Efficacy and safety of anti-PD-1/PD-L1 combinations versus standard of care in cancer: a systematic review and meta-analysis

Immune checkpoint inhibitors (ICIs) as monotherapy in different solid tumors showed an early detrimental effect in a subset of patients reflected by the early crossover of the progression-free survival (PFS) curves. Currently, combination therapies with ICIs added to chemotherapy or targeted therapy are expanding the landscape of metastatic solid tumors. We have examined the benefits and risks of adding ICIs to the standard of care (SOC) versus SOC alone.

A search of randomized clinical trials (RCTs) comparing ICIs combinations versus the corresponding SOC in different metastatic tumors according to the PRISMA guidelines was performed. Selected endpoints included PFS, time-to-response (TTR), overall survival (OS), overall response rate (ORR), and ≥ grade 3 adverse events (AEs). Subgroup analyses based on backbone treatment and tumor type were included.

A total of 10536 patients (19 studies) were included (ICIs-arm: 5596 patients; SOC-arm: 4940 patients). Globally, PFS, OS, and ORR results favored ICIs-arm. No differences in terms of TTR were found between arms. ICI-arm was associated with a slight increase of ≥ G3 AEs (relative risk: 1.07). The results in multiple myeloma patients are controversial in favor of ICIs combinations.

Adding ICIs to SOC benefits a greater number of patients, prolonging survival with no early detrimental effect. The toxicity profile is safe, with a mild increase of high-grade manageable AEs.

Abstract 4854: A translational multiplexed hypothesis generating study on circulating cytokines in patients with cancer cachexia

Cancer cachexia is a frequent pathophysiological state associated to terminal stage cancer patients, characterized by a significant reduction in body weight and resistant to nutritional interventions. It is an unmet medical need, and its underlying mechanisms are not completely understood.

Objectives: To measure multiple soluble cytokines in patients with cachexia, to develop new hypotheses on pathways and/or eventual therapeutic targets.

Methods: This is part of a pilot, observational, cross-sectional, case-control, IRB-reviewed translational research in cancer patients with/without cachexia. Anthropometric, clinical and biochemical data from consenting eligible cancer patients were collected. Blood samples were collected from all the participants, and plasma was separated and immediately stored at -20°C until analysis. For this substudy, human 63-plex kits were purchased from eBiosciences and used according to the manufacturer's recommendations. Plates were read using a Luminex 200 instrument, and the assay was performed in the Human Immune Monitoring Center at Stanford University (CA, USA). Data were analyzed by univariate and multivariate methods, using error adjustments for multiple testings (False Discovery Rate, FDR).

A total of 15 subjects were included in this study, 8 cachectic and 7 non-cachectic patients. Median age in cachectic group was 61.5 (36-81) years versus 63.9 (48-80) in non-cachectic group. The respective relative weight loss within the prior 3 months was 17.6% and 1.0%. Clinical, analytical and metabolomics from these patients have been reported elsewhere (doi: 10.1002/jcsm.12270). Of the 63 cytokines tested in our panel, 18 have been selected for fold-change (FC) analysis: for 12, their log2(FC)>1 (IL1RA, ENA78, IL8, GROA, IL23, MCP1, BDNF, PDGFB, IL18, IL21, RESISTIN, IL6), being the FC > 10x for IL1RA, ENA78, IL8, GROA and IL23. For the remaining 6, their log2(FC) < -1 (LEPTIN, GMCSF, IL12P40, IL1B, CD40L, IL5). The cytokines selected for their FDR were: LEPTIN, LIF, GMCSF, RESISTIN, TNFA, IL1B, IL12P40, IL4, IL12p70, BDNF, IL2, IL5, IL23, IL17A and IL13. We integrated these results with prior metabolomics research and performed pathway analyses that enabled us to identify a significant enrichment in several pathways related with infections, immune response, inflammation, energy homeostasis and cancer. This study, despite the size constraints, is able to capture known players in cancer cachexia (leptin, IL6, IL1). We show a potential role for BDNF (brain derived neurotrophic factor), which and has been described as a master coordinator of the physiological mechanisms that regulate food intake and energy expenditure, and identified as a player in murine models for cancer cachexia.

Results from this study will be integrated with data from additional research in the same patients (clinical, analytical, metabolomics and proteomics).

Citation Format: Mª Teresa Agullo-Ortuño, Virginia Pardo-Marques, Elena Prieto-Garcia, C. Vanesa Diaz-Garcia, Irene Otero, Jose A. Lopez-Martin. A translational multiplexed hypothesis generating study on circulating cytokines in patients with cancer cachexia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4854.

Comparative safety analysis of immunotherapy combined with chemotherapy versus monotherapy in solid tumors: a meta-analysis of randomized clinical trials

Background: Combination treatment (chemotherapy plus immune checkpoint blockade [ICB]) has shown promising activity in terms of efficacy, but it has been suggested that its toxicity profile is less favorable compared to monotherapy.

Methods: We conducted a meta-analysis of published randomized clinical trials comparing combination treatment to monotherapy (chemotherapy or ICB) in patients with metastatic solid tumors. Differences in rates of safety issues (all-grade adverse events, grade 3/4 adverse events, treatment-related deaths, treatment discontinuations) between groups were estimated. Subgroup analyses for the control group (chemotherapy or ICB as monotherapy) and immune checkpoint inhibitor (anti-CTLA-4 or anti-PD-1/PD-L1 antibodies) were performed.

Results: A total of 4379 patients (ten studies) were included (monotherapy: 2026 patients; combination treatment: 2353 patients). Combination treatment presented more grade 3/4 adverse events (RR 1.32, 95% CI 1.12–1.55) and discontinuations (RR 2.31, 95% CI 1.28–4.16). There were no differences in the mortality rate between groups. Subgroup analyses showed a potentially more toxic profile with anti-CTLA-4 agents.

Conclusions: Combination treatment is associated with an increase in grade 3/4 adverse events and treatment discontinuations compared to monotherapy, but not increased mortality. The toxicity profile of combination therapy should be considered with regard to the overlapping safety profiles.

Health impacts of bike sharing systems in Europe

BACKGROUND

Bike-sharing systems (BSS) have been implemented in several cities around the world as policies to mitigate climate change, reduce traffic congestion, and promote physical activity. This study aims to assess the health impacts (risks and benefits) of major BSS in Europe.

METHODS

We performed a health impact assessment study to quantify the health risks and benefits of car trips substitution by bikes trips (regular-bikes and/or electric-bikes) from European BSS with >2000 bikes. Four scenarios were created to estimate the annual expected number of deaths (increasing or reduced) due to physical activity, road traffic fatalities, and air pollution. A quantitative model was built using data from transport and health surveys and environmental and traffic safety records. The study population was BSS users between 18 and 64 years old.

RESULTS

Twelve BSS were included in the analysis. In all scenarios and cities, the health benefits of physical activity outweighed the health risk of traffic fatalities and air pollution. It was estimated that 5.17 (95%CI: 3.11-7.01) annual deaths are avoided in the twelve BSS, with the actual level of car trip substitution, corresponding to an annual saving of 18 million of Euros. If all BSS trips replaced car trips, 73.25 deaths could be avoided each year (225 million Euros saving) in the twelve cities.

CONCLUSIONS

The twelve major Bike-sharing systems in Europe provide health and economic benefits. The promotion of shifting car drivers to use BSS can significantly increase the health benefits. BSS in Europe can be used as a tool for health promotion and prevention.

Urothelial cancer proteomics provides both prognostic and functional information

Traditionally, bladder cancer has been classified based on histology features. Recently, some works have proposed a molecular classification of invasive bladder tumors. To determine whether proteomics can define molecular subtypes of  muscle invasive urothelial cancer (MIUC) and allow evaluating the status of biological processes and its clinical value. 58 MIUC patients who underwent curative surgical resection at our institution between 2006 and 2012 were included. Proteome was evaluated by high-throughput proteomics in routinely archive FFPE tumor tissue. New molecular subgroups were defined. Functional structure and individual proteins prognostic value were evaluated and correlated with clinicopathologic parameters. 1,453 proteins were quantified, leading to two MIUC molecular subgroups. A protein-based functional structure was defined, including several nodes with specific biological activity. The functional structure showed differences between subtypes in metabolism, focal adhesion, RNA and splicing nodes. Focal adhesion node has prognostic value in the whole population. A 6-protein prognostic signature, associated with higher risk of relapse (5 year DFS 70% versus 20%) was defined. Additionally, we identified two MIUC subtypes groups. Prognostic information provided by pathologic characteristics is not enough to understand MIUC behavior. Proteomics analysis may enhance our understanding of prognostic and classification. These findings can lead to improving diagnosis and treatment selection in these patients.

Ultrasound-guided saphenous nerve block is an effective technique for perioperative analgesia in ambulatory arthroscopic surgery of the internal knee compartment

OBJECTIVES

Arthroscopic knee surgery is a minimally invasive technique with moderate pain during the first 24h. Our main objective was to evaluate the efficacy of ultrasound guided saphenous nerve block as a method of pain control intraoperatively and postoperatively for this surgery.

MATERIAL AND METHODS

A prospective and observational study. All patients received general anesthesia with laryngeal mask in the saphenous group, nerve block was performed with 10 ml ropivacaine 0.475%. Location of the surgery (external compartment group/internal compartment group), morphine consumption, VAS for pain at 5, 30, 60 and 120 min and 24 h after surgery, need for rescue medication, onset of nausea and vomiting, length of stay in PACU, delayed discharge and satisfaction were evaluated.

RESULTS

The study included 73 patients. Of these, 46 received saphenous nerve block and 27 didn't receive it. Consumption of intraoperative, postoperative and total morphine was significantly lower in the saphenous group as well as VAS at 24h. In the subgroup of internal compartment surgery differences in VAS 24 h, morphine consume and lenght of stay in PACU were mantained.

CONCLUSIONS

The ultrasound-guided block of saphenous nerve, particularly in the internal compartment arthroscopic knee surgery, decreases analgesic requirements, obtaining more effective pain control in the first 24 h postoperatively and without any known side effects.

Variability in chemical composition of Vitis vinifera cv Mencía from different geographic areas and vintages in Ribeira Sacra (NW Spain)

A chemical study was conducted from 2009 to 2012 to examine spatial and seasonal variability of red Vitis vinifera Mencía located in different geographic areas (Amandi, Chantada, Quiroga-Bibei, Ribeiras do Sil and Ribeiras do Miño) from NW Spain. Mencía samples were analysed for phenolic, (flavan-3-ols, flavonols, anthocyanins, acids and resveratrol), nitrogen (TAC, TAN, YAN and TAS) and volatiles compounds (alcohols, C6 compounds, ethyl esters, terpenes, aldehydes, acids, lactones, volatile phenols and carbonyl compounds) by GC-MS and HPLC. Results showed that the composition of Mencía cultivar was more affected by the vintage than the geographic area. The amino acid composition was less affected by both geographic origin and vintage, showing more varietal stability. Application of Principal Component Analysis (PCA) to experimental data showed a good separation of Mencía grape according to geographical origin and vintages. PCA also showed high correlations between the ripening ratio and C6 compounds, resveratrol and carbonyl compounds.

The production process of "Étude sur le Rein des Urinaires", doctoral thesis of Joaquin María Albarrán at the Faculty of Medicine in Paris

OBJECTIVES

The manuscript of the Doctoral Thesis of Joaquín Albarrán in the Faculty of Medicine in Paris "Étudesur le Rein des Urinaires" has been donated to Asociación Española de Urología. Direct comparison of the original and printed material gives information of the production process of this master work.

MATERIAL AND METHODS

Direct comparison between the original hand-written work, a single hard bound volume covered with loin cloth and water paper composed of 145 numbered pages plus 206 newly numbered pages of clinico-pathological (37 subjects) and experimental (19 assays in 20 rabbits) data, and the printed work edited by Georges Steinheil in 1889. Prints included 4 plates with 14 figures, 9 temperature charts and 5 tables describing urine examinations. Figures were trichromic and charts and tables black & white. Chromolithographs were produced by Mr. Leuba in the printing owned by Lemercier et Cie, Paris.

RESULTS

The original work was completed in 1887 without any correction or deletion. Differences are noticeable between the text in the master and printed works: rearrangement of data and inclusion of a new clinical observation, 5 new experiments, summary and dedications. Changes in iconography are noticeable. The masterwork included 24 plates (numbered from 1 to 22, 13bis, 16bis) with 46 figures (44 colored) integrated within the text and 26 double-page temperature registries that accompany clinical observations. Anatomical, histological and microbiological illustrations, including culture media, microbiological stains and histobacteriological preparations were depicted as watercolors (44%), watercolors mixed with pencil or ink (52%) or pencil drawings (4%). Four (9%) were signed by the author, 5 (11%) had numerical annotations and only 14 (30%) were definitely printed with loss of the black component and redrawn of 4/14 (29%) images. The largest images were not printed.

CONCLUSIONS

Joaquín Albarrán described and beautifully illustrated himself the role "pyogenic bacillus" (E. coli) played in renal infection, bacteriemia, renal failure sepsis and patient death. The evolution of pyelonephritis to perinephritis and perinephric abscess was masterly interpreted, with new description of ascending infection and lymphatic peritubular dissemination of bacteria. The differences detected between written and printed work are numerous and can be explained by the corrections of Prof. Guyon before definite presentation and the technical process to perform the lithographs.

Evolution, antimicrobial susceptibility and assignment to international clones of methicillin-resistant Staphylococcus aureus isolated over a 9-year period in two Spanish hospitals

Antimicrobial resistance profiles, restriction fragment length polymorphism of the coagulase gene and repetitive element sequence-based PCR were used to classify 210 methicillin-resistant Staphylococcus aureus isolates recovered between 1997 and 2005 in two hospitals in Vigo, north-west Spain. Representative isolates belonging to the epidemic clones were analysed by spa typing and multilocus sequence typing, and the staphylococcal chromosomal cassette (SCC)mec type was determined for all isolates. The New York/Japan clone (t002-ST5-II) was detected in Spain for the first time. However, the New York/Japan and the Brazilian (t037-ST239-IIIA) clones were replaced by EMRSA-16 (t018-ST36-II), which at present is the predominant clone.

[Lung cancer in the health care area of A Coruña (Spain): incidence, clinical approach and survival]

OBJECTIVE

To determine the incidence, clinical approach, diagnostic delay and survival for bronchogenic carcinoma (BC) in the public health area of A Coruña (Spain).

PATIENTS AND METHOD

This was a retrospective study of patients with a diagnosis of BC made in 1995 and 1996 in a health care area with 509,000 inhabitants. For analysis we gathered demographic, clinical and cyto-histologic data and analyzed diagnostic delay, extension of disease and time of death. Crude, age-specific and age-standardized incidences were calculated.

RESULTS

BC was diagnosed in 378 patients (95% men and 5% women). The crude incidence was 37 per 100,000 inhabitants (73.7 per 100,000 men and 3 per 100,000 women) and the age-standardized incidence was 21.7 per 100,000. Diagnosis was by cyto-histology in 87% of the cases, and the most frequent biopsy finding was epidermoid carcinoma. Diagnosis was by clinical or radiologic findings for 13.7%, and patients in that group were older and had greater comorbidity. No symptoms were present in 13% and in those patients diagnosis was earlier, with non-small BC predominating and 60% treated surgically. The diagnostic delay (time from the first symptom to histologic confirmation) was 2.5 months (median, 2.1), and length of delay did not affect survival. Surgery was performed in 23% of the patients with non-small BC. The median survival was 7.1 months (5.2 months for patients who were not treated surgically, and 37.6 for those who were).

CONCLUSIONS

The incidence of BC in men in our study is consistent with that reported for other Spanish regions, although the incidence we observed for women is much lower. Diagnostic delay did not affect survival. The percentage of patients with surgical-stage disease is very low and survival is very short. These findings support the need for early diagnosis.

Biliary tract infection caused by Haemophilus parainfluenzae

Haemophilus parainfluenzae was isolated from the bile specimens of 2 patients with acute cholecystitis. The strains were genetically unrelated by the random amplified polymorphic DNA (RAPD). The 2 H. parainfluenzae strains represented 11.7% of all positive bile cultures inoculated in blood culture bottles. The routine inoculation of bile specimens in media able to support growth of Haemophilus species should be considered.

Frequency of oropharyngeal candidiasis in HIV-infected patients on protease inhibitor therapy

OBJECTIVE

The purpose of this study was to investigate the effect of HIV-1 protease inhibitors on the frequency of oropharyngeal candidiasis in HIV-infected patients.

STUDY DESIGN

A clinical and analytic follow-up was carried out to determine the number of episodes of oropharyngeal candidiasis during HIV-1 protease inhibitor therapy and the relation of this incidence to the CD4 lymphocyte count and circulating neutrophils level. Seventy-five HIV-positive patients were selected, and HIV-1 protease inhibitor therapy was administered to each patient over a minimum of 6 months. These patients did not receive long-term preventive antifungal therapy for oral candidiasis, even as secondary prophylaxis against cryptococcosis. Results were compared with those obtained during the previous 6 months, during which patients had been treated only with reverse transcriptase inhibitors.

RESULTS

At least one episode of oropharyngeal candidiasis was seen in 56% (42/75) of patients during reverse transcriptase inhibitor therapy and in only 9.3% (7/75) of patients after the initiation of protease inhibitor therapy. The number of relapses decreased significantly when the 2 follow-up periods were compared (P<.0001). The CD4 and CD8 lymphocyte counts increased significantly with protease inhibitor therapy (P<.001 and P<.05, respectively). During reverse transcriptase inhibitor treatment, the probability of the presentation of oropharyngeal candidiasis correlated with falling CD4 counts (P<.0001). The HIV-1 protease inhibitor therapy was associated with a significant increase in the neutrophil count (P<.01). The probability of the occurrence of some episode of candidiasis correlated inversely with the circulating neutrophil level (P<.05).

CONCLUSIONS

Protease inhibitor therapy decreases the frequency of HIV-related oropharyngeal candidiasis. The mechanism involved is unknown, but it can be speculated that a reduction of the viral load increases the number of intact T helper cells, which in turn enhances the number of circulating polymorphonuclear neutrophils and regulates their function by means of colony-stimulating factors.

Asthma visits to emergency rooms and soybean unloading in the harbors of Valencia and A Coruña, Spain

Soybean unloading in the harbor of Barcelona, Spain, has been associated with large increases in the numbers of asthma patients treated in emergency departments between 1981 and 1987. In this study, the association between asthma and soybean unloading in two other Spanish cities, Valencia and A Coruña, was assessed. Asthma admissions were retrospectively identified for the period 1993-1995, and harbor activities were investigated in each location. Two approaches were used to assess the association between asthma and soybean unloading: One used unusual asthma days (days with an unusually high number of emergency room asthma visits) as an effect measure, and the other estimated the relative increase in the daily number of emergency room visits by autoregressive Poisson regression, adjusted for meteorologic variables, seasonality, and influenza incidence. No association between unusual asthma days and soya unloading was observed in either Valencia or A Coruña, except for one particular dock in Valencia. When the association between unloaded products and the daily number of emergency asthma visits was studied, a statistically significant association was observed for unloading of soya husk (relative risk = 1.50, 95% confidence interval 1.16-1.94) and soybeans (relative risk = 1.31, 95% confidence interval 1.08-1.59) in A Coruña. In Valencia, a statistical association was found only for the unloading of soybeans at two particular docks. Although these findings support the notion that asthma outbreaks are not a common hidden condition in most harbors where soybeans are unloaded, the weak associations reported are likely to be causal. Therefore, appropriate control measures should be implemented to avoid soybean dust emissions, particularly in harbors with populations living in the vicinity.

[Benign fibrous mesothelioma: report of 8 cases]

Benign fibrous mesothelioma (BFM) is a primary, isolated tumor of the pleura. In 80% of patients the tumor originates in the visceral pleura. BFM is rare and localized malignant mesothelioma, whose prognosis and treatment is significantly different, must be considered as a differential diagnosis. We report 8 cases of BFM excised by thoracotomy. In 6 asymptomatic patients, diagnosis was based on radiological images. One patient with a large tumor suffered dyspnea, acropachia and hypertrophic osteoarthropathy. The last patient experienced long-lasting chest pain even though the tumor was small (3 x 3 x 1 cm). Diagnosis was before thoracotomy in 3 cases, 2 by punch biopsy (tru-cut) and the other by thoracoscopy. The results of pleural fluid analysis were nonspecific in 2 of the 3 cases in which pleural effusion was present. Thoracotomy allowed removal of the entire tumor in all patients.

[Biliopancreatic ascariasis: an infrequent disease in our environment]

Ascariasis is one of the most frequent helminthic diseases in man. Most cases follow a subclinical form but may show symptoms related to pulmonary hypersensitivity or digestive complications. Although biliopancreatic complications have been widely described in endemic areas, references in Western countries are scarce. The authors therefore report their experience in 3 cases of this infrequent disease which were recently attended in their hospital over a brief period of time.

Isolated deficiency of follicle-stimulating hormone in man: a case report and literature review

A 34-year-old male patient was studied because of primary infertility. He was a normally virilized man with normal potency, habitus, and sense of smell. The testes were of normal consistency and volume. Semen analysis showed azoospermia. The baseline serum concentrations of luteinizing hormone (LH) were normal, but those of follicle-stimulating hormone (FSH) were undetectable. After stimulation with gonadotrophin-releasing hormone (GnRH), 100 micrograms, iv, the response of LH was normal, whereas the rise in FSH levels was minimal. The administration of clomiphene citrate (100 mg/day for 21 days) increased LH levels, but FSH levels remained low. Serum concentrations of testosterone and estradiol were normal. Baseline serum levels of thyrotrophin, prolactin, growth hormone, corticotrophin and cortisol were also normal. The patient refused testicular biopsy and treatment with purified human FSH. Our results suggest a possible defect for FSH production at the pituitary level.

[Oro-esophageal candidiasis resistant to fluconazole in patients with AIDS]

BACKGROUND

Fluconazole-resistant Candida albicans has been seldom reported in the literature. in this study, two clinical cases of oro-esophageal candidosis resistant to this antifungal drug are described.

METHOD

Infection was confirmed by isolation of yeasts (culture of mouth swabs, oesophagoscopy and histology of biopsy specimens). In vitro antifungal susceptibility tests were performed with standard methods (NCCLS).

RESULTS

Clinical and microbiological fluconazole-resistant Candida albicans was isolated.

CONCLUSIONS

Causes of development of resistances are commented, and the role of immunodeficiency and the possibility of a Candida strain selection is discussed.