Vol 22, No 3 (2020)

Guidelines
Mantle cell lymphoma
Vorob’ev V.I., Tumian G.S., Falaleeva N.A., Ptushkin V.V., Osmanov E.A., Poddubnaya I.V., Baikov V.V., Kovrigina A.M., Nevol’skikh A.A., Ivanov S.A., Khailova Z.V., Gevorkian T.G.
Abstract

Mantle cell lymphoma. Clinical recommendations

Journal of Modern Oncology. 2020;22(3):6-23
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Chronic lymphocytic leukemia/small lymphocytic lymphoma
Nikitin E.A., Bialik T.E., Zaritskii A.I., Iseber L., Kaplanov K.D., Lopatkina T.N., Lugovskaia S.A., Mukhortova O.V., Osmanov E.A., Poddubnaya I.V., Samoilova O.S., Stadnik E.A., Falaleeva N.A., Baikov V.V., Kovrigina A.M., Nevol’skikh A.A., Ivanov S.A., Khailova Z.V., Gevorkian T.G.
Abstract

Chronic lymphocytic leukemia/small lymphocytic lymphoma. Clinical recommendations

Journal of Modern Oncology. 2020;22(3):24-44
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Review
Polyploid giant cancer cells and their role in the formation of resistance to therapeutic treatment
Vartanyan N.L., Pinevich A.A., Bode I.I., Samoylovich M.P.
Abstract

The review considers the properties of polyploid giant tumor cells – a new target for the development of cancer therapy. Various number of polyploid giant tumor cells are detected in almost all human solid tumors. Their number increases under the influence of hypoxia, radiation, and after chemotherapy. Previously, these cells were not considered to be worth studying as they do not proliferate and eventually die as a result of one of the cell death mechanisms action. Recent data have demonstrated that polyploid giant cells can give rise to daughter cells that possess tumorigenicity and are characterized as stem tumor cells. Giant tumor cells and daughter cells are involved in the processes of metastasis, recurrence, drug resistance formation and radio-resistance of tumors. The search is under way for molecular targets that could prevent the appearance or contribute to the elimination of previously formed polyploid giant tumor cells. The combination of traditional therapy that causes the death of proliferating tumor cells and allows their elimination, with the use of tools that could prevent the ­appearance of resistant polyploid giant cells and their daughter cells, can be the key to the effective treatment of malignancies.

Journal of Modern Oncology. 2020;22(3):105-108
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Modern perspectives in sequential therapy for metastatic colorectal cancer with reference to the use of regorafenib
Sekacheva M.I., Nuriev R.I., Rozhkov A.A., Semenkov A.V., Bagmet N.N., Boroda A.M.
Abstract

Over the past two decades, many new variants of targeted therapy for metastatic colorectal cancer (mCRC) had appeared, and significantly increased patient survival. However, there were questions relating to the definition of the optimal sequence and the combination of different drugs. Cytotoxic agents, including irinotecan, oxaliplatin, 5-fluorouracil and capecitabine, are the basis of the treatment of mCRC. In addition, the arsenal of modern oncologist includes the group of drugs inhibiting the epidermal growth factors (for example, cetuximab and panitumumab) and inhibiting tumor angiogenesis factors (for example, bevacizumab and aflibercept). Moreover, the use of immuno-oncology drugs, trastuzumab or encorafenib is possible in case of knowing tumor-specific molecular signature. Unfortunately, these new indications can be used only in small proportion of patients. The multikinase inhibitor regorafenib takes a special place, it can be used in patients in spite of RAS mutation status. The increasing attention has been paid to the selection of the drugs for sequential therapy of mCRC, recently. This review discusses important clinical data on the direct role of targeted drugs in the treatment of mCRC in different subgroups of patients.

Journal of Modern Oncology. 2020;22(3):109-113
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Reduction of febrile neutropenia by using long-acting granulocyte colony-stimulating factors in patients with solid tumors receiving every-2-week chemotherapy
Kononenko I.B., Snegovoy A.V., Grebennikova O.P., Sel’chuk V.Y., Palchinskaia O.V.
Abstract

Neutropenia is a common hematological complication of chemotherapy (СT). The number of studies showed that the underperformance of the treatment program due to the development of this type of hematological toxicity could lead to the decrease in therapy efficacy and to the increase in cancer mortality. Infections that occur as a result of prolonged neutropenia are extremely dangerous. The most severe manifestation of grade 4 neutropenia is febrile neutropenia (FN), which can lead to death from severe infections. Such patients should be immediately hospitalized and should receive empirical therapy with broad-spectrum antibiotics. The costs, associated with the hospitalization, due to FN increase total cost of cancer patients’ treatment. The application of recombinant forms of the natural protein granulocyte colony-stimulating factor (G-CSF) in clinical practice has solved the number of important problems on that front. The clinical studies and common use show that primary and secondary prevention using recombinant G-CSF reduces the risk of FN development and improves the results of the treatment of malignancies. The review provides actual data concerning pharmacological properties, clinical efficacy and reasonable use of G-CSF with prolonged action to prevent FN in patients with solid tumors during 2-week CT cycles. Special attention is paid to CH regimens with the inclusion of 5-fluorouracil, oxaliplatin, irinotecan in the treatment of colorectal cancer (CRC). The use of neoadjuvant treatment in such patients allows to achieve resectability of the tumor and to perform radical surgery. The maintenance of drugs dose intensity throughout the cycle of CT plays an important role in achieving the treatment success. Therefore, the prevention of CT-induced severe neutropenia and FN is especially important in patients who are the candidates for surgical treatment. The results of some studies confirm the necessity of using G-CSF with prolonged action during 2-week CT cycles in patients with CRC.

Journal of Modern Oncology. 2020;22(3):133-141
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Managing menopausal symptoms in patients with hormone receptor-positive gynecologic cancers
Shabalova O.V., Yureneva S.V., Khokhlova S.V., Gardanova Z.R., Ermakova E.I.
Abstract

Young women with reproductive tract neoplasms who receive treatment leading to termination of ovarian function often suffer from menopause symptoms that contribute to dramatic drop in quality of life. Climacteric symptoms in women with iatrogenic menopause are more severe than in case of natural menopause, especially in women with reproductive tract neoplasms. They lead to dramatic drop in quality of life and are one of the main reasons to stop applying endocrine therapy in women with hormone-positive tumors, which leads to decrease in disease free survival and to decline the prognosis. The most effective treatment option for climacteric symptoms of moderate to severe degrees is menopause hormone therapy; however, such therapy is not suitable for patients with estrogen-dependent tumors in past medical history due to the likelihood risk of progression of cancer, as well as the risk of venous thrombosis, the frequency of which in cancer patients increases. Non-hormonal pharmacological and non-pharmacological correction methods are used as first-line therapy for menopause disorders in women with estrogen-dependent tumors of the reproductive system. Among non-hormonal non-pharmacological correction methods actively study such methods as acupuncture, yoga, exercise to control weight, and a diet rich in phytoestrogens. The most effective non-hormonal methods of correcting vasomotor symptoms are serotonin and norepinephrine reuptake inhibitors. However, currently in Russia these drugs can be prescribed only by a psychiatrist. The finding of effective and safe non-hormonal methods to correct menopause symptoms in women with hormone-positive reproductive tract tumors is the important task in practice among doctors in different specialties.

Journal of Modern Oncology. 2020;22(3):154-159
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Original Article
Malignant neoplasms mortality rates in Moscow and Saint Petersburg in 2015 and 2018
Samorodskaya I.V., Semenov V.Y.
Abstract

Significant differences in mortality rates of the most of the death causes were detected between Moscow and Saint-Petersburg in the number of researches.

Aim. Comparison and ranging of standardized mortality rates (SMR) from malignant neoplasms (MN) of different localizations in Moscow and in Saint-Petersburg in 2015 and 2018; determination of the localizations with main input in SMR from MN.

Materials. Number of citizens and number of deaths from tumors accordingly to Rosstat Short nomenclature of the death reasons were evaluated. Death rates were calculated using the special computer programs on the base of European standard, comparison was provided with help of non-parametric criteria.

Results. SMR of 29 from 33 MN localizations became lower in 2018 comparing to 2015 both in Moscow and in Saint-Petersburg. The average SMR decreased in 2018 in Saint-Petersburg statistically significant (p=0.003) and in Moscow non-significant (p=0.34). The largest SMR value both in 2015 and in 2018 in Moscow and in Saint-Petersburg as well were registered from 7 cancer localizations (trachea, bronchus, lungs; large intestine; breast; pancreas; rectum; prostate). The share of these SMR localizations in all MN was 57% and 54% in Moscow and 57 and 56% in Saint-Petersburg correspondingly. SMR of all 7 localizations were lower in Moscow comparing to Saint-Petersburg. SMR was lower in 2018 comparing to 2015 in both cities. The share of MN of others, unspecified, non-classified, etc. localizations in all MN was 11% in 2015 in both cities. Its share was in 2018 13.5% in Moscow and 10.1% in Saint Petersburg.

Conclusions. SMR of most MN was higher in Saint Petersburg as in Moscow both in 2015 and in 2018. The analyses of the effectiveness of screening programs and of health care organization for patients with MN with highest SMR is needed. The questions of the differential diagnostics (intravital and postmortem) and of control the quality of medical death certificates filling in should be solved for the decrease of mortality of “nonrefinement” MN.

Journal of Modern Oncology. 2020;22(3):79-84
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Molecular genetic portrait of non-small cell lung cancer in Tambov region: regional experience
Ognerubov N.A., Sychev V.D., Kozlova N.A., Chang V.L.
Abstract

80–90%. The identification of gene mutation profile of non-small cell cancer allows to make a molecular portrait, which plays the crucial role in choosing the targeted therapy with tyrosine kinase inhibitors.

The aim is to study the frequency and spectrum of activating mutations in non-small cell lung cancer in Tambov region.

The study of the presence of mutations and the main driver gene mutation profile: EGFR, ALK, BRAF, ROS1 and PDL-1 using sections of paraffin-embedded after the surgery and biopsy in 238 patients with the help of polymerase chain reaction and immunohistochemistry. The age of patients ranged from 28 years to 82 years, with a mean age of 60.3 years.

Results. Adenocarcinoma was detected in 80.3% of patients, and squamous cell variant – in 19.7% of cases. The frequency of the driver gene activating mutations in non-small cell lung cancer was 29%, this index exceeded the frequency in the European population. Statistically significant predominance of female (63.6%) vs male (36.4%) was achieved. The mutation frequency increases with age. In this case, EGFR mutations were observed more often – 22.3%. This index was slightly higher than in the European population. Statistically significant predominance of female was achieved. The highest frequency of mutations was demonstrated in patients 65–70 years of age (24%). The deletion of exon 19 and single-nucleotide replacement L858R of exon 21 were observed in 54.5% and 45.5% of cases, respectively. The mutation of exon 19 was more often detected in male, at the same time the mutations of exons 19 and 21 in female were detected in almost the same frequency. Maximum frequency mutation rate (77.7%) in the EGFR gene was detected free from metastases to the regional lymph nodes. ALK mutations were found in 14.6% of patients, this index was slightly higher than the European level.

PDL-1 expression is found in 40% male patients.

Conclusion. The results of the study revealed some features of the profile of activating mutations in non-small cell lung cancer in the region. This data should be taken into account on planning and applying targeted therapy.

Journal of Modern Oncology. 2020;22(3):88-93
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Detection of disseminated tumor cells and their relationship with a population of bone marrow lymphocytes in patients with non-small cell lung cancer
Djumanazarov T.M., Chulkova S.V., Tupitsyn N.N., Chernysheva O.A., Allakhverdiev A.K., Palladina A.D., Kupryshina N.A., Kolbatskaya O.P., Kononetz P.V., Akhmedov B.B., Gerasimov S.S.
Abstract

Introduction. Detection of disseminated tumor cells (DTC) in solid tumors is an important component of the assessment of disease prognosis. Bone marrow damage is common. There is evidence indicating an important role for bone marrow lymphocyte subpopulations in hematogenous metastasis.

Aim. To evaluate the frequency of bone marrow damage in patients with non-small cell lung cancer (NSCLC) based on the detection of DTC by flow cytometry, as well as their effect on the population of bone marrow lymphocytes.

Materials and methods. 62 bone marrow samples of patients with a verified diagnosis of NSCLC: adenocarcinoma (33), squamous cell carcinoma (27), other types (2). Methods: morphological, multicolor flow cytometry. Studied DTC, lymphocyte populations CD3, CD4, CD8, CD19, CD20, CD16, CD27. Collection and analysis: FACS Canto II, USA, Kaluza Analysis v2.1.

Results. In bone marrow, DTC (EPCAM+CD45-) were found in 43.5% of patients with NSCLC (1 cell per 10 million myelocariоcytes was taken as the threshold value). The presence of DTC did not correlate with the size of the tumor, the status of the lymph nodes, and the stage of the tumor process. DTC was more often observed in more differentiated tumors (p=0.023). A significant increase in the level of subpopulations of CD16+CD4-NK-cells (p=0.002), CD27+CD3+T-cells (p=0.015) with bone marrow damage was revealed.

Conclusion. The possibility of detecting DTC in the bone marrow of patients with NSCLC was established, in 43.5% of patients with NSCLC in the bone marrow DTC was detected, and their presence was established even with a localized tumor process. More frequent bone marrow damage was observed with well-differentiated tumors. The relationship between DTC and bone marrow lymphocyte populations was revealed: subpopulations of CD16+CD4-, CD27+CD3+.

Journal of Modern Oncology. 2020;22(3):94-99
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Comparative analysis of the effectiveness of «Chaos and Clues», «Triage Amalgamated Dermoscopic Algorithm» dermatoscopic algorithms and BLINСK techniques in the diagnosis of melanoma and other skin cancers depending on previous dermatoscopy experience
Silina L.V., Khvostovoi V.V., Ovsianikov V.V., Zubtsov M.S.
Abstract

Aim. Comparison of the results of the use of dermatoscopic algorithms «Chaos and Clues», «Triage Amalgamated Dermoscopic Algorithm» (TADA) and BLINCK technique in the diagnosis of melanoma and other malignant skin tumors depending on the presence of previous dermatoscopy experience.

Materials and methods. Algorithms were tested on 85 patients with 85 skin formations who visited the polyclinic of Kursk Regional Clinical Oncology Clinic in 2017–2019. The average age of the patients was 54.8 years old. Dermatoscopy was performed by the non-polarized dermatoscope HEINE mini 3000, photo documentation by the Canon PowerShot SX540 HS camera. Immersion medium – ethyl alcohol (conc. 70%). Patients were carefully examined physiologically and clinically. A clinical and epiluminescence pattern of all neoplasms was obtained, their morphological examination was performed. For the research 2 groups of 3 participants were formed based on the criterion of previous dermatoscopy experience. Each algorithm was evaluated by objective (sensitivity, specificity) and subjective (speed, convenience) criteria. The dermatoscopic results obtained by the techniques used were compared to the histological findings.

Results. Using algorithms by a group having previous dermatoscopy experience, the following results were obtained: in the method «Chaos and Clues» sensitivity – 93.75±3.3%, specificity – 77.4±4.6%, speed – 3 points, convenience – 3 points. TADA sensitivity – 96.8±2.2%, specificity – 79.2±4.8%, speed – 4 points, convenience – 5 points. BLINCK sensitivity – 96.8±2.2% specificity – 77.4±4.6%, speed – 4 points, convenience – 5 points. In the group with no previous dermatoscopy experience, the results were as follows: in the «Chaos and Clues» algorithm, sensitivity – 93.75±3.3%, specificity – 62.3±5.7%, speed – 3 points, convenience – 3 points. TADA sensitivity – 84.4±4.6%, specificity – 64.2±5.8%, speed – 4 points, convenience – 5 points; BLINCK sensitivity – 80.6±4.4%, specificity – 77.4±4.6%, speed – 5 points, convenience – 4 points. Thus, these algorithms can be used in the diagnosis of malignant skin neoplasms. At the same time, individuals with no experience of dermatoscopy are encouraged to use the «Chaos and Clues» algorithm. In a group having experience in dermatoscopy, both the TADA and the BLINCK technique can be used equally.

Journal of Modern Oncology. 2020;22(3):100-104
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Prognostic relevance of the TNM classification 8th edition and new criteria of staging for retroperitoneal liposarcoma
Nered S.N., Volkov A.Y., Kozlov N.А., Stilidi I.S., Archery P.P.
Abstract

For the first time a section appeared for staging of non-organ retroperitoneal tumors in the UICC TNM classification 8th edition.

Aim. To assess the prognostic significance of the TNM classification eighth edition for the most common retroperitoneal tumors-liposarcoma.

Materials and methods. The distribution of patients by stages and survival in accordance with the TNM-8 classification were studied in 192 patients with retroperitoneal non-organ liposarcoma (RLPS).

Results. In the TNM-8 classification, only the degree of malignancy of the tumor has a prognostic value, and the T-category does not reflect the actual size of the RLPS and is considered T4 in 93%, which leads to inadequate staging. During the 15-year period, there were no cases with stages II and IIIA, and the survival rate was estimated only in patients with stages I and IIIB. A TNM classification with new values of the T-category was proposed, which demonstrated a more adequate distribution of patients by stages and the reliability of intergroup differences in the survival rate.

Conclusion. It is advisable to create a special TNM classification for RLPS, which makes up more than half of all retroperitoneal sarcomas.

Journal of Modern Oncology. 2020;22(3):120-126
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Meta-analysis of the studies dedicated to the predictive significance of circulating tumor DNA in pancreatic cancer
Popova A.S., Fedyanin M.Y., Pokataev I.A., Tyulyandin S.A.
Abstract

The method of liquid biopsy allows detection of circulating tumor DNA (ctDNA) in patient blood, but the clinical significance of this approach in pancreatic cancer is still unclear. In this regard, we have carried out a meta-analysis of the studies dedicated to the predictive significance of ctDNA in pancreatic cancer.

Materials and methods. We carried out the search for the articles and abstracts in PubMed, ASCO and ESMO databases published before February 2020, containing data about the connection between ctDNA and the prognosis of pancreatic cancer. The exclusion criteria were the studies including 10 or less participating patients, absence of the data about the relative risk of mortality and/or progression, and the 95% confidence interval. The meta-analysis was carried out by using the Review Manager software (RevMan), Version 5.3.

Results. There were no significant systematic errors associated with the publications. The presence of ctDNA in patient blood showed poor overall survival of patients (odds ratio – OR 2.21, 95% confidence interval – CI 1.35-3.33, p=0.001) regardless of the prevalence of the disease. In case of the resectable process, the detection of ctDNA in patient blood both before and after surgery was a factor of worse progression-free survival (OR 2.32, 95% CI 1.54–3.5, p<0.001 and OR 3.06, 95% CI 1.63–5.76, р=0.0005 and overall survival (OR 2.01, 95% CI 1.12–3.63, р=0,02 and OR 3.39, 95% CI 2.12–5.44, р<0.00001, respectively).

Conclusions. The detection of ctDNA in the bloodstream in pancreatic cancer patients is a factor of poor prognosis in both localized and advanced cancer. It is very important to make further prospective studies to develop the optimal protocol for detecting ctDNA in patient bloodstream.

Journal of Modern Oncology. 2020;22(3):127-132
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Lecture
Features of management of oncohematological patients in the context of the COVID-19 pandemic
Poddubnaya I.V., Tumian G.S., Trofimova O.P., Babicheva L.G., Bariakh E.A., Poliakov A.S.
Abstract

Features of management of oncohematological patients in the context of the COVID-19 pandemic. Lecture

Journal of Modern Oncology. 2020;22(3):45-58
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Patient blood management in oncology in the Russian Federation: resolution to improve oncology care.
Hofmann A., Aapro M., Fedorova T.A., Zhiburt Y.B., Snegovoy A.V., Kaganov O.I., Ognerubov N.A., Lyadov V.K., Moiseenko V.M., Trofimova O.P., Ashrafyan L.A., Khasanov R.S., Poddubnaya I.V.
Abstract

The huge global burden of oncological diseases is growing and measures to counter this complex challenge are high on national health agendas. The Russian National Long-Term Oncology Strategy 2030 defines priorities, goals and directions in the fight against cancer. It also contains action plans for more effective prevention, earlier and more specific diagnosis and more effective treatment options. Against this backdrop, experts now suggest to complement standard oncology treatment strategies by adding Patient Blood Management (PBM). For many clinical disciplines where a low blood count and considerable blood loss are commonly encountered, this bundle of care is the new standard. Based on clinical and scientific evidence, it aims to optimise medical and surgical patient outcomes by clinically managing and preserving a patient’s blood. The principles of this comprehensive concept can and must be transferred to oncology, thus offering value in improving cancer care and the efficacy of medical institutions. Accumulating evidence demonstrates that anaemia and iron deficiency, but also thrombocytopenia, blood loss and coagulopathy are independent risk factors for adverse patient outcomes including morbidity, mortality, reduced quality of life and prolonged average length of hospital stay in both surgical and medical patients. For the timely and effective detection and correction of these risk factors, an international network of multi-disciplinary clinicians and researchers has developed PBM. The rapidly growing body of evidence for PBM not only shows improved patient outcomes, but also reduced resource utilisation including the use of allogeneic blood components. The reduction of allogeneic blood transfusion further improves patient safety and outcomes, since transfusion is another independent risk factor for adverse outcomes. Supported by WHO endorsements and following the recommendations of an increasing number of state or national health authorities, PBM is about to become a new standard of care. However, even though the aforementioned risk factors are highly prevalent in oncology settings due to chemo-/radiotherapy and the pathology of the disease, the integration of PBM in standard oncology treatment pathways is lagging behind. Thus, and in support of the Russian National Long-Term Oncology Strategy 2030 to improve quality of oncological care, with the support of the National Association of Specialists in PBM (NASPBM), the PBM Oncology Working Group of the Russian Federation was created, consisting of national and international experts in oncology and PBM. On July 9, 2020, the Working Group met to discuss the rationale for PBM in oncology and to assess the need to implement PBM in Russian oncology care. As a result, the Group recommended to include PBM as an integral part of standard oncology treatment pathways, delineated the action required from facilitating stakeholders in the Russian Federation, determined a roadmap for implementation and developed a national resolution as a call to action on the matter. Presented herein, this resolution acknowledges the global and local impetus to reduce cancer mortality, and the rationale for PBM interventions to improve patient outcomes and alleviate the social and economic burden of cancer on the healthcare system.

Journal of Modern Oncology. 2020;22(3):59-78
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Prospects for the development of adjuvant therapy for non-small cell lung cancer
Laktionov K.K., Kazakov A.M., Reutova E.V., Ardzinba M.S., Arzumanian A.L.
Abstract

The standard approach for stage IB and II–IIIA non-small cell lung cancer (NSCLC), associated with the high risk of relapse, after total lung resection is adjuvant chemotherapy, nowadays. The 5-year survival benefit for this approach is about 5%, and the risk of relapse reduces from 11 to 15%, depending on the stage. However, the relapse rate within 5 years after surgery and adjuvant chemotherapy in stage IB–IIIA NSCLC is up to 70%. This fact requires the search for new solutions. The efficacy and safety profile of targeted drugs in metastatic NSCLC show the possibility to use them as adjuvant therapy in the early stages of the disease. This approach was actively studied in patients with mutations in the EGFR gene, and the most promising were the results of the ADAURA trial, which had been studied the use of Osimertinib, a third-generation EGFR tyrosine kinase inhibitor, as adjuvant therapy. The use of adjuvant targeted therapy in ALK-positive patients is currently less studied and its efficacy will be determined as the results of the ALINA and ALCHEMIST trials are obtained.

Journal of Modern Oncology. 2020;22(3):85-87
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Lenvatinib as the key component of first-line therapy for patients with unresectable hepatocellular carcinoma
Bolotina L.V.
Abstract

Throughout the last 10 years, liver cancer mortality rate in the Russian Federation consistently exceeded the morbidity rate, which is related to the complexity of early diagnostics, absence of effective screening and oncological alertness of allied-profession doctors. In the situation when late disease intelligence does not frequently allow radical treatment, palliative methods remain the only option of survivability enhancement and improving the patients’ quality of life. Lenvatinib was approved as the first-line drug in the treatment of unresectable hepatocellular carcinoma based on the data of the REFLECT trial, in which the drug demonstrated achieving the patients’ overall survival (OS) comparable to the activity of sorafenib (13.6 months for lenvatinib vs 12.3 months for sorafenib; hazard ratio – HR 0.92; 95% confidence interval – CI 0.79–1.06). At the same time, significant inferiority of lenvatinib was observed for secondary endpoints: progression-free survival – PFS (7.4 months for lenvatinib vs 3.7 months for sorafenib; HR 0.66; 95% CI 0.57–0.77; р<0.0001), time to progression (8.9 months for lenvatinib vs 3.7 months for sorafenib; HR 0.63; 95% CI 0.53–0.73; р<0.0001) and objective response rate – ORR (24.1% for lenvatinib vs 9.2% for sorafenib). The further analysis of the results of the REFLECT study revealed the additional factors impacting patients’ survival, such as the level of a-fetoprotein (AFP) before treatment, treatment ORR, performance of subsequent antitumor therapy and procedures after completion of the target first-line therapy. In patients responding to lenvatinib in the first line and further receiving any second-line therapy, the mOS was 25.7 months as compared with the median overall survival (mOS) of 22.3 months in patients responding to sorafenib and receiving further second-line therapy. Additionally, in “responders” switching from lenvatinib to sorafenib, the mOS was 26.2 months. In the recently published comparative study of lenvatinib and transarterial chemoembolization on the BCLC B stage, inferiority of lenvatinib was demonstrated in terms of OS, PFS and ORR in certain patient categories. Considering the data obtained in the REFLECT population, where in patients achieving the RR to the first-line treatment with lenvatinib and further receiving the local antitumor procedures the mOS increased to 27.2 months (95% CI 20.7–29.8), prescribing target and locoregional therapy in certain cases in this very sequence is possible. The recently published data about administration of lenvatinib outside of the inclusion criteria for the REFLECT trial, have proved the efficacy and safety of this drug administration in real clinical practice, thus significantly expanding our understanding of the key role of lenvatinib in the first-line treatment of unresectable hepatocellular carcinoma.

Journal of Modern Oncology. 2020;22(3):142-148
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Clinical Case
Use of nivolumab for colon cancer with Lynch syndrome
Khakimov G.A., Tryakin A.A., Khakimova G.G.
Abstract

Lynch syndrome (LS), which occurs as a result of the defects in DNA mismatch repair, is characterized by an increased risk of colon, endometrial and urinary tract cancers. It is known that in case of colorectal cancer, the presence of high-frequency microsatellite instability (MSI-H) is associated with better survival rates, independent of other prognostic factors, including the stage of tumor development. Thus, in stage II sporadic colorectal cancer, MSI-H occurs in 22% of cases, in stage III – in 12% of cases, and in stage IV – only in 2% of cases. Regardless of the type of the tumor, immunotherapy using checkpoint inhibitors has been approved for treating patients with unresectable or metastatic tumors with deficient DNA mismatch repair (dMMR), this fact can be used as an approach to treatment patients with LS. The article describes the clinical observation of the patient with germline mutation in MLH1 gene, suffering from multiple primary malignancies of the colon, who has been receiving nivolumab for 26 months. This observation demonstrates the success of immunotherapy after sixth-line chemotherapy, showing the potential control of tumor growth in patients with LS.

Journal of Modern Oncology. 2020;22(3):114-119
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Metastatic renal cell carcinoma of unknown primary site. Clinical follow-up
Ognerubov N.A., Antipova T.S., Gumareva G.E.
Abstract

Renal cell cancer metastases without evidence of a primary tumor are extremely rare. These variants are usually showed as a spontaneous description of single clinical cases.

Aim. This contribution is a clinical follow-up of synchronous renal cell cancer metastases of unknown primary site.

Results. A 52-year-old patient U. with a history of increased blood pressure, up to 170/100 mmHg for the last 5 years, who had undergone many instrumental examinations, including ultrasound examination, because of this disease. The computed tomography of the abdomen showed a 49×75 mm heterogeneous tumor in the right adrenal gland in October 2017. The combined positron emission and X-ray computed tomography showed a 79×54×41 mm mass in the right adrenal gland, associated with elevated fluorodeoxyglucose metabolic activity SUVmax 7.25. Focal accumulation of the radiopharmaceutical SUVmax 4.31 in a 17×11×24 mm mass was detected in the space of bifurcation in the mediastinum. The lytic lesion (10×15 mm) was found in right superior L3 articular process. The patient underwent retroperitoneoscopic adrenalectomy and thoracoscopic removal of mediastinal tumor in November 2017 because of the oligometastatic nature of the process. The histological study identified clear-cell carcinoma with areas of papillary structure in the right adrenal gland. The immunohistochemical study showed carcinoma cells intensively expressing CD10, and some other cells – RCC. The immune phenotype of the tumor was identified as clear-cell renal cell carcinoma. The immunohistological and immunohistochemical analysis reviled the metastases of the same variant of renal cell carcinoma in one of 9 lymph nodes. The patient was treated with pazopanib. The primary renal tumor was not detected during the dynamic observation, including the application of annual combined positron emission and X-ray computed tomography. The patient is alive without disease progression with a follow-up of 32 months.

Conclusion. Metastases of clear-cell renal cell carcinoma, including adrenal gland, without evidence of a primary site are extremely rare. The main method of treatment is a combination of surgery and targeted therapy, providing long-term local control of the course of the disease.

Journal of Modern Oncology. 2020;22(3):149-153
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