Efficacy of gemcitabine plus platinum chemotherapy compared with other platinum containing regimens in advanced non-small-cell lung cancer: a meta-analysis of survival outcomes

PURPOSE

Gemcitabine-platinum combination activity has been clearly established in a number of phase II studies. It has also been compared against other combinations in many phase III trials. It is generally believed that all such regimens have an equivalent impact on survival. This meta-analysis aims to quantify the treatment effect of gemcitabine plus a platinum agent in the treatment of advanced NSCLC and compare the combination to other regimens used globally.

DESIGN

Data from a total of 4556 patients from 13 randomized trials investigating gemcitabine in combination with a platinum agent versus any other platinum-containing regimen were included in a meta-analysis of time-to-event outcomes.

RESULTS

A significant reduction in overall mortality in favor of gemcitabine-platinum regimens was observed, hazard ratio (HR) 0.90 (95% CI: 0.84-0.96) with an absolute benefit at 1 year of 3.9%. Median survival was 9.0 months for the gemcitabine-platinum regimens and 8.2 months for the comparator regimens. Sub-group analysis of the first- and second-generation platinum-based comparator regimens also indicated a significant benefit for gemcitabine-platinum regimens, HR 0.84 (CI: 0.71-0.9985). Analysis of third-generation agent plus platinum regimens showed a non-significant trend favoring gemcitabine-platinum regimens, HR 0.93 (CI: 0.86-1.01). There was a significant decrease in the risk of disease progression in favor of gemcitabine-platinum regimens, HR 0.88 (CI: 0.82-0.93). An absolute benefit of 4.2% at 1 year was estimated. Median progression-free survival was 5.1 months for gemcitabine-platinum regimens compared with 4.4 months for the comparator regimens. Sub-group analysis indicated a statistically significant progression-free survival benefit for patients assigned to gemcitabine-platinum treatment compared to first- and second-generation platinum regimens, HR 0.85 (CI: 0.77-0.94), and third-generation agent plus platinum regimens, HR 0.89 (CI: 0.82-0.96).

Pharmacotherapy of chemotherapy-induced anaemia

Anaemia in cancer patients is multifactorial. Anaemia of chronic disease due to the effects of cancer, as well as side effects of cancer treatment, are important factors. The impact of anaemia on the quality of life and social function of cancer patients has recently become more acknowledged. The traditional treatment for chemotherapy-induced anaemia (CIA) has been the use of red blood cell transfusions, with only short-lived effects and all their inherent risks. The finding of deficiency in erythropoietin, the endogenous hormone responsible for the production and maintenance of red blood cells in these patients, was the basis for the therapeutic development of erythropoietic proteins. With the introduction of epoetins (recombinant forms of human erythropoietin) in oncology and more recently, the novel long-acting darbepoetin alpha, physicians gained new pharmacotherapeutic approaches to treat CIA. Several forms of erythropoietic proteins are available in various regions of the world. Their characteristics, clinical evidence for use, guidelines for clinical administration and their safety are described in this review.

Mediastinal emphysema and small cell lung cancer (SCLC): a case-report

We present a case of a 59-year-old man with small cell lung cancer (SCLC) who developed heavy thoracic pain because of spontaneous mediastinal emphysema. Autopsy documented a mucosal lesion in the posterior tracheal wall with air leak towards the mediastinum. The occurrence of spontaneous mediastinal emphysema in patients with small cell lung cancer has rarely been described in the literature.

Positron-emission tomography in prognostic and therapeutic assessment of lung cancer: systematic review

Positron-emission tomography (PET) with 18-fluorodeoxyglucose has a role in the diagnosis and staging of lung cancer, but is also appealing for assessment of prognosis and treatment. A systematic search of the published work shows good evidence that [(18)F]FDG uptake on PET has independent prognostic value in newly diagnosed non-small-cell lung cancer. PET is a sensitive method of measuring the biological effects of anticancer therapy, but until better standardisation and large-scale experience is available, it should only be used for additional assessments of early response in clinical trials. Further studies are needed to define the role of [(18)F]FDG-PET in restaging after induction therapy in multimodality approaches for locally advanced lung cancer. The assessment of prognosis by [(18)F]FDG-PET is less substantiated in treated lung cancer than in newly diagnosed patients. Good prospective evidence documents the effectiveness of [(18)F]FDG-PET over CT in the correct identification of recurrent lung cancer.

Long-term survival of surgically staged IIIA-N2 non-small-cell lung cancer treated with surgical combined modality approach: analysis of a 7-year prospective experience

BACKGROUND

The aim of this study was to analyse the outcome of surgically staged IIIA-N2 non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgical exploration.

METHODS

Univariate and multivariate analyses were carried out on a prospective cohort of 131 mediastinoscopy-proven IIIA-N2 NSCLC patients. Three preoperative cycles of vindesine-ifosfamide-cisplatin (VIP) were given. Patients with at least stable disease (SD) were considered for surgery, or radical radiotherapy in selected cases.

RESULTS

The response rate after VIP was 54% (95% confidence interval 45% to 63%) and was important for the final outcome. The median and 5-year survival for the total group were 24 months and 21% (38 months and 30% in responders), respectively. Involvement of subcarinal nodes at diagnosis was the most important prognostic factor (P=0.022). Seventy-five patients were considered for surgery. Downstaging occurred in 34 of 70 resection specimens, with a pathological complete response in six. Median and 5-year survival in the surgical cohort were 45 months and 35%, respectively. Surgery was rewarding both in patients with a response and in those with SD, although the complete resection rate was significantly lower in the latter. On multivariate analysis, favourable prognostic factors were low pathological T-stage (P=0.001) and downstaging of mediastinal nodes in the resection specimen (P=0.008).

CONCLUSIONS

VIP induction chemotherapy followed by surgical exploration was rewarding in mediastinoscopy-proven stage IIIA-N2 NSCLC, both in cases of response and SD, despite a lower complete resection rate in the latter. Patients with subcarinal nodes at diagnosis (5-year survival 8.5%) or without nodal downstaging at post-induction surgery (13.7%) might preferably be treated with a non-surgical approach.

The Role of PET Scan in Diagnosis, Staging, and Management of Non‐Small Cell Lung Cancer

Positron emission tomography (PET) is now an important cancer imaging tool, both for diagnosis and staging, as well as offering prognostic information based on response. This report attempts to comprehensively review the value of PET in the locoregional and distant staging of non-small cell lung cancer (NSCLC), illustrate the potential effects on patient management, and give a short overview of newer applications. PET sets the gold standard in the evaluation of an indeterminate solitary pulmonary nodule or mass, where PET has proven to be significantly more accurate than computed tomography (CT) in the distinction between benign and malignant lesions. In the evaluation of metastatic spread to locoregional lymph nodes, PET is significantly more accurate than CT, so that invasive surgical staging may be omitted in many patients with negative mediastinal PET images. In patients with positive mediastinal PET images, invasive surgical staging remains mandatory because of the possibility of false-positive findings due to inflammatory nodes or granulomatous disorders. In the search for metastatic spread, PET is a useful adjunct to conventional imaging. This may be due to the finding of unexpected metastatic lesions or due to exclusion of malignancy in lesions that are equivocal on standard imaging. However, at this time, PET does not replace conventional imaging. Large-scale randomized studies are currently examining whether PET staging will actually improve the appearance of lung cancer outcome.

Interstitial lung diseases: characteristics at diagnosis and mortality risk assessment

As the diagnostic assessment of the different forms of interstitial lung disease (ILD) is similar, this study aims to compare age, sex, the functional and broncho-alveolar lavage fluid (BALF) findings at diagnosis between the different forms of ILDs. In addition we want to determine which of these variables determine survival. We evaluated 315 patients (176 males and 139 females) in whom the diagnosis was made of sarcoidosis (n = 87), ILD due to connective tissue disease (n = 56), hypersensitivity pneumonitis (n = 50), idiopathic pulmonary fibrosis (IPF) (n = 64), other forms of idiopathic interstitial pneumonia (n = 29) or ILD due to an undefined form of fibrosis (n = 29). We analysed the role on outcome of type of disease, gender, age at diagnosis, type of cells in BALF, FVC and DLCO. In a Kaplan-Meier analysis IPF has the worst outcome in comparison with other types of ILDs. A Cox regression analysis showed that type of ILD, FVC, age at diagnosis and % of macrophages in BALF predict outcome of patients affected by ILD.

Darbepoetin alfa in lung cancer patients on chemotherapy: a retrospective comparison of outcomes in patients with mild versus moderate-to-severe anaemia at baseline

GOALS

Currently, there is some debate concerning the haemoglobin level at which treatment of anaemia with erythropoiesis-stimulating agents should be initiated in cancer patients on chemotherapy. We report several analyses of data from a phase III trial of darbepoetin alfa versus placebo, comparing outcomes for patients with mild and moderate-to-severe anaemia.

PATIENTS AND METHODS

Data were obtained from a phase III trial of darbepoetin alfa versus placebo in anaemic patients with lung cancer receiving chemotherapy ( n=314). Outcomes were compared for patients with baseline haemoglobin > or =10-11 g/dl and <10 g/dl.

RESULTS

Darbepoetin alfa significantly reduced transfusions compared with placebo, irrespective of haemoglobin level at treatment initiation. For patients with baseline haemoglobin <10 g/dl, 31% and 59% of those receiving darbepoetin alfa and placebo, respectively, required a transfusion from week 5 to the end of the treatment phase ( P<0.038). For patients with baseline haemoglobin > or =10 g/dl, the proportions were 15% and 41%, respectively ( P<0.001). Darbepoetin alfa also improved fatigue compared with placebo in both haemoglobin categories.

CONCLUSIONS

These findings show that initiating treatment at haemoglobin levels both <10 g/dl and > or =10-11 g/dl results in substantial clinical benefits, supporting the use of erythropoietic therapy also in patients with mild anaemia.

Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer

BACKGROUND

On the basis of a previous meta-analysis, the International Adjuvant Lung Cancer Trial was designed to evaluate the effect of cisplatin-based adjuvant chemotherapy on survival after complete resection of non-small-cell lung cancer.

METHODS

We randomly assigned patients either to three or four cycles of cisplatin-based chemotherapy or to observation. Before randomization, each center determined the pathological stages to include, its policy for chemotherapy (the dose of cisplatin and the drug to be combined with cisplatin), and its postoperative radiotherapy policy. The main end point was overall survival.

RESULTS

A total of 1867 patients underwent randomization; 36.5 percent had pathological stage I disease, 24.2 percent stage II, and 39.3 percent stage III. The drug allocated with cisplatin was etoposide in 56.5 percent of patients, vinorelbine in 26.8 percent, vinblastine in 11.0 percent, and vindesine in 5.8 percent. Of the 932 patients assigned to chemotherapy, 73.8 percent received at least 240 mg of cisplatin per square meter of body-surface area. The median duration of follow-up was 56 months. Patients assigned to chemotherapy had a significantly higher survival rate than those assigned to observation (44.5 percent vs. 40.4 percent at five years [469 deaths vs. 504]; hazard ratio for death, 0.86; 95 percent confidence interval, 0.76 to 0.98; P<0.03). Patients assigned to chemotherapy also had a significantly higher disease-free survival rate than those assigned to observation (39.4 percent vs. 34.3 percent at five years [518 events vs. 577]; hazard ratio, 0.83; 95 percent confidence interval, 0.74 to 0.94; P<0.003). There were no significant interactions with prespecified factors. Seven patients (0.8 percent) died of chemotherapy-induced toxic effects.

CONCLUSIONS

Cisplatin-based adjuvant chemotherapy improves survival among patients with completely resected non-small-cell lung cancer.

Clinical-radiological presentation and outcome of surgically treated pulmonary carcinoid tumours: a long-term single institution experience

PURPOSE

To determine the presenting features and the outcome of surgically treated pulmonary carcinoid tumours.

METHODS

Retrospective analysis of all consecutive cases with preoperatively suspected or proven pulmonary carcinoid, treated between 1964 and 1994, in order to have full 5-year survival data.

RESULTS

Seventy-three patients were retrieved, six had a postoperative histology other than carcinoid. The mean age of the 67 eligible cases was 44 years (range 17-74). There were 59 typical and eight atypical carcinoids. The most frequent presenting symptom was infection, followed by haemoptysis. Sixteen patients were asymptomatic, 15 of these had an abnormal chest X-ray, showing a solitary nodule in 13. Bronchoscopy was abnormal in almost all symptomatic patients. Bronchial biopsy results suggested a malignancy other than carcinoid in seven of eight patients whose postoperative histology was found to be atypical carcinoid. There were 40 lobectomies, 14 bi-lobectomies, nine pneumonectomies, and four limited resections. Ten patients had lymph node involvement (seven typical and three atypical). There was no correlation between the diameter of the primary tumour and the presence of nodal involvement. In particular, three of eight peripheral lesions <30 mm were found to have metastatic lymph nodes. The 5-year survival was 92% (95% in N0 versus 56% in N1-2; 92% in typical versus 67% in atypical). The 10-year survival was 84%.

CONCLUSION

The specific diagnosis of atypical carcinoid cannot be reliably made on bronchial biopsies. No relationship was found between tumour size and the presence of lymph node metastases, suggesting that radical excision with detailed lymph node sampling is as important in carcinoids as in other lung cancers. Long-term survival was excellent, nodal status and pathology (typical/atypical) were independent prognostic factors.

Induction treatment before surgery for non-small cell lung cancer

Surgery alone is currently still accepted "standard of care" for patients with operable NSCLC, this includes stages IA and IIB, as well as selected early subsets of IIIA disease. In more advanced and inoperable stage III disease, combinations of chemotherapy and radiotherapy remain the standard treatment approach for patients with good performance status. The role of surgery following induction therapy in these advanced stage III patients is at the moment not conclusively defined. More evidence from randomized trials is clearly needed to tailor treatment for the large number of patients that present in these locally advanced stages. Enrollment of patients into ongoing prospective clinical trials should be encouraged, whenever possible, to further define prognostic factors and improve multimodality strategies in this clinical setting.

Multi-institutional randomized phase II trial of gefitinib for previously treated patients with advanced non-small-cell lung cancer (The IDEAL 1 Trial) [corrected]

PURPOSE

To evaluate the efficacy and tolerability of two doses of gefitinib (Iressa [ZD1839]; AstraZeneca, Wilmington, DE), a novel epidermal growth factor receptor tyrosine kinase inhibitor, in patients with pretreated advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This was a randomized, double-blind, parallel-group, multicenter phase II trial. Two hundred ten patients with advanced NSCLC who were previously treated with one or two chemotherapy regimens (at least one containing platinum) were randomly assigned to receive either 250-mg or 500-mg oral doses of gefitinib once daily.

RESULTS

Efficacy was similar for the 250- and 500-mg/d groups. Objective tumor response rates were 18.4% (95% confidence interval [CI], 11.5 to 27.3) and 19.0% (95% CI, 12.1 to 27.9); among evaluable patients, symptom improvement rates were 40.3% (95% CI, 28.5 to 53.0) and 37.0% (95% CI, 26.0 to 49.1); median progression-free survival times were 2.7 and 2.8 months; and median overall survival times were 7.6 and 8.0 months, respectively. Symptom improvements were recorded for 69.2% (250 mg/d) and 85.7% (500 mg/d) of patients with a tumor response. Adverse events (AEs) at both dose levels were generally mild (grade 1 or 2) and consisted mainly of skin reactions and diarrhea. Drug-related toxicities were more frequent in the higher-dose group. Withdrawal due to drug-related AEs was 1.9% and 9.4% for patients receiving gefitinib 250 and 500 mg/d, respectively.

CONCLUSION

Gefitinib showed clinically meaningful antitumor activity and provided symptom relief as second- and third-line treatment in these patients. At 250 mg/d, gefitinib had a favorable AE profile. Gefitinib 250 mg/d is an important, novel treatment option for patients with pretreated advanced NSCLC [corrected]

Darbepoetin alfa: a new approach to the treatment of chemotherapy-induced anaemia

Chemotherapy-induced anaemia has important consequences on the quality of life and social function of cancer patients. The finding of erythropoietin (EPO) deficiency in these patients led to the therapeutic development of erythropoietic proteins. Darbepoetin alfa (Aranesp), Amgen Inc, Thousand Oaks, California), a new erythropoietic growth factor, has eight more sialic acids than epoetin alfa. The increased sialic acid content confers a three-fold longer half-life and allows the drug to be administered less frequently than epoetin alfa. Darbepoetin alfa affects the same early haematopoietic cells as epoetin alfa and the endogenous hormone EPO. Preclinical pharmacokinetic studies suggest that the intrinsic pharmacological properties of darbepoetin alfa are comparable to those of epoetin alfa, but that the increased sialic acid content allows for less-frequent administration with superior performance. Darbepoetin alfa has been shown to have safe clinical efficacy in a variety of tumour settings and with several types of chemotherapy.

Influence of cisplatin-use, age, performance status and duration of chemotherapy on symptom control in advanced non-small cell lung cancer: detailed symptom analysis of a randomised study comparing cisplatin-vindesine to gemcitabine

BACKGROUND

We previously reported that treatment of patients with symptomatic advanced non-small cell lung cancer with single agent Gemcitabine (GEM) resulted in a superior clinical-benefit response rate (RR) compared to cisplatin-based combination chemotherapy. We now report the detailed individual symptom control analysis, and the influence of cisplatin-use, age, performance status (PS) and duration of treatment.

PATIENTS AND METHODS

Patients received either GEM (1000 mg/m(2), days 1, 8 and 15) or cisplatin (100 mg/m(2), day 1) plus Vindesine (3 mg/m(2), days 1 and 15) (PV), both every 4 weeks. Scores of 9 symptoms were listed weekly by the patient on visual analogue scales. Improvement of a symptom was defined as 2 consecutive cycles of improvement over baseline.

RESULTS

Baseline symptoms in the 169 patients were well balanced between the 2 arms (84 GEM, 85 PV). Both patients with objective response and disease stabilisation had clearly better symptom control than those with disease progression. Symptom control in both arms was similar for 'disease-specific' symptoms such as cough, dyspnea, pain or haemoptysis. Compared to PV, a significantly larger number of GEM-patients had better scores for 'constitutional' items such as anorexia (P=0.007), ability to carry on with daily activities (P=0.04) and overall impression of quality-of-life (P=0.008). Symptom control was very similar in younger (<65 years) versus older (>/=65 years) patients, and only slightly better in those with a Karnofsky PS >/=80% compared to those <80%. Most of the symptom improvement occurred in the first 3 cycles, with some further symptom improvement in the following cycles in the GEM-arm only.

CONCLUSIONS

Both GEM and PV yield a symptom control rate much higher than expected by the objective tumour RR. GEM is equally effective in controlling 'disease-specific' symptoms, but superior in controlling 'constitutional' symptoms. Most of the symptom control was achieved during the first 3 cycles of treatment, with some further improvement thereafter in the GEM-arm only.

The value of [18F]fluoro-2-deoxy-D-glucose positron emission tomography in the selection of patients with stage IIIA-N2 non-small cell lung cancer for combined modality treatment

Combined modality treatment (CMT) for patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) is at present studied extensively. To select patients with truly stage IIIA-N2 disease, however, proves to be difficult with current diagnostic tests. Distant metastases may become clinically overt during induction chemotherapy (IC) or shortly after, revealing the inaccuracies of current staging algorithms. A prospective study with [18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) in IIIA-N2 NSCLC patients was performed to assess its value in the selection of this patient group. Fifty-seven patients received a whole body FDG PET scan as part of an ongoing response monitoring trial. Results were compared with conventional staging. In 32/57 (56%) PET suggested upstaging, which was confirmed in 17/57 (30%) with a median follow-up of 16 (range 2-49) months. These results show that using the conventional staging algorithm a substantial group of patients was understaged. FDG PET improves the selection of patients suitable for CMT.

Value of FDG-PET in the management of non-small cell lung cancer

In the past 5 years, metabolic imaging with positron emission tomography (PET) using 18F-fluoro-2-deoxy-glucose (FDG) has become an important imaging modality in lung cancer patients. FDG-PET consistently proved to be superior to structure-based imaging modalities in both the diagnosis and staging of lung cancer. At this moment the use of FDG-PET in these indications needs further validation in multi-centre large-scale randomised studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. More recently, interesting findings have also been reported in the response assessment to cytotoxic treatments providing information of greater prognostic significance than can be obtained using conventional approaches. This review focuses on the potential role of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of non-small cell lung cancer. Emphasis is put on the potential clinical implementation of the numerous data of the last decade.

Methods to monitor response to chemotherapy in non-small cell lung cancer with 18F-FDG PET

PET using 18F-FDG is a promising technique to monitor response in oncology. Unfortunately, a multitude of analytic methods is in use. To date, it is not clear whether simplified methods could replace complex quantitative methods in routine clinical practice. The aim of this study was to select those methods that would qualify for further assessment in a future prospective response-monitoring study by comparing results with patient outcome.

METHODS

Dynamic 18F-FDG PET scans were obtained on 2 groups of patients. First, 10 patients with advanced non-small cell lung cancer (NSCLC) were scanned on consecutive days before treatment to assess test-retest variability. Second, 30 scans were obtained on 19 patients with locally advanced NSCLC as part of an ongoing response-monitoring study. These scans were analyzed by 2 observers to assess observer variability. In addition, these studies were used to compare various methods with the gold standard, full kinetic analysis (nonlinear regression [NLR]).

RESULTS

Using an image-derived input function, NLR showed excellent test-retest and observer agreement confirming that it could be used as a gold standard method. From a total of 34 analytic methods, 10 showed good correlation with NLR. Taking into account the degree of complexity of the methods, 4 remain for further evaluation.

CONCLUSION

The optimal method for analysis of 18F-FDG PET data was determined for several levels of complexity. Four methods need to be evaluated further to determine the optimal trade-off between simplicity and accuracy for routine clinical practice.

Darbepoetin alfa: impact on treatment for chemotherapy-induced anemia and considerations in special populations

Our objective was to evaluate the effects of darbepoetin alfa (Aranesp) on hemoglobin and transfusions in anemic patients with cancer undergoing chemotherapy, and the impact of age, sex, baseline hemoglobin, chemotherapy type, and tumor type. Patients were randomized to one of three darbepoetin alfa groups based on average weekly dose (< 1.5 microg/kg, 1.5 to 2.25 microg/kg, and > 2.25 microg/kg) or to placebo. Dose response was evaluated for change in hemoglobin, hemoglobin and hematopoietic responses, and red blood cell transfusion rates. Hazard ratios for the incidence of hemoglobin response and transfusions were calculated. Adverse events and antibody formation were assessed. Treatment effects were observedfor all hemoglobin end points and incidence of transfusion. The incidence of hematopoietic response among the darbepoetin alfa dose groups ranged from 46% (95% confidence interval [CI] = 33%-60%) to 74% (95% CI = 66%-81%) and increased with higher darbepoetin alfa dose. Patients receiving darbepoetin alfa were more likely to exhibit a hemoglobin response and less likely to require a transfusion, compared with placebo, irrespective of the patient characteristics examined. No increased risk of adverse events and no development of neutralizing antibodies were observed with darbepoetin alfa use. Darbepoetin alfa increased the likelihood of a hemoglobin response and decreased the need for transfusions in cancer patients with chemotherapy-induced anemia.

Double-blind, placebo-controlled, randomized phase III trial of darbepoetin alfa in lung cancer patients receiving chemotherapy

BACKGROUND

Patients receiving chemotherapy often develop anemia. Darbepoetin alfa (Aranesp(TM)) is an erythropoiesis-stimulating glycoprotein that has been shown, in dose-finding studies, to be safe and clinically active when administered to patients with cancer every 1, 2, or 3 weeks. This phase III study compared the safety and efficacy of darbepoetin alfa with placebo in patients with lung cancer receiving chemotherapy.

METHODS

In this multicenter, double-blind, placebo-controlled study, 320 anemic patients (hemoglobin <or=11.0 g/dL) were randomly assigned to receive darbepoetin alfa or placebo injections weekly for 12 weeks. The 297 patients who completed at least the first 28 days of study were assessed for red blood cell transfusions, the primary endpoint. Patients were also assessed for hemoglobin concentration (i.e., hematopoietic response), adverse events, antibody formation to darbepoetin alfa, hospitalizations, Functional Assessment of Cancer Therapy (FACT)-Fatigue score, and disease outcome. Efficacy endpoints were assessed using Kaplan-Meier analyses, Cox proportional hazards analyses, and chi-square tests where appropriate. All statistical tests were two-sided.

RESULTS

Patients receiving darbepoetin alfa required fewer transfusions (27% versus 52%; mean difference = 25%; 95% confidence interval [CI] = 14% to 36%; P<.001), required fewer units of blood (0.67 versus 1.92; mean difference = 1.25, 95% CI = 0.65 to 1.84; P<.001), had more hematopoietic responses (66% versus 24%; mean difference = 42%; 95% CI = 31% to 53%; P<.001), and had better improvement in FACT-Fatigue scores (56% versus 44% overall improvement; 32% versus 19% with >or=25% improvement; mean difference = 13%; 95% CI = 2% to 23%, P =.019) than patients receiving placebo. Patients receiving darbepoetin alfa did not appear to have any untoward effect in disease outcome and did not develop antibodies to the drug. Adverse events were similar between the groups.

CONCLUSIONS

Patients with chemotherapy-associated anemia can safely and effectively be treated with weekly darbepoetin alfa therapy. Darbepoetin alfa decreased blood transfusion requirements, increased hemoglobin concentration, and decreased fatigue. Although no conclusions can be drawn about survival from this study, the potential salutary effect on disease outcome warrants further investigation in a prospectively designed study.

Dose-intensified accelerated vindesine-ifosfamide-cisplatin (VIP) chemotherapy followed by high-dose accelerated hyperfractionated radiotherapy in patients with pathologically proven stage IIIB non-small cell lung cancer: a feasibility study

This study shows the feasibility of accelerated vindesine-ifosfamide-cisplatin chemotherapy, immediately followed by intensive radiotherapy to the residual tumour in responding patients, in 16 patients with pathologically proven stage IIIB non-small lung cancer. All toxicities were reversible, with only two of ten patients experiencing grade 3 oesophagitis, no treatment-related deaths and no serious late effects.

Gemcitabine plus etoposide in chemonaive extensive disease small-cell lung cancer: a multi-centre phase II study

BACKGROUND

Both gemcitabine and etoposide are active in the treatment of small-cell lung cancer (SCLC), and are characterised by mild toxicity profiles. The combination of both drugs was found to be feasible and active in a phase I dose-finding study in solid tumours. Therefore, a phase II trial was initiated to examine the activity and toxicity of this schedule in extensive disease SCLC.

PATIENTS AND METHODS

Forty-two chemo-naïve extensive disease SCLC patients were enrolled to receive gemcitabine 1000 mg/m2, days 1, 8 and 15, and etoposide 80 mg/m2, days 8, 9 and 10 of a 28-day cycle.

RESULTS

Thirty-seven patients were evaluable for efficacy (five received less than one cycle). No complete responses were observed, but partial responses were seen in 17 patients, yielding an overall response rate of 46%. The median duration of response was 5.8 months. Disease stabilisation was obtained in another 10 patients (27%). The median survival of the 37 protocol-qualified patients was 10.5 months (95% confidence interval (CI): 7.5-12.0). The levels of WHO grade 3 and 4 toxicities were low and clinically manageable.

CONCLUSION

In comparison with standard platinum-based regimens, this combination of gemcitabine and etoposide resulted in a somewhat lower response rate, but a similar median survival time. Haematological toxicity was more pronounced than expected from the toxicity data of each agent individually. However, because of its mild non-haematological toxicity, and its ability to be administered in an outpatient setting, this combination provides a reasonable palliative option for patients with extensive disease SCLC.

Chest radiotherapy in limited-stage small cell lung cancer: facts, questions, prospects

OBJECTIVE AND STUDY DESIGN

Limited-disease small cell lung cancer (LD-SCLC) is initially very sensitive to both radiotherapy and chemotherapy. However, the 5-year survival is generally only 10-15%, with most patients failing with therapy refractory relapses, both locally and in distant sites. The addition of chest irradiation to chemotherapy increases the absolute survival by approximately 5%. We reviewed the many controversies regarding optimal timing and irradiation technique.

RESULTS

No strong data support total radiation doses over 50 Gy. According to one phase III trial and several retrospective studies, increasing the volume of the radiation fields to the pre-chemotherapy tumour volume instead of the post-chemotherapy volume does not improve local control.

CONCLUSIONS

The total time in which the entire combined-modality treatment is delivered may be important. From seven randomized trials, it can be concluded that the timing of the radiotherapy as such is not very important. Some phase III trials support the use of accelerated chest radiation together with cisplatin-etoposide chemotherapy, delivered from the first day of treatment, although no firm conclusions can be drawn from the available data. The best results are reported in studies in which the time from the start of treatment to the end of the radiotherapy was less than 30 days. This has to be taken into consideration when treatment modalities incorporating new chemotherapeutic agents and radiotherapy are considered.

Phase II study of docetaxel alternating with cisplatin in chemotherapy-naïve patients with advanced non-small cell lung cancer

The objective of this study was to evaluate a regimen of full doses of docetaxel and cisplatin, using an alternating schedule, as first-line therapy for patients with inoperable non-small cell lung cancer (NSCLC). The standard concomitant schedule does not allow full doses of both drugs to be administered. We wanted to see if there was an advantage to be gained by administering full doses of both docetaxel and cisplatin, using a different schedule. Docetaxel 100 mg/m2 was given once every 6 weeks from week 1 and cisplatin (120 mg/m2 for two doses and 100 mg/m2 thereafter) once every 6 weeks from week 4, for six cycles (three docetaxel and three cisplatin). Thirty-six of the 44 patients enrolled were evaluable for efficacy. Forty-eight percent of the patients had good (KPS 90-100%) performance status. A median of five cycles was administered, for which no dose reductions were necessary. There were 13 of 36 partial responses (36%; 95% CI 21-54%) and 15 of 36 patients achieved stable disease (42%). The median duration of response was 10.5 months, the median time to progression was 4.5 months and the median survival was 9 months. The 1 and 2 year survival rates were 39 and 16%, respectively. The most frequent grade 3-4 toxicities were nausea (23% of patients), vomiting (18%) and neutropenia (77%). Infections were also common, but not severe. The alternating schedule produced response, toxicity and survival figures that compared favorable with those using the concomitant schedule. This study could serve as a model for future studies of non-cisplatin-containing regimens, in which full doses of docetaxel could alternate with full doses of other new agents active against NSCLC.

Medical thoracoscopic lung biopsy in interstitial lung disease: a prospective study of biopsy quality

The aim of this study was to analyse the quality and diagnostic value of lung biopsies for the diagnosis of interstitial lung disease (ILD), taken with diathermy coagulation cup forceps during medical thoracoscopy. Patients with ILD, not specified after thorough clinical assessment, high-resolution CT (HRCT), bronchoalveolar lavage and transbronchial biopsy, were studied. Medical thoracoscopy was performed in an endoscopy suite under neuroleptic anaesthesia with spontaneous ventilation. Biopsy specimens were analysed prospectively by one lung pathologist blinded to the clinical findings. Over 2 yrs, 118 samples were analysed from 24 consecutive patients. A good quality biopsy was obtained in 23 patients, and 78% of the samples were of good quality. Biopsy findings plus clinical and HRCT data revealed a relevant diagnosis in 18 patients and some diagnostic clues in four patients, for whom further examinations were needed. No major complications occurred. Chest tube drainage averaged 5.3+/-4.7 days, and was related to the total lung capacity (p=0.008), which mirrors the severity of ILD. Separate sampling of biopsies from different lobes proved to be useful in one third of the cases. In conclusion, lung biopsy sampling can be performed safely by interventional pulmonary endoscopists and has a good diagnostic yield in interstitial lung disease of unknown origin.

Preoperative work-up of a solitary diaphragmatic mass in a patient with right shoulder pain: a case for diagnosis

A patient presented with right shoulder pain. Imaging studies revealed an apparently solitary soft tissue pleural lesion, accompanied by a very small pleural effusion. On medical thoracoscopy, a diffuse malignant pleural mesothelioma was found. Thoracoscopy proved to play an essential part in the diagnostic work-up, avoiding a futile thoracotomy for a presumed solitary soft tissue tumour.

Result of induction chemotherapy followed by surgery in patients with stage IIIA N2 NSCLC: importance of pre-treatment mediastinoscopy

OBJECTIVE

Data from the literature indicate that chemotherapy prior to resection may improve the results. However, only few and conflicting data are reported regarding the correlation between downstaging of mediastinal nodes and outcome. The aim of this study was to look at the correlation between downstaging, survival and pre-treatment staging.

MATERIAL AND METHODS

Between March 1995 and August 1998, 46 consecutive patients with pathology proven N2 disease were treated with three cycles of vindesine-ifosfamide-platinum (VIP). All patients underwent a rigorously performed cervical mediastinoscopy. Patients with at least partial response (n = 26) were surgically explored.

RESULTS

The clinical response rate to chemotherapy was 57% (26 patients). Resection was complete in 23 patients (88.5%). Pneumonectomy was performed in 16 patients. In 11 patients (42.9%) the mediastinal nodes (which were positive at mediastinoscopy) had become negative (downstaging group). The projected 2-year survival of resected patients is 41%. Patients with downstaging of nodes had no better survival compared to patients with no downstaging. Patients with involved subcarinal nodes at mediastinoscopy and patients with involvement of more than one level had a worse survival.

CONCLUSION

Surgery in N2-patients responsive to induction chemotherapy resulted in a high complete resectability rate. Findings at pre-treatment mediastinoscopy proved to be the most important prognostic factor.

Sequential treatment with vindesine-ifosfamide-platinum (VIP) chemotherapy followed by platinum sensitized radiotherapy in stage IIIB non-small cell lung cancer: a phase II trial

PURPOSE

Daily administration of cisplatin concomitant with radiotherapy improved the overall survival in inoperable non-small cell lung cancer (NSCLC) in one EORTC study. In this study, we prospectively investigated the efficacy and toxicity of a sequential treatment with three cycles of vindesine-ifosfamide-platinum (VIP) induction chemotherapy, followed by daily cisplatin-sensitized radiotherapy.

METHODS

Between June 1993 and June 1995, 23 previously untreated patients with stage IIIB NSCLC with World Health Organization performance status 0 or 1 were included. Chemotherapy consisted of platinum 30 mg/m2 and ifosfamide 1200 mg/m2 i.v. on days 1, 2 and 3, and vindesine 3 mg/m2 i.v. on days 1 and 8, every 4 weeks. After three cycles and at least stable disease, radiotherapy was started (30 Gy in 10 fractions, followed by a boost of 22 Gy in 10 fractions). Each fraction was preceded by Platinum 6 mg/m2 i.v.

RESULTS

Nineteen patients completed the sequential therapy. One patient died from neutropenic sepsis during the first cycle of chemotherapy, and three patients had progressive disease after chemotherapy. The overall response rate after sequential therapy was 47% (95% confidence interval 24-80), median survival was 10.6 months, 1- and 2-year survival rates were 47 and 16%, respectively. Major toxicity consisted of neurotoxicity grade III-IV in 18% and of leukopenia grade III-IV in 22% of the patients. Acute radiation pneumonitis grade III occurred in 11% of the patients.

CONCLUSION

Three-drug VIP induction chemotherapy followed by cisplatin-sensitized radiotherapy is feasible, with acceptable, albeit substantial, toxicity. In spite of the theoretically promising sequence of therapies, survival results remain disappointingly low.

Long-term treatment with cyclosporin A and coumarin in pulmonary thromboembolic Behçet's disease

Long-term favourable effects of a treatment with both cyclosporin A and coumarin in a 35 year old Caucasian female patient with Behçet's disease, presenting with haemoptysis caused by pulmonary thromboemboli and a single major pulmonary artery aneurysm, are reported. All disease activity and complications were well controlled during 9 years of follow-up.

Chronic lymphocytic alveolitis with migrating pulmonary infiltrates after localized chest wall irradiation

In a number of patients, radiotherapy following surgery for breast carcinoma may induce radiation injury to the lungs. This has classically been divided into an early radiation pneumonitis and a late fibrosis, both confined to the irradiated lung volume. However we observed a female patient who similarly to other recent reports in the literature developed a recurring pneumonitis migrating from one lung to the other after radiotherapy for breast carcinoma. This migratory BOOP (bronchiolitis obliterans organizing pneumonia) was characterized by a lymphocytic alveolitis and responded well to corticosteroids. Clinicians should be aware of the possibility of a lymphocytic pneumonitis in both lungs after unilateral thoracic irradiation and recognize the distinctive features of fever, cough, dyspnoea and malaise in order to start an effective treatment with corticosteroids. They should also be aware of the high tendency for recurrence when tapering off.

Present status of induction treatment in stage IIIA-N2 non-small cell lung cancer: a review. The Leuven Lung Cancer Group

BACKGROUND

Surgical exploration in mediastinoscopy proven N2 non-small cell lung cancer (NSCLC) is unrewarding. Theoretical concepts suggest a beneficial role for preoperative induction treatment. The solidity of the therapeutic results with this approach in the currently available data is examined.

METHODS

Literature on induction therapy followed by surgical exploration, consisting of randomized reports and phase II reports meeting some essential criteria, are reviewed.

RESULTS

Of the twenty-four analyzed phase II studies, thirteen lack adequate surgical staging. Stratification for various important prognostic factors in N2 disease is missing in many instances. Results with induction with a cisplatinum dose of less than 80 mg/m2 seem to be inferior. The use of mitomycin-C in patients scheduled for lung resection or irradiation deserves caution. No evident difference in efficacy between induction chemotherapy or chemo-radiotherapy is suggested, but toxicity and mortality appear to be somewhat higher with chemo-radiotherapy. Pathological complete response is mainly found after an at least partial clinical response. Effect on survival in non-controlled phase II studies and small randomized reports is encouraging.

CONCLUSIONS

the role of chemotherapy induction in improving the long-term survival of N2 NSCLC is promising, but needs to be confirmed by large multi-center randomized data. Adequate surgical staging and attention to important prognostic factors in N2 disease should minimize the numerous institution based differences interfering in the currently available non-controlled studies.

Role of cervical mediastinoscopy in staging of non-small cell lung cancer without enlarged mediastinal lymph nodes on CT scan

OBJECTIVE

The results of primary surgery for non-small cell lung cancer (NSCLC) with involved ipsilateral mediastinal or subcarinal lymph nodes (N2 disease) remains poor. However, several studies suggest that induction chemotherapy could increase long-term survival in patients with N2 disease. Therefore, accurate preoperative staging of the mediastinum remains of paramount importance for the treatment policy in patients with NSCLC. Enlarged mediastinal lymph nodes (MLN) on CT scan are positive in only half of the patients. Small lymph nodes can contain metastatic deposits of clinical importance. However, many surgeons believe that a normal mediastinum at computed tomography allows them to cancel their preoperative mediastinal exploration. It was the aim of this study to evaluate the results of cervical mediastinoscopy in patients without enlarged MLN on CT scan.

METHODS

Between January 1990 and June 1994, 235 patients with potentially operable NSCLC underwent a cervical mediastinoscopy despite the absence of enlarged MLN on CT scan. MLN were considered enlarged if they were equal to or larger than 15 mm at their maximal cross-sectional diameter.

RESULTS

Cervical mediastinoscopy was positive in 47 patients (20%). In 21 patients, N2 disease was extranodal and in 16 patients more than one level was involved. Mediastinoscopy was positive in 9.5% of the cT1N0 cases, in 17.7% of the cT2N0 lesions, in 31.2 and 33.3% of cT3N0 or cT4N0 tumors, respectively. After a negative cervical mediastinoscopy, resectability for unforeseen N2 disease was as high as 95%.

CONCLUSION

We recommend a cervical mediastinoscopy in every patient with potentially operable NSCLC.

Second primary lung cancer in Flanders: frequency, clinical presentation, treatment and prognosis

Patient and tumour characteristics of 23 patients presenting with a second primary lung cancer were analysed and compared with 534 patients with radically resected stage 1 non-small cell lung cancer (NSCLC). None of these characteristics is associated with a higher occurrence rate for second primary lung cancer. Prognosis in the latter patients is significantly worse than after resection of a 'solitary' NSCLC: the median survival time (MST) after resection of the first tumour is 50 months; after diagnosis of the second tumour only 14 months. Surgically retreated patients have a prognosis that is similar to that after resection of a 'solitary' NSCLC. No separate independent prognostic factors responsible for this survival difference could be isolated. Squamous histology and central location are associated with a longer recurrence free survival time. We conclude that the occurrence of a second primary lung cancer can not be predicted based on patient or tumour characteristics and that only surgical retreatment offers a chance of long survival in these patients.

Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

OBJECTIVE

Although the results after surgery for N2 disease are disappointing, there seems to be a subgroup of patients which may benefit from primary resection. These patients have clinically unrecognized N2 involvement that is discovered only at the time of thoracotomy (unsuspected or unforeseen N2 disease). It was the aim of this retrospective study to analyze the survival after resection for unforeseen N2 disease and to evaluate different prognostic factors. We were interested to see whether our strategy of rigorous staging of the mediastinum with mediastinoscopy or anterior mediastinotomy had an effect on the resectability rate and survival of unsuspected N2 disease.

METHODS

Between 1985 and 1990, 859 patients with potentially operable non-small cell lung cancer were referred to our surgical department. Despite rigorous preoperative staging with computed tomography scan and cervical mediastinoscopy and/or anterior mediastinotomy, 103 patients (14.5%) had unsuspected N2 disease at thoracotomy. The tumor could be completely resected in 90 patients (87.5%).

RESULTS

The 5-year survival after complete resection was 22%. Histology of the tumor, number of involved levels and extent of nodal disease had no effect on survival.

CONCLUSION

We conclude that resection is justified in patients with unforeseen N2 disease. Rigorous staging of the mediastinum by cervical mediastinoscopy or anterior mediastinotomy results in a high resectability rate and avoids unnecessary thoracotomies. Mediastinoscopy plays a central role in the staging of patients with carcinoma of the lung.

Combination chemotherapy with vindesine-ifosfamide-cisplatin (VIP) in locally advanced unresectable stage III and in stage IV non-small cell lung cancer: a phase II trial

The efficacy and toxicity of a regimen adding ifosfamide to the more classical cisplatin-vindesine combination was studied in patients with advanced non-small cell lung cancer. Sixty-four good performance patients with inoperable stage III or stage IV were treated with VIP: vindesine 3 mg/m2 days 1 and 8, ifosfamide 1200 mg/m2 and platinum 30 mg/m2 days 1, 2 and 3, repeated every 4 weeks, up to a maximum of six cycles. Response rate, clinical data and radiological tests were rigourously reviewed by a panel. Overall response rate was 39% (95% confidence interval, 27%-51%) with three patients achieving a complete response; response rate in stage III was 48%. Median survival was 9 months. Toxicity consisted mainly of bone marrow toxicity and nausea/vomiting, but was manageable. There was no renal toxicity greater than grade 2, four severe infections, but no treatment-related deaths.

CONCLUSION

VIP as mentioned above is very active in good performance patients with advanced non-small cell lung cancer. Its activity, together with its manageable toxicity--without severe renal or pulmonary toxicity--makes it an attractive candidate for induction chemotherapy.

Surgical treatment of small cell lung cancer

From 1970 till 1989, 30 patients underwent surgical resection for small cell lung cancer (SCLC). The 5-year survival in stage I patients was 31%, in stage II 17% and in stage III the projected 5-year survival was 9%. Among N2 patients there were only 25% survivors after 1 year and none after 2 years. The first group of 15 patients (1970-1979) received no adjuvant chemotherapy in contrast to the second group of 15 patients (1980-1989). The overall 5-year survival for the first group was 13% and the estimated 5-year survival for the second group was 27%. In stage I SCLC, the 5-year survival was 12% and 60%, respectively. These results confirm that surgery may lead to long-term survival in stage I and possibly stage II SCLC, with better prognosis in stage I when adjuvant chemotherapy is added.