bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of stratifying levels of serum lactate dehydrogenase (LDH) at diagnosis on the overall survival (OS) in newly diagnosed multiple myeloma (NDMM).
Authors: Evans Laura , Kumar Shaji , Dingli David , Dispenzieri Angela , Lacy Martha , Go Ronald S. , Buadi Francis , Leung Nelson , Lin Yi , Hayman Suzanne R. , Russell Stephen J. , Muchtar Eli , Kapoor Prashant , Siddiqui Mustaqeem Ahmad , Warsame Rahma M. , Kourelis Taxiarchis , Kyle Robert A. , Gertz Morie A. , Rajkumar S. Vincent , Gonsalves Wilson I.
Published: June 2021

e20016

Background: An elevated serum LDH level is an adverse prognostic factor in NDMM. However, this category includes quantitative serum LDH levels that range from just over the upper limit of normal (ULN) to levels that may be 2 or more-fold higher than the ULN. This binary classification of serum LDH level of “normal versus elevated” fails to discriminate between the different disease biology that exists among NDMM patients with elevated serum LDH levels. Thus, we attempted to further stratify NDMM patients by the level of their serum LDH and determine its impact on OS. Methods: The cohort included patients diagnosed with NDMM from the Mayo Clinic, Rochester from 2003 - 2017 who were treated with novel agent induction therapy and had serum LDH levels measured at the time of diagnosis. The serum LDH levels were stratified into three levels: Normal (LDH < 222 U/L), Elevated (LDH 223-444 U/L), and Very Elevated (LDH >444 U/L or >2x upper limit of normal). Survival analysis was performed using the Kaplan-Meier survival analysis and compared via the log-rank method. Results: The cohort consists of 1,196 NDMM patients with a median age of 65 (22 – 95). R-ISS classification and cytogenetic risk were available for 968 and 970 patients respectively. The median serum LDH level was (162 U/L (3- 1260)) and an elevated LDH was present in 199 patients (17%). The median OS for patients with normal (N = 997; 83%), elevated (N = 170; 13%) and very elevated (N = 29; 3%) LDH levels were 76 months, 57 months and 23 months respectively (P < 0.001). The impact of these different levels of LDH on OS by R-ISS stage and cytogenetic risk is shown in the Table. Conclusions: A very small subset of NDMM patients has very elevated LDH levels that confer an exceptionally poor OS irrespective of R-ISS stage and cytogenetic risk. Future studies elucidating their disease biology responsible for such poor OS outcomes are warranted.[Table: see text]
Genomic features of lung cancer patients harboring germline mutations associated with hereditary cancer syndromes.
Authors: Sun Jian , Wang Weiran , Wang Danhua , Yuan Hongling , Ma Tonghui
Published: June 2021

e20511

Background: Smoking and air pollution are the major causes of lung cancer; however, numerous studies have demonstrated that genetic factors also contribute to the development of lung cancer. Here, we reported an analysis of genomic features in 65 lung cancer patients with autosomal-dominant or autosomal-recessive inheritance of germline mutations. Methods: We retrospectively reviewed next-generation sequencing data of 26,904 lung cancer patients in a Chinese cohort. The germline mutation patterns, as well as the co-occurrence with somatic driver mutations were analyzed. Results: A total of 65 (0.24%) patients with heterozygous germline mutations associated with hereditary cancer syndromes were detected, including 27 (0.10%) patients with autosomal-dominant inheritance (BRCA1, BRCA2, RET and TP53) and 38 (0.14%) patients with autosomal-recessive inheritance (ATM, BLM, FANCA, FANCG, MUTYH, NBN, RECQL4 and WRN). Comparing to patients with autosomal-dominant inheritance (Age 56±17.8), patients with autosomal-recessive inheritance (Age 65±11.7, P = 0.009) were older, and there is no gender difference. Additionally, 66.7% (18/27) of patients with autosomal-dominant inheritance were identified co-mutated actionable variations, such as 12 patients harboring mutations in exon 18–21 of EGFR, 2 patients harboring ERBB2 exon 20 insertions, 3 patients harboring mutations in exon 2 of KRAS and 1 patient harboring EML4-ALK fusion. The coexistence of germline autosomal-dominant mutations and somatic driver mutations indicated that germline mutations have weak impact on lung cancer. Simultaneously, 52.6% (20/38) of patients with autosomal-recessive inheritance were identified co-mutated actionable variations, such as 15 EGFR+ patients, 2 ERBB2+ patients and 3 KRAS+ patients. And there was no significant difference in population frequency of co-mutated actionable variations between the two groups. Conclusions: In summary, studies on germline mutations of lung cancer patients may help to elucidate the etiology and mechanism of lung cancer, and may help for early detection and diagnosis, targeted therapy and improved prevention strategies.
Correlation of clinical characteristics and immunologic profile of stage III NSCLC patients.
Authors: Suriyaphan Nattanit , Incharoen Pimpin , Oranratnachai Songporn , Sanvarinda Pimtip , Trachu Narumol , Muntham Dittapol , Chansriwong Phichai , Reungwetwattana Thanyanan
Published: June 2021

e20552

Background: Recently, immunotherapy has significantly increased mPFS and mOS in unresectable stage III NSCLC whom completed concurrent chemoradiation (CCRT). Predictive biomarker for immunotherapy in this setting has not been established yet. Methods: This is a retrospective study in stage III NSCLC patients in Ramathibodi hospital between year of 2013 and 2019. Clinical data of 176 patients were retrieved from electronic medical record. Only 64 patients had adequate tissue for tissue array for immunohistochemistry (IHC) staining of protein expression in CD3, CD4, CD8, FOXP3, PDL-1, CD163, CD 138, CD20 in stroma and tumor cells. We also performed IHC staining for Microsatellite Instability (MSI). Optimum cut point for each protein expression was performed by C-statistic. Survival analysis was performed. All statistical analysis was performed by Stata version 15. Results: Of 176 patients, majority of patient were male (63.6%), age ≥65 years (63.6%), never-smoker (40.9%), stage IIIB (44.9%) and adenocarcinoma (67.6%). EGFR-positive patients were 47.7%. Most of the patients underwent CCRT (32.4%), only 11.9% underwent trimodality treatment. Doublet-carboplatin based chemotherapy was the most common regimen (61.5%). The mOS was 2.9 years and mPFS was 1.6 years. Multivariable analysis showed stage IIIB patients, patients whom received only systemic treatment or best palliative care had significantly shorter OS. Trimodality treatment showed significantly longer OS compared to bimodality (CCRT) (HR = 0.18, P= 0.02), as well as cisplatin-based chemotherapy had significantly longer OS compared to carboplatin-based regimen (HR = 0.47, P= 0.005). Of 64 patients whom had tissue testing in our study, majority of patients had of MSI-low (81.25%), PD-L1 negative (78.13%). Regarding tumor microenvironment, patients with high protein expression of CD3, CD4, CD8 and CD20 in stromal cells showed significantly longer OS, whereas MSI and PD-L1 were not significantly associated with survival outcomes. Conclusions: OS in stage III NSCLC in our population (2.9 years) is comparable with other studies (2.4 years). Trimodalities treatment significantly increased OS compared to CCRT. High protein expression of CD3, CD4, CD8 and CD20 in stroma probably potential prognostic and predictive biomarkers for immunotherapy in stage III NSCLC. Larger cohort is needed to explore.
Molecular characterization of Kita-Kyushu lung cancer antigen (KK-LC-1) expressing carcinomas.
Authors: Hsu Robert , Baca Yasmine , Xiu Joanne , Wang Rongfu , Bodor Joseph Nicholas , Kim Chul , Khan Hina , Mamdani Hirva , Nagasaka Misako , Puri Sonam , Liu Stephen V. , Korn Wolfgang Michael , Nieva Jorge J.
Published: June 2021

e21000

Background: Cancer/testis antigens (CTAs) are strongly expressed in some solid tumors but minimally expressed in normal tissue, making them appealing therapeutic targets. KK-LC-1 (CXorf61) has cytoplasmic expression in some types of gastric and breast cancer and reports of expression in one-third of lung cancer tumors. Here, we characterize the molecular subtype of lung cancers expressing KK-LC-1 to plan rational clinical trials of T-cell receptor therapy (TCR-T) targeting KK-LC-1. Methods: A total of 9790 non-small cell lung cancer (NSCLC) tumors that underwent whole transcriptome sequencing (Illumina NovaSeq) and NextGen DNA sequencing (NextSeq, 592 Genes and NovaSEQ, WES) at Caris Life Sciences (Phoenix, AZ) were analyzed. Tumors were split into quartiles based on KK-LC-1 expression and pathological and molecular differences were investigated. PD-L1 expression was tested by IHC using 22c3 (Dako) and TPS scores were reported. Immune cell fraction was calculated by QuantiSeq (Finotello 2019, Genome Medicine). Statistical significance was determined using chi-square/Fisher-Exact and adjusted for multiple comparisons (adjusted p < 0.05). Results: Adenocarcinoma had significantly higher KK-LC-1 expression than squamous cell carcinoma (median 3.25 vs. 1.17 transcripts per million (TPM), p < 0.0001). There is statistically higher expression of KK-LC-1 in pan wild type (3.95 TPM) compared to tumors with EGFR mutation (1.95 TPM), ALK fusion (0.6 TPM), MET exon-14-skip mutation (1.22 TPM), RET fusion (1.42 TPM), and ROS1 fusion (1.78 TPM). Tumors within the highest quartile of KK-LC-1 expression (Q4) had a greater proportion of TMB > 10 mutations per megabase (mt/MB) (44% vs. 28%) compared to Q1. No difference was seen in PD-L1 expression. In adenocarcinoma, Q4 had a higher TMB compared to Q1 (9 mt/MB vs. 5 mt/MB). There was a higher KRAS mutation prevalence in Q3/Q4 (34.8%/35.0%) than Q1/Q2 (22%/29%) but a lower ALK fusion prevalence in Q3/Q4 (1.0%/0.5%) compared to Q1/Q2 (3.3%/2.6%). Increased KK-LC-1 expression is associated with increased M1 Macrophage abundance. Conclusions: In our population, KK-LC-1 expression was higher in adenocarcinoma. Higher levels of KK-LC-1 expression were seen in pan-wild type and KRAS mutated tumors and associated with higher TMB while lower levels of expression were seen in driver positive cancers including EGFR, ALK, MET, RET and ROS1. TCR-T therapy directed against KK-LC-1 should be explored in patients whose clinical features reflect these characteristics.
Expanding the molecular taxonomy of NUT midline carcinomas with multiomic analyses.
Authors: Kaplan Henry G. , Barrett Alex , Niu Jiaxin , Subramaniam Somasundaram , Matsangou Maria
Published: June 2021

e21008

Background: NUT midline carcinoma (NMC) is an aggressive squamous cell carcinoma molecularly defined by a chromosomal rearrangement of nuclear protein in testis (NUTM1) with bromodomain-containing protein 3 or 4 (BRD3/4). While NMCs are characterized by this rare canonical gene rearrangement little is known about the transcriptome and proteosome of this rare disease. As such, we set out to comprehensively characterize five NMC cases in which we attained targeted DNA sequencing, full-transcriptome RNA sequencing, and targeted proteomics. We further examine and integrate these results in order to better understand the relationship between gene expression and protein abundance within the context of NMC. Methods: All cases were analyzed for genomic and transcriptomic alterations against a custom panel via the Tempus xT tissue biopsy assay (DNA sequencing of 648 genes in tumor and matched normal samples at 500x depth and full-transcriptome RNA sequencing) for germline and/or somatic mutations. The xT assay detects single nucleotide variants, specific insertion/deletions, amplifications and gene fusions, as well as tumor mutational burden (TMB) and microsatellite instability (MSI) status. Proteomic data were obtained utilizing digital spatial profiling through Nanostring immune, MAPK and PI3/AKT, and pan tumor nCounter GeoMix panels. Results: Clinical characteristics, histology, and genomic/proteomic alterations for 5 NMC cases are presented. Cases were defined by pathological assessment and the identification of the canonical NUTM1 fusion, further broken down by fusion partner with three patients having NUTM1-BRD4 fusions, one NUT-BRD3, and one NUT-ZMYND8. TMBs ranged for 0.8-.6 mutations/megabases (n=5). All patients were MSI stable (5/5). Of three patients with available PD-L1 IHC result, one had elevated PD-L1 tumor staining at 70%. Results will be presented from full-transcriptome RNA expression analysis indicating overexpression of BRAF, MYC, mTOR, and EGFR, among others. Targeted proteomics were performed to assess relative abundance at the protein level (results to be presented). Clinical follow up for the five patients revealed that two have survived beyond 7 months. A lung primary patient treated with surgical resection and post op radiation (XRT) is NED at 63 months. A sinus primary patient is NED at 16 months after a partial response (PR) to taxotere/5FU/Cisplatin followed by resection and XRT/cis platin. One patient had a brief PR from ifosphamide/etoposide/vorinostat. One patient's tumor grew through XRT/cisplatin. Conclusions: Multi-omic analysis has the potential to further elucidate the mechanisms of tumor growth in NMC and identify new targets for the treatment of this aggressive and poor prognosis disease.
POLR2A/TPR mutations as potential biomarker for better efficacy of immunoterpy in non-small cell lung cancer (NSCLC).
Authors: Zeng Xiaoyuan , Zhao Fei , Chen Yaoxu
Published: June 2021

e21011

Background: Immunotherapy represents promising treatment in patients with non-small cell lung cancer (NSCLC).However, response rates for immunotherapy remain limited. There is a need to identify potential biomarkers to distinguish patients who respond to immunotherapy. POLR2A has been reported to be a potential target gene for immunotherapy of HER2-low breast cancer with 17p loss, together with TPR, responsible for RNA binding that is essential for cell survival. It is unclear whether POLR2A/TPR mutations could predict the efficacy of immunotherapy in NSCLC. Methods: WES (Whole Exome Sequencing) and survival data of NSCLC patients treated with anti–PD-1/PD-L1 or anti–CTLA-4 antibodies (Rizvi2015; Miao2018) were analyzed. WES, survival data of 1144 patients with NSCLC was obtained from The Cancer Genome Atlas (TCGA). In addition, the tumor-infiltrating immune cells present in NSCLC were analyzed by CIBERSORT, utilizing data from 515 patients by lung adenocarcinoma (LUAD) in TCGA pan-cancer cohort. Results: POLR2A/TPR mutations were significantly associated with better PFS in Rizvi2015 cohort (HR = 0.3; 95% CI, 0.09-1.02; P = 0.041), MIAO2018 cohort (HR = 0; 95% CI, 0-INF; P = 0.01). In TCGA, no association between POLR2A/TPR mutations and OS was observed (P = 0.67), suggesting that POLR2A/TPR mutations were not prognostic factor. POLR2A/TPR mutations were associated with higher TMB and TNB (p = 0.00018 and p = 0.00016 in Rizvi2015 cohort, p = 0.0042 and 0 = 0.0038 in Miao2018 cohort). In addition, POLR2A or TPR mutations was positively correlated with infiltrating levels of T cells CD4+ memory activated( p = 0.011), T cells CD8+(p = 0.017), and Macrophages M1(p = 0.0055). Conclusions: Our finding suggests that POLR2A/TPR mutations were associated with better PFS in NSCLC patients treated with Immunotherapy, with significantly higher TMB and TNB. The role of PTPRD/PTPRT in immunotherapy could be related with better immune cell infiltration.
Correlation of microsatellite-instable (MSI) status and genomic characteristics in 12,000 Chinese lung cancer patients.
Authors: Su Liufu , Liu Xinyi , Huang Xiaochun , Huang Mengli
Published: June 2021

e21019

Background: Microsatellite-instable-high (MSI-H) is a strong biomarker for favorable response to immune checkpoint blockade (ICI) therapies. The objective response rate was 30%̃40% in advanced MSI-H solid tumors receiving ICI treatment, while MSI status is rarely considered in lung cancer in setting of ICI treatment. MSI-H occurred in 0.8%̃2% lung cancer patients tested by PCR method. Immune microenvironment of MSI-H lung cancer had not been studied on a large scale. We explored the association of MSI status, genetic profile and PD-L1 expression in a large Chinese lung cancer cohort to elucidate the molecular characteristics of MSI-H lung cancer. Methods: MSI status was determined by PCR test in tumor tissue and by an in-house algorithm in blood specimen. The tumor samples were sequenced by next-generation sequencing to call single nucleotide variants (SNVs) and copy number variants (CNVs). PD-L1 expression was evaluated by TPS. Results: 67 pts were determined as MSI-H in total of 12,485 pts, namely the frequency of MSI-H was 0.5% in Chinses lung cancer. 26 MSI-H pts were harboring EGFR mutations, including Ex19del in 10 pts, L858R in 6 pts, T790M in 5 pts, EGFR gain in 4 pts, and other uncommon mutations such as C797, L861Q. Interestingly, no EGFR Ex20ins was detected. In the other 41 non-EGFR-mutant pts, RET fusion were detected in 2 pts, FGFR2/3 SNV were detected in 5 pts, KRAS activating SNVs were detected in 5 pts, and PIK3CA SNV/amplification were detected in 8 pts. No ICI response negative alterations (CDKN2A/B loss, MDM2/4 gain) were detected in MSI-H patients. 125 genes, including MSH6, MLH1, BRCA2, NOTCH1, TGFBR2, ACVR2A and etc, had higher frequency in MSI-H lung cancers than MSS lung cancers in our cohort. Moreover, only MAP3K1 gene SNV occurred more frequently in MSS lung cancers (4.5% vs 7.7%, p < 0.001). MSI-H lung cancer had a trend for enrichment of PD-L1 positivity (TPS > 1%) but no significance (58% vs 43%, p = 0.205). Conclusions: About 50% MSI-H lung cancers harbored actionable mutations for targeted agents (EGFR TKIs or other TKIs), while EGFR Ex20ins might exist mutually exclusively with MSI-H. MSI-H lung cancer had much more mutational genes than MSS lung cancer, which was consistent with previous studies. On the other hand, MAP3K1 was the only gene with lower mutational frequency in MSI-H lung cancer. Our results revealed the genetic mutational characteristics of MSI-H lung cancer and provided suggestions for treatment decisions of this patient population.
Whole-exome sequencing on circulating tumor cells explores platinum-based chemotherapy resistance in advanced non-small cell lung cancer.
Authors: Li Rong , Wu Shuangxiu , Chang Yuanyuan , Wang Yin , Li Boyi
Published: June 2021

e21021

Background: Circulating tumour cells (CTCs) have important applications in clinical practice on early tumour diagnosis, prognostic prediction and treatment evaluation. Platinum-based chemotherapy is the first-line treatment for non-small cell lung cancer (NSCLC) patients without targeted drugs. But most patients progressed after a period of treatment. Therefore, to dissect the genetic information contributing to drug resistance and tumour progression in CTCs is valuable for guidance of treatment adjustment. Methods: In this study, we enrolled 9 NSCLC patients treated with platinum-based chemotherapy. For each patient, 10 CTCs were isolated after progression to perform a single cell-level whole-exome sequencing (WES). Meanwhile the patients’ paired primary-diagnosed FFPE sample and progressive biopsy specimens were also performed WES. Results: Comparisons of WES data between primary and progressive specimens, as well as CTCs revealed that more than half patients’ tumour mutation burden (TMB) increased after progression. Dozes to hundreds of single-nucleotide variants (SNVs) and insertions or deletions (Indels) were detected in the CTCs. Slightly more proportion of SNVs/Indels in CTCs shared with paired primary tumours (1.2%-23.1%) than with progressive samples (0.6%-11.7%). Conclusions: Functional annotation on SNVs/Indels showed that CTCs not only harboured cancer driver gene mutations, such as EGFR and TP53, shared with primary and/or progressive tumours, but also harboured chemotherapy-resistance and stem cell-related gene mutations, including SHKBP1, NUMA1, ZNF143, MUC16, ORC1, PON1, PELP1, etc. which have crucial roles in drug resistance and poor prognosis for NSCLCs. Thus, detection of genetic information in CTCs was necessary for guidance of individual therapy and drug resistance study.
Outcomes of KRAS mutated, EGFR mutated, ALK mutated and wildtype patients in non-small cell lung cancer brain metastases.
Authors: Rauf Yasmeen , Tatineni Vineeth , Oshea Patrick joseph , Jia Xuefei , Peereboom David M. , Ahluwalia Manmeet Singh
Published: June 2021

e21028

Background: Non-small cell lung cancer (NSCLC) is the most common primary tumor leading to brain metastases. Multiple genetic markers have been profiled in NSCLC patients for potential targeted therapies. EGFR is mutated in up 50% of NSCLCs, while ALK is mutated in around 4-7%. KRAS is the most commonly overexpressed marker, seen in up to 85% of all lung cancers. In this retrospective study, we evaluated the overall survival (OS) and progression-free survival (PFS) between NSCLCBM patients with KRAS mutations, ALK mutations, EGFR mutations, and wildtype. Methods: NSCLCBM patients diagnosed between 2010 and 2019 were analyzed. We collected information regarding molecular marker status, systemic therapies, and date of progression. We defined OS as the date of diagnosis of brain metastases to the date of last follow-up or death. OS and PFS were estimated by the Cox proportional model. Results: We found a total of 2989 NCSLCBM patients, 184 were KRAS mutated, 68 had an ALK gene rearrangement, 184 were EGFR mutated, and 1469 were wildtype. The respective median age was 64.3 years, 64.5 years, 58.2 years, and 64.2 years. Females made up 61.8% of KRAS-positive, 51.8% of ALK-positive, 63% of EGFR-positive, and 46.4% of wildtype patients. The median OS (mOS) in patients who were KRAS-positive, ALK-positive, EGFR-positive, and wildtype were 43.3 months, 119.2 months, 57.9 months, and 33.1 months, respectively. The median PFS (mPFS) for the same cohort was 38.0 months, 112.4 months, 55.3 months, and 30.5 months, respectively. ALK-positive patients showed statistically significant mOS (p-value (p) < 0.001) and mPFS (p = 0.002) when compared to EGFR-positive, KRAS-positive, and wildtype patients. Conclusions: Molecular mutations serve as both prognostic predictors and alternative targeted therapies for NSCLCBM treatment. Our retrospective study showed improved mOS and mPFS in NSCLCBM patients with ALK rearrangements when compared to patients with EGFR mutations, KRAS mutations, and the wildtype. While these results looked at patient outcomes with specific tumor markers, further investigation needs to be done regarding outcomes of specific therapies in each cohort, as well as, intracranial lesion response.
Anlotinib combined with pemetrexed and carboplatin as first-line treatment in advanced nonsquamous non-small cell lung cancer (NSCLC): ALTER L012.
Authors: Wang Qiming , Yang Xiuli , Ma Tianjiang , Yang Qiumin , Zhang Chenghui , Chen Yunfang
Published: June 2021

e21040

Background: The anti-angiogenic drug bevacizumab combined with chemotherapy has achieved positive results in previous studies. In particular, the median progression-free survival (PFS) for EGFR-negative patients was increased to 8.3 months in the BEYOND study. Unlike bevacizumab, anlotinib is a novel multitarget tyrosine kinase inhibitor and can be conveniently orally administered. In the phase III trial ALTER 0303, anlotinib significantly improved overall survival (OS) and PFS in advanced NSCLC patients. This exploratory study aims to establish the efficacy and safety of anlotinib in combination with pemetrexed and carboplatin as first-line treatment in advanced non-squamous NSCLC. Methods: This is a multi-center, single-arm clinical trial. Adults with treatment-naive, histologically confirmed stage IIIB-IV non-squamous NSCLC, ECOG 0-1, and without known sensitizing EGFR/ALK alterations are included. Patients received anlotinib (12 mg p.o., QD, d1 to 14, 21 days per cycle) combined with pemetrexed (500 mg/m2, iv, d15-21, Q3W) + carboplatin (AUC = 5, iv, d15-21, Q3W) for 4 cycles followed by anlotinib and pemetrexed maintenance until disease progression (PD). The primary endpoint was PFS. Secondary endpoints were OS, objective response rate (ORR), disease control rate (DCR) and safety. Results: Between Mar 2019 and Dec 2020, 40 patients were enrolled in six centers and 31 of them have received at least one tumor assessment. Median age was 62 (33, 75); 66.7% male, 11.1% brain metastasis. At data cutoff (Dec 31, 2020), patients were followed up for a median of 8.26 months. Median PFS was 10.5 months (95% CI: NE, NE); ORR was 67.7% (0 CR, 21 PR), DCR was 96.8% (0 CR, 21 PR, 9 SD) and median OS was NE. The most common Grade ≥ 3 AEs were hypertension 22.2%, neutropenia 19.44%, myelosuppression 11.1%, thrombocytopenia 8.33%, leukopenia 5.56%, hand-foot syndrome 5.56% and there were no Grade 5 toxicities. Conclusions: This study finds that anlotinib plus pemetrexed and carboplatin can significantly improve PFS and ORR compared to standard chemotherapy for treatment-naive non-squamous NSCLC patients. The combination was well tolerated, and the AEs were manageable. The follow-up time is not sufficient, and the OS outcomes need further evaluation. Clinical trial information: NCT03790228.
Costs comparison of the immune check point inhibitors versus survival ratio in first-line non-small lung cancer.
Authors: Guirgis Helmy M.
Published: June 2021

e21050

Background: Five-year overall survival (OS) was reported in 20% of patients treated by Pembrolizumab (Pembro) in 1st-line advanced/metastatic (a/m)-non-small lung cancer (nsLC). Costs of the immune check point inhibitors (ICI) are relatively high and bound to increase with extended use. We purposed to weigh and compare costs of ICI vs outcome. Methods: OS, hazard ratio (HR) and survival ratio (SR) defined as (1.0-HR) were used. Chemo-drug excluded; costs were calculated in US$. Results: Adjuvant Durv one-year costs in unresectable stage III were $130,956, OS gain 363 days and SR 0.47. Pembro one-year costs were $134,778. OS were 474 and SR 0.37 in programmed death receptor-ligand-1 > 50%. At 5 years, costs were $673,890. Costs of 35-cycle Pembro combination were $336,945, OS 339 and SR 0.51. Costs increased with extended use. Atezolizumab/Bevacizumab-combination (Atezo/Bev) costs x 2-years were $492,114, OS 135 and SR 0.22. Using Biosimilar Bev costs dropped to $429,744. Ipilimumab/Nivolumab (Ipi/Nivo) costs x 2 were $544,696, OS 141 and SR 0.34. Costs of both Atezo/Bev and Ipi/Nivo increased by 50% with one year of extended use. Costs of Pembro-combination were 0.78 lower than Atezo/Bev and 0.62 than Ipi/Nivo. Pembro SR were 2.32 higher than Atezo/Bev and 1.65 than Ipi/Nivo. Absence of direct comparison, however, cast doubts on Pembro advantage. Conclusions: Costs of one-year adjuvant Durv, 3-year Pembro and 35-cycle Pembro-combination were considered fair and equitable with their corresponding SR. Pembro-combination costs were cheaper than Atezo/Bev and Nivo/Ipi. Costs of all drugs and combinations multiplied with extended use.
Comparison of fusions detection by next generation sequencing between malignant pleural effusion and tumor tissue in lung cancer.
Authors: Xu Yurong , Qi Yingxue , Luo Ningning , Zhang Qin , Wu Yaqing , Qi Chuang
Published: June 2021

e21059

Background: Anaplastic lymphoma kinase ( ALK), c-ros oncogene 1 receptor tyrosine kinase ( ROS1), ret proto-oncogene ( RET) and neurotrophic receptor kinase ( NTRK) are important driver genes in lung cancer. Each of these four genes fusions as therapeutic targets have been recommended by the national comprehensive cancer network (NCCN) guidelines for non-small cell lung cancer (NSCLC). Malignant pleural effusion (MPE) is observed in multy types of malignancies, especially in lung cancer. Studies have indicated that next generation sequencing (NGS) detection of somatic mutations by MPE is reliable. Nevertheless, the distribution and comparison of fusions in lung cancer between malignant pleural effusion and tumor tissue specimen have not been well characterized yet. Methods: In this study, 9-gene, 69-gene and 539-gene panel NGS profiling were performed by MPE and tumor tissue in 640 and 10013 patients with lung cancer respectively. The variation analysis between patients with or without gene fusion in different sample groups were calculated by fisher exact test via SPSS v26.0. Results: In lung cancer patients using MPE detection, 59 of 640 (9.22%) were found harboring at least one of the four gene fusions, and the ratio of ALK, ROS1, RET and NTRK fusion was 6.25% (40/640), 1.41% (9/640), 0.63% (4/640) and 0.47% (3/640) respectively. Meanwhile, we found gene fusions in 6.25% (626/10013) lung cancer patients using tumor tissue detection, including 3.66% (366/10013) ALK fusion, 1.07% (107/10013) ROS1 fusion, 1.09% (108/10013) RET fusion and 0.22% (626/10013) NTRK fusion. Significant differences of gene fusion frequency between different sample groups were found via fisher exact test ( p = 0.005), especially ALK fusion ( p = 0.001). Conclusions: The frequency of fusion in MPE was significantly higher than in tumor tissue, especially ALK fusion. However, as a retrospective study, the conclusions and the specific mechanisms are needed to be verified.
The efficacy and safety of EGFR-TKI combined with chemotherapy in NSCLC patients with EGFR co-mutation with other oncogenic alterations.
Authors: Zhao Wenhua , Jiang Wei , Qiu Hongtu , Zeng Aiping , Song Xiangqun , Zhou Shaozhang , Ning Ruiling , Su Cuiyun , Wang Huilin , He Jianbo , Zhao Yun , Tan Liping , Yu Qitao
Published: June 2021

e21077

Background: Previous studies indicated primary resistance to EGFR-TKIs might occur in EGFR co-mutation with other oncogenic alterations. However, the optimal therapeutic regimen for advanced NSCLC with EGFR co-mutation was still unknown. This respective observation study aimed to assess the efficacy and safety of the combination therapy with EGFR-TKI and chemotherapy in this sub-population. Methods: In this retrospectively study, from March 2017 to November 2019 advanced NSCLC patients with EGFR mutation detected using next-generation sequencing targeting 59 genes were screened for eligibility. We included patients of EGFR co-mutation with other oncogenic alterations receiving EGFR-TKI monotherapy or TKI plus chemotherapy as first-line therapy. The primary outcome was objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Disease control rate (DCR) and safety profile were considered to be the secondary endpoints. Results: Total 48 patients were enrolled. Among patients with concomitant mutation, the combination of chemotherapy with TKI was found to prolong mPFS (12.5 vs 7.3 months; HR, 0.38; 95%CI: 0.17-0.81; P = 0.012) compared with TKI monotherapy, with a trend of longer mOS (27.0 vs 22.4 months; HR, 0.40; 95%CI: 0.15-1.05; P = 0.062) and higher ORR (68.4% vs 44.8%, P = 0.113). The DCR were 100% in combination group and 93.1% in monotherapy group (P = 0.99). A proportion of 13.8% patients reported grade≥3 treatment-related adverse events in monotherapy group and 36.8% in combination group. Conclusions: EGFR co-mutation with other oncogenic alterations associated with poor treatment outcome with EGFR-TKI monotherapy. The combination of EGFR-TKI and chemotherapy was effective in this sub-population and side-effects were tolerable. The outcomes of this study should be confirmed by prospective clinical trials in future.
Adverse events in non-small cell lung cancer patients receiving immune checkpoint inhibitors: A single center, real-world study in China.
Authors: Xu Chongrui , Tu Hai-Yan , Sun Yueli , Li Yang-Si , Xu Bingfei , Wang Binchao , Chen Hua-Jun , Wang Zhen , Zhou Qing , Yang Jinji , Yang Qi , Wu Yi-Long
Published: June 2021

e21081

Background: Immune checkpoint inhibitors (ICIs) have improved clinical outcomes in non-small cell lung cancer (NSCLC), whereas they also can cause various adverse events (AEs). We reported the incidences, spectrum and severity of AEs in real-life practice after the approval of ICIs in Chinese NSCLC patients. Methods: In this single center, retrospective study, anonymized electronic medical record data were collected from the dedicated lung cancer immunotherapy outpatient clinic of Guangdong Provincial People’s Hospital through the LinkDoc database. The patients (≥18 years old) with pathologically diagnosed metastatic NSCLC who receiving ICIs between 1 June 2019 and 31 December 2020 were included. The immune-related adverse events (irAEs) were diagnosed and assessed by oncologists. All AEs were classified and graded according to the National Cancer Institute Common Toxicity Criteria for Adverse Events (CTCAE V5.0). Results: A total of 203 patients with a median age of 60.5 years were included in this study. Most patients were male (81.8%), smokers (49.8%), non-squamous histological type (51.7%). 61.1% of patients visited the outpatient clinic more than once. Pembrolizumab and Nivolumab were given to the majority of patients (80.8%). 114 patients (56.2%) received single-agent and 89 patients (43.8%) received combination therapy. The median duration of ICIs therapy was 271.2 days. In our study, 68.0% of patients experienced any-grade AEs, and 19.7% experienced grade≥3 AEs. The most commonly AEs were abnormal laboratory findings (57.1%), blood and lymphatic system disorders (25.1%), and respiratory disorders (19.7%). All of 93 patients (45.8%) experienced irAEs and 6 patients (8.4%) developed grade≥3 irAEs. The most frequent irAEs included blood and lymphatic system disorders (25.1%), hepatobiliary disorders (17.7%), and cardiac disorders (9.9%). Cough (3.4%), sputum (2.5%), and pain (2.0%) were the most frequent AEs which received treatment. Conclusions: Our results showed 68.0% and 45.8% patients experienced AEs and irAEs, respectively. The AEs and irAEs were primarily low grade. This study also demonstrated the information of AEs could be well collected and managed through our dedicated lung cancer immunotherapy outpatient clinic. [Table: see text]
Analysis of first-line treatment (tx) patterns in advanced non-small cell lung cancer (NSCLC) patients (pts) with compromised performance status (PS), organ dysfunction (dfxn) or other significant comorbidities.
Authors: Judd Julia , Handorf Elizabeth A. , Gupta Brinda , Edelman Martin
Published: June 2021

e21093

Background: NSCLC is a disease of the elderly and most cases are related to tobacco. Therefore, concomitant organ dfxn, which increases the risk of toxicity with cancer directed therapy, is prevalent. Patterns of care studies have shown that the elderly, those with organ dfxn or compromised PS are frequently not treated, despite prospective studies demonstrating survival benefit with active tx. We hypothesized that the advent of new, more active therapies has resulted in practice changes in these populations. Methods: We conducted a retrospective, observational cohort study using the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database to compare first line tx patterns from 2011 to 2020 in pts with advanced NSCLC meeting at least 1 of the following criteria: age > 70 years, organ dfxn (serum creatinine > 1.5 times the upper limit of normal [ULN] and/or total bilirubin > 2 times ULN), ECOG PS > 2 or documented HIV. Pts were excluded if there was a > 90-day post-diagnosis gap in EHR data. Tx patterns were categorized as having received standard, non-standard or no frontline tx. Tx groups included PD-1/PD-L1 inhibitor single agent, chemoimmunotherapy, platinum-based (Plat) doublet +/- VEGF inhibitors (VEGFi), single agent chemotherapy (chemo) and tyrosine kinase inhibitors (TKIs). Descriptive statistics were used to analyze tx patterns, and the relationship between txs and variables of interest were tested using Chi-squared tests or t-tests. Results: Of the 58,145 pts with advanced NSCLC in the database, 33,701 met at least 1 criterion for inclusion. There was a small but significant increase in the number of pts treated with standard therapy from 2011 to 2020 (p < 0.001). There was rapid uptake of PD-1/PD-L1 inhibitors as well as chemoimmunotherapy upon FDA approvals in 2016 and 2018, respectively. This correlated with a rapid decrease in the use of Plat-doublet chemo +/- VEGFi as well as a decrease in the number of pts receiving single agent chemo or not treated at all (Table). Conclusions: Real world data from 2011 to 2020 demonstrates an increase in the use of standard therapies as well as the rapid incorporation of immunotherapy into first line tx in advanced NSCLC pts who are elderly, have a poor PS, or organ dfxn. However, a substantial proportion of pts (28.9%) still do not receive any documented tx, within the Flatiron Health network.[Table: see text]
Fibroblast growth factor receptor (FGFR) inhibitor rogaratinib in patients with advanced pretreated squamous-cell non-small cell lung cancer over-expressing FGFR mRNA: The SAKK 19/18 phase II study.
Authors: Addeo Alfredo , Joerger Markus , Rothschild Sacha , Eboulet Eric I. , Godar Gilles , Waibel-Pachinger Christine , Haefliger Simon , Mark Michael Thomas , Fernandez Eugenio , Mach Nicolas , Mauti Laetitia A. , Frueh Martin
Published: June 2021

e21119

Background: A substantial proportion of patients with squamous lung cell carcinoma (SQCLC) (46%) exhibit tumor overexpression of fibroblast growth factor receptor (FGFR) messenger ribonucleic acid (mRNA). Rogaratinib is a novel pan-FGFR inhibitor with anti-tumor activity in pre-clinical models as a single agent in FGFR pathway-addicted tumor models. Phase I data showed promising activity and good safety profile. The objective of the SAKK 19-18 trial was to determine clinical activity and safety of rogaratinib in patients with advanced SQCLC overexpressing tumor FGFR1-3 mRNA. Methods: Patients with metastatic SQCLC, previously treated with systemic treatment, overexpressing tumour FGFR mRNA were treated with rogaratinib 600 mg BID until progression of disease or drug intolerance. A rate ≤15% of PFS at 6 months was considered uninteresting, whereas a PFS rate at 6 months ≥38% was considered promising. Ten patients were needed in the first stage with at least 2 achieving 6 months PFS in order to continue the accrual. Results: Between May and November 2020, 49 patients were screened and 20 were classified FGFR positive. Among them15 patients were registered in the trial and the first 10 were assessed for the first stage analysis. Most commons treatment related adverse events (TRAEs) were hyperphosphatemia (60%), diarrhoea (20%), and dry mouth (20%). Grade ≥3 TRAEs occurred in 50% of the patents with Hypercalcemia being the most frequent one (20%). Among 10 first patients only 1 achieved 6 months PFS while 2 was the boundary required for continuing this trial. Conclusions: Despite preliminary signal of activity, rogaratinib failed to improve PFS in patients overexpressing tumor FGFR mRNA. Further studies on a more reliable biomarker are needed, the development of rogaratinib in SQCLC has been put on hold by Bayer and the SAKK 19/18 study was terminated early due to lack of efficacy. Clinical trial information: NCT03762122.
Association between germline DNA damage repair-related genes mutation and tumor mutational burden in lung cancer patients.
Authors: Nie Wei , Zhong Hua , Zhang Ding , Chen Shiqing , Han Baohui
Published: June 2021

e21163

Background: Deleterious somatic DNA damage repair (DDR) gene mutations are frequent in non-small cell lung cancer (NSCLC) and are associated with improved clinical outcomes of immunotherapy. DDR gene mutations are associated with higher tumor mutational burden (TMB) in cancer. However, the effect of germline DDR-related genes mutation with different functional annotations on TMB in NSCLC patients is still unclear. Methods: 1671 Chinese patients with NSCLC were enrolled in this study. Genomic profiling was performed on formalin-fixed paraffin-embedded tumor samples or peripheral blood by next generation sequencing (NGS) with 733 cancer-related genes panel. The germline mutation data were obtained. All annotations in clinical significance were according to the 2015 American College of Medical Genetics and Genomics-Association for Molecular Pathology (ACMG-AMP) guidelines. Results: 1076 patients (64.39%) had germline DDR-related gene mutations and 595 (35.61%) had no germline DDR-related gene mutations. Among patients with DDR-related gene mutations, 78 (7.25%) patients had the pathogenic (P) mutations or likely pathogenic (LP) mutations and 1056 (98.14%) had variants of unknown significance (VOUS) mutations. In total, the median TMB was 3.91 mutations/MB (range, 0-68.16) and 4.47 mutations/MB (range, 0-51.40) in patients with P, LP or VOUS mutations and no germline DDR-related gene mutations, respectively. To the further analysis, we divided patients with germline DDR-related gene mutations into three groups: only P or LP mutations (Group 1), only VOUS mutations (Group 2) and concurrence with P/LP/VOUS mutations (Group 3). Compare to the DDR-negative group, TMB was significantly lower in Group 2 (P < 0.001). No significant differences in Group 1 and Group 3 were observed. In addition, we found that mutations in different DDR pathway could not affect TMB value significantly. Conclusions: Germline DNA damage repair-related genes mutation may be not associated with TMB.
A multicenter, randomized, phase II trial of anlotinib plus docetaxel versus docetaxel in EGFR-negative NSCLC patients after progression on first-line platinum-base chemotherapy: ALTER-L018.
Authors: Wu Lin , Wu Zhijun , Xiao Zemin , Ma Zhongsha , Weng Jie , Chen Yanhua , Cao Yongqing , Cao Peiguo , Xiao Maoliang , Zhang Hui , Duan Huaxin , Wang Qianzhi , Li Jia , Xu Yan , Pu Xingxiang , Li Kang
Published: June 2021

e21186

Background: Docetaxel is one of the standard second-line treatments for advanced non-small cell lung cancer (NSCLC), but the effect is limited. The combination of docetaxel and antiangiogenic drug (ramucirumab/nintedanib) has demonstrated antitumor activity as second-line therapy in advanced NSCLC. Anlotinib, an oral multi-target angiogenesis TKI targeting the VEGFR, FGFR, PDGFR and c-Kit, can prolong both PFS and OS of refractory advanced NSCLC patients in phase III trial (ALTER0303). We conducted ALTER-L018 to evaluate improvement of the efficacy and safety of anlotinib plus docetaxel in EGFR-negative refractory advanced NSCLC. Methods: ALTER-L018 (NCT03624309) is an ongoing, open-label, multicenter, randomized, controlled comparative, phase II trial, which was performed at 10 sites in China. Eligible EGFR-negative NSCLC patients (pts), who has been assessed progression after first-line platinum-based chemotherapy (combined with or without Immune checkpoint inhibitors), were randomly assigned (in a 1:1 ratio) to group A (anlotinib: 12mg QD from day 1 to 14 of a 21-day cycle +docetaxel: 75mg/m2 Q3W) and group B (docetaxel: 75mg/m2 Q3W). The primary end point was PFS, and secondary end points included OS, ORR, DCR and safety. Results: Between Jan 14, 2019, and Feb 7, 2021, 73 patients (pts.) were enrolled and 8 pts. were excluded from the safety and efficacy analysis set (n = 65) due to inclusion violations. 65 pts characteristics (28 pts in group A / 37 pts in group B): median age: 55(40-71)/57(39-74); male: 82% / 78%; non-squamous NSCLC: 75% / 65%; Immunotherapy in the front line: 18% / 22%. Median PFS were 4.03 months (95%CI: 2.98-5.08) in group A and 1.7 months (95%CI: 0.45-2.95) in group B (HR 0.40; 95% CI :0.21-0.77; p = 0.004); In group A and B, ORR and DCR were 32.14% versus 8.11%(p = 0.042), 82.12% versus 54.05%(p = 0.29), respectively. The adverse events that possibly or definitely related to therapy occurred in 26 (93%) of pts. experienced total of 52 grade 1-2 adverse events in group A, and in 25 (68%) of pts. experienced total of 25 grade 1-2 adverse events in group B. The most common grade ≥3 TRAE were leukopenia (5, 18%), neutropenia (5, 18%) and thrombocytopenia (3, 11%) in group A, and leukopenia (3, 8%), neutropenia (2, 5%) and thrombocytopenia (1, 3%) in group B. Conclusions: This combination of anlotinib and docetaxel showed clinical benefit in EGFR-negative NSCLC patients in terms of PFS, ORR, and with manageable safety profile. It is a viable option for relapsed NSCLC, who has been assessed progression on first-line platinum-base chemotherapy combined with/without Immune checkpoint inhibitors, or who can’t tolerate Immunotherapy. Clinical trial information: NCT03624309.
PREX2 mutation serves as a novel predictor of response to anti-PD-1/PD-L1 treatment in melanoma.
Authors: Cai Lifang , Chen Dongsheng , Zhang Qin , Duan Qianqian , Liu Yaqin , Li Si , Xiao Mingzhe
Published: June 2021

e21504

Background: Melanoma is notable for its metastatic propensity, lethality in the advanced setting and association with ultraviolet exposure early in life. Analysis of whole-genome sequence data identified PREX2 (phosphatidylinositol-3,4,5-trisphosphate-dependent Rac exchange factor 2)-a PTEN-interacting protein and negative regulator of PTEN in breast cancer--as a significantly mutated gene with a mutation frequency of approximately 14% in an independent extension cohort of 107 human melanomas. PREX2 mutations are biologically relevant, as ectopic expression of mutant PREX2 accelerated tumour formation of immortalized human melanocytes. Previous work suggested that PREX2 alterations may enrich for responses to immune checkpoint inhibitors (ICI), validation of function in melanoma is needed. Methods: Using 539-gene target-capture next generation sequencing, we analyzed the PREX2 mutation in 3547 tumor tissue or plasma ctDNA samples (including 122 melanoma) from different patients, and the public database of TACG was also compared. Data from Snyder-64 study (n = 64, anti- CTLA-4 therapy) was retrieved and analysed. In survival analysis, Kaplan-Meier curves were compared by log-rank test, and the hazard ratio (HR) was determined through a multivariable Cox regression model. Results: In clinical cohort, the frequency of PREX2 mutation in 3547 tumor tissue or plasma ctDNA samples from different patients was 5.94 % (211 in 3547). Meanwhile, the frequency of PREX2 mutation in TCGA cohort was 5.06 % (555 in 10953). In melanoma datebase, the frequency of PREX2 mutation in 122 melanoma tumor tissue or plasma ctDNA samples from different patients was 6.55 % (78 in 122). Meanwhile, the frequency of PREX2 mutation in melanoma in TCGA cohort was 25.56 % (113 in 422). We further analyzed Kaplan-Meier curves from Snyder-64 study (n = 64, anti- CTLA-4 therapy). In Snyder-64 study melanoma cohort, mutation of PREX2 was associated with higher neoantigen load (P = 0.02) and higher mutation count (P = 0.0027) in melanoma. PREX2 mutation was associated with prolonged overall survival (OS) trend compared with PREX2 wt in melanoma cohort (P = 0.09). Conclusions: In our study, the frequency of PREX2 mutation in pan cancers and melanoma was investigated in clinical and TCGA cohort, which might provide useful information to guide precision medicine. PREX2 mutation may serve as a novel predictor of response to anti-PD-1/PD-L1 treatment in melanoma via upregulating neoantigen load and mutation count.