The outcome of patients with metastatic tumors who discontinued immune checkpoint inhibitors (ICIs) not for progressive disease (PD) has been poorly explored. We performed a meta-analysis of all studies reporting the clinical outcome of patients who discontinued ICIs for reasons other than PD. We searched PubMed, Embase and Scopus databases, from the inception of each database to December 2023, for clinical trials (randomized or not) and observational studies assessing PD-(L)1 and CTLA-4 inhibitors in patients with metastatic solid tumors who discontinued treatment for reasons other than PD. Each study had to provide swimmer plots or Kaplan-Meier survival curves enabling the reconstruction of individual patient-level data on progression-free survival (PFS) following the discontinuation of immunotherapy. The primary endpoint was PFS from the date of treatment discontinuation overall and according to tumor histotype, type of treatment and reason of discontinuation. The Combersure's method was used to estimate meta-analytical non-parametric summary survival curves assuming random effects at study level. Thirty-six studies (2180 patients) were included. The pooled median PFS (mPFS) was 24.7 months (95% CI, 18.8-30.6) and the PFS-rate at 12, 24, and 36 months was respectively 69.8% (95% CI, 63.1-77.3), 51.0% (95% CI, 43.4-59.8) and 34.0% (95% CI, 27.0-42.9). Univariable analysis showed that the mPFS was significantly longer for patients with melanoma (43.0 months), as compared with non-small cell lung cancer (NSCLC, 13.5 months) and renal cell carcinoma (RCC, 10.0 months; between-strata comparison test p-value < 0.001); for patients treated with anti-PD-(L)1 + anti-CTLA-4 as compared with anti-PD-(L)1 monotherapy (44.6 versus 19.9 months; p-value < 0.001), and in NSCLC when the reason of treatment discontinuation was elective as compared with toxicity onset (19.6 versus 4.8 months; p-value = 0.003). The multivariable analysis confirmed these differences. The long-term outcome of patients who stopped ICIs for reasons other than PD was substantially affected by clinicopathological features: PFS after treatment discontinuation was longer in patients with melanoma, and/or treated with anti-PD-(L)1 + anti-CTLA-4, and shorter in patients with RCC or in those patients with NSCLC who stopped treatment for toxicity onset. The Italian Ministry of University and Research (PRIN 2022Y7HHNW).

Cholangiocarcinoma (CCA) is a rare and aggressive cancer, mostly diagnosed at advanced or metastatic stage, at which point systemic treatment represents the only therapeutic option. Chemotherapy has been the backbone of advanced CCA treatment. More recently, immunotherapy has changed the therapeutic landscape, as immune checkpoint inhibitors have yielded the first improvement in survival and currently, the addition of either durvalumab or pembrolizumab to standard of care cisplatin plus gemcitabine represents the new first-line treatment option. However, the use of immunotherapy in subsequent lines has not demonstrated its efficacy and therefore, it is not approved, except for pembrolizumab in the selected microsatellite instability-high population. In addition, advances in comprehensive genomic profiling have led to the identification of targetable genetic alterations, such as isocitrate dehydrogenase 1 (IDH1), fibroblast growth factor receptor 2 (FGFR2), human epidermal growth factor receptor 2 (HER2), proto-oncogene B-Raf (BRAF), neurotrophic tropomyosin receptor kinase (NTRK), rearranged during transfection (RET), Kirsten rat sarcoma virus (KRAS), and mouse double minute 2 homolog (MDM2), thus favoring the development of a precision medicine approach in previously treated patients. Despite these advances, the use of molecularly driven agents is limited to a subgroup of patients. This review aims to provide an overview of the newly approved systemic therapies, the ongoing studies, and future research challenges in advanced CCA management.

Background: Aromatase inhibitors (AI) are widely used for treating hormone-sensitive breast cancer (BC). Obesity, however, due to aromatase-mediated androgen conversion into estradiol in the peripheral adipose tissue, might impair AI inhibitory capacity. We aimed at identifying a cut-off of body mass index (BMI) with significant prognostic impact, in a cohort of stage I-II BC patients on systemic adjuvant therapy with AI. Methods: we retrospectively evaluated routinely collected baseline parameters. The optimal BMI cut-off affecting disease-free survival (DFS) in AI-treated BC patients was identified through maximally selected rank statistics; non-linear association between BMI and DFS in the AI cohort was assessed by hazard-ratio-smoothed curve analysis using BMI as continuous variable. The impact of the BMI cut-off on survival outcomes was estimated through Kaplan–Meier plots, with log-rank test and hazard ratio estimation comparing patient subgroups. Results: A total of 319 BC patients under adjuvant endocrine therapy and/or adjuvant chemotherapy were included. Curve-fitting analysis showed that for a BMI cut-off >29 in AI-treated BC patients (n = 172), DFS was increasingly deteriorating and that the impact of BMI on 2-year DFS identified a cut-off specific only for the cohort of postmenopausal BC patients under adjuvant therapy with AI. Conclusion: in radically resected hormone-sensitive BC patients undergoing neoadjuvant or adjuvant chemotherapy and treated with AI, obesity represents a risk factor for recurrence, with a significantly reduced 2-year DFS.

Introduction: Two distinct molecular groups of HCC have been recently associated with a better response to atezolizumab-bevacizumab. One of these, “angiogenesis-driven,” is related to HCC vascularization. Vessels that encapsulate tumor clusters (VETCs) is a morphological form of angiogenesis associated with worse prognosis in resected and transplanted HCC. The aim of this study was to explore if VETC can be used, at morphological level, to potentially surrogate the angiogenesis-driven molecular subgroup to identify HCC patients who might benefit of antiangiogenic treatments. Methods: The significance of VETC was first explored in a retrospective, single institution series of 75 patients with unresectable HCC (study cohort) and later validated in an external, retrospective series of 82 patients (validation cohort). The VETC phenotype was identified in the liver biopsy obtained just before the onset of systemic treatment. Results: Patients with VETC+ HCC experienced a significant survival benefit from antiangiogenic drugs, as tyrosine kinase inhibitors and/or bevacizumab (TKI/BEVA), across the study, validation, and overall cohorts. In the whole series of 157 patients, those with VETC+ HCC (n = 70, 45%) treated with TKI/BEVA had a significantly longer overall survival (OS) as compared to those receiving immune checkpoint inhibitors (19.8 months vs. 8.8 months; HR: 0.34; 95% CI: 0.20–0.59; p = 0.0001). The significant treatment-by-biomarker interaction test (p = 0.002) demonstrated that treatment effect varies by VETC status. Case with higher extent of VETC+ or with VETC+ detected before the onset of 1st-line treatment showed even longer survival. Conclusion: VETC+ predicts a significantly longer OS in patients with unresectable HCC treated with TKI/BEVA and can be used as surrogate marker on liver biopsy of angiogenesis-driven molecular class.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide with most of patients diagnosed at advanced stage. Thus, systemic therapy remains a cornerstone of treatment. In recent years, immunotherapy has changed therapeutic scenario, being investigated also in combination with anti-vascular endothelial growth factor (VEGF) agents. This approach has demonstrated safety and efficacy in several trials, paving the way for their investigation in earlier disease stages and in different settings. A structured literature review was conducted using PubMed and ClinicalTrials.gov to identify published evidence supporting safety and efficacy of anti-programmed death-1/programmed death-ligand-1(PD-1/PD-L1) and anti-VEGF agents in different therapeutic settings and identifying ongoing clinical trials and key research directions. Combination of anti-PD-1/PD-L1 and anti-VEGF agents has demonstrated safety and efficacy as a first-line treatment for advanced HCC, supported by results from phase 3 trials. These results suggest that further investigation is warranted to optimize first-line efficacy, second-line choice, and potential application in earlier disease stages. The clinical benefit of anti-PD-1/PD-L1 and anti-VEGF agents have also opened the door to a new clinical paradigm, where transitioning from systemic therapy to locoregional therapies, resection or even liver transplantation could be a feasible treatment strategy.

Despite the proven superiority against sorafenib, atezolizumab plus bevacizumab (A+B) lacks long-term efficacy data in unresectable hepatocellular carcinoma (uHCC). This study assessed clinicopathologic factors associated with long-term survival with A+B. We analyzed patients receiving first-line A+B within AB-Real, a large multicenter registry across Europe, Asia, and the USA. Long-term survivors (LTS) were defined as patients surviving at 24 months. Landmark survival outcomes and associations between baseline clinicopathologic factors and overall survival (OS) were evaluated. Of 1346 patients enrolled, 1085 with Child-Pugh A and ECOG 0-1 received first-line A+B. The median OS was 19.2 months (95% CI: 17.6-20.9), and 2- and 3-year survival rates were 41.4% and 29.3%. Among 695 patients with adequate follow-up, 190 were classified as LTS. The overall response rate was 24.7%, and long-term survivorship was significantly enhanced in radiologic responders (52.2% vs 8.8%, p < 0.001). Compared to non-LTS, LTS more frequently had ALBI grade 1 liver reserve (64.6% vs 38.5%), less PVI (17.9% vs 36.4%), smaller maximum tumor size (3.8 vs 7.0 cm), and lower AFP (median 23.0 vs 240.8 ng/mL) (all p < 0.001). Notably, nearly half (48.8%) of radiologic responders who did not achieve long-term survival had ≥ 2 adverse baseline features, underscoring that tumor burden and liver reserve remain prognostically relevant even among responders. AB-Real provides the first global real-world evidence of long-term efficacy of A+B in uHCC. Long-term survivorship is enhanced in radiological responders and strongly associated with pre-treatment tumor factors and liver function.