- Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | | | | | - Joseph Fiore
- Oncology Development, Bristol Myers Squibb, Princeton, NJ
| | - Rachel Hodge
- Late Oncology Statistics, Oncology Biometrics, AstraZeneca, Cambridge, United Kingdom
| | - Darren Hodgson
- Translational Medicine, Oncology Research & Development, AstraZeneca, Waltham, MA
| | - Nathan Hunkapiller
- GRAIL, Menlo Park, CA
- During the conduct of this work and development of the manuscript, N.H. was affiliated with GRAIL, Inc; however, is not affiliated with GRAIL, Inc at the time of submission
| | - Daniel M. Klass
- Assay Development, Roche Sequencing Solutions, Pleasanton, CA
| | - Julie Kobie
- Translational Oncology, Early Oncology Statistics, Merck Research Laboratories, Kenilworth, NJ
| | - Carol Peña
- Companion Diagnostics, Oncology Early Development, Merck Research Laboratories, Kenilworth, NJ
| | - Gene Pennello
- Division of Imaging, Diagnostics, and Software Reliability, Office of Science and Engineering Laboratories, Food and Drug Administration (FDA), Silver Spring, MD
| | | | - Reena Philip
- Division of Molecular Genetics, Office of Health Technology 7 (In Vitro Diagnostics and Radiological Health), Food and Drug Administration (FDA), Silver Spring, MD
| | | | - David Raben
- Product Development Oncology, Genentech Inc, South San Francisco, CA
| | - Gary L. Rosner
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark Sausen
- Translational Medicine, Bristol Myers Squibb, Princeton, NJ
| | | | - Qi Xia
- Product Development Data Sciences, Genentech Inc, South San Francisco, CA
| | - Jing Yi
- Product Development Oncology, Genentech Inc, South San Francisco, CA
| | - Amanda G. Young
- Research and Development, Foundation Medicine Inc, Cambridge, MA
| | | | - Erica L. Carpenter
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeff Allen
- Friends of Cancer Research, Washington, DC
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Singh A, Horng H, Roshkovan L, Weeks JK, Hershman M, Noël P, Luna JM, Cohen EA, Pantalone L, Shinohara RT, Bauml JM, Thompson JC, Aggarwal C, Carpenter EL, Katz SI, Kontos D. Development of a robust radiomic biomarker of progression-free survival in advanced non-small cell lung cancer patients treated with first-line immunotherapy. Sci Rep 2022; 12:9993. [PMID: 35705618 PMCID: PMC9200843 DOI: 10.1038/s41598-022-14160-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/05/2022] [Indexed: 12/03/2022] Open
Abstract
We aim to determine the feasibility of a novel radiomic biomarker that can integrate with other established clinical prognostic factors to predict progression-free survival (PFS) in patients with non-small cell lung cancer (NSCLC) undergoing first-line immunotherapy. Our study includes 107 patients with stage 4 NSCLC treated with pembrolizumab-based therapy (monotherapy: 30%, combination chemotherapy: 70%). The ITK-SNAP software was used for 3D tumor volume segmentation from pre-therapy CT scans. Radiomic features (n = 102) were extracted using the CaPTk software. Impact of heterogeneity introduced by image physical dimensions (voxel spacing parameters) and acquisition parameters (contrast enhancement and CT reconstruction kernel) was mitigated by resampling the images to the minimum voxel spacing parameters and harmonization by a nested ComBat technique. This technique was initialized with radiomic features, clinical factors of age, sex, race, PD-L1 expression, ECOG status, body mass index (BMI), smoking status, recurrence event and months of progression-free survival, and image acquisition parameters as batch variables. Two phenotypes were identified using unsupervised hierarchical clustering of harmonized features. Prognostic factors, including PDL1 expression, ECOG status, BMI and smoking status, were combined with radiomic phenotypes in Cox regression models of PFS and Kaplan Meier (KM) curve-fitting. Cox model based on clinical factors had a c-statistic of 0.57, which increased to 0.63 upon addition of phenotypes derived from harmonized features. There were statistically significant differences in survival outcomes stratified by clinical covariates, as measured by the log-rank test (p = 0.034), which improved upon addition of phenotypes (p = 0.00022). We found that mitigation of heterogeneity by image resampling and nested ComBat harmonization improves prognostic value of phenotypes, resulting in better prediction of PFS when added to other prognostic variables.
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Affiliation(s)
- Apurva Singh
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hannah Horng
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Leonid Roshkovan
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Joanna K Weeks
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Michelle Hershman
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Peter Noël
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - José Marcio Luna
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Eric A Cohen
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Lauren Pantalone
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Russell T Shinohara
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Joshua M Bauml
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jeffrey C Thompson
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Medicine, Pulmonary, Allergy and Critical Care Medicine, Thoracic Oncology Group, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Charu Aggarwal
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Erica L Carpenter
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sharyn I Katz
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Despina Kontos
- Department of Radiology, Center for Biomedical Image Computing and Analytics (CBICA), University of Pennsylvania, Rm D702 Richards Bldg., 3700 Hamilton Walk, Philadelphia, PA, 19104, USA.
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47
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Affiliation(s)
- Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Department of Oncology and Department of Public Health Sciences, Queen's University, Kingston, Canada
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Joga S, Goyal S, Mehta A, Sharma M, Koyyala V, Doval D, Goyal P, Aggarwal C, M. swamy, Patel A, Nathani S, Suryavanshi M, Narayan S, Soni S, Jain A, Redhu P. P-21 Molecular subtypes (profile) of colorectal cancer and their correlation with clinical and pathological profile in a tertiary care centre in India. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.04.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Govindan R, Aggarwal C, Antonia SJ, Davies M, Dubinett SM, Ferris A, Forde PM, Garon EB, Goldberg SB, Hassan R, Hellmann MD, Hirsch FR, Johnson ML, Malik S, Morgensztern D, Neal JW, Patel JD, Rimm DL, Sagorsky S, Schwartz LH, Sepesi B, Herbst RS. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of lung cancer and mesothelioma. J Immunother Cancer 2022; 10:jitc-2021-003956. [PMID: 35640927 PMCID: PMC9157337 DOI: 10.1136/jitc-2021-003956] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/24/2022] Open
Abstract
Immunotherapy has transformed lung cancer care in recent years. In addition to providing durable responses and prolonged survival outcomes for a subset of patients with heavily pretreated non-small cell lung cancer (NSCLC), immune checkpoint inhibitors (ICIs)— either as monotherapy or in combination with other ICIs or chemotherapy—have demonstrated benefits in first-line therapy for advanced disease, the neoadjuvant and adjuvant settings, as well as in additional thoracic malignancies such as small-cell lung cancer (SCLC) and mesothelioma. Challenging questions remain, however, on topics including therapy selection, appropriate biomarker-based identification of patients who may derive benefit, the use of immunotherapy in special populations such as people with autoimmune disorders, and toxicity management. Patient and caregiver education and support for quality of life (QOL) is also important to attain maximal benefit with immunotherapy. To provide guidance to the oncology community on these and other important concerns, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). This CPG represents an update to SITC’s 2018 publication on immunotherapy for the treatment of NSCLC, and is expanded to include recommendations on SCLC and mesothelioma. The Expert Panel drew on the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for lung cancer and mesothelioma, including diagnostic testing, treatment planning, immune-related adverse events, and patient QOL considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers using immunotherapy to treat patients with lung cancer or mesothelioma.
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Affiliation(s)
- Ramaswamy Govindan
- Department of Medicine, Oncology Division, Medical Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Charu Aggarwal
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott J Antonia
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute Center for Cancer Immunotherapy, Durham, North Carolina, USA
| | - Marianne Davies
- Yale School of Nursing, Yale Cancer Center, New Haven, Connecticut, USA
| | - Steven M Dubinett
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Patrick M Forde
- Upper Aerodigestive Division, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward B Garon
- Division of Hematology/Oncology, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Sarah B Goldberg
- Section of Medical Oncology, Yale University School of Medicine, Yale Cancer Center, New Haven, Connecticut, USA
| | - Raffit Hassan
- Thoracic and GI Malignancies Branch, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Fred R Hirsch
- Center for Thoracic Oncology, Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa L Johnson
- Sarah Cannon Research Institute, Nashville, Tennessee, USA
- Tennessee Oncology/One Oncology, Nashville, Tennessee, USA
| | - Shakun Malik
- Division of Cancer Treatment & Diagnosis, CTEP, National Cancer Institute, Rockville, Maryland, USA
| | - Daniel Morgensztern
- Department of Medicine, Oncology Division, Medical Oncology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Joel W Neal
- Stanford Cancer Institute, Stanford University, Stanford, California, USA
| | - Jyoti D Patel
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Evanston, Illinois, USA
| | - David L Rimm
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Sagorsky
- Upper Aerodigestive Division, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lawrence H Schwartz
- Department of Radiology, Vagelos College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roy S Herbst
- Section of Medical Oncology, Yale University School of Medicine, Yale Cancer Center, New Haven, Connecticut, USA
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Yegya-Raman N, Friedes C, Sun L, Marmarelis ME, Levin WC, Cengel KA, Lally B, Davella C, Kosteva JA, Singh AP, Cohen RB, Aggarwal C, Ciunci C, Berman AT, Langer CJ, Feigenberg SJ. Checkpoint inhibitor consolidation after definitive chemoradiation for stage III non–small cell lung cancer: Real-world experience in a large academic health system. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.8523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8523 Background: The PACIFIC trial demonstrated a 10% improvement in 5-year survival with the addition of consolidation durvalumab versus placebo after chemoradiation (CRT) in good performance status patients (pts) with stage III non-small cell lung cancer (NSCLC). However, not all patients who complete CRT go on to receive consolidation durvalumab. We sought to describe real-world use of consolidation durvalumab or other immune checkpoint inhibitors (ICI) in this setting within a single academic health system. Methods: We retrospectively identified pts with unresectable stage III NSCLC treated with definitive CRT between October 2017 and October 2020 within the University of Pennsylvania Health System, including two urban hospitals and two satellite centers. Pts either received consolidation ICI (ICI group) or did not (no ICI group). Baseline characteristics of the groups were compared with the Chi-squared, Fisher exact, or Wilcoxon rank-sum test as appropriate. Overall survival (OS), measured from the last day of CRT, was compared using the Kaplan-Meier method and log-rank test. Results: Of the 148 consecutively treated pts who completed CRT, 108 (73%) received consolidation ICI; 40 (27%) did not. Within the ICI group, 42% completed 1 year (yr) of treatment. Within the no ICI group, reasons for non-receipt included disease progression (n = 14, 35%), CRT toxicity (n = 7, 18%), comorbidity or decline unrelated to CRT (n = 7, 18%), provider choice (n = 6, 15%) due to EGFR mutation (n = 5) or atypical histology (n = 1), pt refusal (n = 3, 8%), and death without progression (n = 3, 8%). The ICI group had better performance status (ECOG 0/1/2, 46%/49%/5% ICI vs 25%/48%/28% no ICI, p < 0.001) lower Charlson Comorbidity Index (median, 5 [IQR 4-6] ICI vs 6 [IQR 5-8] no ICI, p = 0.02), and lower rates of active autoimmune disease or immunosuppression (5% ICI vs 15% no ICI, p = 0.03). There were no differences between groups in age (median, 68 yrs [IQR 63-73] ICI vs 71 yrs [IQR 65-73] no ICI, p = 0.25), sex (female, 60% ICI vs 50% no ICI, p = 0.27), race (Black, 19% ICI vs 20% no ICI, p = 0.82), stage (IIIA/B/C, 42%/48%/11% ICI vs 40%/50%/10% no ICI, p = 0.96), and PD-L1 expression ( < 1%/1-50%/ > 50%/unknown, 36%/25%/29%/10% ICI vs 40%/25%/28%/8% no ICI, p = 0.97). 1- and 2-yr OS were 83% and 61% in the ICI group versus 52% and 34% in the no ICI group, respectively (p < 0.001). Within the no ICI group, OS was worse among those with versus those without disease progression (PD) post-CRT (1-yr OS 24% vs 74%, p = 0.03). Conclusions: In this retrospective study within a large academic health system, we found that over one-quarter of pts who completed chemoradiation for stage III NSCLC did not receive consolidation ICI, most commonly due to disease progression, CRT toxicity, or comorbidity. Survival amongst these pts is particularly poor, especially for those who experience PD shortly after CRT.
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Affiliation(s)
| | | | - Lova Sun
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Brian Lally
- University of Pennsylvania, Philadelphia, PA
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