Clinical and biomarker results from a phase II trial of combined cabozantinib and durvalumab in patients with chemotherapy-refractory colorectal cancer (CRC): CAMILLA CRC cohort

CAMILLA is a basket trial (NCT03539822) evaluating cabozantinib plus the ICI durvalumab in chemorefractory gastrointestinal cancer. Herein, are the phase II colorectal cohort results. 29 patients were evaluable. 100% had confirmed pMMR/MSS tumors. Primary endpoint was met with ORR of 27.6% (95% CI 12.7-47.2%). Secondary endpoints of 4-month PFS rate was 44.83% (95% CI 26.5-64.3%); and median OS was 9.1 months (95% CI 5.8-20.2). Grade≥3 TRAE occurred in 39%. In post-hoc analysis of patients with RAS wild type tumors, ORR was 50% and median PFS and OS were 6.3 and 21.5 months respectively. Exploratory spatial transcriptomic profiling of pretreatment tumors showed upregulation of VEGF and MET signaling, increased extracellular matrix activity and preexisting anti-tumor immune responses coexisting with immune suppressive features like T cell migration barriers in responders versus non-responders. Cabozantinib plus durvalumab demonstrated anti-tumor activity, manageable toxicity, and have led to the activation of the phase III STELLAR-303 trial.

Cabozantinib plus durvalumab in advanced gastroesophageal cancer and other gastrointestinal malignancies: Phase Ib CAMILLA trial results

This is the phase Ib part of the phase I/II CAMILLA trial evaluating cabozantinib plus durvalumab in advanced chemo-refractory proficient mismatch repair or microsatellite stable (pMMR/MSS) gastrointestinal malignancies including gastric/gastroesophageal junction/esophageal (G/GEJ/E) adenocarcinoma, colorectal cancer (CRC), and hepatocellular carcinoma (HCC). Thirty-five patients are enrolled. There are no observed dose-limiting toxicities during dose escalation. The overall grade 3/4 treatment-related adverse event rate is 34%. Among evaluable patients (n = 30), the objective response rate (ORR) is 30%, disease control rate (DCR) 83.3%, 6-month progression-free survival (PFS) 36.7%, median PFS 4.5 months, and median overall survival (OS) 8.7 months. Responses are seen in 4 of 17, 3 of 10, and 2 of 3 patients with CRC, G/GEJ/E adenocarcinoma, and HCC, respectively. Participants with a PD-L1 combined positive score (CPS) ≥5 have numerically higher ORR, PFS, and OS. Cabozantinib plus durvalumab demonstrates a tolerable safety profile and potential efficacy in previously treated advanced pMMR/MSS gastrointestinal malignancies.

Phase 2 trial in acetylcholine receptor antibody-positive myasthenia gravis of transition from intravenous to subcutaneous immunoglobulin: The MGSCIg study

BACKGROUND AND PURPOSE

Data on maintenance therapy with subcutaneous immunoglobulin (SCIg) in myasthenia gravis (MG) are limited. We report on transitioning acetylcholine receptor (AChR) antibody-positive (Ab+) MG patients on stable intravenous immunoglobulin (IVIg) regimens as part of routine clinical care to SCIg 1:1.2.

METHODS

This multicenter North American open-label prospective investigator-initiated study had two components: the IVIg Stabilization Period (ISP) enrolling patients already on IVIg as part of routine clinical care (Weeks -10 to -1), followed by transition of stable MG subjects to SCIg in the Experimental Treatment Period (ETP; Weeks 0 to 12). We hypothesized that >65% of patients entering the ETP would have a stable Quantitative Myasthenia Gravis (QMG) score from Week 0 to Week 12. Secondary outcome measures included other efficacy measures, safety, tolerability, IgG levels, and treatment satisfaction.

RESULTS

We recruited 23 patients in the ISP, and 22 entered the ETP. A total of 12 subjects (54.5%) were female, and 18 (81.8%) were White, with mean age 51.4 ± 17 years. We obtained Week 12 ETP QMG data on 19 of 22; one subject withdrew from ETP owing to clinical deterioration, and two subjects withdrew due to dislike of needles. On primary analysis, 19 of 22 participants (86.4%, 95% confidence interval = 0.72-1.00) were treatment successes using last observation carried forward (p = 0.018). Secondary efficacy measures supported MG stability. SCIg was safe and well tolerated, and IgG levels were stable. Treatment satisfaction was comparable between ISP and ETP.

CONCLUSIONS

MG patients on IVIg as part of their routine clinical care remained stable on monthly IVIg dosage, and most maintained similar disease stability on SCIg.

A phase II study of perioperative mFOLFOX chemotherapy plus pembrolizumab combination in patients with potentially resectable adenocarcinoma of the esophageal, gastroesophageal junction (GEJ), and stomach

329

Background: Surgical rection is the only potentially curative intervention for locally advanced adenocarcinoma of esophagus, GEJ and stomach. Results from various studies have demonstrated the benefits of perioperative treatment including neoadjuvant and adjuvant chemotherapy or chemoradiation, however, there is lack of universally accepted standard. Recent data demonstrated the benefit of immune checkpoint inhibitor in adjuvant setting in patients who had pre-operative chemoradiation. This single arm phase 2 trial is aimed to evaluate efficacy and safety of pembrolizumab, an immune checkpoint inhibitor, in combination with mFOLFOX in patients with potentially resectable adenocarcinoma of distal esophagus, GEJ and stomach with the primary objectives of pathological response rate (ypRR with tumor regression score, TRS ≤ 2). We are reporting the preliminary analyses while the study nears completion. Methods: Patients with newly diagnosed locally advanced (T1N1-3M0 or T2-3NanyM0), potentially resectable adenocarcinoma of distal esophagus, GEJ and stomach by PET, EUS, CT C/A/P and staging laparoscopy were treated with pre-operative mFOLFOX6 (oxaliplatin 85mg/m2, Leucovorin 400mg/m2, 5-FU bolus 400mg/m2, and 5-FU 2400mg/m2 infusion every 2 weeks) for 4 cycles and pembrolizumab (200 mg IV q3week) for 3 cycles. Patients with no evidence of metastatic disease by PET and CT C/A/P who are eligible for resection underwent surgery. Post-operative treatment consisted of 4 cycles of mFOLFOX and 13 cycles of pembrolizumab 4-8 weeks postoperatively. Results: Of 35 patients enrolled (age range 44-86, mean of 65 years; with male:female of 28:7), 33 finished preoperative treatment, 26 had curative intended operations with R0 resection for all, 1 is pending for surgery, and 2 are still on pre-operative treatment. 5 of 26 pts achieved ypCR (19% regression score of 0). All except 2 patients (24/26, 92%) had shown pathologic response to the treatment with TRS ≤ 2. 23/26 (88%) finished post-operative treatment. 20 patients completed all planned treatment with an average follow-up of 22.7 months. Amount them, 2 patients had recurrence/ metastatic disease (at 9 and 10 months, respectively) with 1 died 23.3 months from enrollment, and the rest are all free of disease. G3/4 toxicities were reported in 19 of all 35 treated patients. There were no unexpected toxicities. Conclusions: The combination of FOLFOX and pembrolizumab as peri-operative (pre- and post-operative) therapy in patients with locally advanced adenocarcinoma of distal esophagus, GEJ and stomach is safe and preliminary benefit data are very encouraging with ypRR of 92% and ypCR of 19% and supporting the combination of chemotherapy and Immune checkpoint inhibitor at perioperative setting. Clinical trial information: NCT03488667.

CA209-8YD: A phase I/II trial of rucaparib in combination with ramucirumab with or without nivolumab in previously treated advanced gastroesophageal adenocarcinoma (GEA) (RiME)

TPS377

Background: GEA is one of the leading causes of cancer-related deaths worldwide and in the US. In chemo refractory GEA, therapeutic options are limited with modest efficacy. About 35% of GC have DNA damage response (DDR) gene alterations and PARP inhibitors have shown to induce synthetic lethality and reduce tumor burden in in vitro and in vivo models of GEA. DDR deficient tumors have increased tumor mutational load, tumor infiltrating lymphocytes, and increased chemokines and PD-L1 expression in the tumor microenvironment. PARP inhibitors like rucaparib enhance antigen presentation, induce pro-inflammatory cytokines, influence PD-1/PD-L1 expression, and modulate T- and B- cell activity. Furthermore, results from multiple GEA early phase trials have supported the immune modulatory impact of VEGF targeted agents like ramucirumab. We hypothesize that modulation of the tumor microenvironment via PARP and VEGF inhibition will enhance anti-tumor immunity and lead to clinical synergy when combined with immune checkpoint inhibitors like nivolumab in this population. Methods: A safety lead in phase of 6-9 patients will be followed by an open label, two parallel cohorts phase II study. A total of 52 patients (26 in each cohort) will be enrolled. A starting rucaparib dose of 600 mg BID in combination with the standard doses of ramucirumab and flat doses of nivolumab will be used for the safety lead in. Rucaparib dose will be lowered for phase II if > 1/6 patients experienced DLTs. Participants enrolled to cohort A will receive rucaparib at the recommended phase II dose (RP2D) PO twice daily + ramucirumab 8mg/kg IV q2w + nivolumab 480mg IV q4w (28-day cycles). Participants in cohort B will receive rucaparib at RP2D PO twice daily + ramucirumab 8mg/kg IV q2w (28-day cycles). Assessment of tumor response using modified RECIST v1.1 will be done every 2 cycles. 50% of Pts who will be enrolled in each of the 2 cohorts must have a deleterious tumor gene alteration in at least 1 gene in a screening 17-gene homologous recombination deficient (HRD) panel. Eligible Pts received ≥1 line of therapy, ECOG PS 0-1, adequate organ function, no prior PARP inhibitors, and have mismatch repair (MMR) proficient tumors with measurable disease. Primary objectives are to determine the RP2D and overall response rate (ORR) in phase I and II respectively. Secondary objectives include safety, overall benefit rate (OBR), median PFS, OS, and ORR in HRD positive and negative cohorts. Enrollment to the RiME trial is currently ongoing. The study is funded by research grants from Bristol Myers Squibb and Clovis. Clinical trial information: NCT03995017.

Phase II trial of cabozantinib (Cabo) plus durvalumab (Durva) in chemotherapy refractory patients with advanced mismatch repair proficient/microsatellite stable (pMMR/MSS) colorectal cancer (CRC): CAMILLA CRC cohort results

135

Background: Cabo is an anti-VEGFR2/MET/AXL drug with broad multi-kinase inhibitory spectrum. Preclinical and clinical studies in various solid tumors demonstrated favorable immune modulatory activity of Cabo with clinical synergy seen when combined with PD-1/ PD-L1 inhibitors like Durva. Upon completion of phase Ib gastrointestinal (GI) basket CAMILLA trial evaluating Cabo + Durva in 30 patients (pts) demonstrating favorable safety & efficacy, the trial was expanded to phase 2 multi-cohort, multi-center trial of 117 pts. Herein, we report results of the phase 2 CRC cohort, the first evaluation of cabo + IO in this population. Methods: Pts enrolled in this cohort were administered Cabo + Durva at the RP2D of 40mg QD and 1500mg IV Q4W respectively. Enrolled pts must have progressed on 2 or more lines of therapy. Primary outcome measure was investigator assessed overall response rate (ORR) and secondary outcomes were rate of treatment related adverse events (TRAE), investigator assessed disease control rate (DCR), progression free survival (PFS), and overall survival (OS). Subgroup analysis was done in pts with RAS wild type tumors. Exploratory analysis of pathogenic molecular tumor alterations using next generation sequencing (NGS) was done in pts who achieved confirmed partial response (PRc)/ stable disease (SD) > 6 months. Results: Of the 36 pts enrolled, 29 (16F, 13M) were evaluable for efficacy. Median age 57 years (27-76). 90% (26) had ECOG of 1. All had pMMR/MSS, 41% (12) had RAS wild type tumors, and 6.9% (2) had HER2 amplification. 52% (15) had received ≥ 3 lines of therapy. All had metastases at ≥ 3 sites and 79% (23) metastases in the liver. Among 36 pts evaluable for safety, treatment related serious adverse events (SAEs) occurred in 31% (11/36). Most common TRAEs were grade 1-2 fatigue (53%), nausea (42%), diarrhea (36%), anorexia (31%), hand-foot syndrome (22%), & hypertension (16%). Grade ≥ 3 immune-related adverse events (IRAE) occurred in 16.6% (6/36). Efficacy analysis revealed an ORR 27.6% (8/29); PRc 21% (6/29); DCR 86.2% (25/29); median DOR was not reached (NR); median PFS 4.4 months; 6-month PFS 28% & median OS 9.1 months. In the RAS wild type subgroup, ORR (PRc) was 50.0%; DCR 83.3%; median PFS 6.3 months and median OS was NR. Of the 7 pts who achieved PRc/SD > 6 months, one had KRAS G12V tumor mutation along with mutations in ARID1A & IDH1. Remaining pts had RAS wild type tumors & among those, the following NGS alterations were detected: 1 HER-2 amplification, 1 MET amplification, & 2 alterations in ATM. Conclusions: Cabo + Durva demonstrated promising efficacy and was fairly tolerated without new safety signals in heavily treated pMMR/MSS CRC pts. These encouraging results warrant further evaluation of this regimen in a randomized setting as salvage therapy in pMMR/MSS CRC. Clinical trial information: NCT03539822.

345 Phase I/II trial of cabozantinib plus durvalumab in advanced gastroesophageal cancer and other gastrointestinal malignancies (CAMILLA): phase Ib safety and efficacy results

Background

Cabozantinib is a multi-tyrosine kinase inhibitor primarily targeting VEGFR, MET, and AXL. These targets promote a tumor immune permissive microenvironment. Cabozantinib has demonstrated immunomodulatory properties & clinical synergy when paired with PD-L1 inhibitors such as durvalumab. Here, we present final results of phase Ib of the Camilla trial assessing cabozantinib plus durvalumab in advanced GE adenocarcinoma (GEA), colorectal cancer (CRC), and hepatocellular carcinoma (HCC). This is an investigator-initiated trial funded by Exelixis & Astrazeneca.

Methods

Patients were administered cabozantinib + durvalumab in a dose escalation (3+3) then expansion to find the Dose Limiting Toxicities (DLTs), Recommended Phase 2 Dose (RP2D), ORR, PFS, and OS. Subgroup analysis was conducted to assess efficacy in patients with PD-L1 Combined Positive Score (CPS) ≥ 5. Dosing of cabozantinib was 20mg QD, 40mg QD, and 60mg QD PO in the 1st, 2nd, and 3rd cohorts. Dosing of durvalumab was 1500mg IV Q4W in all cohorts. DLT window was 28 days. Treatment beyond progression was allowed following modified RECIST v1.1 criteria.

Results

35 patients (14F, 21M), median age 53 years (range 27–79) were enrolled. 10 patients had GEA, 20 had CRC, and 5 had HCC; none had MMR deficiency. Median number of prior systemic therapies was 3 (range 0–3). No DLTs were observed during dose escalation. Per mature tolerability data, 11/14 patients receiving cabozantinib 60mg required dose-reduction post cycle 2 to 40mg. RP2D was determined to be cabozantinib 40mg QD plus durvalumab 1500mg Q4W. Of the 247 observed Treatment-Related Adverse Events (TRAEs), 10% (24) were grade≥3. Most common TRAEs were grade 1–2 fatigue (57%), nausea (43%), anorexia (40%), diarrhea (37%), transaminitis (34%), hand-foot syndrome (23%), & weight loss (23%). 2 patients each developed grade≥3 fatigue, weight loss, & abdominal pain. Overall, 30 pts were evaluable for efficacy. ORR 26.7%; DCR 83.3%; median PFS 4.5 months; 6-month PFS 36.7%; and median OS 9.1 months. 12 patients had PD-L1 CPS ≥5. In this subgroup, ORR 33.33%; DCR 91.67%; median PFS 6.13 months; 6-month PFS 50%; and median OS was not reached.

Conclusions

Cabozantinib plus durvalumab demonstrated promising efficacy and was fairly tolerated without new safety signals. High PD-L1 expression defined as CPS ≥ 5 was associated with improved efficacy & survival. The phase II multi-cohort part of the trial is currently ongoing.

Trial Registration

NCT03539822

Ethics Approval

The study was approved by the participating site’s local IRB.

Consent

All study participants granted a written informed consent prior to treatment initiation.

Romidepsin (HDACi) plus cisplatin and nivolumab triplet combination in patients with metastatic triple negative breast cancer (mTNBC)

1076

Background: Histone deacetylase inhibitors (HDACi) upregulate genes involved in antigen presentation machinery and increase expression of natural killer group 2, member D ligands (NKG2DL), thus resulting in enhanced tumor cell recognition and response to PD-1/CTLA-4 blockade. Cisplatin and HDACi combination synergistically induces cytotoxicity, apoptosis, and DNA damage. This phase I-II trial investigated combination of romidepsin (HDACi) plus cisplatin and nivolumab (PD-1 inhibitor) in mTNBC. Patients and Methods: Eligible patients had mTNBC with any number of prior chemotherapies. Phase I was 3+3 dose-escalation design with three dose levels of romidepsin (8, 10, 12mg/m2, D2, 9) plus cisplatin 75mg/m2 D 1 every 21 days. Phase II treatment included romidepsin plus cisplatin plus nivolumab 360mg every 21 days and was designed according to Simon’s two stage minimax design. Primary endpoints were recommended phase 2 dose (RP2D) and objective response rate (ORR). Additional endpoints included safety, PFS, and pharmacokinetics. Results: 51 patients were enrolled (N=13 phase I, N=38 phase II) between 2015-2020. 69% had received ≥1 prior metastatic chemotherapy, 47% had prior platinum, 53% had liver metastasis, 12% had BRCA1/2 mutation, and 11% had PD-L1 positive disease. There were no dose limiting toxicities in phase I. The RP2D was romidepsin 12mg/m2 D2,9 + cisplatin 75mg/m2 D1 + nivolumab 360mg D1 every 21 days. Thrombocytopenia (G3:27%, G4:0%), neutropenia (G3:25%, G4:0%), anemia (G3:22%, G4:0%), nausea (G3:22%, G4:0%), and vomiting (G3:20%, G4:0%) were the most common grade 3/4 adverse events. 21% of patients had immune AEs (G3-4:8%). Among 34 evaluable phase II patients, ORR was 44% (Table), median PFS was 4.4 months, and 1-year PFS was 23%. Median OS was 10.3 months and 1-year OS was 43%. No pharmacokinetic interactions were detected with co-administration of romidepsin-cisplatin-nivolumab. Conclusions: The triplet combination of romidepsin plus cisplatin and nivolumab was well tolerated and shows encouraging efficacy in pretreated mTNBC, including in patients with PD-L1 negative disease and in those with liver metastasis. Correlative biomarker work is ongoing. This combination warrants further evaluation in larger studies. Clinical trial information: NCT02393794 .[Table: see text]

Randomized Phase II Trial of Anthracycline-free and Anthracycline-containing Neoadjuvant Carboplatin Chemotherapy Regimens in Stage I-III Triple-negative Breast Cancer (NeoSTOP)

PURPOSE

Addition of carboplatin (Cb) to anthracycline chemotherapy improves pathologic complete response (pCR), and carboplatin plus taxane regimens also yield encouraging pCR rates in triple-negative breast cancer (TNBC). Aim of the NeoSTOP multisite randomized phase II trial was to assess efficacy of anthracycline-free and anthracycline-containing neoadjuvant carboplatin regimens.

PATIENTS AND METHODS

Patients aged ≥18 years with stage I-III TNBC were randomized (1:1) to receive either paclitaxel (P) weekly × 12 plus carboplatin AUC6 every 21 days × 4 followed by doxorubicin/cyclophosphamide (AC) every 14 days × 4 (CbP → AC, arm A), or carboplatin AUC6 + docetaxel (D) every 21 days × 6 (CbD, arm B). Stromal tumor-infiltrating lymphocytes (sTIL) were assessed. Primary endpoint was pCR in breast and axilla. Other endpoints included residual cancer burden (RCB), toxicity, cost, and event-free (EFS) and overall survival (OS).

RESULTS

One hundred patients were randomized; arm A (n = 48) or arm B (n = 52). pCR was 54% [95% confidence interval (CI), 40%-69%] in arm A and 54% (95% CI, 40%-68%) in arm B. RCB 0+I rate was 67% in both arms. Median sTIL density was numerically higher in those with pCR compared with those with residual disease (20% vs. 5%; P = 0.25). At median follow-up of 38 months, EFS and OS were similar in the two arms. Grade 3/4 adverse events were more common in arm A compared with arm B, with the most notable differences in neutropenia (60% vs. 8%; P < 0.001) and febrile neutropenia (19% vs. 0%; P < 0.001). There was one treatment-related death (arm A) due to acute leukemia. Mean treatment cost was lower for arm B compared with arm A (P = 0.02).

CONCLUSIONS

The two-drug CbD regimen yielded pCR, RCB 0+I, and survival rates similar to the four-drug regimen of CbP → AC, but with a more favorable toxicity profile and lower treatment-associated cost.

1059 Sleep Parameters In People With Type 2 Diabetes With And Without Insomnia Symptoms

Introduction

There is an increasing awareness of the high prevalence of insomnia symptoms in people with type 2 diabetes (T2D). Past studies have demonstrated the importance of measuring sleep parameters in both averages and variabilities using subjective and objective methods. Thus, we aimed to compare the averages and variability of sleep parameters in people with T2D with and without insomnia symptoms.

Methods

Actigraph measurements and sleep diaries were used in 59 participants to assess sleep parameters, including sleep efficiency (SE), sleep latency, total sleep time, and wake after sleep onset over seven nights. Validated instruments were used to assess the symptoms of depression, anxiety, and pain. Circular data were used to describe the distribution of bed distribution with SE as a magnitude for both groups. Mann Whitney U test was utilized to compare averages and variability of sleep parameters between the two groups. Multivariable general linear model to control for demographic and clinical variables. For the secondary aim, multiple linear regression tests were utilized to assess the association between averages and variability values for both groups.

Results

SE was found to be lower in average and higher in variability for participants with T2D and insomnia symptoms, than those with T2D only subjectively and objectively. SE variability was also the only sleep parameter higher in people with T2D and insomnia symptoms, with psychological symptoms potentially playing a role in this difference. We observed that people in T2D+Insomnia tend to go to bed earlier compared to the T2D only group based on objective measures, but no difference was observed between groups in subjective measures. The only significant relationship in both objective and subjective measures was between the averages and variability of SE.

Conclusion

Our findings suggest a discrepancy between subjective and objective measures in only average of total sleep time, as well as agreement in measures of variability in sleep parameters. Also, the relationship between averages and variabilities suggested the importance of improving SE to minimize its variability. Further research is warranted to investigate the complex relationship between sleep parameters and psychological factors in people with T2D and insomnia symptoms.

Support

None

Cabozantinib (cabo) combined with durvalumab (durva) in gastroesophageal (GE) cancer and other gastrointestinal (GI) malignancies: Preliminary phase Ib CAMILLA study results

4563

Background: Cabo targets multiple tyrosine kinases, including VEGFR, MET, and AXL, and has been reported to show immunomodulatory properties that may counteract tumor-induced immunosuppression, providing a rationale for combining it with PD-L1 inhibitors like durva. We conducted a phase Ib GI basket trial to evaluate the safety & efficacy of this regimen in advanced GE adenocarcinoma (GEA), colorectal cancer (CRC), & hepatocellular carcinoma (HCC). Methods: Patients received cabo and durva in 3+3 dose escalation then expansion to determine the dose limiting toxicity (DLT), Recommended Phase 2 Dose (RP2D), ORR, PFS & OS. Cabo was dosed at 20mg QD, 40mg QD, and 60mg QD in the first, second, and third cohorts respectively. Durva was dosed at 1500mg IV Q4W in all cohorts. DLT window was 28 days. Scans were obtained every 8 wks. Treatment beyond progression was allowed. Results: 23 Pts (16 M, 7 F), median age 60 yrs (range 33-79) were currently enrolled. 12 in the dose escalation cohort with cabo 20mg (6 pts), or 40mg (3 pts), or 60mg (3 pts). 11 pts enrolled in the dose expansion cohort with cabo 60mg. 8 pts had GEA, 13 pts had CRC, and 2 pts had HCC. Median number of prior chemotherapies was 3 (range 1-3). 3 pts were not evaluable for DLT due to missing ≥30% of DLT window doses, not related to DLT. No DLTs were observed. Drug-related Grade (G) 1&2 AEs included fatigue (83%), abnormal LFTs (39%), anorexia (26%), diarrhea (26%), nausea (13%), & hand foot syndrome (13%). One pt each developed drug related G3 hypertension, hyperthyroidism, thrombocytopenia, & thromboembolic event, all occurring outside the DLT window. 19 pts were evaluable for response: 4 PR (2 GEA & 2 CRC), 12 SD, 3 PD; ORR 21%; clinical benefit rate 84%; median time to PD 16 wks (range 8-40+). Conclusions: RP2D was determined to be Cabo 60mg QD and Durva 1500mg Q4W. Enrollment to phase I dose expansion is ongoing. RP2D may be adjusted based on additional experience & long-term tolerability. Early efficacy data was encouraging. This is an investigator-initiated trial funded by Exelixis & Astrazeneca. Clinical trial information: NCT03539822 .

Effect of Long-term Nicotine Replacement Therapy vs Standard Smoking Cessation for Smokers With Chronic Lung Disease: A Randomized Clinical Trial

IMPORTANCE

Smokers with chronic obstructive pulmonary disease (COPD) have particular difficulty quitting. Long-term nicotine replacement therapy (LT-NRT) might offer a strategy for reducing harm from cigarettes and provide a pathway for later cessation.

OBJECTIVE

To compare the effect of LT-NRT vs standard smoking cessation (SSC) on exposure to cigarette smoke, harm related to smoking, and cessation among smokers with COPD.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded, randomized clinical trial recruited smokers who self-reported a diagnosis of COPD at any level of readiness to quit from May 23, 2014, through November 30, 2015. The 12-month follow-up was completed December 6, 2016. Patients were recruited at a clinical research unit of an academic medical center. Analysis was based on intention to treat and performed from March 8 through November 30, 2017.

INTERVENTIONS

Standard smoking cessation treatment included 10 weeks of NRT and 4 follow-up counseling sessions for those willing to make a quit attempt. Long-term NRT included 12 months of NRT and 6 follow-up counseling sessions regardless of initial willingness to quit. Overall, 198 patients were randomized to SSC, and 197 were included in the primary analysis; 200 patients were randomized to LT-NRT, and 197 were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was 7-day abstinence verified by carbon monoxide (CO) levels at 12 months. Secondary outcomes included cigarettes smoked per day (CPD), exposure to CO, urinary excretion of 4-methylnitrosamino-1-3-pyridyl-1-butanol (NNAL) (a smoking-related carcinogen), and adverse events.

RESULTS

Among 398 patients who were randomized (59.8% female; mean [SD] age, 56.0 [9.3] years), the mean (SD) CPD was 23.1 (12.3). Twelve-month follow-up was completed by 373 participants (93.7%), and 394 (99.0%) were included in the primary analysis. At 12 months, CO-verified abstinence occurred in 23 of 197 participants (11.7%) in the SSC arm and 24 of 197 (12.2%) in the LT-NRT arm (risk difference, 0.5%; 95% CI, -5.9% to 6.9%). Continuing smokers in the SSC and LT-NRT arms had similar, significantly reduced harms caused by smoking, including cigarette consumption by 12.4 and 14.5 CPD, respectively, exhaled CO level by 5.5 and 7.8 ppm, respectively, and mean urinary NNAL excretion by 21.7% and 23.0%, respectively. In multivariate analyses, continuing smokers with greater adherence to NRT experienced less reduction in NNAL exposure. The frequency of major adverse cardiac events was similar in both groups.

CONCLUSIONS AND RELEVANCE

Similar rates of cessation and similar reductions in exposure to tobacco smoke resulted with LT-NRT and SSC. Among continuing smokers, ongoing use of NRT was not associated with reductions in smoke exposure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148445.

Retrospective Analysis of Intrathecal Drug Delivery: Outcomes, Efficacy, and Risk for Cancer-Related Pain at a High Volume Academic Medical Center

OBJECTIVES

Cancer pain is common and difficult to treat, as conservative medical management fails in approximately 20% of patients for reasons such as intolerable side-effects or failure to control pain. Intrathecal drug delivery systems (IDDS), while underutilized, can be effective tools to treat intractable cancer pain. This study aims to determine the degree of pain relief, efficacy, and safety of patients who underwent IDDS implantation at a multidisciplinary pain clinic.

MATERIALS AND METHODS

A retrospective review was conducted of patients with an intrathecal pain pump implanted for malignant pain. Charts were reviewed for demographics, cancer type, pain scores before and after implantation, and intrathecal drugs utilized. A Wilcoxon Signed-Rank test was conducted on the paired differences of pain scores before and after implant. A regression analysis was conducted using a linear model to assess effects of demographic variables on change in pain scores.

RESULTS

160 patients were included in analysis. The median pain score was 7.1 at time of implantation and 5.0 at one-month postimplantation. For patients with both baseline and one-month pain scores available, the median decrease in pain was 2.5 (p < 0.0001). Pain scores three-month postimplantation did not significantly differ from one-month postimplantation. Median longevity was 65 days. Five patients had pumps explanted due to infection with a median time to pump extraction of 28 days.

CONCLUSIONS

IDDS has the potential to improve cancer pain in a variety of patients and should be strongly considered as an option for those with cancer pain intractable to conservative medical management.

Atrial fibrillation and risk of stroke in dialysis patients

PURPOSE

Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF.

METHODS

A cohort of dually eligible (Medicare and Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke.

RESULTS

Of 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (hazard ratio [HR], 1.26; 99% confidence interval [CI], 1.06-1.49; P = .0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African Americans (HR, 1.46; 99% CI, 1.08-1.96), Hispanics (HR, 1.64; 99% CI, 1.16-2.31), and others (HR, 1.76; 99% CI, 1.16-2.78) had higher rates than did Caucasians (all P < .001).

CONCLUSIONS

Chronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes owing to hemorrhage is much higher than in the general population.

Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions

BACKGROUND

Few studies have evaluated the impact of biliary stents on EUS-guided FNA.

AIM

To compare diagnostic yield of EUS-FNA in patients with or without biliary stents.

DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

Patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years.

MAIN OUTCOME MEASURES

The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis.

RESULTS

Of 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1-3] vs 2 [IQR = 1-4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1-4] vs 2 [IQR = 1-4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001).

LIMITATIONS

Retrospective study.

CONCLUSIONS

The presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA.

Management of pancreatic fluid collections: a changing of the guard from surgery to endoscopy

The aim of this study was to assess for any trend in management of pancreatic fluid collections (PFCs) and identify impacting factors. The endoscopy and surgical databases were queried for PFC patients. PFCs were categorized as pseudocysts (PP) or complex collections (CC) that included abscess/necrosis. The outcome measures were to compare the utilization of surgery and endoscopy from 2004 to 2007 (group I) and from 2008 to 2010 (group II) and identify factors impacting practice patterns. A total of 285 patients were treated: group I included 119 and group II 166. Of 119 group I patients, 29 per cent were treated by surgery and 71 per cent by endoscopy. Of 85 endoscopy patients, 42 per cent were drained by conventional transmural drainage and 58 per cent by endoscopic ultrasound (EUS). Of 166 group II patients, 31 per cent were treated surgically and 69 per cent endoscopically. Of the 115 endoscopy patients, 17 per cent were drained by conventional transmural drainage and 83 per cent by EUS. Compared with group I, all pseudocysts in group II were treated by endoscopy (84% vs 100%, P = 0.001). There was no difference in the rate of CC treated by endoscopy between both groups (57.7% vs 56.8%, P = 0.9). PFCs not causing luminal compression (P < 0.0001) or measuring <9 cm in size (P < 0.0001) were more likely to require EUS. There was a significant trend at our institution in the management of PFCs with all pseudocysts presently being treated only by endoscopy. The ability of EUS to access smaller size PFCs and those not causing luminal compression has significantly expanded the role of endoscopy in PFC management.

Biliary stent placement is associated with post-ERCP pancreatitis

BACKGROUND

A variety of factors have been linked to post-ERCP pancreatitis. However, the role of biliary stenting has not been well studied.

OBJECTIVE

To evaluate the relationship between biliary stenting and post-ERCP pancreatitis.

DESIGN

Prospective study of all patients undergoing ERCP with biliary stenting over a 7.5-year period. All patients had follow-up at 24 to 48 hours after the procedure and at 1 month.

SETTING

A single-center tertiary referral academic medical center.

PATIENTS

Consecutive patients undergoing ERCP over a 7.5-year period.

INTERVENTIONS

Endoscopic therapy based on the indication for and findings of ERCP.

MAIN OUTCOME MEASUREMENTS

The rate of post-ERCP pancreatitis.

RESULTS

A total of 3499 patients underwent ERCP with bile duct stent placement of a native papilla performed in 660: 544 (83%) 10F and 116 (17%) 7F. The most common indication for stent placement was pancreaticobiliary malignancy in 250 patients (37%). The overall rate of pancreatitis for the entire cohort was 3.17%. Multivariate analysis identified 6 factors that were associated with pancreatitis: previous ERCP pancreatitis (odds ratio [OR], 2.44; 95% CI, 1.31-4.55), age (OR, 2.30; 95% CI, 1.44-3.67), history of acute pancreatitis (OR, 1.78; 95% CI, 1.12-2.88), pancreatic sphincterotomy (OR, 2.30, 95% CI, 1.43-3.70), suspected sphincter of Oddi dysfunction (OR, 3.91; 95% CI, 2.36-6.46), and bile duct stenting (OR, 1.72; 95% CI, 1.03-2.88). The rates of pancreatitis were not significantly different based on performing sphincterotomy before stent placement, stent type, stent length, stent size, or indication.

LIMITATIONS

Single-center study.

CONCLUSIONS

Bile duct stent placement is an independent predictor for pancreatitis, and pancreatitis is not related to performing sphincterotomy before stenting or to stent characteristics.

Absence of gastrointestinal infections in a cohort of patients with Zollinger-Ellison syndrome and other acid hypersecretors receiving long-term acid suppression with lansoprazole

BACKGROUND

The relationship between proton pump inhibitor therapy and other acid suppressing medications and the risk of gastrointestinal infections remains controversial.

METHODS

Patients enrolled in a long-term trial of lansoprazole for Zollinger-Ellison syndrome and other acid hypersecretory states had interval histories taken every six months regarding hospitalizations or other intercurrent medical conditions. All medications taken were also reviewed at each visit. In addition, available patients were specifically queried during the study period 2006-2007 regarding the development of any gastrointestinal infections, hospitalizations, and prescriptions for antibiotics.

RESULTS

Ninety patients were enrolled in our long-term study and 81 were available for review. The median basal gastric pH for the cohort after stabilization on therapy was 2.9 and ranged from 1.1 - 8.4 with a median pentagastrin stimulated gastric pH of 1.60 (range 1.0 - 8.2). No patient developed a clinically significant gastrointestinal infection during the study. The median patient years of follow-up were 6.25 years.

CONCLUSION

In a cohort of patients with gastric acid hypersecretion in whom acid secretion status was monitored on lansoprazole, all were free of significant gastrointestinal infections on long-term follow-up.

TRIAL REGISTRATION

NCT00204373.