Medicine (St Vincent's) - Research Publications
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ItemNo Preview AvailableFDG PET in the evaluation of immune-related hypophysitis and thyroiditis following combination ipilimumab and nivolumab in advanced melanoma(Society of Nuclear Medicine and Molecular Imaging, 2020-05-01)Objectives: Hypophysitis and thyroiditis are among the most commonly reported immune-related adverse events (irAEs) following combined ipilimumab/nivolumab therapy for melanoma. The role of 18F-FDG PET/CT (FDG-PET) in the evaluation of these endocrinopathies has not been systematically assessed. Methods: Between 2016 to 2019, all patients (pts) with advanced melanoma who received combined ipilimumab/nivolumab therapy were reviewed. Pts with a pre-treatment and post-treatment FDG-PET were included. On FDG-PET, PET-hypophysitis was defined as a discernable new uptake in the pituitary fossa and PET-thyroiditis as new diffuse uptake in the thyroid. Pre- and post-treatment SUVmax of pituitary and thyroid gland was measured. ROC analysis was used to derive the optimal threshold for metabolic changes on FDG-PET for distinguishing endocrinopathy. FDG-PET, clinical data and brain MRI were reviewed independently by a Nuclear Medicine physician, endocrinologist, and radiologist, respectively, and then findings were correlated. Results: Of 162 pts, 133 and 134 had assessable FDG-PET for hypophysitis and thyroiditis, respectively, with post-treatment FDG-PET performed at a median 76 days (IQR 52-83, range 18-225) from the start of immunotherapy. Overall 41/133 (29%) pts had PET-hypophysitis, of which 18 were clinically-confirmed, 3 were false-positive and 20 were not clinically-assessable due to receiving high-dose glucocorticoids for a concurrent irAE at the time of imaging, although 6 of these also had supportive contemporaneous MRI findings. For PET-hypophysitis pts, median pre- and post-treatment pituitary SUVmax were 2.7 (IQR 2.5-2.9, range 1.9-3.9) and 4.7 (IQR 3.6-5.5, range 2.6-16.2), with a percentage increase of 63% (IQR 39-94%, range 13-431%). The abnormal PET findings preceded the clinical diagnosis in 7/18 pts by a median of 16 days (range 5-50). FDG-PET was negative for hypophysitis in 12/29 pts with a prior or subsequent clinical diagnosis of hypophysitis. Where the clinical presentation was not masked by high-dose glucocorticoids, the positive and negative predictive value of FDG-PET for hypophysitis was 86% and 87%, respectively. Based on ROC analysis the optimal percentage change in SUVmax was 30% for distinguishing hypophysitis. PET-thyroiditis was detected in 30/134(22%) pts. The pre- and post-treatment SUVmax were 2.1 (IQR 1.7-2.3, range 1.3-3.3) and 4.8 (IQR 3.8-5.9, range 2.8-9.1), respectively, with an increase of 116% (IQR 84-177%, range 52-300%). Overall 41/134 (31%) pts had documented biochemical evidence of thyroiditis. The positive and negative predictive value of PET was 97% and 89%, respectively. Based on ROC analysis, the optimal percentage change in SUVmax for distinguishing thyroiditis was 42%. Further follow-up FDG-PET (30/39 pts with PET-hypophysitis and 25/30 pts with PET-thyroiditis) revealed resolution of SUVmax to baseline in all cases by a median of 104 days (IQR 77-133, range 40-484) and 32 days (IQR 79-194, range 49-1045), respectively. Conclusions: FDG-PET detects transient increases in FDG uptake in the pituitary and thyroid gland following combined ipilimumab/nivolumab which appears to be highly predictive of the development of these endocrinopathies, therefore prompting more stringent monitoring. A high incidence of uninterpretable biochemical assessment of the pituitary-adrenal axis likely contributed to the underestimation of hypophysitis incidence. A multimodality approach is important in the timely diagnosis of immune-related endocrinopathies.
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ItemNo Preview AvailableOpportunistic Assessment of Pituitary Gland with Routine MRI and PET/CT Can Guide in Earlier and Increased Identification of Hypophysitis in Patients Treated with Combination Checkpoint Inhibitors(The Endocrine Society, 2020-05-08)Background: Hypophysitis is one of the commonly reported adverse events related to immune checkpoint inhibitors (ICI), and the incidence is expected to rise with increased use of combined programmed cell death protein 1 (PD1) and cytotoxic T lymphocyte associated protein 4 (CTLA4) blockade. The clinical diagnosis can be delayed due to non-specific symptoms. At our centre, subjects undergo periodic imaging to assess tumour response to ICI. We reviewed whether neuroimaging studies can guide us in the diagnosis of hypophysitis and whether early changes can be detected before the onset of the clinical syndrome. Methods: We retrospectively reviewed the medical charts, biochemistry, structural brain imaging and whole-body positron emission tomography (PET) with specific reference to hypophysitis in 162 patients treated with combination ICI at a tertiary melanoma referral centre. Suspected cases were identified based on meeting one or more of the following criteria: 1) A documented diagnosis of hypophysitis or pituitary dysfunction found on chart review, 2) A relative change in pituitary size or appearance from baseline on neuroimaging studies, or 3) An increase in pituitary maximum standardized uptake value (SUVmax) greater than 25% from baseline on 18F-FDG PET. Results: 58/162 patients (36%) met criteria for suspected hypophysitis. Only 4 patients were identified on routine screening of early morning cortisol. 14 patients presented with symptoms leading to biochemical work up. A further 40 patients were found to have suspicious imaging changes, 13 of which went on to receive a formal diagnosis of hypophysitis. Of the remaining 27 patients, 23 were receiving high dose glucocorticoids for concomitant immune related adverse events at the time of the abnormal imaging study.Conclusion: We report the highest incidence to date of suspected hypophysitis in cohort of patients treated with combination ICI. This study highlights the important role of structural and functional neuroimaging in the early recognition of hypophysitis. Imaging may also play a role when the clinical syndrome is masked by concurrent glucocorticoid use.
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ItemPhase 2 Study of Cemiplimab in Patients with Advanced Cutaneous Squamous Cell Carcinoma (CSCC): Longer Follow-Up(National Society for Cutaneous Medicine, 2020-10-27)Abstract not available.
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ItemNo Preview Available
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ItemA PHASE II STUDY OF CONTINUOUS LOW DOSE PANOBINOSTAT IN PAEDIATRIC PATIENTS WITH MALIGNANT RHABDOID TUMORS/ATYPICAL TERATOID RHABDOID TUMORS(OXFORD UNIV PRESS INC, 2020-12)Abstract
BACKGROUND
Panobinostat treatment has been shown to terminally differentiate malignant rhabdoid tumor (MRT)/atypical teratoid rhabdoid tumors (ATRT) in pre-clinical models. This is an open label, phase II study of panobinostat in patients with newly diagnosed or relapsed MRT/ATRT. AIMS: To assess the anti-tumor activity of low dose, continuous panobinostat, its associated toxicities, the biological activity of low dose panobinostat by measuring histone acetylation status in peripheral mononuclear cells (PMNC), and markers of differentiation in fresh tumor tissue specimens.METHODS
Following cycles of induction and consolidation chemotherapy and/or radiation treatment, patients were enrolled and commenced on panobinostat as a continuous daily oral dose starting at 10mg/m2 following a three-week wash out period between therapies. Real-time acetylation status, measuring acetylated H4 on PMNC, was performed to determine the pharmacodynamics of panobinostat. Patients were monitored for drug toxicities with the possibility of dose reductions in decrements of 2mg/m2.RESULTS
Six patients with newly diagnosed ATRT/MRT and one patient with relapsed MRT have been enrolled to date. The average age at enrollment was 2.5 years. Currently, six patients (85.7%) remain on study with a mean treatment duration of 170 days (range 44–327 days). One patient was removed from study at day 44 due to disease progression. The main dose-limiting toxicity observed to date has been myelosuppression. Panobinostat, at a dose of 10mg/m2, caused significant acetylation of H4 in PMNC.CONCLUSIONS
Treatment with panobinostat appears to be well tolerated in infants with MRT/ATRT, with successful real-time pharmacodynamic assessment of H4 acetylation. -
ItemAutologous stem cell transplantation for untreated transformed indolent B-cell lymphoma in first remission: an international, multi-centre propensity-score-matched study(WILEY, 2020-12)High-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT) are used as consolidation in first remission (CR1) in some centres for untreated, transformed indolent B-cell lymphoma (Tr-iNHL) but the evidence base is weak. A total of 319 patients with untreated Tr-iNHL meeting prespecified transplant eligibility criteria [age <75, LVEF ≥45%, no severe lung disease, CR by positron emission tomography or computed tomography ≥3 months after at least standard cyclophosphamide, doxorubicin, vincristine and prednisolone with rituximab (R-CHOP) intensity front-line chemotherapy] were retrospectively identified. Non-diffuse large B-cell lymphoma transformations were excluded. About 283 (89%) patients had follicular lymphoma, 30 (9%) marginal-zone lymphoma and six (2%) other subtypes. Forty-nine patients underwent HDC/ASCT in CR1, and a 1:2 propensity-score-matched cohort of 98 patients based on age, stage and high-grade B-cell lymphoma with MYC, BCL2 and/or BCL6 rearrangements (HGBL-DH) was generated. After a median follow-up of 3·7 (range 0·1-18·3) years, ASCT was associated with significantly superior progression-free survival [hazard ratio (HR) 0·51, 0·27-0·98; P = 0·043] with a trend towards inferior overall survival (OS; HR 2·36;0·87-6·42; P = 0·1) due to more deaths from progressive disease (8% vs. 4%). Forty (41%) patients experienced relapse in the non-ASCT cohort - 15 underwent HDC/ASCT with seven (47%) ongoing complete remission (CR); 10 chimeric antigen receptor-modified T-cell (CAR-T) therapy with 6 (60%) ongoing CR; 3 allogeneic SCT with 2 (67%) ongoing CR. Although ASCT in CR1 improves initial duration of disease control in untreated Tr-iNHL, the impact on OS is less clear with effective salvage therapies in this era of CAR-T.
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ItemLupus Low Disease Activity State and Reduced Direct Health Care Costs in Patients With Systemic Lupus Erythematosus(WILEY, 2020-09)OBJECTIVE: Treat-to-target end points for systemic lupus erythematosus (SLE) have been assessed for their impact on damage accrual and flare, but whether they have an impact on the high health care utilization and costs in SLE has not been studied. The purpose of this study was to examine our hypothesis that the recently described lupus low disease activity state (LLDAS) would be associated with reduced health care cost. METHODS: Data from a single tertiary hospital longitudinal SLE cohort were assessed. Baseline demographics, disease activity (Systemic Lupus Erythematosus Disease Activity Index 2000 [SLEDAI-2K], physician global assessment [PhGA], and flare index), and medication use were evaluated, and direct health care utilization and cost data were obtained from hospital information systems. LLDAS was defined as previously published: briefly, SLEDAI-2K ≤4 with no new activity, PhGA ≤1, prednisolone ≤7.5 mg/day, and optimal standard immunosuppressive agents. Analysis was performed using multivariable linear regression. RESULTS: Two hundred SLE patients, contributing 357.8 person-years of observation, were included. A history of lupus nephritis was present in 42% of patients, and damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index >0) was present at study commencement in 57.3% of patients. The mean ± SD annual direct medical cost per patient was US$7,413 ± 13,133/year. In multivariable analysis, increased cost was associated with the presence of baseline organ damage (41.7% increase; P = 0.009) and corticosteroid use (>7.5-15 mg/day: 55.7% increase; P = 0.02; and >15 mg/day: 202% increase; P < 0.001). In contrast, spending ≥50% of the observation period in LLDAS was associated with a 25.9% reduction in annual direct medical cost (P = 0.04). CONCLUSION: Greater time spent in LLDAS was associated with significantly reduced direct hospital health care costs among patients with SLE.
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ItemPEMBROLIZUMAB PLUS LENVATINIB VS CHEMOTHERAPY AND LENVATINIB MONOTHERAPY FOR RECURRENT/METASTATIC HEAD AND NECK SQUAMOUS CELL CARCINOMA THAT PROGRESSED ON PLATINUM THERAPY AND IMMUNOTHERAPY: LEAP-009(BMJ PUBLISHING GROUP, 2020-11)Background Pembrolizumab alone and in combination with platinum-based chemotherapy have become standard first-line treatment options for recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC), and there is a growing unmet need for safe and efficacious treatment options for R/M HNSCC that has progressed on or after platinum-based chemotherapy and immunotherapy. Data from Study 111/KEYNOTE-146 showed promising antitumor activity and acceptable safety for the PD-1 inhibitor pembrolizumab given in combination with the multikinase inhibitor lenvatinib in patients with metastatic HNSCC.1 LEAP-009 (NCT04428151), a global, randomized, open-label, phase 2 trial, will assess the efficacy and safety of pembrolizumab in combination with lenvatinib versus SOC chemotherapy, as well as the efficacy and safety of lenvatinib monotherapy, in patients with R/M HNSCC that has progressed after platinum-based chemotherapy and a PD-(L)1 inhibitor. Methods Eligible patients are adults with histologically confirmed, locally incurable R/M HNSCC of the oral cavity, oropharynx, hypopharynx, or larynx, disease progression at any time during or after platinum-containing chemotherapy (with or without cetuximab), disease progression within 12 weeks from the last dose of treatment with ≥2 doses of a PD-(L)1 inhibitor, measurable disease based on RECIST v1.1 as confirmed by BICR, ECOG performance status of 0 or 1, and no major blood vessel invasion/infiltration. Patients will be randomized 3:3:2 to pembrolizumab (200 mg IV Q3W for up to 35 cycles) plus lenvatinib (20 mg orally once daily), investigator’s choice of SOC chemotherapy (docetaxel, paclitaxel, cetuximab, or capecitabine), or lenvatinib monotherapy (24 mg orally once daily). Randomization will be stratified by PD-L1 tumor proportion score (<50% versus ≥50%) and ECOG performance status (0 versus 1). Treatment will continue until centrally verified disease progression, unacceptable toxicity, or decision to withdraw. Patients in the chemotherapy and lenvatinib monotherapy arms may be eligible to receive pembrolizumab plus lenvatinib upon disease progression. The primary endpoint is ORR according to modified RECIST v1.1 as assessed by BICR. Secondary endpoints include PFS, OS, DOR, and safety. Interim futility analysis will be conducted for the lenvatinib monotherapy arm. Tumor imaging by CT or MRI will be performed 6 weeks after randomization, every 6 weeks through year 1, and every 9 weeks thereafter. Safety will be monitored throughout the study and for 30 days after treatment end (90 days for serious AEs if no new anticancer treatment is initiated, and at any time if the AE is considered treatment-related). Recruitment is ongoing; Planned enrollment is ~400 patients. Results N/A Conclusions N/A Trial Registration ClinicalTrials. gov Identifier, NCT04428151 Ethics Approval The study and protocol were approved by the Institutional Review Board or ethics committee at each site. Consent All patients provided written informed consent to participate in the clinical trial. Reference Matthew H Taylor, Chung-Han Lee, Vicky Makker, et al. Phase IB/II trial of lenvatinib plus pembrolizumab in patients with advanced renal cell carcinoma, endometrial cancer, and other selected advanced solid tumors. J Clin Oncol 2020;38(11):1154–1163.
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ItemSUN-127 Diagnostic Challenges Associated with the Rising Incidence of Endocrine Toxicity in the Era of Combination Immunotherapy(The Endocrine Society, 2020-05-08)Abstract Background: Immune checkpoint blockade is now established as standard of care in several malignancies. Trials involving combined cytotoxic T lymphocyte associated protein 4 (CTLA4) and programmed cell death protein 1 (PD1) blockade demonstrate improved tumour responses in melanoma but at the cost of severe grade 3-4 immune related adverse events (irAEs) in 55%, and endocrine irAEs in up to 10% [1]. Immune-mediated damage to endocrine glands can be a diagnostic and management challenge. We aimed to review the incidence, biochemical evolution and imaging findings of endocrine toxicity related to combined anti CTLA-4 and anti-PD-1 therapy. Methods: We undertook a retrospective chart review of patients who received combined ipilimumab and nivolumab for metastatic melanoma at a tertiary referral centre between 2016-2019. We recorded onset and duration of abnormal biochemistry in endocrine irAEs, reviewed all available MRI images for pituitary size (mm) and appearance and 18-F FDG PET images for features of hypophysitis, thyroiditis and pancreatitis. Results: 162 patients received combination therapy. At least one irAE was recorded in 135 patients (83%), 100 (62%) required glucocorticoids, and 84 (52%) had an unplanned hospital presentation due to irAEs. Thyroiditis occurred in 50 (30.9%), with median time to onset of 30.9 days (range 1-234 days). 35 cases were identified with routine biochemistry performed every 4-6 weeks. TSH receptor antibody was measured in 13 patients and all were negative. 29 (58%) developed permanent hypothyroidism. Central cortisol deficiency was documented in 31 (19%) with a median time to diagnosis of 67.5 days (range 5-286). 4 cases were diagnosed on routine biochemistry and 14 presented with symptoms prompting investigation. 13 were diagnosed after routine neuroimaging demonstrated a pituitary abnormality, and a further 27 patients without the clinical syndrome had features of hypophysitis on neuroimaging. New onset diabetes occurred in 3 people, in which pancreatic inflammation on imaging was found in 2. A further 3/5 patients with an asymptomatic elevated lipase were found to have abnormal pancreatic imaging. In one patient with no features of endocrine or exocrine failure, there was a significant increase in FDG uptake and a subsequent loss of pancreatic volume. Conclusion: We report real world incidence of endocrine irAEs with combination immunotherapy. Routine biochemistry leads to the detection of some but not all cases. Early recognition and avoidance of unplanned presentations remains a challenge. Opportunistic assessment of endocrine gland appearance on routine imaging studies may provide useful early diagnostic information. Reference: Larkin J, Chiarion-Sileni V, Gonzalez R, Grob JJ, Cowey CL, Lao CD, et al. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma. N Engl J Med. (2015) 1:23-34. 10.1056/NEJMoa1504030
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ItemClinical, FDG-PET and molecular markers of immune checkpoint inhibitor response in patients with metastatic Merkel cell carcinoma(BMJ PUBLISHING GROUP, 2020)BACKGROUND: Metastatic Merkel cell carcinoma (mMCC) is an aggressive neuroendocrine malignancy of the skin with a poor prognosis. Immune checkpoint inhibitors (ICIs) have shown substantial efficacy and favorable safety in clinical trials. METHODS: Medical records of patients (pts) with mMCC treated with ICIs from August 2015 to December 2018 at Peter MacCallum Cancer Centre in Australia were analyzed. Response was assessed with serial imaging, the majority with FDG-PET/CT scans. RNA sequencing and immunohistochemistry for PD-L1, CD3 and Merkel cell polyomavirus (MCPyV) on tumor samples was performed. RESULTS: 23 pts with mMCC were treated with ICIs. A median of 8 cycles (range 1 to 47) were administered, with treatment ongoing in 6 pts. Objective responses (OR) were observed in 14 pts (61%): 10 (44%) complete responses (CR) and 4 (17%) partial responses (PR). Median time to response was 8 weeks (range 6 to 12) and 12-month progression-free survival rate was 39%. Increased OR were seen in pts aged less than 75 (OR 80% vs 46%), no prior history of chemotherapy (OR 64% vs 50%), patients with an immune-related adverse event (OR 100% vs 43%) and in MCPyV-negative tumors (OR 69% vs 43%). Pts with a CR had lower mean metabolic tumor volume on baseline FDG-PET/CT scan (CR: 35.7 mL, no CR: 187.8 mL, p=0.05). There was no correlation between PD-L1 positivity and MCPyV status (p=0.764) or OR (p=0.245). 10 pts received radiation therapy (RT) during ICI: 4 pts started RT concurrently (OR 75%, CR 50%), 3 pts had isolated ICI-resistant lesions successfully treated with RT and 3 pts with multisite progression continued to progress despite RT. Overall, 6 pts (26%) had grade 1-2 immune-related adverse events. CONCLUSION: ICIs showed efficacy and safety in mMCC consistent with trial data. Clinical and imaging predictors of response were identified.