Effect of treatment of residual disease after immunotherapy-based combinations on complete response rate in metastatic renal cell carcinoma

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Background: Immunotherapy (IO) has revolutionized the management of metastatic renal cell carcinoma (mRCC) by improving survival, overall response and complete response (CR) rates. CR is achieved in 11 to 17% with the different PD-1-based IO combinations in first-line setting of mRCC. However, local treatment of residual disease after systemic treatment exposure may improve CR rates. We performed a retrospective study to characterize patients (pts) in CR with systemic therapy alone or combined to an ablative approach of residual disease. Methods: We included all consecutive mRCC pts treated with mRCC in first-line treatment with IO combination with IO or TKI, either alone or with local treatment at the Institut de Cancérologie Strasbourg Europe. Pts were characterized according to IMDC risk group. Radiologic response was defined according to RECIST v1.1. Results: We enrolled 80 pts with mRCC between 5/2015 and 5/2022; median age was 68 (41-89) years; 75% male; 36 pts (45%) had prior nephrectomy; IMDC risk group: 12 favorable (15%), 50 intermediate (63%), 18 poor risk pts (22%), respectively; 47 pts (59%) received IO + IO, 24 (30%) received IO + TKI and 9 pts (11%) received another IO-based therapy; 35 pts (44%) achieved partial response, 23 pts (29%) stable disease, 13 pts progressive disease and 9 pts achieved CR (11%) as best response with systemic therapy alone; 10 pts out of 35 PR pts achieved CR by adding local treatment on residual disease. Among CR pts: 5 out of 19 pts had a component of sarcomatoid histology; median age was 60 years. Characteristics of pts with CR are reported in the table. Median duration of IO exposure before local therapy was 13 months. Residual disease resected sites included kidney (N = 6), lymph node (N = 4), lung metastasis (N = 2) and liver metastasis (N = 1). Local treatment was surgery for 9 pts and liver thermoablation for 1 patient. Conclusions: The resection of residual disease after first line IO-based therapy in mRCC improves CR rates (from 11% up to 24%). This approach should be considered as an option for a selected population. Prospective trials assessing this strategy should be performed in the future. Characteristics of patients in CR. [Table: see text]

Impact of the app-based and nurse-led supportive care program AKO@dom on dose intensity of oral-targeted therapies in patients with metastatic renal cell cancer: a multicentric observational retrospective study

BACKGROUND

Tyrosine kinase inhibitors (TKIs) remain a cornerstone of metastatic kidney cancer (mRCC). Adverse events (AEs) may lead to dose downregulation, and optimal management of AEs is needed to maintain an efficient dose intensity (DI). The aim of our study was to evaluate the impact of an app-based and nurse-led supportive-care program on DI in mRCC patients.

METHOD

This multicenter (n = 3), retrospective study evaluated all consecutive mRCC patients who participated in the AKO@dom program, which consisted of an app-based and nurse-led weekly patient evaluation at home during the first 3 months of TKI intake. Treatment patterns and modifications were described, and the mean DI (mDI) was calculated at the end of AKO@dom.

RESULTS

Eighty-nine patients were included: 12 had sunitinib, 18 pazopanib, 12 axitinib, and 47 cabozantinib. Median age was 69 years (60-76). TKIs were mainly initiated at standard doses except for cabozantinib (53% started at 40 mg/day); 71% had prior systemic treatment. Nine patients discontinued permanent treatment during the program. Thirty-two patients required ≥ 1 dose interruption, and 29% experienced ≥ 1 grade 3 AE of any type. The mDI (in mg/day) at 3 months was 34.4 ± 17.7 for sunitinib, 672.8 ± 144 for pazopanib, 8.6 ± 2.6 for axitinib, and 40 (36-48) for cabozantinib. Fifty-five patients [68.75% (95% CI: 57-78%)] had a mDI ≥ than reported in the literature. Overall survival at 12 months was 64.2% (CI 95%: 55-75%).

CONCLUSION

The AKO@dom program allowed 68.75% of patients to maintain a high dose intensity after 3 months of TKI treatment. The impact on survival outcomes needs to be evaluated in randomized clinical trials.

Factors improving the outcome of patients re-irradiated with intensity-modulated radiotherapy (IMRT) for relapse or new head and neck cancer developed in irradiated areas

BACKGROUND

Patients with secondary/recurrent squamous cell head and neck cancer have poor prognoses. Re-irradiation is a treatment option. However, best technique to re-irradiate is not known. This study aims to evaluate the outcome of patients treated with curative-intent intensity-modulated radiotherapy (IMRT) re-irradiation (re-RT) for head and neck (H&N) cancers.

METHODS

Fifty patients with recurrent H&N cancers underwent fractionated IMRT re-RT. The median time between the two courses of radiotherapy was 22 months. The median dose of re-RT was 66 Gy.

RESULTS

The median follow-up of surviving patients was 13.6 months. The median overall survival (OS) was 15.7 months, and the 1- and 2-year OS rates were 62.4% and 33.9%, respectively. On multivariate analysis, performance status (PS) 0-1 (HR, 0.518; 95% CI: 0.292-0.917; P=0.024) and 3D-RT use during the first irradiation course technique (HR, 0.415; 95% CI: 0.183-0.938; P=0.035) were favorable, independent of significant prognostic factors of OS. The median loco-regional progression-free survival (LRPFS) was 8.3 months, and, the 1- and 2-year LRPFS rates were 46.6% and 35.9%, respectively. On multivariate analysis, a surgical resection before re-RT (HR, 0.107; 95% CI: 0.027-0.428; P=0.002), a higher age (HR, 0.894; 95% CI: 0.833-0.960; P=0.002), a PS 0-1 (HR, 0.316; 95% CI: 0.140-0.715; P=0.006), and a long re-RT interval (HR, 0.970; 95% CI: 0.945-0.996; P=0.024) were favorable independent significant prognostic factors of LRPFS. The median progression-free survival (PFS) was 7.0 months and, the 1- and 2-year PFS rates were 45.0% and 30.4%, respectively. On multivariate analysis, a surgical resection before re-RT (HR, 0.129; 95% CI: 0.036-0.466; P=0.002), a PS 0-1 (HR, 0.399; 95% CI: 0.208-0.764; P=0.006) and, a long re-RT interval (HR, 0.958; 95% CI: 0.927-0.989; P=0.009) were favorable, independent significant prognostic factors. The early and late toxicities rates were 28% and 34%, respectively.

CONCLUSIONS

Re-RT for H&N cancers can be curative, and the complications can be manageable but patients need to be strictly selected. Surgery before re-RT could improve the patient outcome. Dose and irradiation schedules should be prospectively evaluated.

Prognostic factors in second-line targeted therapy for metastatic clear-cell renal cell carcinoma after progression on an anti-vascular endothelial growth factor receptor tyrosine kinase inhibitor

BACKGROUND

About 40% of metastatic clear-cell renal cell carcinoma (m-ccRCC) patients receive a second-line targeted therapy after failure of anti-vascular endothelial growth factor receptor tyrosine kinase inhibitors (anti-VEGFR-TKI). Efficacy of second-line therapy is usually limited and prognostic and predictive factors at the start of second-line therapy are lacking. To identify the subgroup of patients that will benefit from such treatment remains a challenge.

METHODS

We performed a multi-institutional, retrospective study of patients who received a second-line therapy after progression on an anti-VEGFR-TKI. Univariate and multivariate analyses were performed in order to identify prognostic factors for progressive disease (PD) as best response, progression-free survival (PFS) and overall survival (OS) on second-line therapy.

RESULTS

For the whole cohort of 108 patients, mOS from the start of second-line therapy was 8.9 months while mPFS on second-line therapy was 2.8 months. A total of 49/105 (47%) patients had PD, 50/105 (48%) stable disease (SD) and 6/105 (6%) a partial response (PR). On multivariate analysis, the following markers were associated with improved outcome on second-line therapy: a PFS on first-line therapy ≥12 months (HR for PFS: 1.961; p = 0.008) (HR for OS: 1.724; p = 0.037) and Fuhrman grade 1-2 tumors (HR for OS: 2.198; p = 0.007). Markers associated with poorer outcome on second-line therapy were: elevated serum lactate dehydrogenase (LDH) levels (HR for PFS: 0.511; p = 0.04) (HR for OS: 0.392; p = 0.017), low albumin (HR for OS: 0.392; p = 0.01) and elevated corrected calcium levels (HR for OS: 0.416; p = 0.01). The impact on OS of the Memorial Sloan Kettering Cancer Centre (MSKCC) and International Renal Cell Carcinoma Database Consortium (IMDC) prognostic scores as calculated at start of second-line therapy was validated in our patient series.

CONCLUSIONS

Duration of first-line PFS, Fuhrman grade, serum LDH levels, albumin levels, corrected calcium levels and the MSKCC and IMDC scores calculated at start of second-line therapy are prognostic factors for m-ccRCC patients treated with second-line targeted therapy.

First report of trastuzumab treatment after postoperative Takotsubo cardiomyopathy

BACKGROUND

Trastuzumab is a humanized monoclonal antibody used for the treatment of HER2-positive breast cancer. Cardiotoxicity is a well-known adverse event of trastuzumab use but little has been documented regarding its use in patients with a history of cardiac disease.

CASE REPORT

We describe a case in which trastuzumab treatment was administered to a 40-year-old female patient with early breast cancer after acute heart failure secondary to postoperative Takotsubo cardiomyopathy. After one year of follow-up with close monitoring by echocardiography, there have been no heart-related symptoms. Additional surgery was performed because of positive resection margins at first surgery, without complications, despite the risk of recurrence of Takotsubo cardiomyopathy.

CONCLUSION

Trastuzumab can be safely administered after acute heart failure secondary to postoperative Takotsubo cardiomyopathy.