Brief Report on the Efficacy of Nivolumab in Patients With Previously Treated Advanced Large-Cell Neuroendocrine Cancer of the Lung

Introduction

The optimal management of large cell neuroendocrine cancer of the lung (LCNEC) is unclear, and data regarding anti–programmed cell death protein 1 (PD-1) antibodies are scarce. This study reports the clinical efficacy of a PD-1 inhibitor in patients with advanced LCNEC.

Methods

All patients with stage III to IV LCNEC treated with at least one previous cycle of chemotherapy between January 1, 2015 and December 31, 2018 were reviewed retrospectively. Patients were divided into two groups depending on their exposure to nivolumab as second-line treatment or beyond. The primary objective was to assess nivolumab’s efficacy.

Results

A total of 51 patients with advanced LCNEC from eight centers were analyzed, including 17 who received nivolumab. The PD-1 inhibitor was used as second-line treatment in 77% of cases, with a median number of eight doses (range: 1–62). After nivolumab treatment, the median overall survival was 12.1 months (95% confidence interval [CI]: 7.10–14.20). The objective response rate was 29.4% (95% CI: 10.3–56.0), and median progression-free survival was 3.9 months (95% CI: 1.68–7.17). The programmed death-ligand 1 status was unknown. There was no difference in the efficacy of first-line chemotherapy; the objective response rate was 23.5% (n = four of 17) in the nivolumab group versus 32.4% (n = 11 of 34) in the conventional treatment group, and progression-free survival was 3.5 months (95% CI: 1.7–4.4) versus 2.1 months (95% CI: 1.4–4.2), respectively.

Conclusions

In a real-world setting, nivolumab seems to be an effective second-line treatment in patients with advanced LCNEC. Large prospective studies in this setting are still required.

High-flow nasal oxygen: a safe, efficient treatment for COVID-19 patients not in an ICU

The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19), now recognised by the World Health Organization as a pandemic, emerged in late 2019 in China [1]. Patients infected with SARS-CoV-2 can develop severe pneumonia and respiratory failure, which often require treatment in intensive care units (ICU) in Western European countries [2]. Oxygen therapy and supportive care are still the main forms of therapy for SARS-CoV-2 pneumonia until suitable anti-infective therapies become available.

SARS-CoV-2 infected patients with nonhypercapnic acute hypoxaemic respiratory failure can benefit from high-flow nasal oxygen outside an ICU. The technique appears to be safe for healthcare workers and could well liberate critical ICU resources.https://bit.ly/2Xq80iu

Duration of nivolumab for pretreated, advanced non-small-cell lung cancer

Background

A standard of care for pretreated, advanced non–small‐cell lung cancers (NSCLCs), nivolumab has demonstrated long‐term benefit when administered for 2 years. We aimed to better discern an optimized administration duration by retrospectively analyzing real‐life long‐term efficacy in a prospective cohort.

Methods

All nivolumab‐treated adults with advanced NSCLCs (01/09/2015 to 30/09/2016) from nine French centers were eligible. On 31/12/2018, patients who are alive ≥ 2 years after starting nivolumab were defined as long‐term survivors (LTSs) and were divided into three nivolumab treatment groups: <2, 2, or > 2 years. Co‐primary endpoints were LTSs’ progression‐free survival (PFS) and overall survival (OS).

Results

The median follow‐up was 32 months (95% CI, 31.0 to 34.0). The 3‐year OS rate for the 259 cohort patients was 16.6%. Among them, 65 were LTSs: 47 treated < 2 years, 7 for 2 years, and 11 > 2 years. Their respective characteristics were: median age: 59, 52, and 58 years; smoking history: 92.9, 100, and 100%; adenocarcinomas: 66, 57.1, and 54.5%. LTSs’ median (m)PFS was 28.4 months; mOS was not reached. LTSs’ objective response rate was 61.6%. mOS was 32.7 months for those treated < 2 years and not reached for the others. The > 2‐year group's 3‐year OS was longer. Twenty‐eight LTSs experienced no disease progression; 7 had durable complete responses. However, LTSs had more frequent and more severe adverse events.

Conclusion

In real‐life, prolonged nivolumab use provided long‐term benefit with 16.6% 3‐year OS and 25% LTSs. Survival tended to be prolonged with nivolumab continued beyond 2 years. Prospective randomized trials with adequate design are needed.

First-line pembrolizumab for non-small cell lung cancer patients with PD-L1 ≥50% in a multicenter real-life cohort: The PEMBREIZH study

Background

The KEYNOTE‐024 trial demonstrated that pembrolizumab, a PD‐1 inhibitor, significantly improves progression‐free survival (PFS) and overall survival (OS) in selected patients with previously untreated advanced non–small cell lung cancer (NSCLC) with a PD‐L1 tumor proportion score (TPS) ≥50% and without EGFR/ALK aberrations. The main aim of this study was to report the efficacy and safety profile of pembrolizumab in real‐life conditions.

Method

This was a French retrospective multicenter longitudinal study of 108 consecutive patients with advanced NSCLC, a PD‐L1 TPS ≥50% and without EGFR/ALK aberrations who were treated by pembrolizumab, in first line. Patient data were obtained from medical files.

Results

The main characteristics of the cohort were: median age [range] 66.7 [37‐87] years, 64.8% male, 23.1% with a performance status (PS) of 2, and 88.9% current or former smokers. Eighty‐seven percent had stage IV NSCLC at diagnosis, 9.2% untreated brain metastases at inclusion,. With a median follow‐up of 8.2 months, the median PFS was 10.1 months (95% CI, 8.8‐11.4). The objective response rate was 57.3% (complete response 2.7%, partial response 54.6%). Disease control rate was 71.1%. At 6 months, the OS rate estimated was 86.2%. Treatment‐related adverse events (AE) of grade 3 occurred in 8% of patients. There were no grade 4 or 5 AEs.

Conclusion

In a real‐life cohort of advanced NSCLC patients (including PS 2 and untreated brain metastases), with PD‐L1 TPS ≥50%, pembrolizumab demonstrates similar PFS to the pivotal clinical trial.

[A diseased esophagus is frequently the cause of chronic hiccup. A prospective study of 184 cases]

INTRODUCTION

Chronic hiccup, defined as repetitive hiccup spells during more than 48 h, is an uncommon and neglected pathological condition, in which preliminary findings suggested an upper digestive origin.

METHODS

We prospectively included 184 rebel chronic hiccups in this clinical and endoscopic study. Our rule of thumb was to consider upper digestive findings as first-rank in imputability and thus to treat them in priority. If treatment failed or no abnormality was found in the upper digestive tract, a neurological survey was done and baclofen tried.

RESULTS

We thus discovered upper digestive abnormalities in 80% of the patients and the treatment rule yielded 66% of success, including 48 complete remissions and 116 partial remissions. There were 20 failures, generally due to untreatable neurological diseases such as brain tumors.

CONCLUSION

A diseased esophagus is frequently the cause of chronic hiccup.

Baclofen therapy for chronic hiccup

Chronic hiccup is a rare but potentially severe condition, that can be symptomatic of a variety of diseases, or idiopathic. Many therapeutic interventions have been reported, most often as case reports. Among other drugs, baclofen has been suggested as a therapy for chronic hiccup. In a large series of patients, we have evaluated its therapeutic position. In patients with chronic hiccup, defined as hiccup spell or recurring hiccup attacks lasting more than 7 days, investigation of the upper gastro-oesophageal tract (fibroscopy, manometry, and pH monitoring) was systematically performed. Most patients had tried numerous drugs in the past, without success. Baclofen was used as a first treatment in patients without evidence of any gastro-oesophageal disease (n = 17), and was undertaken only after full treatment of such disease (n = 55) had failed to solve the hiccup problem (n = 20). Baclofen has, therefore, been administered to 37 patients with chronic hiccup (average duration 4.6 yrs). Baclofen produced a long-term complete resolution (18 cases) or a considerable decrease (10 cases) of hiccups in 28 of the 37 patients. There was no significant difference between patients with or without gastro-oesophageal disease. We conclude that so-called idiopathic chronic hiccup often results from gastro-oesophageal abnormalities. Also, if controlled studies confirm our encouraging results, baclofen can be a major element in the treatment of chronic hiccup that is idiopathic, or that cannot be helped by treatment of gastro-oesophageal diseases.

Hiccup in adults: an overview

Hiccup is a forceful, involuntary inspiration commonly experienced by fetuses, children and adults. Its purpose is unknown and its pathophysiology still poorly understood. Short hiccup bouts are mostly associated with gastric distention or alcohol intake, resolve spontaneously or with simple folk remedies and do not require medical attention. In contrast, prolonged hiccup is a rare but disabling condition which can induce depression, weight loss and sleep deprivation. A wide variety of pathological conditions can cause chronic hiccup: myocardial infarction, brain tumour, renal failure, prostate cancer, abdominal surgery etc. Detailed medical history and physical examinations will often guide diagnostic investigations (abdominal ultrasound, chest or brain CT scan...). Gastric and duodenal ulcers, gastritis, oesophageal reflux and oesophagitis are commonly observed in chronic hiccup patients and upper gastrointestinal investigations (endoscopy, pH monitoring and manometry) should be included in the diagnostic evaluation systematically. Etiological treatment is not always available and chronic hiccup treatment has classically relied on metoclopramide and chlorpromazine. Recently, baclofen (LIORESAL) has emerged as a safe and often effective treatment.

Hiccup in adults: an overview

Hiccup is a forceful, involuntary inspiration commonly experienced by fetuses, children and adults. Its purpose is unknown and its pathophysiology still poorly understood. Short hiccup bouts are mostly associated with gastric distention or alcohol intake, resolve spontaneously or with simple folk remedies and do not require medical attention. In contrast, prolonged hiccup is a rare but disabling condition which can induce depression, weight loss and sleep deprivation. A wide variety of pathological conditions can cause chronic hiccup: myocardial infarction, brain tumour, renal failure, prostate cancer, abdominal surgery etc. Detailed medical history and physical examinations will often guide diagnostic investigations (abdominal ultrasound, chest or brain CT scan...). Gastric and duodenal ulcers, gastritis, oesophageal reflux and oesophagitis are commonly observed in chronic hiccup patients and upper gastrointestinal investigations (endoscopy, pH monitoring and manometry) should be included in the diagnostic evaluation systematically. Etiological treatment is not always available and chronic hiccup treatment has classically relied on metoclopramide and chlorpromazine. Recently, baclofen (LIORESAL) has emerged as a safe and often effective treatment.

[Chronic hiccups]

We report 18 cases of chronic hiccup (defined as lasting for more than 48 hours) in adults. Among the numerous possible causes, reflux esophagitis proved to be by far the most frequent (50% of the cases). However, hiccup often initiated a self-perpetuating vicious circle. This is possibly because hiccup per se can give esophageal dyskinesia, which in turn leads to gastro-esophageal reflux. The treatment was difficult and whenever possible has been directed chiefly towards the cause. However hiccup remained intractable in many cases even after a possible cause had been adequately cured (e.g., successful Nissen procedure in reflux cases). Central nervous system depressants and myorelaxing drugs were not very helpful, except for baclofen (initial response rate = 60%).

Diagnosis of pulmonary embolism by transoesophageal echocardiography

A 68-year-old woman was admitted for major dyspnoea. A transoesophageal echocardiogram was performed after the occurrence of acute circulatory shock. During the examination, the patient was under mechanical ventilation. We found a thrombus that had almost occluded the right pulmonary artery and which was later confirmed by selective angiography. Despite treatment, the patient died 2 days later; autopsy confirmed the thrombus in the right pulmonary artery.

[Treatment of reflex vagal hypertonia in infants. Role of diphemanil (apropos of 50 cases)]

For a period of 20 months, 50 consecutive infants (mean age: 11 months) were given Diphemanil (atropine like synthetic drug) for reflex symptomatic bradycardia of probable vagal origin. Treatment's results were evaluated with the study of oculo-cardiac reflex (OCR) and Holter monitoring performed before and 3 months after the beginning of Diphemanil. If tolerance was generally good, it was not possible to demonstrate the clinical efficacy of the treatment on the whole group. However, assertive success was seen on individual cases. Holter and OCR data improved statistically. The other therapeutical means aiming at warning possible complications of the hypertonic vagal reflex were reviewed: inserting a cardiac pace-maker does not always prevent sudden death; a nodal sinus surgical selective denervation might be justified in certain exceptional cases, because of the severity of the spontaneous evolution or of the resistance to medical treatment.