Face to face among different chemo-immunotherapy combinations in the first line treatment of patients with advanced non-small cell lung cancer: Results of an international expert panel meeting by the italian association of thoracic oncology (AIOT)

BACKGROUND

The combination of platinum-based chemotherapy with immune-checkpoint inhibitors (ICIs) is a standard of care option in the front-line treatment of advanced non-small cell lung cancer (NSCLC). Positive efficacy and safety results have been demonstrated with different chemo-ICI combinations in the corresponding clinical trials, however no randomized prospective comparison is available and there is no evidence on how to choose among the available regimens.

METHODS

A virtual International Expert Panel took place in July 2023 to review data on chemo-ICI regimens available in the first-line setting in patients with NSCLC, and reach common considerations both in clinical practice and in research setting.

RESULTS

Overall, all panelists agreed that safety of the chemo-immunotherapy combination regimens is supported by reviewed data, showing no additional toxicity concerns over those of the individual components of each regimen and highlighting differences in toxicity profile based on ICI component (single anti-PD-1 versus double anti-PD-1 and anti-CTLA-4). Among disease characteristics, PD-L1 value (<1%) but not histology was considered a potential selection factor in favor of the combination with dual ICI. With regards to clinical features, the panelists agreed that chemotherapy, whichever the ICI combination regimen, remains the backbone to counteract disease-related symptoms included those conditioning worse performance status. The panelists defined high, medium, and low priorities in clinical research. High priority was attributed to prospectively evaluating the impact of the addition of anti-CTLA-4 on brain metastasis, biomarker subgroups, and the optimal duration and schedule of combination regimens.

CONCLUSIONS

Based on the available evidence, the panelists reached common considerations on strengths and differences between chemotherapy plus single agent ICI and chemotherapy plus double agent ICIs in patients with advanced NSCLC. In the absence of direct comparison, different toxicity profile and subgroup analysis by PD-L1 are considered as the main potential features to select among the two regimens, however to be confirmed by recommended prospective randomized clinical research.

Tepotinib in patients with non-small cell lung cancer with high-level MET amplification detected by liquid biopsy: VISION Cohort B

High-level MET amplification (METamp) is a primary driver in ∼1%-2% of non-small cell lung cancers (NSCLCs). Cohort B of the phase 2 VISION trial evaluates tepotinib, an oral MET inhibitor, in patients with advanced NSCLC with high-level METamp who were enrolled by liquid biopsy. While the study was halted before the enrollment of the planned 60 patients, the results of 24 enrolled patients are presented here. The objective response rate (ORR) is 41.7% (95% confidence interval [CI], 22.1-63.4), and the median duration of response is 14.3 months (95% CI, 2.8-not estimable). In exploratory biomarker analyses, focal METamp, RB1 wild-type, MYC diploidy, low circulating tumor DNA (ctDNA) burden at baseline, and early molecular response are associated with better outcomes. Adverse events include edema (composite term; any grade: 58.3%; grade 3: 12.5%) and constipation (any grade: 41.7%; grade 3: 4.2%). Tepotinib provides antitumor activity in high-level METamp NSCLC (ClinicalTrials.gov: NCT02864992).

STYLE (NCT03449173) a phase II Trial of Sunitinib in patients with type B3 Thymoma or Thymic Carcinoma in second and further lines

BACKGROUND

Thymic malignancies are rare tumors with few therapeutic options. The STYLE trial was aimed to evaluate activity and safety of sunitinib in advanced/recurrent type B3 thymoma (T) and thymic carcinoma (TC).

METHODS

In this multicenter Simon 2 stages phase II trial, patients with pretreated T/TC were enrolled in two cohorts and assessed separately. Sunitinib was administered 50mg daily for 4-weeks, followed by a 2-week rest period (schedule 4/2), until disease progression or unacceptable toxicity. The primary endpoint was objectives response rate (ORR). Progression free survival (PFS), overall survival (OS), disease control rate (DCR) and safety were secondary endpoints.

RESULTS

From 03/2017 to 01/2022, 12 T and 32 TC patients were enrolled. At stage 1 ORR was 0% (90%CI 0.0-22.1) in T and 16.7% (90%CI 3.1-43.8) in TC, so T cohort was closed. At stage 2, the primary endpoint was met for TC with ORR of 21.7% (90%CI 9.0%-40.4%). In the ITT analysis DCR was 91.7% (95%CI 61.5%-99.8%) in Ts and 89.3% (95%CI 71.8%-97.7%) in TCs. mPFS was 7.7 months (95%CI 2.4-45.5) in Ts, 8.8 (95%CI 5.3-11.1) in TCs; mOS was 47.9 months (95%CI 4.5-not reached) in Ts, and 27.8 (95%CI 13.2-53.2) in TCs. Adverse events (AEs) occurred in 91.7% T and 93.5% TCs. Grade ≥3 treatment-related AEs were reported in 25.0% T and 51.6% TC.

CONCLUSIONS

This trial confirms the activity of sunitinib in TC patients, supporting its use as second line treatment.

Abstract 3431: Molecular determinants of KRAS p.G12C inhibitor efficacy in advanced NSCLC

Background: Irreversible allosteric KRAS p.G12C inhibitors (KG12Ci) such as sotorasib and adagrasib have revolutionized the therapeutic landscape of advanced KG12C-mutant NSCLC, however individual responses are heterogeneous and curtailed by innate and adaptive/acquired resistance. Molecular determinants of KG12Ci efficacy in NSCLC are poorly defined. We dissected the impact of major KG12C co-mutations and explored the effects of less prevalent co-alterations on the clinical activity of KG12Ci in the largest treated cohort to date of patients (pts) with advanced NSCLC. Key findings were validated in preclinical KG12C NSCLC models.

Methods: Baseline clinico-genomic features and clinical outcome data from pts with stage IV KG12C NSCLC (ECOG PS 0-2) treated with single-agent KG12Ci were collected retrospectively from 20 centers in the US and Europe. The Kaplan-Meier method was used to estimate PFS and OS and differences were assessed with the log-rank test. Hazard ratios (HR) and their 95% CI were estimated using a Cox proportional hazards model stratified for clinical co-variates. The impact of selected co-alterations on sotorasib efficacy was assessed in syngeneic (C57BL/6) KG12C NSCLC models.

Results: 411 eligible pts were included in the study. Median age was 68 years, 77% of pts had received both platinum-based chemotherapy and PD-(L)1 inhibitors and 35% had brain metastases. 83% of pts received sotorasib. ORR with KG12Ci was 32.4% (95% CI, 27.9-37.1), PFS was 5.1m (95% CI, 4.5-5.6) and OS was 10.2m (95% CI, 8.4-12.1). Co-alterations in KEAP1, SMARCA4 and CDKN2A/B were each associated with significantly shorter PFS (KEAP1: 2.8m vs 5.5m, HR 2.50, P&lt;0.001; SMARCA4: 1.7m vs 5.5m, HR 2.64, P=0.001; CDKN2A/B: 2.3m vs 5.3m, HR 2.57, P&lt;0.001) and OS with KG12Ci even after adjustment for clinical covariates. STK11 co-mutations without concurrent KEAP1 alterations did not impact clinical outcomes with KG12Ci. In an exploratory analysis, co-mutations in DNA damage repair (DDR) genes and genes encoding components of the ATRX/DAXX/EZH2 pathway were associated with improved KG12Ci efficacy, whereas PI3K/AKT/MTOR/PTEN alterations and missense ROS1/ALK/BRAF/NTRK1-3 mutations resulted in inferior outcomes. The impact of SMARCA4 and DDR gene inactivation was validated in isogenic syngeneic KG12CNSCLC models; additional co-alterations are under evaluation. Integration of KEAP1/SMARCA4/CDKN2A/B co-mutations identified a subgroup (KSCMUT, 37.6% of all pts) with significantly shorter PFS (2.7m vs 6.2m, P&lt;0.001) and OS (6.3m vs 14.6m, P&lt;0.001) that accounted for 57.3% of pts with primary refractory (PFS≤3m) disease.

Conclusions: Co-mutations in KEAP1, SMARCA4 and CDKN2A/2B define subgroups of KG12C NSCLC pts with markedly distinct outcomes with KG12Ci monotherapy. Tailoring of KG12C inhibitor-anchored therapeutic strategies and patient stratification should take into account the co-mutation status of individual tumors.

Citation Format: Marcelo V. Negrao, Haniel A. Araujo, Giuseppe Lamberti, Alissa J. Cooper, Teng Zhou, Neal Akhave, Lukas Delasos, J Kevin Hicks, Mihaela Aldea, Gabriele Minuti, Jacobi Hines, Jacqueline V. Aredo, Michael J. Dennis, Turja Chakrabarti, Susan Scott, Paolo Bironzo, Matthias Scheffler, Petros Christopoulos, So Yeon Kim, Sarah Goldberg, Ying Ni, Blerina Resuli, Lorenza Landi, Shu-Chi Tseng, Mizuki Nishino, Dwight Owen, Collin Blakely, Giannis Mountzios, Catherine A. Shu, Christine Bestvina, Marina Garassino, Kristen Marrone, Jhanelle Gray, Sandip Pravin Patel, Amy L. Cummings, Heather A. Wakelee, Jurgen Wolf, Giorgio V. Scagliotti, Federico Cappuzzo, Fabrice Barlesi, Pradnya Patil, Don L. Gibbons, Funda Meric-Bernstam, J Jack Lee, John V. Heymach, David S. Hong, Rebecca S. Heist, Mark M. Awad, Ferdinandos Skoulidis. Molecular determinants of KRAS p.G12C inhibitor efficacy in advanced NSCLC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3431.

Autoantibody positivity predicts severity of rheumatic immune-related adverse events to immune-checkpoint inhibitors

OBJECTIVE

Immune-related adverse events (irAEs) due to immune checkpoint inhibitors are responsible for a considerable burden of morbidity and mortality. Predictors of severity of rheumatic irAEs have not been identified yet. The objective of this study was to test the hypothesis whether the presence of autoantibodies could be associated with a more severe and difficult-to-treat clinical phenotype of rheumatic irAEs.

METHODS

Patients referred to our centre due to the onset of rheumatic irAEs were prospectively recruited between June 2018 and December 2020. A pre-specified panel of autoantibodies was tested in each patient at baseline visit. All patients were started on glucocorticoids and then followed-up. Conventional or biologic immunosuppressants were started in case of steroid-refractory or relapsing disease. Logistic regression analysis was performed to evaluate the association between the baseline positivity of at least one autoantibody and the necessity of an add-on therapy.

RESULTS

Fourty-three patients with rheumatic irAEs were enrolled. Twenty-five (58%) patients had positivity of at least one of the tested autoantibodies. Twenty-two (51%) patients required the start of an additional immunosuppressant during follow-up. The only factor associated with the necessity of an add-on therapy was autoantibody positivity (OR=9.65, 95% CI:2.09-44.56; p-value 0.004).

CONCLUSIONS

The presence of autoantibodies in patients with cancer who develop rheumatic irAEs could predict their progression to difficult-to-treat clinical manifestations. This finding might prompt a future therapeutic approach based on a tailored and earlier immunosuppressive treatment in selected cases.

Abstract CT037: Canakinumab in combination with first-line (1L) pembrolizumab plus chemotherapy for advanced non-small cell lung cancer (aNSCLC): Results from the CANOPY-1 phase 3 trial

Background: Pembrolizumab improves overall survival (OS) when added to platinum-based doublet chemotherapy (PDC) in patients with aNSCLC. However, progression-free survival (PFS) and OS remain disappointing for most patients and can vary depending on programmed death-ligand 1 (PD-L1) status. This highlights the need for additional therapeutic options. Canakinumab is a monoclonal anti-interleukin-1β antibody that inhibits pro-tumor inflammation and potentially enhances anti-tumor immune responses, with the potential to synergize with programmed death 1 inhibitors plus chemotherapy.

Methods: CANOPY-1 is a randomized, double-blind phase 3 study investigating the addition of canakinumab or placebo (PBO) to 1L pembrolizumab + PDC. Patients with previously untreated stage IIIB/C or IV NSCLC, of any histology and no known EGFR or ALK alterations, were randomized 1:1 and stratified based on PD-L1 status, geographic region, and histology to canakinumab 200 mg or PBO every 3 weeks, plus pembrolizumab and histology-guided PDC for 4 cycles, followed by maintenance canakinumab or PBO, with pembrolizumab ± pemetrexed. The primary endpoints were investigator-assessed PFS (Response Evaluation Criteria In Solid Tumors 1.1) and OS. Exploratory biomarker analyses were also investigated and will be presented at the time of the congress. The cut-off dates for these analyses were May 18, 2020 (PFS) and August 9, 2021 (OS).

Results: A total of 643 patients were randomized to canakinumab (n=320) or PBO (n=323) in combination with pembrolizumab + PDC. Baseline characteristics were well balanced across treatment arms. Median PFS was 6.8 months for both treatment arms (HR 0.85, 95% CI, 0.67-1.09; one-sided P=0.102). Median OS was 20.8 and 20.2 months for the canakinumab and PBO arms, respectively (HR 0.87, 95% CI, 0.70-1.10; one-sided P=0.123). Grade 3/4 adverse events (AEs) were reported for 205 (64.1%) patients in the canakinumab arm and 191 (59.3%) patients in the PBO arm, and fatal AEs were reported for 37 (11.6%) and 47 (14.6%) patients, respectively. AEs (any grade) leading to discontinuation of any study drug were reported for 72 (22.5%) patients in the canakinumab arm and 61 (18.9%) patients in the PBO arm.

Conclusions: The addition of canakinumab to pembrolizumab plus PDC did not statistically improve PFS nor OS for 1L treatment of patients with aNSCLC. No unexpected safety findings were observed with the addition of canakinumab to pembrolizumab plus PDC.

Citation Format: Daniel S. Tan, Enriqueta Felip, Gilberto Castro, Benjamin J. Solomon, Alastair Greystoke, Byoungchul Cho, Manuel Cobo, Tae Min Kim, Sandip Ganguly, Enric Carcereny, Luis Paz-Ares, Jaafar Bennouna, Marina Garassino, Michael Schenker, Sang-We Kim, Bijoyesh Mookerje, Vanessa Q. Passos, Stephanie Deudon, Bharani Dharan, Yuanbo Song, Rafael Caparica, Bruce E. Johnson. Canakinumab in combination with first-line (1L) pembrolizumab plus chemotherapy for advanced non-small cell lung cancer (aNSCLC): Results from the CANOPY-1 phase 3 trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT037.

Poziotinib in Non-Small-Cell Lung Cancer Harboring HER2 Exon 20 Insertion Mutations After Prior Therapies: ZENITH20-2 Trial

PURPOSE

Insertion mutations in Erb-b2 receptor tyrosine kinase 2 gene (ERBB2 or HER2) exon 20 occur in 2%-5% of non-small-cell lung cancers (NSCLCs) and function as an oncogenic driver. Poziotinib, a tyrosine kinase inhibitor, was evaluated in previously treated patients with NSCLC with HER2 exon 20 insertions.

METHODS

ZENITH20, a multicenter, multicohort, open-label phase II study, evaluated poziotinib in patients with advanced or metastatic NSCLC. In cohort 2, patients received poziotinib (16 mg) once daily. The primary end point was objective response rate evaluated by independent review committee (RECIST v1.1); secondary outcome measures were disease control rate, duration of response, progression-free survival, and safety and tolerability. Quality of life was assessed.

RESULTS

Between October 2017 and March 2021, 90 patients with a median of two prior lines of therapy (range, 1-6) were treated. With a median follow-up of 9.0 months, objective response rate was 27.8% (95% CI, 18.9 to 38.2); 25 of 90 patients achieved a partial response. Disease control rate was 70.0% (95% CI, 59.4 to 79.2). Most patients (74%) had tumor reduction (median reduction 22%). Median progression-free survival was 5.5 months (95% CI, 3.9 to 5.8); median duration of response was 5.1 months (95% CI, 4.2 to 5.5). Clinical benefit was seen regardless of lines and types of prior therapy, presence of central nervous system metastasis, and types of HER2 mutations. Grade 3 or higher treatment-related adverse events included rash (48.9%), diarrhea (25.6%), and stomatitis (24.4%). Most patients had poziotinib dose reductions (76.7%), with median relative dose intensity of 71.5%. Permanent treatment discontinuation because of treatment-related adverse events occurred in 13.3% of patients.

CONCLUSION

Poziotinib demonstrates antitumor activity in previously treated patients with HER2 exon 20 insertion NSCLC.

307 Interaction of anti-PD-1/PD-1 immunocomplexes with human FcRs: binding properties and functional implication

Background

Rescue of exhausted T cell immunity through the inhibition of PD-1/PD-L1 interaction is a pillar of immunotherapeutic anti-PD-1 monoclonal antibodies (mAbs), as Nivolumab and Pembrolizumab. Despite the IgG4 subclass, anti-PD-1 mAbs can bind different FcγRs and trigger immunosuppressive activity in FcR-expressing myeloid cells. This effect is evident when anti-PD-1 mAbs engage soluble PD-1 (sPD-1) forming a stable sPD-1-antiPD-1mAb immune complex (PD-1 IC). In the present study we dissect the process by investigating which of the FcγRs displays the highest affinity for monomeric or complexed Nivolumab. In addition, methods for detecting and quantifying PD-1 ICs in plasma of patients treated with PD-1 blockers mAbs are under development for clinical application.

Methods

By surface plasmon resonance (SRP) (BiacoreTM T200, Cytiva), the interaction of FcγRI/CD64, FcγRIIa/CD32a, FcγRIIb/CD32b, FcγRIIIa/CD16a and FcγRIIIb/CD16b with anti-PD1 Nivolumab and the corresponding PD-1-IC has been evaluated, and their cellular localization has been assessed by confocal microscopy. Further, sPD-1 and PD-1 IC has been determined by customized ELISAs and western blot approaches in plasma of anti-PD-1 mAb-treated patients.

Results

The binding of anti-PD1 and PD-1-IC occurred with all the FcγRs tested, albeit sensorgrams revealed diverse degrees of affinity. No major difference in the overall affinity of the monomeric anti-PD-1 versus PD-1 IC is observed for FcγRI/CD64, FcγRIIa/CD32a, FcγRIIb/CD32b. Instead, the dissociation phase was clearly slowest for PD-1 IC with respect to the monomeric mAb in FcγRIIIa/CD16a and FcγRIIIb/CD16b binding studies. Nevertheless, only PD-1 IC undergoes internalization when interacting with human FcγR+ myeloid cells in vitro, through pathways that does not appear to lead to lysosomal co-localization. Customized ELISA for PD-1 IC quantification has been developed to detect the complex after enrichment of plasma IgG4 by specific matrix. Data concerning the evaluation of PD-1 IC concentration in plasma of cancer patients treated with Nivolumab, will be presented.

Conclusions

Despite the IgG4 subclass is expected to display the lowest binding affinity to Fcγs, we report here that anti-PD-1 therapeutic antibodies bind significantly to CD16, CD32 and CD64, particularly if stabilized in the IC form by engaging soluble PD-1. This evidence, if occurring in vivo, could introduce novel functional properties to these therapeutic agents, with potential detrimental effects on their clinical efficacy. Our findings imply that tools to antagonize PD-1-related exhaustion by Fc-null mAbs or non-mAb-based strategies could be preferred to engage full-fledged antitumor immune responses without unwanted effects related to FcR triggering.

15 First-line platinum-based chemotherapy combined with PD-1/PD-L1 inhibitors (ICI) prevents hyperprogression in non-small cell lung cancer (NSCLC) patients by reducing circulating immature neutrophils

Background

Hyperprogression (HPD) has been described in ≃14–26% of NSCLC patients upon single-agent ICI1 and has not been reported upon ICI and platinum-based chemotherapy (PCT) combinations. Both high circulating neutrophils2 and senescent T-cells3 correlated with HPD, however the exact neutrophils-T-cells interplay and the role of specific neutrophils subsets in driving HPD is unknown.

Methods

NSCLC patients treated with 1st line ICI as single-agent or in combination with PCT were assessed for HPD and circulating neutrophils’ phenotype. HPD required 3 assessment (2 before ICI, 1 upon ICI) and was defined as delta tumor growth rate (TGR) (TGR upon ICI – TGR before ICI) >50% and/or TGR ratio (TGR upon ICI/TGR before ICI) ≥2. Circulating low density neutrophils (LDNs) subtypes were assessed by flow cytometry on peripheral blood mononuclear cells (PMBCs). LDNs were defined as CD66b+CD15+ cells among CD11b+ PBMCs. Immature subtypes were defined as CD10- LDNs. T-cells were isolated from healthy donors and cocultured with patients‘ LDNs to characterize the neutrophils-T-cells interplay. LDNs subtypes were isolated from patients and treated in-vitro with cisplatin to assess cell death.

Results

46 NSCLC patients were treated with single-agent ICI and 17 with PCT+ICI (table 1). In the ICI single-agent cohort, PD and HPD occurred in 21 (41%) and 4 (9%) patients. Before ICI start, HPD patients had significantly higher median% of circulating immature CD10- LDNs neutrophils [43.5 (min 29.5; max 82.6) vs 10.3 (min 0.1; max 79.4), p=0.01] compared to PD patients (figure 1). In the ICI-PCT cohort no HPD was reported. 5 patients had baseline CD10- LDNs ≥ 43.5% (median% of CD10- LDNs in HPD patients upon single-agent ICI), 2 of them had stable disease and 3 PD upon ICI-PCT. In these 5 patients, CD10- LDNs significantly decreased during ICI-PCT compared to what observed in HPD patients upon single-agent ICI [median variation -43.4 (min -67.6, max -31.6) vs +6.9 (min -33, max +44), p= 0.03] (figure 2). After 7 days of coculture with T-cells, immature CD10- LDNs significantly reduced T-cells survival and promoted a T-cell senescent phenotype (CD28 loss, CD57 gain) impairing T-cells proliferation and increasing IFN-gamma production (figure 3). Cisplatin treatment significantly increased necrotic cell death among CD10- LDNs compared to CD10+ LDNs (figure 4).

Abstract 15 Table 1

Patients characteristics in the single-agent ICI and PCT+ICI cohorts

Abstract 15 Figure 1

Patterns of response, progression and hyperprogression to single-agent ICI and correlation with mature (CD10+) or immature (CD10-) LDNs’ subtypes

Abstract 15 Figure 2

Neutrophils dynamic variation upon treatment (5 patients with high baseline CD10- LDNs and PD/SD to chemo-ICI vs 4 patients with HPD upon single-agent ICI)

Abstract 15 Figure 3

Mature (CD10+) and immature (CD10-) LDNs in coculture with T-cells from an healthy donor differently influence CD8 and CD4 T-cells survival, proliferation, IFN-gamma production and expression of a senescent (CD28- CD57+) phenotype.

Abstract 15 Figure 4

Cisplatin in-vitro treatment at different concentration (1 uM and 5 uM) increases necrotic (7AAD expression) cell death preferentially of immature (CD10-) rather than mature (CD10+) LDNs

Conclusions

Higher baseline immature CD10- LDNs impair T-cell survival and promote T-cell senescence being a circulating biomarker of HPD upon single-agent ICI. The addition of PCT prevents HPD by inducing immature neutrophils cell death.

References

Ferrara R, Mezquita L, Texier M, Lahmar J, Audigier-Valette C, Tessonnier L, et al. Hyperprogressive disease in patients with advanced non-small cell lung cancer treated with pd-1/pd-l1 inhibitors or with single-agent chemotherapy. JAMA Oncol 2018;4:1543–52. https://doi.org/10.1001/jamaoncol.2018.3676

Kim Y, Kim CH, Lee HY, Lee S-H, Kim HS, Lee S, et al. Comprehensive clinical and genetic characterization of hyperprogression based on volumetry in advanced non-small cell lung cancer treated with immune checkpoint inhibitor. J Thorac Oncol 2019;14:1608–18. https://doi.org/10.1016/j.jtho.2019.05.033

Ferrara R, Naigeon M, Auclin E, Duchemann B, Cassard L, Jouniaux JM, et al. Circulating T-cell immunosenescence in advanced non-small cell lung cancer patients treated with single agent PD-1/PD-L1 inhibitors or platinum-based chemotherapy. Clin Cancer Res 2020. https://doi.org/10.1158/1078-0432.CCR-20-1420.

Ethics Approval

Patients blood was obtained after signature of informed consent and within an observational prospective study (INT 22_15) approved by local Institutional Ethical Committee.

Tocilizumab for the treatment of immune-related adverse events: a systematic literature review and a multicentre case series

OBJECTIVE

Research is moving towards a more personalized management of immune-related adverse events (irAEs) due to immune checkpoint inhibitors (ICI). Our objective was to evaluate the efficacy and safety of tocilizumab in the treatment of these clinical manifestations.

METHODS

A systematic literature review was performed to retrieve data about the use of tocilizumab in the treatment of irAEs. Additionally, data from cancer patients referred to our Immune-related Adverse Event Clinic and treated with tocilizumab were collected.

RESULTS

Our literature review identified 20 articles and 11 meeting abstracts. Data about 91 cancer patients who received tocilizumab for the treatment of irAEs were collected. In 85% of cases, this therapy was associated with clinical benefit and no case of disease progression was reported. ICI therapy was continued following irAE onset and biologic therapy initiation in only three patients. Five patients developed irAEs upon ICI initiation and were subsequently treated with tocilizumab at our Centre. At a median follow-up of eight months, tocilizumab was safely continued along with ICI in three out of five patients, and an adequate control of irAE was obtained in all cases. No significant adverse reactions to tocilizumab were reported. Only one patient experienced a disease progression 18 months after ICI discontinuation.

CONCLUSION

Both our systematic literature review and case series highlight the efficacy and safety of tocilizumab in the treatment of irAEs. Furthermore, they both support the possibility of a combined approach with tocilizumab and ICI, to guarantee an effective irAEs management without losing the oncologic response.

TRLS-03. Intracranial activity of tepotinib in patients with MET exon 14 (METex14) skipping NSCLC enrolled in VISION

Background

Brain metastases (BMs) are reported in 20–40% patients with METex14 skipping NSCLC. Tepotinib, a highly selective MET inhibitor, has demonstrated an objective response rate (ORR) of 45% and median duration of response (mDOR) of 11.1 months, in METex14 skipping NSCLC patients in Cohort A of the Phase II VISION study. Here, we report the intracranial activity of tepotinib in Cohort A.

Methods

Patients received oral tepotinib 500 mg QD. Study eligibility allowed for patients with BM (asymptomatic and symptomatic/stable). Primary endpoint: systemic objective response (RECIST v1.1); subgroup analysis in patients with BM (RECIST v1.1) was predefined.

An ad hoc retrospective analysis of brain lesions (by CT/MRI) was conducted by an IRC using Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Responses were determined in patients with ≥1 evaluable post-baseline tumor assessment. For non-measurable lesions (enhancing and non-enhancing non-target lesions [NTL]), disease control in the brain was defined as non-complete response/non-progressive disease. Data cut-off: July 1, 2020.

Results

Twenty-three patients had baseline BM. Systemic efficacy in patients with BM (ORR 47.8% [95% CI: 26.8, 69.4]; mDOR 9.5 months [95% CI: 5.5, not estimable]) was consistent with the overall population.

Fifteen patients were evaluable by RANO-BM; 12 received prior radiotherapy for BM (median 6.4 weeks before treatment). Systemic best objective responses (BORs) were partial response (PR, n=9), stable disease (SD, n=3), and progressive disease (PD; n=3).

Of seven patients with measurable CNS disease (all of whom received prior radiotherapy), intracranial BORs were PR (n=5), SD (n=1), and PD (n=1). For patients with NTL only (n=8), one had PD, and seven achieved intracranial disease control with three patients achieving CR of the enhancing NTL.

Conclusions

Tepotinib demonstrated intracranial activity in patients with METex14 skipping NSCLC with BM. Prospective evaluation of intracranial activity in VISION Cohort C is ongoing.

Targeting KRAS in non-small-cell lung cancer: recent progress and new approaches

Rat sarcoma (RAS) is the most frequently mutated oncogene in human cancer, with Kirsten rat sarcoma (KRAS) being the most commonly mutated RAS isoform. Overall, KRAS accounts for 85% of RAS mutations observed in human cancers and is present in 35% of lung adenocarcinomas (LUADs). While the use of targeted therapies and immune checkpoint inhibitors (CPIs) has drastically changed the treatment landscape of advanced non-small-cell lung cancer (NSCLC) in recent years, historic attempts to target KRAS (both direct and indirect approaches) have had little success, and no KRAS-specific targeted therapies have been approved to date for patients in this molecular subset of NSCLC. With the discovery by Ostrem, Shokat, and colleagues of the switch II pocket on the surface of the active and inactive forms of KRAS, we now have an improved understanding of the complex interactions involved in the RAS family of signaling proteins which has led to the development of a number of promising direct KRAS^G12C inhibitors, such as sotorasib and adagrasib. In previously treated patients with KRAS^G12C-mutant NSCLC, clinical activity has been shown for both sotorasib and adagrasib monotherapy; these data suggest promising new treatment options are on the horizon. With the stage now set for a new era in the treatment of KRAS^G12C-mutated NSCLC, many questions remain to be answered in order to further elucidate the mechanisms of resistance, how best to use combination strategies, and if KRAS^G12C inhibitors will have suitable activity in earlier lines of therapy for patients with advanced/metastatic NSCLC.

POS1341 TOCILIZUMAB FOR THE TREATMENT OF IMMUNE-RELATED ADVERSE EVENTS TO IMMUNE CHECKPOINT INHIBITORS: A CASE SERIES

Background:

Immune checkpoint inhibitors (ICI) are pharmacological agents effectively used in the treatment of several malignant tumors. The hyperactivation of the immune system induced by ICI may trigger an inflammatory involvement of healthy tissues, a phenomenon referred to as immune-related adverse event (irAE). No clinical trials are available to guide the management of irAEs. Observational data suggest tocilizumab might be effective in severe cases of irAEs, but data are scant. The possibility of continuing ICI treatment despite the development of irAE and the subsequent initiation of tocilizumab has never been evaluated.

Objectives:

To evaluate the efficacy and safety of tocilizumab, as monotherapy or alongside the continuation of ICI treatment, in the management of irAEs.

Methods:

We retrospectively identified patients who developed irAEs and were referred to our specialized Clinic between May 2018 and December 2020. Among these patients, we identified those who had been treated with tocilizumab and collected information about their oncologic history and outcome, ICI therapy and irAEs.

Results:

Thirty-nine patients were referred to our outpatient Clinic following the development of irAEs. Five of them were treated with tocilizumab. Disease and demographic features are reported in Table 1. At irAEs onset all patients were treated with glucocorticoids. A steroid-sparing agent was started to permit an adequate prednisone tapering without the irAE relapsing. Before tocilizumab start, two patients were treated with methotrexate monotherapy, one with anakinra monotherapy, and one with methotrexate and anakinra combination therapy. A significant therapeutic effect was confirmed in all patients and no significant adverse reactions were reported. ICI therapy was permanently discontinued in two patients. In the other three cases, cancer immunotherapy was safely continued alongside tocilizumab without further irAEs occurring. Only one patient experienced tumor progression two years after ICI suspension and subsequently died despite the improvement of his myocardial inflammatory involvement.

Conclusion:

In our cohort, tocilizumab proved to be an effective and safe therapy for the management of irAEs.

Our case series also supports the possibility of maintaining ICI while introducing tocilizumab for irAE treatment. This combined approach might represent a suitable therapeutic option to guarantee a significant anti-inflammatory activity without losing the oncologic response.

References:

[1]Kostine M et al, Ann Rheum Dis, 2021;80:36-48.

Table 1.

Clinical characteristics of patients who developed irAEs secondary to ICI therapy and who received tocilizumab.

Patient 1Patient 2Patient 3Patient 4Patient 5Age at irAE onset (years)6952725775SexMaleMaleMaleFemaleFemaleNeoplastic histologyNSCLCNSCLCNSCLCNSCLCPleural mesotheliomaICI treatmentNivolumabNivolumabPembrolizumabPembrolizumabPembrolizumabirAEMyocarditisArthritisCutaneous vasculitisArthritisArthritisLarge vessel vasculitis ICI discontinuation due to irAEYesNoNoNoYes PDN initial dose (mg daily)5037.5252537.5 DMARD therapy *T16: ANKT20: TCZT26: TCZ + MMFT5: MTXT6: MTX + ANKT11: MTX + TCZT3: MTXT11: MTX + TCZT4: MTXT6: MTX + TCZT3: TCZ irAE outcomeImprovementLow disease activityLow disease activityRemissionRemissionFollow-up length (months)Since oncologic diagnosisSince TCZ start50104725572255268Oncological outcomeProgressive disease and deathComplete responseStable diseaseStable diseaseComplete response

* Treatment chronology is referred to as a T followed by the number of months since irAE onset.

ANK, anakinra; ICI, immune checkpoint inhibitor; irAE, immune-related adverse events; DMARD, disease modifying anti-rheumatic drug; MTX, methotrexate; NSCLC, non-small cell lung cancer; PDN, prednisone; TCZ, tocilizumab.

Disclosure of Interests:

Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Nicola Farina: None declared, Alessandro Tomelleri: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, MSD, Pfizer, Giulio Cavalli Speakers bureau: SOBI, Chiara Lazzari: None declared, Roberto Ferrara: None declared, Marina Garassino: None declared, Vanesa Gregorc: None declared, Lorenzo Dagna Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, SOBI, Celgene Janssen, MSD, MP

Thymoma and thymic carcinoma in children and adolescents: The EXPeRT/PARTNER diagnostic and therapeutic recommendations

Thymic tumors are epithelial tumors arising from the anterior mediastinum and constitute 0.2-1.5% of all adult malignancies but are exceptional in pediatric population. Thymic epithelial tumors (TETs) encompass a variety of histologic subtypes associated with different clinical outcomes. Due to its rarity in children, TETs' management requires a multidisciplinary approach. However, prognosis remains still poor, especially among patients with thymic carcinoma. This study presents the internationally recognized recommendations for the diagnosis and treatment of thymic tumors in children and adolescents, established by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) group within the EU-funded project Paediatric Rare Tumours Network - European Registry (PARTNER).

Avelumab Versus Docetaxel in Patients With Platinum-Treated Advanced NSCLC: 2-Year Follow-Up From the JAVELIN Lung 200 Phase 3 Trial

INTRODUCTION

In the JAVELIN Lung 200 trial, avelumab (anti-programmed death-ligand 1 [PD-L1] antibody) did not significantly prolong overall survival (OS) versus docetaxel in patients with platinum-treated PD-L1+ NSCLC. We report greater than 2-year follow-up data.

METHODS

Patients with stage IIIB or IV or recurrent NSCLC with disease progression after platinum-doublet chemotherapy were randomized 1:1 to avelumab 10 mg/kg every 2 weeks or docetaxel 75 mg/m² every 3 weeks. The primary end point was OS in patients with PD-L1+ tumors (greater than or equal to 1% tumor cell expression; IHC 73-10 pharmDx assay).

RESULTS

Of 792 patients, 529 had PD-L1+ tumors (264 versus 265 in the avelumab versus docetaxel arms, respectively). As of March 4, 2019, median duration of follow-up for OS in the PD-L1+ population was 35.4 months in the avelumab arm and 34.7 months in the docetaxel arm; study treatment was ongoing in 25 (9.5%) versus 0 patients, respectively. In the PD-L1+ population, 2-year OS rates (95% confidence interval [CI]) with avelumab versus docetaxel were 29.9% (24.5%-35.5%) versus 20.5% (15.6%-25.8%); in greater than or equal to 50% PD-L1+ subgroups, 2-year OS rates were 36.4% (29.1%-43.7%) versus 17.7% (11.8%-24.7%) and in the greater than or equal to 80% subgroup were 40.2% (31.3%-49.0%) versus 20.3% (12.9%-28.8%), respectively. Median duration of response (investigator assessed) was 19.1 months (95% CI: 10.8-34.8) versus 5.7 months (95% CI: 4.1-8.3). Safety profiles for both arms were consistent with the primary analysis.

CONCLUSIONS

Although the JAVELIN Lung 200 primary analysis (reported previously) revealed that avelumab did not significantly prolong OS versus docetaxel in patients with platinum-treated PD-L1+ NSCLC, posthoc analyses at 2 years of follow-up revealed that 2-year OS rates were doubled with avelumab in subgroups with higher PD-L1 expression (greater than or equal to 50% and greater than or equal to 80%).

OncoAlert Round Table Discussions: The Global COVID-19 Experience

The speed and spread of the COVID-19 pandemic has been affecting the entire world for the past several months. OncoAlert is a social media network made up of more than 140 oncology stakeholders: oncologists (medical, radiation, and surgical), oncology nurses, and patient advocates who share the mission of fighting cancer by means of education and dissemination of information. As a response to the COVID-19 pandemic, OncoAlert hosted The Round Table Discussions. We have documented this effort along with further discussion about the COVID-19 pandemic and the consequences on patients living with cancer to disseminate this information to our colleagues worldwide.

Patient Preferences for Lung Cancer Treatment: A Qualitative Study Protocol Among Advanced Lung Cancer Patients

Introduction: Lung cancer is the deadliest and most prevalent cancer worldwide. Lung cancer treatments have different characteristics and are associated with a range of benefits and side effects for patients. Such differences may raise uncertainty among drug developers, regulators, payers, and clinicians regarding the value of these treatment effects to patients. The value of conducting patient preference studies (using qualitative and/or quantitative methods) for benefits and side effects of different treatment options has been recognized by healthcare stakeholders, such as drug developers, regulators, health technology assessment bodies, and clinicians. However, evidence-based guidelines on how and when to conduct and use these studies in drug decision-making are lacking. As part of the Innovative Medicines Initiative PREFER project, we developed a protocol for a qualitative study that aims to understand which treatment characteristics are most important to lung cancer patients and to develop attributes and levels for inclusion in a subsequent quantitative preference survey.

Methods: The study protocol specifies a four-phased approach: (i) a scoping literature review of published literature, (ii) four focus group discussions with stage III and IV Non-Small Cell Lung Cancer patients, (iii) two nominal group discussions with stage III and IV Non-Small Cell Lung Cancer patients, and (iv) multi-stakeholder discussions involving clinicians and preference experts.

Discussion: This protocol outlines methodological and practical steps as to how qualitative research can be applied to identify and develop attributes and levels for inclusion in patient preference studies aiming to inform decisions across the drug life cycle. The results of this study are intended to inform a subsequent quantitative preference survey that assesses patient trade-offs regarding lung cancer treatment options. This protocol may assist researchers, drug developers, and decision-makers in designing qualitative studies to understand which treatment aspects are most valued by patients in drug development, regulation, and reimbursement.

Bringing Onco-Innovation to Europe's Healthcare Systems: The Potential of Biomarker Testing, Real World Evidence, Tumour Agnostic Therapies to Empower Personalised Medicine

Simple Summary

The increasing number of data supporting use of a personalized approach in cancer treatment, is changing the path of patient’s management. In the same time, the availability of technologies should allow patients to receive the best test for the specific individual condition. This is theoretically true, when a specific test is designed for the specific disease condition, while it is difficult to implement in the setting of agnostic therapies. Financial sources availability related to the non homogeneous health systems working in the different countries do not allow for an immediate implementation of the technologies and test commercially available. Future perspectives for targeted oncology include tumor-agnostic drugs, which target a given mutation and could be used in treating cancers from multiple organ types. Therefore, the present paper is aimed to both underline a how much important is this new view and also to sensitize the international bodies that supervise health policies at the decision-making level, with the aim of harmonizing cancer treatment pathways in at least all European countries.

Abstract

Rapid and continuing advances in biomarker testing are not being matched by uptake in health systems, and this is hampering both patient care and innovation. It also risks costing health systems the opportunity to make their services more efficient and, over time, more economical. The potential that genomics has brought to biomarker testing in diagnosis, prediction and research is being realised, pre-eminently in many cancers, but also in an ever-wider range of conditions—notably BRCA1/2 testing in ovarian, breast, pancreatic and prostate cancers. Nevertheless, the implementation of genetic testing in clinical routine setting is still challenging. Development is impeded by country-related heterogeneity, data deficiencies, and lack of policy alignment on standards, approval—and the role of real-world evidence in the process—and reimbursement. The acute nature of the problem is compellingly illustrated by the particular challenges facing the development and use of tumour agnostic therapies, where the gaps in preparedness for taking advantage of this innovative approach to cancer therapy are sharply exposed. Europe should already have in place a guarantee of universal access to a minimum suite of biomarker tests and should be planning for an optimum testing scenario with a wider range of biomarker tests integrated into a more sophisticated health system articulated around personalised medicine. Improving healthcare and winning advantages for Europe’s industrial competitiveness and innovation require an appropriate policy framework—starting with an update to outdated recommendations. We show herein the main issues and proposals that emerged during the previous advisory boards organised by the European Alliance for Personalized Medicine which mainly focus on possible scenarios of harmonisation of both oncogenetic testing and management of cancer patients.

Abstract PO-087: COVID-19 pandemic in Italy: Social distress and gender imbalance among health care professionals

Introduction: During the last months coronavirus disease 2019 (COVID-19) has spread abruptly to nearly every country, taking on pandemic proportions. The Italian government ordered a nationwide lockdown to hinder the spread of the contagion with unavoidable social isolation and substantial changes in lifestyle habits. Therefore, COVID-19 affected not only physical but also psychological health and well-being. Health care professionals fighting the epidemic represent the most involved category, resulting in more physical and emotional involvement. The aim of this study is to assess the social stress level of health care workers in Italy.

Materials and Methods: In this online, totally anonymous survey, 24 multiple-choice questions were broadcast to medical staffs employed in the Italian health care system during COVID-19 pandemic. Data collection was performed from 30th March to 24th April 2020. Descriptive statistics have been applied to describe and summarize our findings and the correlation analyses between categorical variables were performed using Pearson’s Chi-Square.

Results: A total of 600 health care professionals completed the questionnaire with a prevalence of young (32.3% between 36 and 45 years old), female (74.0%) oncologists (58.8%). Participants mainly belong to Lombardy (31.3%) and Marche (30.3%), two of the most affected regions, but almost all the Italian regions contributed to the survey. The majority of respondents expressed the fear of being at higher risk of contagion than the general population (83.3%) and the weighty concern of infecting their own families (72.5%). An insufficient supply of personal protective equipment (p = 0.0003) and inadequate training about procedures to follow (p = 0.0092) significantly correlated with these worries. Furthermore, more than two thirds declared a change in family organization and daily life, showing a significant correlation with worry about infecting their own relatives (p &lt; 0.0001).

Discussion: This is the first Italian survey on social distress among health care professionals during the COVID-19 pandemic. The unavailability of personal protective equipment, periodic screening procedures, adequate training, and the correct spread of information strongly conditioned health care professionals’ emotional status, family organization, and daily life. With this survey we underlined the social impact that this health emergency has on health care workers, especially on women, who deal with “caring” in the hospital as well as at home, juggling to fulfill multiples roles of professionals, mothers, wives, and caregivers for elderly parents. We wish that institutions could involve themselves concretely to guarantee that health care professionals safely perform their work in a context appropriate to proper professional skills and with the adequate social and psychological support. Reducing workers’ fear of contagion and psychological distress will certainly bring significant positive repercussions for the national health system.

Citation Format: Rossana Berardi, Mariangela Torniai, Maria Silvia Cona, Fabiana Cecere, Rita Chiari, Valentina Guarneri, Nicla La Verde, Laura Locati, Domenica Lorusso, Erika Martinelli, Marina Garassino. COVID-19 pandemic in Italy: Social distress and gender imbalance among health care professionals [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-087.

Bringing Greater Accuracy to Europe's Healthcare Systems: The Unexploited Potential of Biomarker Testing in Oncology

Rapid and continuing advances in biomarker testing are not being matched by take-up in health systems, and this is hampering both patient care and innovation. It also risks costing health systems the opportunity to make their services more efficient and, over time, more economical. This paper sets out the potential of biomarker testing, the unfolding precision and range of possible diagnosis and prediction, and the many obstacles to adoption. It offers case studies of biomarker testing in breast, ovarian, prostate, lung, thyroid and colon cancers, and derives specific lessons as to the potential and actual use of each of them. It also draws lessons about how to improve access and alignment, and to remedy the data deficiencies that impede development. And it suggests solutions to outstanding issues - notably including funding and the tangled web of obtaining reimbursement or equivalent coverage that Europe's fragmented health system implies. It urges a European evolution towards an initial minimum testing scenario, which would guarantee universal access to a suite of biomarker tests for the currently most common conditions, and, further into the future, to an optimum testing scenario in which a much wider range of biomarker tests would be introduced and become part of a more sophisticated health system articulated around personalised medicine. For exploiting genomics to the full, it argues the need for a new policy framework for Europe. Biomarker testing is not an issue that can be treated in isolation, since the purpose of testing is to improve health. Its use is therefore always closely linked to specific health challenges and needs to be viewed in the broader policy context in the EU and more widely. The paper is the result of extensive engagement with experts and decision makers to develop the framework, and consequently represents a wide consensus of views on how healthcare systems should respond from push and pull factors at local, national and cross-border and EU level. It contains strong views and clear recommendations springing from the convictions of patients, clinicians, academics, medicines authorities, HTA bodies, payers, the diagnostic, pharmaceutical and ICT industries, and national policy makers.

Abstract CT198: Efficacy of metfOrmin in PrevenTIng glucocorticoid-induced diabetes in Melanoma, breAst or Lung Cancer patients with brain metastases: The phase II OPTIMAL study

Background: Brain metastases frequently occur in patients with late-stage cancers. Treatment with high-dose glucocorticoids (GCs) is usually started to prevent or reduce tumor-related edema and its deadly complications. However, treatment with high-dose GCs is associated with serious side effects, including diabetes and immunosuppression, which could promote tumor growth or reduce the effectiveness of antitumor therapies. Based on its potential antitumor properties and on its ability to prevent GC-induced diabetes, the antidiabetic compound Metformin could reduce short-term mortality in patients with brain metastases taking high-dose GCs. Methods: The OPTIMAL study is a monocentric, open label, randomized Phase II trial in patients with brain metastases from melanoma, lung or breast cancer, who require treatment with high-dose dexamethasone, as defined as a minimum of 8 mg daily based on the clinician judgment, for at least three consecutive weeks. At enrollment, patients are randomized in a 1:1 ratio to receive high-dose dexamethasone +/- metformin 2550 mg/day for 30 days. At randomization, patients are stratified according to: tumor origin, dose of dexamethasone (8-12 vs. &gt; 12 mg/day) and baseline fasting glycemia (&lt; 100 vs. 100-125 mg/dl). Patients may receive concomitant radiotherapy based on the judgment of the physician. The primary study endpoint is the rate of precocious (14 days) dexamethasone-induced diabetes, as defined as fasting plasma glucose levels ≥ 126 mg/dl. Discussion: The OPTIMAL study aims to evaluate the efficacy of upfront use of metformin in preventing the onset of GCs-induced diabetes and other metabolic perturbations in patients with brain metastases from melanoma, lung or breast cancer. Other clinical objectives consist in investigating the impact of metformin on precocious mortality, deterioration of ECOG PS and local (brain) disease control rate at one month after dexamethasone initiation. The effect of dexamethasone +/- metformin on other metabolites or growth factors, including amino acids, fatty acids, ketone bodies, IGF-1, as well as on the number, activation status and metabolism of peripheral blood immune cell populations will be evaluated as well. Trial registration: The OPTIMAL trial is registered at ClinicalTrials.gov (NCT04001725, June 28, 2019) and EudraCT (2019-000105-73, January 8, 2019).

Citation Format: Claudio Vernieri, Federico Nichetti, Francesca Ligorio, Emma Zattarin, Teresa Beninato, Riccardo Lobefaro, Giulia Bianchi, Giuseppe Capri, Marina Garassino, Giuseppe Lo Russo, Michele Del Vecchio, Paola Corsetto, Licia Rivoltini, Chiara Castelli, Filippo de Braud. Efficacy of metfOrmin in PrevenTIng glucocorticoid-induced diabetes in Melanoma, breAst or Lung Cancer patients with brain metastases: The phase II OPTIMAL study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT198.

FRI0478 SEROLOGICAL AUTOIMMUNITY IN PATIENTS WITH RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS: CORRELATION WITH SEVERITY AND TREATMENT

Background:

Immune checkpoint inhibitors (ICIs) can induce a variety of rheumatic immune-related adverse events (Rh-irAEs). Few data are available on which features can predict the occurrence of long-lasting and severe Rh-irAE

Objectives:

To describe the serological features associated with long-lasting and severe Rh-irAE.

Methods:

ICI-treated patients were identified. Patients’ demographics, histotype of cancer, ICI, time interval from ICI start to Rh-irAE onset, characteristics of Rh-irAEs were recorded. Patients were tested for autoimmunity panel (a-IP): RF, ACPA, ANA, anti-SSA, anti-SSB, anti-Sm, anti-RNP, anti-Jo1, ANCA, ASMA, AMA, anti-dsDNA, anti-tireoglobulin, anti-tireoperoxidas, IgM and IgG anti-cardiolipin and anti-β2 glicoprotein I, crioglobulins. All patients were treated with steroids (CS). In case of flare of the Rh-irAE, csDMARDs or bDMARDs were started. Associations between a-IP status and need for DMARD start was evaluated. Non parametric tests were used.

Results:

22 Rh-irAE were included (see Table 1). Median age at Rh-irAE onset was 70 (50 – 84) years. 2 patients (9%) had a personal history of psoriasis. Median time from ICI start to Rh-irAE onset was 5 (1 – 26) months. 11 patients (50%) developed 1 Rh-irAE, 10 (45.4%) 2 and 1 (4.5%) 3. The most frequent were arthritis (A, 14, 63.6%), cutaneous vasculitis (CV, 5, 22.7%), PMR-like (4, 18.2%), polymyositis (PM, 4, 18.2%), myocarditis (Myo, 3, 13.6%) and dermatomyositis (DM, 2, 9.1%). Median initial prednisone dose was 25 (10 – 75) mg daily. In 14 patients (63.6%) a csDMARD was started upon steroids tapering. 9 patients (41%) were treated with methotrexate (MTX, 4, 18.2%) with hydroxychloroquine (HCQ, 2, 9.1%) with mycophenolate (MMF, 2, 9.1%) with colchicine (colch). 6 patients were treated with bDMARDs. 3 patients (50%) were treated with anakinra (ANK), 2 (33.3%) with IVIG and 3 (50%) with tocilizumab (TCZ). 13 patients (59.1%) were a-IP+. A significantly higher percentage of a-IP+ patients received DMARDs (11, 84.6%) compared to a-IP- patients (2, 22.2%,p = 0.0007). A significantly higher percentage of a-IP+ patients were treated with bDMARDs (5, 38.5%) compared to a-IP- patients (0, 0%, p = 0.05). We analysed whether in csDMARD-treated patients the need for bDMARDs was higher in a-IP+ but we found no statistical significance (45.4% vs 0%, p = 0.487).

Table 1.

Characteristics and treatment of Rh-irAEs patients.

Age, SexCancerICIOnset (monts)Rhem-irAETreatmentResponseICI stopAutoAb169, MLung, adenoNivo3MyoCS, MMF, ANK, TCZLDAY, DpANCA270, MBladderAtezo1A,CS, MTXRemY, TNeg379, MLung SCCPembro1ACSRemNoRo52452, MLung, LCCNivo6A, CVCS, MTX, ANK, TCZLDANoANA 1:160 s582, MLung, LCCPembro3PMRCSRemNoNeg656, MMelanomaPembro26PMR, PMCS, MTXDeathY, DANA 1:160 s, pANCA772, MLung, adenoPembro5A, CVCS, MTX, TCZHDA (TCZ)Y, TANA 1:160 s874, MLung, adenoPembro1PMRCS, MTXLDANoANA 1:160 s975, MLung, adenoPembro1PM, MyoCSRemY, DNeg1075, MLung, adenoNivo9ACSRemNoNeg1168, FLung, adenoAtezo18ACS, MTXLDAY, TNeg1235, MMelanomaNivo2ACS, MTXLDANoANA 1:640 s1379, MLung, SCCNivo15A, PMRCS, MTX, ANKDeath (NR)Y, DRo521477, MLung, adenoPembro8DMCS, HCQ, IVIGLDAY, DANA 1:320 PCNA1567, MLung, adenoNivo13ACS, MTXLDANoASMA1674, MLung, SCCAtezo1A, CVCS, HCQ, ColchLDAY, DNeg1770, MLung, adenoNivo5A, CVCSRemY, DNeg1870, MLung, adenoPembro15ACSLDANoASMA1969, MLung, adenoNivo5DMCS, HCQ, MMF, IVIG, TacroMDAY, TANA 1:!60 s2084, MH&N, SCCNivo3PhCSRemY, DNeg2167, MLung, adenoDurva5A, PM, MyoCSLDAY, DANA 1:160 h2250, FLung, LCCNivo1A, CVCS, HCQRemY, DNeg

Conclusion:

The presence of serological autoimmunity might be helpful in detecting patients with Rh-irAEs refractory to steroid therapy.

Disclosure of Interests:

Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Alessandro Tomelleri: None declared, Roberto Ferrara: None declared, Chiara Lazzari: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Diego Signorelli: None declared, Alessandra Bulotta: None declared, Vanesa Gregorc: None declared, Marina Garassino: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI

Safety and patient-reported outcomes of atezolizumab, carboplatin, and etoposide in extensive-stage small-cell lung cancer (IMpower133): a randomized phase I/III trial

BACKGROUND

The addition of atezolizumab to carboplatin and etoposide (CP/ET) significantly improved progression-free and overall survival for patients with extensive-stage small-cell lung cancer (ES-SCLC) in the IMpower133 study (NCT02763579). We have evaluated adverse events (AEs) and patient-reported outcomes in IMpower133 to assess the benefit-risk profile of this regimen.

PATIENTS AND METHODS

Patients received four 21-day cycles of CP/ET plus intravenous atezolizumab 1200 mg or placebo (induction phase), followed by atezolizumab or placebo (maintenance phase) until progression or loss of benefit. AEs were assessed and patient-reported outcomes were evaluated every 3 weeks during treatment using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (QLQ-C30) and QLQ-LC13.

RESULTS

Overall, 394 patients were assessable for safety in the induction phase and 318 in the maintenance phase. The frequency of AEs, grade 3-4 AEs, and serious AEs was similar between arms in both phases. Immune-related AEs were more frequent in the atezolizumab arm during both induction (28% versus 17%; leading to atezolizumab/placebo interruption 9% versus 5%, leading to withdrawal 4% versus 0%) and maintenance (26% versus 15%; leading to atezolizumab/placebo interruption, 3% versus 2%, leading to withdrawal 1% versus 1%), most commonly rash (induction 11% versus 9%, maintenance 14% versus 4%), and hypothyroidism (induction 4.0% versus 0%, maintenance 10% versus 1%). Changes in patient-reported treatment-related symptoms commonly associated with quality of life impairment were generally similar during induction and most of the maintenance phase. Patient-reported function and health-related quality of life (HRQoL) improved in both arms after initiating treatment, with more pronounced and persistent HRQoL improvements in the atezolizumab arm.

CONCLUSIONS

In patients with ES-SCLC, atezolizumab plus CP/ET has a comparable safety profile to placebo plus CP/ET, and the addition of atezolizumab did not adversely impact patient-reported HRQoL. These data demonstrate the positive benefit-risk profile of first-line atezolizumab plus CP/ET in ES-SCLC and further support this regimen as a new standard of care in this setting.

CLINICAL TRIALS NUMBER

NCT02763579.

Nivolumab versus docetaxel in previously treated advanced non-small-cell lung cancer (CheckMate 017 and CheckMate 057): 3-year update and outcomes in patients with liver metastases

Background

Long-term data with immune checkpoint inhibitors in non-small-cell lung cancer (NSCLC) are limited. Two phase III trials demonstrated improved overall survival (OS) and a favorable safety profile with the anti-programmed death-1 antibody nivolumab versus docetaxel in patients with previously treated advanced squamous (CheckMate 017) and nonsquamous (CheckMate 057) NSCLC. We report results from ≥3 years' follow-up, including subgroup analyses of patients with liver metastases, who historically have poorer prognosis among patients with NSCLC.

Patients and methods

Patients were randomized 1 : 1 to nivolumab (3 mg/kg every 2 weeks) or docetaxel (75 mg/m2 every 3 weeks) until progression or discontinuation. The primary end point of each study was OS. Patients with baseline liver metastases were pooled across studies by treatment for subgroup analyses.

Results

After 40.3 months' minimum follow-up in CheckMate 017 and 057, nivolumab continued to show an OS benefit versus docetaxel: estimated 3-year OS rates were 17% [95% confidence interval (CI), 14% to 21%] versus 8% (95% CI, 6% to 11%) in the pooled population with squamous or nonsquamous NSCLC. Nivolumab was generally well tolerated, with no new safety concerns identified. Of 854 randomized patients across both studies, 193 had baseline liver metastases. Nivolumab resulted in improved OS compared with docetaxel in patients with liver metastases (hazard ratio, 0.68; 95% CI, 0.50-0.91), consistent with findings from the overall pooled study population (hazard ratio, 0.70; 95% CI, 0.61-0.81). Rates of treatment-related hepatic adverse events (primarily grade 1-2 liver enzyme elevations) were slightly higher in nivolumab-treated patients with liver metastases (10%) than in the overall pooled population (6%).

Conclusions

After 3 years' minimum follow-up, nivolumab continued to demonstrate an OS benefit versus docetaxel in patients with advanced NSCLC. Similarly, nivolumab demonstrated an OS benefit versus docetaxel in patients with liver metastases, and remained well tolerated.

Clinical trial registration

CheckMate 017: NCT01642004; CheckMate 057: NCT01673867.

Four-year survival with nivolumab in patients with previously treated advanced non-small-cell lung cancer: a pooled analysis

BACKGROUND

Phase 3 clinical data has shown higher proportions of patients with objective response, longer response duration, and longer overall survival with nivolumab versus docetaxel in patients with previously treated advanced non-small-cell lung cancer (NSCLC). We aimed to evaluate the long-term benefit of nivolumab and the effect of response and disease control on subsequent survival.

METHODS

We pooled data from four clinical studies of nivolumab in patients with previously treated NSCLC (CheckMate 017, 057, 063, and 003) to evaluate survival outcomes. Trials of nivolumab in the second-line or later setting with at least 4 years follow-up were included. Comparisons of nivolumab versus docetaxel included all randomised patients from the phase 3 CheckMate 017 and 057 studies. We did landmark analyses by response status at 6 months to determine post-landmark survival outcomes. We excluded patients who did not have a radiographic tumour assessment at 6 months. Safety analyses included all patients who received at least one dose of nivolumab.

FINDINGS

Across all four studies, 4-year overall survival with nivolumab was 14% (95% CI 11-17) for all patients (n=664), 19% (15-24) for those with at least 1% PD-L1 expression, and 11% (7-16) for those with less than 1% PD-L1 expression. In CheckMate 017 and 057, 4-year overall survival was 14% (95% CI 11-18) in patients treated with nivolumab, compared with 5% (3-7) in patients treated with docetaxel. Survival subsequent to response at 6 months on nivolumab or docetaxel was longer than after progressive disease at 6 months, with hazard ratios for overall survival of 0·18 (95% 0·12-0·27) for nivolumab and 0·43 (0·29-0·65) for docetaxel; for stable disease versus progressive disease, hazard ratios were 0·52 (0·37-0·71) for nivolumab and 0·80 (0·61-1·04) for docetaxel. Long-term data did not show any new safety signals.

INTERPRETATION

Patients with advanced NSCLC treated with nivolumab achieved a greater duration of response compared with patients treated with docetaxel, which was associated with a long-term survival advantage.

FUNDING

Bristol-Myers Squibb.