Long term activity of vemurafenib in cancers with BRAF mutations: the ACSE basket study for advanced cancers other than BRAFV600-mutated melanoma

BACKGROUND

BRAF inhibitors are approved in BRAFV600-mutated metastatic melanoma, non-small-cell lung cancer (NSCLC), Erdheim-Chester disease (ECD), and thyroid cancer. We report here the efficacy, safety, and long-term results of single-agent vemurafenib given in the AcSé vemurafenib basket study to patients with various BRAF-mutated advanced tumours other than BRAFV600-mutated melanoma and NSCLC.

PATIENTS AND METHODS

Patients with advanced tumours other than BRAFV600E melanoma and progressing after standard treatment were eligible for inclusion in nine cohorts (including a miscellaneous cohort) and received oral vemurafenib 960 mg two times daily. The primary endpoint was the objective response rate (ORR) estimated with a Bayesian design. The secondary outcomes were disease control rate, duration of response, progression-free survival (PFS), overall survival (OS), and vemurafenib safety.

RESULTS

A total of 98 advanced patients with various solid or haematological cancers, 88 with BRAFV600 mutations and 10 with BRAFnonV600 mutations, were included. The median follow-up duration was 47.7 months. The Bayesian estimate of ORR was 89.7% in hairy cell leukaemias (HCLs), 33.3% in the glioblastomas cohort, 18.2% in cholangiocarcinomas, 80.0% in ECD, 50.0% in ovarian cancers, 50.0% in xanthoastrocytomas, 66.7% in gangliogliomas, and 60.0% in sarcomas. The median PFS of the whole series was 8.8 months. The 12-, 24-, and 36-month PFS rates were 42.2%, 23.8%, and 17.9%, respectively. Overall, 54 patients died with a median OS of 25.9 months, with a projected 4-year OS of 40%. Adverse events were similar to those previously reported with vemurafenib.

CONCLUSION

Responses and prolonged PFS were observed in many tumours with BRAF mutations, including HCL, ECD, ovarian carcinoma, gliomas, ganglioglioma, and sarcomas. Although not all cancer types responded, vemurafenib is an agnostic oncogene therapy of cancers.

POS1379 HYPERMETABOLIC BONE SARCOIDOSIS ON 18F-FDG PET-CT: IMPACT ON TREATMENT AND DISEASE RELAPSE IN A COHORT OF 165 PATIENTS FROM A SINGLE UNIVERSITY HOSPITAL

Background

Sarcoidosis is a multisystemic granulomatosis of unknown cause. Prevalence of bone sarcoidosis is estimated between 3 and 30%. Bone sarcoidosis is symptomatic in about half of the cases. 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) is a useful imaging modality in sarcoidosis, to search for a biopsiable site, evaluate organ involvement or assess disease activity. It is a sensitive imaging modality to detect bone involvement. However, clinical and prognostic significance of hypermetabolic bone involvement of sarcoidosis is not well known.

Objectives

The aim of this study was to compare the characteristics of patients with and without hypermetabolic bone involvement of sarcoidosis and to evaluate the impact of metabolic bone involvement on treatments and outcomes.

Methods

This was an observational, comparative, retrospective monocentric study of prospectively collected data. Inclusion criteria were a diagnosis of sarcoidosis according to the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) criteria and at least one 18F-FDG PET-CT during follow-up. Metabolic bone involvement of sarcoidosis was defined as bone hypermetabolism for which alternative causes had been reasonably excluded, following the WASOG criteria of « at least probable » bone sarcoidosis. Characteristics of patients with and without bone involvement were compared using bilateral Fisher or Mann-Whitney tests. Relapse-free survival curves were constructed following the Kaplan-Meier method and compared using a log-rank test. A p-value < 0.05 was considered significant.

Results

Among 503 patients with sarcoidosis, 165 with definite sarcoidosis who had undergone at least one 18F-FDG PET-CT were included. Fourteen patients had positive bone PET-CT findings which were attributed to other cause than sarcoidosis. Metabolic bone involvement of sarcoidosis was found in 29 patients (18%), among which 9 (31%) had structural bone lesions on CT. Metabolic bone involvement of sarcoidosis was associated with more frequent intrathoracic lymph node involvement (28 [96%] and 107 [79%], p < 0.001), extrathoracic lymph node involvement (15 [52%] and 40 [30%], p = 0.03) and a higher number of organ involvements (median [interquartile range], 6 [4-7] and 4 [2-5], p < 0.001). Patients with metabolic bone involvement received more frequently corticosteroids (29 [100%] and 99 [73%], p < 0.001), methotrexate (26 [90%] and 66 [48%], p < 0.001), tumor necrosis factor (TNF) alpha inhibitors (22 [76%] and 41 [30%], p < 0.001), and a higher number of treatments (3 [3-4] and 2 [1-3], p < 0.001). Despite more intensive treatments, disease relapse occurred significantly sooner in patients with metabolic bone involvement of sarcoidosis (median time to the first relapse, 63 [44-84] months and 96 [72-156] months respectively, p = 0.01).

Conclusion

Metabolic bone involvement on PET-CT was present in 18% of patients with sarcoidosis. It was predominantly axial and without structural lesions. In this comparative study, patients with metabolic bone involvement received significantly more treatments and had a shorter time to relapse. It could therefore reflect a more severe multisystemic involvement and chronic evolution of the disease. This could help adjust individual therapeutic strategy for patients with sarcoidosis.

References

[1]Challenges of Sarcoidosis and Its Management. Drent M, Crouser ED, Grunewald J. N Engl J Med. 2021 Sep 9;385(11):1018-1032.

[2]Clinical Presentation and Treatment of High-Risk Sarcoidosis. Perlman DM, Sudheendra MT, Furuya Y, Shenoy C, Kalra R, Roukoz H, Markowitz J, Maier LA, Bhargava M. Ann Am Thorac Soc. 2021 Sep 15. doi: 10.1513/AnnalsATS.202102- 212CME

Figure 1.

Disclosure of Interests

None declared

Évolution clinique et facteurs de risque de développer une forme grave de la maladie à coronavirus 2019 (COVID-19) chez les patients atteints de lupus systémique

Introduction

Matériels et méthodes

Résultats

Conclusion

AB0323 INTIMA-MEDIA THICKNESS IS INDEPENDENTLY ASSOCIATED WITH STROKE IN PRIMARY ANTIPHOSPHOLIPID SYNDROME

Background:

Compared to secondary antiphospholipid syndrome (APS), little is known on intima-media thickness (IMT) in primary APS. Previous reports suggest that intima-media thickness may be associated with anti-cardiolipin antibodies, anti-β2-glycoprotein-1 antibodies, and with stroke in APS1.

Objectives:

To assess clinical significance of intima-media thickness in primary APS.

Methods:

We have included 29 patients with primary APS (defined according to international consensus criteria) seen, at least once, in our tertiary center for a cardiovascular risk assessment from April 2014 to November 2018.

Results:

29 patients were included (females 83%). Mean (SD) age at evaluation was 48 years (16.1). Mean APS duration before assessment was 9.1 years (6.2). 27 patients had thrombotic APS (93%), among which 13 (45%) had a history of arterial thrombosis (12 strokes and 1 myocardial infarction) and 16 (55%) of venous thrombosis. Obstetrical APS was present in 7 patients (24%). Positive APL antibodies were: anti-cardiolipin antibodies (aCL) n = 15 (54%), anti-β2-glycoprotein I (anti-β2GP1) n = 10 (36%), lupus-anticoagulant (LAC) n = 11 (39%) and anti-phospholipid antibodies (aPL) n = 19 (68%). Mean IgG levels (GPL) were 52.4 (80.3) UGPL, 52.2 (124) UI, 39.2 (40.5) UGPL for aCL anti-βG2P1, and aPL, respectively. 6 patients (21%) were simple positive, 3 (11%) were double positive, and 10 (36%) were triple positive.

Cardiovascular risk factors were: smoking n = 6 patients (21%), overweight n = 11 (39%), hypercholesterolemia n = 12 (43%), arterial hypertension n = 11 (38%), chronic kidney disease (defined by estimated glomerular filtration rate < 60 mL/mn) n = 5 (17%). No patient had diabetes mellitus. Median risk SCORE was 0.65 (0-2.4). Male sex, obesity, chronic kidney disease and risk SCORE were significantly more frequent in patients with arterial APS compared to patients with venous and/or obstetrical APS (38% vs 0%, P=0.01; 33% vs 0%, P=0.02; 38% vs 0%, P=0.01; 2.3 vs 0.7, P=0.03).

22 patients (76%) underwent an IMT measurement. Mean IMT was 0.57 (0.14) millimeters (mm). Median IMT was significantly higher in APS patient with stroke than in those without (0.63 IQR (0.55-0.77) mm versus 0.51 (0.44-0.55) mm, P=0.02) (Figure 1A). IMT was neither correlated with duration of APS nor with antibody titers.

Variables associated with IMT were studied on uni- and multivariate analysis (Table 1). On univariate analysis, age, aCL positivity and stroke were significantly associated with IMT and were included in the multivariate analysis. On multivariate analysis, there was a positive, independent and significant association between IMT and stroke (P=0.047) and between IMT and age (P=0.024). aCL positivity was not associated with IMT on multivariate analysis (Figure 1B).

Conclusion:

Intima-media thickness is independently associated with stroke in primary antiphospholipid antibody syndrome.

References:

[1]Medina G. Increased carotid artery intima-media thickness may be associated with stroke in primary antiphospholipid syndrome. Ann Rheum Dis. 2003;62(7):607-610. doi:10.1136/ard.62.7.607

Characters from table content including title and footnotes.

Table 1.

Predictors of intima-media thickness on uni- and multivariate analysis.

Univariate analysisMultivariate analysis*βP-valueβP-valueAge (years)0.006<0.0010.0040.024Female sex-0.1020.18APS duration (years)0.00040.31Smoker-0.050.61Overweight0.0660.39Arterial hypertension0.0470.48Hypercholesterolemia0.054290.412Anti-cardiolipin antibodies0.120.050.0840.076Anti-phospholipid antibodies0.0540.44Anti-β2GP10.0940.15Lupus-anticoagulant0.0440.49Anticoagulation-0.070.31Stroke0.1390.020.0990.047

β Linear regression coefficients

APS Antiphospholipid antibody syndrome

* Variables with a P-value <0.1 on univariate analysis were included

Figure 1.

A.Intima-media thickness according to stroke statusB.Multivariate analysis forest-plot of intima-media thickness predictorsOR Odds-ratioaCL anti-cardiolipin antibodies

Disclosure of Interests:

None declared

MRI features of intra-axial histiocytic brain mass lesions

AIM

To describe MRI features, including diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS), and perfusion-weighted imaging (PWI), of intra-axial tumour-like presentations of four different subtypes of histiocytosis.

MATERIAL AND METHODS

The brain MRI findings of 23 patients with histologically proven histiocytosis were reviewed retrospectively (11 Langerhans cell histiocytosis [LCH], eight Erdheim-Chester disease [ECD], one overlap form LCH/ECD, two Rosai-Dorfman disease [RDD], and one haemophagocytic lymphohistiocytosis [HLH]) with single or multiple enhancing intraparenchymal brain lesions.

RESULTS

Histiocytic brain mass lesions show some similar MRI features including Supra and/or infratentorial and/or paraventricular subcortical well-delineated masses, linear ependymal enhancement along the ventricles and brain stem lesions. Masses always present with mixed hyper- and hypointense signal on T2-weighted imaging (WI). Their enhancement is often homogeneous. Apparent diffusion coefficient (ADC) values are often normal or elevated.

CONCLUSION

The presence of multiple periventricular and subcortical enhancing lesions with mixed signal intensity on T2WI and normal or high ADC values should lead radiologists to consider the diagnosis of histiocytic lesions and search for associated systemic lesions.

[Infection associated cerebral vasculitis]

Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.

Drug-induced sarcoidosis: an overview of the WHO pharmacovigilance database

BACKGROUND

There is a documented association between drug exposure and sarcoidosis-like reactions. In this study, we used the largest pharmacovigilance database to describe drug-induced sarcoidosis.

METHODS

Data were collected from the World Health Organization (WHO) pharmacovigilance database (VigiBase). We excluded steroids and vaccines from the analysis. The primary end-point was the lower end-point of the 95% credibility interval for the information component (IC₀₂₅ ).

RESULTS

A total of 127 reports had significant IC₀₂₅ values for drug-induced sarcoidosis, and 110 were included in the final analysis, accounting for 2425 adverse drug reactions. Overall, 2074 (85.5%) reactions were considered 'serious' and 86 (3.5%) were fatal. Most of the drugs that led to sarcoidosis adverse reactions were TNF-alpha antagonists, interferon or peg-interferon therapeutics, and immune checkpoint inhibitors. Other biologic drugs were less frequently associated with sarcoidosis adverse events. Cancer-targeted therapies such as BRAF or MEK inhibitors were associated with sarcoidosis reactions in 37 cases. Pulmonary hypertension drugs were also reported for drug-induced sarcoidosis. Amongst the 55 drugs considered as potential sarcoidosis inducers, 25 (45.4%) were never reported in Medline as drug-induced sarcoidosis.

CONCLUSIONS

We provide a detailed list of suspected drugs associated with drug-induced sarcoidosis that will improve the recognition of this drug-induced adverse event.

AB1056 SYMPTOMATIC SCLEROSING MESENTERITIS REVEALING ERDHEIM-CHESTER DISEASE: A RARE CONDITION MEDIATED BY BRAF

Background:

Sclerosing Mesenteritis (SM) refers to an entire spectrum of digestive inflammatory disorders. Diagnosis is based on imaging showing an increase of fat attenuation displacing bowel loops and is in most cases non-symptomatic. Several conditions (abdominal trauma/surgery, neoplasia, infectious and inflammatory diseases) are responsible for SM (1). Among neoplasia, Erdheim-Chester disease (ECD) is a rare clonal histiocytosis characterized by long bone involvement, peri-nephric fat infiltration and cardio-vascular involvement associated with compatible histology (2). Biopsy is mandatory to confirm tissue infiltration by histiocytes and detect somatic mutation. Almost 80% of ECDpatients harbor mutation in mitogen activated protein(MAP) kinase pathway especiallyBRAFV600Egene mutation in about 60% of cases(3). No series of patients presenting both pathologies has been reported. Furthermore, no correlation withBRAFmutation status has been described in patient harboring SM and ECD.

Objectives:

To describe the clinical, radiological and mutational status of patients harboring SM and ECD.

Methods:

We reviewed the database of patients with histiocytic disorders in Besancon University Hospital. Patient required one abdominal computed tomography showing sclerosing mesenteritis and clinical/histological features of ECD to fulfill the inclusion criteria. All biopsy samples were investigated for mutation ofMAPkinase pathway gene.

Results:

Four patients suffered from SM and ECD. The median age at the diagnosis of ECD was 68 years old (61-72). All patients described abdominal pain and the mean duration between first symptoms and diagnosis of ECD was 12 months (4-19). The mean CRP level at diagnosis was 40.75 mg/L (5-117). Two patients were found to have myeloid neoplasms (chronic myelomonocytic leukemia (#2) and essential thrombocythemia (#4)) concurrent with ECD diagnosis.

Regarding abdominal computed tomography, all patients had a mesenteric mass associated with hyper-attenuated mesenteric fat and a “fat halo sign”. One patient (#2) had ascites and one had splenomegaly (#4) but no patient had enlarged lymph nodes. CT also demonstrated peri-nephric fat infiltration (“hairy kidney”) (4/4), vascular sheathing of aortic branches (3/4), adrenal hypertrophy (1/4) or ureter dilation (1/4). The mean SUVmaxof the mesentery was 7.5 (4.1-10.9) at diagnosis on (18F)- fluorodeoxyglucose-PET. Three patients underwent mesentery fat biopsy and all samples exhibited ECD histology. Regarding mutational status, 75% (3/4) patients hadBRAFV600Emutation.

After initiation of therapies for ECD (targeted therapies for ¾ patients), all patients had improvement of digestive symptoms and decreased of SUVmaxon evaluation18FDG-PET during the follow up.

Conclusion:

ECD should be investigated in patient with symptomatic SM especially if it is associated with peri-nephric fat infiltration. This condition is rare and might be driven by BRAF gene.

TABLE 2.Full term pregnancyMultiple gestationPreconception CZP exposureLabor complicationsMaternal infectionsNeonatal infections (< 6 m after birth)Congenital malformationsBreast-feedingNeonates, n/N15/152/155/150/151/150/150/156/15

References:

[1]Danford CJ, Lin SC, Wolf JL. Sclerosing Mesenteritis. Am J Gastroenterol. 2019 Jun;114(6):867–73.

[2]Diamond EL, Dagna L, Hyman DM, Cavalli G, Janku F, Estrada-Veras J, et al. Consensus guidelines for the diagnosis and clinical management of Erdheim-Chester disease. Blood. 2014 Jul 24;124(4):483–92.

[3]Haroche J, Cohen-Aubart F, Rollins BJ, Donadieu J, Charlotte F, Idbaih A, et al. Histiocytoses: emerging neoplasia behind inflammation. Lancet Oncol. 2017 Feb;18(2):e113–25.

Disclosure of Interests:

None declared

AB0038 IMMUNE PHENOTYPING OF ERDHEIM-CHESTER DISEASE THROUGH MASS CYTOMETRY

Background:

The understanding of Erdheim-Chester Disease (ECD) pathogenesis has been greatly improved these past few years with the discovery of activating MAPK pathway mutations in most of ECD patients. However, the inflammatory phenotype of ECD remains widely unknown.

Objectives:

We aimed to explore the inflammatory phenotype of Erdheim-Chester disease (ECD) using mass cytometry.

Methods:

We analyzed peripheral blood mononuclear cells from 13 ECD patients and 11 healthy donors (HD) using mass cytometry with 29 metal-conjugated antibodies.

Results:

Compared to HD, untreated ECD patients had increased proportion of classical monocytes (90.8 [87.1-96.5] vs 81.6 [76.2-87.5] %, p=0.02) and decreased proportion of non-classical monocytes (4.7 [3.4-9.7] vs 11.8 [6.6-17.2] %, p=0.047). Untreated ECD patients had more circulating Th17 cells compared to HD (3.3 [3-5.3] vs 1.3 [0.4-2.3] %, p=0.015) and ECD patients treated with BRAF or MEK inhibitors (3.3 (3-5.3] vs 1.9 [0.6-2.4] %, p=0.005). Moreover Treg cells were lower in ECD patients than HD, with an increased Th17/Treg ratio (1.37 [0.74-1.9] vs 0.34 [0.19-0.43], p=0.0004). There was no difference regarding Th1 cells, Th2 cells, B cells, NK cells and circulating dendritic cells.

Conclusion:

ECD monocyte profile seems similar to what have been described in CMML. Inflammation observed in ECD may be driven through Th17 cells, and might be targeted with specific treatment.

Disclosure of Interests:

None declared

[Use of targeting therapy in Erdheim-Chester disease: A case report with neurologic involvement]

INTRODUCTION

Erdheim-Chester disease (ECD) is a rare multisystemic disease characterised by an infiltration of various organs by CD68⁺ CD1a^- histiocytes. The clinical and radiological presentation is very variable.

CASE REPORT

We report the case of a 71-year-old woman with ECD which was revealed by neurological and cutaneous manifestations. The diagnosis was confirmed by skin biopsy and the BRAFV600E mutation was identified in skin tissue, leading to the use of combined therapy targeting the RAS-RAF-ERK-MEK pathway. This therapy allowed an improvement of cutaneous manifestations but neurological manifestations lead to death, underlying their notable severity.

CONCLUSION

Our case report shows the persistent diagnostic difficulty of the ECD and the particular gravity of neurologic involvement.

The cerebrospinal fluid CD4/CD8 ratio and interleukin-6 and -10 levels in neurosarcoidosis: a multicenter, pragmatic, comparative study

BACKGROUND AND PURPOSE

Neurosarcoidosis is a rare inflammatory disorder of unknown cause. The aim of this study was to evaluate the value of T/B lymphocyte population counts and the concentrations of the cytokines interleukin (IL) 6 and IL-10 in the cerebrospinal fluid (CSF) of neurosarcoidosis patients.

METHODS

A retrospective study CSF biomarkers was conducted in patients with neurosarcoidosis who underwent CSF analysis between 2012 and 2017 as well as various control populations.

RESULTS

Forty-three patients with neurosarcoidosis, 14 with multiple sclerosis (MS) and 48 with other inflammatory disorders were analyzed. The CSF IL-6 levels were higher in sarcoidosis patients than in MS patients (median 8 vs. 3 pg/ml, P = 0.006). The CSF CD4/CD8 ratio was higher in sarcoidosis patients than in MS patients and in patients with other inflammatory disorders (median 3.18 vs. 2.36 and 2.10, respectively, P = 0.008). The CSF IL-6 level was higher in patients with active neurosarcoidosis than in non-active neurosarcoidosis patients (median 13 vs. 3 pg/ml, P = 0.0005). In patients with neurosarcoidosis, a CSF IL-6 concentration >50 pg/ml was associated with a higher risk of relapse or progression-free survival (hazard ratio 3.60; 95% confidence interval 1.78-23.14). A refractory neurosarcoidosis patient was treated with an anti-IL-6 monoclonal antibody that produced a complete neurological response.

CONCLUSIONS

The CSF CD4/CD8 ratio and IL-6 concentration are increased in neurosarcoidosis compared to MS and other inflammatory disorders. A CSF IL-6 concentration >50 pg/ml is associated with relapse or progression of neurosarcoidosis. IL-10 levels may be elevated in neurosarcoidosis.

[Rosai-Dorfman disease: Diagnosis and therapeutic challenges]

Rosai-Dorfman disease (RDD) was first described by the French pathologist Paul Destombes in 1965. It frequently affects children or young adults and is characterized by the presence of large histiocytes with emperipolesis. More than 50 years after this first description, the pathogenesis of this rare disease is still poorly understood. The revised classification of histiocytoses published in 2016 identified various forms of RDD, from familial RDD to IgG4-associated RDD. Almost 90% of the patients with RDD have cervical lymph nodes involvement although all the organs may virtually be involved. Outcomes are typically favorable. Treatments may be necessary in case of compression or obstruction, and are not well codified. The main therapeutic strategies rely on surgery, radiotherapy, steroids, immunosuppressive drugs or interferon-alpha and cladribine.

[Sarcoidosis flare after autologous stem cell transplantation: An immune paradox?]

INTRODUCTION

Sarcoidosis is a systemic granulomatous disorder of unknown cause. Apparition or flare of previously diagnosed sarcoidosis following hematopoietic stem cell transplantation (HSCT) has rarely been reported.

OBSERVATION

We report a 62-year-old woman who presented a radiological flare of sarcoidosis post-autologous stem cell transplantation for a POEMS syndrome. Imaging findings and lymph node histology, which revealed non-caseating granuloma, were consistent with the sarcoidosis diagnosis. The patient was asymptomatic and was kept free of treatment.

CONCLUSION

Sarcoidosis must be considered ahead of compatible clinicoradiological presentation occurring after HSCT. Sarcoidosis can mimic metastatic cancer or lymphatic relapse. Tissue biopsies and exclusion of differential diagnosis of granuloma diseases are warranted to confirm sarcoidosis diagnosis.