Phase II trials of erlotinib or gefitinib in patients with recurrent meningiomas

2062

Background: No effective treatment is available for recurrent meningiomas when surgical and radiation options are exhausted. The epidermal growth factor receptor (EGFR) is often over-expressed in meningiomas and may promote tumor growth. In open label, single arm phase II studies of the EGFR inhibitors gefitinib (NABTC 00–01) and erlotinib (NABTC 01–03) for recurrent malignant gliomas, we included exploratory subsets of recurrent meningioma patients. We have pooled the data and report the results here. Methods: Patients with recurrent histologically confirmed meningiomas and no more than two previous chemotherapy regimens were treated with gefitinib 500 mg/day or erlotinib 150 mg/day until tumor progression or unacceptable toxicity. Results: Twenty-five eligible patients were enrolled with median age 57 years (range 29–81) and median Karnofsky performance status (KPS) score 90 (range 60–100). Sixteen patients (64%) received gefitinib and nine (36%) erlotinib. Eight patients (32%) had benign tumors, 9 (36%) atypical, and eight (32%) malignant. For benign tumors, the 6-month progression-free survival (PFS6) was 29%, 12-month PFS (PFS12) 0%, 6-month overall survival (OS6) 63%, and 12-month OS (OS12) 50%. For atypical/malignant tumors, PFS6 was 25%, PFS12 19%, OS6 81%, and OS12 68%. There were no significant PFS or OS differences by histology. Of 21 evaluable patients, there were no responses; eight patients (38%) had stable disease, and 13 (62%) had progressive disease. Treatment was well-tolerated. Rash was not a significant predictor of PFS or OS. Conclusions: Neither gefitinib nor erlotinib appear to have significant activity against recurrent meningioma. The role of EGFR inhibitors in meningiomas is unclear but evaluation of EGFR inhibitors in combination with other targeted molecular agents may be warranted.

No significant financial relationships to disclose.

Phase II study of carboplatin and erlotinib (Tarceva, OSI-774) in patients with recurrent glioblastoma

Targeting the epidermal growth factor receptor (EGFR) may be effective in a subset of glioblastoma patients. This phase II study assessed the clinical activity of erlotinib plus carboplatin and to determine molecular predictors of response. The primary endpoint was progression free survival (PFS). Patients with recurrent glioblastoma with no more than two prior relapses received carboplatin intravenously on day 1 of every 28-day cycle (target AUC of 6 mg x ml/min). Daily erlotinib at 150 mg/day was dose escalated to 200 mg/day, as tolerated. Clinical and MRI assessments were made every 4 and 8 weeks, respectively. Tumor tissue was evaluated for EGFR, AKT and phosphatase and tensin homolog (PTEN) status. One partial response (PR) was observed out of 43 assessable patients. Twenty patients (47%) had stable disease (SD) for an average of 12 weeks. Median PFS was 9 weeks. The 6-month PFS rate was 14%. Median overall survival (OS) was 30 weeks. This regimen was well tolerated with grade 3/4 toxicities of fatigue, leukopenia, thrombocytopenia and rash requiring dose reductions. A recursive partitioning analysis (RPA) predicted that patients with KPS >or=90 treated with more than 1 prior regimen had the highest OS. No correlation was observed between EGFR, Akt or PTEN expression and either PFS or OS. Carboplatin plus erlotinib is well tolerated but has modest activity in unselected patients. Future trials should be stratified based on optimal molecular or clinical characteristics.

Antiepileptic drugs for preventing seizures in people with brain tumors

BACKGROUND

Seizures can present at any time before or after diagnosis of a brain tumor. The risk of seizures varies by tumor type and its location in the brain. For a long time we believed that preventing seizures with antiepileptic drugs (seizure prophylaxis) was effective and necessary, but the supporting evidence was little and mixed. Such evidence was the basis for previous reviews to conclude that seizure prophylaxis was ineffective in people with brain tumors.

OBJECTIVES

To estimate the effectiveness of seizure prophylaxis in people with brain tumors, and to estimate the adverse event rates in the identified clinical trials.

SEARCH STRATEGY

A search strategy that included free-text and MeSH terms in LILACS, EMBASE, PubMed, CENTRAL, and The Cochrane Library (1966 to 2007).

SELECTION CRITERIA

Controlled clinical trials with random allocation, blinded or unblinded, and placebo or observation in the control groups.

DATA COLLECTION AND ANALYSIS

We screened the articles, extracted the data, and rated the validity of each trial to assess the risk of bias. Our primary outcome was the occurrence of a first seizure. The secondary outcome was adverse events. We pooled the aggregate data for each outcome into a random-effects model meta-analysis using the relative risk (RR). For adverse events, we also included the number needed to harm (NNH) using the absolute risk increase to compute the NNH.

MAIN RESULTS

There was no difference between the treatment interventions and the control groups in preventing a first seizure in participants with brain tumors. The risk of an adverse event was higher for those on antiepileptic drugs than for participants not on antiepileptic drugs (NNH 3; RR 6.10, 95% CI 1.10 to 34.63; P = 0.046).

AUTHORS' CONCLUSIONS

The evidence is neutral, neither for nor against seizure prophylaxis, in people with brain tumors. These conclusions apply only for the antiepileptic drugs phenytoin, phenobarbital, and divalproex sodium. The decision to start an antiepileptic drug for seizure prophylaxis is ultimately guided by assessment of individual risk factors and careful discussion with patients.

The utility of the MDASI-BT in assessing symptoms in patients with brain metastases

2052

Background: Symptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. The M. D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) was recently validated in patients with primary brain. This study evaluated the reliability and validity of the MDASI-BT as well as symptom severity and prevalence in patients with brain metastases. Methods: Patients diagnosed with systemic cancer with brain metastases participated in this cross-sectional study. Data collection included demographic and clinical factors, and the MDASI-BT (0–10 scale). The average for the 22 symptoms and 6 interference items scores the MDASI-BT was computed. Construct validity was assessed using confirmatory factor analysis, and known-group validity was evaluated by detecting group differences due to disease severity and performance status. For reliability, Cronbach’s alpha values were computed for each subscale. Results: A sample of 124 patients participated, of which 53.2% females. Participants were primarily white (79.8%) and married (78.2%), with a variety of solid tumor malignancies represented. Factor analysis revealed six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, gastrointestinal, and interference with life. This solution explained 68.4% of the variance, and satisfied Harman’s criteria for model fit. Known-group validity was established for the MDASI-BT using the Karnofsky performance status (KPS). Mean symptom scores were 1.2 and 2.6, and mean interference were 1.8 and 4.3, for patients with good (90–100) and poor KPS (80 and below) respectively (p<0.001). These subscales were also sensitive to opioid analgesic use with group differences of 1.5 and 2.2 (p<0.001). Cronbach’s alpha was 0.9 for each of the two subscales. Fatigue, sleep disturbance, drowsiness, distress, and dry mouth were the most severe symptoms. Conclusions: The MDASI-BT demonstrated validity and reliability in patients with brain metastases and can be used to identify symptom occurrence related to the tumor and therapies.

No significant financial relationships to disclose.

Phase II study of combination carboplatin and erlotinib in patients with recurrent glioblastoma multiforme

2024

Background: Targeting the epidermal growth factor receptor (EGFR) in glioblastoma is effective in a subset of patients whose tumors express the phosphatase and tensin homolog (PTEN) tumor suppressor gene and overexpress the EGF variant vIII receptor. Therefore, this study was designed to assess the clinical activity of the EGFR inhibitor erlotinib when combined with carboplatin and to determine molecular predictors of response. The primary endpoint is progression-free survival (PFS). To be eligible for the study, patients had to have recurrent, histologically confirmed glioblastoma or gliosarcoma, no more than two prior relapses, a KPS = 60, and no enzyme-inducing anticonvulsants. Methods: In this ongoing phase II study, patients are given carboplatin intravenously on day 1 of every 28-day cycle to achieve a target AUC of 6 (mg x ml/min) based on creatinine clearance. Erlotinib is administered orally once daily throughout the 28-day cycle at 150 mg/day with dose escalation to 200 mg/day, as tolerated. Patients undergo clinical and MRI assessment every 4 weeks. The primary endpoint is median PFS using a Bayesian time-to-event design. To determine histologic correlates of response, tumor tissue is undergoing immunohistochemical evaluation for known markers of response to EGFR inhibitors, including PI3K/AKT and PTEN status. Results: Of the first 20 patients enrolled, 17 were evaluable and all had failed temozolomide-based therapy. The median age is 56 years, and the median KPS is 80. The median time to progression is 15.2 weeks with a 95% credible interval of 8.0 to 28.4 weeks. These results compare favorably with historical data (median of 9.0 weeks, 95% CI of 8.1 to 10.1 weeks). Bayesian analysis using computer-based simulations indicate a high probability (69%) that the median PFS in our study is at least 3 weeks longer than the historical median PFS. Grade 3 and 4 toxicities included fatigue, leukopenia, thrombocytopenia and rash requiring dose reductions. Conclusions: The results from this ongoing study suggest that the combination of carboplatin and erlotinib has promising activity in patients with recurrent glioblastoma who have failed temozolomide-based therapy. Tumor tissue is being analyzed to determine molecular markers of response.

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Temozolomide as a vaccine adjuvant in GBM

2020

Background: Cytotoxic chemotherapy that induces lymphopenia is predicted to ablate the benefits of active antitumor immunization. Temozolomide (TMZ) is an effective chemotherapeutic for patients with glioblastoma multiforme (GBM), but it induces significant lymphopenia. Methods: In a Phase II trial, patients with newly-diagnosed, completely resected GBM are vaccinated with an EGFRvIII-specific peptide q2 weeks X 3 after radiation (XRT)(∼60Gy) and TMZ (75mg/m2/d) and then monthly with 5 day TMZ cycles (200mg/m2/d). Results: TMZ induces transient, Grade 3 lymphopenia (< 500 cells/uL) in 70% of patients after the first TMZ cycle with nadirs occurring 14–21 days after treatment (n=10). Regulatory T cell (TReg) (CD4+CD25++CD45RO+FOXP3+) levels increased from 5.2+1.5% (3.3 - 7.5) to 11.8+2.6% (6.9 - 13.8)(P=0.0004; paired t-test) with TMZ and XRT and averaged 12.2+4.0% (6.4 - 18.1) after the second TMZ cycle (P=0.007) (n=6). Despite these findings, in patients assayed, both humoral and cellular EGFRvIII-specific immune responses appear to be enhanced with TMZ. Median survival and TTP after vaccination is 26.2 weeks with no patients progressing (n=8). Conclusions: Despite conventional dogma, we demonstrated that both chemotherapy and immunotherapy can be delivered concurrently without negating the effects of immunotherapy. TMZ-induced lymphopenia may prove to be synergistic with a peptide vaccine.

No significant financial relationships to disclose.

Validation of the M. D. Anderson symptom inventory (MDASI-BT)

1546

Background: The occurrence of symptoms has been shown to predict treatment course and survival in a number of solid tumor patients. Primary brain tumor patients are unique in the neurologic symptoms that occur. Currently, no instrument exists that measures both neurologic and cancer-related symptoms. Methods: Patients diagnosed with Primary Brain Tumors (PBT) participated in this study. Data collection tools included a patient completed demographic data sheet, an investigator completed clinician checklist, and the core M.D. Anderson Symptom Inventory to which 18 neurologic symptoms were added (M.D. Anderson Symptom Inventory-Brain Tumor Module, MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients. Results: 201 patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22. Regression analysis showed more than half (56%) of the variability in symptom severity was explained by the 9 remaining brain tumor items. Factor analysis was then performed to determine the underlying constructs being evaluated by the remaining items. The 22 item MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the sets of items comprising the six factors and also the interference scale were .87, .82, .72, .81, .69, .67 and .91 respectively). Test-retest reliability was good in a subset of 19 patients completing the instrument at two points in time. The MDASI-BT was sensitive to disease severity based on Karnofsky performance status (KPS) based on mean symptom severity (1.7 versus 3.8, p < .001) and mean symptom interference (2.2 versus 6.1, p < .001). Conclusions: The 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to describe symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.

[Table: see text]

A phase I study of temozolomide (TMZ) and the farnesyltransferase inhibitor (FTI), lonafarnib (Sarazar, SCH66336) in recurrent glioblastoma

1556

Background: Farnesylation is essential for the post-translational modification of several proteins that play a role in cell proliferation and growth. FTIs demonstrate antiproliferative effects in a variety of tumor cell lines and xenograft models and enhanced efficacy by combining lonafarnib with TMZ compared with TMZ alone. Clinical studies show that dose-intense TMZ may have better efficacy then conventional dosing (Wick, Neurology 2004). Objective: Determine the maximum tolerated dose of lonafarnib when combined with a dose-intensified schedule of TMZ. Eligibility criteria: Histologically proven GBM; evidence of relaspe or progression; up to 2 prior chemotherapy regimens, prior TMZ permitted; KPS ≥ 60. No enzyme-inducing anticonvulsants. Methods: TMZ was given at 150 mg/m2 days 1–7 and 15–21; lonafarnib escalated by cohort: 100 mg BID, 150 mg BID, 200 mg BID on days 8–14 and 22–28 of a 28-day cycle. Response: Toxicity measured after cycle 1 using NCI CTCAE v3. Patient (pt)accrual used a 3 + 3 design. Response was evaluated q2 cycles. Standard response criteria (MacDonald) were used. Results: 15 patients were accrued. Median age 47 yrs; median KPS 90. M:F ratio was 11:4. No DLTs in any dose cohort, a pt (cohort 1) died day 29 of unrelated cardiac disease. 4 pts demonstrated partial response, all with prior TMZ failure, 3 pts showed prolonged stable disease. 6-month PFS rate estimated at 33%, median PFS 14 weeks. Treatment was well tolerated: 1 episode each of grade 3 diarrhea, esophagitis, fatigue and hypokalemia; 3 episodes of grade 3/4 leukopenia, 2 episodes of grade 3/4 neutropenia, and 2 episodes of grade 4 thrombocytopenia. Seven pts had grade 3/4 lymphopenia, some with persistant lymphopenia from prior TMZ. 1 pt had grade 4 pneumonitis of uncertain etiology. Conclusions: The alternating week schedule of TMZ/lonafarnib was well tolerated. Preliminary results suggest anti-tumor activity even in pts who had failed prior TMZ. It is not certain whether this activity is due to the dose-intensified TMZ or the treatment combination. Studies are planned to evaluate potential predictors of response (i.e MGMT gene promoter methylation) and expand the trial to obtain pharmacokinetic and additional efficacy data.

[Table: see text]

Initial report of Radiation Therapy Oncology Group (RTOG) 9802: Prospective studies in adult low-grade glioma (LGG)

1500

Background: Treatment of adult LGG is controversial. Favorable patients (pts) (age <40 years [yrs] who undergo gross total resection [GTR]) are typically observed. Unfavorable pts (age ≥40 who have subtotal resection [STR] or biopsy [B]) are usually given initial radiation therapy (RT), reserving chemotherapy (historically procarbazine, CCNU and vincristine [PCV]) for recurrence. In 1998, the RTOG, in conjunction with SWOG, NCCTG, and ECOG initiated prospective studies of adult LGG, the results of which are reported herein. Methods: Favorable pts were observed postoperatively in a single arm Phase II study (Arm 1). Unfavorable pts were stratified by age, histology, KPS, and presence/absence of contrast enhancement on preoperative magnetic resonance imaging and randomized to either RT alone (54Gy in 30 fractions to a local treatment field) (Arm 2) or RT followed by 6 cycles of standard dose PCV (Arm 3). Reported results include overall survival (OS) rate, median overall survival time (MOST), progression-free survival (PFS) rate, and median progression-free survival time (MPFST). Survival data are compared using Wilcoxon p-values. Results: A total of 362 eligible/analyzable pts were accrued between 1998 and 2002. Median follow-up time is 4 years. For the 111 favorable pts observed on Arm 1, OS at 2- and 5-yrs is 99% and 94%. PFS at 2- and 5-yrs is 82% and 50%. For the 251 unfavorable pts on Arms 2 (RT alone) and 3 (RT+PCV), there was no difference in OS or PFS. OS at 2- and 5-yrs was 87% and 61% with RT alone versus (vs) 86% and 70% with RT+PCV (p=0.72). MOST was not reached in RT alone pts and was 6.0 yrs in RT+PCV pts. PFS at 2- and 5-yrs was 73% and 39% with RT alone vs 72% and 61% with RT+PCV (p=0.38). MPFST was 4.0 yrs with RT alone vs 6.0 yrs with RT+PCV. Acute grade 3–4 toxicity occurred in 9% of pts who received RT alone, 67% who received RT+PCV (mostly hematologic). There were no treatment deaths on either arm. Conclusions: 5-yr PFS was poor in all three arms ranging from 39% to 61%. Only half of favorable pts were disease-free at 5 yrs. In unfavorable pts, there was no OS advantage with the addition of PCV to RT. Both PFS and MPFST were better with the addition of PCV, but not significantly. Analysis of outcome by 1p19q status is pending.

No significant financial relationships to disclose.

Validation of the M.D. Anderson Symptom Inventory Brain Tumor Module (MDASI-BT)

BACKGROUND

Symptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. Primary brain tumor (PBT) patients are unique in the occurrence of neurologic symptoms. Currently, no instrument exists that measures both neurologic and cancer-related symptoms.

METHODS

Patients diagnosed with PBT participated in this study. Data was collected at one point in time and included demographic and clinical factors, and the M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients.

RESULTS

Two hundred and one patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22 (13 core, 9 brain tumor items). Regression analysis showed more than half (56%) of the variability in symptom severity was explained by brain module items. The MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the instrument was 0.91. The MDASI-BT was sensitive to disease severity based on performance status (P<0.001), tumor recurrence (P<0.01), and mean symptom interference (P<0.001).

CONCLUSIONS

The 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to identify symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.

Brain metastases: still an 'orphan' disease?

The diagnosis of brain metastases from systemic cancer has been associated with a poor prognosis. In fact, most chemotherapy clinical trials exclude patients with metastatic disease. In the past, clinical and basic research activity in this area has been only moderate. Recent developments in clinical trial design, as evidenced by recursive partitioning analysis and complemented by new treatment strategies in neurosurgery and radiotherapy, suggest a change in attitude and approach to the management of brain metastases. The role of chemotherapy will require more focused investigation, but recent advances in our understanding of the biology of brain metastases suggest that the next generation of chemotherapy treatments will involve targeting specific pathways of metastatic disease.

Application of advances in molecular biology to the treatment of brain tumors

Recent advances in molecular biology have substantially improved our understanding of the molecular genetics of primary brain neoplasms. Soon each histopathologic category of glioma will be further divided into subgroups according to similar genetic background, gene expression profile, and similarity of biologic responses to radiotherapy or chemotherapy. Identification of key molecules that are specifically altered in neoplastic cells will provide candidate molecular targets for tumor treatment. Novel therapeutic tools for targeting tumor cells, such as viral vectors for gene therapy, have been created. In the near future, the accumulation of new knowledge in brain tumor biology and genetics, combined with rational drug design, will revolutionize the treatment of malignant gliomas, which are among the most lethal human cancers.

Metastatic brain tumors: diagnosis, treatment, and nursing interventions

Metastatic tumors are by far the most common cause of brain cancer, with an incidence rate higher than all other types of primary brain tumors combined. Cancer cells can spread to the brain from other sites via the blood supply, lymphatic system, or direct extension. Neurologic symptoms, which are dependent on tumor location, often include headache, weakness, or cognitive deficits. Although the standard of care is evolving, treatment often includes some combination of surgery and radiation therapy. Newer treatments, including radiosurgery and novel chemotherapy approaches, currently are being investigated. These treatment advances have markedly altered the prognosis for patients with brain metastases. Consequently, the status of the systemic components of the malignancy often may be the determinant of outcome.

Chemotherapy of astrocytomas: an overview

OBJECTIVES

To provide an overview of the use of chemotherapy in the treatment of malignant brain tumors, with an emphasis on malignant gliomas.

DATA SOURCES

Published articles, research studies, and reference books.

CONCLUSIONS

Chemotherapy has primarily been used in a adjuvant setting after radiation therapy for primary brain tumors. This focus has not had a significant effect on survival. In an effort to more effectively treat the tumor, innovative chemotherapy treatments have been developed. These include the use of neoadjuvant chemotherapy, changes in timing of administration, new classes of chemotherapeutic agents, new routes of delivery, and augmentation of the body's own immune system to treat the tumor.

IMPLICATIONS FOR NURSING PRACTICE

It is the challenge of the oncology nurse caring for the patient with a malignant brain tumor to gain knowledge of the disease process, side effect management, and the most up-to-date treatment regimens.

Phase II study of paclitaxel in patients with recurrent malignant glioma

PURPOSE

To assess the efficacy and toxicity of paclitaxel administered as a 3-hour infusion to patients with recurrent malignant glioma.

PATIENTS AND METHODS

Adult patients with recurrent malignant glioma following radiation therapy, who had received no more than one prior chemotherapy regimen and who had a Karnofsky performance status (KPS) > or = 60, were treated with a 3-hour infusion of paclitaxel every 3 weeks. The initial dose was 210 mg/m2; dose escalation to 240 mg/m2 was allowed. Tumor response was assessed at 6-week intervals using radiographic and clinical criteria. Treatment was continued until documented tumor progression or a total of 12 paclitaxel infusions.

RESULTS

Of 41 eligible patients, all were assessable for treatment toxicity and 40 (98%) were assessable for response. The response rate (disease stabilization or better) was 35%. Twenty-nine patients (71%) underwent dose escalation to 240 mg/m2 without the use of growth factors. Toxicities included alopecia (98%), nausea (22%), arthralgias (32%), CNS toxicity (24%), peripheral neuropathy (15%), cardiac toxicity (7%), and myelosuppression (10% grade 3 or 4 hematologic toxicity). No patient developed febrile neutropenia. There was one allergic reaction (2%).

CONCLUSION

Paclitaxel is well tolerated at this dose schedule in patients with recurrent malignant glioma, and affords a modest response rate. Because minimal myelotoxicity was encountered in our patients, a dose-escalating phase I/II study of paclitaxel is planned to determine the maximal-tolerated dose (MTD).