Safety Profile and Adverse Event Management for Futibatinib, An Irreversible FGFR1-4 Inhibitor: Pooled Safety Analysis of 469 Patients

PURPOSE

Futibatinib, a covalently-binding inhibitor of fibroblast growth factor receptor (FGFR)1-4 gained approval for the treatment of refractory, advanced intrahepatic cholangiocarcinoma (iCCA) harboring an FGFR2 fusion/other rearrangement. An integrated analysis was performed to evaluate safety and provide guidance on the management of futibatinib-associated adverse events (AEs) in patients with unresectable/metastatic tumors, including iCCA.

PATIENTS AND METHODS

Data from three global phase I or II studies of futibatinib (NCT02052778; JapicCTI-142552) were pooled. AEs were graded per NCI CTCAE v4.03, where applicable. Safety was analyzed for patients receiving any futibatinib starting dose (overall population) and in those receiving the approved starting dose of 20 mg once every day.

RESULTS

In total, 469 patients with one of 33 known tumor types were analyzed, including 318 patients who received futibatinib 20 mg every day. AEs of clinical interest (AECI; any grade/grade ≥3) in the overall population included hyperphosphatemia (82%/19%), nail disorders (27%/1%), hepatic AEs (27%/11%), stomatitis (19%/3%), palmar-plantar erythrodysesthesia syndrome (PPES; 13%/3%), rash (9%/0%), retinal disorders (8%/0%), and cataract (4%/1%). Median time to onset of grade ≥3 AECIs ranged from 9 days (hyperphosphatemia) to 125 days (cataract). Grade ≥3 hyperphosphatemia, hepatic AEs, PPES, and nail disorders resolved to grade ≤2 within a median of 7, 7, 8, and 28 days, respectively. Discontinuations due to treatment-related AEs were rare (2%), and no treatment-related deaths occurred. AE management included phosphate-lowering medication and dose adjustments.

CONCLUSIONS

Futibatinib showed a consistent and manageable safety profile across patients with various tumor types. AECIs were mostly reversible with appropriate clinical management.

A phase I, open-label, single-dose study to evaluate the effect of hepatic impairment on the pharmacokinetics and safety of futibatinib

Futibatinib is a covalently binding FGFR1-4 inhibitor that received US Food and Drug Administration approval for the treatment of patients with previously treated, advanced intrahepatic cholangiocarcinoma harboring FGFR2 gene fusions/rearrangements. This phase I trial evaluated the pharmacokinetics (PKs), safety, and tolerability of futibatinib in subjects with impaired hepatic function and matched healthy volunteers. Twenty-two subjects with hepatic impairment (8 mild [Child-Pugh 5-6], 8 moderate [7-9], and 6 severe [10-15]) and 16 matched healthy control subjects received a single oral dose of futibatinib 20 mg. Futibatinib PKs were compared between subjects with mild/moderate/severe hepatic impairment and each corresponding control cohort and the overall control cohort. Relationships between futibatinib PKs and Child-Pugh scores and liver function tests were examined via scatter/regression plots. Compared with matched controls, the area under the plasma concentration-time curve from time zero to infinity increased by 21%/20%/18% and the maximum plasma concentration (Cmax ) increased by 43%/15%/10% in subjects with mild/moderate/severe hepatic impairment, respectively. Changes were not considered clinically relevant: geometric mean ratios were within 80%-125%, except for Cmax in subjects with mild hepatic impairment (143%). No obvious trends were observed among futibatinib PK parameters versus Child-Pugh scores, bilirubin, albumin, international normalized ratio, and aspartate aminotransferase (all p > 0.05). Futibatinib was well-tolerated, with only four grade 1 treatment-emergent adverse events (mild hepatic impairment = 2 and control = 2). The results demonstrate that futibatinib dose adjustments due to mild/moderate/severe hepatic impairment are not necessary in patients receiving futibatinib 20 mg daily.

Management (mgmt) of futibatinib-associated adverse events (AEs) in patients (pts) with advanced cancers: Results of a pooled analysis

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Background: Futibatinib, a covalently binding FGFR1–4 inhibitor, showed a 42% objective response rate with a 9.7 mo median duration of response in pts with advanced intrahepatic cholangiocarcinoma (iCCA) and FGFR2 fusions/rearrangements in the phase 2 FOENIX-CCA2 trial. Futibatinib treatment (tx) was safe and tolerable with a predictable and manageable side effect profile. This pooled retrospective analysis examined mgmt of futibatinib-associated AEs in pts with advanced tumors, including iCCA. Methods: Pts from a global phase 1/2 study (NCT02052778) and a Japanese phase 1 study (JapicCTI-142552) who received futibatinib 20 mg QD (recommended dose) were included. Futibatinib dose modifications and supportive medications (meds) for AE mgmt were analyzed for futibatinib-associated AEs of clinical interest (group terms: hyperphosphatemia, hepatic AEs, retinal disorders, nail disorders, rash, palmar plantar erythrodysesthesia [PPE], cataract). The Kaplan-Meier method was used for time-to-resolution (TTR) analysis. Results: As of October 1, 2020, 318 pts with advanced solid tumors (60% CCA; 98% with ≥1 prior tx) had received ≥1 futibatinib 20 mg QD dose (median tx duration, 3.6 mo). Table includes incidence and mgmt of key AEs of clinical interest. Hyperphosphatemia was the most frequent cause of futibatinib dose modifications; 85% and 30% of pts with hyperphosphatemia received phosphate binders and/or phosphaturic agents, respectively, with no obvious TTR differences. Other common supportive meds included analgesics (in 55% of pts with nail disorders; 71% with PPE) and corticosteroids (37% of pts with rash). Retinal disorders occurred in 8% of pts (all grade [gr] 1-2 and resolved). Cataract, a late-onset AE on continued tx, occurred in 12 (4%; 4 [1%] gr ≥3) pts, leading to dose modifications in 3 pts. One pt underwent cataract surgery and resumed futibatinib tx the next day. Discontinuations due to tx-related AEs were rare (2.5%) and included 1 pt each with retinal detachment, onycholysis, and cataract. Conclusions: This analysis of AE mgmt showed a consistent and manageable safety profile for futibatinib in pts with pretreated advanced tumors. Commonly observed AEs with futibatinib were well managed with dose adjustments and supportive meds and rarely led to tx discontinuation. Clinical trial information: NCT02052778 /JapicCTI-142552. [Table: see text]

Application of differential display to identify genes for lung cancer detection in peripheral blood

A blood assay for detection of lung cancer biomarkers could significantly improve cancer patient prognosis and survival rates. Amplified fragment length polymorphism-differential display (AFLP-DD) was used to identify gene transcripts found in lung cancer tissue and the peripheral blood of lung cancer patients. The clones were evaluated for gene expression in lung cancer tissue, peripheral blood of lung cancer patients and healthy volunteers' blood. The isolated gene transcript clones were found to be from the syndecan 1 gene, collagen 1 gene and 2 novel genes. All 4 transcripts were expressed in normal lung tissue, 4 cultured primary lung cells and 6 lung cancer cell lines. RNA was isolated from peripheral blood samples of 69 lung cancer patients. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to test for the presence of cytokeratin 19 and the 4 gene mRNA transcripts in blood RNA. The positive detection rate of at least 1 of the 5 transcripts was 79% for lung adenocarcinoma and 62% for squamous carcinoma. Using RT-PCR, at least 1 of the markers was found in 53% of stage I patients, 100% of stage II, 71% of stage III and 81% of stage IV lung cancer patients. Blood samples from 20 healthy volunteers were also tested, but only 1 of the 5 transcripts was found in 1 patient. These new molecular markers may aid early detection, staging and follow-up of lung cancer patients by RNA isolated from blood.

[Order-made therapy for early lung cancer patients]

To give optimal treatment to the patients with early lung cancer, we are trying to establish two new techniques to select the patients of poor prognosis and sensitive to the chemotherapy. To pick up the patients of poor prognosis nevertheless the early stage of their lung cancer, we are developing a new method to detect cancer cells floating in the peripheral blood flow with RT-PCR using cancer specific mRNA. To choose optimal chemotherapy regimens, we have established a new chemosensitivity testing (collagen gel droplet embedded culture drug sensitivity test: CDDST) for non-small cell lung cancer (NSCLC). Median survival time (MST) of the patients (n = 11) with unresectable NSCLC, who were given optimal chemotherapy according to CDDST, was 15.8 months and MST of those (n = 16) who did not have any sensitive agents according to CDDST was 5.6 months. There was significant difference between these two groups (p = 0.0048; logrank).

One hundred consecutive treatments with holmium: YAG laser for pulmonary bullae: especially in conjunction with gelatin-resorcinol formaldehyde-glutaraldehyde glue adhesion

BACKGROUND AND OBJECTIVE

We have widely used a Ho:YAG laser to treat bullae thoracoscopically.

STUDY DESIGN/MATERIALS AND METHODS

Bullae with broad necks were treated with a Ho:YAG laser thoracoscopically. Because one patient relapsed after application of fibrin glue in the early period, a DEXON (polyglycolic acid) mesh patch soaked in fibrin glue was used through a 2-cm opening in the subsequent cases. Lastly, gelatin-resorcinol formaldehyde-glutaraldehyde (GRFG) glue was applied through a 5-mm opening instead of a DEXON mesh after coagulation.

RESULTS

In the 38 patients patched with DEXON mesh soaked in fibrin glue and 56 patched with GRFG glue after coagulation, none relapsed.

CONCLUSION

Combined uses of fibrin glue plus DEXON mesh or GRFG glue were effective when bullae were treated with the Ho:YAG laser. However, the wound was smaller and more cosmetic in the GRFG glue group than in the DEXON mesh plus fibrin glue group.

Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy

BACKGROUND

Data regarding pulmonary function and prognosis after video-assisted thoracic surgery lobectomy are limited.

METHODS

From September 1992 to April 2000, 204 video-assisted thoracic surgery lobectomies were performed, and their preoperative and postoperative pulmonary function test results and prognoses were evaluated.

RESULTS

The postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1 s) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy (p < 0.0001). Furthermore, the 5-year survival rate of pathologic stage I lung cancers after video-assisted thoracic surgery was 97.0%, whereas that after open thoracotomy was 78.5% (p = 0.0173; Mantel-Cox).

CONCLUSIONS

Pulmonary function and prognosis were far better after video-assisted thoracic surgery lobectomy than after open thoracotomy.

Treating bullous lung disease with Holmium YAG laser in conjunction with fibrin glue and DEXON mesh

BACKGROUND AND OBJECTIVE

Holmium YAG (Ho:YAG) laser energy is highly absorbed by water, and this property is useful to uniformly ablate pulmonary bullae. The current study summarizes the data of a 39-month follow-up of patients treated for bullae with a Ho:YAG laser.

STUDY DESIGN/MATERIALS AND METHODS

We used a Ho:YAG laser from August 1994 to April 1997 to treat small pulmonary bullae in 50 patients. For the first five patients, Ho:YAG laser ablation was followed by resection for histological assessment. In the next six patients, fibrin glue was applied following bullae ablation with the Ho:YAG laser. In all subsequent patients, a DEXON, (polyglycolic acid) mesh patch soaked in fibrin glue was employed after ablation.

RESULTS

From the six patients receiving only the fibrin glue following laser ablation, delayed pneumothorax developed in one patient. In the subsequent 39 patients patched with DEXON mesh soaked in fibrin glue, none encountered delayed pneumothorax.

CONCLUSION

The combined use of fibrin glue and Dexon mesh with the Ho:YAG laser may be an effective technique for treating bullous lung disease.

Obstructive jaundice caused by a huge liver cyst riding on the hilum: report of a case

A 71-year-old man presented to our hospital with obstructive jaundice, found to be caused by a huge liver cyst which was centrally located and riding on the hilum. Percutaneous transhepatic cyst drainage was performed, following which obstruction of the bile duct was relieved and the jaundice subsided. As jaundice recurred after removal of the drainage tube, the patient underwent deroofing, since when he has remained well. Only 13 cases of liver cysts producing obstructive jaundice have been reported in the English literature, most of which were characteristically enormous, located centrally, and riding on the hilum. Liver cysts possessing such features are likely to cause obstructive jaundice by compressing the hepatic hilum. Cyst drainage is helpful for ameliorating the jaundice and making an accurate diagnosis; however, subsequent deroofing or injection therapy is necessary to prevent recurrence.

Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience

Between September 1992 and October 1997, we performed 128 video-assisted thoracic surgery (VATS) lobectomies. The indications for surgery were 103 cases of lung cancer, 11 cases of bronchiectasis, 8 cases of granuloma, 4 cases of benign lesions, and 2 cases of metastatic tumors. Of the 103 cases of lung cancer, 62 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, and the 4-year survival rate of final stage I lung cancer was 94.4%. VATS lobectomy is far less invasive than open thoracotomy, and survival rates after VATS lobectomy with extended lymph node dissection are comparable with those after open thoracotomy. Thus, VATS lobectomy with extended lymph node dissection should be considered as a standard surgical alternative to open thoracotomy for stage I lung cancer.

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

BACKGROUND

Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies.

METHODS

The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels.

RESULTS

Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence.

CONCLUSIONS

This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer.

Experimental tracheal replacement using the esophagus and an expandable metallic stent

An experimental study was conducted to investigate whether a segment of autogenous esophagus with its lumen supported by an expandable metallic stent (EMS) could be successfully used as a tracheal substitute. Seven rings of the cervical trachea were circumferentially removed and reconstructed by interposing a pedicled segment of the esophagus with an EMS in six mongrel dogs. The interposed esophagus was observed endoscopically at various stages after the operation. By 1 month, the EMS was found to be buried under the esophageal mucosa, and the lumen was patent. The dogs died 5, 17, 61, 92, 210, and 478 days after the operation, but the cause of death could not be determined by postmortem examination and no respiratory tract complications were detected. The results of this study indicated that a segment of the esophagus with its lumen supported by an EMS could work as a reliable tracheal substitute, though its practical use is not clinically feasible. Nevertheless, we conclude that some autogenous material other than the esophagus with its lumen supported by an EMS could provide a feasible method for tracheal replacement.

[A case of traumatic diaphragmatic hernia repaired 40 years after the injury]

A 65-year-old male complaining dyspnea on exertion and epigastric discomfort was diagnosed to have left traumatic diaphragmatic hernia elsewhere and referred to Keio university Hospital for treatment. He had thoracicio-abdominal trauma which was conservatively treated, 40 years ago. Because he was symptomatic and the possibility of future strangulation could not be denied, surgical repair of the hernia was performed. The defect in the diaphragm was too large to be directly sutured and it was repaired with GORE-TEX patch. The gastric fundus partially prolapsed in the paraesophageal region, but the diaphragm was repaired quite satisfactorily otherwise. Pulmonary function and dyspnea on exertion improved.

Bronchoplastic procedures for tuberculous bronchial stenosis

Thirty-six patients underwent tracheobronchoplastic procedures for treatment of tuberculous tracheobronchial stenosis. The modes of operations were left upper sleeve lobectomy in 13 patients, sleeve resection of the left main bronchus in 12 patients (two underwent concomitant left upper lobectomy), right upper sleeve lobectomy in five patients, sleeve resection of the right intermediate bronchus in two patients, right sleeve superior segmentectomy of the lower lobe in one patient, sleeve resection of the trachea with concomitant left pneumonectomy in one patient, carinal resection with right upper sleeve lobectomy and middle lobectomy in one patient, and dilatation of the left main bronchus with a free skin graft reinforced with a steel wire in one patient. One patient died of pulmonary edema of unknown cause on the first postoperative day. Anastomotic stenosis occurred in seven patients. One of these patients underwent reoperation and six underwent endoscopic dilatation. One patient died in the hospital of massive bleeding during endoscopic dilatation 4 months after operation. Slight to moderate stenosis resulted in the remaining patients. Although there are some complications, we believe bronchoplastic operation is worthwhile for restoring pulmonary function in patients with tuberculous tracheobronchial stenosis.

[Multidisciplinary treatment for a patient with recurrent thymoma associated with myasthenia gravis (MG), pure red cell aplasia (PRCA), and hypogammaglobulinemia]

The patient is 62-year-old female. When she was 43 years old, MG occurred. At age of 49 years thymoma was found and complete thymectomy (stage III) and postsurgical irradiation were performed. At age of 57 years pleural dissemination of the thymoma was found. Chemotherapy was effective but did not obtain total tumor cell kill. Though chemotherapy has been repeated for each tumor regrowth, the regimen used at first recurrence became ineffective and the interval between tumor regrowth became shorter. This year, when she is 62 years old, PRCA and hypogammaglobulinemia were accompanied with the forth tumor regrowth.

[Nd-YAG laser therapy of tracheobronchial lesions by malignant tumor]

Thirty-seven patients with tracheobronchial lesions by malignant tumor were treated with Nd-YAG laser. Thirty-seven patients were twenty-three males and fourteen females and ages ranged from 34 to 79 years. Diseases included were primary tracheal tumor in 3 cases, lung cancer in 16 (8 squamous cell carcinoma, 5 adenocarcinoma, 2 large cell carcinoma, 1 small cell carcinoma), cancer of adjacent organs in 9 (5 thyroid cancers, 4 esophageal cancers), and metastatic cancer to the lung or mediastinal lymph nodes in 9 (4 renal cell carcinoma, 2 thyroid cancer, one patient respectively, colon cancer and breast cancer). Intermittent irradiation of YAG laser was done for 0.5 second at 30-40 Watt through flexible bronchoscope under local anesthesia. It was repeated 1 to 41 times (mean 4.1 times) and energy amount was 148 Joules to 18,513 Joules (mean 3,305 J). The result was; stenosis disappeared in 22 cases (59.4%), improved in 14 (37.8%), and in one case YAG laser therapy discontinued due to intractable bleeding. The Nd-YAG laser therapy for tracheobronchial lesions by malignant tumor is very useful to improve dyspnea or atelectasis.