Advanced renal cell carcinoma management: the Latin American Cooperative Oncology Group (LACOG) and the Latin American Renal Cancer Group (LARCG) consensus update

PURPOSE

Renal cell carcinoma is an aggressive disease with a high mortality rate. Management has drastically changed with the new era of immunotherapy, and novel strategies are being developed; however, identifying systemic treatments is still challenging. This paper presents an update of the expert panel consensus from the Latin American Cooperative Oncology Group and the Latin American Renal Cancer Group on advanced renal cell carcinoma management in Brazil.

METHODS

A panel of 34 oncologists and experts in renal cell carcinoma discussed and voted on the best options for managing advanced disease in Brazil, including systemic treatment of early and metastatic renal cell carcinoma as well as nonclear cell tumours. The results were compared with the literature and graded according to the level of evidence.

RESULTS

Adjuvant treatments benefit patients with a high risk of recurrence after surgery, and the agents used are pembrolizumab and sunitinib, with a preference for pembrolizumab. Neoadjuvant treatment is exceptional, even in initially unresectable cases. First-line treatment is mainly based on tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs); the choice of treatment is based on the International Metastatic Database Consortium (IMCD) risk score. Patients at favourable risk receive ICIs in combination with TKIs. Patients classified as intermediate or poor risk receive ICIs, without preference for ICI + ICIs or ICI + TKIs. Data on nonclear cell renal cancer treatment are limited. Active surveillance has a place in treating favourable-risk patients. Either denosumab or zoledronic acid can be used for treating metastatic bone disease.

CONCLUSION

Immunotherapy and targeted therapy are the standards of care for advanced disease. The utilization and sequencing of these therapeutic agents hinge upon individual risk scores and responses to previous treatments. This consensus reflects a commitment to informed decision-making, drawn from professional expertise and evidence in the medical literature.

Computed tomography on lung cancer screening is useful for adjuvant comorbidity diagnosis in developing countries

Purpose

The aim of this study was to analyse and quantify the prevalence of six comorbidities from lung cancer screening (LCS) on computed tomography (CT) scans of patients from developing countries.

Methods

For this retrospective study, low-dose CT scans (n=775) were examined from patients who underwent LCS in a tertiary hospital between 2016 and 2020. An age- and sex-matched control group was obtained for comparison (n=370). Using the software, coronary artery calcification (CAC), the skeletal muscle area, interstitial lung abnormalities, emphysema, osteoporosis and hepatic steatosis were accessed. Clinical characteristics of each participant were identified. A t-test and Chi-squared test were used to examine differences between these values. Interclass correlation coefficients (ICCs) and interobserver agreement (assessed by calculating kappa coefficients) were calculated to assess the correlation of measures interpreted by two observers. p-values <0.05 were considered significant.

Results

One or more comorbidities were identified in 86.6% of the patients and in 40% of the controls. The most prevalent comorbidity was osteoporosis, present in 44.2% of patients and in 24.8% of controls. New diagnoses of cardiovascular disease, emphysema and osteoporosis were made in 25%, 7% and 46% of cases, respectively. The kappa coefficient for CAC was 0.906 (p<0.001). ICCs for measures of liver, spleen and bone density were 0.88, 0.93 and 0.96, respectively (p<0.001).

Conclusions

CT data acquired during LCS led to the identification of previously undiagnosed comorbidities. The LCS is useful to facilitate comorbidity diagnosis in developing countries, providing opportunities for its prevention and treatment.

Lung cancer screening is useful to facilitate comorbidity diagnosis in developing countries, providing opportunities for its prevention and treatmenthttps://bit.ly/3KEdGuW

PF-06439535 (a Bevacizumab Biosimilar) Compared with Reference Bevacizumab (Avastin®), Both Plus Paclitaxel and Carboplatin, as First-Line Treatment for Advanced Non-Squamous Non-Small-Cell Lung Cancer: A Randomized, Double-Blind Study

BACKGROUND

PF-06439535 is a bevacizumab biosimilar. We aimed to compare the efficacy and safety of PF-06439535 with that of reference bevacizumab (Avastin®) sourced from the EU (bevacizumab-EU), each with paclitaxel and carboplatin, in the first-line treatment of advanced non-squamous non-small-cell lung cancer (NSCLC).

METHODS

In this double-blind, parallel-group study, we recruited patients from 159 centers in 27 countries. Participants were randomized 1:1 to receive PF-06439535 plus paclitaxel and carboplatin or bevacizumab-EU plus paclitaxel and carboplatin on day 1 of each 21-day cycle for 4-6 cycles, followed by blinded monotherapy with PF-06439535 or bevacizumab-EU until disease progression, unacceptable toxicity, withdrawal of consent, or the end of the study. Randomization was stratified by region, sex, and smoking history. The primary endpoint was objective response rate (ORR) in accordance with RECIST 1.1, based on responses achieved by week 19 and confirmed by week 25.

RESULTS

Between 21 May 2015 and 14 November 2016, 719 patients were randomized to the PF-06439535 group (n = 358) or the bevacizumab-EU group (n = 361). As of data cutoff for analysis of the primary endpoint (8 May 2017), 45.3% (95% confidence interval [CI] 40.01-50.57) of patients in the PF-06439535 group and 44.6% (95% CI 39.40-49.89) of patients in the bevacizumab-EU group achieved an objective response by week 19 that was confirmed by week 25. The unstratified ORR risk ratio was 1.015 (95% CI 0.863-1.193; 90% CI 0.886-1.163), and the unstratified ORR risk difference was 0.653% (95% CI - 6.608 to 7.908); all three CIs fell within pre-specified equivalence margins. Using final data after study completion (22 December 2017), no notable differences in progression-free survival or overall survival were observed between the groups. The most frequently reported grade 3 or higher treatment-emergent adverse events were hypertension, neutropenia, and anemia. There were no clinically meaningful differences in safety, pharmacokinetics, or immunogenicity across treatment groups.

CONCLUSION

Among patients with advanced non-squamous NSCLC, PF-06439535 demonstrated similarity to bevacizumab-EU in terms of efficacy. Safety profiles for the two treatments were comparable.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02364999.

FUNDING

Pfizer.

Pemetrexed in advanced non-small cell lung cancer: A randomized trial of 500 mg/m2 vs 900 mg/m2 in 588 patients who progressed after platinum-containing chemotherapy

LBA7727

Introduction: The mild toxicity profile of pemetrexed (P), seen in a phase III trial of P 500 mg/m2 vs docetaxel 75 mg/m2 in vitamin-supplemented patients (pts), suggests higher doses of P can be given in pts with previously treated advanced non-small cell lung cancer (NSCLC) without significant toxicity. We conducted a phase III trial to determine if a higher dose of P (900 mg/m2) could improve survival vs the standard P dose in pts with NSCLC. Methods: Pts with stage III/IV NSCLC, previously treated with platinum-based chemotherapy, were randomized to P 500 or 900 mg/m2 iv q3week. After the second planned interim analysis, the Data Safety Monitoring Board recommended discontinuation of enrollment due to low probability of demonstrating a survival advantage and a greater incidence of some toxicities on the P 900 arm. Patients were allowed to continue treatment at the P 500 dose. Results: 588 randomized pts were evaluated for efficacy and 581 pts, who received =1 dose, for safety. Safety data for pts who transitioned from P 900 to P 500 were analyzed separately. The treatment arms were balanced regarding baseline characteristics and prior treatment. Both arms had: ∼67% males, median age 62 yrs, 87% pts with an ECOG PS of 0 or 1, and 77% pts with stage IV disease. Key results are shown in the table . There was no statistical difference between arms for any efficacy measure. In general, the incidence of adverse events (AEs) was comparable or numerically higher in the P 900 arm. Some AEs (all grades) reported a >5% difference between the P 900 (N=240) and P 500 arms: fatigue (41.7% vs 32.8%), anemia (32.9% vs 22.1%), vomiting (20.0% vs 13.1%), stomatitis (17.9% vs 10.0%), diarrhea (15.4% vs 10.0%), and thrombocytopenia (11.3% vs 5.5%). Conclusion: P 900 offers no advantage over P 500 mg/m2 as second-line therapy for pts with advanced NSCLC. Certain toxicities were somewhat more pronounced in the P 900 group.

No significant financial relationships to disclose.

[Table: see text]

Herpes simplex virus type 2 and Chlamydia trachomatis in adenocarcinoma of the uterine cervix

INTRODUCTION

Adenocarcinoma of the uterine cervix (AC) occurs in 15-20% of primary cervical neoplasias. Although some etiologic factors for squamous cell carcinoma are well defined, and its relationship with sexually transmitted disease as human papillomavirus (HPV) is established, we still do not know about the causative factors of most of AC besides HPV infection.

OBJECTIVES

To determine the presence of herpes simplex virus type 2 (HSV-2) and Chlamydia trachomatis (CT) DNA in AC specimens, and its correlation with HPV infection.

METHODS

206 paraffin-embedded cases of AC were selected to DNA extraction. The specimens and the DNA were isolated. Samples were first screened for beta-globin DNA sequences, and 67 cases were considered adequate to further analysis. In a previous analysis, DNA of HPV was identified in 79.4% of specimens included in this series (51% HPV 18 and 34% HPV 16). The local ethical committee approved the study.

RESULTS

All samples were negative for HSV-2 DNA and CT DNA.

CONCLUSIONS

In our series HSV-2 DNA and CT DNA were not found to be integrated to the genome of adenocarcinoma of the uterine cervix and do not seem to be a co-factor for HPV on the etiology of this histologic subtype.

Herpes simplex virus 2 (HSV-2) is not a co-factor of human papillomavirus (HPV) in adenocarcinoma of the uterine cervix (AUC)

5048

Background: Cervical cancer is an important public health problem worldwide. Following skin and breast carcinoma, cervical cancer is the third most common cancer among Brazilian women, ranking first in some developing countries. AUC occurs in 15–20% of primary cervical neoplasias. Although some etiologic factors for squamous cell carcinoma are well defined, and its relationship with sexually transmitted disease as HPV is established, we still don’t know about the causative factors of most of AUC. The objective of this abstract is to determine the presence of HSV-2 DNA in AUC specimens, and its correlation with HPV infection. Methods: From 1995 to 2003, 229 cases of AUC were diagnosed in a hospital from Brazil. Data was collected retrospectively from medical records. The local ethical committee approved the study. Paraffin embedded tissue was selected and DNA extraction was performed. Samples were first screened for betaglobin DNA sequences. To detect HSV-2 DNA using polymerase chain reaction, a pair of primers that bracket 391 base pair segment of DNA polymerase gene was used as described by Madhavan et al. (2003). The sequences are an upstream primer HSV-5’-ATG GTG AAC ATC GAC ATG TAC GG-3’ and one type specific downstream primer HSV-2–5’- CCT CCT TGT CGA GGC CCC GAA AC-3’ (Invitrogen Custom Primers, Sao Paulo, Brazil). The reaction conditions contained 1microlitre sample DNA. The thermal profile consisted of denaturation 94° for 2” followed by 40 cycles with 45’ of denaturation (94°), annealing (60°) and extension (72°). Analysis with agarose gel electrophoresis with ethidium bromide staining was performed. HSV-2 positive sample was used as control. Results: In our series, patient’s mean age was 53.2 years (from 21 to 94), most of them were multiparous (60.6%) and 42% never used any kind of anticontraception method. In 79.4% of specimes DNA of HPV was identified (51% HPV 18 and 34% HPV 16). All samples were negative for DNA of HVS-2. Conclusion: Although some epidemiologic studies reported an interaction between HPV and HSV-2 in increasing cervical cancer risk, in our series HSV-2 is not found integrated to human genome of adenocarcinoma of the uterine cervix and does not seems to be a co-factor of HPV on the etiology of this cancer subtype.

No significant financial relationships to disclose.

p53 and Bcl-2 Protein Expression and Its Relationship with Prognosis in Small-Cell Lung Cancer

Small-cell lung cancer (SCLC) has a poor prognosis despite good initial response to chemotherapy. Therefore, it is important to identify molecular markers that might influence survival and serve as potential therapeutic targets. Previous studies have demonstrated immunohistochemical expression of p53 and Bcl-2 in approximately 40%-90% and 55%-90% of patients with SCLC, respectively, but its relationship with prognosis remains controversial. To determine the correlation between the expression of p53 and Bcl-2 and disease-free survival, age (< 70 vs. >or= 70 years), sex, clinical stage (limited vs. extensive), performance status (World Health Organization stages 0-4), and weight loss (10% of body weight), we retrospectively studied 58 SCLC parafin sections of transbronchial biopsy specimens immunostained using monoclonal antibody against N-terminus of the human p53 protein and monoclonal antibody against Bcl-2 oncoprotein. p53 and Bcl-2 expression were observed in 41% and 57% of patients, respectively. p53 and Bcl-2 expression were not correlated with disease-free survival. There was also no correlation of p53 and Bcl-2 expression with age, sex, weight loss, and performance status. There was a significant correlation of p53 (P < 0.001) and Bcl-2 (P < 0.045) expressions with limited-stage disease.