Recurrent Ovarian Cancer — Basic Knowledge, Current Management, and Future Directions

Recurrent ovarian cancer is incurable. Chemotherapy is indicated to control disease-related symptoms. The benefit from chemotherapy in these patients depends on the platinum-free interval. Patients with platinum-resistant disease (a relapse of less than six months from the completion of platinum treatment) are managed with non-platinum agents. Patients with platinum semi-sensitive relapse (six to 12 months from the completion of treatment) have a response rate of 30% to second-line platinum treatment. In patients with platinum-sensitive relapse (more than 12 months from the completion of treatment), the response rate to platinum is 60–70%. Limited data is available regarding the benefits of secondary cytoreductive surgery. GOG 213 and the AGO Desktop III studies will define the role of this procedure in patients with recurrent disease. Two studies have shown benefit of bevacizumab in the treatment of patients with platinum-sensitive (Oceans) and refractory disease (Aurelia). Additional studies are needed to establish the optimal duration and timing of treatment. Cediranib has shown activity in patients with recurrent platinum-sensitive ovarian cancer (ICON 6 trial). Numerous novel biological agents are being investigated in relapsed ovarian cancer. This chapter focuses on current management and future directions in patients with relapsed ovarian cancer

Management and Supportive Care of Patients Undergoing Immunotherapy

In many tumor types, where the prognosis was shown to be extremely dismal before, immunotherapy is now a new beacon of hope to many patients. Immunotherapy has been approved for use in a many different cancers including metastatic melanoma, advanced non-small cell lung cancer, metastatic renal cell carcinoma, refractory Hodgkin’s lymphoma, metastatic bladder cancer advanced head and neck cancer, and the list keeps growing each day. It seems to be generally better tolerated in most patients and less toxic compared to what we have seen in different anticancer treatments from before. However, the toxicities here are termed immune-related adverse events. There is almost no prospective data on these toxicities, and guidelines or recommendations are mostly based on symptomatic management from the ongoing clinical trials. Treating oncologists need to be aware of the subtleties in presentation and the huge difference in the way we mange these side effects. Although most adverse events are low-grade and manageable, they have the potential to be life-threatening if not treated promptly. In this chapter, we address the different immune-related adverse events relating to the organ system they can involve, presentation and symptomatology, general recommendations of management, and individual toxicities. Keywords: immunotherapy, PD-1, CTLA-4

Editorial : Management of immune-related adverse events for patients undergoing treatment with checkpoint inhibitors

Immunotherapy with immune checkpoint inhibitors has emerged as the most significant advance in the treatment of cancer in recent years and has revolutionized cancer management (1). Until recently, it had been assumed that the immune system was not effective in protecting humans against the development of neoplastic diseases. Checkpoints inhibitors are co-receptors expressed by T cells. These co-receptors regulate T cell activation negatively and play a central role in the maintenance of peripheral self-tolerance. Co-inhibitory receptor ligands are significantly expressed in a variety of malignancies resulting in evasion of anti-cancer immunity. These molecules include programmed cell death protein 1 (PD-1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and were discovered by Tasuku Honjo and James P. Allison in 1992 and 1996, respectively (2, 3). These scientists were jointly awarded the 2018 Nobel Prize for Physiology or Medicine in recognition of this ground-breaking research. Monoclonal antibodies targeting the CTLA-4 and PD-1 and their ligands have produced significant clinical responses against a variety of malignancies (4). FDA registered checkpoint inhibitors include pembrolizumab (5), nivolumab (6), cemiplimab (7), atezolizumab (8), darvolumab (9) and avelumab (10) for numerous indications including melanoma, lung cancer (small and non-small cell types), bladder cancer, Hodgkin’s disease and others (5–10). Other co-inhibitory molecules under research include T cell immunoglobulin and mucin domain-containing molecule-3 (TIM-3) (11), Lymphocyte activation gene-3 (LAG-3) (12), V-domain Ig-containing Suppressor of T cell Activation (VISTA) (13), and B- and T-lymphocyte attenuator (BTLA) (14). Treatment with antibodies inhi biting immune checkpoints are well-tolerated by the vast majority of patients and are less toxic compared to standard anticancer chemotherapy agents. These immune side-effects are referred to as immune-related adverse events (IrAE) (15).http://www.frontiersin.org/Oncologyam2019Immunolog

Recent advances, patient selection & challenges in managing cancer patients undergoing treatment with immune checkpoint inhibitors

This editorial is published on the occasion of World Cancer day - February 4, 2022.Cancer immunotherapy with humanized monoclonal antibodies (mAbs) that target co-inhibitory immune checkpoint molecules (ICMs) is the most meaningful advance in the management of malignant diseases in recent years. This has coincided with the acquisition of eloquent, cutting edge insights into the molecular mechanisms, which regulate cell–cell interactions that are fundamental to maintain a balanced, well-synchronized human immune system. These developments have also revitalized the practice of immunotherapy, especially the realization of novel immunomodulatory therapeutic modalities that have the potential to restore weakened anti-cancer immune responses.The Cancer Association of South Africa and the National Research Foundation of South Africa.https://journals.lww.com/ijmr/pages/default.aspxam2023Immunolog

Dermatologic immune-related adverse events : the toxicity spectrum and recommendations for management

Immune checkpoint inhibitors are a new class of oncologic drugs that act via the inhibition of check- points, thereby unlocking the immune system to attack cancer cells. Their emergence has radically changed the concept of therapy in oncologic patients. However, despite their overall favorable profile, their use has been associated with specific toxicities that may potentially affect treatment. The so-called immune-related adverse events (irAEs) mostly correspond to dysimmune reactions that can affect nearly every organ system, in theory, notably with the development of colitis, hepatitis, pneumonitis, or thy- roiditis. Dermatologic irAEs are also among the most common, reaching a rate of approximately 40%. They are characterized by a wide phenotypic range, including mainly eczematous or lichenoid rashes, psoria- sis, or autoimmune bullous disorders. Pruritus may accompany the aforementioned rashes or develop as an isolated symptom without the presence of skin changes. Depigmentation and hair/nail changes can be also observed in association with immune checkpoint inhibitor treatment. In the current article, we present an overview of the clinical spectrum of irAEs and provide tips for early recognition and manage- ment of dermatologic irAEs. We highlight the role that dermatologists can play in relieving patients and allowing for oncologic treatment to be maintained and administered more safely.The Cancer Association of South Africa and the National Research Foundation of South Africa.https://www.sciencedirect.com/journal/international-journal-of-womens-dermatologyam2022Immunolog

MASCC 2020 recommendations for the management of immune-related adverse events of patients undergoing treatment with immune checkpoint inhibitors

Oncoimmunotherapy with immune checkpoint inhibitor–targeted antibodies has developed as the most significant advance in the management of cancer in recent years. The concept that the immune system was unsuccessful in protecting humans against the development of cancer has changed over the last decade. Checkpoint molecules are inhibitory (PD-1, PDL-1, CTLA-4, TIM-3, LAG-3, BTLA, and HEVM) and stimulatory (CD27, CD40, OX40, GITR, ICOS, and CD137) co-receptors expressed mostly by T cells, but also by other immune cells including antigen-presenting dendritic cells. The basic function of these inhibitory co-receptors is to negatively regulate T cell activation, which is critical in the maintenance of peripheral self-tolerance. The co-inhibitory receptor ligands for these immune checkpoint molecules are, however, also significantly upregulated in various types of cancers, resulting in evasion of anticancer immunity.The Cancer Association of South Africa (CANSA) and the National Research Foundation (NRF) of South Africa.http://link.springer.com/journal/5202021-09-04hj2020Immunolog

Meta-analysis comparing incidence of grade 3-4 neutropenia with ALK inhibitors and chemotherapy in patients with non-small-cell lung cancer

AIM : This meta-analysis compared incidence of grade 3-4 neutropenia with ALK inhibitors versus chemotherapy in patients with non-small-cell lung cancer. MATERIALS AND METHODS : PubMed/MEDLINE was searched to identify Phase II and III randomized clinical trials published up to 25 October 2018. Summary incidence, relative risk and corresponding 95% CIs were calculated for grade 3-4 neutropenia. RESULTS : Five randomized clinical trials were included. Relative risk (95% CI) of developing grade 3-4 neutropenia with ALK inhibitor versus chemotherapy was 0.27 (0.07-1.06). Probabilities of developing grade 3-4 neutropenia were 6.56 and 14.19%, respectively; no significant difference was found. CONCLUSION : In patients with non-small-cell lung cancer, incidence of grade 3-4 neutropenia with ALK-targeted therapy is not significantly different compared with chemotherapy.This meta-analysis was funded by Hexal AG, Holzkirchen, Germany. B Rapoport has received grants from Sandoz, personal fees from Amgen South Africa, Roche Malaysia, Teva and Cipla South Africa.https://www.futuremedicine.com/loi/fonhj2019Immunolog

A case report of post-radiotherapy c-MYC-positive angiosarcoma of the breast

Angiosarcoma of the breast is an unusual malignancy and carries a poor prognosis, with a 5-year overall survival rate ranging from 27 to 48%. Radiotherapy-induced angiosarcoma (RIAS) of the breast is very uncommon, with an estimated incidence of 1 in 1,000 cases of breasts treated with radiotherapy for breast cancer. The increase in radiotherapy usage may lead to an increased incidence of RIAS. A case presentation of a 67-year-old patient with tubular adenocarcinoma of the left breast who developed c-MYC-positive RIAS of the breast is presented. The patient was successfully treated with surgery. We presented a classic case of c-MYC RIAS. c-MYC was reported to be positive in RIAS and other types of angiosarcomas. Clinical examination and early detection of RIAS breast angiosarcoma is vital to improving outcomes in these patients.The Cancer Association of South Africa (CANSA) and the National Research Foundation (NRF) of South Africa.https://www.karger.com/CROam2023Immunolog

Tuberculosis infection in a patient treated with Nivolumab for non-small cell lung cancer : case report and literature review

Nivolumab (PD-1 inhibitor) and other immune checkpoint inhibitors are used primarily to promote reactivation of anti-tumor immunity. However, due to their generalized immunorestorative properties, these agents may also trigger an unusual spectrum of side-effects termed immune-related adverse events. In the case of the lung, pulmonary infiltrates in patients treated with the anti-PD-1 inhibitors, nivolumab, or pembrolizumab, especially patients with non-small cell lung cancer, can result from immune-related pneumonitis, which, until fairly recently was believed to be of non-infective origin. This, in turn, may result in progression and pseudo-progression of disease. An increasing body of evidence has, however, identified pulmonary tuberculosis as an additional type of anti-PD-1 therapy-associated, immune-related adverse event, seemingly as a consequence of excessive reactivation of immune responsiveness to latentMycobacteriumtuberculosis infection. The current case report describes a 56-year old Caucasian female who presented with microbiologically-confirmed tuberculosis infection while on nivolumab therapy for non-small cell lung cancer. Notably, the patient, seemingly the first described from the African Continent, had not received immunosuppressive therapy prior to the diagnosis of tuberculosis.http://www.frontiersin.org/Oncologyam2020Immunolog