Clinical outcomes of elective nodal irradiation (ENI) compared with involved field radiotherapy (IFRT) in NSCLC

7541

Background: Local failure rates in patients treated with definitive radiotherapy for non-small cell lung cancer (NSCLC) remain high. IFRT allows higher radiation doses to the primary tumor with the goal of reducing local failure rates while minimizing toxicity. This approach, however, raises concern for increased nodal failures. Our retrospective analysis evaluates clinical outcomes of patients treated at our institution with ENI or IFRT. Methods: We assessed all patients (pts) with stage III locally advanced or stage IV oligometastatic NSCLC treated with definitive radiotherapy (RT) from January 1, 2003 to August 21, 2008. The decision to treat with ENI vs. IFRT was based on physician treatment philosophy. We compared baseline demographics in each group as well as toxicities and therapeutic outcomes. Involved nodal failures (INF) were defined as radiographic progression in lymph nodes that were initially involved at the time of treatment. Elective nodal failures (ENF) were defined as progression in initially uninvolved lymph nodes. Results: A total of 104 consecutive pts (56 ENI vs. 48 IFRT) were assessed. Pts in both groups had similar characteristics with respect to age, baseline KPS, and percentage receiving chemotherapy. The average RT dose was 6,345 cGy in the ENI group and 6988 cGy in the IFRT group. The median follow-up time was 8.4 mos (0.3–43.4) for all pts and 9.7 mos (1.5–40.1) for survivors. The results follow in the table below. Conclusions: Our data suggest that IFRT does not result in increased nodal failures or decreased survival compared to ENI, and may result in increased local control. The majority of patients who experienced a local failure also experienced nodal failure, suggesting that local relapse may be linked to subsequent nodal failure. This may explain the increased nodal failure rates in patients treated with ENI. Decreased esophagitis rates in patients treated with IFRT may allow the integration of concurrent, full dose systemic therapy in a greater proportion of patients, as well as higher RT doses.

[Table: see text]

No significant financial relationships to disclose.

Phase I dose escalation of temozolomide with thiotepa and carboplatin with autologous hematopoietic cell reinfusion in patients with recurrent/refractory malignant brain tumors

2060

Background: The prognosis for most patients with recurrent malignant brain tumors is dismal. Treatment options are limited especially for patients who have already received irradiation. TMZ is an oral alkylating agent which is approved for use in patients with high grade glioma and has also been shown to have activity in patients with recurrent medulloblastoma. It’s primary dose-limiting toxicity is non- cumulative bone marrow suppression. In the present study, TMZ is given in a dose escalation fashion with fixed doses of high dose thiotepa and carboplatin with AHCR in the treatment of patients with recurrent or refractory malignant brain tumors. Methods: Treatment consisted of TMZ twice daily on days -10 to -6 followed by thiotepa 300 mg/m2/day and carboplatin AUC=7/day on days -5 to -3 with AHCR on day 0. Filgrastim was given day +1 and continued until engraftment. Results: 27 patients (18M; 9F) ages 3–46 years were treated from 11/00 until 10/04. Diagnoses included high grade glioma (n=12); medulloblastoma/PNET (n=9); CNS germ cell tumor (GCT) (n=4); and 1 each ependymoma and spinal cord PNET. TMZ doses ranged from 50 mg/m2 twice daily (100 mg/m2/day) to 200 mg/m2 twice daily (400 mg/m2/day) for 5 days. One patient had dose limiting toxicity consisting of reversible veno-occlusive disease at dose level 3 (TMZ 100 mg/m2 twice daily). Two patients had dose limiting toxicity at dose level 7 (TMZ 200 mg/m2 twice daily) consisting of transient encephalopathy (n=1) and severe mucositis (n=1). Additional toxicities included bacteremia (n=11), C. difficile enteritis (n=6) and grade 4 elevation of bilirubin and/or liver transaminases (n=2). There were no toxic deaths. Survival included 3 patients with glioma (38–48 months); two of whom had relapsed following standard dose TMZ; 3 patients with PNET/MB (48–72 months) and 3 patients with CNS GCT (26–71 months). Conclusions: Increased doses of TMZ are feasible when given with AHCR. There is presently a phase II study underway through the Pediatric Blood and Marrow Transplant Consortium evaluating the efficacy of TMZ at a dose of 175 mg/m2/day twice daily for 5 days with high dose thiotepa and carboplatin and AHCR.

No significant financial relationships to disclose.

Newly diagnosed high-risk malignant brain tumors with leptomeningeal dissemination in young children: A final update on Head Start II Regimen A2 intensified with high-dose methotrexate

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Background: The prognosis for young children with newly diagnosed malignant brain tumors with leptomeningeal dissemination remains poor. From Jan 1997 to Mar 2003, “Head Start II” Regimen A2, intensified with high-dose methotrexate, was offered to this high-risk population. Methods: Eligibility: patients < 10 yrs of age; confirmed diagnosis of medulloblastoma (MB), primitive neuroectodermal tumor (PNET), ependymoma and choroid plexus carcinoma (CPC); and high-risk status as determined by neuroaxis dissemination. Patients with atypical teratoid/rhabdoid tumor (ATRT), regardless of stage, were also eligible. Treatment: 5 cycles of vincristine (0.05 mg/kg/week × 3 doses), cisplatin (3.5 mg/kg), etoposide (4 mg/kg/day × 2 days), cyclophosphamide (65 mg/kg/day × 2 days), and methotrexate (400 mg/kg) with leucovorin. Children without progressive disease (PD) by the end of induction underwent a single consolidation cycle (carboplatin, etoposide, thiotepa) with autologous stem cell rescue. Reduced dose RT (2340cGy CSI and focal boost) was reserved for any with residual disease at the end of induction or for the older patient (>6 yrs of age). Results: 40 patients were enrolled (MB, 22; PNET, 6; ependymoma, 5; AT/RT, 6; CPC, 1), med age at diagnosis 38 mos (range 5 to 119 mos). Significant toxicities of this intensified regimen included GI toxicities and infections. Among the entire cohort, there were 26 CR, 6 PR, 2 with stable disease and 4 with PD (and 2 toxic deaths), for a CR +PR response rate of 82%. For disseminated MB (4 M1; 2 M2; 16 M3), the CR rate alone is 77% (17/22). The 5-year EFS and OS for disseminated MB are 45% (95% CI, 24 % to 64%) and 54% (95% CI, 31% to 72%), respectively. Of note, 6/12 MB survivors (all M3) did not receive RT and all are NED >5 years from diagnosis. In addition, there are 3 AT/RT survivors, 12, 54 and 66 mos post-diagnosis who did not receive RT. Conclusions: This intensified regimen is feasible and tolerable. For patients with disseminated MB, the majority of whom had M3 disease at diagnosis, the impressive response rate and outcomes suggest that the addition of methotrexate is justified for future studies. Long- term neuropsychological outcomes are being studied at this time.

No significant financial relationships to disclose.

Outcome of children less than three years old at diagnosis with non-metastatic medulloblastoma treated with chemotherapy on the “Head Start” I and II protocols: Final report

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Background: The use of dose-intensive chemotherapy with autologous hematopoietic cell rescue (AuHCR) is a potentially curative approach to the management of infants and young children with non-metastatic (M-0) medulloblastoma, with the additional benefit of avoiding the late effects of irradiation. We report the results of the “Head Start” I (1991 to 1997) and “Head Start” II (1997 to 2002) clinical trials, using this approach, to treat children with M-0 medulloblastoma, who were less than three years of age at diagnosis. Methods: Twenty one children were enrolled on these two serial studies. After surgery, patients received a uniform induction chemotherapy regimen consisting of five cycles of vincristine, cisplatin, cyclophosphamide and etoposide. Following completion of induction, all patients underwent myeloablative consolidation chemotherapy using carboplatin, thiotepa and etoposide followed by AuHCR, and did not receive irradiation. Irradiation was used only at relapse. Quality of life (QoL) and social and emotional behavior were evaluated on “Head Start” I, and cognitive functioning was evaluated on “Head Start” II survivors. Results: The five-year event-free (EFS) and overall survival (OS) rates (±SE) for all patients, patients with gross total resection, and patients with residual tumor were 52 ± 11% and 70 ± 10%, 64 ± 13% and 79 ± 17%, and 29 ± 17% and 57 ± 19%, respectively. The five-year EFS and OS (±SE) for patients with desmoplastic and classical medulloblastoma were 67 ± 16% and 78 ± 14%, and 42 ± 14 and 67 ± 14%, respectively. Young age (<2 years versus 2 to 3 years) at diagnosis did not appear to impact adversely upon outcome. There were four treatment related deaths. A majority of survivors (71%) avoided irradiation altogether. Neuropsychological functioning in children surviving without irradiation was well within the normal range for most patients. Conclusions: The strategy of brief intensive chemotherapy without irradiation for young children with M-0 medulloblastoma has eliminated the need for craniospinal irradiation in over half (52%) of the patients, with preservation of QoL and cognitive functioning in the majority.

No significant financial relationships to disclose.

Primary peripheral primitive neuroectodermal tumors of the spinal cord: report of two cases and review of the literature

Primary intraspinal peripheral primitive neuroectodermal tumors (pPNETs) are extremely rare tumors with only seven reported cases in the literature. The histopathologic diagnosis of this tumor is complex and has led to a variety of treatment approaches. The distinction between central and peripheral type primary spinal cord PNETs has not always been made in the literature, leading to a paucity of data in this disease. We present here two young patients with primary intraspinal pPNET, their treatment and outcome. The first patient, a 27 year old male, presented with an intradural mass extending from L2 through L5, after multiple relapses, he is currently alive with disease after 72 months, the longest survival yet reported. The second patient, a 16 year old female, presented with an intradural mass at the cauda equina from L2 through L5, and is currently alive with responsive disease at 5 months after initial diagnosis. Here, we discuss the clinical course, the pathology and treatment for this disease and review the literature.

Factors affecting event free survival (EFS) after high dose chemotherapy with stem cell rescue (HDC/SCR) in children with brain tumors

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Background: HDC/SCR is a novel approach for treatment of children with brain tumors. Despite several studies suggesting results are better in children with primitive neural ectodermal tumors (PNET) or medulloblastoma (MB), it is controversial whether other factors can predict outcome. Methods: We retrospectively analyzed data from 53 patients who underwent HDC/SCR for brain tumors at Children Hospital Los Angeles between June 1992 and June 2005. Patients were aged 4 months to 15.8 years at diagnosis and 9 months to 18.1 years at transplant. In all cases the conditioning regimen included thiotepa and/or etoposide and/or carboplatin. The variables considered were age at diagnosis, histology, extent of disease, conditioning regimen, radiation therapy, stem cell type and timing of transplant. Results: Diagnoses included 33 PNET/MB, 8 high-grade gliomas, 5 ependymomas, 3 germinomas, 2 choroid plexus carcinomas and 2 rhabdoid tumors. Overall event free survival at 36 months was 53±9.1% in PNET/MB and 40±15.5% in tumors with other histology. Variables associated with better EFS in PNET/MB were no prior progression (p=0.00094), no spread into bone marrow (p=1.2 E-10) and age less than 3 years at diagnosis (p=0.046). There was a trend toward improved outcome if there was gross total resection of the tumor (p=0.11). Patients with PNET transplanted before progression had better EFS if they had localized disease at diagnosis (p=0.00024), and if gross total surgical resection was accomplished (p=0.11). Patients with PNET/MB transplanted after progression had better EFS if there was no spread of disease into blood or bone marrow (p=0.00023), if they were male (p=0.053), had localized disease at relapse (p=0.12) and if radiotherapy was given after transplant (p=0.053). In patients with tumors of other histology, the only variable associated with prolonged EFS was gross total resection (p=0.026). Conclusions: Children most likely to benefit from HDC/SCR for brain tumors are those less than 3 years old who are newly diagnosed with PNET that is locally confined, and those with a non-PNET diagnosis who have gross total resection of tumor.

No significant financial relationships to disclose.

Comparative in vitro activity of gemifloxacin against gram-positive and gram-negative clinical isolates in Argentina

The in vitro activity of gemifloxacin against 1,000 clinical isolates of 147 Streptococcus pneumoniae (115, penicilin susceptible; 26, intermediate penicillin-resistant and 6, penicillin-resistant), 127 Hemophilus influenzae (109, beta lactamasa non-producer; 18, beta lactamase producers), 95 Streptococcus pyogenes (6, azytromycin-resistant), 84 Moraxella catarrhalis (79, beta lactamase producers), 110 Staphilococcus aureus (89, methicillin-susceptible; 21, methicilin-resistant), 98 Eenterococcus faecalis and 339 Enterobacteriacea, (recovered from patients with respiratory tract infection; skin and soft tissue infection and urinary tract infection), was compared with the activities of four fluorquinolones and five other antimicrobial agents. Of the quinolones tested, gemifloxacin was the most potent against Streptococcus pneumoniae, including penicillin intermediate and resistant strains. Mic(90) values obtained for gemifloxacin, ciprofloxacin, ofloxacin, levofloxacin and trvafloxacin were 0.03, 2, 2, 1 and 0.25 mg/L respectively. Gemifloxacin was 16 fold more potent than ciprofloxacin against methicillin-susceptible Staphylococcus aureus and 32 fold more potent than ciprofloxacin against Streptococcus pyogenes. When tested against Hemophilus influenzae, Moraxella catarrhalis and Enterobacteriaceae, all the quinolones showed similar activity. Our results demonstrate that gemifloxacin has similar activity than the other quinolones tested against Gram-negative organisms and is considerably more potent against Gram-positive organisms.

Phase II study of combination taxol and estramustine phosphate in the treatment of recurrent glioblastoma multiforme

Taxol has activity in the treatment of high grade gliomas but estramustine phosphate (EMP) has not been used in this setting. In vitro data demonstrates that EMP is cytotoxic to glioma cell lines and estramustine binding proteins are expressed by glioma cells. The combination of Taxol and EMP is reported to be active in the treatment of hormone-refractory prostate cancer and in taxane-resistant breast and ovarian cancer. We therefore performed a phase II study to assess the activity and toxicity of this combination in high grade gliomas. Taxol was given at a dose of 225 mg/m2 intravenously over three hours on day 1 and EMP was given at a dose of 900 mg/m2 orally on days 1 through 3. Cycles were repeated every three weeks. Twenty patients with recurrent glioblastoma multiforme (GBM) were enrolled: 11 male, median age 45 years. All patients received anti-epileptic medications and 17 (80%) had received prior chemotherapy. Of 18 evaluable patients, two had partial responses (11) and six had stable disease (33%) for a minimum of eight weeks. Treatment was well tolerated with grade 3 neutropenia occurring in only three patients. There were no other grade 3 or 4 toxicities. The median time to progression for the cohort was only six weeks (range 3-60+ weeks). The median overall survival was 12 weeks (range 3-60+ weeks). In conclusion, the combination of Taxol and EMP is well tolerated and has modest activity in the treatment of recurrent GBM.

Emergence of resistance during mupirocin treatment: is it a problem in clinical practice?

Mupirocin (pseudomonic acid A) is indicated for primary and secondary skin infections, and for the eradication of nasal colonization of Staphylococcus aureus, particularly methicillin-resistant S. aureus (MRSA). This paper reviews the mechanisms by which resistance to mupirocin can develop, discusses clinically relevant breakpoints, and the clinical significance of reports of resistance. Following more than 10 years' use, short courses of treatment, even when repeated, are associated with remarkably little resistance and this resistance is unlikely to be clinically significant.