Tamponade during immune checkpoint inhibitors therapy in lung cancer: case-reports and systematic review of the literature

Introduction

Immune therapy is a new option that has revolutionized cancer therapy. Immune checkpoint inhibitors target mostly either PD-1 (Pembrolizumab, Nivolumab) or PD-L1 (Durvalumab). Immune-related cardiotoxic side effects, among them, tamponade, initially thought to be rare, seem to be increasingly cited in the literature. Moreover, tobacco smoking is linked to 80% of lung cancers. Smoking during cancer therapy may influence on radiotherapy and chemotherapy outcomes but little is known on immunotherapy.

Purpose

We aimed to review all the published cases of tamponade during immune therapy for lung cancer and to report all the cases that occurred in the University Hospital Ambroise Paré. We also wanted to highlight the possible impact of tobacco on immunotherapy.

Methods

We conducted a literature review in the PubMED database, from database inception up to 02/14/2020, with a combination of the following terms: “tamponade AND ((immune checkpoint inhibitors) OR (PD-1) OR (PD-L1))”. We also reported all the tamponade cases occurred in our hospital from the beginning of immune checkpoint inhibitors therapy existence up to 02/14/2020.

Results

Seventeen cases citing tamponade were identified in the literature to which we added 3 cases from our hospital. Mortality rate at 1 month was of 20%. Nivolumab was involved in 80%, Pembrolizumab in 10% and Durvalumab in 10%. In 75%, lung cancer was with a stage IV. Men accounted for 85% and mean age was of 62 years. Active smokers represented 85% and passive smokers existed in 5%, after diagnosis, smoking cessation was done in 10%. Tamponade occurred either shortly after the first administrations but also after several doses. Pericardial fluid cytology revealed malignant cells in half of the cases and microbiology was always negative. For all the cases, excepted for one who was directly considered as palliative, an evacuation of the pericardial fluid was done. In 45% a corticotherapy was initiated. Two cases quickly worsened after pericardial evacuation by unmasking a probable myocarditis with cardiogenic shock which needed the use of a veno-arterial extracorporeal membrane oxygenation.

Conclusions

Tamponade under immune checkpoint inhibitors therapy appears less rare than initially thought and mortality rate at one month was not negligible. The use of regular echocardiography during this immune therapy may be crucial in detecting early stages of the disease process and smoking cessation should also be advised for these patients. The prevalence of complications among all the patients both exposed to immune therapy and tobacco could not be calculated in this work (case-reports), but some recent studies may indicate survival gains of smoking cessation. Further research establishing more specific guidelines is naturally necessary in dealing with this potentially fatal effect but also in establishing the possibly additional role of smoking in the cardiotoxicity of immunotherapy.

Funding Acknowledgement

Type of funding source: None

Perceived sources of stress amongst dental students: A multicountry study

AIMS

The aim of this study was to explore the perceived sources of stress reported by dental students from fourteen different countries.

METHODS

A total of 3568 dental students were recruited from 14 different dental schools. The dental environmental stress (DES) questionnaire was used including 7 domains. Responses to the DES were scored in 4-point Likert scale. Comparison between students was performed according to the study variables. The top 5 stress-provoking questions were identified amongst dental schools. Data were analysed using SPSS software program. Mann-Whitney and Kruskal-Wallis tests were used as appropriate. Logistic regression analysis was also conducted to determine the effect of the studied variables on the stress domains. The level of statistical significance was set at <.05.

RESULTS

Internal consistency of the scale was excellent (0.927). Female students formed the majority of the total student population. The percentage of married students was 4.8%. Numbers of students in pre-clinical and clinical stages were close together. The most stress-provoking domain was "workload" with a score of 2.05 ± 0.56. Female students scored higher stress than male students did in most of the domains. Significant differences were found between participating countries in all stress-provoking domains. Dental students from Egypt scored the highest level of stress whilst dental students from Jordan scored the lowest level of stress.

CONCLUSION

The self-reported stress in the dental environment is still high and the stressors seem to be comparable amongst the participating countries. Effective management programmes are needed to minimise dental environment stress.

Does KRAS mutational status predict chemoresistance in advanced non-small cell lung cancer (NSCLC)?

BACKGROUND

Clinical implications of KRAS mutational status in advanced non-small cell lung cancer (NSCLC) remain unclear. To clarify this point, we retrospectively explored whether KRAS mutations could impact tumor response, and disease control rate (DCR) to first-line platinum-based chemotherapy (CT) as well as progression-free survival (PFS) or overall survival (OS).

METHODS

Between June 2009 and June 2012, 340 patients with advanced (stage IIIB/IV) NSCLC were reviewed in a single institution (Institut Gustave Roussy). Two hundred and one patients had a biomolecular profile and received a platinum-based first-line CT. Patients with an unknown mutational status or with actionable alterations were excluded. We retained two groups: patients with KRAS mutated tumor (MUT) and patients with wild-type KRAS/EGFR (WT). Multivariate analyses with Cox model were used. Survival curves were calculated with Kaplan-Meier method.

RESULTS

One hundred and eight patients were included in the analysis: 39 in the MUT group and 69 in the WT group. Baseline radiological assessment demonstrated more brain (P=0.01) and liver (P=0.04) metastases in MUT patients. DCR was 76% for MUT vs. 91% for WT group (P=0.03), regardless of the type of platinum-based CT (use of pemetrexed or not). Although no statistically significant differences were found, shorter PFS (4.9 vs. 6.0 months; P=0.79) and OS (10.3 vs. 13.2 months; P=0.40) were observed for patients with KRAS mutated tumors in univariate analysis.

CONCLUSIONS

KRAS mutant tumors had a lower DCR after the first-line platinum-based CT, but this difference did not translate in PFS or OS. The presence of KRAS mutations may confer a more aggressive disease, with greater baseline incidence of hepatic and cerebral metastases.

Management of adverse skin reactions to anticancer agents: The Gustave Roussy Institute experience

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Background: Anticancer therapies are associated with various and multiple cutaneous side effects frequently impacting patients’ quality of life and sometimes impairing treatment continuation. Some new skin syndromes and their potential relationship with drug efficacy have been the subject of hundreds of publications over the last few years. Methods: All physicians in our institution were informed by mail about the creation of a weekly consultation and the availability of an emergency call number specifically devoted to the management of adverse cutaneous reactions to anticancer agents. Patients could be referred to us from our institute or from other french institutes. All cutaneous side effects were recorded. Type, severity, and duration of symptoms were described. Imputability of the drugs was evaluated according to semiological, chronological and bibliographical criteria. Results: Over a 4 months period, 215 visits have been performed for a total of 128 patients. 169 events were reported among which 123 were considered to be imputable to the drugs. Several new cutaneous side effects were identified. Hiring a beautician and a pedicure for aesthetic complaints or hand foot skin reactions has been necessary in several cases. Causative agents were mostly targeted therapies (76.4%). Topical (n=132) or systemic treatments (n=45) were prescribed. Temporary dose reduction or treatment interruption was recommended in 18 cases (10.6%). This pilot experience was highly appreciated by both patients and physicians. It was consolidated as a permanent organization at the frontier between oncology and dermatology with the creation of an adapted case report form (CRF). Conclusions: There is a real need for dermatological management of skin side effects in a cancer institute, especially if early trials testing new agents are performed. Dedicated collaboration between oncologists and dermatologists should be promoted as well as the creation of a global skin-oriented CRF in order to facilitate international collaborations and to evaluate the impact of this dermatological management on compliance to treatment.

No significant financial relationships to disclose.

Jaw elevator silent periods in complete denture wearers and dentate individuals

Functional meaning and underlying mechanisms of jaw elevator silent period (SP) have still not been completely understood. Since complete denture wearers (CDWs) have no periodontal receptors in their jaws, the aim was to examine SPs in CDWs and to compare it with dentate individuals (DIs). Thirty six DIs (skeletal/occlusal Class I) and 24 eugnath CDWs participated. EMG signals were registered using the EMGA-1 apparatus from the left and the right side anterior temporalis (ATM) and masseter muscles (MM). Ten registrations of an open-close-clench (OCC) cycle were obtained for each individual. DIs had the average latency between 12.5 and 12.9 ms and always one single short inhibitory pause (IP) with complete inhibition of motoneurons (20.1-21.1 ms). On the other hand, in CDWs various types of SPs emerged: single or single prolonged SPs, double SPs, SPs with three IPs, periods of depressed muscle activity following the first, or the second IP, SPs with relative inhibition of motoneurons or even in several registrations the SP was missing. Unless more than one IP emerged, complete duration of inhibitory pauses (CDIP) was measured. CDIP varied from 37.17 to 42.49 ms. Average latencies were from 16.22 to 16.76 ms. Based on the results of this study it is obvious that both, the duration and the latencies were significantly longer in CDWs than in DIs (p<0.05), which can be explained by different mechanisms responsible for the muscle reflex behaviour.

Differences on breast cancer management and surgical approach in six European breast cancer units

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Background: Paper was aimed to compare differences in pre-operative management, decision on surgery and surgical approach for breast cancer in six European Breast Cancer Units in Italy, France, Czech Republic and Serbia and Montenegro, and to discuss impact of detected differences on outcome of the disease. Methods: The authors of this paper, who have been invited as young visiting/observing/training guests by four prestigious European Breast Cancer Units in Italy and France (National Cancer Institute - Milan, European Institute of Oncology - Milan, Institute Gustave Roussy - Villejuif, Institute Curie - Paris) as fellows of different European and international institutions (EUSOMA, EACR, ESSO, UICC, ESO, FECS, French Government) in the period 2003–2005, tried to detect and compare differences regarding pre-surgical evaluation, decision making and surgical approach for breast cancer as well as to discuss the impact of identified changes on outcome of the disease. The special attention has been directed to inspection of such small details as waiting list for consultation and hospitalisation, way of decision for surgical intervention (individual or oncology meeting/staff), horizontal or oblique incision for mastectomy, duration of hospital stay, sentinel node procedure (blue dye, radioactive tracer or both, one or two-days protocol, imunochistochemistry examinations during frozen section or not), preferred way of breast reconstruction, number of assistants during operation, drainage, preservation of intercostobrachial nerve during axillary surgery, suture, etc. The data were collected according to personal presence in different institutes, observation and asking the questions. Descriptive statistics were used to show the differences among the parameters under comparison. Results: This study which clearly showed a great range of differences, sometimes very significant, in parameters regarding pre-surgical evaluation and surgical treatment of breast cancer. Conclusions: Although being found, and sometimes significant, the observed differences in several parameters regarding pre-operative evaluation and surgical treatment of breast cancer in six European breast cancer units do not have influence to the outcome of the breast cancer.

No significant financial relationships to disclose.

Bond strengths of silicoated and acrylic resin bonding systems to metal

STATEMENT OF PROBLEM

The Kevloc bonding system is based on the bond of acrylic resin with the metal surface, in contrast to the Silicoater system, which covers the metal surface with a SiOx-C layer. Bonding prevents the occurrence of the marginal gap between the metal and the resin, which causes weaker bond strengths and discoloration.

PURPOSE

This investigation examined the bond strength values achieved by using the Kevloc technique on Ag-Pd and Co-Cr alloys, and compared them with those obtained by the Silicoater technique. After artificial aging, shear testing of the specimens was performed.

MATERIAL AND METHODS

A microscope image analyzer measured the thickness of bonding layers to reveal any marginal gap.

RESULTS

No marginal gap was noticed for either technique. The Kevloc technique provided better results than Silicoater regardless of alloy used. Immersion in water (7.64 to 8. 05 MPa) and thermocycling (6.12 to 6.95 MPa) reduced the initial bond strength values (12.52 to 12.94 MPa), but the breakdown occurred between the opaque layers or between the opaque and the resin, thus giving a cohesive type of failure.

CONCLUSION

The dental alloy used did not affect bond strengths and artificial aging caused reduction in bond strengths. The Kevloc bonding system exhibited higher bond strengths than Silicoater, but the marginal gap was not seen for either bonding system.

The bond strength of polymers and metal surfaces using the 'silicoater' technique

The silicoater technique, or silicoating, is a chemical bond system (makes mechanical retentions unnecessary) which prevents the rising of a gap in the margin area between resin and metal. This procedure solves the problems of fracture and detachment of the veneer or its discolourization. The purpose of this investigation was to find out the values of the bond strength achieved by using the silicoater technique on Ag-Pd alloy with smooth surface and with mechanical retentions on the surface. Ninety specimens were divided into groups, subjected to water storage and thermocycling. The values of the bond strength were investigated in combination with this technique with Ag-Pd alloy and three veneer materials. The silicoater technique gave the best results in combination with Dentacolor XS veneer material and mechanical retentions on the surface of the dental alloy.

Bronchial provocation tests before and after cessation of smoking

We studied the effect of smoking cessation on airway reactivity. We recruited cigarette smokers who were attempting to stop smoking. Entry criteria required each subject to be smoking at least 10 cigarettes each day and report a chronic cough. Exclusion criteria included significant airflow obstruction or the presence of any medical condition contraindicating challenge testing. Carbachol challenge was performed to assess airway reactivity according to a standardized method. Baseline measurements of forced expiratory volume in 1 s (FEV1), specific airway conductance (SGaw) and the provocative dose of carbachol causing a 35% reduction in SGaw (PD35), and a 20% reduction in FEV1 (PD20) were established on entry while each subject was still smoking. Thereafter, repeat measurements were performed after 2 and 6 months of smoking cessation. Adherence to smoking cessation was checked by self-report and verified by measurement of alveolar carbon monoxide levels at each session. Of the 34 subjects who gave consent, 13 relapsed prior to the 2nd month and an additional 8 relapsed before the 6th month. Thirteen of the 34 remained abstinent throughout the 6-month study. All 13 subjects had complete resolution of their cough. The difference in reactivity on entry to that at the 2nd and 6th month was not significant. We conclude that (1) the symptom of chronic cough resolved completely after 2 months of smoking cessation, and (2) airway reactivity remained unchanged at 2 and 6 months of smoking cessation.

Can postoperative pulmonary complications after elective cholecystectomy be predicted?

To determine predictors of postoperative morbidity in elective cholecystectomy patients, the authors examined prospectively the consequences of age, sex, active and past smoking, respiratory history, obesity, type of surgical incision, and preoperative pulmonary function, upon the incidence of postoperative pulmonary complications and length of hospitalization. They identified 31 (14.8%) complications in 209 patients; 21 had atelectasis, 8 purulent bronchitis, and 2 pneumonia. These patients averaged 1.5 days longer in the hospital (p less than 0.001 by analysis of variance) than control patients. Abnormal spirometry (MEFV) and the single-breath nitrogen test (SBN2) were significant predictors of postoperative pulmonary complications (p less than 0.001 by discriminant analysis method). Active smoking and history of respiratory disease were associated with abnormal small airway function (p less than 0.001 by chisquare test), but did not predict postoperative morbidity. By analysis of variance, only a reduction in preoperative FVC emerged as predictive of prolonged hospitalization (p less than 0.001). These results were used to determine if the selection of patients by preoperative pulmonary function testing permits more cost-effective administration of respiratory therapy (RT) services. Neither the MEFV nor SBN2 had sufficient specificity to enhance the cost effectiveness of postoperative RT.

Small airway testing and smoking in predicting risk in surgical patients

A prospective study was performed on 185 surgical patients without overt respiratory disease to determine whether three sensitive tests for early airway obstruction or cigarette smoking at the time of hospitalization were useful in identifying the patient at risk for a postoperative pulmonary complication. Subjects were evaluated by questionnaire. Pulmonary function testing consisted of the single breath nitrogen test (SBN2) to determine the closing volume (CV) and slope of the alveolar plateau, and a maximum expiratory flow volume curve (MEFV) to determine expiratory flow at low lung volumes. Fifty-five patients had upper abdominal surgery and 130 a major surgical procedure under general or spinal anesthesia upon another part of the body. Ninety-six (52%) of the 185 patients were smokers. Seventy-nine patients (43%) had one or more abnormal function parameters. The CV was abnormal in 59, alveolar plateau in 18, and MEFV in 12. Fifty-four percent of smokers and 30 percent of nonsmokers had abnormal small airway tests. Sixteen of 185 patients (8.6%) developed a postoperative respiratory complication determined by review of the hospital record. Eleven were in the 96 smokers, but 13 were in the 79 patients with abnormal small airway tests. The incidence was highest (38%) in smokers with an abnormal alveolar plateau who underwent upper abdominal surgery. Identification of the patient at risk was better served by tests of small airway abnormality than by smoking history alone.