Translational Breast Cancer Research Consortium (TBCRC) 022: A Phase II Trial of Neratinib for Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer and Brain Metastases

PURPOSE

Evidence-based treatments for metastatic, human epidermal growth factor receptor 2 (HER2)-positive breast cancer in the CNS are limited. Neratinib is an irreversible inhibitor of erbB1, HER2, and erbB4, with promising activity in HER2-positive breast cancer; however, its activity in the CNS is unknown. We evaluated the efficacy of treatment with neratinib in patients with HER2-positive breast cancer brain metastases in a multicenter, phase II open-label trial.

PATIENTS AND METHODS

Eligible patients were those with HER2-positive brain metastases (≥ 1 cm in longest dimension) who experienced progression in the CNS after one or more line of CNS-directed therapy, such as whole-brain radiotherapy, stereotactic radiosurgery, and/or surgical resection. Patients received neratinib 240 mg orally once per day, and tumors were assessed every two cycles. The primary endpoint was composite CNS objective response rate (ORR), requiring all of the following: ≥ 50% reduction in volumetric sum of target CNS lesions and no progression of non-target lesions, new lesions, escalating corticosteroids, progressive neurologic signs/symptoms, or non-CNS progression--the threshold for success was five of 40 responders.

RESULTS

Forty patients were enrolled between February 2012 and June 2013; 78% of patients had previous whole-brain radiotherapy. Three women achieved a partial response (CNS objective response rate, 8%; 95% CI, 2% to 22%). The median number of cycles received was two (range, one to seven cycles), with a median progression-free survival of 1.9 months. Five women received six or more cycles. The most common grade ≥ 3 event was diarrhea (occurring in 21% of patients taking prespecified loperamide prophylaxis and 28% of those without prophylaxis). Patients in the study experienced a decreased quality of life over time.

CONCLUSION

Although neratinib had low activity and did not meet our threshold for success, 12.5% of patients received six or more cycles. Studies combining neratinib with chemotherapy in patients with CNS disease are ongoing.

Relationships between neurocognitive functioning, mood, and quality of life in patients with temporal lobe glioma

OBJECTIVE

While neurocognitive functioning (NCF) and mood disturbance share a relationship with health-related quality of life (HRQOL), few studies have examined relationships between these constructs in glioma patients prior to treatment.

METHODS

Newly diagnosed patients with glioma in the left (N = 73; 49% glioblastoma) or right (N = 30; 57% glioblastoma) temporal lobe completed neuropsychological testing and self-report measures of HRQOL (Functional Assessment of Cancer Therapy (FACT)-General and Brain module) and mood (Beck Depression Inventory-Second Edition and State-Trait Anxiety Inventory).

RESULTS

Verbal learning and memory, executive function, and language abilities were associated with various HRQOL scales. Stepwise linear regression showed that verbal learning predicted scores on the general well-being scale and brain module, processing speed predicted social well-being scores, and executive functioning predicted functional well-being scores on the FACT. Upper extremity strength also predicted scores on the functional well-being subscale and brain module. Mood was more strongly associated with HRQOL domains than NCF, with depressive symptoms accounting for a large proportion of variance across most subscales.

CONCLUSIONS

In patients with temporal lobe glioma, depressive symptoms are strongly related to most aspects of HRQOL but not with NCF. NCF, specifically verbal learning and memory, executive functioning, and processing speed, also show direct relationships with numerous aspects of HRQOL. These findings underscore the importance of multimodal assessment of NCF and mood in this population. Copyright © 2015 John Wiley & Sons, Ltd.

Impact of Cancer and Its Treatments on Cognitive Function: Advances in Research From the Paris International Cognition and Cancer Task Force Symposium and Update Since 2012

CONTEXT

Although cognitive impairments have been identified in patients with non-central nervous system cancer, especially breast cancer, the respective roles of cancer and therapies, and the mechanisms involved in cognitive dysfunction remain unclear.

OBJECTIVES

To report a state-of-the-art update from the International Cognitive and Cancer Task Force conference held in 2012.

METHODS

A report of the meeting and recent new perspectives are presented.

RESULTS

Recent clinical data support that non-central nervous system cancer per se may be involved in cognitive dysfunctions associated with inflammation parameters. The role of chemotherapy on cognitive decline was confirmed in colorectal and testicular cancers. Whereas the impact of hormone therapy remains debatable, some studies support a negative impact of targeted therapies on cognition. Regarding interventions, preliminary results of cognitive rehabilitation showed encouraging results. The methodology of future longitudinal studies has to be optimized by a priori end points, the use of validated test batteries, and the inclusion of control groups. Comorbidities and aging are important factors to be taken into account in future studies. Preclinical studies in animal models highlighted the role of cancer itself on cognition and support the possible benefits of prevention/care during chemotherapy. Progress in neuroimaging will help specify neural processes affected by treatments.

CONCLUSION

Clinical data and animal models confirmed that chemotherapy induces direct cognitive deficit. The benefits of cognitive rehabilitation are still to be confirmed. Studies evaluating the mechanisms underlying cognitive impairments using advanced neuroimaging techniques integrating the evaluation of genetic factors are ongoing.

Verbal Learning Processes in Patients with Glioma of the Left and Right Temporal Lobes

Recent research supports the utility of process variables in understanding mechanisms underlying memory impairments. The Hopkins Verbal Learning Test-Revised (HVLT-R) was administered to 84 patients with left (LTL, n = 58) or right temporal lobe glioma (RTL, n = 26) prior to surgical resection. Primary HVLT-R measures of learning and memory and numerous learning process indices were computed. Both groups exhibited frequent memory impairment (>30%), with greater severity in the LTL group. Patients with LTL glioma also exhibited lower semantic clustering scores than RTL patients, which were highly associated with Total Recall (ρ = 0.83) and Delayed Recall (ρ = 0.68). Learning slope and a novel measure of learning efficiency were also significantly associated with primary memory measures, though scores were similar across the LTL and RTL groups. While lesions to either temporal lobe impact verbal memory, semantic encoding appears to depend upon the integrity of LTL structures in particular.

Genetic Modulation of Neurocognitive Function in Glioma Patients

PURPOSE

Accumulating evidence supports the contention that genetic variation is associated with neurocognitive function in healthy individuals and increased risk for neurocognitive decline in a variety of patient populations, including cancer patients. However, this has rarely been studied in glioma patients.

EXPERIMENTAL DESIGN

To identify the effect of genetic variants on neurocognitive function, we examined the relationship between the genotype frequencies of 10,967 single-nucleotide polymorphisms in 580 genes related to five pathways (inflammation, DNA repair, metabolism, cognitive, and telomerase) and neurocognitive function in 233 newly diagnosed glioma patients before surgical resection. Four neuropsychologic tests that measured memory (Hopkins Verbal Learning Test-Revised), processing speed (Trail Making Test A), and executive function (Trail Making Test B, Controlled Oral Word Association) were examined.

RESULTS

Eighteen polymorphisms were associated with processing speed and 12 polymorphisms with executive function. For processing speed, the strongest signals were in IRS1 rs6725330 in the inflammation pathway (P = 2.5 × 10(-10)), ERCC4 rs1573638 in the DNA repair pathway (P = 3.4 × 10(-7)), and ABCC1 rs8187858 in metabolism pathway (P = 6.6 × 10(-7)). For executive function, the strongest associations were in NOS1 rs11611788 (P = 1.8 × 10(-8)) and IL16 rs1912124 (P = 6.0 × 10(-7)) in the inflammation pathway, and POLE rs5744761 (P = 6.0 × 10(-7)) in the DNA repair pathway. Joint effect analysis found significant gene polymorphism-dosage effects for processing speed (Ptrend = 9.4 × 10(-16)) and executive function (Ptrend = 6.6 × 10(-15)).

CONCLUSIONS

Polymorphisms in inflammation, DNA repair, and metabolism pathways are associated with neurocognitive function in glioma patients and may affect clinical outcomes.

Relationship between cognitive function and prognosis in glioblastoma

The association between increased signs and symptoms and poorer survival in glioblastoma is well recognized and confirmed in virtually every clinical trial and patient series. Measurement and consideration of performance status is, therefore, vital when counseling patients regarding their expected survival or evaluating the results of clinical trials. Unfortunately, measures of patient function in clinical trials have remained quite crude, in stark contrast to the rapid advances seen in the pathological characterization of brain tumors. Recently, clinical investigators have begun to examine the subcomponents of performance status in more detail, revealing that objective measures of cognition are significantly associated with patient survival in both newly diagnosed and recurrent glioblastoma. Furthermore, cognitive function does not appear to be a simple proxy for performance status but rather an independent predictor of survival, even within patient groups defined by currently available clinical prognostic systems. Therefore, objective measures of cognition must be evaluated for inclusion in future prognostic models and the simple addition of new tumor biomarkers to the current clinical prognostic models will likely prove insufficient. In order for the field of neuro-oncology to move forward in this regard, evaluation of cognition must become a routine part of future clinical trials, and the data must be recorded and analyzed with the same diligence as other trial end points.

Clinical characteristics, pathophysiology, and management of noncentral nervous system cancer-related cognitive impairment in adults

Answer questions and earn CME/CNE Over the past few decades, a body of research has emerged confirming what many adult patients with noncentral nervous system cancer have long reported-that cancer and its treatment are frequently associated with cancer-related cognitive impairment (CRCI). The severity of CRCI varies, and symptoms can emerge early or late in the disease course. Nonetheless, CRCI is typically mild to moderate in nature and primarily involves the domains of memory, attention, executive functioning, and processing speed. Animal models and novel neuroimaging techniques have begun to unravel the pathophysiologic mechanisms underlying CRCI, including the role of inflammatory cascades, direct neurotoxic effects, damage to progenitor cells, white matter abnormalities, and reduced functional connectivity, among others. Given the paucity of research on CRCI with other cancer populations, this review synthesizes the current literature with a deliberate focus on CRCI within the context of breast cancer. A hypothetical case-study approach is used to illustrate how CRCI often presents clinically and how current science can inform practice. While the literature regarding intervention for CRCI is nascent, behavioral and pharmacologic approaches are discussed.

Relationships between tumor grade and neurocognitive functioning in patients with glioma of the left temporal lobe prior to surgical resection

BACKGROUND

Various tumor characteristics have been associated with neurocognitive functioning (NCF), though the role of tumor grade has not been adequately examined.

METHODS

Seventy-two patients with histologically confirmed grade IV glioma (n = 37), grade III glioma (n = 20), and grade II glioma (n = 15) in the left temporal lobe completed preoperative neuropsychological assessment. Rates of impairment and mean test performances were compared by tumor grade with follow-up analysis of the influence of other tumor- and patient-related characteristics on NCF.

RESULTS

NCF impairment was more frequent in patients with grade IV tumor compared with patients with lower-grade tumors in verbal learning, executive functioning, as well as language abilities. Mean performances significantly differed by tumor grade on measures of verbal learning, processing speed, executive functioning, and language, with the grade IV group exhibiting worse performances than patients with lower-grade tumors. Group differences in mean performances remained significant when controlling for T1-weighted and fluid attenuated inversion recovery MRI-based lesion volume. Performances did not differ by seizure status or antiepileptic and steroid use.

CONCLUSIONS

Compared with patients with grade II or III left temporal lobe glioma, patients with grade IV tumors exhibit greater difficulty with verbal learning, processing speed, executive functioning, and language. Differences in NCF associated with glioma grade were independent of lesion volume, seizure status, and antiepileptic or steroid use, lending support to the concept of "lesion momentum" as a primary contributor to deficits in NCF of newly diagnosed patients prior to surgery.

Elevated prefrontal myo-inositol and choline following breast cancer chemotherapy

Breast cancer survivors are at increased risk for cognitive dysfunction, which reduces quality of life. Neuroimaging studies provide critical insights regarding the mechanisms underlying these cognitive deficits as well as potential biologic targets for interventions. We measured several metabolite concentrations using (1)H magnetic resonance spectroscopy as well as cognitive performance in 19 female breast cancer survivors and 17 age-matched female controls. Women with breast cancer were all treated with chemotherapy. Results indicated significantly increased choline (Cho) and myo-inositol (mI) with correspondingly decreased N-acetylaspartate (NAA)/Cho and NAA/mI ratios in the breast cancer group compared to controls. The breast cancer group reported reduced executive function and memory, and subjective memory ability was correlated with mI and Cho levels in both groups. These findings provide preliminary evidence of an altered metabolic profile that increases our understanding of neurobiologic status post-breast cancer and chemotherapy.

A randomized trial of bevacizumab for newly diagnosed glioblastoma

BACKGROUND

Concurrent treatment with temozolomide and radiotherapy followed by maintenance temozolomide is the standard of care for patients with newly diagnosed glioblastoma. Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor A, is currently approved for recurrent glioblastoma. Whether the addition of bevacizumab would improve survival among patients with newly diagnosed glioblastoma is not known.

METHODS

In this randomized, double-blind, placebo-controlled trial, we treated adults who had centrally confirmed glioblastoma with radiotherapy (60 Gy) and daily temozolomide. Treatment with bevacizumab or placebo began during week 4 of radiotherapy and was continued for up to 12 cycles of maintenance chemotherapy. At disease progression, the assigned treatment was revealed, and bevacizumab therapy could be initiated or continued. The trial was designed to detect a 25% reduction in the risk of death and a 30% reduction in the risk of progression or death, the two coprimary end points, with the addition of bevacizumab.

RESULTS

A total of 978 patients were registered, and 637 underwent randomization. There was no significant difference in the duration of overall survival between the bevacizumab group and the placebo group (median, 15.7 and 16.1 months, respectively; hazard ratio for death in the bevacizumab group, 1.13). Progression-free survival was longer in the bevacizumab group (10.7 months vs. 7.3 months; hazard ratio for progression or death, 0.79). There were modest increases in rates of hypertension, thromboembolic events, intestinal perforation, and neutropenia in the bevacizumab group. Over time, an increased symptom burden, a worse quality of life, and a decline in neurocognitive function were more frequent in the bevacizumab group.

CONCLUSIONS

First-line use of bevacizumab did not improve overall survival in patients with newly diagnosed glioblastoma. Progression-free survival was prolonged but did not reach the prespecified improvement target. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00884741.).

A prospective study of cognitive function in men with non-seminomatous germ cell tumors

OBJECTIVE

Longitudinal neuropsychological assessments were performed to determine if adjuvant chemotherapy was associated with cognitive dysfunction in men with non-seminomatous germ cell tumors (NSGCT).

METHODS

Patients with NSGCT status post-orchiectomy that either received adjuvant chemotherapy (n = 55) or did not (n = 14) were recruited. Patients were tested before chemotherapy, 1 week post-chemotherapy (or 3 months later in the surveillance group) and 12 months after the baseline evaluation.

RESULTS

Compared with the surveillance group, patients treated with chemotherapy had higher rates of cognitive decline at 12 months (overall cognitive decline: 0%, 52%, and 67% in the surveillance, low exposure (LE), and high exposure (HE) group, respectively), greater number of tests that declined (mean of 0.1, 1.4, and 2.0 in the surveillance, LE, and HE group, respectively), and more frequent worsening in motor dexterity (0%, 48%, and 46% in the surveillance, LE, and HE group, respectively). Compared with the surveillance group, patients receiving more cycles of chemotherapy demonstrated worse psychomotor speed and learning and memory. Younger age was associated with greater incidence of overall cognitive decline at 12-month follow-up.

CONCLUSIONS

Men with NSGCT that received chemotherapy demonstrated greater rates of cognitive decline in a dose-response manner. Reductions in motor dexterity were most common. Decline in learning and memory also was evident particularly at later follow-up time points and in men receiving more chemotherapy. Men that receive chemotherapy for NSGCT are at risk for cognitive decline and may benefit from monitoring and referral for psychosocial care.

Challenges relating to solid tumour brain metastases in clinical trials, part 1: patient population, response, and progression. A report from the RANO group

Therapeutic outcomes for patients with brain metastases need to improve. A critical review of trials specifically addressing brain metastases shows key issues that could prevent acceptance of results by regulatory agencies, including enrolment of heterogeneous groups of patients and varying definitions of clinical endpoints. Considerations specific to disease, modality, and treatment are not consistently addressed. Additionally, the schedule of CNS imaging and consequences of detection of new or progressive brain metastases in trials mainly exploring the extra-CNS activity of systemic drugs are highly variable. The Response Assessment in Neuro-Oncology (RANO) working group is an independent, international, collaborative effort to improve the design of trials in patients with brain tumours. In this two-part series, we review the state of clinical trials of brain metastases and suggest a consensus recommendation for the development of criteria for future clinical trials.

Dose-dense temozolomide for newly diagnosed glioblastoma: a randomized phase III clinical trial

PURPOSE

Radiotherapy with concomitant and adjuvant temozolomide is the standard of care for newly diagnosed glioblastoma (GBM). O(6)-methylguanine-DNA methyltransferase (MGMT) methylation status may be an important determinant of treatment response. Dose-dense (DD) temozolomide results in prolonged depletion of MGMT in blood mononuclear cells and possibly in tumor. This trial tested whether DD temozolomide improves overall survival (OS) or progression-free survival (PFS) in patients with newly diagnosed GBM.

PATIENTS AND METHODS

This phase III trial enrolled patients older than age 18 years with a Karnofsky performance score of ≥ 60 with adequate tissue. Stratification included clinical factors and tumor MGMT methylation status. Patients were randomly assigned to standard temozolomide (arm 1) or DD temozolomide (arm 2) for 6 to 12 cycles. The primary end point was OS. Secondary analyses evaluated the impact of MGMT status.

RESULTS

A total of 833 patients were randomly assigned to either arm 1 or arm 2 (1,173 registered). No statistically significant difference was observed between arms for median OS (16.6 v 14.9 months, respectively; hazard ratio [HR], 1.03; P = .63) or median PFS (5.5 v 6.7 months; HR, 0.87; P = .06). Efficacy did not differ by methylation status. MGMT methylation was associated with improved OS (21.2 v 14 months; HR, 1.74; P < .001), PFS (8.7 v 5.7 months; HR, 1.63; P < .001), and response (P = .012). There was increased grade ≥ 3 toxicity in arm 2 (34% v 53%; P < .001), mostly lymphopenia and fatigue.

CONCLUSION

This study did not demonstrate improved efficacy for DD temozolomide for newly diagnosed GBM, regardless of methylation status. However, it did confirm the prognostic significance of MGMT methylation. Feasibility of large-scale accrual, prospective tumor collection, and molecular stratification was demonstrated.

Dose-dense temozolomide for newly diagnosed glioblastoma: a randomized phase III clinical trial

PURPOSE

Radiotherapy with concomitant and adjuvant temozolomide is the standard of care for newly diagnosed glioblastoma (GBM). O(6)-methylguanine-DNA methyltransferase (MGMT) methylation status may be an important determinant of treatment response. Dose-dense (DD) temozolomide results in prolonged depletion of MGMT in blood mononuclear cells and possibly in tumor. This trial tested whether DD temozolomide improves overall survival (OS) or progression-free survival (PFS) in patients with newly diagnosed GBM.

PATIENTS AND METHODS

This phase III trial enrolled patients older than age 18 years with a Karnofsky performance score of ≥ 60 with adequate tissue. Stratification included clinical factors and tumor MGMT methylation status. Patients were randomly assigned to standard temozolomide (arm 1) or DD temozolomide (arm 2) for 6 to 12 cycles. The primary end point was OS. Secondary analyses evaluated the impact of MGMT status.

RESULTS

A total of 833 patients were randomly assigned to either arm 1 or arm 2 (1,173 registered). No statistically significant difference was observed between arms for median OS (16.6 v 14.9 months, respectively; hazard ratio [HR], 1.03; P = .63) or median PFS (5.5 v 6.7 months; HR, 0.87; P = .06). Efficacy did not differ by methylation status. MGMT methylation was associated with improved OS (21.2 v 14 months; HR, 1.74; P < .001), PFS (8.7 v 5.7 months; HR, 1.63; P < .001), and response (P = .012). There was increased grade ≥ 3 toxicity in arm 2 (34% v 53%; P < .001), mostly lymphopenia and fatigue.

CONCLUSION

This study did not demonstrate improved efficacy for DD temozolomide for newly diagnosed GBM, regardless of methylation status. However, it did confirm the prognostic significance of MGMT methylation. Feasibility of large-scale accrual, prospective tumor collection, and molecular stratification was demonstrated.

Acute cognitive impairment in patients with multiple myeloma undergoing autologous hematopoietic stem cell transplant

BACKGROUND

Few studies have examined the acute effects of autologous hematopoietic stem cell transplantation (Au-HSCT) on the neuropsychological functioning of patients with multiple myeloma (MM). The prevalence of cognitive deficits after induction chemotherapy (pre-AuHSCT) was examined in patients with MM, clinically significant changes in cognitive function 1 and 3 months post-AuHSCT were determined, and patients who may be vulnerable to cognitive decline during this period were identified.

METHODS

A total of 53 patients with MM were recruited pre-AuHSCT. Neuropsychological tests measuring multiple cognitive domains (attention, psychomotor speed, learning/memory, language, executive function, motor function) were administered pre-AuHSCT and 1 and 3 months post-AuHSCT. A pretreatment assessment was not available. An Overall Cognitive Function Index was computed to determine cognitive impairment pre-AuHSCT, and a practice-effect-adjusted Reliable Change Index was used to determine cognitive change over time.

RESULTS

Overall, deficits were more frequent in learning/memory, executive function, motor function, and psychomotor speed. Before AuHSCT, 47% of patients (25/53) exhibited cognitive impairment as determined by the Overall Cognitive Function Index. One month post-AuHSCT, 49% of patients (20/41) demonstrated clinically significant decline on 1 or more measures; 3 months post-AuHSCT, 48% (14 of 29 patients) showed decline on 1 or more measures. Older patients, minorities, and those with advanced disease, more induction cycles, or postinduction deficits showed greater vulnerability to decline.

CONCLUSIONS

Nearly half of the patients showed vulnerability to impairment in learning/memory or executive function after receiving induction therapy, and the prevalence of impairment remained high post-AuHSCT. Awareness of cognitive impairment and associated risk factors in actively treated patients is important for considering psychosocial or other support for patients with acute cognitive symptoms.

Challenges relating to solid tumour brain metastases in clinical trials, part 2: neurocognitive, neurological, and quality-of-life outcomes. A report from the RANO group

Neurocognitive function, neurological symptoms, functional independence, and health-related quality of life are major concerns for patients with brain metastases. The inclusion of these endpoints in trials of brain metastases and the methods by which these measures are assessed vary substantially. If functional independence or health-related quality of life are planned as key study outcomes, then the reliability and validity of these endpoints can be crucial because methodological issues might affect the interpretation and acceptance of findings. The Response Assessment in Neuro-Oncology (RANO) working group is an independent, international, and collaborative effort to improve the design of clinical trials in patients with brain tumours. In this report, the second in a two-part series, we review clinical trials of brain metastases in relation to measures of clinical benefit and provide a framework for the design and conduct of future trials.

Memantine for the prevention of cognitive dysfunction in patients receiving whole-brain radiotherapy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

To determine the protective effects of memantine on cognitive function in patients receiving whole-brain radiotherapy (WBRT).

METHODS

Adult patients with brain metastases received WBRT and were randomized to receive placebo or memantine (20 mg/d), within 3 days of initiating radiotherapy for 24 weeks. Serial standardized tests of cognitive function were performed.

RESULTS

Of 554 patients who were accrued, 508 were eligible. Grade 3 or 4 toxicities and study compliance were similar in the 2 arms. There was less decline in delayed recall in the memantine arm at 24 weeks (P = .059), but the difference was not statistically significant, possibly because there were only 149 analyzable patients at 24 weeks, resulting in only 35% statistical power. The memantine arm had significantly longer time to cognitive decline (hazard ratio 0.78, 95% confidence interval 0.62-0.99, P = .01); the probability of cognitive function failure at 24 weeks was 53.8% in the memantine arm and 64.9% in the placebo arm. Superior results were seen in the memantine arm for executive function at 8 (P = .008) and 16 weeks (P = .0041) and for processing speed (P = .0137) and delayed recognition (P = .0149) at 24 weeks.

CONCLUSIONS

Memantine was well tolerated and had a toxicity profile very similar to placebo. Although there was less decline in the primary endpoint of delayed recall at 24 weeks, this lacked statistical significance possibly due to significant patient loss. Overall, patients treated with memantine had better cognitive function over time; specifically, memantine delayed time to cognitive decline and reduced the rate of decline in memory, executive function, and processing speed in patients receiving WBRT. RTOG 0614, ClinicalTrials.gov number CT00566852.

Phase II trial of erlotinib plus concurrent whole-brain radiation therapy for patients with brain metastases from non-small-cell lung cancer

PURPOSE

Brain metastasis (BM) is a leading cause of death from non-small-cell lung cancer (NSCLC). Reasoning that activation of the epidermal growth factor receptor (EGFR) contributes to radiation resistance, we undertook a phase II trial of the EGFR inhibitor erlotinib with whole-brain radiation therapy (WBRT) in an attempt to extend survival time for patients with BM from NSCLC. Additional end points were radiologic response and safety.

PATIENTS AND METHODS

Eligible patients had BM from NSCLC, regardless of EGFR status. Erlotinib was given at 150 mg orally once per day for 1 week, then concurrently with WBRT (2.5 Gy per day 5 days per week, to 35 Gy), followed by maintenance. EGFR mutation status was tested by DNA sequencing at an accredited core facility.

RESULTS

Forty patients were enrolled and completed erlotinib plus WBRT (median age, 59 years; median diagnosis-specific graded prognostic assessment score, 1.5). The overall response rate was 86% (n = 36). No increase in neurotoxicity was detected, and no patient experienced grade ≥ 4 toxicity, but three patients required dose reduction for grade 3 rash. At a median follow-up of 28.5 months (for living patients), median survival time was 11.8 months (95% CI, 7.4 to 19.1 months). Of 17 patients with known EGFR status, median survival time was 9.3 months for those with wild-type EGFR and 19.1 months for those with EGFR mutations.

CONCLUSION

Erlotinib was well tolerated in combination with WBRT, with a favorable objective response rate. The higher-than-expected rate of EGFR mutations in these unselected patients raises the possibility that EGFR-mutated tumors are prone to brain dissemination.

Effects of different amounts of a low fluoride toothpaste on primary enamel lesion progression: a preliminary study using in vitro pH-cycling system

AIMS

To evaluate and compare the efficacy of pea and half-pea portions of child formula fluoride (500 ppm) toothpaste on artificially created enamel lesions in primary teeth.

METHODS

Sound primary incisors were painted with nail varnish, leaving a 1 mm wide window and then placed in a demineralising solution for 96 h to produce artificial carious lesions 60-100 microm deep. The teeth were longitudinally sectioned (100 microm thick) and divided into 3 groups. Group A: treated with a pea-sized portion of a non-fluoride containing toothpaste (1:3, toothpaste: deionized water), while Groups B and C were treated with half-pea-sized and pea-sized portions of a 500 ppm fluoride containing toothpaste, respectively. The pH-cycling model was utilized for 7 days.

RESULTS

Groups A and B lesions increased in depth by 60% while those in Group C increased by 19%. The mineral content of the surface zone decreased significantly in Groups A and B but not in Group C.

CONCLUSION

Reduction of the amount of fluoride toothpaste to less than a pea-size in order to minimize the risk of fluorosis should be undertaken with caution because it may compromise the cariostatic effects of the toothpaste.