Trastuzumab deruxtecan in patients with metastatic non-small-cell lung cancer (DESTINY-Lung01): primary results of the HER2-overexpressing cohorts from a single-arm, phase 2 trial

BACKGROUND

DESTINY-Lung01 is a multicentre, open-label, phase 2 study evaluating the antitumour activity and safety of trastuzumab deruxtecan, a HER2-directed antibody-drug conjugate, in patients with HER2-overexpressing or HER2 (ERBB2)-mutant unresectable or metastatic non-small-cell lung cancer (NSCLC). The results of the HER2-mutant cohort (cohort 2) have been reported elsewhere. Herein, we report the primary analysis of cohorts 1 and 1A, which aimed to evaluate the activity and safety of trastuzumab deruxtecan 5·4 mg/kg and 6·4 mg/kg in patients with HER2-overexpressing NSCLC.

METHODS

Patients aged 18 years or older with unresectable or metastatic (or both unresectable and metastatic) non-squamous NSCLC who had relapsed following or were refractory to standard treatment or for whom no standard treatment was available, with an HER2 immunohistochemistry score of 3+ or 2+ (without known HER2 mutations) and an Eastern Cooperative Oncology Group performance status score of 0 or 1, were enrolled at 20 specialist hospitals in France, Japan, the Netherlands, Spain, and the USA. Patients were assigned to cohorts sequentially, first to cohort 1, to receive trastuzumab deruxtecan 6·4 mg/kg (cohort 1), then to cohort 1A, to receive trastuzumab deruxtecan 5·4 mg/kg, both administered intravenously once every 3 weeks. The primary endpoint was confirmed objective response rate by independent central review and was assessed in the full analysis set, which included all patients who signed an informed consent form and were enrolled in the study. Safety was assessed in all enrolled patients who received at least one dose of trastuzumab deruxtecan. This trial is registered with ClinicalTrials.gov, NCT03505710, and is ongoing (closed to recruitment).

FINDINGS

Between Aug 27, 2018, and Jan 28, 2020, 49 patients were enrolled in cohort 1 (median age 63·0 years [IQR 58·0-68·0], 30 [61%] male, 19 [39%] female, and 31 [63%] White), and from June 16 to Dec 9, 2020, 41 patients were enrolled in cohort 1A (median age 62·0 years [IQR 56·0-66·0], 22 [54%] male, 19 [46%] female, and 31 [76%] White). As of data cutoff (Dec 3, 2021), the median treatment duration was 4·1 months (IQR 1·4-7·1) in cohort 1 and 5·5 months (1·4-8·7) in cohort 1A, and median follow-up was 12·0 months (5·4-22·4) in cohort 1 and 10·6 months (4·5-13·5) in cohort 1A. Confirmed objective response rate by independent central review was 26·5% (95% CI 15·0-41·1; 13 of 49, all partial responses) in cohort 1 and 34·1% (20·1-50·6; 14 of 41; two complete responses and 12 partial responses) in cohort 1A. The most common treatment-emergent adverse events of grade 3 or worse were neutropenia (12 [24%] of 49 in cohort 1, none in cohort 1A), pneumonia (six [12%] and two [5%], respectively), fatigue (six [12%] and three [7%], respectively), and disease progression (six [12%] and four [10%], respectively). Drug-related treatment-emergent adverse events of grade 3 or worse occurred in 26 (53%) of 41 patients in cohort 1 and nine (22%) of 49 patients in cohort 1A. Drug-related serious adverse events were reported in ten (20%) patients and three (7%) patients, respectively. Deaths due to treatment-emergent adverse events occurred in ten (20%) patients in cohort 1 (disease progression in six (12%) patients and bronchospasm, hydrocephalus, respiratory failure, and pneumonitis in one [2%] patient each), and in seven (17%) patients in cohort 1A (due to disease progression in four (10%) patients and dyspnoea, malignant neoplasm, and sepsis in one (2%) patient each). One death due to a treatment-emergent adverse event was determined to be due to study treatment by the investigator, which was in cohort 1 (pneumonitis). Independent adjudication of interstitial lung disease or pneumonitis found that drug-related interstitial lung disease or pneumonitis occurred in ten (20%) patients in cohort 1 (two [4%] grade 1, five [10%] grade 2, and three [6%] grade 5) and two (5%) patients in cohort 1A (one [2%] grade 2 and one [2%] grade 5). An additional patient in cohort 1A had grade 4 pneumonitis after the data cutoff, which was subsequently adjudicated as drug-related grade 5 interstitial lung disease or pneumonitis.

INTERPRETATION

Given the low antitumour activity of existing treatment options in this patient population, trastuzumab deruxtecan might have the potential to fill a large unmet need in HER2-overexpressing NSCLC. Our findings support further investigation of trastuzumab deruxtecan in patients with HER2-overexpressing NSCLC.

FUNDING

Daiichi Sankyo and AstraZeneca.

First-Line Dual Immunotherapy, a Treatment Option in First-Line Metastatic Non-Small-Cell Lung Cancer: Are We Ready to Use It?

This article provides valuable insights into the use of dual immunotherapy for patients with metastatic NSCLC.

Malignant Pericardial Effusion, or Fluid Around the Heart Due to Cancer

This JAMA Oncology Patient Page describes the accumulation of excess fluid around the heart caused by cancer, known as malignant pericardial effusion.

Maintenance of Certification (MOC)-Benefit vs Burden

This Viewpoint examines the demands of maintenance of certification (MOC) requirements from the ABIM on balance with the projected benefits to quality of patient care.

Perioperative Therapy for Resectable Non-Small-Cell Lung Cancer: Weighing Options for the Present and Future

Anatomic surgical resection followed by cisplatin-based platinum-doublet adjuvant chemotherapy has been a long-standing standard of care for patients with early-stage, resectable non-small-cell lung cancer (NSCLC). More recently, incorporating of immunotherapy and targeted therapy in the perioperative setting has demonstrated improved disease-free or event-free survival in biomarker-defined subsets of patients. This article summarizes the results of major trials that led to approvals beyond chemotherapy in the perioperative setting. Alongside adjuvant osimertinib as a favored strategy for patients with EGFR mutation-positive NSCLC, there are competing potential standards of care for integrating immunotherapy in the neoadjuvant versus adjuvant setting, with advantages and disadvantages for each strategy. Emerging data in the coming years will provide further insight that may potentially lead to a combination of neoadjuvant and adjuvant treatment for many patients. Future trials should focus on clarifying the benefit of each component of treatment, defining an optimal treatment duration, and incorporating minimal residual disease to optimize treatment decisions.

ChatGPT-A promising generative AI tool and its implications for cancer care

PLAIN LANGUAGE SUMMARY

Since its launch, ChatGPT has taken the internet by storm and has the potential to be used broadly in the health care system, particularly in a setting such as medical oncology. ChatGPT is well suited to review and extract key content from records of patients with cancer, interpret next-generation sequencing reports, and offer a list of potential clinical trial options.

A Multicenter, Open-Label, Phase I/II Study of FN-1501 in Patients with Advanced Solid Tumors

BACKGROUND

FN-1501, a potent inhibitor of receptor FMS-like tyrosine kinase 3 (FLT3) and CDK4/6, KIT, PDGFR, VEGFR2, ALK, and RET tyrosine kinase proteins, has demonstrated significant in vivo activity in various solid tumor and leukemia human xenograft models. Anomalies in FLT3 have an established role as a therapeutic target where the gene has been shown to play a critical role in the growth, differentiation, and survival of various cell types in hematopoietic cancer and have shown promise in various solid tumors. An open-label, Phase I/II study (NCT03690154) was designed to evaluate the safety and PK profile of FN-1501 as monotherapy in patients (pts) with advanced solid tumors and relapsed, refractory (R/R) AML.

METHODS

Pts received FN-1501 IV three times a week for 2 weeks, followed by 1 week off treatment in continuous 21-day cycles. Dose escalation followed a standard 3 + 3 design. Primary objectives include the determination of the maximum tolerated dose (MTD), safety, and recommended Phase 2 dose (RP2D). Secondary objectives include pharmacokinetics (PK) and preliminary anti-tumor activity. Exploratory objectives include the relationship between pharmacogenetic mutations (e.g., FLT3, TP53, KRAS, NRAS, etc.), safety, and efficacy; as well as an evaluation of the pharmacodynamic effects of treatment with FN-1501. Dose expansion at RP2D further explored the safety and efficacy of FN-1501 in this treatment setting.

RESULTS

A total of 48 adult pts with advanced solid tumors (N = 47) and AML (N = 1) were enrolled at doses ranging from 2.5 to 226 mg IV three times a week for two weeks in 21-day cycles (2 weeks on and 1 week off treatment). The median age was 65 years (range 30-92); 57% were female and 43% were male. The median number of prior lines of treatment was 5 (range 1-12). Forty patients evaluable for dose-limiting toxicity (DLT) assessment had a median exposure of 9.5 cycles (range 1-18 cycles). Treatment-related adverse events (TRAEs) were reported for 64% of the pts. The most common treatment-emergent adverse events (TEAEs), defined as those occurring in ≥20% of pts, primarily consisted of reversible Grade 1-2 fatigue (34%), nausea (32%), and diarrhea (26%). The most common Grade ≥3 events occurring in ≥5% of pts consisted of diarrhea and hyponatremia. Dose escalation was discontinued due to DLTs of Grade 3 thrombocytopenia (N = 1) and Grade 3 infusion-related reaction (N = 1) occurring in 2 pts. The maximum tolerated dose (MTD) was determined to be 170 mg.

CONCLUSIONS

FN-1501 demonstrated reasonable safety, tolerability, and preliminary activity against solid tumors in doses up to 170 mg. Dose escalation was terminated based on 2 DLTs occurring at the 226 mg dose level.

MET alterations in NSCLC—Current Perspectives and Future Challenges

Targeted therapies have revolutionized the treatment and improved the outcome for oncogene-driven NSCLC and an increasing number of oncogenic driver therapies have become available. For MET-dysregulated NSCLC (especially MET exon 14 skipping mutations and MET-amplifications, which is one of the most common bypass mechanisms of resistance in oncogene-addicted NSCLC), several anti-MET-targeted therapies have been approved recently (MET exon 14 skipping mutation) and multiple others are in development. In this narrative review, we summarize the role of MET as an oncogenic driver in NSCLC, discuss the different testing methods for exon 14 skipping mutations, gene amplification, and protein overexpression, and review the existing data and ongoing clinical trials regarding targeted therapies in MET-altered NSCLC. As immunotherapy with or without chemotherapy has become the standard of care for advanced NSCLC, immunotherapy data for MET-dysregulated NSCLC are put into perspective. Finally, we discuss future challenges in this rapidly evolving landscape.

Characterization of MET Exon 14 Skipping Alterations (in NSCLC) and Identification of Potential Therapeutic Targets Using Whole Transcriptome Sequencing

Introduction

Genomic alterations in the juxtamembrane exon 14 splice sites in NSCLC lead to increased MET stability and oncogenesis. We present the largest cohort study of MET Exon 14 (METex14) using whole transcriptome sequencing.

Methods

A total of 21,582 NSCLC tumor samples underwent complete genomic profiling with next-generation sequencing of DNA (592 Gene Panel, NextSeq, whole exome sequencing, NovaSeq) and RNA (NovaSeq, whole transcriptome sequencing). Clinicopathologic information including programmed death-ligand 1 and tumor mutational burden were collected and RNA expression for mutation subtypes and MET amplification were quantified. Immunogenic signatures and potential pathways of invasion were characterized using single-sample gene set enrichment analysis and mRNA gene signatures.

Results

A total of 533tumors (2.47%) with METex14 were identified. The most common alterations were point mutations (49.5%) at donor splice sites. Most alterations translated to increased MET expression, with MET co-amplification resulting in synergistic increase in expression (q < 0.05). Common coalterations were amplifications of MDM2 (19.0% versus 1.8% wild-type [WT]), HMGA2 (13.2% versus 0.98% WT), and CDK4 (10.0% versus 1.5% WT) (q < 0.05). High programmed death-ligand 1 > 50% (52.5% versus 27.3% WT, q < 0.0001) and lower proportion of high tumor mutational burden (>10 mutations per megabase, 8.3% versus 36.7% WT, p < 0.0001) were associated with METex14, which were also enriched in both immunogenic signatures and immunosuppressive checkpoints. Pathways associated with METex14 included angiogenesis and apical junction pathways (q < 0.05).

Conclusions

METex14 splicing alterations and MET co-amplification translated to higher and synergistic MET expression at the transcriptomic level. High frequencies of MDM2 and CDK4 co-amplifications and association with multiple immunosuppressive checkpoints and angiogenic pathways provide insight into potential actionable targets for combination strategies in METex14 NSCLC.

A multicenter, open-label, phase I/II study of FN-1501 in patients with advanced solid tumors and acute myeloid leukemia

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Background: FN-1501, a potent inhibitor of receptor FMS-like tyrosine kinase 3 (FLT3) and CDK4/6, KIT, PDGFR, VEGFR2, ALK and RET tyrosine kinase proteins, has demonstrated significant in vivo anti-tumor activity in a broad range of solid tumor and leukemia xenograft models. FLT3 mutations have an established role as a therapeutic target in Acute Myeloid Leukemia (AML), where the gene plays a critical role in the growth, differentiation, and survival of hematopoietic cells. An open-label, Phase I/II study ( NCT03690154 ) is evaluating the safety and PK profile of FN-1501 as monotherapy in patients (pts) with advanced solid tumors and relapsed, refractory (R/R) AML. Methods: Pts received FN-1501 IV thrice weekly for 2 weeks followed by 1 week off treatment in 21-day cycles. Dose escalation follows a 3+3 design. Primary objectives include determination of maximum tolerated dose (MTD), safety, and recommended phase 2 dose (RP2D). Secondary objectives include pharmacokinetics (PK) and preliminary anti-tumor activity. Exploratory objectives include the relationship between pharmacogenetic mutations (e.g., FLT3, TP53, KRAS, NRAS), safety, efficacy and pharmacodynamic effects of FN-1501. Dose expansion at RP2D was designed to further explore safety and efficacy. Results: As of Dec 3, 2021 data cut-off (DCO), 47 pts with advanced solid tumors (N = 46) or AML (N = 1) were enrolled at doses ranging from 2.5 to 226 mg. The median age was 65 (range 30-92) with 57% female and 43% male. The median prior lines of treatment were 5 (range 1-12). Forty pts with median exposure of 9.5 cycles (range 1-18 cycles) were evaluable for dose limiting toxicity (DLT). Treatment-related adverse events (TRAEs) were reported in 64% of pts. The most common treatment-emergent adverse events (TEAEs) defined as those occurring in ≥ 20% of patients primarily consisted of reversible grade 1-2 fatigue (34%), nausea (32%) and diarrhea (26%). The most common grade ≥ 3 events occurring in ≥ 5% of pts consisted of diarrhea and hyponatremia. Dose escalation was discontinued due to DLTs of grade 3 thrombocytopenia (N = 1) and grade 3 infusion related reaction (N = 1) in 2 pts in the 226 mg dose group (2nd DLT reported after DCO). At the time of DCO, 33 pts were evaluable for disease response showing 1 with partial response (PR) (47% target lesion shrinkage), 15 with stable disease (SD) and 17 with progression of disease (PD). The PR lasted > 4 months (mts) in a patient with endometrial carcinoma (ca) at the 40 mg dose level. The longest treatment exposures were recorded in 6 pts with SD of 2.6 to > 12 mts (thymoma [1]; ovarian ca [2]; renal cell ca [1]; laryngeal ca [1] and intestinal adeno ca [1]) at doses ranging from 15 mg to 170 mg. Conclusions: FN-1501 IV has shown reasonable safety, tolerability, and preliminary activity against solid tumors up to 170 mg. Dose escalation was terminated based on 2 DLTs occurring at the 226 mg dose level. Clinical trial information: NCT03690154.

Surfaceome profiling to reveal unique therapeutic vulnerabilities in transcriptional subtypes of small cell lung cancer (SCLC)

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Background: Effective treatment options for SCLC remain limited and new treatment approaches are needed to improve outcome. We sought to validate the initial observation in cell lines and limited tissue samples of SCLC of a differential expression of cancer/testis (CT) antigens and TACSD2 gene that encodes surface protein, Trop2 across various subtypes of SCLC. We also tested whether overall surfaceome profile as previously described in other tumor types will show hierarchical priority of expression between transcriptionally defined SCLC subtypes. Methods: We conducted a comprehensive surfaceome profiling of SCLC samples using data generated by RNA sequencing (whole transcriptome) at Caris Life Sciences (Phoenix, AZ). SCLC tumors were stratified into 5 subgroups (SCLC-A/N/Y/P and -mixed) based on the relative expression of the four transcription factors. Expression values were converted to z-scores (the expression value for each gene is normalized to the average expression of that specific gene such that the z-score reflects the number of standard deviations above or below the average). The highest positive z-score among the 4 transcription factors determined subgroup. If all transcription factor z-scores for a given sample were negative, the sample was assigned to ‘Mixed’ subgroup. Significance was tested by Chi-square, Fisher’s exact test, or Mann-Whitney U test. Results: We employed data generated from 674 SCLC samples; median age of 66 years and male (48.7%). The SCLC subtype distribution was 241 (35.8%), 120 (17.8%), 40 (5.9%), 143 (21.2%), 130 (19.3%) for types A, N, P, Y and mixed respectively. Supervised analysis for TACSTD2 expression showed highest levels in YAP1 subtype and was overall significantly increased in SCLC-Y (̃3-fold) and SCLC-P (̃2-fold) subtypes compared to A, N and mixed subtypes. Similarly, SCLC-Y subtype showed the highest median expression as well as the strongest correlation with most TACSTD2-interacting and regulatory genes. A top 10 list of candidate surface protein gene out of 3699 surfaceome genes was defined for each subtype based on the strength of correlation. The top candidate surface protein gene and CT antigen gene respectively by subtype were: SCN3A (r = 0.7033, p = 1.08E-101) and NOL4, (r = 0.574, p = 2.46E-60) for SCLC-A; SSTR2, (r = 0.742, p = 8.18E-119) and TMEFF1, (r = 0.3601, p = 4.53E-22) for SCLC-N; TMPRSS13 (r = 0.5699, p = 2.64E-59) and LY6K (r = 0.4778, p = 9.80E-40) for SCLC-P; and CYBRD1 (r = 0.8559, p = 1.18E-194) and CTAGE5 (r = 0.5521, p = 4.95E-55) for SCLC-Y. Conclusions: SCLC-Y subtype showed the highest expression of TACSTD2 and its interacting and regulatory genes. This subtype could serve as an enrichment factor for antibody-drug-construct targeting TROP2. Several candidate CT antigens and surfaceome genes showing strong correlation with lineage-defining transcription factors offer additional therapeutic targets in SCLC.

Association of PAK4 expression with overall survival in patients with non-small cell lung cancer (NSCLC)

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Background: P21-activated kinase 4 (PAK4) is a crucial effector of the Rho GTPases. It acts as a regulatory switch that controls a wide range of cellular functions and plays a pivotal role in cancer progression and metastasis. Very little is known about the expression and prognostic value of PAK4 in NSCLC. Methods: 17,689 NSCLC tumor samples were analyzed using next-generation sequencing (NextSeq, 592 Genes, or WES NovaSeq), immunohistochemistry (IHC), and whole transcriptome sequencing (NovaSeq) (Caris Life Sciences, Phoenix, AZ). PD-L1 expression was analyzed by IHC (Dako 22c3; PD-L1 positive: TPS >1%). TMB was measured by counting all somatic mutations found per tumor (TMB-high: >10 mutations/MB). Tumors with PAK4-high (H) and PAK4-low (L) expression were classified as those in top quartile and bottom 3 quartiles, respectively. Immune cell infiltrates were calculated by Quantiseq. Significance was determined using chi-square and Wilcoxon rank sum test and adjusted for multiple comparisons (q-value < 0.05). Survival was extracted from insurance claims data and calculated from the time of tissue collection to the last contact using Kaplan-Meier estimates. Results: There was no difference in median age, gender, smoking status, and histologic distribution between PAK-H and PAK-L tumors. Compared to PAK4-L, the PAK4-H was associated with higher frequency of co-mutations in TP53 (76.3% vs 63.9%, p < 0.0001) and RB1 (13.6% vs 8.1%, p < 0.0001). PAK4-H tumors were associated with greater genomic loss of heterozygosity (24.1% vs 16.4%, p < 0.0001), and expression of immune checkpoint genes ( LAG3, PDCD1, PDCD1LG2, CD274, IDO1, CTLA4, CD80, HAVCR2; p < 0.05). KRAS (including KRAS G12C) , BRAF, STK11, and EGFR mutations, and ALK and ROS1 fusions were less frequent in PAK4-H tumors (p < 0.001). A greater proportion of PAK4-H tumors were TMB-H (40.3% vs 33.3%, p < 0.0001) and PD-L1 negative (48.2% vs 40.8%, p < 0.001). PAK4-H tumors had lower infiltration of B cells, M1/M2 macrophages, CD8+ T-cells, and Tregs (p < 0.001). Overall survival (OS) was inferior among patients with PAK4-H tumors (median, 14.9 vs 21.5 months, HR = 1.28, 95% CI, 1.21-1.36, p < 0.001), which was driven by adenocarcinoma histology. Survival with immunotherapy was also inferior in patients with PAK4-H adenocarcinoma (median, 23.6 vs 30.3 months, HR = 1.23, 95% CI, 1.02-1.48, p = 0.03), but not squamous cell carcinoma. A similar trend in survival was noted in patients who received EGFR- and ALK inhibitors. Conclusions: PAK4-H expression in NSCLC is associated with a higher frequency of alterations predisposing to genomic instability, differentially modulated immune phenotype, and a lower frequency of actionable genomic alterations. Patients with PAK4-H adenocarcinoma have inferior OS, and survival with immunotherapy and targeted therapy. PAK4-H expression defines a subgroup of patients with un unmet need for novel treatment strategies.

Characterization of MET exon 14 skipping alterations (METex14) in non–small cell lung cancer (NSCLC) using whole transcriptome sequencing (WTS)

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Background: Multiple DNA alterations in exon 14 splice sites have been identified in NSCLC and result in skipping of the juxtamembrane domain Cbl-E3 ubiquitin ligase binding region, leading to increased MET stability and oncogenesis. The effects of these alterations on transcriptome-level have not been fully characterized. We present the largest cohort study of METex14 using WTS and identify key cellular pathways associated with invasion and metastases in METex14. Methods: 17,666 NSCLC tumor samples underwent genomic profiling at Caris Life Sciences. Analyses included next generation sequencing of DNA (592 Gene Panel, NextSeq, whole exome sequencing, NovaSeq) and RNA (NovaSeq, WTS). METex14 was captured via WTS. ssGSEA analysis was used to evaluate pathway enrichment. Wilcoxon, Fisher’s exact were used for statistical significance (p without and q values with multiple comparison correction). Results: 440 patients (2.5%) with METex14 were identified. METex14 patients were of older age, female gender, and enriched in sarcomatoid histology (Table 1). The most common alterations were point mutations (51.5%) and deletions (17.3%) at donor splice sites. Splice site alterations except point mutations at splice acceptor site translated to increased mRNA expression compared to wild-type MET (WT). MET amplification translated to higher mRNA expression compared to METex14 and WT with synergistic expression when co-altered with METex14 (q<0.05). The most common co-alterations were amplifications of MDM2 (18.5% vs. 1.8% WT), HMGA2 (13.7% vs 0.9% WT), and CDK4 (10.4% vs 1.4% WT) (q < 0.05). METex14 were mutually exclusive to mutations in KRAS and EGFR. High PD-L1 (22c3) > 50% (53% vs. 27.6% WT, q<0.001) and lower TMB (4 mut/Mb vs. 7 mut/Mb WT, p<0.001) were observed with METex14 and pathways associated with skipping variants included IFNγ signaling, angiogenesis, and apical junction pathways on univariate analysis (q<0.05). Conclusions: We present the largest WTS analysis of METex14. Splicing alterations and MET co-amplification translated to higher and synergistic MET expression at transcriptome level, respectively. Association with upregulated angiogenic and apical junction pathways support preclinical observation of vascular and cytoskeletal remodeling as potential mechanisms of invasion and metastases in MET ex14 NSCLC.[Table: see text]

Inhibitor of the Nuclear Transport Protein XPO1 Enhances the Anticancer Efficacy of KRAS G12C Inhibitors in Preclinical Models of KRAS G12C-Mutant Cancers

The identification of molecules that can bind covalently to KRAS G12C and lock it in an inactive GDP-bound conformation has opened the door to targeting KRAS G12C selectively. These agents have shown promise in preclinical tumor models and clinical trials. FDA has recently granted approval to sotorasib for KRAS G12C mutated non-small cell lung cancer (NSCLC). However, patients receiving these agents as monotherapy generally develop drug resistance over time. This necessitates the development of multi-targeted approaches that can potentially sensitize tumors to KRAS inhibitors. We generated KRAS G12C inhibitor-resistant cell lines and observed that they exhibit sensitivity toward selinexor, a selective inhibitor of nuclear export protein exportin1 (XPO1), as a single agent. KRAS G12C inhibitors in combination with selinexor suppressed the proliferation of KRAS G12C mutant cancer cell lines in a synergistic manner. Moreover, combined treatment of selinexor with KRAS G12C inhibitors resulted in enhanced spheroid disintegration, reduction in the number and size of colonies formed by G12C mutant cancer cells. Mechanistically, the combination of selinexor with KRAS G12C inhibitors suppressed cell growth signaling and downregulated the expression of cell cycle markers, KRAS and NF-kB as well as increased nuclear accumulation of tumor suppressor protein Rb. In an in vivo KRAS G12C cell-derived xenograft model, oral administration of a combination of selinexor and sotorasib was demonstrated to reduce tumor burden and enhance survival. In conclusion, we have shown that the nuclear transport protein XPO1 inhibitor can enhance the anticancer activity of KRAS G12C inhibitors in preclinical cancer models.

Significance

In this study, combining nuclear transport inhibitor selinexor with KRAS G12C inhibitors has resulted in potent antitumor effects in preclinical cancer models. This can be an effective combination therapy for cancer patients that do not respond or develop resistance to KRAS G12C inhibitor treatment.

Challenges in the Use of Targeted Therapies in NSCLC

Precision oncology has fundamentally changed how we diagnose and treat cancer. In recent years, there has been a significant change in the management of patients with oncogene-addicted advanced-stage non–small cell lung cancer (NSCLC). Increasing amounts of identifiable oncogene drivers have led to the development of molecularly targeted drugs. Undoubtedly, the future of thoracic oncology is shifting toward increased molecular testing and the use of targeted therapies. For the most part, these novel drugs have proven to be safe and effective. As with all great innovations, targeted therapies pose unique challenges. Drug toxicities, resistance, access, and costs are some of the expected obstacles that will need to be addressed. This review highlights some of the major challenges in the use of targeted therapies in NSCLC and provides guidance for the future strategies.

Abstract P224: Update from the Phase 2 registrational trial of repotrectinib in TKI-pretreated patients with ROS1+ advanced non-small cell lung cancer and with NTRK+ advanced solid tumors (TRIDENT-1)

Background: Repotrectinib is a next-generation ROS1/TRK tyrosine kinase inhibitor (TKI) that is currently in a registrational Phase 2 trial (TRIDENT-1). A previous update from the TRIDENT-1 trial showed a generally well tolerated safety profile in 185 treated patients. Interim efficacy data were previously presented. In ROS1+ NSCLC patients with 1 prior TKI and prior platinum-based chemotherapy (EXP-2), confirmed overall response rate (cORR) was 40% (2 of 5 patients); in ROS1+ NSCLC patients with 1 prior TKI without prior platinum-based chemotherapy (EXP-4), cORR was 67% (4 of 6 patients); in ROS1+ NSCLC patients with 2 prior TKIs without prior platinum-based chemotherapy (EXP-3), cORR was 40% (2 of 5 patients). In NTRK+ TKI-pretreated advanced solid tumor patients (EXP-6), cORR was 50% (3 of 6 patients). In addition, efficacy was demonstrated in patients who developed solvent front mutations (SFM) following prior ROS1/TRK TKI treatment. cORR was 67% (4 of 6 patients) and 50% (2 of 4 patients) in ROS1+ NSCLC and NTRK+ solid tumors patients with SFMs, respectively. One patient who developed a SFM after entrectinib treatment (EXP-2) had a cCR with 5.6+ months duration of response. Methods: TRIDENT-1 (NCT03093116) is an ongoing registrational Phase 2 trial enrolling patients whose cancers harbor a ROS1 or NTRK gene fusion. Patients are enrolled into 6 defined expansion cohorts (EXP 1-6), based on cancer type and prior therapy. The primary endpoint is cORR by Blinded Independent Central Review using RECIST v1.1. Results: An updated safety analysis across Phase 1 and Phase 2 patients (n=243) based on a data cut-off date of 4 May 2021 was conducted. Treatment-emergent adverse events (TEAEs) observed in ≥20% of patients were dizziness (62%), dysgeusia (43%), constipation (33%), dyspnea (30%), paresthesia (28%), anemia (26%), and fatigue (26%). Grade ≥3 treatment-related AEs (TRAEs) were observed in 17% of patients; no Grade 5 TRAEs were observed. The majority (77%) of dizziness TEAEs were Grade 1 and 4% were Grade 3; none of the dizziness events led to treatment discontinuation. Dose modifications remained infrequent including 24% of patients with a TEAE that led to a dose reduction and 10% of patients with a TEAE that led to drug discontinuation. Updated efficacy information for TKI-pretreated ROS1+ NSCLC and NTRK+ advanced solid tumor patients is being collected and will be available for presentation. Conclusions: Repotrectinib is a next-generation ROS1/TRK inhibitor. In an ongoing registrational Phase 2 trial, repotrectinib was generally well tolerated with low frequency of dose modifications. Updated Phase 2 efficacy data will be available for presentation.

Citation Format: Jessica J. Lin, Byoung Chul Cho, Christoph Springfeld, D. Ross Camidge, Benjamin Solomon, Christina Baik, Vamsidhar Velcheti, Young-Chul Kim, Victor Moreno, Anthonie J. van der Wekken, Enriqueta Felip, Dipesh Uprety, Denise Trone, Shanna Stopatschinskaja, Alexander Drilon. Update from the Phase 2 registrational trial of repotrectinib in TKI-pretreated patients with ROS1+ advanced non-small cell lung cancer and with NTRK+ advanced solid tumors (TRIDENT-1) [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P224.

Abstract P02-01: Repotrectinib in patients with NTRK fusion-positive advanced solid tumors: update from the registrational phase 2 TRIDENT-1 trial

Background: NTRK fusions drive a broad range of solid tumors. Two FDA approved TRK tyrosine kinase inhibitors (TKIs) have demonstrated efficacy in patients (pts) with NTRK fusion+ advanced solid tumors; however, emergent TRK solvent front (SF) and gatekeeper resistance mutations occur. Repotrectinib is a next-generation ROS1/TRK TKI with potency against wildtype and mutant forms of ROS1 and TRK. In preclinical studies, repotrectinib was more potent than larotrectinib, entrectinib, and selitrectinib against wildtype TRK, SF and gatekeeper mutations. Early interim data from the Phase 1/2 TRIDENT-1 trial led to Fast Track designation by the FDA for repotrectinib in TRK TKI-pretreated pts. This abstract is an updated analysis of this population and the first presentation of repotrectinib activity in TRK TKI-naïve pts. Methods: Pts with NTRK fusion+ advanced solid tumors were enrolled into the ongoing registrational Phase 2 TRIDENT-1 trial (NCT03093116). Pts with no prior TRK TKIs were enrolled into Expansion Cohort 5 (EXP-5) and pts who received up to 2 lines of prior TRK TKIs were enrolled into EXP-6. Prior chemotherapy and/or immunotherapy were allowed in both cohorts. The primary endpoint is cORR by Blinded Independent Central Review using RECIST v1.1. Results: As of efficacy data cutoff date of 28 July 2021, 8 pts in EXP-5 and 19 pts in EXP-6 had at least 2 post-baseline scans and were evaluable for efficacy analysis. Median age was 63 y (range 33–80) in EXP-5 and 50 y (range 23–81) in EXP-6; median number of prior lines of chemo/immunotherapy was 1 (range 0–2) in EXP-5 and 1 (range 0–4) in EXP-6. In EXP-6, 79% (15/19) of pts received 1 prior TRK TKI. Confirmed responses were reported by physician assessment. In EXP-5, cORR was 63% (5 of 8 pts; 95% CI: 24–91%) with DOR from 1.9+ to 7.4+ months (mo). In EXP-6, cORR was 47% (9 of 19 pts; 95% CI: 24–71%) with DOR from 1.9+ to 15.1 mo. In 10 pts enrolled in EXP-6 with a SF mutation, the cORR was 60% (6 of 10 pts; 95% CI: 26–88%). Median duration of treatment was 6.3 mo (range 0.9–13.4+) in EXP-5 and 8.1 mo (range 1.1–20.8) in EXP-6. An updated safety analysis for Phase 1 and Phase 2 (n=243) based on a data cut-off date of 4 May 2021 was conducted. Repotrectinib was generally well tolerated. Treatment-emergent adverse events (TEAEs) observed in ≥20% of patients were dizziness (62%), dysgeusia (43%), constipation (33%), dyspnea (30%), paresthesia (28%), anemia (26%), and fatigue (26%). The majority (77%) of dizziness TEAEs were Grade 1 and 4% were Grade 3; none of the dizziness events led to treatment discontinuation. Dose modifications remained infrequent (24% of pts had a dose reduction and 10% of pts discontinued study drug due to a TEAE). Conclusions: Repotrectinib is a next-generation ROS1 and TRK inhibitor. In an ongoing registrational Phase 2 trial, repotrectinib demonstrated efficacy in TRK TKI-naïve and TKI-pretreated pts and was generally well tolerated. Enrollment in the multi-cohort Phase 2 trial is ongoing.

Citation Format: Benjamin Besse, Christina Baik, Christoph Springfeld, Alice Hervieu, Victor Moreno, Lyudmila Bazhenova, Jessica J. Lin, D. Ross Camidge, Benjamin Solomon, Vamsidhar Velcheti, Anthonie J. van der Wekken, Enriqueta Felip, Dipesh Uprety, Denise Trone, Shanna Stopatschinskaja, Byoung Chul Cho, Alexander Drilon. Repotrectinib in patients with NTRK fusion-positive advanced solid tumors: update from the registrational phase 2 TRIDENT-1 trial [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P02-01.

The Effects of HER2 Alterations in EGFR Mutant Non-small Cell Lung Cancer

BACKGROUND

HER2 alteration (mutation and/or amplification) is associated with poor survival in NSCLC and can mediate resistance to EGFR tyrosine kinase inhibitors.

METHODS

We retrospectively analyzed de-identified molecular information from 12,946 NSCLC samples that underwent next-generation sequencing (NGS) with Caris Life Sciences. The objectives were to determine the prevalence and type of HER2 alterations with and without EGFR as a co-mutation. Insurance claims were utilized to obtain outcomes data.

RESULTS

Three hundred and twenty-one patients (2.5%) had HER2 alteration: mutation in 197 patients and amplification in 134. Median age was 65 years and 62% were female. A total of 84% were adenocarcinoma. HER2 exon 20 insertion was most common (69%). A total of 1551 (12%) patients had EGFR mutations. Among samples with EGFR mutations, 24 (1.5%) had concurrent HER2 alteration (8 with HER2 mutation and 16 with amplification). Among 8 patients who had both EGFR and HER2 mutations, 3 had EGFR exon 19 deletions and exon 8 HER2 mutation (S310F). One-third of the patients (7/21) with HER2 extracellular domain (ECD) mutation had co-occurring EGFR mutations. All 7 were S310. Patients with concurrent EGFR mutation and HER2 amplification had longer median time on treatment with EGFR TKI(s) than those with EGFR mutation without HER2 amplification (HR 2.284, P =.004).

CONCLUSION

A minority of NSCLC samples with EGFR mutations had HER2 alterations. In patients with both mutations, exon 21 mutations for EGFR and exon 8 mutations for HER2 were common. It will be critical to continue to accumulate valuable clinical data for further real-world outcomes analysis.

Impact of XPO1 mutations on survival outcomes in metastatic non-small cell lung cancer (NSCLC)

BACKGROUND

Nuclear protein transport is essential in guiding the traffic of important proteins and RNAs between the nucleus and cytoplasm. Export of proteins from the nucleus is mostly regulated by Exportin 1 (XPO1). In cancer, XPO1 is almost universally hyperactive and can promote the export of important tumor suppressors to the cytoplasm. Currently, there are no studies evaluating XPO1 amplifications and mutations in NSCLC and the impact on outcomes.

METHODS

Tumor samples were analyzed using next-generation sequencing (NGS) (NextSeq, 592 Genes), immunohistochemistry (IHC), and whole transcriptome sequencing (WTS, NovaSeq) (Caris Life Sciences, Phoenix, AZ). Survival was extracted from insurance claims data and calculated from time of tissue collection to last contact using Kaplan-Meier estimate.

RESULTS

Among 18,218 NSCLC tumors sequenced, 26 harbored XPO1 mutations and 24 had amplifications. XPO1 mutant tumors were more likely to have high TMB (79% vs. 52%, p = 0.007) and less likely to have high PD-L1 (32% vs. 68%, p = 0.03). KRAS co-mutations were seen in 19% (n = 5) and EGFR co-mutations were rare (n = 2). Among the 17,449 NSCLC tumors with clinical data, there were 24 XPO1 mutant. Comparison of survival between XPO1 mutant and WT showed a negative association with a hazard ratio (HR) of 1.932 (95% CI: 1.144-3.264 p = 0.012). XPO1 amplification was not associated with survival.

CONCLUSIONS

XPO1 pathogenic mutations were associated with a poor survival in NSCLC. Although XPO1 mutations are rare in NSCLC, further studies to assess its associations with treatment responses are warranted.

Outcomes of COVID-19 in Patients With Cancer: A Closer Look at Pre-Emptive Routine Screening Strategies

PURPOSE

The benefit of routine pre-emptive screening for severe acute respiratory syndrome coronavirus 2 infections in patients with cancer before cancer-directed therapies is unclear. Herein, we characterize the outcomes of a cohort of patients with cancer who were diagnosed with COVID-19 by routine screening (RS) in comparison with those diagnosed on the basis of clinical suspicion or exposure history (nonroutine screening [NRS]).

METHODS

A multisite prospective observational study was conducted at three major and five satellite campuses of the Mayo Clinic Cancer Center between March 18 and July 31, 2020. The primary outcome was COVID-19-related hospital admission. Secondary outcomes included intensive care unit admissions and all-cause mortality.

RESULTS

Five thousand four hundred fifty-two patients underwent RS in the outpatient setting only, and 44 (0.81%) were diagnosed with COVID-19. RS detected 19 additional patients from the scheduled inpatient admissions for surgical or interventional procedures or inpatient chemotherapy. One hundred sixty-one patients were diagnosed with COVID-19 on the basis of NRS. COVID-19-related hospitalization rate (17.5% v 26.7%; P = .14), intensive care unit admission (1.6% v 5.6%; P = .19), and mortality (4.8% v 3.7%; P = .72) were not significantly different between the RS and NRS groups. In the multivariable analysis, age ≥ 60 years (odds ratio, 4.4; P = .023) and an absolute lymphocyte count ≤ 1.4 × 10⁹/L (odds ratio, 9.2; P = .002) were independent predictors of COVID-19-related hospital admission.

CONCLUSION

The COVID-19 positivity rate was low on the basis of RS. Comparing the hospital admission and mortality outcomes with the NRS cohort, there were no significant differences. The value of routine pre-emptive screening of asymptomatic patients with cancer for COVID-19 remains low.

Abstract S06-03: Outcomes of COVID-19 in patients with cancer: Results of a prospective observational comparison of routine screening strategy versus testing based on clinical suspicion

Abstract Importance: The benefit of routine screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in patients with cancer before cancer-directed therapies is unclear. Herein, we characterize the outcomes of a cohort of cancer patients diagnosed with Coronavirus Disease 2019 (COVID-19) by routine screening in comparison with those diagnosed based on clinical suspicion or exposure history (non-routine screening). Objective: To describe and compare the outcomes of cancer patients diagnosed with COVID-19 on routine screening vs. non-routine screening at a multi-site tertiary cancer center. To identify risk factors for COVID-19-related hospital admission. Design: A multi-site prospective observational study was conducted between March 18 and July 31, 2020. Setting: Three major and 5 satellite campuses of the Mayo Clinic Cancer Center. Participants: Adult patients diagnosed with active cancer within the past five years and confirmed SARS-CoV-2 infection were included. Primary Outcomes and Measures: Clinical and laboratory data were assessed as independent variables. The primary outcome was COVID-19-related hospital admission. Secondary outcomes included intensive care unit (ICU) admissions and all-cause mortality. Results: Between March 18 and July 31, 2020, 5452 patients underwent routine screening in the outpatient setting, 44 (0.81%) were diagnosed with COVID-19. Routine screening detected additional 19 patients from inpatient and pre-procedural settings; 161 patients were diagnosed with COVID-19 based on non-routine screening. The median age of the entire cohort at diagnosis was 54 years, and 95 patients (42.2%) were female. COVID-19 related-hospitalization rate (17.5% vs. 26.7%, p=0.14), ICU admission (1.6% vs. 5.6%, p=0.19), and mortality (4.8% vs. 3.7%, p=0.72) were not significantly different between routine screening and non-routine screening groups. In the multivariable analysis, age ≥ 60 years (odds ratio: 4.4, p=0.023) and an absolute lymphocyte count ≤1.4 × 109/L (odds ratio: 9.2, p=0.002) were independent predictors of COVID-19-related hospital admission. Conclusions and Relevance: The COVID-19 positivity rate was low based on routine screening. Comparing the outcome with the non-routine screening cohort, there was no significant difference. These results led to an important practice change at our cancer center. We currently follow a testing strategy based on symptoms, exposure, risk factors, and clinical judgment.

Citation Format: Zhuoer Xie, Antoine N. Saliba, Jithma Abeykoon, Umair Majeed, Daniel Almquist, Julia Wiedmeier-Nutor, Evandro Bezerra, Xavier Andrade-Gonzalez, Ashley Hickman, Karl Sorenson, Sagar Rakshit, Christopher Wee, Sri Tella, Anuhya Kommalapati, Nadine Abdallah, Joshua Pritchett, Mariza De Andrade, Dipesh Uprety, Andrew Badley, Joleen Hubbard, Naseema Gangat, Carrie A. Thompson, Thomas Witzig, Robert R. McWilliams, Konstantinos Leventakos, Thorvardur R. Halfdanarson. Outcomes of COVID-19 in patients with cancer: Results of a prospective observational comparison of routine screening strategy versus testing based on clinical suspicion [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr S06-03.

Current understanding and future implications of sepsis-induced thrombocytopenia

Sepsis is a global health burden that needs intensive medical care. Thrombocytopenia in sepsis is well known to increase morbidity as well as mortality. Several studies have been performed both in animal models and in humans to understand the mechanism by which sepsis causes thrombocytopenia. Recent studies have shown that inhibiting thrombocytopenia improves outcomes in sepsis patients. Understanding these mechanisms to identify targets in use of newer treatment modalities besides using resuscitation measures, antibiotics and removal of thrombocytopenia inducing agent could potentially help us improve outcomes in sepsis.

Changing paradigm in advanced and metastatic non-small cell lung cancer

Lung cancer is the most common cancer worldwide. Approximately 18% of all deaths related to cancer are associated with lung cancer. Management of non-small cell lung cancer (NSCLC) has been changing rapidly in last few years. For patients with unresectable non-metastatic disease, maintenance durvalumab is now given after offering chemo-radiation concurrently based on the result from the PACIFIC trial. Management of metastatic disease greatly depends on the status of sensitizing driver mutation and PD-L1 level of the tumor cells. In this review article, we will summarize the outcome of various clinical trials and will provide the most up-to-date information on the management of patients with advanced and metastatic NSCLC.

Pulmonary Neuroendocrine Tumors: Adjuvant and Systemic Treatments

OPINION STATEMENT

Bronchial carcinoids are uncommon tumors accounting for 20 to 30% of all neuroendocrine tumors and about 1-2% of all cancers of pulmonary origin. Bronchial carcinoids are well-differentiated neuroendocrine tumors and have a favorable survival outcome when compared with other subtypes of lung cancers. Treatment of bronchial carcinoids is not simple owing to intricacy of symptom presentation and heterogeneity of disease biology. Successful treatment of patients requires a multimodality approach. Resection is curative in the majority of patients with localized tumors and adjuvant treatment is not routinely recommended. Multiple options for systemic therapy exist for patients with advanced disease. To date, very few randomized clinical trials have been done, partly owing to the relative rarity of this malignancy. Somatostatin analogs (SSAs) are reasonable first-line choice for patients with tumors expressing somatostatin receptors. Everolimus is an appropriate first-line choice for somatostatin receptor negative tumors and for any patients with progressive disease. PRRT can also be considered for progressive tumors expressing somatostatin receptors. Based on retrospective series, cytotoxic chemotherapy can be selected in patients with progressive tumors, primarily when cytoreduction is needed. Herein, we will discuss evidence supporting the role of adjuvant and systemic treatment therapies for those with bronchial carcinoid tumors by focusing on various studies.

External Validation of AJCC Eighth Edition of Non-small-cell Lung Cancer Staging Among African Americans

INTRODUCTION

The American Joint Committee on Cancer (AJCC) eighth staging classification system for non-small-cell lung cancer was based on data from a multinational study consisting of 94,708 patients. African Americans were not included in this large database.

MATERIALS AND METHODS

The authors aimed to compare the performance of the AJCC eighth staging system with that of the seventh in predicting overall survival among African Americans utilizing the National Cancer Database. Cases with T- and M- categories were classified into 2 groups based on the AJCC seventh and eighth edition staging systems. Kaplan-Meier curves for overall survival were then constructed for each subgroup. Concordance index was computed using Uno's methodology to assess the overall performance between the 2 staging systems in predicting the mortality. Time-dependent area under the curve was calculated at each follow-up event for the seventh and eighth edition clinical and pathologic staging using an inverse probability of censoring weighted methodology. A 2-sided P-value < .05 was considered to show statistical significance.

RESULTS

The database identified a total of 70,606 African American patients in the study period of 2004 through 2014. Area under the curve values were consistently higher for the eighth edition scheme compared with the seventh edition (concordance 0.630 vs. 0.624, respectively; P < .0001 for clinical staging scheme and 0.596 vs. 0.591, respectively; P = .01 for pathologic staging scheme).

CONCLUSION

The AJCC eighth edition staging system showed better prognostic value in predicting overall survival when compared with the AJCC seventh edition staging scheme among African American patients with non-small-cell lung cancer.

Role of adjuvant chemotherapy in patients with pathological stage I NSCLC with high-risk features

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Background: Lobectomy is the current standard of care for patients with stage I non-small cell lung cancer (NSCLC). There is a lack of prospective data on the benefit of adjuvant chemotherapy (CT) in patients with negative margins but with high-risk features: lympho-vascular invasion (LVI) or visceral pleural invasion (VPI). We aimed to investigate the benefit of adjuvant CT in patients with pathological stage I NSCLC with high-risk features. Methods: The 2016 National Cancer Database was queried to identify patients with pathological stage I NSCLC (8th edition AJCC staging) diagnosed from 2010-2015 who received lobectomy/pneumonectomy with clear surgical margins. Patients were stratified into high risk (tumor size ≥2 cm with LVI and/or VPI) or low risk group. Multivariate Cox proportional hazards regression and propensity score matched Kaplan-Meier survival analysis were used to compare overall survival between those who received adjuvant CT and those who did not. Results: 34,556 patients were identified with 1114 (3.2%) receiving adjuvant CT. On multivariate Cox regression analysis, high risk tumors (hazard ratio [95% confidence interval] = 1.31 [1.25-1.38]) and lack of adjuvant chemotherapy (1.25 [1.09-1.44]) were associated with worse overall survival (OS). Additionally, male sex, age ≥ 60 years, higher comorbidity burden, lack of insurance, low facility volume, low median income, non-squamous histology were associated with worse OS. After propensity score matching, Kaplan-Meier survival analysis of the high risk subgroup (n = 2923) showed a significant difference in overall survival (OS) between those who received adjuvant CT (n = 1032, 5 year OS, 74.7%; 95% CI, 70.9%-78.0%) and those who did not (n = 1891, 5 year OS, 66.9%; CI, 63.9%-69.6%; p = 0.0002). In patients with no high risk factors for recurrence (n = 384), OS was not significantly different between the patients who received adjuvant CT (n = 78, 5 year OS, 75.8%; CI, 61.3%-85.5%) and those who did not receive adjuvant CT (n = 306, 5 year OS, 77.1%; CI, 70.0%-82.7%; p = 0.3). Conclusions: Our study showed better survival with adjuvant CT in patients with pathological stage I NSCLC who have tumor size greater than 2 cm, LVI and/or VPI.

Clinical utility of ramucirumab in non-small-cell lung cancer

Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small-cell lung cancer (NSCLC) accounts for about 85% of all lung cancer cases and approximately 70% of patients with NSCLC have locally advanced or metastatic disease at presentation. In NSCLC patients with advanced or metastatic disease, second line treatment with chemotherapy is associated with a poor response rate. In this article, we have reviewed the role of ramucirumab in patients with NSCLC. Ramucirumab is not current standard of care in the first line setting in the treatment of advanced or metastatic NSCLC, based on phase II data which did not show any progression-free survival (PFS) and overall survival (OS) benefit when ramucirumab was compared with non-ramucirumab arm. The REVEL study was a phase III, placebo-controlled trial which included patients with stage IV NSCLC who had progressed during or after platinum-based chemotherapy, with or without bevacizumab. Median OS was 9.1 months vs 10.5 months (HR 0.86, 95% CI 0.75-0.98) in the placebo and ramucirumab group respectively. Seventy-nine percent of patients in ramucirumab arm and 71% of patients in non-ramucirumab arm had grade ≥3 treatment-related adverse events. The addition of ramucirumab to docetaxel can be considered in younger patients with good performance status as a second line treatment option. Additionally, combined blockage of the VEGFR and EGFR pathway has been utilized to overcome resistance to EGFR therapy. The RELAY trial was a phase III, placebo-controlled trial which included patients with sensitizing EGFR mutation positive stage IV NSCLC. Patients were randomized to either ramucirumab plus erlotinib or erlotinib. The trial showed that the combination therapy showed superior PFS benefit.

In-hospital mortality in acute promyelocytic leukemia patients: A study of national inpatient sample

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Background: Acute Promyelocytic Leukemia (APL), a subtype of acute myeloid leukemia, has excellent outcomes, but continues to show high rates of early mortality. An epidemiologic study utilizing SEER between 1992 & 2007 showed an early death rate of 17.3%. There is limited data on the incidence of inpatient mortality in APL patients in the United States and the factors that contribute to early death. Methods: National Inpatient Sample was utilized to identify adult patients (≥18 years) diagnosed with APL using International Classification of Diseases, 10th edition (ICD-10-CM) code C92.40. Since the United States transitioned from using ICD-9-CM to ICD-10-CM on October 2015, we included APL patients diagnosed between 2015 & 2016. Clinical, sociodemographic and hospital characteristic data were examined; hospital volume was divided into quartiles. The association between overall inpatient survival & receipt of chemotherapy was examined in a propensity score matched cohort of patients not discharged to another acute care facility. Statistical analyses were conducted utilizing SAS version 9.4. Results: In total, 433 APL patients were identified (median age 52 years, 52% males, 65% whites). The inpatient mortality rate was 9.93%. 59.5% (n = 258) of patients did not receive chemotherapy. On univariate-analysis, patients with younger age, black-race, transfer in from other hospital, elective admissions, private insurance, large bed size hospital & large hospital volume were more likely to receive chemo. In the matched-cohort, receipt of chemo was associated with decreased mortality (Hazard Ratio 0.27, 95% CI: 0.12-0.60). We ran additional mortality analysis landmarked at 3 days and 7 days: 75% of chemo patients receiving treatment within 3 days had survival advantage with chemo (HR: 0.35 [0.15-0.82]). 90% of chemo patients receiving treatment within 7 days didn’t show any difference in survival (HR: 0.49 [0.18-1.32]) but the sample size was small. Conclusions: Our study showed an early survival benefit when patient with APL received chemotherapy within 3 days of admission. Early recognition & prompt treatment initiation will help reduce the rate of early mortality in patients with APL.

The risk of second primary malignancy in patients with localized thymoma: A U.S. population-based study

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Background: Thymoma is a rare neoplasm of anterior mediastinum. Patients often have an indolent disease. The prognosis of limited stage disease is excellent with a 10-year survival rate of 70 to 80%. Data regarding the risk of second primary malignancy in thymoma survivors are limited in recent years. In this study, we aimed to determine the risk of second primary malignancies (SPMs) among patients with limited stage thymoma. Methods: We utilized the Surveillance, Epidemiology and End Results (SEER)-13 registry to identify adult patients (≥ 18 years) with limited stage thymoma. We calculated the risk of SPM, developing ≥ 6 months after an index thymoma diagnosis, using Multiple Primary Standardized Incidence Ratio and an Absolute Excess Risk (AER) between 2004 and 2010. Statistical significance was defined as p < 0.05. Results: The database identified a cohort of 1,544 patients with limited stage thymoma with a median follow-up duration of 107 months (11-281 months). A total of 176 (11.39%) patients developed SPMs with a median latency of 62.5 months (range 6-272 months). Median age at diagnosis of SPM was 69 years (range 25- 96 years). Overall, SPM occurred at an observed to expected (O/E) ratio of 1.53 (95% CI 1.32-1.76), p < 0.001 with an AER of 60.52 per 10,000 patient-years at risk. A significantly increased risk was noted for cancer of lung and bronchus (O/E 1.77, 95% CI 1.21-2.52, p = 0.004; AER 12.17/10,000), skin excluding basal and squamous (O/E 2.09, 95% CI 1.04-3.75, p = 0.03; AER 5.17/10,000), urinary bladder (O/E 2.14, 95% CI 1.17-3.6, p = 0.014; AER 6.72/10,000), thyroid (O/E 3.48, 95% CI 1.4-7.17,p = 0.009; AER 4.49/10,000), and leukemia (O/E 3.26, 95% CI 1.63-5.83, p = 0.001; AER 6.86/10,000), including acute lymphocytic leukemia (O/E 16.09, CI: 1.95-58.11; AER 1.69/10,000), acute myeloid leukemia (O/E 3.83, CI: 1.04-9.8; AER 2.66/10,000) and other acute leukemia (O/E 29.45, CI: 3.57-106.39; AER 1.74/10,000). The risk was not significant for lymphoma (Hodgkin and non-Hodgkin), chronic leukemia, oropharyngeal, digestive tract and hepatobiliary cancer as SPM. Conclusions: The risk for SPMs is significantly increased in patient with thymoma compared to general population. Given the long-term risk of SPM, patient should be followed closely with judicious use of age-appropriate cancer screening.

Rovalpituzumab Tesirine: A Novel DLL3-Targeting Antibody-Drug Conjugate

Small cell lung cancer (SCLC) comprises about 15% of all cases of lung cancer. In recent years, owing to a change in the epidemiology of smoking habits, the incidence of the tumor has decreased; however, it remains a significant challenge to global health. While the tumor has a favorable initial response to chemoradiation, relapse is invariable, and second-line regimens may be intolerable given the severity of side effects. For patients with tumors resistant to second-line regimens, no current standard regimens exist. Rovalpituzumab tesirine is a novel antibody-drug conjugate, targeting delta-like protein 3, fundamental in the downstream cellular signaling for proliferation and apoptosis. This drug is reported to have shown promise in pre-clinical and phase I trials. It appears effective in decreasing tumor burden and is reported to be well tolerated, albeit with a significant adverse effect profile. Currently, it is being studied as part of initial and subsequent line chemotherapeutic regimens; it remains to be seen if this is a viable option in the treatment of SCLC. This may add to the agents that can be used against SCLC, and help improve outcomes.

Chlamydia trachomatis in women with pelvic inflammatory disease (PID): report from a tertiary center in eastern Nepal

Chlamydia trachomatis is an important agent of pelvic inflammatory disease (PID) globally. Laboratory diagnosis, which is vital for early and appropriate treatment, remains a challenge in resource-limited settings. Our study was undertaken to detect C. trachomatis in women with clinical features of PID. Three endocervical swabs, each obtained from 100 women clinically diagnosed with PID, were subjected to C. trachomatis antigen detection, microscopy and bacteriological culture. Logistic regression was used to assess the risk factors associated with PID. C. trachomatis antigen was present in 6%. The use of hormonal contraception, previous history of PID and a smoking habit were found to have statistically significant association in those who tested positive. Adjunctive use of rapid Chlamydia antigen test with a routinely practiced syndromic approach is beneficial for timely and appropriate antimicrobial therapy in women with PID.