Tumor mutational burden for the prediction of PD-(L)1 blockade efficacy in cancer: challenges and opportunities

Tumor mutational burden (TMB) is a biomarker that measures the number of somatic mutations in a tumor's genome. TMB has emerged as a predictor of response to immune checkpoint inhibitors (ICIs) in various cancer types, and several studies have shown that patients with high TMB have better outcomes when treated with programmed death-ligand 1-based therapies. Recently, the Food and Drug Administration has approved TMB as a companion diagnostic for the use of pembrolizumab in solid tumors. However, despite its potential, the use of TMB as a biomarker for immunotherapy efficacy is limited by several factors. Here we review the limitations of TMB in predicting immunotherapy outcomes in patients with cancer and discuss potential strategies to optimize its use in the clinic.

Polymyositis following varicella and mumps infection in adults: report of two cases

Idiopathic immune myopathies (IIMs) are autoimmune diseases caused by immune-mediated muscle damage. The etiology remains unclear. Epidemiological and experimental studies, both in animals and humans, hint at viruses as major environmental factors able to trigger aberrant immune responses through many different mechanisms. However, only a few cases of either dermatomyositis or polymyositis following a specific viral infection have been reported in the literature. The objective of this study is to describe the clinical features and the treatment strategy of 2 cases of polymyositis developing shortly after chickenpox and mumps, respectively, and to review the existing literature on the topic. The clinical records of the 2 patients suspected to have developed inflammatory myositis following a viral infection were reviewed. Their clinical history, main laboratory findings, and treatment outcome are presented here. Moreover, a literature search was performed in the PubMed and MEDLINE databases to identify reports describing the association between viral infections and IIMs in patients aged ≥18. The 2 patients reported here developed polymyositis shortly after chickenpox and mumps, respectively, suggesting a causal role for viruses in triggering autoimmunity. Only a few reports published between 1990 and 2020 were found in the literature, possibly linking infections to myositis development. Intravenous immunoglobulin and rituximab were effective for the treatment of viral-triggered polymyositis.

Parents-children co-regulation as therapeutic variable and target in autism spectrum disorders. From observation of drive to need of cooperative parent-mediated therapy

Abstract

Autism spectrum disorders (ASDs) belong to the category of neurodevelopmental disorders. ASD emerges in early childhood and involves deficits in communication, language, behavioural inflexibility and fixity, and sensorial neurodivergent perception. ASDs have a biological pathogenesis related to genetic and epigenetic factors. Additionally, research has shown that starting from childhood, autistic persons could find emotional regulation challenging during communication with caregivers. The importance of emotional co-regulation has always been under-lined in psychology, starting with Freud who introduced the concept of the Compassionate Other. Emotional difficulties are grasped immediately and almost instinctively by parents, who try to modulate their approach to the child's needs from the very beginning. This paper seeks to highlight the importance of emotional co-regulation as a wake-up call-in developmental trajectories that present peculiarities or anomalies. It also emphasizes the significance of emotional co-regulation as a useful tool for intervening in the dysfun-ctionality of such trajectories. This intervention aims to directly involve parents in treatment, as seen in Cooperative parent-mediated therapy. This approach is crucial for facilitating the evolution of the cognitive framework while utilizing this target. This article aims to review the most recent literature on co-regulation after explaining the theoretical framework that gave rise to this concept. It's now well established the importance of adopting a develop-mental approach that starts from the bodily dimension as the basis for the relationship with caregivers, pairs, and unfamiliar people. It is from this basis that starts the affective, emotional, and cognitive construction of the internal and external world of the child. This scoping review takes into account the most recent evidence on co-regulation and autism, emphasizing the importance of this process in diagnostic and therapeutic settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PEOPLE (NCT03447678), a first-line phase II pembrolizumab trial, in negative and low PD-L1 advanced NSCLC: clinical outcomes and association with circulating immune biomarkers

BACKGROUND

The PEOPLE trial aimed to identify new immune biomarkers in negative and low programmed death-ligand 1 (PD-L1) (0%-49%) advanced non-small-cell lung cancer (aNSCLC) patients treated with first-line pembrolizumab. Here we report the main outcomes and the circulating immune biomarkers analysis.

PATIENTS AND METHODS

The primary endpoint of this phase II trial was the identification of immune biomarkers associated with progression-free survival (PFS). Overall survival (OS), objective response rate (ORR), disease control rate (DCR), duration of response (DoR) and safety were secondary endpoints. Absolute cell counts for 36 subsets belonging to innate and adaptive immunity were determined by multiparametric flow cytometry in peripheral blood at baseline and at first radiologic evaluation. An orthoblique principal components-based clustering approach and multivariable Cox regression model adjusted for clinical variables were used to analyze immune variables and their correlation with clinical endpoints.

RESULTS

From May 2018 to October 2020, 65 patients were enrolled. After a median follow-up of 26.4 months, the median PFS was 2.9 months [95% confidence interval (CI) 1.8-5.6 months] and median OS was 12.1 months (95% CI 8.7-17.1 months). The ORR was 21.5%, DCR was 47.7% and median DoR was 14.5 months (95% CI 6.4-24.9 months). Drug-related grade 3-4 adverse events were 9.2%. Higher T cell and natural killer (NK) cell count at baseline and at the first radiologic evaluation were associated with improved PFS, DCR and OS. On the contrary, higher myeloid cell count at baseline or at the first radiologic evaluation was significantly associated with worse OS and DCR.

CONCLUSIONS

Circulating immune biomarkers can contribute to predict outcomes in negative and low PD-L1 aNSCLC patients treated with first-line single-agent pembrolizumab.

Levodopa-dependent differences in the non-oscillatory activity of the subthalamic nucleus

The study of local field potentials (LFP) recorded from the basal ganglia of patients with movement disorders led to significant advancement in the understanding the pathophysiology of Parkinson's disease (PD). The possibility of investigating possible changes in the activity of the brain caused by the levodopa administration may provide a useful tool to evaluate the influence or the side-effects of the treatment from patient to patient. The analysis was carried out through a systematic analysis of the fractal component of the subthalamic local field potentials (STN-LFP) that may reveal, with respect to the classical power spectrum analysis, novel important information about the dynamic modulation caused by the drug intake. Indeed, so far, much of what is known about that is related to the presence of a spectral peak in the beta frequency band then attenuated after the levodopa administration. The nonlinear power-law exponent goes beyond this feature, exploring differences that reflect the fractal (scale-free) behavior of the PD brain dynamics. Here, in order to demonstrate that the presence or absence of the peak has no effect on the computation of the power-law exponent, we used simulated LFP recordings. After that, we performed the fractal analysis in shorts epochs of STN LFPs recordings ( N=24 patients, 12 females and 12 males) before and after Levodopa administration. We found no differences in the nonlinear power-law exponent for simulated data, reinforcing the idea that the parameter was not influenced by the attenuation of the hallmark peak for PD patients. As regard real LFP time series, we found that pharmacological treatment for PD differently altered LFP power of non-oscillatory activity, as well as changed the level of fractal exponent in specific frequency bands. Particularly we observed an increase of the fractal exponent in condition of post-levodopa with significant differences related to the response to levodopa in Parkinson's disease. Clinical Relevance- This study points out a potentially novel non-oscillatory biomarker which could reflect intrinsic properties of complex biological systems thus constituting a potential target parameter for novel and alternative neuroprosthetic applications.

AB0694 VITAMIN D LEVELS IN SERUM OF PATIENTS WITH SYSTEMIC SCLEROSIS AND VERY-EARLY SYSTEMIC SCLEROSIS (VEDOSS)

Background

Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy, and visceral and cutaneous fibrosis and very-early systemic sclerosis VEDOSS is characterized by Raynaud’s phenomenon with SSc marker autoantibodies and typical capillaroscopic finding. Vitamin D has several functions in the immunological system, and different studies have suggested a potential role in triggering autoimmune diseases. (1,2)

Objectives

Our goal was to verify the difference of Vitamin D levels causal in SSC definite and VEDOSS population, and relationship between hypovitaminosis D and SSc characteristics

Methods

42 adults with SSc were recruited: 24 with American College of Rheumatology criteria were affected by diffuse systemic sclerosis (4) and limited systemic sclerosis (20); 18

with VEDOSS criteria.

Patients were evaluated from medical history and physical examination (modified Rodnan skin score and the presence / number of ulcers), biohumoral evaluation of routine, electrocardiogram, echocardiogram, pulmonary function tests, high resolution computed tomography of the chest, capillaroscopy. For the determination of total vitamin D levels (25-OH), the serum samples were suitably centrifuged at 4 ° C at 3500g. Vitamin D levels were then determined by a two-step chemiluminescence enzyme immunoassay (CLIA), with a maximum limit of 100 ng / ml.

Results

The 42 subjects recruited (4 men and 38 women); age 48.2 ± 11.5 years (mean ± SD). All subjects were ANA positive, with anti-Scl70 positivity in dcSSc patients (4) and anti-centromere lcSSc patients (18). Patients with VEDOSS showed optimal serum levels of vitamin D (33.93 ± 3.5 ng / ml). Conversely, patients with systemic sclerosis showed serum levels of vitamin D at the limit of sufficiency (21.75 ± 4.0 ng / ml). (Figure 1) In particular, in the group of patients with systemic sclerosis, vitamin D levels were significantly reduced by 1.5 times (P <0.05) compared to VEDOSS group. In patients with SSc the serum levels of vitamin D were inversely proportional to the presence of mega capillaries. Furthermore, a directly proportional correlation of the serum levels of vitamin D with the age of the patient. It is therefore possible to assume that higher levels of vitamin D delay the onset of the disease, while lower levels of vitamin D favor the onset of the same.

Conclusion

Considering our findings from this work, it is possible to consider the Vitamin D supplement in patients suffering from sclerosis, especially as an adjuvant in the initial phase of the disease, thus hypothesizing a slowdown in the progression of the disease and an improvement in prognosis.

References

[1]S. Bellando-Randone, F.Del Galdo, G. Lepri, t al. Progression of patients with Raynaud’s phenomenon to systemic sclerosis: a five-year analysis of the European Scleroderma Trial and Research group multicentre, longitudinal registry study for Very Early Diagnosis of Systemic Sclerosis (VEDOSS). Lancet Rheumatol 2021; 3: e834–43

[2]Rosen Y, Daich J, Soliman I, Brathwaite E, Shoenfeld Y. Vitamin D and autoimmunity. .Scand J Rheumatol. 2016 Nov;45(6):439-447.

Figure 1.

Disclosure of Interests

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

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

References:

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

Table 1.

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

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

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

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

Disclosure of Interests:

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

Natural history of right ventricle: longitudinal study in veteran athletes

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Right ventricular (RV) enlargement is a physiologic adaptation to long lasting athletic training. Its clinical implications for veteran athletes are poorly understood. In recent years, controversial data suggest an association between ultra-endurance exercise and a RV cardiomyopathy similar to arrhythmogenic cardiomyopathy (ACM). In this context, the effects of exercise detraining have not been extensively studied yet.

PURPOSE

The aim of this study was to assess the morphological and functional RV changes in veteran athletes and to evaluate the effect of a long period of detraining.

METHODS

This is a longitudinal study including 22 veteran rowers with at least 10 years of competitive career. We evaluated them with an echocardiographic assessment at baseline and after a minimum of 3 years of detraining (age: 23.2 ± 4.4 and 43 ± 7.4 years), by reducing the weekly training volume from 26 ± 0.7 to 3 ± 2 hours. In this second evaluation we also performed an RV strain analysis and a cardiac magnetic resonance (CMR) study.

RESULTS

RV end diastolic (ED) areas significantly reduced after detraining (31.48 ± 5.8 versus 28.59 ± 6.8; p = 0.001), although remaining larger than normal. RV enlargement was balanced: the ratio between inflow (IT) and outflow tract (OT) (RVIT/RVOT = 1.4 ± 0.1) and the ratio between RV and left ventricle (LV) (RV/LV = 0.81 ± 0.1) were within normal limits. The fractional area change (FAC%) was normal at baseline and increased significantly (41.5 ± 6% versus 45.8 ± 7%; p = 0.011). After detraining, RV longitudinal strain was normal (-19.7 ± 2.7%). CMR assessment showed enlarged RVED volumes (97.9 ± 14 ml/m2) but normal RV ejection fraction (55.5 ± 4.1%).

CONCLUSIONS

RV enlargement in endurance athletes persists after a long period of detraining. However, detraining results in a significant reduction of RV dimensions. Furthermore, the absence of RV dysfunction or disproportionate RV geometry are reassuring findings that suggest a physiological remodeling of the RV.

Significant echo findings. RV ECHO PARAMETERS BASELINE DETRAINING MEAN DIFF. (C.I. 95%) p VALUE RVOT plax (mm) 34.8 ± 4 33.7 ± 14 1.1 (0.18; 2.1) p = 0.011 RVOT psax (mm) 34.9 ± 3.3 33.09 ± 3.5 1.8 (0.9; 2.7) p &lt; 0.001 RV basal diameter (mm) 47.31 ± 5.3 45.86 ± 6.4 1.4 (0.04; 2.8) p = 0.022 RV end-diastolic area (cm&sup2;) 31.48 ± 5.8 28.59 ± 6.8 2.8 (1.1; 4.6) p = 0.001 FAC% 41.5 ± 6 45.8 ± 7 0.04 (-0.07; -0.007) p = 0.011 RV inflow/outflow ratio 1.36 ± 0.1 1.36 ± 0.2 -0.003 (-0.06; 0.06) p = 0.454 RV/LV ratio 0.82 ± 0.07 0.81 ±0.1 0.01 (-0.01; 0.04) p = 0.219

Abstract Figure. Comparison in the same veteran athlete.

Immune checkpoint inhibitors versus second line chemotherapy for patients with lung cancer refractory to first line chemotherapy

PURPOSE

Anti Programmed Death-ligand (PD1/PD-L1) directed immune-checkpoint-inhibitors (ICI) are widely used to treat patients with advanced non-small cell lung cancer (NSCLC) who progress after first line chemotherapy. The best strategy after early progression under first line has not been specifically studied.

PATIENTS AND METHODS

We conducted a multicenter, retrospective study including all consecutive NSCLC patients progressing within the first 3 months following introduction of first-line chemotherapy and being treated with second line ICI monotherapy or chemotherapy between March 2010 and November 2017. We analysed the clinicopathological data and outcome under second line chemotherapy vs. second line ICI: objective response rate (ORR), progression-free survival (PFS), overall survival (OS.

RESULTS

We identified 176 patients with refractory disease, 99 who received subsequent immunotherapy and 77 undergoing chemotherapy. The 2 populations were comparable regarding the main prognostic criteria, median age was 60, main histology was adenocarcimoma (68.2%). PFS was not significantly different between both treatments 1.9 [1.8-2.1] versus 1.6 month [1.4-2.0] (P=0.125). Compared to chemotherapy, ICI treated patients had a superior OS (P=0.03) (Median [95% CI] OS 4.6 [2.8-6.7] versus 4.2 months [3.4-5.9] and a non-significant improvement in ORR (17.2% versus 7.9%, respectively, P=0.072). Poor performance status (ECOG PS≥2) and a higher number of metastatic sites (≥3) were associated with poorer prognosis. KRAS-mutated patients did not seem to benefit more from ICI than chemotherapy.

CONCLUSIONS

ICI appears to be the preferred second-line treatment for patients who are refractory to first line chemotherapy.

A multidimensional approach to improve migrants’ health in the new context of living

Background

Quantitative data analysis performed by the multidisciplinary team in a Primary Care setting, addressing migrants' health in Parma, showed poor adherence and lower completion rate of Latent Tuberculosis Infection (LTBI) treatment among 2701 refugees and asylum seekers, registered from 2013 to 2018. Soon afterwards, qualitative data analysis revealed that health operators, intercultural mediators and operators working for no-profit-organizations (NGOs) did not share the same approach towards LTBI care cascade. Different knowledge about patient engagement, Health Literacy (HL) interventions, disagreement about the objectives and motivation to screening and treatment of LTBI, could be the consequence of an ineffective communication and not well-structured cooperation between health operators, private sectors and other stakeholders.

Objectives

In order to enhance migrants' capability for self-care management of LTBI, the multidisciplinary team plans seven meetings with intercultural mediators and operators working for NGOs, from March to June, within the I.C.A.R.E European Project. The interactive meetings aim at improving knowledge about Tuberculosis (TB) and LTBI, awareness about the relationship between self-decision making and health outcomes, motivation to patient engagement and finally at identifying culturally competent and HL oriented strategies.

Results

It is expected a structured, evidence-based approach, according to national guidelines, enabling newly arrived immigrants to improve self-care management of health and LTBI. Indicators, outcomes, challenges managed within the participatory meetings will be presented at the conference.

Conclusions

A co-construction of a multidimensional approach, supporting individual capacity building to improve self-care management of LTBI among newly arrived immigrants, could be an effective strategy for patient engagement and health promotion.

Key messages

Newly arrived immigrants’ health is not only a matter of individual capability but also of a multifactorial approach, actively involving stakeholders from the public, private and no-profit sectors. This multidimensional cooperation to improve migrants’ health considers HL as a fundamental factor, supporting individual engagement and decreasing in fear about TB.

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Table 1.

Characteristics and treatment of Rh-irAEs patients.

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

Conclusion:

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

Disclosure of Interests:

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

AB0800 CLINICAL ASSOCIATION BETWEEN URIC ACID/25-HYDROXYVITAMIN D SERUM LEVELS RATIO IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

The association between hyperuricemia and psoriatic arthritis (PsA) is actually generally accepted. Previous studies have demonstrated that uric acid suppress 25(OH)D metabolism [1]. More evidence is required to demonstrate the immune modulatory effects in psoriasis, psoriatic arthritis and other autoimmune diseases. In particular, the potential association between 25-hydroxyvitamin D serum levels and PsA still remains unknown.

Objectives:

To assess a clinical association between uric acid/25(OH)D serum levels ratio related to PASI, BASDAI and DAPSA, if any, in patients with psoriatic arthritis.

Methods:

We retrospectively observed 61 patients with psoriatic arthritis referred to our outpatients clinic, independently from already being on therapy or naïve. All selected patients underwent only conventional non-biological therapy at baseline and none received vitamin D supplementation and either allopurinol or febuxostat previously. Blood samples were drawn from all participants for assessment of 25-hydroxyvitamin D and uric acid serum levels. Disease activity of psoriasis and psoriatic arthritis were assessed by the Psoriasis Area and Severity Index (PASI), the Disease Activity Index for Psoriatic Arthritis (DAPSA) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). We assessed the covariates of interest by the Wilcoxon non parametric test, through the SPSS 24 Software.

Results:

We observed 61 patients, mainly females (83.6%). At the univariate analysis, the uric acid/25(OH)D serum levels ratio revealed significantly associated with DAPSA and BASDAI indexes (p<0.001 and p<0.001, respectively), whilst no significant association emerged with the PASI index (p=0.462).

Conclusion:

Data in the literature about these associations in the context of psoriatic arthritis are really poor. As a consequence, our findings, though preliminary, suggest us to hypothesize a potential role of uric acid/25(OH)D serum levels ratio as potential inflammation marker in order to better assess the disease activity. However, future larger studies are needed to investigate more in depth this association.

[1]Charoenngam N, Ponvilawan B, Ungprasert P. Vitamin D insufficiency and deficiency are associated with a higher level of serum uric acid: A systematic review and meta-analysis. Mod Rheumatol. 2019 Mar 4:1-6.

Disclosure of Interests:

None declared

Diagnosis and treatment of early and locally advanced non-small-cell lung cancer: The 2019 AIOM (Italian Association of Medical Oncology) clinical practice guidelines

The Italian Association of Medical Oncology (AIOM) has developed clinical practice guidelines for the diagnosis and treatment of patients with early and locally advanced non-small cell lung cancer. In the current paper a panel of AIOM experts in the field of thoracic malignancies discussed these topics, analyzing available scientific evidences, with the final aim of providing a summary of clinical recommendations, which may guide physicians in their current practice.

Treatment of advanced non-small-cell lung cancer: The 2019 AIOM (Italian Association of Medical Oncology) clinical practice guidelines

The Italian Association of Medical Oncology (AIOM) has developed clinical practice guidelines for the treatment of patients with advanced non-small cell lung cancer (NSCLC). In the current paper a panel of AIOM experts in the field of thoracic malignancies discussed the available scientific evidences, with the final aim of providing a summary of clinical recommendations, which may guide physicians in their current practice.

Choosing wisely first line immunotherapy in non-small cell lung cancer (NSCLC): what to add and what to leave out

Immunotherapy has dramatically changed the therapeutic scenario in treatment naïve advanced non-small cell lung cancer (NSCLC). While single agent pembrolizumab has become the standard therapy in patients with PD-L1 expression on tumor cells ≥ 50%, the combination of pembrolizumab or atezolizumab and platinum-based chemotherapy has emerged as an effective first line treatment regardless of PD-L1 expression both in squamous and non-squamous NSCLC without oncogenic drivers. Furthermore, double immune checkpoint inhibition has shown promising results in treatment naïve patients with high tumor mutational burden (TMB). Of note, the presence of both negative PD-L1 expression and low TMB may identify a subgroup of patients who has little benefit from immunotherapy combinations and for whom the best treatment option may still be platinum-based chemotherapy. To date, first-line single agent immune checkpoint blockade has demonstrated limited activity in EGFR mutated NSCLC and the combination of immunotherapy and targeted agents has raised safety concerns in both EGFR and ALK positive NSCLC patients. Finally, in EGFR mutated or ALK rearranged NSCLC, atezolizumab in combination with platinum-based chemotherapy and bevacizumab is emerging as a potential treatment option upon progression to first line tyrosine kinase inhibitors.