Osimertinibe comparado a Erlotinibe Gefitinibe ou quimioterapia para tratamento de carcinoma pulmonar de células não pequenas com mutação do gene do receptor do fator de crescimento epidérmico (EFGR): revisão rápida / Osimertinib compared to erlotinib, gefitinib or chemotherapy for the treatment of non-small cell pumonary carcinoma with epidermal growth factor receptor (EFGR) gene mutation: rapid review

Mesilato de osimertinibe, gefitinibe, erlotinibe, quimioterapia padrão. Indicação: Câncer de pulmão de células não pequenas com mutação do receptor do fator de crescimento epidérmico (EGFR). Pergunta: Mesilato de osimertinibe é mais eficaz e seguro que gefitinibe, erlotinibe ou quimioterapia para os desfechos de sobrevida global, sobrevida livre de progressão e de segurança no tratamento de carcinoma pulmonar de células não pequenas com mutação do EGFR? Métodos: Levantamento bibliográfico foi realizado na base de dados PUBMED e EPISTEMONIKOS, seguindo estratégias de buscas predefinidas. Foi feita avaliação da qualidade metodológica das revisões sistemáticas com a ferramenta AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews Version 2). Resultados: Foram selecionadas duas revisões sistemáticas que atenderam aos critérios de elegibilidade. Conclusão: Mesilato de osimertinibe é mais eficaz do que gefitinibe ou erlotinibe na melhora da sobrevida global e da sobrevida livre de progressão em pacientes virgens de tratamento. Em pacientes previamente tratados, o mesilato de osimertinibe não é superior à quimioterapia padrão à base de platina no prolongamento da sobrevida global, mas é mais eficaz no aumento da sobrevida livre de progressão. Para câncer avançado, mesilato de osimertinibe não é mais eficaz do que a quimioterapia com ou sem pemetrexede para prolongar a sobrevida global, mas é mais eficaz em melhorar a sobrevida livre de progressão. Gefitinibe combinado com quimioterapia à base de pemetrexede foi superior à quimioterapia com ou sem pemetrexede na melhora da sobrevida global e da sobrevida livre de progressão

Osimertinib mesylate, gefitinib, erlotinib, standard chemotherapy. Indication: Non-small cell lung cancer with epidermal growth factor receptor (EGFR) mutation. Question: Is osimertinib mesylate more effective and safer than gefitinib, erlotinib or chemotherapy for overall survival, progression-free survival and safety outcomes in the treatment of non-small cell lung cancer with EGFR mutation? Methods: A bibliographic search was done in the PUBMED and EPISTEMONIKOS database, following predefined search strategies. The methodological quality of systematic reviews was evaluated using the Assessing the Methodological Quality of Systematic Reviews Version 2 tool. Results: Two systematic reviews were selected because they met the eligibility criteria. Conclusion: Osimertinib mesylate is more effective than gefitinib or erlotinib in improving overall survival and progression-free survival in treatment-naive patients. In previously treated patients, osimertinib mesylate is not superior to standard platinum-based chemotherapy in prolonging overall survival, but it is more effective in increasing progression-free survival. For advanced cancer, osimertinib mesylate is not more effective than chemotherapy with or without pemetrexed in prolonging overall survival, but it is more effective in improving progression-free survival. Gefitinib combined with pemetrexed-based chemotherapy was superior to chemotherapy with or without pemetrexed in improving overall survival and progression-free survival

Tratamientos de primera línea para pacientes estadio IV con adenocarcinoma pulmonar de mutación EGFR / First-line treatments for stage IV patients with EGFR-mutated lung adenocarcinoma

Lung cancer is one of the leading causes of death in the world. Current treatments act directly on the signal transduction pathways in cancer cells, mainly. One of the main pathways is associated with the Epidermal Growth Factor (EGFR), whose mutations leads to uncontrolled cell proliferation and a higher rate of cell invasion. Activating mutations in the EGFR gene, which includes deletions in exon 19 and the L858R mutation in exon 21, were detected in most patients with non-small cell lung cancer (NSCLC). Studies of EGFR tyrosine kinase inhibitors (EGFR-TKIs) such as Gefitinib, Erlotinib and Afatinib, compared with platinum-based treatments, showed that EGFR-TKIs produce increased disease-free survival, although only in patients whose cancers harbor activating mutations in the EGFR gene. Clinical trials also demonstrated that EGFR-TKIs are effective as first-line therapies in stage IV pulmonary adenocarcinoma. Here, the main aspects of the activation of the EGFR pathway in NSCLC will be reviewed, highlighting the importance for health professionals of correctly identifying activating mutations in the EGFR gene and acting quickly at the molecular level based on aforementioned treatments. (AU)

The Risk of Herpes Zoster in Patients with Non-small Cell Lung Cancer according to Chemotherapy Regimens: Tyrosine Kinase Inhibitors versus Cytotoxic Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Despite the successful use of tyrosine kinase inhibitors (TKIs) in cancer patients, their effect on herpes zoster development has not been studied. The aim of this study was to evaluate and compare the effects of epidermal growth factor receptor (EGFR) TKI and cytotoxic chemotherapy on the risk of herpes zoster development in non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS: We conducted a medical review of all eligible NSCLC patients in Seoul National University hospital between 2002 and 2015. We classified patients based on whether they previously underwent EGFR TKI therapy into either the TKI group or the cytotoxic group. We compared the incidence rates of herpes zoster during TKI therapy and cytotoxic chemotherapy. Additionally, the longitudinal risk of herpes zoster from TKIs was analyzed using the incidence rate ratio (IRR) of the TKI group to the cytotoxic group and the log-rank test of the Kaplan-Meier method. RESULTS: Of the 2,981 NSCLC patients, 54 patients (1.54%) developed herpes zoster. In the TKI group (2,002 patients), the IRR of herpes zoster during TKI therapy compared to that during cytotoxic chemotherapy was 1.05 (95% confidence interval [CI], 0.53 to 2.09). The IRR of the TKI group compared to the cytotoxic group was 1.33 (95% CI, 0.64 to 2.76). The Kaplan-Meier cumulative risk of both groups was not significantly different. CONCLUSION: Our results show that the incidence rate of herpes zoster in the TKI group was not statistically different from the incidence in the cytotoxic group during and after chemotherapy in NSCLC patients.

Acute Myocardial Infarction and Purpuric Drug Eruption Caused by Erlotinib Combined with Cabozantinib:Report of One Case / 中国医学科学院学报

Multi-target anticancer drugs have a more comprehensive and extensive range of action,and there is an uncertain risk in the combination of two drugs.A case of acute toxicity induced by erlotinib combined with cabozantinib is reported in this article.

Bevacizumab Plus Erlotinib Combination Therapy for Advanced Hereditary Leiomyomatosis and Renal Cell Carcinoma-Associated Renal Cell Carcinoma: A Multicenter Retrospective Analysis in Korean Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is a rare genetic syndrome resulting from germline mutations in fumarate hydratase. The combination of bevacizumab plus erlotinib showed promising interim results for HLRCC-associated RCC. Based on these results, we analyzed the outcome of bevacizumab plus erlotinib in Korean patients with HLRCC-associated RCC. MATERIALS AND METHODS: We retrospectively reviewed the efficacy and safety of bevacizumab plus erlotinib in patients with HLRCC-associated RCC who were confirmed to have germline mutations in fumarate hydratase. The primary endpoint was the objective response rate (ORR), while the secondary endpoints were progression-free survival (PFS) and overall survival (OS). RESULT: We identified 10 patients with advanced HLRCC-associated RCC who received bevacizumab plus erlotinib. Median age at diagnosis was 41 years, and five of the patients had received the combination as first- or second-line treatments. The ORR was 50% and the median PFS and OS were 13.3 and 14.1 months, respectively. Most adverse events were predictable and manageable by conventional measures, except for one instance where a patient died of gastrointestinal bleeding. CONCLUSION: This is the first real-world outcome of the treatment of advanced HLRCC-associated RCC. Bevacizumab plus erlotinib therapy showed promising activity with moderate toxicity. We should be increasingly aware of HLRCC-associated RCC and bevacizumab plus erlotinib should be a first-line treatment for this condition, unless other promising data are published.

EGFR Mutation Is Associated with Short Progression-Free Survival in Patients with Stage III Non-squamous Cell Lung Cancer Treated with Concurrent Chemoradiotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study was conducted to evaluate the relationship between epidermal growth factor receptor (EGFR) mutation and clinical outcomes in patients with stage III non-squamous cell lung cancer treated with definitive concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: From January 2008 to December 2013, the medical records of 197 patients with stage III non- squamous non-small cell lung cancer treated with definitive CCRT were analyzed to determine progression-free survival (PFS) and overall survival (OS) according to EGFR mutation status. RESULTS: Among 197 eligible patients, 81 patients were EGFR wild type, 36 patients had an EGFR mutation (exon 19 Del, n=18; L858R, n=9, uncommon [G719X, L868, T790M], n=9), and 80 patients had unknown EGFR status. The median age was 59 years (range, 28 to 80 years) and 136 patients (69.0%) were male. The median follow-up duration was 66.5 months (range, 1.9 to 114.5 months). One hundred sixty-four patients (83.2%) experienced disease progression. Median PFS was 8.9 months for the EGFR mutation group, 11.8 months for EGFR wild type, and 10.5 months for the unknown EGFR group (p=0.013 and p=0.042, respectively). The most common site of metastasis in the EGFR mutant group was the brain. However, there was no significant difference in OS among the three groups (34.6 months for EGFR mutant group vs. 31.9 months for EGFR wild type vs. 22.6 months for EGFR unknown group; p=0.792 and p=0.284). A total of 29 patients (80.6%) with EGFR mutation were treated with EGFR tyrosine kinase inhibitor (gefitinib, n=24; erlotinib, n=3; afatinib, n=2) upon progression. CONCLUSION: EGFR mutation is associatedwith short PFS and the brain is the most common site of distant metastasis in patients with stage III non- squamous cell lung cancer treated with CCRT.

Efficacy and Safety of Afatinib for EGFR-mutant Non-small Cell Lung Cancer, Compared with Gefitinib or Erlotinib / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We tried to evaluate whether there are any specific features in treatment outcomes of firstline afatinib in patients with epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC), compared with gefitinib or erlotinib. MATERIALS AND METHODS: We analyzed patients treated with first-line afatinib, gefitinib, or erlotinib for advanced EGFR-mutant NSCLC at Samsung Medical Center between 2014 and 2016. RESULTS: In total, 467 patients received first-line afatinib (n=165), gefitinib (n=230), or erlotinib (n=72). Afatinib was used more often in patients with tumors harboring deletion in exon 19 (Del19), whereas the gefitinib group had more elderly, females, and never smokers. The median progression-free survival (PFS) time for afatinib, gefitinib, and erlotinib was 19.1 months, 13.7 months, and 14.0 months, respectively (p=0.001). The superior PFS of afatinib was more remarkable in subgroups of Del19 or uncommon EGFR mutations. Overall toxicity profiles of the three drugs were comparable, though more grade 3 or 4 toxicities were detected in afatinib (7.3%) compared with gefitinib (2.6%) or erlotinib (1.8%). The common grade 3 or 4 toxicities of afatinib included diarrhea (3.0%), paronychia (2.4%), and skin rash (1.8%). Dose modification was more frequently required in patients treated with afatinib (112/165, 68%), compared with gefitinib (5/230, 2%) and erlotinib (4/72, 6%). Interestingly, however, dose reduction in the afatinib group did not impair its efficacy in terms of PFS (dose reduction vs. no reduction group, 23.5 months vs. 12.4 months). CONCLUSION: First-line afatinib showed satisfactory efficacy data and manageable toxicity profiles.

Eficacia y seguridad de afatinib como tratamiento de primera línea en pacientes adultos con cáncer de pulmón de células no pequeñas avanzado (estadios IIIB/IV), con mutaciones activadoras del gen del receptor del factor de crecimiento epidérmico, con contraindicación a erlotinib por hipersensibilidad / Efficacy and safety of afatinib as first-line treatment in adult patients with advanced non-small cell lung cancer (stages IIIB/IV), with activating mutations of the epidermal growth factor receptor gene, with contraindication to erlotinib due to hypersensitivity

INTRODUCCIÓN: El cáncer de pulmón de células no pequeñas (CPCNP) es la causa más frecuente (85 % - 90 %) de tumores pulmonares malignos que generalmente afectan a adultos que fuman y que tienen ≥ 65 años. En Perú, en 2017, el cáncer de pulmón fue la segunda causa de muerte entre todos los cánceres, con una mortalidad anual de 8.8 muertes por cada 100,000 personas.  La terapia de primera línea del CPCNP avanzado (estadio IIIB/IV) depende del estado de las mutaciones conductoras oncogénicas, la expresión de PD-L1 y la histología. Así, para los casos en los que se detecta una mutación sensibilizante1 del receptor de factor de crecimiento epidérmico (EGFR, por sus siglas en inglés), se recomienda ofrecer una terapia dirigida contra el EGFR utilizando los inhibidores de la tirosina quinasa del EGFR (de aquí en adelante llamados TKI, por sus siglas en inglés) de primera línea (e.g., erlotinib, afatinib).  En el Seguro Social de Salud del Perú (EsSalud), los pacientes con CPCNP avanzado cuyos tumores poseen mutaciones positivas2 del EGFR disponen de erlotinib como tratamiento de primera línea según lo establecido en el Petitorio Farmacológico de EsSalud. Sin embargo, existe un grupo de pacientes que presentan eventos adversos (EA) cutáneos severos (grado 3 o mayor) asociados al tratamiento con erlotinib, quienes, en ciertos casos, requerirán de la discontinuación de uso del medicamento, a pesar del manejo óptimo de las toxicidades cutáneas (e.g., reducción de dosis). En este grupo de pacientes con hipersensibilidad a erlotinib (contraindicación de uso), los médicos especialistas de la institución sugieren el uso de un TKI alternativo: afatinib. OBJETIVO: Evaluar la mejor evidencia disponible sobre la eficacia y seguridad de afatinib, en comparación con la quimioterapia, en pacientes adultos con CPCNP avanzado, con mutaciones activadoras3 del gen del EGFR, con contraindicación a erlotinib por hipersensibilidad. TECNOLOGÍA SANITARIA DE INTERÉS: Afatinib: Afatinib es un inhibidor selectivo e irreversible de la actividad de la tirosina quinasa de los receptores de la familia ErbB: EGFR (ErbB1), HER2 (ErbB2), HER3 (ErbB3) y HER4 (ErbB4). Afatinib se une en forma covalente a los dominios de la tirosina quinasa de estos receptores e inhibe irreversiblemente la autofosforilación de la tirosina quinasa, lo que resulta en un bloqueo de las señales de los receptores ErbB (European Medicines Agency 2019). METODOLOGÍA: Se realizó una búsqueda sistemática de literatura con el objetivo de identificar evidencia sobre la eficacia y seguridad de afatinib, en comparación con la quimioterapia, en pacientes adultos con CPCNP avanzado, con mutaciones activadoras del gen del EGFR, con contraindicación a erlotinib por hipersensibilidad. Se utilizó la base de datos The Cochrane Library, PubMed, LILACS y el metabuscador TRIP Database, priorizándose evidencia proveniente de ensayos clínicos aleatorizados. Asimismo, se realizó una búsqueda dentro de bases de datos pertenecientes a grupos que realizan evaluaciones de tecnologías sanitarias y guías de práctica clínica, incluyendo el Scottish Medicines Consortium (SMC), el National Institute for Health and Care Excellence (NICE), la Canadian Agency for Drugs and Technologies in Health (CADTH), la Haute Autorité de Santé (HAS), el Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), además de la Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA) y páginas web de sociedades especializadas en cáncer de pulmón. Se hizo una búsqueda adicional en la página web de clinicaltrials.gov, para poder identificar ensayos clínicos en curso o que no hayan sido publicados para, de este modo, disminuir el riesgo de sesgo de publicación. La búsqueda sistemática se basó en una metodología escalonada, la cual consistió en la búsqueda inicial de estudios secundarios (tipo revisiones sistemáticas con o sin metaanálisis). RESULTADOS: Se realizó una búsqueda de la literatura con respecto a la eficacia y seguridad de afatinib, en comparación con la quimioterapia, en pacientes adultos con CPCNP avanzado, con mutaciones activadoras del gen del EGFR, con contraindicación a erlotinib por hipersensibilidad. Dado que no se identificaron estudios en una población específica de pacientes con contraindicación a erlotinib, se procedió a revisar la evidencia para la población general de pacientes con CPCNP avanzado, con mutaciones activadoras del gen del EGFR. CONCLUSIONES: Dado que no se identificaron estudios en la población específica de pacientes con contraindicación a erlotinib, se procedió a revisar la evidencia para la población general de pacientes con CPCNP avanzado, con mutaciones activadoras del gen del receptor del factor de crecimiento epidérmico. En líneas generales, todas las GPC y ETS basaron sus recomendaciones y/o conclusiones en los resultados de los estudios LUX-Lung 3 y/o LUX-Lung 6. La evidencia procedente de los estudios LUX-Lung 3 y LUX-Lung 6 muestra que afatinib comparado con la quimioterapia ofrece un beneficio clínico en términos de una mayor sobrevida global (aproximadamente 11 meses adicionales) en los pacientes con CPCNP metastásico, ECOG 0-1 y mutaciones del EGFR tipo Del19, sin tratamiento previo. Además, afatinib tuvo un perfil de seguridad similar al de la quimioterapia con cisplatino más pemetrexed y un mejor perfil de seguridad que la quimioterapia con gemcitabina más cisplatino, en términos de EA severos, EA serios y discontinuación debido a EA. A diferencia de las GPC identificadas, que recomendaron el uso de afatinib en la población general de pacientes con CPCNP y mutaciones positivas del EGFR, esta evaluación de la evidencia identificó que los pacientes con mutaciones Del19 serían el subgrupo con mayor probabilidad de beneficiarse del tratamiento con afatinib. Por otro lado, no se identificó evidencia directa que sustente el uso de afatinib en el grupo de pacientes previamente tratados. Sin embargo, tal como se menciona en el Dictamen Preliminar de Evaluación de Tecnología Sanitaria N° 041-SDEPFyOTSDETS-IETSI-2019: Eficacia y Seguridad de erlotinib en pacientes adultos con CPCNP, metastásico o irresecable, con mutación del gen del EGFR, tras fallo a al menos una línea de quimioterapia, se valora que la evidencia del uso de afatinib en el contexto de primera línea puede ser extrapolada al grupo de pacientes que han sido previamente tratados con quimioterapia sistémica y que han experimentado hipersensibilidad severa a erlotinib. Adicionalmente, es importante analizar el contexto de intercambio de TKI (de erlotinib a afatinib) debido a EA cutáneos severos como resultado de uma hipersensibilidad a erlotinib (contraindicación de uso) en pacientes con CPCNP avanzado y mutación del EGFR, ya que es el grupo específico de pacientes en quienes se propone el uso de afatinib en la institución. Así, si bien la evidencia sobre el intercambio de TKI debido a EA es limitada, algunas series de casos han sugerido que esta aproximación proporciona un efecto beneficioso en pacientes con CPCNP avanzado y mutaciones del EGFR. Además, el intercambio de erlotinib a afatinib podría justificarse biológicamente dada las diferencias en las estructuras químicas de erlotinib y afatinib, que podrían influir en los EA asociados con estos medicamentos. De este modo, teniendo en cuenta que los pacientes que recibirían un segundo TKI tendrían que haber demostrado no tener una mutación resistente a TKI, se estima que los pacientes que discontinúan el tratamiento con erlotinib debido a hipersensibilidad severa aún podrían beneficiarse de "cambiar" a un segundo TKI (afatinib). Con ello, y considerando la experiencia de uso de TKI a nivel institucional y la opinión favorable por parte de los médicos especialistas de la institución, el equipo evaluador del IETSI encuentra suficientes argumentos técnicos para aprobar el uso de afatinib en pacientes adultos con CPCNP avanzado, con mutaciones activadoras del gen del EGFR (Del19), con contraindicación a erlotinib por hipersensibilidad. Por lo expuesto, el IETSI aprueba el uso de afatinib en pacientes adultos con CPCNP avanzado, con mutaciones activadoras del gen del receptor del factor de crecimiento epidérmico, con contraindicación a erlotinib por hipersensibilidad, según lo establecido en el Anexo N° 1. La vigencia del presente dictamen preliminar es de un año a partir de la fecha de publicación. Así, la continuación de dicha aprobación estará sujeta a los resultados obtenidos de los pacientes que reciban este tratamiento, a los reportes de seguridad que puedan surgir durante farmacovigilancia activa y nueva evidencia que pueda surgir en el tiempo.

Impacto na Sobrevida Livre de Progressão pela Falta de Acesso a Inibidores de EGFR em Carcinoma de Pulmão de Células não Pequenas no Sistema de Saúde Público Brasileiro / Impact that Lack of Access to EGFR Inhibitors has on Progression-Free Survival in Non-Small Cell Lung Cancer treated via the Public Health Care System in Brazil / Impacto en la Sobrevida Libre de Progresión por la Falta de Acceso a los Inhibidores de EGFR en el Carcinoma de Pulmón de Células no Pequeñas en el Sistema de Salud Pública Brasileña

Introdução: O advento de terapias-alvo antirreceptor do fator de crescimento epidérmico (anti-EGFR) impactou na sobrevida dos pacientes com câncer de pulmão de células não pequenas avançado e portadores de mutação no EGFR, que são tratados no Sistema Único de Saúde Brasileiro (SUS). Objetivo: Estimar o impacto da falta de acesso a terapias anti-EGFR na sobrevida livre de progressão (SLP) desses pacientes. Método: Por meio da base de dados do Instituto Nacional de Câncer José Alencar Gomes da Silva e de estudos que descrevem a prevalência de mutação em EGFR na população brasileira, foi estimado o número de pacientes com adenocarcinoma de pulmão avançado, portadores de mutação EGFR, candidatos à terapia-alvo no ano de 2017. Para a estimativa de efetividade, quatro diferentes esquemas de tratamentos foram considerados: quimioterapia, erlotinib, afatinib e gefitinib. O número de pacientes livres de progressão de doença, após dois anos, foi estimado com base nos resultados para SLP em ensaios clínicos randomizados. Resultados: Foram estimados 1.735 pacientes com adenocarcinoma de pulmão metastático portadores de mutações ativadoras de EGFR no Brasil para o ano de 2017. Projetou-se que, caso fossem tratados com quimioterapia, apenas 71 estariam livres de progressão após 24 meses do início do tratamento. Em contrapartida, com o uso de inibidores de tirosina-quinase anti-EGFR, a expectativa seria de 312 pacientes livres de doença para erlotinib, 377 para gefitinib e 388 para afatinib. Conclusão: Apesar de recomendadas internacionalmente, as terapias anti-EGFR não são disponibilizadas no SUS, sendo oferecida aos pacientes apenas a quimioterapia. Isso problematiza a situação de falta de acesso no âmbito do SUS e embasa, localmente, a discussão acerca da incorporação dessas terapias no âmbito público.

Introduction: The advent of targeted anti-epidermal growth factor receptor (anti-EGFR) therapies have improved survival in patients with metastatic non-small cell lung cancer that carry the EGFR mutation, including those treated via the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System). Objective: To estimate the impact that lack of access to anti-EGFR therapies has on progression-free survival (PFS) among such patients. Method: On the basis of epidemiologic data obtained from the José Alencar Gomes da Silva National Cancer Institute and from studies reporting the prevalence of the EGFR mutation in the Brazilian population, we estimated the number of patients with advanced lung adenocarcinoma and the EGFR mutation who were candidates for targeted therapy in 2017. To estimate effectiveness, we evaluated four different treatments: chemotherapy, erlotinib, afatinib, and gefitinib. The number of patients with PFS after 2 years of follow-up was estimated on the basis of the results of randomized clinical trials. Results: We evaluated 1,735 patients with EGFR mutation-positive metastatic lung adenocarcinoma in Brazil in 2017. We estimated that, if treated with chemotherapy, only 71 of those patients would be free of progression after 24 months. In contrast, if all of the patients were treated with anti-EGFR tyrosine kinase inhibitors, the expectation was that PFS would be achieved in 312 patients for erlotinib, 377 for gefitinib, and 388 for afatinib. Conclusion: Although recommended by international guidelines, anti-EGFR therapies are not available via the SUS, which offers only chemotherapy. This complicates the problem of lack of access in the SUS and promotes local discussion in the public sphere about the incorporation of these therapies.

Introducción: El advenimiento de terapias objetivo anti receptor del factor de crecimiento epidérmico (EGFR) impactó en la supervivencia de los pacientes con cáncer de pulmón de células no pequeñas avanzado y portadores de mutación en el EGFR, que son tratados en el sistema único de salud brasileño (SUS). Objetivo: Estimar el impacto de la falta de acceso a terapias anti-EGFR en la sobrevida libre de progresión (SLP) de esos pacientes. Método:A través de la base de datos del Instituto Nacional de Cáncer José Alencar Gomes da Silva y de estudios que describen la prevalencia de mutación de EGFR en la población brasileña, se estima el número de pacientes con adenocarcinoma de pulmón avanzado portadores de mutación EGFR candidatos a la terapia objetivo en el año de Para la estimación de efectividad, cuatro diferentes esquemas de tratamientos fueron considerados: quimioterapia, erlotinib, afatinib y gefitinib. El número de pacientes libres de progresión de la enfermedad después de dos años se calculó sobre la base de los resultados para SLP en los ensayos clínicos aleatorizados. Resultados: Se estimó 1.735 pacientes con adenocarcinoma de pulmón metastático, portadores de mutaciones activadoras de EGFR en Brasil para el año 2017. Se proyectó que si se tratar con quimioterapia sólo 81 estarían libres de progresión después de 24 meses. En contrapartida, con el uso de inhibidores de tirosina quinasa anti-EGFR, la expectativa sería de 312 pacientes libres de enfermedad para erlotinib, 377 para gefitinib y 388 para afatinib. Conclusión: A pesar de ser recomendadas internacionalmente, las terapias anti-EGFR no están disponibles en el SUS, siendo ofrecido a los pacientes sólo quimioterapia. Esto problematiza claramente la situación de falta de acceso en el ámbito del SUS y basan, localmente, la discusión sobre la incorporación de estas terapias en el ámbito público.

Erlotinib-related Severe Hair Loss with Severe Exanthematous Drug Eruption: A Case Report / 대한피부과학회지

Erlotinib inhibits the epidermal growth factor receptor and is used in patients with various cancers. However, it can affect the epidermis and hair because the receptor is expressed in normal skin cells. A 54-year-old woman with metastatic non-small-cell lung cancer presented with erythematous patches over her entire body and severe hair shedding 2 weeks after starting erlotinib. Histopathological examinations showed lymphocytic exocytosis; perivascular infiltration of lymphohistiocytes and eosinophils in the right arm; and marked infiltration of eosinophils, neutrophils, and lymphohistiocytes in the scalp. Erlotinib discontinuation improved hair loss and skin lesions. Hair loss has been reported in 5% of patients taking erlotinib. Our case was unusual in that there was complete baldness, and to our knowledge, no report of complete hair loss and exanthematous drug eruption after erlotinib treatment has been previously reported. Here, we report a case of severe hair loss with concurrent exanthematous drug eruption that may have been linked to erlotinib hypersensitivity.

PET Imaging-Based Phenotyping as a Predictive Biomarker of Response to Tyrosine Kinase Inhibitor Therapy in Non-small Cell Lung Cancer: Are We There Yet? / 대한핵의학회잡지

The increased understanding of the molecular pathology of different malignancies, especially lung cancer, has directed investigational efforts to center on the identification of different molecular targets and on the development of targeted therapies against these targets. A good representative is the epidermal growth factor receptor (EGFR); a major driver of non-small cell lung cancer tumorigenesis. Today, tumor growth inhibition is possible after treating lung tumors expressing somatic mutations of the EGFR gene with tyrosine kinase inhibitors (TKI). This opened the doors to biomarker-directed precision or personalized treatments for lung cancer patients. The success of these targeted anticancer therapies depends in part on being able to identify biomarkers and their patho-molecular make-up in order to select patients that could respond to specific therapeutic agents. While the identification of reliable biomarkers is crucial to predict response to treatment before it begins, it is also essential to be able to monitor treatment early during therapy to avoid the toxicity and morbidity of futile treatment in non-responding patients. In this context, we share our perspective on the role of PET imagingbased phenotyping in the personalized care of lung cancer patients to non-invasively direct and monitor the treatment efficacy of TKIs in clinical practice.

Predictive Factors for Switched EGFR-TKI Retreatment in Patients with EGFR-Mutant Non-Small Cell Lung Cancer / 결핵및호흡기질환

BACKGROUND: Third-generation tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR-TKIs) have proved efficacious in treating non-small cell lung cancer (NSCLC) patients with acquired resistance resulting from the T790M mutation. However, since almost 50% patients with the acquired resistance do not harbor the T790M mutation, retreatment with first- or second-generation EGFR-TKIs may be a more viable therapeutic option. Here, we identified positive response predictors to retreatment, in patients who switched to a different EGFR-TKI, following initial treatment failure. METHODS: This study retrospectively reviewed the medical records of 42 NSCLC patients with EGFR mutations, whose cancers had progressed following initial treatment with gefitinib or erlotinib, and who had switched to a different first-generation EGFR-TKI during subsequent retreatment. To identify high response rate predictors in the changed EGFR-TKI retreatment, we analyzed the relationship between clinical and demographic parameters, and positive clinical outcomes, following retreatment with EGFR-TKI. RESULTS: Overall, 30 (71.4%) patients received gefitinib and 12 (28.6%) patients received erlotinib as their first EGFR-TKI treatment. Following retreatment with a different EGFR-TKI, the overall response and disease control rates were 21.4% and 64.3%, respectively. There was no significant association between their overall responses. The median progression-free survival (PFS) after retreatment was 2.0 months. However, PFS was significantly longer in patients whose time to progression was ≥10 months following initial EGFR-TKI treatment, who had a mutation of exon 19, or whose treatment interval was <90 days. CONCLUSION: In patients with acquired resistance to initial EGFR-TKI therapy, switched EGFR-TKI retreatment may be a salvage therapy for individuals possessing positive retreatment response predictors.

A Phase II Study of Poziotinib in Patients with Epidermal Growth Factor Receptor (EGFR)-Mutant Lung Adenocarcinoma Who Have Acquired Resistance to EGFR–Tyrosine Kinase Inhibitors / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We examined the efficacy of poziotinib, a second-generation epidermal growth factor receptor (EGFR)–tyrosine kinase inhibitor (TKI) in patients with lung adenocarcinoma with activating EGFR mutations, who developed acquired resistance (AR) to EGFR-TKIs. MATERIALS AND METHODS: This single-arm phase II study included EGFR-mutant lung adenocarcinoma with AR to erlotinib or gefitinib based on the Jackman criteria. Patients received poziotinib 16 mg orally once daily in a 28-day cycle. The primary endpoint was progression-free survival (PFS). Prestudy tumor biopsies and blood samples were obtained to determine resistance mechanisms. RESULTS: Thirty-nine patients were treated. Tumor genotyping was determined in 37 patients; 19 EGFR T790M mutations and two PIK3CA mutations were detected in the prestudy tumors, and seven T790M mutations were detected in the plasma assay. Three (8%; 95% confidence interval [CI], 2 to 21) and 17 (44%; 95% CI, 28 to 60) patients had partial response and stable disease, respectively. The median PFS and overall survival were 2.7 months (95% CI, 1.8 to 3.7) and 15.0 months (95% CI, 9.5 to not estimable), respectively. A longer PFS was observed for patients without T790M or PIK3CA mutations in tumor or plasma compared to those with these mutations (5.5 months vs. 1.8 months, p=0.003). The most frequent grade 3 adverse events were rash (59%), mucosal inflammation (26%), and stomatitis (18%). Most patients required one (n=15) or two (n=15) dose reductions. CONCLUSION: Low activity of poziotinib was detected in patients with EGFR-mutant non-small cell lung cancer who developed AR to gefitinib or erlotinib, potentially because of severe-toxicityimposed dose limitation.

Suppressors for Human Epidermal Growth Factor Receptor 2/4 (HER2/4): A New Family of Anti-Toxoplasmic Agents in ARPE-19 Cells

The effects of tyrosine kinase inhibitors (TKIs) were evaluated on growth inhibition of intracellular Toxoplasma gondii in host ARPE-19 cells. The number of tachyzoites per parasitophorous vacuolar membrane (PVM) was counted after treatment with TKIs. T. gondii protein expression was assessed by western blot. Immunofluorescence assay was performed using Programmed Cell Death 4 (PDCD4) and T. gondii GRA3 antibodies. The TKIs were divided into 3 groups; non-epidermal growth factor receptor (non-EGFR), anti-human EGFR 2 (anti-HER2), and anti-HER2/4 TKIs, respectively. Group I TKIs (nintedanib, AZD9291, and sunitinib) were unable to inhibit proliferation without destroying host cells. Group II TKIs (lapatinib, gefitinib, erlotinib, and AG1478) inhibited proliferation up to 98% equivalent to control pyrimethamine (5 μM) at 20 μM and higher, without affecting host cells. Group III TKIs (neratinib, dacomitinib, afatinib, and pelitinib) inhibited proliferation up to 98% equivalent to pyrimethamine at 1–5 μM, but host cells were destroyed at 10–20 μM. In Group I, TgHSP90 and SAG1 inhibitions were weak, and GRA3 expression was moderately inhibited. In Group II, TgHSP90 and SAG1 expressions seemed to be slightly enhanced, while GRA3 showed none to mild inhibition; however, AG1478 inhibited all proteins moderately. Protein expression was blocked in Group III, comparable to pyrimethamine. PDCD4 and GRA3 were well localized inside the nuclei in Group I, mildly disrupted in Group II, and were completely disrupted in Group III. This study suggests the possibility of a vital T. gondii TK having potential HER2/4 properties, thus anti-HER2/4 TKIs may inhibit intracellular parasite proliferation with minimal adverse effects on host cells.

Patient-Derived Xenograft Models of Epithelial Ovarian Cancer for Preclinical Studies / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Patient-derived tumor xenografts (PDXs) can provide more reliable information about tumor biology than cell line models. We developed PDXs for epithelial ovarian cancer (EOC) that have histopathologic and genetic similarities to the primary patient tissues and evaluated their potential for use as a platform for translational EOC research. MATERIALS AND METHODS: We successfully established PDXs by subrenal capsule implantation of primary EOC tissues into female BALB/C-nude mice. The rate of successful PDX engraftment was 48.8% (22/45 cases). Hematoxylin and eosin staining and short tandem repeat analysis showed histopathological and genetic similarity between the PDX and primary patient tissues. RESULTS: Patients whose tumors were successfully engrafted in mice had significantly inferior overall survival when compared with those whose tumors failed to engraft (p=0.040). In preclinical tests of this model, we found that paclitaxel-carboplatin combination chemotherapy significantly deceased tumor weight in PDXs compared with the control treatment (p=0.013). Moreover, erlotinib treatment significantly decreased tumor weight in epidermal growth factor receptor–overexpressing PDX with clear cell histology (p=0.023). CONCLUSION: PDXs for EOC with histopathological and genetic stability can be efficiently developed by subrenal capsule implantation and have the potential to provide a promising platform for future translational research and precision medicine for EOC.

Incorporating Erlotinib or Irinotecan Plus Cisplatin into Chemoradiotherapy for Stage III Non-small Cell Lung Cancer According to EGFR Mutation Status / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Concurrent chemoradiotherapy (CCRT) is the standard care for stage III non-small cell lung cancer (NSCLC) patients; however, a more effective regimen is needed to improve the outcome by better controlling occult metastases. We conducted two parallel randomized phase II studies to incorporate erlotinib or irinotecan-cisplatin (IP) into CCRT for stage III NSCLC depending on epidermal growth factor receptor (EGFR) mutation status. MATERIALS AND METHODS: Patients with EGFR-mutant tumors were randomized to receive three cycles of erlotinib first and then either CCRT with erlotinib followed by erlotinib (arm A) or CCRT with IP only (arm B). Patients with EGFR unknown or wild-type tumors were randomized to receive either three cycles of IP before (arm C) or after CCRT with IP (arm D). RESULTS: Seventy-three patients were screened and the study was closed early because of slow accrual after 59 patients were randomized. Overall, there were seven patients in arm A, five in arm B, 22 in arm C, and 25 in arm D. The response rate was 71.4% and 80.0% for arm A and B, and 70.0% and 73.9% for arm C and D. The median overall survival (OS) was 39.3 months versus 31.2 months for arm A and B (p=0.442), and 16.3 months versus 25.3 months for arm C and D (p=0.050). Patients with sensitive EGFR mutations had significantly longer OS than EGFR-wild patients (74.8 months vs. 25.3 months, p=0.034). There were no unexpected toxicities. CONCLUSION: Combined-modality treatment by molecular diagnostics is feasible in stage III NSCLC. EGFR-mutant patients appear to be a distinct subset with longer survival.

Analysis of Dermatologic Diseases in Patients Receiving Anticancer Treatments: A Retrospective Study of 140 Cases / 대한피부과학회지

BACKGROUND: A number of anticancer agents are known to induce many adverse reactions in the skin. Related cutaneous adverse drug reactions influence the morbidity, mortality, and anti-cancer regimen of the patients. A multidisciplinary approach to cancer management has been emphasized. OBJECTIVE: To identify the causative anticancer agents and frequency of adverse reactions in the skin. METHODS: We retrospectively reviewed the medical records of patients who consulted at the Dermatology Department of Busan Paik Hospital and Haeundae Paik Hospital from January 2013 to February 2015. RESULTS: A total of 140 patients were enrolled. Among the 45 patients treated with antimetabolite analogs (30 cytarabine, 7 gemcitabine, 3 methotrexate, 2 fludarabine, 2 doxifluridine, and 1 decitabine), exanthematous drug eruption (49.1%) was the most common reaction, followed by hand-foot syndrome (28.3%). Among the 35 patients treated with fluorouracil (22 5-fluorouracil and 13 capecitabine), hand-foot syndrome (47.2%) was the most common, followed by acneiform eruption (25.0%). Among the 24 patients treated with epidermal grow factor receptor inhibitors (10 erlotinib, 10 cetuximab, and 4 gefitinib), acneiform eruption (54.8%) was the most common, followed by xerosis (19.4%). Among the 11 patients treated with anthracyclines (9 doxorubicin, 1 daunorubicin, and 1 idarubicin), acneiform eruption (45.5%) was the most common, followed by hand-foot syndrome (36.4%). Among the 7 patients treated with taxanes (4 docetaxel and 3 paclitaxel), hand-foot syndrome (42.8%) was the most common. Among the 6 patients treated with angiogenesis-inducing inhibitors (3 sorafenib, 2 pazopanib, and 1 sunitinib), hand-foot skin reaction (66.7%) was the most common. Only 2 patients (1.4%) changed treatments due to intolerable skin reactions. CONCLUSION: Clinicians should be aware of the various skin reactions of anticancer agents and predict their clinical course effectively.

Seguridad y eficacia del uso consecutivo de afatinib y erlotinib en el tratamiento de primera línea de cáncer de pulmón de células no pequeñas (nsclc) en pacientes con mutacion en el gen del receptor del factor de crecimiento epidérmico (EFGR), que hayan respondido previamente al tratamiento con uno de ellos / Safety and efficacy of consecutive use of afatinib and erlotinib in the first-line treatment of non-small cell lung cancer (nsclc) in patients with mutation in the epidermal growth factor receptor gene (egfr) who have previously responded to treatmen

En el Dictamen Preliminar de Evaluación de Tecnología Sanitaria N° 002-SDEPFyOTS-DETS IETSI-2015, luego de concluir que no existían diferencias en relación a la eficacia y seguridad entre afatinib y erlotinib, se decide aprobar el uso de erlotinib por tener un menor costo en el mercado. A partir de la aprobación del uso de erlotinib, surge una nueva pregunta a resolver con respecto a los pacientes que ya se encontraban en tratamiento con afatinib extra institucionalmente. De hecho, existen situaciones como ésta en las que se plantea el cambio de un TKI a otro, aún en condiciones en las que se ha logrado buena evolución clínica y en ausencia de efectos adversos serios al TKI de inicio, por razones más bien extramédicas (como también pueden ser cambios en la disponibilidad del TKI y costos). Así, se plantea la pregunta si el intercambio entre TKIs en dichas condiciones mantiene la respuesta lograda con el primer TKI. \tEs por ello que el presente dictamen expone la evaluación de la eficacia y seguridad del uso consecutivo, de dos TKIs distintos (i.e afatinib y erlotinib) para el tratamiento de primera línea de NSCLC avanzando (estadio 111E3) o metastásico (estadio IV) en pacientes con mutaciones en el gen EGFR, que hayan obtenido respuesta completa sin toxicidad inaceptable previamente al tratamiento con un TKI. En la presente evaluación sobre el uso consecutivo de dos TKIs (i.e afatinib y erlotinib) no se ha encontrado evidencia directa que evalúe la eficacia y seguridad sostenida al intercambiar TKIs para el tratamiento de primera línea de NSCLC en pacientes con mutación en EGFR, en pacientes que han respondido a uno de dichos TKIs sin presentar toxicidad inaceptable. -\tTomando en consideración la evidencia expuesta en el dictamen N° 002-SDEPFyOTS-DETS IETSI-2015 donde no se encontraron diferencias entre afatinib y erlotinib a nivel clínico con respecto a su eficacia y seguridad, es razonable esperar por analogía que ambos fármacos al ser similares pueden ser intercambiables con un bajo riesgo de que se modifique el curso clínico de la enfermedad logrado con el TKI inicial. La población de interés en la presente evaluación de tecnología son los pacientes que han presentado una respuesta excepcional al TKI utilizado (i.e., respuesta completa sin toxicidad importante). En estos casos, y considerando la ausencia de evidencia directa que demuestre que el intercambio de TKIs, en el contexto de no progresión, mantiene la seguridad y eficacia del TKI ya iniciado, el grado de incertidumbre escala a un mayor nivel de complejidad. Por lo tanto, se acude a la opinión de expertos. Así, en opinión de expertos se establece que ante la ausencia de evidencia directa que respalde el intercambio de TKIs y en los casos de pacientes que presentan una respuesta completa al tratamiento, lo mejor es intentar mantener la terapia con la que se ha logrado dicha respuesta y no correr el riesgo, aunque éste sea bajo, de que al cambiar de tratamiento de un TKI a otro, el curso de esta respuesta excepcional varíe. Por lo expuesto, el Instituto de Evaluación de Tecnologías en Salud e Investigación ­ IETSI, aprueba por el periodo de un año a partir de la fecha de publicación del presente Dictamen Preliminar, el uso de afatinib en pacientes con cáncer de pulmón de células no pequeñas (NSCLC) con mutación del gen EGFR, con enfermedad localmente avanzada o metastásica, que presentan respuesta completa sin toxicidad inaceptable con afatinib recibido extra institucionalmente (Anexo 01). Notar que todos aquellos pacientes nuevos con diagnóstico de NSCLC con mutación en el gen EGFR, y aquellos que no cumplen los criterios de respuesta completa al afatinib sin toxicidad inaceptable, deberán acogerse al Dictamen Preliminar N° 002-SDEPFyOTS-DETS IETSI-2015. Los Comités Farmacoterapéuticos de las redes asistenciales deberán evaluar estos casos de manera exhaustiva, bajo responsabilidad, teniendo en cuenta que el presente Dictamen Preliminar no reemplaza al Dictamen Preliminar N° 002-SDEPFyOTS-DETS IETSI-2015, dado que cada dictamen responde a una población diferente. Dado que la evidencia que respalda el intercambio de TKIs, es aún limitada, se establece que el efecto de dicho intercambio se evaluará con los datos de los pacientes que hayan recibido afatinib, bajo las condiciones del presente dictamen. Esta información será tomada en cuenta en la reevaluación de este medicamento al terminar la vigencia de este Dictamen Preliminar (un año a partir de la fecha de publicación).(AU)

Successful Treatment with Empirical Erlotinib in a Patient with Respiratory Failure Caused by Extensive Lung Adenocarcinoma / 대한구급학회지

We herein describe a 70-year-old woman who presented with respiratory failure due to extensive lung adenocarcinoma. Despite advanced disease, care in the intensive care unit with ventilator support was performed because she was a newly diagnosed patient and was considered to have the potential to recover after cancer treatment. Because prompt control of the cancer was needed to treat the respiratory failure, empirical treatment with an oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor was initiated before confirmation of EGFR-mutant adenocarcinoma, and the patient was successfully treated. Later, EGFR-mutant adenocarcinoma was confirmed.

Prognostic Factors for Risk Stratification of Patients with Recurrent or Metastatic Pancreatic Adenocarcinoma Who Were Treated with Gemcitabine-Based Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aim of this study was to verify prognostic factors including sarcopenia in patients with recurrent or metastatic pancreatic cancer receiving gemcitabine-based chemotherapy. MATERIALS AND METHODS: Medical records and computed tomography scan of consecutive patients treated with palliative gemcitabine-based chemotherapy from 2008 to 2014 were reviewed. The lumbar skeletal muscle index at third lumbar spine level was computed, and together with clinicolaboratory factors, univariate and multivariable analyses for overall survival (OS) were performed. RESULTS: A total of 88 patients were found. Median age was 65 years, and male patients were predominant (67.0%). Most patients had initially metastatic disease (72.7%), and gemcitabine monotherapy was administered in 29 patients (33.0%) while gemcitabine plus erlotinib was administered in 59 patients (67.0%). Seventy-six patients (86.3%) had sarcopenia. With a median follow-up period of 44.3 months (range, 0.6 to 44.3 months), median OS was 5.35 months (95% confidence interval [CI], 4.11 to 6.59). In univariate and multivariable analysis, high carcinoembryonic antigen level (hazard ratio [HR], 4.18; 95% CI, 1.95 to 8.97; p < 0.001), initially metastatic disease (HR, 3.37; 95% CI, 1.55 to 7.32; p=0.002), sarcopenia (HR, 2.97; 95% CI, 1.20 to 7.36; p=0.019), neutrophilia (HR, 2.94; 95% CI, 1.27 to 6.79; p=0.012), and high lactate dehydrogenase level (HR, 1.96; 95% CI, 1.07 to 3.58; p=0.029) were identified as independent prognostic factors for OS. CONCLUSION: Five independent prognostic factors in patients with recurrent or metastatic pancreatic cancer who received gemcitabine-based chemotherapy were identified. These findings may be helpful in prediction of prognosis in clinical practice and can be used as a stratification factor for clinical trials.