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Brain metastases in metastatic breast cancer (July 2021)
As patients with advanced breast cancer live longer, the incidence of brain metastases appears to be increasing, with one meta-analysis suggesting that approximately one-third of patients with HER2-positive, one-third of those with triple-negative, and 15 percent of those with hormone receptor positive, HER2-negative metastatic breast cancer will develop brain metastases [1]. Brain metastases have highly variable clinical features and should be suspected in any cancer patient who develops neurologic symptoms or behavioral abnormalities.
Sentinel lymph node assessment in patients with endometrial carcinoma (July 2021)
Sentinel lymph node (SLN) dissection is routinely performed during surgical staging of endometrial carcinoma; however, the optimal tracer (indocyanine green [ICG], technetium-99m [99mTC], isosulfan, or methylene blue) for mapping is unclear. In a meta-analysis including 33 studies evaluating the diagnostic accuracy of various tracers for SLN assessment in patients with early-stage disease, use of ICG alone or in combination with blue dye or 99mTC detected more SLNs compared with non-ICG tracers (mean SLN detection rate: 92 to 100 percent versus 78 to 87 percent); however, the sensitivity (ie, ability to identify malignancy in a detected SNL) was high (>90 percent) for all tracers [2]. In our practice, we use ICG alone when performing SLN mapping in patients with endometrial cancer.
Adjuvant pembrolizumab for resected cutaneous melanoma (July 2021)
For patients with resected high-risk melanoma, the use of adjuvant immunotherapy is established, but long-term outcomes are not known. In preliminary results from a randomized phase III trial (S1404) of approximately 1300 patients with high risk (Stage IIIA-IVC), resected melanoma, one year of adjuvant therapy with the programmed cell death protein 1 (PD-1) inhibitor pembrolizumab improved relapse-free survival (HR 0.74) and was better tolerated compared with high-dose interferon alfa-2b or ipilimumab [3]. Based on these data, we continue to recommend the use of one year of adjuvant immunotherapy using a single agent PD-1 inhibitor, and pembrolizumab remains one of our preferred options.
Radiation plus temozolomide in non-1p/19q-codeleted anaplastic gliomas (July 2021)
The CATNON trial evaluated radiation therapy with or without temozolomide in patients with grade III 1p/19q-non-codeleted anaplastic gliomas. In the second interim analysis, 12 cycles of monthly adjuvant temozolomide improved median overall survival compared with no adjuvant temozolomide (82 versus 47 months) [4]. When analyzed according to isocitrate dehydrogenase (IDH) status, the benefit was observed only in IDH-mutant tumors. Use of daily temozolomide during radiation did not result in additional benefit. These findings reinforce post-radiation chemotherapy as the standard of care for patients with grade III IDH-mutant astrocytomas. Further data are needed to clarify the optimal approach in grade III IDH-wildtype astrocytomas.
Convalescent plasma therapy in patients with a hematologic malignancy hospitalized for COVID-19 (June 2021)
Convalescent plasma is not suggested for routine use in the general population of patients hospitalized with severe COVID-19, but it may benefit certain vulnerable populations. In a retrospective multicenter cohort study of nearly 1000 patients with a hematologic malignancy hospitalized for COVID-19, plasma recipients had a 50 percent lower risk of 30-day all-cause mortality compared with propensity-matched untreated controls [5]. Benefits were observed across a range of illness severity including in those requiring intensive care unit admission or mechanical ventilation. We now suggest the use of convalescent plasma therapy for patients with a hematologic malignancy who are hospitalized for COVID-19 and who lack access to monoclonal antibodies targeting SARS-CoV-2.
1. Kuksis M, Gao Y, Tran W, et al. The incidence of brain metastases among patients with metastatic breast cancer: a systematic review and meta-analysis. Neuro Oncol. 2021;23(6):894.
2. Nagar H, Wietek N, Goodall RJ, et al. Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer. Cochrane Database Syst Rev. 2021;6:CD013021. Epub 2021 Jun 9.
3. Grossman KF, Othus M, Patel SP, Tarhini A. Final analysis of overall survival (OS) and relapse-free-survival (RFS) in the intergroup S1404 phase III randomized trial comparing either high-dose interferon (HDI) or ipilimumab to pembrolizumab in patients with high-risk resected melanoma. J Clin Oncol. 2021;39;15S; https://meetinglibrary.asco.org/record/195948/abstract.
4. van den Bent MJ, Tesileanu CMS, Wick W, et al. Adjuvant and concurrent temozolomide for 1p/19q non-co-deleted anaplastic glioma (CATNON; EORTC study 26053-22054): second interim analysis of a randomised, open-label, phase 3 study. Lancet Oncol. 2021;22(6):813. Epub 2021 May 14.
5. Thompson MA, Henderson JP, Shah PK, et al. Association of Convalescent Plasma Therapy With Survival in Patients With Hematologic Cancers and COVID-19. JAMA Oncol. 2021.
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