Immune checkpoint inhibitor-associated thrombosis in patients with bladder and kidney cancer: a study of the Spanish Society of Medical Oncology (SEOM) thrombosis and cancer group

Purpose Both venous and arterial thrombotic events (VTE/AT) can be associated with immune checkpoint inhibitors (ICI). However, there is a paucity of information apropos patients in routine clinical practice. Methods/patients Retrospective, multicenter study promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Individuals with kidney or bladder cancer who initiated ICI between 01/01/2015 and 12/31/2020 were recruited. Minimum follow-up was 6 months (except in cases of demise). The primary objective was to calculate the incidence of ICI-associated VTE/AT and secondary objectives included to analyze their impact on survival and identify variables predictive of VTE/AT. Results 210 patients with kidney cancer were enrolled. The incidence of VTE/AT during follow-up (median 13 months) was 5.7%. Median overall survival (OS) was relatively lower among subjects with VTE/AT (16 months, 95% CI 0.01–34.2 vs. 27 months, 95% CI 22.6–31.4; p = 0.43). Multivariate analysis failed to reveal predictive variables for developing VTE/ AT. 197 patients with bladder were enrolled. There was a 9.1% incidence rate of VTE/AT during follow-up (median 8 months). Median OS was somewhat higher in patients with VTE/AT (28 months, 95% CI 18.4–37.6 vs 25 months, 95% CI 20.7–29.3; p = 0.821). Serum albumin levels < 3.5 g/dl were predictive of VTE/ AT (p < 0.05). Conclusions There appears to be no association between developing VTE/AT and ICI use in patients with renal or bladder cancer. Serum albumin levels are a predictive factor in individuals with bladder cancer (AU)

Immune checkpoint inhibitor-associated thrombosis in patients with bladder and kidney cancer: a study of the Spanish Society of Medical Oncology (SEOM) thrombosis and cancer group.

PURPOSE: Both venous and arterial thrombotic events (VTE/AT) can be associated with immune checkpoint inhibitors (ICI). However, there is a paucity of information apropos patients in routine clinical practice. METHODS/PATIENTS: Retrospective, multicenter study promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Individuals with kidney or bladder cancer who initiated ICI between 01/01/2015 and 12/31/2020 were recruited. Minimum follow-up was 6 months (except in cases of demise). The primary objective was to calculate the incidence of ICI-associated VTE/AT and secondary objectives included to analyze their impact on survival and identify variables predictive of VTE/AT. RESULTS: 210 patients with kidney cancer were enrolled. The incidence of VTE/AT during follow-up (median 13 months) was 5.7%. Median overall survival (OS) was relatively lower among subjects with VTE/AT (16 months, 95% CI 0.01-34.2 vs. 27 months, 95% CI 22.6-31.4; p = 0.43). Multivariate analysis failed to reveal predictive variables for developing VTE/ AT. 197 patients with bladder were enrolled. There was a 9.1% incidence rate of VTE/AT during follow-up (median 8 months). Median OS was somewhat higher in patients with VTE/AT (28 months, 95% CI 18.4-37.6 vs 25 months, 95% CI 20.7-29.3; p = 0.821). Serum albumin levels < 3.5 g/dl were predictive of VTE/ AT (p < 0.05). CONCLUSIONS: There appears to be no association between developing VTE/AT and ICI use in patients with renal or bladder cancer. Serum albumin levels are a predictive factor in individuals with bladder cancer.

Utility of Genomic Platforms in Treatment Decisions in Axilla-Positive Breast Cancer.

Genomic platforms have proven to be more accurate as a prognostic tool than immunohistochemistry studies in patients with early, hormone receptor positive, HER 2 negative breast cancer and, in some cases, have also demonstrated predictive ability for chemotherapy benefit. They are now widely applied in node-negative disease, but their use in node-positive disease is more recent and more controversial, especially in premenopausal patients. In this article, we review the use of these tests in node-positive disease.

Do Antiangiogenics Promote Clot Instability? Data from the TESEO Prospective Registry and Caravaggio Clinical Trial.

BACKGROUND: Venous thromboembolism (VTE) is a common complication in cancer patients. Much of its morbidity stems from the development of fatal pulmonary embolisms (PE). Little is known about the factors involved in clot stability, with angiogenesis possibly being implicated. METHODS: The database is from the TESEO prospective registry that recruits cancer patients with VTE from 41 Spanish hospitals. Independent validation was conducted in a cohort from the Caravaggio trial. The objective is to evaluate the association between exposure to antiangiogenic therapies and the PE/VTE proportion in oncological patients. RESULTS: In total, 1,536 subjects were evaluated; 58.4% (n = 894) had a PE and 7% (n = 108) received antiangiogenic therapy (bevacizumab in 75%). The PE/VTE proportion among antiangiogenic-treated individuals was 77/108 (71.3%) versus 817/1,428 (57.2%) among those receiving other alternative therapies (p = 0.004). The effect of the antiangiogenics on the PE/VTE proportion held up across all subgroups except for active smokers or those with chronic obstructive pulmonary disease. Exposure to antiangiogenics was associated with increased PEs, odds ratio (OR) 2.27 (95% CI, 1.42-3.63). In the Caravaggio trial, PE was present in 67% of the individuals treated with antiangiogenics, 50% of those who received chemotherapy without antiangiogenic treatment, and 60% without active therapy (p = 0.0016). CONCLUSION: Antiangiogenics are associated with increased proportion of PE in oncological patients with VTE. If an effect on clot stability is confirmed, the concept of thrombotic risk in cancer patients should be reconsidered in qualitative terms.

A randomized, placebo-controlled phase 2 study of paclitaxel in combination with reparixin compared to paclitaxel alone as front-line therapy for metastatic triple-negative breast cancer (fRida).

PURPOSE: CXCR1, one of the receptors for CXCL8, has been identified as a druggable target on breast cancer cancer stem cells (CSC). Reparixin (R), an investigational oral inhibitor of CXCR1, was safely administered to metastatic breast cancer patients in combination with paclitaxel (P) and appeared to reduce CSC in a window-of-opportunity trial in operable breast cancer. The fRida trial (NCT02370238) evaluated the addition of R to weekly as first-line therapy for metastatic (m) TNBC. SUBJECTS AND METHODS: Subjects with untreated mTNBC were randomized 1:1 to R or placebo days 1-21 in combination with weekly P 80 mg/m2 on days 1, 8, 15 of 28-day cycles. The primary endpoint was PFS by central review. RESULTS: 123 subjects were randomized (62 to R + P and 61 to placebo + P). PFS was not different between the 2 groups (median 5.5 and 5.6 months for R + P and placebo + P, respectively; HR 1.13, p = 0.5996). ALDH+ and CD24-/CD44+ CSC centrally evaluated by IHC were found in 16 and 34 of the 54 subjects who provided a metastatic tissue biopsy at study entry. Serious adverse events (21.3 and 20% of subjects) and grade ≥ 3 adverse reactions (ADR) (9.1 and 6.3% of all ADRs) occurred at similar frequency in both groups. CONCLUSION: fRida is the first randomized, double-blind clinical trial of a CSC-targeting agent in combination with chemotherapy in breast cancer. The primary endpoint of prolonged PFS was not met. CLINICAL TRIAL REGISTRATION/DATE OF REGISTRATION: NCT01861054/February 24, 2015.

Prevalencia y caracterización del dolor irruptivo oncológico en pacientes hospitalizados en Vigo. Estudio Dolopaho / Prevalence and characterization of breakthough cancer pain in hospitalized patients in Vigo. The Dolopaho study

Introducción: El dolor sigue siendo en la actualidad un problema no resuelto en los pacientes con cáncer. A pesar de los avances en el tratamiento del dolor en los últimos años, persisten lagunas que dificultan un tratamiento global, como es el caso del dolor irruptivo oncológico (DIO). Objetivos: Evaluar la prevalencia de DIO de una muestra de pacientes ingresados en un servicio de oncología médica, analizar si el dolor era el principal motivo de ingreso en estos pacientes, así como determinar si existe un infradiagnóstico y, por tanto, un infratratamiento en los mismos previamente al ingreso. Métodos: Estudio observacional prospectivo. Se reclutaron los pacientes de forma consecutiva, independientemente del motivo de ingreso. Las variables analizadas en relación con el dolor irruptivo fueron las siguientes: presencia de dolor irruptivo según el algoritmo de Davies; semejanza de los episodios de dolor irruptivo entre sí y respecto al dolor basal; número de crisis de dolor a lo largo del día y a lo largo de la semana; escala visual analógica del dolor irruptivo; tiempo desde el inicio del dolor hasta su máxima intensidad medida en los siguientes rangos: < 5 min, 5-30 min, > 30 min; la duración de los episodios: < 5 min, 5-30 min, > 30 min; desencadenantes del dolor irruptivo (incidental, espontáneo); percepción individual de la alteración en la calidad de vida y efectividad de los fármacos utilizados. Resultados: Se incluyeron un total de 115 pacientes. En la muestra analizada el 33,9 % de los pacientes presentaron dolor irruptivo, de ellos el 95 % recibían tratamiento con opioides mayores, pero en solo el 56 % de los casos se asociaron a opioides de liberación ultrarrápida. Conclusión: El manejo de los pacientes con DIO continúa siendo un reto a día de hoy. Cerca de la mitad de los pacientes con dolor irruptivo no habían recibido tratamiento adecuado en nuestro estudio y, por tanto, probablemente no estaban bien caracterizados. (AU)

Background: Pain is often inadequately treated in patients with cancer. Although in recent years there have been major advances in the treatment of pain, there are still gaps for a global treatment, such as breakthrouth cancer pain (BCP). Objectives: The main objective was to evaluate the prevalence of BCP in a sample of patients admitted to a oncology medical department, in order to see whether pain is the main reason for admission in these patients, as well as to determine whether they were correctly treated and diagnosed before admission. Methods: An observational, prospective study. Patients were enrolled consecutively, regardless of reason for admission. The variables analyzed in relation to breakthrough pain were the following: presence of breakthrough pain according to the Davies scale; similarities of breakthrough pain events to each other and to baseline pain; number of irruptive pain events throughout the day and throughout the week; visual analogue scale of breakthrough pain; time between the onset of breakthrough pain and maximum intensity as measured in the following ranges: < 5 minutes, 5-30 minutes, > 30 minutes; duration of the breakthrough pain event (< 5 minutes, 5-30 minutes, > 30 minutes); triggers of breakthrough pain (incidental, spontaneous); perceived quality of life impairment and effectiveness of the drugs used. Results: A total of 115 patients consecutively admitted were analyzed regardless of reason for admission. In the analyzed sample, 33.9 % of patients had breakthrouth pain, and 95 % of the patients with breakthrough pain received treatment with strong opioids, though only in 56.4 % of cases associated with ultra-rapid-release opioids.Conclusions: The management of BCP is still a challenge. About half of patients with breakthrough cancer pain had not received adecuated treatment in our study, and were therefore poorly diagnosed. (AU)

A snapshot of cancer-associated thromboembolic disease in 2018-2019: First data from the TESEO prospective registry.

BACKGROUND: The ever-growing complexity of cancer-associated thrombosis (CAT), with new antineoplastic drugs and anticoagulants, distinctive characteristics, and decisions with low levels of evidence, justifies this registry. METHOD: TESEO is a prospective registry promoted by the Spanish Society of Medical Oncology to which 34 centers contribute cases. It seeks to provide an epidemiological description of CAT in Spain. RESULTS: Participants (N=939) with CAT diagnosed between July 2018 and December 2019 were recruited. Most subjects had advanced colon (21.4%), non-small cell lung (19.2%), and breast (11.1%) cancers, treated with dual-agent chemotherapy (28.4%), monochemotherapy (14.4%), or immune checkpoint inhibitors (3.6%). Half (51%) were unsuspected events, albeit only 57.1% were truly asymptomatic. Pulmonary embolism (PE) was recorded in 571 (58.3%); in 120/571 (21.0%), there was a concurrent deep venous thromboembolism (VTE). Most initially received low molecular weight heparin (89.7%). Suspected and unsuspected VTE had an OS rate of 9.9 (95% CI, 7.3-non-computable) and 14.4 months (95% CI, 12.6-non-computable) (p=0.00038). Six-month survival was 80.9%, 55.9%, and 55.5% for unsuspected PE, unsuspected PE admitted for another reason, and suspected PE, respectively (p<0.0001). The 12-month cumulative incidence of venous rethrombosis was 7.1% (95% CI, 4.7-10.2) in stage IV vs 3.0% (95% CI, 0.9-7.1) in stages I-III. The 12-month cumulative incidence of major/clinically relevant bleeding was 9.6% (95% CI, 6.1-14.0) in the presence of risk factors. CONCLUSION: CAT continues to be a relevant problem in the era of immunotherapy and targeted therapies. The initial TESEO data highlight the evolution of CAT, with new agents and thrombotic risk factors.

[Venous thrombosis associated with central venous catheter use in patients with cancer]. / Trombosis venosa asociada a catéter venoso central en pacientes con cáncer.

The use of central venous catheters for various applications (administration of chemotherapy, blood products and others) in patients with cancer is increasingly frequent. The association between thrombosis and catheter use has been fully established but aspects such as its causes, diagnosis, prophylaxis and treatment have not. We describe a case of thrombosis in a patient with cancer treated with chemotherapy who carried a central venous catheter. We also perform a review of the risk factors, the role of the prophylaxis and the treatment.

Trombosis venosa asociada a catéter venoso central en pacientes con cáncer / Venous thrombosis associated with central venous catheter use in patients with cancer

La utilización de catéteres venosos centrales en pacientes con cáncer para diferentes usos (administración de quimioterapia, productos sanguíneos y otros) es cada vez más frecuente. La asociación de trombosis con catéter está completamente establecida, pero no así aspectos como causas, diagnóstico, profilaxis y tratamiento. Se describe un caso de trombosis en un paciente con cáncer en tratamiento con quimioterapia portador de catéter venoso central y realizamos una revisión de los factores de riesgo, el papel de la profilaxis y el tratamiento (AU)

The use of central venous catheters for various applications (administration of chemotherapy, blood products and others) in patients with cancer is increasingly frequent. The association between thrombosis and catheter use has been fully established but aspects such as its causes, diagnosis, prophylaxis and treatment have not. We describe a case of thrombosis in a patient with cancer treated with chemotherapy who carried a central venous catheter. We also perform a review of the risk factors, the role of the prophylaxis and the treatment (AU)

Megestrol acetate-induced adrenal insufficiency.

Megestrol acetate is a synthetic progestin that has been used since the 1970s for the treatment of advanced cancer and subsequently to treat anorexia, cachexia and weight loss in AIDS patients. It has been shown that high doses or prolonged treatment with this drug may cause Cushing's syndrome, new-onset diabetes and suppression of plasma ACTH and cortisol levels. Megestrol acetate may cause suppression of the pituitary-adrenal axis due to the affinity of this compound for the glucocorticoid receptor. Recognising the glucocorticoid-like activity of megestrol and its effects at the axis level is important for the diagnosis of sub-clinical adrenal insufficiency. We present the case of a 74-year-old woman with infiltrating ductal breast carcinoma refractory to prolonged hormonal treatment with megestrol acetate, presenting with adrenal insufficiency.