Previous radiotherapy improves treatment responses and causes a trend toward longer time to progression among patients with immune checkpoint inhibitor-related adverse events

BACKGROUND

Immune-related adverse events (irAEs) are frequently encountered by patients during immune checkpoint inhibitor (ICI) treatment and are associated with better treatment outcomes. The sequencing of radiotherapy (RT) and ICIs is widely used in current clinical practice, but its effect on survival has remained unclear.

METHODS

In a real-world multicenter study including 521 patients who received ICI treatment for metastatic or locally advanced cancer, RT schedules and timing, irAEs, time to progression, overall survival, and treatment responses were retrospectively reviewed.

RESULTS

Patients who received previous RT and developed irAE (RT +/AE +) had the best overall response rate (ORR 44.0%). The ORR was 40.1% in the RT -/AE + group, 26.7% in the RT -/AE - group and 18.3% in the RT + /AE - group (p < 0.001). There was a significantly longer time to progression (TTP) in the RT + /AE + group compared to the RT -/AE - and RT + /AE - groups (log rank p = 0.001 and p < 0.001, respectively), but the trend toward longer TTP in the RT + /AE + group did not reach statistical significance in pairwise comparison to that in the RT -/AE + group. Preceding RT timing and intent had no statistically significant effect on TTP. In a multivariate model, ECOG = 0 and occurrence of irAEs remained independent positive prognostic factors for TTP (HR 0.737; 95% CI 0.582-0.935; p = 0.012, and HR 0.620; 95% CI 0.499-0.769; p < 0.001, respectively).

CONCLUSIONS

Better ORR and a trend toward longer TTP were demonstrated for patients with RT preceding ICI treatment and development of irAEs, which suggests that RT may boost the therapeutic effect of immunotherapy in patients with metastatic cancers.

Pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for clear cell renal cell carcinoma (KEYNOTE-564): 30-month follow-up analysis of a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

The first interim analysis of the KEYNOTE-564 study showed improved disease-free survival with adjuvant pembrolizumab compared with placebo after surgery in patients with clear cell renal cell carcinoma at an increased risk of recurrence. The analysis reported here, with an additional 6 months of follow-up, was designed to assess longer-term efficacy and safety of pembrolizumab versus placebo, as well as additional secondary and exploratory endpoints.

METHODS

In the multicentre, randomised, double-blind, placebo-controlled, phase 3 KEYNOTE-564 trial, adults aged 18 years or older with clear cell renal cell carcinoma with an increased risk of recurrence were enrolled at 213 hospitals and cancer centres in North America, South America, Europe, Asia, and Australia. Eligible participants had an Eastern Cooperative Oncology Group performance status of 0 or 1, had undergone nephrectomy 12 weeks or less before randomisation, and had not received previous systemic therapy for advanced renal cell carcinoma. Participants were randomly assigned (1:1) via central permuted block randomisation (block size of four) to receive pembrolizumab 200 mg or placebo intravenously every 3 weeks for up to 17 cycles. Randomisation was stratified by metastatic disease status (M0 vs M1), and the M0 group was further stratified by ECOG performance status and geographical region. All participants and investigators involved in study treatment administration were masked to the treatment group assignment. The primary endpoint was disease-free survival by investigator assessment in the intention-to-treat population (all participants randomly assigned to a treatment). Safety was assessed in the safety population, comprising all participants who received at least one dose of pembrolizumab or placebo. As the primary endpoint was met at the first interim analysis, updated data are reported without p values. This study is ongoing, but no longer recruiting, and is registered with ClinicalTrials.gov, NCT03142334.

FINDINGS

Between June 30, 2017, and Sept 20, 2019, 994 participants were assigned to receive pembrolizumab (n=496) or placebo (n=498). Median follow-up, defined as the time from randomisation to data cutoff (June 14, 2021), was 30·1 months (IQR 25·7-36·7). Disease-free survival was better with pembrolizumab compared with placebo (HR 0·63 [95% CI 0·50-0·80]). Median disease-free survival was not reached in either group. The most common all-cause grade 3-4 adverse events were hypertension (in 14 [3%] of 496 participants) and increased alanine aminotransferase (in 11 [2%]) in the pembrolizumab group, and hypertension (in 13 [3%] of 498 participants) in the placebo group. Serious adverse events attributed to study treatment occurred in 59 (12%) participants in the pembrolizumab group and one (<1%) participant in the placebo group. No deaths were attributed to pembrolizumab.

INTERPRETATION

Updated results from KEYNOTE-564 support the use of adjuvant pembrolizumab monotherapy as a standard of care for participants with renal cell carcinoma with an increased risk of recurrence after nephrectomy.

FUNDING

Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA.

Dosimetric effect of respiratory motion on planned dose in whole-breast volumetric modulated arc therapy using moderate and ultra-hypofractionation

Background and purpose

The interplay effect of respiratory motion on the planned dose in free-breathing right-sided whole-breast irradiation (WBI) were studied by simulating hypofractionated VMAT treatment courses.

Materials and methods

Ten patients with phase-triggered 4D-CT images were included in the study. VMAT plans targeting the right breast were created retrospectively with moderately hypofractionated (40.05 Gy in 15 fractions of 2.67 Gy) and ultra-hypofractionated (26 Gy 5 fractions of 5.2 Gy) schemes. 3D-CRT plans were generated as a reference. All plans were divided into respiratory phase-specific plans and calculated in the corresponding phase images. Fraction-specific dose was formed by deforming and summing the phase-specific doses in the planning image for each fraction. The fraction-specific dose distributions were deformed and superimposed onto the planning image, forming the course-specific respiratory motion perturbed dose distribution. Planned and respiratory motion perturbed doses were compared and changes due to respiratory motion and choice of fractionation were evaluated.

Results

The respiratory motion perturbed PTV coverage (V95%) decreased by 1.7% and the homogeneity index increased by 0.02 for VMAT techniques, compared to the planned values. Highest decrease in CTV coverage was 0.7%. The largest dose differences were located in the areas of steep dose gradients parallel to respiratory motion. The largest difference in DVH parameters between fractionation schemes was 0.4% of the prescribed dose. Clinically relevant changes to the doses of organs at risk were not observed. One patient was excluded from the analysis due to large respiratory amplitude.

Conclusion

Respiratory motion of less than 5 mm in magnitude did not result in clinically significant changes in the planned free-breathing WBI dose. The 5 mm margins were sufficient to account for the respiratory motion in terms of CTV dose homogeneity and coverage for VMAT techniques. Steep dose gradients near the PTV edges might decrease the CTV coverage. No clinical significance was found due to the choice of fractionation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-022-02014-5.

Local survival of pied flycatcher males and females in a pollution gradient of a Cu smelter

Survival is one of the most central population measures when the effects of the pollution are studied in natural bird populations. However, only few studies have actually measured rigorous survival estimates on adult birds. In recent years there has been a methodological advance in survival analyses by mark-recapture models. We modelled local survival (including mortality and emigration) with the program MARK in a population of a small insectivorous passerine bird, the pied flycatcher (Ficedula hypoleuca), around a point source of heavy metals. The local survival of females in the polluted area was about 50% lower than in the other areas. Males, however, survived relatively well in the heavily polluted area, but showed somewhat lower survival in the moderately polluted area. Different pollution effects between two sexes might be due to pollution-related differences in reproductive effort in females and males, and/or more intensive uptake of heavy metals by laying females.

Eimeria-parasites are associated with a lowered mother's and offspring's body condition in island and mainland populations of the bank vole

This study, based on correlative data, tests the hypothesis that infections withEimeriaspp. parasites exert a significant loss of fitness of bank voles (Clethrionomys glareolus) reflected in lower reproductive success and survival, declining host population densities and are associated positively with population size. The study was conducted in 20 mainland and 27 island populations in central Finland during May–September in 1999. Faecal samples showed that 28% of 767 individuals were infected withEimeriaspp. The presence ofEimeriaparasites was higher in dense mainland populations than in sparsely populated islands. Eimerian infections increased during the course of the breeding season, probably as a result of the high infection rate of young individuals. Accordingly, the body masses of bank voles were negatively related to the presence ofEimeriaspp. Reproductive output, as measured by the breeding probability of females and litter size, was not associated with the presence of eimerian infection. Interestingly, the body condition of the infected mothers appeared to be low. Moreover, mother's body condition was the single most important variable studied that showed a positive correlation to pup's body condition at birth. On small islands ([les ]3·2 ha) that were comprehensively trapped, the mean number ofEimeriaspp. in the bank vole population was negatively related to density changes of the bank vole population during the study. Our data are consistent with the idea that infection with coccidian parasites may be one of the factors responsible for declining host populations in small, isolated populations.

Antidepressant pharmacotherapy in the treatment of depression in the very old: a randomized, placebo-controlled trial

OBJECTIVE

This study determined the efficacy of antidepressant medication for the treatment of depression in the "old-old."

METHOD

This randomized 8-week medication trial compared citalopram, 10-40 mg/day, to placebo in the treatment of patients 75 and older with unipolar depression.

RESULTS

A total of 174 patients who were 58% women with a mean age of 79.6 years (SD=4.4) and a mean baseline Hamilton Depression Rating Scale score of 24.3 (SD=4.1) were randomly assigned to treatment at 15 sites. There was a main effect for site but not for treatment condition. The remission rate, defined as a final Hamilton depression scale score <10, was 35% for the citalopram and 33% for the placebo groups. However, patients with severe depression (baseline Hamilton depression scale score >24) tended to have a higher remission rate with medication than with placebo (35% versus 19%).

CONCLUSIONS

In the oldest group of community-dwelling patients to be studied to date, medication was not more effective than placebo for the treatment of depression. However, given the considerable psychosocial support received by all patients, the placebo condition represents more than the ingestion of an inactive pill. Across sites, there was considerable range in response to medication, 18% to 82%, and to placebo, 16% to 80%.

Phase IV research by pharmaceutical companies

The paper reviews the objectives and methods of phase IV studies performed by a pharmaceutical company with psychoactive drugs. After the introduction of a new drug additional information is needed especially regarding the safety of the drug. The term Post-Marketing Surveillance (PMS) covers all the methods used to collect this tolerability data. They include spontaneous monitoring by physicians, monitored release and related techniques, intensive monitoring typically in a hospital setting, case-control studies and cohort studies. Typical examples of new patient populations which are not usually studied extensively during the premarketing phases of drug development and which therefore need to be studied in more detail in phase IV are children and the elderly. In both of these groups certain special aspects have to be taken into consideration when planning and conducting clinical trials. Extension of the drug to new indications often starts spontaneously as observations of alert clinicians which then lead to systematic controlled trials. The methods used in the monitoring of physicians' prescription habits include the use of available commercial statistics, ad hoc physician surveys and the collecting of information through the medical representatives of the company.

Timolol vs propranolol vs placebo in common migraine prophylaxis: a double-blind multicenter trial

Common migraine sufferers (25 males, 71 females) with a history of 2-6 attacks per month participated in a 4-centre trial comparing the prophylactic effect of timolol (10 mg b.i.d.) and propranolol (80 mg b.i.d.) to placebo. After a pretreatment period of 4 weeks they entered a double-blind 3-way cross-over trial with 3 treatment periods of 12 weeks each. 83 patients received all 3 treatments. The mean frequency of attacks per 28 days was 3.35 on timolol, 3.69 on propranolol and 4.83 on placebo. Mean severity of attacks (0-3) was 1.75 on timolol, 1.83 on propranolol, and 1.93 on placebo. Mean duration of attacks was 7.41 h on timolol, 7.38 on propranolol and 7.95 on placebo. The headache index (frequency times severity) was 5.71 on timolol, 6.66 on propranolol and 9.03 on placebo (P less than 0.05, P less than 0.01 compared to placebo). The difference between propranolol and timolol was non-significant: frequency of attacks 0.34 (95% confidence limits - 0.26; 0.89). Headache index 0.95 propranolol and 23 patients on placebo experienced side effects (P less than 0.05). It is concluded that timolol and propranolol are equally effective in the used doses (1:8) for common migraine prophylaxis.

Tolfenamic acid and caffeine: a useful combination in migraine

Tolfenamic acid is a potent inhibitor of prostaglandin biosynthesis, which has been proved effective in the treatment of acute migraine attacks. The usefulness of caffeine, metoclopramide and pyridoxine as adjuncts to tolfenamic acid was tested in acute migraine attacks in ten patients. A combination of tolfenamic acid (200 mg) with either caffeine (100 mg), metoclopramide (10 mg) or pyridoxine (300 mg) was given twice to each patient in random order. Thus 60 attacks were treated. The tolfenamic acid-caffeine combination proved the most effective as judged by duration and intensity of attacks, working ability, vigilance, and overall evaluation of the drugs by the patients. Metoclopramide was somewhat better than pyridoxine as an additive.

Ergotamine vs. Metoclopramide vs. Their Combination in Acute Migraine Attacks

The effect of ergotamine tartrate was compared with that of the antiemetic agent metoclopramide and with those of two combinations in a double-blind trial of 24 adult female patients with migraine. The following combinations of the drugs were used in oral administration in a total of 176 acute migraine attacks: (a) Ergotamine 1 mg, (b) Metoclopramide 20 mg, (c) Ergotamine 1 mg + metoclopramide 20 mg, (d) Ergotamine 2 mg + metoclopramide 20 mg. The duration of attacks was significantly shorter on both of the combinations compared with the single drugs. The intensity of the pain was somewhat weaker and the appearance of nausea and vomiting somewhat but not significantly less during the combination treatments. In their overall opinion the patients favored the 2 mg + 20 mg combination significantly more than the others. Both ergotamine and metoclopramide are efficient in acute migraine attacks. Their combination seems to enhance the therapeutic response in some respects.

Mild analgesics as an alternative to ergotamine in migraine. A comparative trial with acetylsalicylic acid, ergotamine tartrate, and a dextropropoxyphene compound

The effect of ergotamine tartrate was compared with that of acetylsalicylic acid and a dextropropoxyphene compound (Doleron novum) on 525 acute migraine attacks in a double-blind crossover study of 25 adult female patients. Ergotamine tartrate and the dextropropoxyphene compound were equally effective and significantly superior to acetylsalicylic acid in preventing the attacks entirely. If the attacks were only partially prevented, the dextropropoxyphene compound was significantly superior to acetylsalicylic acid in making the attacks shorter and milder, while ergotamine tartrate did not differ significantly from acetylsalicylic acid or the dextropropoxyphene compound. The incidence of nausea and vomiting was lowest during treatment with the dextropropoxyphene compound. In the patients' overall preference, the dextropropoxyphene compound and ergotamine tartrate were significantly superior to acetyl-salicylic acid. In acute migraine the combination of dextropropoxyphene, a centrally acting analgesic, with acetylsalicylic acid and phenazone gives an alternative to ergotamine tartrate that is equally effective and causes less nausea and vomiting.

Tolfenamic acid is as effective as ergotamine during migraine attacks

Tolfenamic acid (a potent inhibitor of prostaglandin biosynthesis), ergotamine tartrate, acetylsalicylic acid, or placebo was administered during 160 migraine attacks in twenty women in a double-blind, cross-over study. Tolfenamic acid and ergotamine were equally effective in reducing the duration and intensity of attacks, but side-effects, especially nausea, were less common with tolfenamic acid. This probably accounted for the patients' preference for tolfenamic acid. The effectiveness of tolfenamic acid in acute migraine attacks accords with the postulated role of prostaglandins in migraine.

Piracetam in the treatment of post-concussional syndrome. A double-blind study

The effect of piracetam, a cyclical derivative of GABA, was compared with that of a placebo in a double-blind study of 60 patients with post-concussional syndrome of 2-12 months' duration. The daily dose of piracetam was 4,800 mg. After 8 weeks of treatment piracetam significantly reduced the occurrence and severity of the following symptoms: vertigo, headache, tiredness, decresed alertness, increased sweating and neurasthenic symptoms. No significant effect was observed on the following symptoms: tremor, orthostatic symptoms, and memory disorders. Side effect were reported by 64% of the patients under piracetam and by 32% under placebo. In the author's opinion, piracetam seems to be a promising new drug for the treatment of post-concussional syndrome.