Efficacy of Immune Checkpoint Inhibitors in Rare Tumours: A Systematic Review

Background

Rare cancers, as defined by the European Union, occur in fewer than 15 out of 100,000 people each year. The International Rare Cancer Consortium defines rare cancer incidence as less than six per 100,000 per year. There is a growing number of reports of the efficacy of immune checkpoint inhibitor (ICI) therapy in patients with rare tumours, and hence, we conducted a comprehensive review to summarise and analyse the available literature.

Methods

A literature search of PubMed was performed on January 31, 2021, using the following ICI names as keywords: ipilimumab, tremelimumab, cemiplimab, nivolumab, pembrolizumab, avelumab, atezolizumab, and durvalumab. Studies on patients with rare tumours who were being treated with ICIs were included. We plotted the overall response rate against the corresponding median survival across a variety of cancer types using linear regression.

Results

From 1,255 publications retrieved during the primary search, 62 publications were selected (with a total of 4,620 patients). Only four were randomised trials. A minority were first-line studies, while the remaining were studies in which ICIs were delivered as salvage therapy in pretreated patients. There was a good correlation between response rate and overall survival (Spearman R2 >0.9) in skin cancers, mesothelioma, and sarcomas.

Conclusions

Treatment of advanced-stage rare tumours with ICI therapy was found to be associated with significant activity in some orphan diseases (e.g., Merkel cell carcinoma) and hepatocellular carcinoma. Several ongoing prospective clinical trials will expand the knowledge on the safety and efficacy of ICI therapy in patients with these rare cancers.

Coexistence of Von Willebrand disease and gastrointestinal stromal tumor (G.I.S.T): Case report of a rare and challenge association

Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by a quantitative (type 1 and 3) or qualitative (type 2) defect of Von Willebrand factor (VWF). Bleeding from the gastrointestinal (GI) tract is not uncommon in VWD and is usually associated with angiodysplasia. We report herein on the management of a patient affected by VWD2B with severe GI bleeding secondary to gastrointestinal stromal tumor (GIST) complicated by deep vein thrombosis (DVT). The current case demonstrated that the hemostatic balance, in RBDs under specific circumstances, can range from a tendency toward a hemorrhagic to normal or prothrombotic state. In these patients, a close collaboration between hematologists and surgeons can guarantee appropriate management in high-risk clinical scenarios.

Neuroendocrine Small-Cell Bladder Cancer: Our Experience

Introduction

Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.35–0.70% of all bladder tumors. The small-cell carcinoma represents the most frequent histologic variant described. Small-cell carcinoma is an epithelial tumor associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. The overall survival rate at 5 years does not exceed 8%. At the time of presentation 59% of patients have clinical stage >T2 and 56% show metastatic disease. In 50% of the patients, fatal progression occurrs within 6 months. Local recurrence after radical surgery occurred in 50–70% of cases.

Patients and Methods

We report three cases of pure neuroendocrine small-cell bladder cancer. Hematuria was the most common presenting symptom. Local advanced disease was present in all the cases with stage >T2, metastatic disease in 1 case, lymph node involvement and ureteral bilateral obstruction in 2. Two patients were treated by radical cystectomy, bilateral pelvic limph node resections and urinary derivation. Platinum-based adjuvant chemotherapy was proposed but only two patients received the treatment. One patient with liver metastasis was managed only by extensive TUR and support regimen.

Results

In 2 patients residual or relapsed cancer reappered within 2 months after surgery. All of the three patients died of metastatic disease at 5, 7, and 13 months. Median overall survival was 7 months. The most common site of relapse and spread of disease was the peritoneum and intestinal tract, and the reason of death was uncontrolled acute hemorrhage from gastro-intestinal district.

Conclusions

In the absence of a prospective study, and because of the rarity of the disease, the best treatment for small-cell bladder cancer remains uncertain. Neoadjuvant chemoterapy with platinum regimen plus aggressive surgical approach will be the treatment of choice. The association of chemotherapy and radiotherapy should also be considered.

[Neuroendocrine small-cell bladder cancer: our experience]

INTRODUCTION

Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.35-0.70% of all bladder tumors. The small-cell carcinoma represents the most frequent histologic variant described. Small-cell carcinoma is an epithelial tumor associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. The overall survival rate at 5 years does not exceed 8%. At the time of presentation 59% of patients have clinical stage >T2 and 56% show metastatic disease. In 50% of the patients, fatal progression occurs within 6 months. Local recurrence after radical surgery occurred in 50-70% of cases.

PATIENTS AND METHODS

We report three cases of pure neuroendocrine small-cell bladder cancer. Hematuria was the most common presenting symptom. Local advanced disease was present in all the cases with stage >T2, metastatic disease in 1 case, lymph node involvement and ureteral bilateral obstruction in 2. Two patients were treated by radical cystectomy, bilateral pelvic limph node resections and urinary derivation. Platinum-based adjuvant chemotherapy was proposed but only two patients received the treatment. One patient with liver metastasis was managed only by extensive TUR and support regimen.

RESULTS

In 2 patients residual or relapsed cancer reappered within 2 months after surgery. All of the three patients died of metastatic disease at 5, 7, and 13 months. Median overall survival was 7 months. The most common site of relapse and spread of disease was the peritoneum and intestinal tract, and the reason of death was uncontrolled acute hemorrhage from gastro-intestinal district.

CONCLUSIONS

In the absence of a prospective study, and because of the rarity of the disease, the best treatment for small-cell bladder cancer remains uncertain. Neoadjuvant chemotherapy with platinum regimen plus aggressive surgical approach will be the treatment of choice. The association of chemotherapy and radiotherapy should also be considered.

The role of fouling mechanisms in a membrane bioreactor

The present study has aimed to quantify the role of pore blocking and cake layer in a laboratory scale hollow fibre membrane module in submerged configuration, The membrane reactor (MBR) was fed with raw wastewater, only screened with a 2-mm sieve, collected from the Palermo WWTP. The MBR was characterised by an operating volume of 190 L and equipped with an aeration system located on the bottom of the reactor. The MBR operated for 65 days. The permeate was extracted by imposing a constant flux through the membrane (21 Lh(-1) m(-2)). The results confirm the importance of pore blocking control during start-up. In particular, it provides a rapid irreversible fouling that takes place at the beginning of the filtration process, before the deposition mechanism. Therefore, low suspended solids concentration in the initial phase causes a fast irreversible fouling. This circumstance creates the need for more frequent chemical cleaning after start-up without inoculum. Finally, the results underline that the cake has a mainly reversible feature.

Severe hypoplasia of medullary arcuate nucleus: quantitative analysis in sudden infant death syndrome

The human arcuate nucleus (ARCn) is postulated to be homologous to ventral medullary cells involved in chemoreception, and respiratory and blood pressure responses. Abnormalities in central respiratory control may result from dysfunction of this anatomic ventral area. We evaluated the changes of the neuronal population of the medullary ARCn in infants victims of the sudden infant death syndrome (SIDS). In this study we tested the hypothesis that anatomical deficiency of the ARCn is associated with SIDS. The volume and neuronal density of the ARCn were morphometrically quantified with an image analyzer in 36 cases of SIDS and 12 age-matched controls. We found a marked hypoplasia in the SIDS ARCn compared to controls and, particularly, in 11 SIDS cases (30%) in which the ARCn exhibited a severe hypoplasia, being almost totally absent. Three-dimensional reconstructions and morphometric measurements of ARCn confirmed this marked hypoplasia in all the serial sections examined (P = 0.0001) and the reduced neuronal density (P = 0.0025) in relation to control cases. In conclusion these abnormalities observed in the ARCn are consistent with the idea that ARCn dysfunction plays an important role among the causative factors of sudden infant death. The hypoplasia of the ARCn represents the most frequent congenital abnormality in our experience, and can be a plausible morphological substrate for a subset of SIDS.

An alternative method for coordinating pulmonary capillary wedge pressure measurements with the respiratory cycle

Changes in intrathoracic pressure during the respiratory cycle cause variations in pulmonary vascular pressures. This affects pulmonary hemodynamic measurements in critically ill patients, particularly those receiving mechanical ventilation. With certain newer ventilators, the machine-pressure and/or expiratory-flow signal can be graphed simultaneously with hemodynamic pressure. The end-expiratory point determined from these graphs can be used to identify the corresponding wedge pressure on the hemodynamic tracing.

Echocardiographic evaluation of Carpentier mitral valvuloplasty

Carpentier's technique for reconstructive mitral valve surgery is an alternative to mitral valve replacement in patients with mitral regurgitation. The procedure involves reconstruction of the mitral valve and insertion of a ring into the mitral anulus. To study the results of this operation, pre- and postoperative M-mode, two-dimensional (2DE), and Doppler echocardiography were performed on 13 patients with severe, symptomatic mitral regurgitation, who underwent reconstructive mitral surgery. A significant clinical improvement was noted in all patients. This correlated with the hemodynamic and angiographic improvement in six of the patients who underwent postoperative cardiac catheterization. Postoperative echocardiography showed that the mitral valve E-F slope decreased from 129 +/- 30 mm/sec preoperatively to 53 +/- 13 mm/sec postoperatively (p less than 0.001). The mitral valve excursion decreased from 28 +/- 6 mm preoperatively to 19 +/- 2 mm postoperatively. The left ventricular minor axis shortening decreased from 32 +/- 9% to 28 +/- 6%. In seven patients the mitral valve area decreased from 4.5 +/- 0.9 cm2 to 2.8 +/- 0.5 cm2 (p less than 0.005). In each patient a new echocardiographic finding was observed: two parallel dense linear echoes from the prosthetic ring were noted on M-mode echocardiography near the base of the mitral valve. 2DE visualized the entire ring. Doppler echocardiography suggested moderate or severe mitral regurgitation in eight of eight patients studied preoperatively. Postoperatively 10 of 11 patients had no Doppler echocardiography finding of mitral regurgitation.

Spasm of a normal or minimally narrowed coronary artery in the presence of severe fixed stenoses of the remaining vessels: clinical and angiographic observations

Four patients with medically refractory unstable angina are presented. Each patient had ST-segment abnormalities during some episode of pain. Three patients had at least one episode of documented ST-segment elevation with their spontaneously occurring chest pain. One had recurrent ventricular tachycardia. Two patients had prior myocardial infarction. Angiography demonstrated localized left ventricular akinesis and a severe fixed stenosis in the coronary artery supplying the abnormal segment. There were severe, fixed lesions in two coronary arteries in two patients and in one vessel in two patients. After i.v. ergonovine maleate, coronary artery spasm was documented in a normal or minimally diseased coronary artery in each patient. In two patients, ergonovine-induced spasm not only occluded the vessel, but also markedly decreased retrograde filling of a vessel with severe, fixed narrowing. Each patient's characteristic symptoms appeared with the ergonovine-induced spasm. Thus, ergonovine maleate can provoke spasm of a normal coronary artery, even in the presence of severe fixed stenoses of the remaining vessels. This observation may have an important role in the diagnosis and clinical management of patients with chest pain.

Methods of intermittent positive pressure breathing

Inspiratory capacity (IC) was evaluated in 60 patients during the following four respiratory maneuvers: (1) coached unassisted inspiration; (2) inspiratory positive-pressure breathing (IPPB) at 15 cm H2O with the patient passively inspiring; (3) IPPB at 15 cm H2O with the patient coached to actively inspire; and (4) IPPB at a peak pressure adjusted according to the judgment of the respiratory therapist, with the patient coached to actively inspire. The IC attained with these maneuvers were, respectively, as follows: (1) 1.29 +/- 0.75 L; (2) 1.13 +/- 0.52 L; (3) 1.77 +/- 0.11 L; and (4) 2.27 +/- 0.11 L (mean +/- SE). The peak ventilator pressure for maneuver 4 averaged 30 +/- 7 cm H2O (mean +/- SD), and no patient experienced harmful side effects from these peak pressures. These data indicate that the method of treatment with IPPB has profound effects upon the degree of pulmonary expansion. All research on therapy with IPPB should be carefully controlled for the method of administering IPPB, and the volumes obtained during the treatment should be carefully documented before general conclusions are drawn concerning the effects of IPPB on morbidity. For the present, we suggest that IPPB, when administered clinically, be given as described in method 4.