Checkpoint inhibitors as dual immunotherapy in advanced non-small cell lung cancer: a meta-analysis

Introduction

Recent clinical trials have confirmed that anti-programmed cell death-1/ligand 1 (anti-PD-1/L1) combined with either anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4) or anti-T-cell immunoreceptor with Ig and ITIM domains (TIGIT) antibodies (dual immunotherapy) produced significant benefits as first-line therapies for patients with advanced non-small cell lung cancer (NSCLC). However, it also increased the incidence of adverse reactions, which cannot be ignored. Our study aims to explore the efficacy and safety of dual immunotherapies in advanced NSCLC.

Methods

This meta-analysis ultimately included nine first-line randomized controlled trials collected from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases until 13 August 2022. Efficacy was measured as the hazard ratio (HR) and 95% confidence interval (CI) for progression-free survival (PFS), overall survival (OS), and risk ratio (RR) for the objective response rates (ORRs). Treatment safety was assessed by RR of any grade of treatment-related adverse events (TRAEs) and grade ≥ 3 TRAEs.

Results

Our results demonstrated that, compared to chemotherapy, dual immunotherapy shows durable benefits in OS (HR = 0.76, 95% CI: 0.69-0.82) and PFS (HR = 0.75, 95% CI: 0.67-0.83) across all levels of PD-L1 expression. Subgroup analysis also presented that dual immunotherapy resulted in improved long-term survival compared with chemotherapy in patients with a high tumor mutational burden (TMB) (OS: HR = 0.76, p = 0.0009; PFS: HR = 0.72, p < 0.0001) and squamous cell histology (OS: HR = 0.64, p < 0.00001; PFS: HR = 0.66, p < 0.001). However, compared with immune checkpoint inhibitor (ICI) monotherapy, dual immunotherapy shows some advantages in terms of OS and ORR and only improved PFS (HR = 0.77, p = 0.005) in PD-L1 < 25%. With regard to safety, there was no significant difference in any grade TRAEs (p = 0.05) and grade ≥ 3 TRAEs (p = 0.31) between the dual immunotherapy and chemotherapy groups. However, compared with ICI monotherapy, dual immunotherapy significantly increased the incidence of any grade TRAEs (p = 0.03) and grade ≥ 3 TRAEs (p < 0.0001).

Conclusions

As for the efficacy and safety outcome, compared with standard chemotherapy, dual immunotherapy remains an effective first-line therapy for patients with advanced NSCLC, especially for patients with high TMB levels and squamous cell histology. Furthermore, compared to single-agent immunotherapy, dual immunotherapy is only considered for use in patients with low PD-L1 expression in order to reduce the emergence of resistance to immunotherapy.Systematic Review Registation: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022336614.

Pseudoprogression during induction treatment with nivolumab plus ipilimumab combined with chemotherapy for metastatic lung adenocarcinoma: A case report

The incidence rate of pseudoprogression during immune checkpoint inhibitor monotherapy for non-small cell lung cancer is reportedly 3.6%-6.9%, while pseudoprogression during chemoimmunotherapy is rare. Reports on pseudoprogression during dual immunotherapy combined with chemotherapy are lacking. Herein, a 55-year-old male with invasive mucinous adenocarcinoma (cT2aN2M1c [OTH, PUL], stage IVB, and programmed death-ligand 1 expression <1%), renal dysfunction, and disseminated intravascular coagulation was treated with carboplatin, solvent-based paclitaxel, nivolumab, and ipilimumab. After treatment initiation, computed tomography (CT) on day 14 showed disease progression. The patient was diagnosed with pseudoprogression because of a lack of symptoms, improved platelet count, and decreased fibrin/fibrinogen degradation product levels. CT on day 36 showed a reduction in the primary lesion size, multiple lung metastases, and mesenteric metastases. Therefore, pseudoprogression should be considered during dual immunotherapy with chemotherapy.

Long-term survival with first-line nivolumab plus ipilimumab in patients with advanced non-small-cell lung cancer: a pooled analysis

BACKGROUND

First-line nivolumab plus ipilimumab prolongs survival versus chemotherapy in advanced non-small-cell lung cancer (NSCLC). We further characterized clinical benefit with this regimen in a large pooled patient population and assessed the effect of response on survival.

PATIENTS AND METHODS

Data were pooled from four studies of first-line nivolumab plus ipilimumab in advanced NSCLC (CheckMate 227 Part 1, 817 cohort A, 568 Part 1, and 012). Overall survival (OS), progression-free survival (PFS), objective response rate, duration of response, and safety were assessed. Landmark analyses of OS by response status at 6 months and by tumor burden reduction in responders to nivolumab plus ipilimumab were also assessed.

RESULTS

In the pooled population (N = 1332) with a minimum follow-up of 29.1-58.9 months, median OS was 18.6 months, with a 3-year OS rate of 35%; median PFS was 5.4 months (3-year PFS rate, 17%). Objective response rate was 36%; median duration of response was 23.7 months, with 38% of responders having an ongoing response at 3 years. In patients with tumor programmed death-ligand 1 (PD-L1) <1%, ≥1%, 1%-49%, or ≥50%, 3-year OS rates were 30%, 38%, 30%, and 48%. Three-year OS rates were 30% and 38% in patients with squamous or non-squamous histology. Efficacy outcomes in patients aged ≥75 years were similar to the overall pooled population (median OS, 20.1 months; 3-year OS rate, 34%). In the pooled population, responders to nivolumab plus ipilimumab at 6 months had longer post-landmark OS than those with stable or progressive disease; 3-year OS rates were 66%, 22%, and 14%, respectively. Greater depth of response was associated with prolonged survival; in patients with tumor burden reduction ≥80%, 50% to <80%, or 30% to <50%, 3-year OS rates were 85%, 72%, and 44%, respectively. No new safety signals were identified in the pooled population.

CONCLUSION

Long-term survival benefit and durable response with nivolumab plus ipilimumab in this large patient population further support this first-line treatment option for advanced NSCLC.

First-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone (four cycles) in advanced non-small-cell lung cancer: CheckMate 9LA 2-year update

BACKGROUND

To further characterize survival benefit with first-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone, we report updated data from the phase III CheckMate 9LA trial with a 2-year minimum follow-up.

PATIENTS AND METHODS

Adult patients were treatment naïve, with stage IV/recurrent non-small-cell lung cancer, no known sensitizing EGFR/ALK alterations, and an Eastern Cooperative Oncology Group performance status ≤1. Patients were randomized 1 : 1 to nivolumab 360 mg every 3 weeks plus ipilimumab 1 mg/kg every 6 weeks with two cycles of chemotherapy, or four cycles of chemotherapy. Updated efficacy and safety outcomes are reported, along with progression-free survival (PFS) after next line of treatment (PFS2), treatment-related adverse events (TRAEs) by treatment cycle, and efficacy outcomes in patients who discontinued all treatment components in the experimental arm due to TRAEs.

RESULTS

With a median follow-up of 30.7 months, nivolumab plus ipilimumab with chemotherapy continued to prolong overall survival (OS) versus chemotherapy. Median OS was 15.8 versus 11.0 months [hazard ratio 0.72 (95% confidence interval 0.61-0.86)]; 2-year OS rate was 38% versus 26%. Two-year PFS rate was 20% versus 8%. ORR was 38% versus 25%, respectively; 34% versus 12% of all responses were ongoing at 2 years. Median PFS2 was 13.9 versus 8.7 months. Improved efficacy outcomes in the experimental versus control arm were observed across most subgroups, including by programmed death-ligand 1 and histology. No new safety signals were observed; onset of grade 3/4 TRAEs was mostly observed during the first two treatment cycles in the experimental arm. In patients who discontinued all components of nivolumab plus ipilimumab with chemotherapy treatment due to TRAEs (n = 61) median OS was 27.5 months; 56% of responders had an ongoing response ≥1 year after discontinuation.

CONCLUSIONS

With a 2-year minimum follow-up, nivolumab plus ipilimumab with two cycles of chemotherapy provided durable efficacy benefits over chemotherapy with a manageable safety profile and remains an efficacious first-line treatment of advanced non-small-cell lung cancer.

Combination of bevacizumab and dual immunotherapy for extensive-disease small-cell lung cancer: a case report

Small-cell lung cancer (SCLC) is sensitive to chemoradiotherapy but remains to have a poor prognosis. In the immunotherapy era, chemotherapy combined with PD-L1 inhibitors has become a new first-line treatment option for advanced SCLC. The CheckMate 032 study combined a PD-1 blockade and a CTLA-4 inhibitor and found that this dual immunotherapy might be a positive treatment choice for SCLC. In our case, a patient with advanced SCLC received bevacizumab combined with dual immunotherapy over the third line with more than 12 months survival time. The overall survival time was 21.5 months from the start of the third-line treatment and 39 months from the time of extensive-disease SCLC diagnosis. The combination of a VEGF blockade and a dual immunotherapy in SCLC resulted in synergistic treatment effects. Therefore, bevacizumab might be a better adjuvant, either combined with chemotherapy or dual immunotherapy, for patients with persistent disease progression after undergoing immunotherapy.

Autoantibody-Negative Immune-Mediated Necrotizing Myopathy Responds to Early and Aggressive Treatment: A Case Report

Immune-mediated necrotizing myopathy (IMNM) is a rare idiopathic disease that is further classified by the presence of serum antibodies. A modicum of patients lack serum autoantibodies. Significantly elevated creatine kinase (CK) is highly characteristic of IMNM. The pathophysiology of IMNM is partially understood, and effective treatment options are limited, particularly in patients without serum autoantibodies. In this case, we report a 76-year-old male presenting with a four-month history of proximal muscle weakness. Muscle biopsy and serology confirmed the diagnosis of autoantibody-negative IMNM. Early and aggressive treatment with high-dose steroids and a course of intravenous immunoglobulin significantly reduced the patient’s symptoms and CK within three months. This case serves as an example of an effective treatment outcome in a patient with this rare idiopathic necrotizing myopathy.

Complete Response to Dual Immunotherapy in a Young Adult with Metastatic Alveolar Soft Part Sarcoma Enabled by a Drug Recovery Program in a Community Practice

Alveolar soft part sarcoma (ASPS) is an extremely rare tumor that frequently occurs in adolescent and young adults (AYA). Survival is poor for patients with metastatic and/or relapsed disease not amenable to local control, and limited therapeutic options are available. A major barrier to cancer care in the United States AYA population is lack of access to coordinated care and appropriate therapies for those who lack insurance or who are underinsured. We report a 25-year-old unemployed, uninsured, single mother who presented with a 12.8 × 21 cm soft tissue thigh mass with heterogeneous avidity, max standardized uptake value of 9, with metastatic disease to the ipsilateral inguinal lymph nodes and to the bilateral lungs. After local control of the primary mass was obtained, a recently developed, comprehensive drug replacement program (DRP) was used to gain access to nivolumab, and after frank progression was noted, ipilimumab was added every 6 weeks. No biomarkers associated with response to immunotherapy were identified. After four cycles, a complete response was observed and patient remains disease free 36 months after beginning dual immunotherapy treatment. We obtained immunotherapy agents through a DRP and describe the development and the utility of this program in the community setting. Our report highlights both first documented sustained complete response to sequenced immunotherapy in an AYA with ASPS as well as a comprehensive DRP, which enabled access to therapy for our patient.