Association of immune-related adverse events with immune-checkpoint inhibitors and treatment response in melanoma patients

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Background: Immune-related adverse effects (irAE´s) of immune-checkpoint inhibitors (ICIs) have been linked with a better treatment response in melanoma patients, especially cutaneous toxicities. However, little is known regarding other irAE´s which is important as they can be used as clinical markers of an adequate therapeutical response. Methods: We conducted a retrospective study on patients who were diagnosed with melanoma and received treatment with ICI´s between January 2015 until December 2021, immune related adverse events and their relationship with overall survival in melanoma patients treated with ICIs was the main objective of this study. Results: 53 records of patients with advance melanoma treated with ICIs between january 2016 to december 2021, demographic characteristics were as follow: 64.2% were male, mean age at diagnoses was 60.3 years, 41.5% had smoking history and 15.1% were Jewish. At diagnosis 73.6% of patients had a good functional status (ECOG 0-1). The most common histological subtypes were epithelioid (34%), and nodular (22.6%). Lung metastases was the most common affected site (49.1%), followed by brain 43.4% and non-regional nodes 42.5%. BRAF mutations was determined in 81.1% of the biopsies and 36% of them being V600E mutation. ICI´s was the preferred first line treatment in 83% of cases, median number of administered cycles were 6 (range 1-54 cycles), 60.4% of patients received pembrolizumab, 37.7% nivolumab plus ipilimumab, 20.8% nivolumab monotherapy and 5.7% ipilimumab. Throughout the studied period IrAE´s were reported in 34% of patients with 66.7% of them being grade 1-2 and 33.3% grade 3-4. The most common IrAE’s: vitiligo 38.8%, hypothyroidism22% and 3.8% pneumonitis. Median PFS at 12 months and OS was significantly better in the group of patients with irAE´s: Patients who develop an irAE´s are 7 times more likely to be disease free at 12 months and 4.1 times more likely to have a longer OS regardless of severity and type of toxicity. The impact of developing irAEs is significantly important for PFS (HR: 11.9, CI 95%: 3.28-4.71) as median PFS was not yet reached in this group. Conclusions: Development of irAEs is associated with favorable outcomes to ICIs with patients being 7 times more likely to be 12-month disease free and 4.1 times more likely to have a longer OS. irAEs can be used as clinical markers of an adequate treatment response.[Table: see text]

Evaluation of changes in lymph node size and metabolism by PET CT in patients with cancer who have been immunized against COVID 19: A Mexican study

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Background: The risk of developing COVID-19 in patients with cancer has increased, directly influenced by age and the magnitude of comorbidities. In this population, the estimated mortality is 10.9%. With this, the urgent need for patients with cancer to get vaccinated against SARS COV 2 has generated an international response. With the ongoing vaccination campaign, experts in nuclear medicine have observed an increment in lymph node uptake in PET CT with 18 FDG. Increased uptake in lymph nodes in patients with a neoplastic diagnosis on PET CT 18 FDG must be closely followed and well-studied to differentiate disease progression from an inflammatory, fleeting reaction. Methods: Amongst the inclusion criteria were patients over 18 years of age with solid tumors, including lymphomas, who were on active oncologic treatment with chemotherapy, immune therapy, radiotherapy or under surveillance between April 2021 and July 2021 who underwent a PET CT scan and had at least one dose of a COVID 19 vaccine, and a prior PET CT to the vaccine for comparison. Patients were excluded who showed evidence of progression or disease recurrence of the primary tumor. We evaluated lymph node size and metabolism measured by SUV max in the PET CT scan prior to being vaccinated and posterior to, as well as patients’ clinical characteristics. Results: A total of 92 patients who met inclusion criteria were included in the study. Amongst those, 54.3% were women, the median age was 68 years (27 - 95 years), the most common neoplastic diagnoses were breast cancer (19.6%), gastrointestinal tumors (17.4%), urothelial tumors (9.8%), lymphomas (9.8%) and ovarian cancer (8.7%). 52.2% of patients were under surveillance and 47.8% were under active treatment. 79% of patients had at least 2 vaccine doses. 59% had received Pfizer vaccines and the measurable adenopathies were axillary in 32.7% and mediastinal in 27%. The medium size of the measured lymph nodes prior to receiving the vaccine was 2.86 mm with an SUV max of 1.24, while after vaccination were 6.01 and 2.27 respectively. A Kruskal Wallis test was conducted to compare median results according to histopathologic reports, with no statistical difference. A Mann Whitney U test was conducted to compare breast cancer to other cancer histologies, where a statistical difference was found for SUV max, p = 0.003 and size with p = 0.033. Conclusions: This work details significant differences between lymph node size and SUV max in oncologic patients pre and post vaccination for COVID 19, showing a statistical difference in patients with breast cancer. This increment in lymph node uptake in patients with a neoplastic diagnosis PET CT 18 FDG must be closely followed and well-studied to differentiate disease progression from an inflammatory reaction.

Clinicopathological characteristics of patients with HER2-positive gastric and gastroesophageal junction cancer in a single tertiary hospital

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Background: Gastric cancer (GC) and gastroesophageal junction cancer (GEJ) are the second most prevalent and lethal digestive malignancies worldwide. According to GLOBOCAN 2020, the incidence in Mexican population is 4.5% and represents 7% of all deaths. In GC and GEJ, the frequency of HER2 overexpression varies widely in the literature. Actually the blocking anti-HER2 is the standard therapy in GC and GEJ with overexpression HER2 according to the ToGa Trial. There are few studies that describe this population in mexican patients. Methods: We conducted a retrospective, observational analysis. Medical records of patients with GC or GEJ cancer from January 2015 to January 2021 were reviewed. A total of 91 patients were retrieved from the pathology database. Clinicalpathologic features collected were sex, age, pTNM stage (AJCC 8th edition), histology type, HER-2 status, metastases sites and treatment. The HER-2 determination was performed in all cases with immunohistochemistry (IHQ). Results: We found 10 patients with GC and GEJ with HER-2 overexpression by IHC, five patients with FISH positive and 2 of them with amplification by next generation sequence (FoundationOne). The median age was 56.9 years (27-68). There were more male patients (n = 8) than female patients (n = 2), with male/female ratio of 4:1. 8 patients had performance status (PS) 0 or 1, and the rest PS 2. The primary site was gastric carcinoma in 3 patients, and in 7 the tumor was located in GEJ. The clinical stage at diagnosis in 7 patients was metastatic, and 3 locally advanced. The most common sites of metastasis were lung (n = 5), liver (n = 4), and pleural, bone and central nervous system (each one with one patient). Intestinal-type GCs were most prevalent with 8 patients, and the rest were diffuse and signet ring cells. All patients received anti-HER2 blockade, 6 in the first line therapy, and 4 patients in the second line or more. Regarding the backbone regimen of the trastuzumab based therapy, fluoropyrimidine/platinum were the mainstay in 9 patients, and 1 with platinum and taxane scheme. Median number of cycles of trastuzumab was 8 (range, 4-24). The tumor responses were as follows: complete response (CR) 10%, partial response (PR) 30%, stable disease 50% and progressive disease 1 patient. The median progression-free survival was 6.6 months (1.3-23.1 months), and a median of overall survival was 21 months (6.4-51.5 months). The most frequently reported adverse events were diarrhoea in 3 patients (all grade 2), and mucositis in 1 patient. Cardiac adverse events were not reported. Conclusions: In our cohort, the prevalence of HER2 overexpression by IHC was 11%. In previous reports, the most important ToGa trial, 22% of the patients with metastatic GC and GEJ were HER2 positive. The PFS and OS in ToGa trial were 13.8 and 17.1 months respectively. By comparison our cohort the PFS and OS in ToGa trial were 6.6 and 21 months.

Immunotherapy experience in malignant pleural mesothelioma in a single tertiary center

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Background: Malignant pleural mesothelioma (MPM) is a rare and aggressive cancer. Prognosis is generally poor, with a median overall survival (mOS) of approximately 12 months. MPM appears to be directly linked to immunosuppressive mechanisms, leading to use of checkpoint inhibitors for patients with this disease. Methods: We performed a retrospective chart review of patients with MPM at our institution between January 2015 to December 2020. All patients were over 18 years at the time of diagnosis of mesothelioma, a total of 8 patients were retrieved from the pathology database of The American British Cowdray Medical Center. The clinical-pathologic features collected were sex, age, performance status, risk factors, pTNM stage (AJCC 8th edition), histology type, sintomatology of onset, metastases sites and treatment. Clinical response rate and other outcomes were assessed. Descriptive statistics were used to describe a patient's demographic and disease characteristics. Results: 8 patients, aged 49 to 71 years (median of 65) at diagnosis of MPM were treated in our center. Both sex presented 4 patients in total. An identifiable risk factor was recorded in 4 patients (2 with asbesto exposure and 2 with heavy smoking). 7 patients (87.5%) had PS 0 or 1, the remaining has PS 2. The clinical stage at diagnosis was unresectable in 7 patients. 3 patients were assessed with PD-L1 expression (SP263 or 22C3), only one with expression of 20%. All patients received at least one scheme of chemotherapy prior to receiving immunotherapy, 25% received bevacizumab/platinum/anti-folate agents. Checkpoint inhibitors were introduced as a second line in 20% and in 80% has a third or more lines. Pembrolizumab was used in 20% and Nivolumab in 80%. The tumor responses with immunotherapy were as follows: partial response 12.5%, stable disease 75% and progressive disease 12.5%. Median progression-free survival of the first line treatment was 18.9 months (4.6-33.6 months), and for the line with checkpoint inhibitors was 11.2 weeks (7-21.2). In the full cohort, mOS was 37.0 months (95% CI:14.5-39.6). According to histology, the mOS for epithelioid-type was 36.6 months and for biphasic-type was 14.6 months (p = 0.42). mOS was 37.0 months for the group with immunotherapy and 15.0 months for those with standard chemotherapy (p = 0.14). The most frequently reported immune mediated adverse events were hypothyroidism and colitis (each one with one patient). Conclusions: In this real-world analysis, mOS was superior to those obtained in the MAPS2 trial (mOS 11.9 months), despite the fact that 80% of the population that received immunotherapy was in third or more lines. Limitations include limited numbers of patients, retrospective review, single institution, and inclusión of many heavily pretreated patients. Also molecular and immunohistochemical results such as PD-L1 status were only available on a limited number of patients.

Recurrence rate according to Oncotype Dx recurrence score (RS) in women with estrogen receptor (ER) positive, Her2 negative and 1 to 3 positive nodes: Real-world data in a Mexican private institution

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Background: Oncotype Dx is a 21 gene assay that evaluates de expression of 21 genes associated with recurrence in early breast cancer (EBC). In women with ER positive, HER2 negative and no lymph node involvement, it has demonstrated it prognostic value and has shown to predict the benefit of adjuvant chemotherapy in high-risk patients, sparing toxicity to patients with low risk of recurrence. Nevertheless, in women with ER positive, HER2 negative and 1 to 3 nodes, the role of de 21 gene assay was not clear until recently. Methods: Retrospective review of medical records of patients with ER +, HER2 negative and 1 to 3 positive nodes breast cancer treated at our institution. Clinicopathological characteristics and 21 gene recurrence score (RS) were collected and a survival analysis by the Kaplan-Meier method was performed in patients with RS < 25 and according to menopausal status as in RxPONDER in SPSS v 25.0 IBM. Results: From January 2008 to December 2018, data from 136 patients with EBC clinical stage (IA-IIB), HR +/ HER2-, N0-1 with Oncotype Dx performed were collected, of which only 25 patients had 1-3 nodal involvement and were included in the statistical analysis. Mean age at diagnosis was 54 years (35-73), the most frequent histology in the general population was invasive ductal carcinoma (92.0%), followed by lobular carcinoma (8.0%), 72.0% of patients presented in stage IIA, followed by stage IB in 20.0%. RE were positive in all patients and progesterone receptors were positive in 72.0%, none of the patients had HER2 overexpression, mean Ki-67 expression was 17.4% (4.0-50.0%). Most tumors were modemoderately differentiated (72.0%). Lymphovascular and perineural invasion were present in 44.0% and 24.0% respectively. Follow up data was available for 17 patients of which 12 had a RS of 25 or less. Recurrence was present in only 3 patients in this group of patients representing 25%. During the first 5 years only 1 patient recurred, which represents a 5-year Recurrence rate (RR) of 8.3% with a 5-year RFS of 91.7%. 10-year Recurrence free survival (RFS) was 75.0% with a median RFS that has not been reached. RFS was 80.0% in postmenopausal women compared 71.4% for those premenopausal at 10 years follow-up (p=0.735). None of the patients in this group received adjuvant chemotherapy. Conclusions: We report our experience at a comprehensive cancer center in a time lapse of 10 years. RFS at 5 years was 91.7% and at 10 years of follow up was 75%. This in accordance with the results of RxPONDER trial that reported a 5-year progression free survival of 92.4% in patients with chemo-endocrine adjuvant therapy and 91.0% in patients in the endocrine therapy only arm. This supports the use of this trial for decision making outside of the controlled clinical trials setting.

Efficacy and Safety of Pembrolizumab Plus Docetaxel vs Docetaxel Alone in Patients With Previously Treated Advanced Non-Small Cell Lung Cancer: The PROLUNG Phase 2 Randomized Clinical Trial

Importance

Because of socioeconomic factors, many patients with advanced non-small cell lung cancer (NSCLC) do not receive immunotherapy in the first-line setting. It is unknown if the combination of immunotherapy with chemotherapy can provide clinical benefits in immunotherapy-naive patients with disease progression after treatment with platinum-based chemotherapy.

Objective

To evaluate the safety and efficacy of the combination of pembrolizumab plus docetaxel in patients with previously treated advanced NSCLC following platinum-based chemotherapy regardless of EGFR variants or programmed cell death ligand 1 status.

Design, Setting, and Participants

The Pembrolizumab Plus Docetaxel for Advanced Non-Small Cell Lung Cancer (PROLUNG) trial randomized 78 patients with histologically confirmed advanced NSCLC in a 1:1 ratio to receive either pembrolizumab plus docetaxel or docetaxel alone from December 2016 through May 2019.

Interventions

The experimental arm received docetaxel on day 1 (75 mg/m2) plus pembrolizumab on day 8 (200 mg) every 3 weeks for up to 6 cycles followed by pembrolizumab maintenance until progression or unacceptable toxic effects. The control arm received docetaxel monotherapy.

Main Outcomes and Measures

The primary end point was overall response rate (ORR). Secondary end points included progression-free survival (PFS), overall survival, and safety.

Results

Among 78 recruited patients, 32 (41%) were men, 34 (44%) were never smokers, and 25 (32%) had an EGFR/ALK alteration. Forty patients were allocated to receive pembrolizumab plus docetaxel, and 38 were allocated to receive docetaxel. A statistically significant difference in ORR, assessed by an independent reviewer, was found in patients receiving pembrolizumab plus docetaxel vs patients receiving docetaxel (42.5% vs 15.8%; odds ratio, 3.94; 95% CI, 1.34-11.54; P = .01). Patients without EGFR variations had a considerable difference in ORR of 35.7% vs 12.0% (P = .06), whereas patients with EGFR variations had an ORR of 58.3% vs 23.1% (P = .14). Overall, PFS was longer in patients who received pembrolizumab plus docetaxel (9.5 months; 95% CI, 4.2-not reached) than in patients who received docetaxel (3.9 months; 95% CI, 3.2-5.7) (hazard ratio, 0.24; 95% CI, 0.13-0.46; P < .001). For patients without variations, PFS was 9.5 months (95% CI, 3.9-not reached) vs 4.1 months (95% CI, 3.5-5.3) (P < .001), whereas in patients with EGFR variations, PFS was 6.8 months (95% CI, 6.2-not reached) vs 3.5 months (95% CI, 2.3-6.2) (P = .04). In terms of safety, 23% (9 of 40) vs 5% (2 of 38) of patients experienced grade 1 to 2 pneumonitis in the pembrolizumab plus docetaxel and docetaxel arms, respectively (P = .03), while 28% (11 of 40) vs 3% (1 of 38) experienced any-grade hypothyroidism (P = .002). No new safety signals were identified.

Conclusions and Relevance

In this phase 2 study, the combination of pembrolizumab plus docetaxel was well tolerated and substantially improved ORR and PFS in patients with advanced NSCLC who had previous progression after platinum-based chemotherapy, including NSCLC with EGFR variations.

Trial Registration

ClinicalTrials.gov Identifier: NCT02574598.

Merkel cell carcinoma in Latin America: a contribution from an expanded access program for avelumab to address issues from experts' recommendations

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive malignancy, associated with poor outcomes in patients with metastatic disease (mMCC). Management has been dramatically altered as a result of incorporating immune checkpoint blockade agents. MCC data from Latin America (LATAM) come from case-series or individual records. Regional registries are lacking. A need for better registries to improve current knowledge about MCC is highlighted. Our objectives were to describe a real-world experience with avelumab as a second-line (or first-line in unfit patients) treatment in a subset of LATAM participants enrolled in a global Expanded Access Program (EAP) for patients with mMCC, and to evaluate its contribution to the resolution of the concerns described in a recent regional experts review.

MATERIALS AND METHODS

We reviewed data of LATAM participants in an avelumab EAP for mMCC treatment (NCT03089658). EAP patient had unresectable or mMCC with progressive disease after one line of chemotherapy, and were ineligible for clinical trials or unfit for chemotherapy.

RESULTS

46 patients (median age: 71.6 years; 60.9% males; median treatment duration: 7.9 months) were included in the LATAM EAP. Physician-assessed objective responses were available for 19 patients. Complete response rate was 15.8% and partial response rate reached 42.1%, summarizing an objective response rate of 57.9%. Stable disease rate was 10.5%, with a disease control response of 68.4%.

CONCLUSION

Avelumab showed robust efficacy and a safety profile consistent with global EAP data. Results are aimed to improve current knowledge about mMCC treatment and access to immunooncologic strategies for treating LATAM patients.

Real-world clinical outcomes in patients receiving cyclin-dependent kinase 4/6 inhibitors (iCDK 4/6) for hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer in Mexico

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Background: Breast cancer was the second most common malignant tumor diagnosed in 2018 worldwide, and the main cause of cancer death in women. In Mexico is the leading cause of cancer deaths, the most common molecular subtypes is HR+/HER2- (63%). The addition of iCDK 4/6 can enhance the benefit seen with endocrine therapy (ET) alone. In this work we will describe the experience in a “real world” model, of two tertiary-level hospitals in Mexico, with the use of iCDK 4/6 in a period of 3 years. Methods: Retrospective review of medical records of all consecutive pts with histological diagnosis of metastatic breast cancer HR+/HER2- and iCDK 4/6 treatment at our Institutions from July 2016 to January 2019. Clinical and pathological variables at diagnosis were recorded. Progression free survival was estimated using Kaplan-Meier method and survival distributions were compared using the Log-rank test. To assess association variables and progression we use Chi square. Results: 65 pts were treated, all with iCDK 4/6 in combination with ET, either aromatase inhibitor or irreversible estrogen receptor antagonist. 62 with palbociclib and 3 with ribociclib; Median age was 53 y/o (IQR 42-63), ECOG 0-1 (92.3%), 80% was metastatic recurrent disease, 92% of these patients received endocrine adjuvant treatment. Median estrogen receptor percentage was 90 (IQR 61-92), progesterone 50 (9-83), KI67 20 (10-30). The metastatic sites were bone (64.6%), liver (41.5%), nodal (33.8%), lung (21.5%), CNS (3.1%) and others (18.5%). 26 pts (40%) received iCDK 4/6 in the first line, 21 (32.3%) in the second line, and 27% in subsequent lines. Any grade of toxicity was presented in 44 pts (67.7%), Most common toxicities were neutropenia (63%), fatigue (16.9%), anemia (9.2%), grade 3-4 toxicities were presented in 21.5% and 17 pts (26.2%) required any dose adjustment. At the cut-off date, 28 pts (43.1%) had disease progression, median time to progression for the 65 pts was 10 months (1-84). OR for first line treatment vs subsequent lines was 0.14 (0.04-0.47, 95%, p = 0.001). OR for pulmonary metastases were 4.21 (1.15-15.31, 95%, p = 0.03), for other sites of metastasis were NS. Conclusions: Our outcomes suggest that the PFS is better when iCDK 4/6 are used as a first line treatment. Pulmonary metastases are may associated with poorly outcomes. In low- and middle-income countries, efforts should be focused on early therapy with iCDK 4/6.

Neutrophil to lymphocyte ratio and lipi score prognostic value in patients with non-small cell lung cancer in a Mexican population

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Background: Non-Small cell lung cancer (NSCLC) is the most common type of lung cancer and accounts for most of all cancer-related morbidity and deaths in the World. Recent Evidence shows that inflammatory response is associated with a poor prognostic in several cancers. Evaluating these markers is of great importance to classify patients of solid tumors including NSCLC. Inflammatory markers like, Glasgow Prognostic Score (GPS), Lung Immune prognostic index (LIPI) and C-Reactive Protein (CRP) have been associated with poor prognosis in patients treated with immune checkpoint inhibitors. Neutrophil to Lymphocyte Ratio (NLR) is a biomarker for the general immune response to various stress stimuli in peripheral blood. It can be easily determined, inexpensive and can correlate with poor outcomes. Methods: A review of medical records was performed including patients from January 2013 to December 2018. The clinical characteristics were described, analyzed and the NLR and the LIPI were calculated. Categorical variables were analyzed with Chi-square test and the correlation was analyzed with the Pearson correlation coefficient. Variables were included in the construction of survival models through Cox multivariate regression using statistical software: STATA SE ver11.0 (StataCorp LLC Texas,USA). Results: A total of 175 patients with complete medical record and pathology samples were included. Around half of patients were female. The mean age was 69 years ± 11 years. The most frequent histology was Adenocarcinoma in 87%, Epidermoid 10% and others 3%. The most frequent mutations were KRAS 25%, EGFR 22% and ALK 1%. PDL-1 > 1% was determined in 20% of patients. Clinical stage IV was found in 58% of the cases followed by Clinical Stage I, II and III with 25%, 9%, 8% respectively. The NLR > 4 is associated with a worse prognosis in Stage I and II HR = 5.4 (95% CI 1.73 - 17.17, p = 0.004). LIPI > 2 had predictive capacity for progression in Stage IV HR = 8.2 (IC 95 % 2.39-23.4, p = < 0.001). Conclusions: NLR > 4 showed prognostic value for recurrence in early clinical stages. LIPI score > 2 resulted in higher risk for progression in metastatic stages. Determination of these indexes has the potential as a readily available prognostic indicator for patients.

Prevalence of immunotherapy-related adverse events due to checkpoint inhibitors: First report in Mexico

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Background: Since 2010, immune checkpoint inhibitors (ICI) have been approved for the treatment of several neoplasms. Their immune-mediated toxicity profile, used as monotherapy (nivolumab [N], Ipilimumab [Ip], pembrolizumab [P]) or in combination (Nivolumab/Ipilimumab [N/Ip]) and their management is still being described, recently. Methods: A retrospective review of medical records, included all cancer patients treated, in our institution, with ICI from January 2014 to February 2018. Frequency, type and grade of immune related adverse events (irAE) by neoplasm, individual agent or combination were recorded. Time to first ir-AE (TTF-irAE) was estimated by Kaplan Meir Method and compared by Cox regression model. Results: 140 patients were evaluated, all in pretreated metastatic setting. Median age 65.8+/-11.8, men in 59.3%. The most frequent neoplasms treated with ICI were: lung (34%), melanoma (33%), genitourinary (17%), H&NC (6%), and GI (6%). Ip alone was indicated in 11.4% cases; N, 30%; P, 54.29%; N/Ip 4.29%. Median number of cycles per drug: Ip: 3 cycles, N/Ip: 4; N: 6; and P: 4 cycles. Toxicity (G1-4) was seen in Ip: 62.5%, N/Ip: 50%, N: 40.5%, P: 31.6%, p > 0.05. The most frequent irAE's were: dermatological 40%, gastrointestinal 18.3%, and endocrine 13.4%; other irAE´s were reported in: pulmonary 7.3%, ophthalmologic 6%, muscle-skeletal 6%, neurologic 2.4%, renal 1.2%, hematologic 1.2%. Severe toxicities (G3-4) were observed with N/Ip: 33.3%, P: 17.4%, Ip: 10%, N: 5.6%. TTF-ir-AE per drug: I: 1st cycle (dermatitis, pruritus, colitis), N/Ip: 2nd cycle (dermatitis, conjunctivitis), N: 3rd cycle (dermatitis, thyroiditis, colitis, hepatitis), P: 1st cycle (pruritus, neuritis, adrenalitis). Ipilimumab was an independent prognostic factor for developing severe ir-AE´s [OR = 12.8, p = 0.038], and any grade toxicity [OR = 1.9 (IC95% 0.92 - 4.1, p = 0.079)]. Conclusions: In this study, the dermatological, gastrointestinal and endocrine toxicities were the most frequent ir-AE´s, and they were observed in a low grade toxicity. The irAE´s profile is different among ICI or their combination and number of cycles administered. Ipilimumab alone or combined was associated to higher risk of severe irAEs.

Abstract P5-11-13: Experience in the ABC Medical Center of Mexico City 2010-2015 using scalp-cooling system (DigniCap) for prevention of alopecia induced by chemotherapy

Background: Alopecia is one of the secondary side effect whit the most emotionally impact for patients undergoing chemotherapy (CTX) The DigniCap System is the first scalp cooling system use to minimize alopecia. Methods: The objetive of this study was to evaluate in a restrospective trial the efficacy of DigniCap preventing alopecia in consecutive patients treated in ABC Medical Center from December 2010 to January 2015. Patients recieve different chemotherapy regimens, with different modalities, neo , adyuvant and for metastases in first and second line, as in many clinical stages whit breast cancer (BC), were evaluated with the visual scale of Dean (score 0: 0-25%, 1: 25-50%, 2: 50-75%, 3: 75-100%) with photographs of the before and after treatment. Results: 120 pts with BC in stages I-V were treated with a taxane and antraciclins regimen of chemotherapy, 66 pts receive 12 treatment weekly of paclitaxe (T)l and 4 adriamicin/cyclophosphamida (AC) every 21 days, 28 pts 6-8 cycles every 21 days AC-Taxol, 22 pts (18%)suspended the treatment because of the loss of more than 50% of hair at the 2nd an 3rd chemotherapy cycle. 98 pts actually finished the treatment (72%). Of these, 82 pts (84%) no had or had a minimal loss of hair (Dean score 0-1), 16 pts (16%) had a 50% of hair loss (Dean score 3). 8pts recieve more than one regimen of chemotherapy. In the tracing any metastases or side effects were presented with the use of DigniCap. Conclusions: The use of DigniCap minimize alopecia in a 84%, including pts with more than one chemotherapy regimen, in a a safety level.

Citation Format: Hernandez RE, Gerson R, Olivares G, Rivera S, Serrano A, Villalobos A, Lazaro M. Experience in the ABC Medical Center of Mexico City 2010-2015 using scalp-cooling system (DigniCap) for prevention of alopecia induced by chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-13.

KI67 in breast cancer: Correlation between proliferation cellular and other prognostic factors

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Background: Breast cancer (BC) is the most common tumor in Mexican women between 35 to 50 years old. KI67 is a nuclear antigen considered as a proliferation marker with potential prognostic significance in BC survival. Objective: To determine the correlation between KI67 and prognostic factors in BC patients (pts). Methods: Of 340 consecutive BC pts seen from January 2000 to September 2008, pts with invasive BC that have a complete IHC assay determination were analyzed (estrogen receptor [ER], progesterone receptor [PR], HER2, p53, KI67). KI67 was determined by monoclonal antibody MIB-1. Patients ´s clinical characteristics and tumor immunohistochemical factors were registered. Patients were divided into 4 groups according to KI67 levels: 1) KI67 < 5%, 2) 6 to 20%, 3) 21 to 50% and 4) > 51%. Descriptive statistical methods and X2, ANOVA tests were used. Results: 154 pts analyzed, mean age 53.5 ± 12 yrs, range 28 -83, median KI67: 25, (0 - 95%). Group 1: 22 pts (14.3%), Group 2: 52 (33.8%); group 3: 49 (31.8%), group 4: 31 pts (20.1%). Median KI67 by group: 5, 15, 30 70%. Among pts with KI67 > 51% we observed: higher proportion of advanced stages (III-IV) [27.3%, 7.7%, 25.6%, 38.7% (p= 0.027)], positive lymph nodes (59%, 25%, 42.8% 70.9%, [p=0.003]), ER negative (27.3%, 5.8%, 28.4%, 51.7% [p= 0.000]), PR negative (36.4%, 26.9%, 22.5%, 61.3%; [p= 0.003]); P53 +ve (9.1%, 71.1%, 73.4%, 77.4%; [p= 0.028]), angiogenesis [> 15 vessels × field] (31.8%, 21.1%, 24.5%, 54.5%; [p=0.006])), triple negative phenotype (4.5%; 3.8%, 10.2%, 41.9%; [p=0.000]). We do not observe correlation among KI67 status age, tumor size and HER2 (p > 0.05). Conclusions: High cellular proliferation through KI 67 (> 51%) was related to poor prognostic factors in BC.

No significant financial relationships to disclose.

[Age associated survival rate in non small cell lung cancer]

BACKGROUND

Worldwide, lung cancer is the leading cause of death due to cancer. Non small cell lung cancer (NSCLC) constitutes 70% of cases. Clinical course and survival differ depending of age at diagnosis

OBJECTIVE

Determine the epidemiology and survival rate of NSCLC associated with age of onset of the disease.

PATIENTS AND METHODS

We carried out a retrospective study between January 1993-January 2007 and included patients with confirmed NSCLC. Three groups were included: group 1: < 49 yrs, group 2: 50-69 yrs, group 3: > 70 yrs. Age, ECOG, comorbidity, family background, smoking, clinical stage, histology, metastatic sites, treatment and overall survival were analyzed. Statistical analysis was done using descriptive methods, Kruskall-Wallis, ANOVA, chi-2, Student's T-test and Kaplan-Meier tests.

RESULTS

183 patients, 23 (12.6%) < 49 years, 108 (59%) from group 2 and 52 cases (28.4%) > 70 yrs. Median age was: 43.2, 61.2 and 75.6 yrs (p < 0.05), respectively. The majority were women (56.4%) in group 1, p= 0.036. Comorbidity: 17.4%, 55.5% and 76.9%, p= 0.000. 52.5% smokers, 87% and 62.9%, p= 0.009. Symptoms included: cough (38.9%, 25%, 43.6%), thoracic pain (33.3%, 41.3%, 30.8%) and dyspnea (33.3%, 16.3%, 38.5%), p > 0.05. Adenocarcinoma was the most frequent type (78.2%, 63.9% and 54.5%). Stage IIIB was observed among 17.4% of patients studied, 23.1%, 23.1% and stage IV 52.2%, 44.4%, 50%, respectively. Median overall survival in stages I and II was 21 months, 18 months in stage IIIA (p > 0.05). Stages IIIB-IV the median overall survival was 11, 8.5 and 4 months respectively (p= 0.034).

CONCLUSIONS

Younger patients displayed a more aggressive disease course yet also displayed a higher survival rate. Patients over 70 years have a higher incidence of comorbidity and ECOG 2.

Chemotherapy with gemcitabine in advanced biliary tract carcinoma

BACKGROUND

Biliary tract carcinoma is infrequent; usually majority of cases are detected in an advanced phase of the disease, thus surgical resection is not feasible and prognosis is poor, mean survival is 6 months and, chemotherapy is the main therapeutic option.

OBJECTIVE

An overall review of all clinical trials published regarding gemcitabine, alone or in combination, as a treatment in advanced biliary tract carcinoma.

RESULTS

Gemcitabine has been reported as a single drug, in 12 trials and as a combination in 21 studies. As a single agent it has been evaluated in a 30 minute infusion, biweekly administration, fixed infusion [10 mg/m2/min] or as a prolonged infusion [24 hours]. Objective response has been reported between 0 and 36%, stable disease 13 to 15%, time to progression 2 - 10.7 months, overall survival 4 to 14 months. Chemotherapy combinations based on gemcitabine have been evaluated with several agents, among them were 5-FU, mitomycin oxaliplatin, capecitabine, cisplatin, docetaxel and irinotecan; the objective response seen: 9.3% to 64%, stable disease 9.3% to 53%, time to progression 3 - 10 months and overall survival 4.7 to 18 months.

CONCLUSION

Gemcitabine is an effective drug in advanced biliary tract carcinoma with a low toxicity profile. It should be considered as the standard treatment for unresectable or metastatic disease while awaiting phase III results.

[Recurrence and survival rates among early breast cancer cases with triple negative immunophenotype]

BACKGROUND

Axillary lymph node status, hormonal receptors (HR) and HER2 expression are significant prognostic factors for early breast cancer. Triple negative immunophenotype (HER2 and HR negative) is associated with a high frequency of recurrence and lower overall survival. The objective was assess clinical behavior, recurrence and survival of patients with triple negative early breast cancer and patients with other immunophenotypes.

MATERIAL AND METHODS

We carried out a retrospective study among women with stages I-IIB over 18 years with determination of HR and HER2 expression by immunohistochemical assay. We identified 5 groups: triple negative, triple positive, HER2 negative & HR positive, HER2 positive & HR negative, HER2 negative & 1 HR positive. We recorded age, date of diagnosis, clinical stage, tumor size, axillary lymph node status, ER, PR, HER2, p53, angiogenesis, Ki67, type of surgery, adjuvant treatment, time to recurrence, number and recurrence site and overall survival.

RESULTS

17 patients (15.4%) had triple negative phenotype, 14 (12.7%) triple positive, 52 (47.3%) were localized in group 3, 11 (10%) in 4 and 16 (14.5%) in group 5. Triple negative phenotype was associated with increased cellular proliferation (p < 0.000); being young (median 43 years), large tumor size (median size 2.5 cm) lower proportion of patients in stage I and high frequency of p53 positive (78.5%). We observed a high frequency of recurrence and death among the triple negative group and among the HER2 positive and HR negative cases.

CONCLUSIONS

Triple negative breast cancer is more common among young women and is associated with a high frequency of recurrence and mortality. Clinical behavior among triple negative breast cancer cases is aggressive and displays a similar clinical profile that observed among HER2 positive and HR negative patients.

Time to recurrence and survival in triple negative early-stage breast cancer

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Background: Breast cancer (BC) is the most common neoplasm among Mexican women. Clinical, tumoral and biologic factors have proven useful in predicting prognosis regarding recurrence and survival. Triple negative (TN) phenotype (ER, PR and HER2 negative) has been reported to be associated with more aggressive clinical behavior. Objective: To compare clinical, tumor, biologic characteristics of TN time to recurrence and survival to other phenotypes in early BC. Methods: Records of women with stage I - II BC evaluated from Jan. 2000 to June 2006 were reviewed. ER/PR+: > 10 fmol/pgr and HER2+, 3+ by immunohistochemistry or FISH > 2.2 were considered. Five groups were designed: 1) TN, 2) triple positive, 3) HER2-/ER/PR+, 4) HER2+/ER/PR-, 5) HER2-/ one hormonal receptor (HR) +. ANOVA, Chi-2 and Kruskal-Wallis tests were applied for the statistical analysis. Results: 110 patients were included (17, 14, 52, 11, 16 respectively). Median age (43, 49.5, 55, 53 51 yrs); clinical stage; tumor size, axillary lymph node status and angiogenesis score were similar in all groups, p > 0.05. Median Ki67 was higher in TN group (47.5, 20, 20, 42.5, 10, p< 0.000). Proportion of patients with conservative surgery was similar, p= 0.308. Fourteen recurrences were observed, 2 local and 12 systemic (3, 1, 3, 5, 2 in each group). Median time to recurrence (6, 54, 30, 20, 27 mos); there were 7 deaths due to tumor. Number of deaths was higher in TN and HER+/HR- (17.4, 7.1, 0, 18.1, 6.2%). Conclusions: TN phenotype represents 15% in this early BC population and was associated to higher Ki67. There are premature signs (age, number of recurrences and deaths) that suggest a poor prognosis for TN patients, similar to those with HER2+/ERPR- .

No significant financial relationships to disclose.

[Biomarkers in the prognosis and treatment response of breast cancer]

PURPOSE

To determine the prognostic value of c-erbB-2, p53, hormone receptors and angiogenesis, on recurrence free time and its relationship to treatment in breast cancer patients.

METHODS

Women with histologic diagnosis of breast cancer and immunohistochemical determination of biologic factors. Clinic, histologic, molecular factors and recurrence free time were registered.

RESULTS

101 patients, ages 51.98 +/- 11.5 years. Follow-up 32.52 +/- 24.3 months. Tumor recurred in 31, (30.69%); 15 (48.33%) had tumor size above 2.1 cm, 19 (61.29%) showed positive estrogen receptors and 18 (58.07%) for progesterone; 20 (64.51%) to c-erbB-2 expression (64.51%); 18 to p53; average microvessels 24.48 +/- 17.27. Tumor size related to recurrence, p = 0.008. Kruskal-Wallis test did not show a difference when correlating survival free time and biologic factors. 24 pts. (77.41%) received hormones; 20 (64.5%) chemotherapy (61.29%); 19 (61.29%) radiotherapy. Response prediction to hormones with estrogen receptor positive, p = 0.059; to chemotherapy in angiogenesis under 40 vessels/field-0.024.

CONCLUSIONS

Tumor size has prognostic implications. A clear positive tendency was observed with p53 and higher microvessel density. Estrogen receptors offer predictive response value to hormone treatment and lower vascular density to chemotherapy, treatment indicators of possible therapeutic association.

[Chemotherapy in germinal and epithelial ovarian cancer]

Generically, ovarian cancer represents a group of tumors with diverse biological and clinical behavior. Thus, germinal cells ovarian tumors, in the vast majority of patients are successfully treated utilizing traditional based on cisplatin chemotherapy. Epithelial ovarian cancer, that accounts for 90% of these cases, although sensitive to chemotherapy has not shown satisfactory results. In the search better tumoral response in the treatment of epithelial ovarian cancer new drugs have surged that promise good results, including docetaxel, topotecan and gemcitabine, both as single agents, or in combination with other therapies utilizing monoclonal antibodies.

Anaplastic carcinoma of the fimbriated end of the fallopian tube as an incidental finding

Carcinoma of the fallopian tube is an uncommon gynecologic tumor that is usually diagnosed in an advanced stage. The majority are tubal in origin, and rarely arise in the fimbriae. It appears that the latter may have a worse prognosis than the equivalent stage of tubal tumors that do not arise from fimbriae. We present a case of a 53-year-old white woman with FIGO stage 1 primary anaplastic carcinoma of the fimbriated end of the fallopian tube that was incidentally found in a specimen resected during a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient underwent surgery because of findings of severe cervical dysplasia, atypia and dyskaryosis on a routine Papanicolau smear. Postoperative recovery was uneventful, and follow-up abdominal and pelvic CT scans showed no evidence of disease. However, because of the poor degree of differentiation, focal serosal infiltration and fimbrial end tube site of the carcinoma she was considered to have a high risk of recurrence. Thus, it was recommended that she undergo adjuvant chemotherapy with cyclophosphamide and carboplatin. Eighteen months after diagnosis, the patient is alive and well with no evidence of disease.

Acute pancreatitis secondary to ifosfamide

Acute pancreatitis in cancer patients can be secondary to the malignant process itself. It is also a rare complication of antineoplastic agent administration. Ifosfamide is an effective drug in the treatment of several tumors and has known neurologic, renal, and hematologic toxicities. There is only one recent report in the literature of pancreatitis associated with ifosfamide. We report a case of a 65-year-old woman with small cell bronchogenic carcinoma without pancreatic metastases who developed acute pancreatitis after ifosfamide administration.

Response of choriocarcinoma to paclitaxel. Case report and review of resistance

Paclitaxel has been reported to inhibit proliferation and to promote differentiation of choriocarcinoma cells. We report a case of a patient with high risk trophoblastic disease who had remission with paclitaxel. The mechanisms of paclitaxel resistance are reviewed.

Family-of-origin frames in couples therapy

Six types of family-of-origin frames-coping, modeling, role, definition, reversal, and loyalty frames-are utilized in understanding three common couple interactional situations: pursuing/distancing, overfunctioning/underfunctioning, and blaming/placating. Clinical examples are used to illustrate the process of constructing family-of-origin frames in couples therapy.

Low toxicity with continuous infusion of high-dose bleomycin in poor prognostic testicular cancer

Bleomycin is a powerful antitumoral antibiotic whose utilization has been limited by pulmonary toxicity. At the Medical Oncology Department of the Hospital General de Mexico, SS, 17 patients with high-risk testicular cancer were treated with therapeutic regimens based on cisplatin and bleomycin in continuous infusion. The mean bleomycin dose was 813 mg. Adequate renal function was observed in all patients during and after chemotherapy. During a minimum 4-year follow-up period, no patient experienced pulmonary toxicity; 3 patients died due to tumoral progression. The remaining 14 patients are alive and none of them had shown x-ray abnormalities nor a significant reduction in pulmonary vital capacity (PVC) or carbon monoxide diffusion capacity (DLCO). Bleomycin in continuous infusion can be an appropriate alternative for reducing pulmonary toxic effects. Therefore, randomized controlled studies should be conducted in order to determine if this treatment regime could enhance the therapeutic index.

AS-101: a modulator of in vitro T-cell proliferation

AS-101 is a tellurate compound originally designed as a drug with cytostatic activity. Nevertheless, in vivo it was found to be an immunomodulator agent due to a stimulation of cytokine production. Mitotic Index (MI) as an indicator of cytotoxicity and cell proliferation kinetics (CPK) in lymphocytes cultures are parameters used in the evaluation of the antineoplastic activity of drugs, such as mitomycin-C and cisplatin. For this reason, we evaluated the effects of AS-101 upon these two parameters. The results show that AS-101 produces an inhibition of MI in proliferating lymphocytes higher than the inhibition mediated by cisplatin. When CPK was evaluated, AS-101 induced a retardation not related with dose, while cisplatin produced a stepwise inhibition. This effect contrasts with the stimulation observed when AS-101 was added to non-proliferating lymphocytes which was measured as an increased [3H]thymidine incorporation in culture. The results confirm the mode of action of AS-101 as a real modulating agent of cell proliferation.

[Ovarian cancer (experience with 186 patients)]

An experience with 186 ovarian carcinomas seen at the Oncology Service of The General Hospital of Mexico, between 1981 to 1990 is reported. Fifty patients, (26.9%) were in stage I; 2, (1.0%) were in stage II; 113 in stage III, (60.7%) and 21, (11.2%) were in stage IV. Epidemiological and clinical aspects are reviewed as well as results of treatment. In 137 cases, (73.6%) we have follow up and it was without evidence of disease between 12 and 60 months with a mean of 18 months in 32, (23.3%). This number includes 22 of 26 patients in stage I, (84.6%); 1 of 2 in stage II; 9 of 89, (10.1%) in stage III and 0 of 20 in stage IV. There were not significant differences in prognosis for stage I with the schemes of treatment employed: only surgery, postoperative radiotherapy and postoperative chemotherapy. Patients in stage III evolutioned without evidence of disease when the surgery left residual disease of 2 cms or less for unit: There were 1 of 59 patients treated only with surgery (1.6%); 3 of 15, (20%) treated with radiotherapy to whole abdomen plus over dosage to pelvis and 5 of 15, (33.3%) treated with two agents of chemotherapy. (cyclophosphamide plus adriamycin of cyclophosphamide plus cisplatin). In 3 of 11 stage III patients, (27.2%) with second look surgeries, we found macroscopic residual tumor.

The computerized genogram

Genograms are used in family therapy and family medicine to assess the family from a systemic perspective. Computerized genograms automate the process and allow the clinician to manipulate data in a number of different ways.

Sarcoma of the buttock: a trend toward limb-saving resection

A retrospective comparison was made between soft tissue sarcomas of the buttock treated during two consecutive periods at one institution: (1) 1966-1978, during which almost all tumors were treated by radical buttectomy with limb preservation, often in conjunction with radiation therapy, and (2) 1934-1966, as previously reported by Wanebo et al, in which treatment by hemipelvectomy was frequently offered. Desmoid tumors were excluded. The five-year survival rates after curative treatment were almost identical, 40% vs 39%, respectively. Distant metastases were the main cause of death. Very high local recurrence rates were recorded after therapy: 45% vs 39% for the respective periods. Local recurrences seemed prone to occur with large, deeply fixed sarcomas, particularly when inadequate or no radiation therapy had been utilized. These observations point to the need for innovative methods to prevent local tumor recurrence and a trial of adjuvant chemotherapy if long-term cure with limb preservation is to be achieved.