Preoperative and Postoperative Systemic Therapy for Operable Non–Small-Cell Lung Cancer

Cisplatin-based adjuvant chemotherapy remains the standard of care for patients with resected stage II or III non–small-cell lung cancer. However, biomarker-informed clinical trials are starting to push the management of early-stage lung cancer beyond cytotoxic chemotherapy. This review explores recent and ongoing studies focused on improving cytotoxic chemotherapy and incorporating targeted and immunotherapies in the management of early-stage, resectable lung cancer. Adjuvant osimertinib for patients with EGFR-mutant tumors, preoperative chemoimmunotherapy, and adjuvant immunotherapy could improve outcomes for selected patients with resectable lung cancer, and ongoing or planned studies leveraging biomarkers, immunotherapy, and targeted therapy may further improve survival. We also discuss the unique barriers associated with clinical trials of early-stage lung cancer and the need for innovative trial designs to overcome these challenges.

Impact of Salvage Cytotoxic Chemotherapy on Prognosis in Patients with Recurrence After Radical Cystectomy: A Multi-Institutional Retrospective Study

Background In patients experiencing disease recurrence after radical cystectomy (RC) for bladder cancer, data about the impact of clinicopathologic factors, including salvage treatment using cytotoxic chemotherapy, on the survival are scarce. We investigated the prognostic value of clinicopathologic factors and the treatment effect of salvage cytotoxic chemotherapy (SC) in such patients. Methods In this retrospective study, we evaluated the clinical data for 86 patients who experienced recurrence after RC. Administration of SC or of best supportive care (BSC) was determined in consultation with the urologist in charge and in accordance with each patient’s performance status, wishes for treatment, and renal function. Statistical analyses explored for prognostic factors and evaluated the treatment effect of SC compared with BSC in terms of cancer-specific survival (CSS). Results Multivariate analyses showed that liver metastasis after RC (hazard ratio [HR]: 2.13; 95% confidence interval [CI]: 1.17 to 3.85; P = 0.01) and locally advanced disease at RC (HR: 1.92; 95% CI: 1.06 to 3.46; P = 0.03) are independent risk factors for worse CSS in patients experiencing recurrence after RC. In a risk stratification model, patients were assigned to one of two groups based on liver metastasis and locally advanced stage. In the high-risk group, which included 68 patients with 1–2 risk factors, CSS was significantly better for patients receiving SC than for those receiving BSC (median survival duration: 9.4 months vs. 2.4 months, P = 0.005). The therapeutic effect of SC was not related to a history of adjuvant chemotherapy. Conclusions The present study indicated the potential value of 1st-line SC in patients experiencing recurrence after RC even with advanced features, such as liver metastasis after RC and locally advanced disease at RC.

Combination of Abemaciclib following Eribulin Overcomes Palbociclib-Resistant Breast Cancer by Inhibiting the G2/M Cell Cycle Phase

Breast cancer remains a leading cancer burden among women worldwide. Acquired resistance of cyclin-dependent kinase (CDK) 4/6 inhibitors occurs in almost all hormone receptor (HR)-positive subtype cases, comprising 70% of breast cancers, although CDK4/6 inhibitors combined with endocrine therapy are highly effective. CDK4/6 inhibitors are not expected to cooperate with cytotoxic chemotherapy based on the basic cytotoxic chemotherapy mode of action that inhibits rapidly proliferating cells. The palbociclib-resistant preclinical model developed in the current study investigated whether the combination of abemaciclib, CDK4/6 inhibitor with eribulin, an antimitotic chemotherapy could be a strategy to overcome palbociclib-resistant HR-positive breast cancer. The current study demonstrated that sequential abemaciclib treatment following eribulin synergistically suppressed CDK4/6 inhibitor-resistant cells by inhibiting the G2/M cell cycle phase more effectively. The current study showed the significant association of the pole-like kinase 1 (PLK1) level and palbociclib resistance. Moreover, the cumulative PLK1 inhibition in the G2/M phase by each eribulin or abemaciclib proved to be a mechanism of the synergistic effect. The synergistic antitumor effect was also supported by in vivo study. The sequential combination of abemaciclib following eribulin merits further clinical trials to overcome resistance to CDK4/6 inhibitors in HR-positive breast cancer.

Quantitative Analysis of SARS-CoV-2 Antibody Status between Patients with Cancer and Healthy Individuals with Extended Vaccination Dosing Intervals in Canada

(1) Background: To date, data addressing the antibody response of cancer patients to SARS-CoV-2 vaccines are limited. To our knowledge, this is the first report to evaluate humoral immunity. responses in Canadian cancer patients. (2) Methods: 116 cancer patients and 35 healthy participants were enrolled in this cross-sectional study. The interval between the first and second doses were closely matched during analysis. IgG antibodies against the SARS-CoV-2 spike receptor–binding domain were determined using an enzyme-linked immunosorbent assay (ELISA). (3) Results: Following two doses of SARS-CoV-2 vaccine (including BNT162b2, AZD1222, and mRNA-1273), the mean serum anti-spike protein antibody level was 382.4 BAU/mL (binding antibody unit, SD ± 9.4) in the control group, 265.8 BAU/mL (±145.7) in solid cancer patients, and 168.2 BAU/mL (±172.9) in hematological cancer patients. Observed differences were significantly lower in both solid and hematological groups when comparing to the control group (p ≤ 0.0001). In solid cancer group, patients with cytotoxic chemotherapy demonstrated significantly lower antibody levels (p < 0.01), whereas the rest of the patients showed similar antibody levels as the healthy control. Antibody levels were lower in those on treatment than those off treatment in patients with hematological malignancies (p < 0.0001) but not for those with solid cancers (p = 0.4553). (4) Conclusions: After two doses of the SARS-CoV-2 vaccination, patients with solid and hematological malignancies demonstrated impaired serological responses. This was particularly prominent if there was cytotoxic chemotherapy or systemic therapy in solid and hematological cancer, respectively.

Combination of Lenvatinib and Pembrolizumab as Salvage Treatment for Paucicellular Variant of Anaplastic Thyroid Cancer: A Case Report

Anaplastic thyroid cancer (ATC) is a rare but aggressive thyroid cancer, responsible for about 50% of all thyroid cancer-related deaths. During the last two decades, the development of a multimodal personalized approach resulted in an increased survival. Here, we present an unusual case of a 54-year old woman with a paucicellular metastatic ATC, a rare variant of ATC, who was treated with a combination of surgery, radiation therapy and cytotoxic chemotherapy. More than two years later, when the disease was rapidly growing, a combination of lenvatinib and pembrolizumab induced a partial tumor response of lung metastasis that persisted over 18 months. Paucicellular ATC may initially show a less aggressive behavior compared to other histological ATC variants. However, over the time, its clinical course can rapidly progress like common ATC. The combination of lenvatinib and pembrolizumab was effective as a salvage therapy for a long period of time.

Neoadjuvant T-DM1/pertuzumab and paclitaxel/trastuzumab/pertuzumab for HER2+ breast cancer in the adaptively randomized I-SPY2 trial

HER2-targeted therapy dramatically improves outcomes in early breast cancer. Here we report the results of two HER2-targeted combinations in the neoadjuvant I-SPY2 phase 2 adaptive platform trial for early breast cancer at high risk of recurrence: ado-trastuzumab emtansine plus pertuzumab (T-DM1/P) and paclitaxel, trastuzumab and pertuzumab (THP). Eligible women have >2.5 cm clinical stage II/III HER2+ breast cancer, adaptively randomized to T-DM1/P, THP, or a common control arm of paclitaxel/trastuzumab (TH), followed by doxorubicin/cyclophosphamide, then surgery. Both T-DM1/P and THP arms ‘graduate’ in all subtypes: predicted pCR rates are 63%, 72% and 33% for T-DM1/P (n = 52), THP (n = 45) and TH (n = 31) respectively. Toxicity burden is similar between arms. Degree of HER2 pathway signaling and phosphorylation in pretreatment biopsy specimens are associated with response to both T-DM1/P and THP and can further identify highly responsive HER2+ tumors to HER2-directed therapy. This may help identify patients who can safely de-escalate cytotoxic chemotherapy without compromising excellent outcome.

A Multi-Center Retrospective Review of COVID-19 Outcomes in Patients with Lymphoid Malignancy

Background: Early reports suggested that cancer patients have a 1.7-fold increased risk of contracting SARS-CoV-2 and higher rates of severe events and mortality compared with general population. Patients with hematologic malignancies may have worse COVID-19 outcomes, due to an impaired humoral immune response from their underlying malignancy and concurrent anticancer therapy. In this multi-center, retrospective, observational study, we evaluate the associations of COVID-19 outcomes with patient and lymphoma disease characteristics. Methods: EMRs at 10 study centers across the USA identified 519 patients with a diagnosis of lymphoma, CLL, or other lymphoid malignancies, who had a documented positive result of SARS-CoV-2 PCR or nucleocapsid antibody testing. Descriptive statistics were used to summarize the demographic and clinical characteristics. Logistic regression was used to evaluate the associations of individual characteristics with COVID-19 outcomes, adjusted for center (NYU vs. other). The interactions between each of the variables was also included in these models; since the interactions were generally small and non-significant, only the main effect of center was included. Two-sided p-values ≤0.05 were considered significant; there were no adjustments for multiple variables or endpoints. Each analysis was based on complete data for that analysis. Results: Tables 1 and 2 provide demographic and clinical characteristics, respectively, of the 519 patients. The mean age was 61.9 years, with 296 (57%) male and 374 (72%) white patients. NYU had the largest cohort (318 patients), with the remaining centers contributing a range of 3 to 69 patients (median 14). Logistic regression models for the association of each COVID-19 outcome with individual clinical and patient characteristics included adjustments for the center (NYU/other). While center effects were statistically significant, center by covariate interaction effects were not and are not included in the final models. The odds ratio (OR) estimates and p-values for each patient and CLL/lymphoma clinical variable are shown in Tables 3 and 4, respectively. The risks of experiencing a severe event, death, and hospital admission increased with age; for each 10 years of age increase, the ORs were 1.58 for experiencing severe events, 1.78 for death, and 1.65 for hospital admission. The risks of poor outcome were higher in males than in females (OR 1.93 for severe events, 1.85 for death, and 1.47 for hospital admission). Patients with Charlson Comorbidity Index (CCI) &gt;5 had a higher risk of severe events (OR 2.46), mortality (3.30) and hospital admission (2.73) compared to patients with CCI ≤5. Compared to patients with HL, patients with aggressive NHL had a higher risk of severe events (OR 4.05), mortality (4.68) and hospital admission (4.65). Patients with CLL similarly had a higher risk of severe events (OR 4.64), mortality (4.65) and hospital admission (5.93) compared to HL patients. Patients with indolent NHL had a higher risk of hospital admission (OR 3.95) but not a higher risk of mortality compared to HL. Patients in remission at the time of COVID-19 diagnosis had a lower risk of severe events (OR 0.42), mortality (0.36) and hospital admission (0.40) relative to those who were not in remission. Patients who received cytotoxic chemotherapy within 28 days of their COVID-19 diagnosis had a higher risk of severe events (OR 2.54), mortality (2.79), and hospital admission (2.31). Patients who received an anti-CD20 monoclonal antibody within 6 months of COVID-19 diagnosis had a higher risk of severe events (OR 2.60), mortality (2.17) and hospital admission (3.28). Conclusions: In addition to demographic and comorbidity risk factors identified in previous studies, our study shows that patients with aggressive NHL and CLL, or patients who have received recent cytotoxic chemotherapy or anti-CD20 mAB, may be at risk for poor COVID-19 outcome. The difference in risk between NHL and HL patients is likely associated with young age of HL patients but may also be related to differences in underlying innate and adaptive immune defects. Patients at high risk for poor outcome should be a priority for studies of monoclonal antibody prophylaxis. If defects in humoral immunity are at the root of poor outcome, this may be compounded by poor response to vaccination. Multivariate analysis of this data will be completed in advance of the meeting. Figure 1 Figure 1. Disclosures Olszewski: Celldex Therapeutics: Research Funding; PrecisionBio: Research Funding; TG Therapeutics: Research Funding; Acrotech Pharma: Research Funding; Genentech, Inc.: Research Funding; Genmab: Research Funding. Barta: Daiichi Sankyo: Honoraria; Seagen: Honoraria; Acrotech: Honoraria; Kyowa Kirin: Honoraria. Hernandez-Ilizaliturri: AbbVie: Other: Advisory Boards; Incyte: Other: Advisory Boards; Celgene: Other: Advisory Boards; BMS: Other: Advisory Boards; Pharmacyclics: Other: Advisory Boards; Amgen: Other: Advisory Boards; Kite: Other: Advisory Boards; Gilead: Other: Advisory Boards; Epyzime: Other: Advisory Boards. Leslie: Janssen: Consultancy, Speakers Bureau; Merck: Consultancy; Abbvie: Consultancy, Honoraria; Epizyme: Consultancy, Honoraria, Speakers Bureau; PCYC/Janssen: Consultancy, Honoraria, Speakers Bureau; Seagen: Consultancy, Honoraria, Speakers Bureau; TG Therapeutics: Consultancy, Honoraria, Speakers Bureau; Celgene/BMS: Consultancy, Honoraria, Speakers Bureau; Kite, a Gilead Company: Consultancy, Honoraria, Speakers Bureau; ADC Therapeutics: Consultancy; BeiGene: Consultancy, Honoraria, Speakers Bureau; Karyopharm Therapeutics: Honoraria, Speakers Bureau; AstraZeneca: Consultancy, Honoraria, Speakers Bureau; Pharmacyclics: Consultancy, Honoraria, Speakers Bureau. Diefenbach: Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding; Merck Sharp & Dohme: Consultancy, Honoraria, Research Funding; Morphosys: Consultancy, Honoraria, Research Funding; Genentech, Inc./ F. Hoffmann-La Roche Ltd: Consultancy, Honoraria, Research Funding; Perlmutter Cancer Center at NYU Langone Health: Current Employment; Incyte: Research Funding; AbbVie: Research Funding; Trillium: Research Funding; IGM Biosciences: Research Funding; IMab: Research Funding; Janssen: Consultancy, Honoraria, Research Funding; Gilead: Current equity holder in publicly-traded company; MEI: Consultancy, Research Funding; Celgene: Research Funding; Seattle Genetics: Consultancy, Honoraria, Research Funding.

Novel Single Agents Are Equivalent to Conventional Chemotherapy Inpatients with Relapsed and Refractory Mature T-Cell Lymphomas: A Meta-Analysis

Background: Patients with advanced peripheral and cutaneous T-cell lymphomas (PTCL and CTCL) have an unfavorable prognosis . Primary refractoriness to traditional chemotherapy and relapse is common. Few FDA-approved "novel" single agents (SA) are available but their effectiveness as salvage agents relative to traditional multiagent cytotoxic chemotherapy (CC) regimens remains unknown. Therefore, we conducted a systematic meta-analysis to compare the response rates of approved and experimental single agents to conventional chemotherapy for patients with relapsed and refractory (R/R) PTCL and CTCL. Methods: This systematic review is reported in accordance with the PRISMA guidelines. Briefly a Harvard University Librarian (PB) systematically searched the publication libraries of: MEDLINE (through Ovid SP), Embase, Web of Science Core Collection, and Cochrane's Central Register for adult patients with R/R PTCL and CTCL enrolled in phase I, II, and III clinical trials of novel single and cytotoxic drugs. Agents determined as novel included antifolates, histone deacetylase inhibitors (HDACi), antibody-drug conjugates, therapeutic antibodies, hypomethylating agents, cereblon modulators, inhibitors of PI3K/AKT/mTOR, JAK/STAT, aurora kinase, farnesyl transferase and proteosome pathways, and CD4 CAR T- cells. Conventional chemotherapy agents included ifosfamide-, gemcitabine-, anthracycline-, and platinum-based treatments. Three researchers (NS, RS and LB) independently reviewed eligible studies and extracted data for baseline demographics, histological subtype, treatment characteristics including response rates, duration of response, overall and progression free survival, toxicity, and risk of bias assessment. Primary outcome was overall response rate (ORR), defined as the best reported partial response (PR) or better. Meta-analyses were conducted for ORR and the scale of logarithm of odd using the generic inverse variance method. The random effects model was used to pool the effect sizes for each study assuming a normal distribution of the random effects. Preplanned subgroup by therapy type and histological subtypes of lymphoma were treated as fixed effects and compared using Wald test. The degree of statistical heterogeneity was evaluated by inconsistency index (I2). Results: Our literature search identified 1873 articles, which after filtering for inclusion and exclusion criteria, ruling in only papers including T-cell lymphoma specific response, was narrowed to 128 studies for data extraction. Of these 128 studies, 35 were phase I trials, 70 phase II, 13 phase III, and 10 were combination. First, we divided all studies into upfront (n=33) versus R/R (n=100) based on timing of their treatments. We specifically focused on patients with R/R TCLs and subdivided those studies into the novel SA (n=84) and conventional chemotherapy (n=16) categories. The ORR for novel agents was lower at 37% (95% confidence interval [CI]: 34, 41) in comparison with 55% (95% CI: 40, 69) for standard chemotherapy agents (p=0.02). When stratified by histological subtype, patients with PTCL-NOS (n=751) had comparable ORR to novel agents (31%; 95% CI: 27, 35) and conventional chemotherapy (40%; 95% CI: 31,50; p=0.08). Similar results were seen with patients with AITL (n=296) who achieved equivocal ORR to single agents (45%; 95% CI: 38, 52) when contrasted with conventional chemotherapy (55%; 95% CI: 27, 80; p=0.52). Similar efficacy was seen for patients with CTCL (n=612) across SA (34%, 95% CI:29, 40) and CC (44%; 95% CI: 33, 56; p=0.11). Conclusions: Our meta-analysis highlights that for particular histological subtypes of PTCL such as PTCL-NOS and AITL, single agents are non-inferior to cytotoxic chemotherapy regimens in the R/R setting. These findings warrant serious consideration in the design and development of clinical trials for patients with R/R PTCL and the need for tailored treatments. Our meta-analysis also informs clinicians and patients about the benefits of single agents in comparison with standard chemotherapy while making clinical decisions for specified histologies. Disclosures Foss: Mallinckrodt: Honoraria; Kyowa: Honoraria; Kura: Honoraria; Seattle Genetics: Honoraria, Speakers Bureau; Acrotech: Honoraria, Speakers Bureau; Daiichi Sankyo: Honoraria. Jain: Trillium Therapeutics, Inc: Research Funding; Acro Biotech, Inc: Research Funding; Abcuro, Inc: Research Funding.

Anti-Spike (S) Antibody Production Post Covid-19 Vaccination after B Cell Depleting Therapy (BCDT) for Non-Hodgkin Lymphoma (NHL)

Introduction: Patients with NHL have a longer duration of illness and higher mortality rate after infection with Covid-19 1-3. Vaccination is strongly recommended to mitigate these problems in the general population, however, patients with cancer were not eligible to enter the pivotal vaccine trials. Furthermore, patients with NHL as well as other hematologic malignancies are frequently treated with B cell depleting therapies (BCDT) such as Rituximab and other anti-CD20 antibodies which in theory affect antibody production after vaccination. There are no data in the literature regarding patients with NHL and scarce data on other tumors concerning the antibody response against the S protein of Sars-Cov-2. To investigate the production of antibodies against the spike protein following vaccination against Sars-Cov-2, we studied 180 patients with cancer. We also aimed to determine if factors such as timing of BCDT in relation to number of days elapsed between such treatment and vaccination, as well as other features such as peripheral blood absolute B cell count correlate with antibody production. Materials and Methods: Anti-spike protein antibody production was evaluated in 104 patients with NHL and 76 with other malignancies. Eligible participants were aged 21 years or older. Study inclusion criteria included diagnosis of lymphoma or other hematological malignancy as well as solid tumors. The Dimension Exel 200 method for qualitative detection of total antibodies was used to determine antibody production. The antibody test was performed &gt; 14 days after the second Moderna or Pfizer vaccine dose or after the Johnson & Johnson single dose. We prospectively evaluated antibody production following administration of BCDT as well as cytotoxic chemotherapy in 104 patients with NHL, 27 hematologic malignancies and in 49 solid tumors. In addition, we explored the timing of such treatments in relation to the vaccination date as well as the type of vaccine administered. Results: Median age was 61 and 59% were females. Of 180 entered, 104 had NHL. Of these, 95 (91.3%) were treated with BCDT, including rituximab (89), obinutuzumab (5) or anti-CD19 CAR-T cell therapy (1). BCDT was usually given together with induction chemotherapy and followed by maintenance. Histologic types of NHL treated with these therapies were: aggressive NHLs (N=35), follicular low grade (N=33), marginal zone NHL (14) and others (N=13). There were 49 patients with solid tumors. We also included 10 patients with other hematologic tumors who received BCDT and were analyzed together with the 95 NHLs to determine if this treatment interfered with anti-spike antibody production. Conclusions: These results imply a deleterious effect of BCDT on the humoral immune response to the SARS-Cov-2 vaccine. The correlation between the administration of BCDT and poor production of anti-spike antibodies is very robust, particularly in those cases who were vaccinated 9 months or less after BCDT. However, administration of cytotoxic chemotherapy without BCDT was not associated with reduced production of antibodies. In fact, almost all patients (94%) who received cytotoxic chemotherapy without BCDT, produced antibodies against spike protein (table 2). However, when chemotherapy was combined with BCDT there was a significant reduction of antibody production. These results strongly suggest that the major problem with poor antibody production following vaccination against Sars-Cov-2 relates to the use of BCDT and not so much to cytotoxic chemotherapy. The same findings apply to the 104 cases of NHL where half of patients treated with BCDT did not produce antibodies while 88% who did not receive BCDT produced antibodies (table 2). Almost all patients with solid tumors in our study (95.9%) were able to produce antibodies, irrespective of whether they received chemotherapy or not. These data raise the question whether vaccinated patients treated with BCDT who failed to make antibodies against the spike protein, could also benefit from a third dose. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.