Phase II study of bevacizumab (Bv) in combination with paclitaxel-carboplatin (PC) as first-line chemotherapy for nonsquamous (SQ) non-small cell lung cancer (NSCLC) with malignant pleural effusion (MPE)

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Background: Vascular endothelial growth factor (VEGF) plays an important role in NSCLC with MPE, but the evidence regarding the efficacy of Bv with PC for treatment of NSCLC with MPE is lacking. Therefore, we prospectively evaluated the efficacy and safety of Bv and PC in non-SQ NSCLC pts. Methods: Chemotherapy-naive non-SQ NSCLC pts with MPE were eligible to participate. Pleurodesis before chemotherapy was not allowed. The treated pts received PC without Bv in the first cycle to prevent Bv-induced delayed wound healing after chest drainage. Subsequently, they received 2–6 cycles of PC with Bv. Patients who completed more than 3 cycles of PC and Bv without disease progression or severe toxicities continued to receive Bv alone as a maintenance therapy. The primary endpoint was overall response, although an increase in MPE was allowed in the first cycle. The plasma and MPE VEGF levels were measured at baseline and the plasma VEGF levels after 3 cycles of chemotherapy. Results: Between September 1, 2010 and June 30, 2012, 23 pts were enrolled. The overall response rate was 60.8%, and the disease control rate was 87.0%. No pts showed complete response, 14 showed partial responses, 6 showed stable disease, 2 showed disease progression, and 1 died in the first cycle. Sixteen pts received maintenance therapy, following a median of 3 cycles. The median progression-free survival period for all pts was 200 days (95% CI, 156–263 days), whereas the median overall survival was 328 days (95% CI, 206–415 days). All pts experienced high levels of hematological toxicities, with most pts experiencing neutropathic toxicities above grade 3. However, none of the pts experienced severe bleeding events. The median baseline MPE VEGF level was 1798.6 (range, 223.4–35,633.4) pg/mL. The plasma VEGF levels showed a significant decrease after 3 chemotherapy cycles (baseline, 513.6 ± 326.4 pg/mL; post-chemotherapy: 25.1 ± 14.1 pg/mL; p < 0.01), regardless of the degree of efficacy. Conclusions: The combination of PC with Bv was confirmed to be effective and reasonably well-tolerated in chemotherapy-naïve non-SQ NSCLC pts with MPE. Clinical trial information: UMIN000005284.

Carboplatin plus paclitaxel in combination with bevacizumab for the treatment of adenocarcinoma with interstitial lung diseases

Interstitial lung diseases (ILDs) are frequently associated with lung cancer. The safety of carboplatin plus paclitaxel in combination with bevacizumab (CP-B) in patients with ILD and lung cancer (ILD-LC) remains to be clarified. In the present study, the safety and efficacy of CP-B treatment in ILD-LC patients were retrospectively investigated. Four patients, who completed CP-B therapy, were included in this study. The dose of carboplatin was the area under the curve 5, paclitaxel was 200 mg/m² and bevacizumab was 15 mg/kg at treatment initiation. The patients were males, had histologically confirmed adenocarcinoma, were smokers and demonstrated non-usual interstitial pneumonia (non-UIP) patterns on computed tomography (CT). Patients received 1-6 cycles of CP-B therapy. Three of the four patients received maintenance bevacizumab therapy for 3-10 cycles. Only one patient demonstrated a partial response. Neutropenia was the most frequent adverse event. One patient experienced gut perforation during the first course of CP-B. No pulmonary toxicity was observed. Thus, treatment of ILD-LC patients with CP-B was not associated with pulmonary toxicity, however, this study population appeared to be at a low risk.

The relationship between tyrosine kinase inhibitor therapy and overall survival in patients with non-small cell lung cancer carrying EGFR mutations

For patients with epidermal growth factor receptor (EGFR) mutation-positive lung cancer, the relationship between the dose or duration of treatment with tyrosine kinase inhibitor (TKI) and overall survival remains unclear. Here, we analyzed clinical data of 39 patients who were diagnosed with EGFR mutation-positive non-small cell lung cancer and treated with TKI, but subsequently died. Several parameters were measured in this study: overall survival; first, second, and overall TKI therapy durations; first TKI intensity (actual dose/normal dose); and TKI rate (overall TKI therapy duration/overall survival). The response rate to TKI therapy was 50%, and the median survival was 553 days. After TKI therapy failed, 38.5% patients were re-challenged with TKI. We observed a moderate relationship [r = 0.534, 95% confidential interval (CI) = 0.263 to 0.727, P < 0.001] between overall TKI therapy duration and overall survival. However, we found no relationship between overall survival and first TKI intensity (r = 0.073, 95% CI = -0.380 to 0.247, P = 0.657) or TKI rate (r = 0.0345, 95% CI = -0.284 to 0.346, P = 0.835). Non-small cell lung cancer patients with mutation-positive tumors remained on TKI therapy for, on average, 33% of the overall survival time. These findings suggest that patients with EGFR mutation-positive tumors should not stick to using TKIs.

Dose escalation study of carboplatin-pemetrexed followed by maintenance pemetrexed for elderly patients with advanced nonsquamous nonsmall-cell lung cancer

BACKGROUND

This study was designed to determine the recommended dose of carboplatin-pemetrexed in elderly (≥75 years old), chemotherapy-naive patients with advanced nonsquamous nonsmall-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients received escalated doses of carboplatin and pemetrexed every 3 weeks for four cycles. Patients with an objective response and stable disease continued pemetrexed therapy until disease progression or unacceptable toxicity was observed.

RESULTS

The combination of carboplatin at an area under the concentration-time curve (AUC) of 5, and 500 mg/m(2) pemetrexed, was determined to be the recommended dose for elderly patients with advanced nonsquamous NSCLC. Of 17 patients, 10 received a median of five cycles of pemetrexed maintenance therapy without unexpected or cumulative toxic effects. The study had an overall response rate of 47.1%. The median progression-free survival time was 142 days (95% confidence interval [CI] 68-216 days) and the median overall survival time was 461 days (95% CI 168-754 days).

CONCLUSIONS

This combination was a tolerable and effective regimen, and recommended dose (RD) was carboplatin [area under the curve (AUC) of 5]/pemetrexed (500 mg/m(2)) every 3 weeks, in chemotherapy-naïve, elderly (≥75 years old) patients with advanced nonsquamous NSCLC.

Efficacy of carboplatin and paclitaxel with bevacizumab as salvage chemotherapy for non-small cell lung cancer after failure of platinum-doublet chemotherapy

BACKGROUND

Salvage chemotherapy using carboplatin (C), paclitaxel (P), and bevacizumab (BEV) for patients with pre-treated, advanced non-squamous non-small cell lung cancer (NSCLC) has not yet been reported.

PATIENT AND METHODS

Medical records of patients with non-squamous NSCLC who received CP plus BEV between November 2009 and September 2011 and experienced progression after at least one platinum-based-chemotherapy regimen, were examined in this retrospective study.

RESULTS

Twenty-one patients were eligible for this study. The median number of prior chemotherapy regimens was 3 (range, 2 to 9). The median number of cycles of CP with BEV was 4 (range, 1 to 6). Seven patients underwent BEV maintenance therapy, and the median number of cycles of BEV maintenance was 8 (range, 2 to 13). Toxicity levels were acceptable. The overall median survival time was not reached and one-year survival rate was 54.95%. The overall progression-free survival was 6.1 months (95% confidence interval, 4.4-9.3 months).

CONCLUSION

CP with BEV was effective and feasible as a salvage chemotherapy after failure of platinum-based chemotherapy for patients with non-squamous NSCLC.

Usefulness of serial measurement of serum N-telopeptides of type I collogen (NTx) in patients with lung cancer who developed bone metastasis: A prospective study

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Background: The bone resorption biomarkers urinary NTx (uNTx) and serum NTx (sNTx) have been shown to aid in the diagnosis of bone metastasis in patients with lung cancer. Patients with metastatic bone disease from lung cancer (MBDLC) are often treated with zoledronic acid. Zoledronic acid reduces the levels of bone resorption biomarkers and also the risk of skeletal adverse events in patients with MBDLC. We studied the effects of treatments including zoledronic acid on levels of sNTx during disease progression. Methods: Patients with MBDLC at the initial diagnosis were entered to this study. sNTx was measured once a month using the sNTx assay OSTEOMARK serum NTx (Alere Medical). MBDLC was characterized by monthly physical examination and by bone scintigraphy every 3 months for 12 months. All patients were required to provide written informed consent. Results: Twenty patients were enrolled between June and December 2010. The mean +/- 1 SD of the sNTx concentrations was 19.8 +/- 5.8 nM BCE/L at baseline. In the 16 patients receiving zoledronic acid, the levels of sNTx showed a significant decrease in the first month of treatment (baseline: 21.3 +/- 5.5 nM BCE/L; one month later: 13.6 +/- 2.7 nM BCE/L; p<0.01). During follow-up period, 12 of the patients treated with zoledronic acid experienced worsening MBDLC or had died from lung cancer, and there were statistically significant differences in the levels of sNTx at baseline (19.7 +/- 4.47 nM BCE/L), at the lowest levels after the administration of zoledronic acid (11.5 +/- 2.73 nM BCE/L) and at the point of measurable disease progression or death (13.0 +/- 2.07 nM BCE/L). Conclusions: Serial measurements of sNTx in patients with MBDLC treated with zoledronic acid might predict disease progression of bone metastasis. Administration of zoledronic acid significantly decreased the level of sNTx from baseline within one month and maintained the level of sNTx lower than baseline during study periods.

Periodic measurement of N-telopeptides of type I collogen in serum (sNTx) for early diagnosis of bone metastasis in patients with lung cancer

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Background: The bone resorption biomarker sNTx has been previously shown to add value as an aid in the diagnosis of bone metastasis in patients with lung cancer. The objective of this prospective study was to determine if periodic sNTx measurements could lead to early diagnosis of bone metastasis in patients with lung cancer. Methods: Patients with newly diagnosed organ-confined lung cancer were enrolled. sNTx values were determined once each month using the OSTEOMARKTM serum NTx assay (Alere Medical). The presence or absence of bone metastasis was determined by monthly physical examination and by bone scintigraphy every 3 months for 12 months. All patients were required to provide written informed consent. Results: Forty patients were enrolled between June and December 2010. One patient withdrew early and was excluded from analysis. The mean +/- 1 SD baseline level of sNTx was 17.5 +/- 4.4 nM BCE/L. Five patients developed bone metastasis (as characterized by bone scintigraphy) during the study period. The level of sNTx in subjects with bone metastasis was slightly increased (21.6 +/- 3.2 nM BCE/L), however, in these patients, there was no statistically significant difference between sNTx values at baseline (18.2 +/- 4.2 nM BCE/L) and when metastasis was diagnosed. (p=0.176). When a cut-off value of sNTx was set to 22.0 nM BCE/L, the sensitivity and the specificity of detection of bone metastasis were 80.0% and 41.2%, respectively. Using this cut-off, the elevation of sNTx could predict bone metastasis at least one month before diagnosis by bone scintigraphy in all 5 patients, however, the specificity was relatively low for clinical implementation. Additionally, the sensitivity and the specificity of early detection of systematic spread of disease (including bone metastasis) were 70.6% and 45.5%, respectively. Conclusions: Periodic determination of sNTx in patients with organ confined lung cancer did not provide sufficient specificity for it to be used for the early diagnosis of bone metastasis or disease progression.

Clinical significance of the serum crosslinked N-telopeptide of type I collagen as a prognostic marker for non-small-cell lung cancer

INTRODUCTION

Lung cancer is the leading cause of cancer-related death. Many patients with lung cancer are in its advanced stages at the time of diagnosis. The 5-year survival rate for lung cancer is 10% to 20%, and the prognosis for patients with lung cancer is still poor. The crosslinked N-terminal telopeptide of type I collagen (NTx) is a metabolite of type I collagen, the main constituent of bone matrix.

PATIENTS AND METHODS

We measured serum NTx levels in patients who underwent staging during hospitalization for the initial treatment of lung cancer in our department. We examined whether serum NTx levels would be relevant to the prognosis of non-small-cell lung cancer (NSCLC).

RESULTS

This study included 176 patients with lung cancer (125 men and 51 women), including 109 with adenocarcinoma, 53 with squamous cell carcinoma, 6 with large-cell carcinoma, and 8 with other cancer types. Univariate and multivariate analysis using the Cox proportional hazards model revealed a particularly close association between sex, performance status, disease stage, and serum NTx levels and overall survival (OS). A median OS of 368 days was observed for patients with a serum NTx level < 22 nmol BCE/L, which was significantly longer than the 197 days for patients with a serum NTx level ≥ 22 nmol BCE/L (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.36-2.99; log-rank P = .00037).

CONCLUSIONS

We have revealed that a high serum NTx level (> 22 nmol BCE/L) appears to be a risk factor for a reduction in OS in patients with NSCLC.

Long-term amrubicin chemotherapy for small-cell lung cancer

BACKGROUND

Amrubicin is an active agent for the treatment of small-cell lung cancer (SCLC). However, there have been no reports of long-term amrubicin use.

PATIENTS AND METHODS

Twelve patients with SCLC who were treated with eight or more cycles of amrubicin chemotherapy were retrospectively reviewed.

RESULTS

The median number of cycles of amrubicin chemotherapy received by the patients was 12 (range=8-20), and the median cumulative dose of amrubicin was 2076 mg (range=1200-2856 mg). The median survival time of the study patients was 1104 days (range=459-1997 days). The main adverse events observed during amrubicin chemotherapy were leukopenia and neutropenia. The cardiothoracic ratio (CTR), expressed as the mean (standard deviation) of the values measured at the initiation and termination of amrubicin chemotherapy was 46.2 (4.0), and 46.1 (5.1), respectively. The change in CTR did not reach statistical significance (p=0.92).

CONCLUSION

Long-term amrubicin chemotherapy is a safe and effective treatment that is associated with a good survival prognosis in properly selected patients.

A retrospective study of chemotherapy with and without pemetrexed in malignant pleural mesothelioma

BACKGROUND

The current standard first-line chemotherapy for malignant pleural mesothelioma (MPM) is pemetrexed and cisplatin. However, other regimens, with or without a platinum agent, are reported to be effective in the treatment of MPM.

PATIENTS AND METHODS

Patients who were diagnosed with MPM and treated with chemotherapy between January 1999 and June 2010 at the Osaka Prefectural Medical Center for Respiratory and Allergic Diseases were studied, and the outcomes of these patients were retrospectively analyzed in relation to therapy.

RESULTS

In total, 48 patients with MPM (42 men and 6 women) treated with chemotherapy were included in the current analysis. The median survival time (MST) and one-year survival rate in the pemetrexed-containing group were 541 days and 63.2%, respectively. The MST and one-year survival rate in the non-pemetrexed group were 516 days and 66.7%, respectively. Overall survival did not differ significantly with respect to the pemetrexed-containing regimen.

CONCLUSION

The superiority of pemetrexed-containing regimens is equivocal. Non-pemetrexed-containing regimens may be potent alternatives.

Prognostic factors in malignant pleural mesothelioma: a retrospective study

OBJECTIVE

The incidence of malignant pleural mesothelioma (MPM) in Japan is predicted to increase over the next few decades. Prognostic factors remain unclear although several studies have reported this disease. In this study, we examined the prognostic factors of MPM from single institution practice data and tested the scoring systems of past reports.

METHODS

We retrospectively obtained clinical data from the medical records of patients who were diagnosed with MPM from 1991 to 2010. The European Organization for Research and Treatment of Cancer prognostic score (EPS) was calculated.

RESULTS

We surveyed the records of 68 patients. Univariate analysis showed that significant prognostic factors were histological type, stage, performance status (PS), chemotherapy, and lactate dehydrogenase (LD). Multivariate analysis identified stage, PS and LD as independent prognostic factors. Low-risk group (EPS ≤1.27) survival was significantly better than that of the high-risk group (EPS >1.27) (17.0 months vs. 8.0 months; p=0.002).

CONCLUSION

Stage, PS and LD were demonstrated to be independent prognostic factors. An EPS >1.27 was still considered a poor prognosis indicator in the practice data of MPM.

Hypersensitivity reactions associated with platinum-containing antineoplastic agents for thoracic malignancies

Recently, the use of platinum-containing antineoplastic agents for extended periods has increased. In this study, we determined the relationship between the hypersensitivity reactions to cisplatin or carboplatin and the frequency of administration among patients with thoracic malignancies. The study included 255 patients with thoracic malignancies who were treated with chemotherapy containing cisplatin or carboplatin in our institution between April 2007 and October 2008. A total of 89 patients received a median of 3 courses of cisplatin and 140 patients a median of 4 courses of carboplatin. A median of 6 courses of cisplatin plus carboplatin was administered to a further 26 patients. The total incidence of hypersensitivity reactions was 1.96%. Patients who were treated with <6 courses of platinum-containing antineoplastic agent did not experience any hypersensitivity reaction, but one patient, who was administered with 6 courses of platinum-containing antineoplastic agent experienced a hypersensitivity reaction (0.44%), as did four patients who were administered ≥7 courses (13.8%). Univariate and multivariate analyses indicated that the number of courses of platinum-containing antineoplastic agents was significantly correlated to the incidence of hypersensitivity reactions to these agents.

Hybrid quantum circuit with a superconducting qubit coupled to a spin ensemble

We report the experimental realization of a hybrid quantum circuit combining a superconducting qubit and an ensemble of electronic spins. The qubit, of the transmon type, is coherently coupled to the spin ensemble consisting of nitrogen-vacancy centers in a diamond crystal via a frequency-tunable superconducting resonator acting as a quantum bus. Using this circuit, we prepare a superposition of the qubit states that we store into collective excitations of the spin ensemble and retrieve back into the qubit later on. These results constitute a proof of concept of spin-ensemble based quantum memory for superconducting qubits.

Long-term chemotherapy may prolong survival in advanced non-small-cell lung cancer among responders to first-line chemotherapy

Survival in patients with advanced non-small-cell lung cancer (NSCLC) has substantially improved. Long-term chemotherapy with epidermal growth factor tyrosine kinase inhibitors (EGFR-TKIs) and other agents has been associated with long survival. We retrospectively examined the associations between overall survival (OS) and clinical variables in patients with advanced NSCLC who received at least one dose or course of outpatient chemotherapy in our institution. Of 360 patients who received first-line chemotherapy between January 1, 2004 and December 31, 2007, 185 subsequently received additional outpatient chemotherapy and 175 underwent inpatient chemotherapy only. Of the 185 patients, 147 (79.5%), 96 (51.9%), and 60 (32.4%) received second-line, third-line, and fourth-line chemotherapy, respectively. Patients who received outpatient chemotherapy had significantly longer median OS (22.3 months) than did those undergoing inpatient chemotherapy only (7.6 months; P < 0.0001). In univariate analysis of the 185 patients, sex, performance status (PS), smoking status, stage, best response to first-line chemotherapy, use of docetaxel, and EGFR-TKIs were significantly associated with OS (P values: 0.0019, 0.0066, 0.0001, 0.0231, 0.0011, 0.0250, and 0.0023, respectively). In multivariate analysis, PS, stage, best response to first-line chemotherapy, and use of docetaxel were significantly associated with OS (P values: 0.0272, 0.0030, 0.0022, and 0.0376, respectively). Survival was significantly longer among patients who responded to docetaxel and/or EGFR-TKIs. Long-term chemotherapy did not increase cumulative hospitalization. In patients with advanced NSCLC, an effective long-term chemotherapy regimen might prolong survival in responders to first-line chemotherapy.

Diagnostic factors of standard bronchoscopy for small (≤15 mm) peripheral pulmonary lesions: a multivariate analysis

BACKGROUND

The aim of this study was to evaluate the factors contributing to an accurate diagnosis of small (≤15 mm) peripheral pulmonary lesions (PPLs) by standard bronchoscopy and to determine the most suitable technology for such a diagnosis.

OBJECTIVE

Bronchoscopy was performed for 115 PPLs (≤15 mm diameter) on chest computed tomography (CT) between August 2003 and December 2006.

METHODS

Univariate and multivariate analyses were conducted retrospectively with the R software.

RESULTS

The diagnostic yield of the 115 PPLs was 65.2%; the yield was 61.9% and 69.2% for the malignant and benign lesions, respectively. In the univariate analysis, the approach to the lesion contributed the most to successful diagnosis, followed by skill and the use of hemostasis. In the multivariate analysis, the most important factor was approach, followed by lower lobe lesion and the use of hemostasis. Although it was better to use a sedative, operator skill was not a contributing factor.

CONCLUSION

The approach to the lesion is the most important factor for a successful diagnosis of PPLs by bronchoscopy. Bronchoscopy is time consuming and painful; therefore, it is very important to establish an accurate diagnosis as soon as possible. Further, endobronchial ultrasonography with a guide sheath (EBUS-GS) and navigation systems are useful tools for the diagnosis of small PPLs.

Cytokeratin 19 fragment/carcinoembryonic antigen ratio in pleural effusion is a useful marker for detecting malignant pleural mesothelioma

BACKGROUND

The clinical utility of tumour markers in pleural effusion is still controversial with regard to the efficient detection of malignant pleural mesothelioma (MPM).

PATIENTS AND METHODS

The levels of carcinoembryonic antigen (CEA) and cytokeratin 19 fragment (CYFRA 21-1) were retrospectively studied in pleural effusion of unknown origin in patients who had undergone medical thoracoscopy under local anaesthesia.

RESULTS

The study included 134 patients (103 men and 31 women); among them, 33 had MPM. The level of pleural effusion CYFRA 21-1 and the CYFRA 21-1/CEA ratio were significantly different between MPM and other diseases (p<0.01). The sensitivity and specificity of the pleural effusion CYFRA 21-1/CEA ratio were 84.8% and 80.2%, respectively, when the CYFRA 21-1/CEA ratio cut-off value determined by receiver operating characteristic curve analysis was 19.1.

CONCLUSION

MPM should be suspected when the CYFRA 21-1/CEA ratio in pleural effusion is greater than 19.1.

[Renal salt-wasting syndrome progressing to severe hyponatremia after chemotherapy--a case report]

A 66-year-old woman with small-cell lung cancer was administered chemo-radiotherapy consisting of cisplatin (CDDP) and etoposide (ETP). From day 3, she developed vomiting and hyponatremia that persisted despite fluid infusion and cortico-steroid administration. On day 7, the hyponatremia worsened (serum sodium level, 109 mEq/L), leading to disturbed consciousness and convulsions. The serum sodium level gradually increased after intravenous administration of hypertonic saline; on day 22, the serum sodium level was almost normal without any neurological implication. We diagnosed this clinical condition as renal salt-wasting syndrome (RSWS) on the basis of dehydration and high urinary sodium excretion at the onset. In the second course of chemotherapy, CDDP was replaced with carboplatin (CBDCA); consequently, hyponatremia was not observed. Hyponatremia that develops after the administration of CDDP may be due to not only the syndrome of inappropriate secretion of anti diuretic hormone (SIADH) but also RSWS. When RSWS is suspected, hypertonic saline should be administered.