A systematic review of the role of etoposide and cisplatin in the chemotherapy of small cell lung cancer with methodology assessment and meta-analysis

PURPOSE

Cisplatin (CDDP) and etoposide (VP16) are considered major standard cytotoxic drugs for small cell lung cancer (SCLC). The present systematic review had as its objective the evaluation of their role, as components of chemotherapy regimens, on survival.

METHODS

Published randomised clinical trials (from 1980 to 1998) were selected comparing, in SCLC patients, chemotherapy regimens, given as first-line therapy. One arm (the experimental arm) had to include CDDP and/or VP16, while another had to omit the same drug(s). Trials quality was assessed by two published scores (Chalmers and European Lung Cancer Working Party (ELCWP)). For each individual trial, the hazard ratio (HR) of the survival distributions was estimated on the basis of reported statistics or, if not available, by extracting, from the survival graphical representations, the data required to construct the difference between expected and observed numbers of events as calculated in the log-rank statistic. A combined hazard ratio was obtained by the Peto method (a value < 1 meaning a benefit for CDDP and/or VP16).

RESULTS

Thirty-six trials eligible for our systematic review were identified, classified into four groups (I-IV): group I, 1 trial testing a CDDP-based regimen (without VP16) against another arm not including either CDDP or VP16; group II, 17 trials testing a VP16-based regimen (without CDDP) against a regimen without VP16 and CDDP; group III, nine trials comparing a regimen including CDDP and VP16 with a regimen using neither drug; and, finally, group IV, nine trials comparing a regimen based on both drugs with a regimen based on VP16 only. Overall, Chalmers and ELCWP scores correlated well (r(S) = 0.76, P < 0. 001) and had respective median scores of 50.3 and 63.7%. The number of eligible patients did not have a significant impact on the scores as well as the trials group, the trial positivity (a positive trial defined as showing itself a statistically significant survival benefit for the experimental regimen), overall or in categories, and the year of publication. Combined hazard ratios with 95% confidence intervals were: 0.70 (0.41-1.21) for group I, 0.72 (0.67-0.78) for II, 0.57 (0.51-0.64) for III, and 0.74 (0.66-0.83) for IV, showing a survival benefit in favour of regimens including etoposide alone or in combination with cisplatin, justifying with high significance levels the use of each of these drugs. Overall survival benefits could also be shown for regimens including CDDP (HR = 0.61; confidence interval (CI), 0.57-0.66), as well as for those including VP16 (HR = 0. 65; CI, 0.61-0.69). Robustness of these results has to be confirmed with appropriate randomised trials.

Prognostic factors for patients with small cell lung carcinoma: analysis of a series of 763 patients included in 4 consecutive prospective trials with a minimum follow-up of 5 years

BACKGROUND

The purposes of this study were to identify prognostic factors for response to chemotherapy, overall survival, and long term survival of patients with small cell lung carcinoma and to construct a classification of patients on the basis of their expected overall survival.

METHODS

In the 763 patients registered in 4 consecutive clinical trials conducted by the European Lung Cancer Working Party from 1982 to 1993, the impact of 21 pretreatment variables assessable in a routine practice was analyzed for the various outcomes with a minimum follow-up of 5 years.

RESULTS

The key prognostic role of disease extent was confirmed for all the outcomes. Additional independent prognostic factors for response to chemotherapy were gender, neutrophil count, and hemoglobin level; for overall survival, these factors were Karnofsky performance status, gender, and neutrophil count. Recursive partitioning and amalgamation algorithms (RECPAM) analysis classified patients into 4 groups, taking into consideration disease extent, Karnofsky performance status, age, gender, and neutrophil count. Median survival times for the 4 groups were 60, 47, 36, and 28 weeks, respectively. For long term survival, defined as a minimum survival of 2 years (9% of the patients), Karnofsky performance status was the only independent predictive factor, along with the achievement of a complete response (if this was taken into consideration). Small cell lung carcinoma remained the main cause of death among these patients. Cure was infrequent, with only 14 patients alive and disease free at 5 years (1.8%).

CONCLUSIONS

In this study the long term prognosis associated with small cell lung carcinoma was poor. The well-known prognostic values of disease extent and Karnofsky performance status were confirmed, but the authors also identified age and gender (which are more controversial) as independent characteristics, in addition to citing the role of complete response in the attainment of long term survival. The independent role of neutrophils observed by the authors. must be validated by further studies.

Scoring systems in cancer patients admitted for an acute complication in a medical intensive care unit

OBJECTIVE

To validate and compare two severity scoring systems, the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II and to determine their prognostic value for mortality during the hospital stay and after discharge in a specific group of cancer patients admitted to intensive care unit (ICU) for an acute medical complication.

DESIGN

Prospective cohort study.

SETTING

The medical ICU of a European cancer hospital.

SUBJECTS

A total of 261 consecutive cancer patients admitted to ICU for an acute medical complication.

MEASUREMENTS

Variables included into the APACHE II and SAPS II scores, as well as characteristics of the cancer, were collected during the first 24 hrs of the ICU stay. Hospital and in-ICU mortalities, overall survival, and survival after day 30 were measured.

RESULTS

Observed hospital and ICU mortalities were 33% and 23%. Median survival time was 94 days and 1-yr survival rate was 23%. The mean predicted risk of death was 26.5% with APACHE II and 26.1% with SAPS II. Correlation between both systems was excellent. Calibration for mortality prediction ability of both scoring systems was similar. Discrimination between survivors and nonsurvivors was superior with SAPS II according to the area under the receiver operating characteristic curve but was better with APACHE II for survivors using thresholds minimizing the overall misclassification rates. Multivariate prognostic analysis showed that the scoring systems were the only significant factors for hospital and in-ICU mortalities, whereas characteristics related to the cancer (extent, phase) were the factors predicting survival after discharge.

CONCLUSION

The prognosis of cancer patients admitted to ICU for a medical problem is first determined by the acute physiologic changes induced by the complication, as evaluated by the severity scores. There is no major difference between the two assessed scoring systems. They are, however, not accurate enough to be used in the routine management of these patients. After recovery from complications, characteristics related to the neoplastic disease, however, retrieve their independent influence on the further survival.

A phase II trial testing gemcitabine as second-line chemotherapy for non small cell lung cancer. The European Lung Cancer Working Party. 101473.1044@compuserve.com

The purpose of the present trial was to determine the activity of gemcitabine as a second-line chemotherapy for non small cell lung cancer (NSCLC). To be eligible, patients had to have pathologically proven NSCLC that has failed to respond to a first-line chemotherapy with a cisplatin-containing regimen, a Karnofsky performance status greater than 50 and adequate renal, haematological and hepatic functions. After registration, patients were treated by gemcitabine given i.v. at a dose of 1 g/m(2) on days 1, 8, 15 every 4 weeks. Response was assessed after two courses of therapy. Eighty-two patients have been registered, five are ineligible and 65 are assessable for response. Four partial responses were observed (6%). No change was documented in 18 cases (28%). Tolerance was good. A few grade III leucopenia and grade III-IV thrombopenia were observed. We conclude that gemcitabine has a modest activity as second-line chemotherapy for NSCLC. It has the advantage to be well tolerated and may thus be one drug to be proposed to the patients who have disease progression after a first-line chemotherapy and who ask for further treatment.

Synchronous roentgenographically occult lung carcinoma in patients with resectable primary lung cancer

OBJECTIVE

To assess the prevalence of synchronous roentgenographically occult lung carcinoma (ROLC) in patients with resectable roentgenographically visible lung cancer (RVLC).

METHODS

Patients undergoing surgery for RVLC in the same University Hospital were prospectively evaluated before surgery by fluorescence bronchoscopy under local anesthesia to detect synchronous ROLC. All abnormal areas, with the exception of the RVLC, had biopsies made.

RESULTS

From June 1996 to January 1999, 43 patients (male/female ratio: 1.7/1.0) were evaluated before lobectomy (n = 34) or pneumonectomy (n = 10) for 44 primary RVLC. There were 10 T1N0, 19 T2N0, 1 T1N1, 9 T2N1, 1 T3N0, 3 T1N2, and 1 T3N1 lesions. The histologic type was mainly squamous carcinoma (n = 21) and adenocarcinoma (n = 14). All but two patients were smokers or ex-smokers (mean +/- SD, 48 +/- 28 pack-years). A total of 177 endobronchial biopsies were performed (4.1 +/- 2.5); 8 were too small to be informative, 43 showed non-preneoplastic alterations, and 50 were normal. There were 7 basal cell hyperplasias, 56 metaplasias, 9 dysplasias, and 4 carcinomas in situ (CIS). All the dysplasias and CIS lesions were observed in eight subjects. The synchronous CIS were treated by surgery (n = 1) or localized therapeutic modalities (n = 3).

CONCLUSIONS

The high prevalence of synchronous early lung cancers (9.3%) as well as metaplasia and dysplasia in this series of patients with resectable RVLC suggests that fluorescence bronchoscopy may be a useful adjunct in the preoperative evaluation of lung cancer.

[Hemoptysis]

An 82 years-old man is admitted for suspicion of bronchial cancer. He has a persistent cough, repeated bronchial infections and haemoptysis. On thoracic CT-scan, there is an increased thickness of the bronchial walls situated at the tracheobronchial cross.

[Adenopathy and eosinophilia]

The exercise topic is the persistence of adenopathies for many years in a young marocan boy who also presents with peripheral blood eosinophilia.

Cisplatin-carboplatin-gemcitabine or ifosfamide-gemcitabine in advanced non-small cell lung carcinoma: two pilot studies

Gemcitabine has been demonstrated active in non-small cell lung cancer (NSCLC). The objective of this trial was to evaluate the feasibility of combinations of gemcitabine (1 g/m2 dl,8,15) with cisplatin (60 mg/m2 dl) and carboplatin (200 mg/m2 dl) (CCG; n = 12) or ifosfamide (4.5 g/m2 dl) (IG;n = 4) in patients with advanced NSCLC, in order to prepare a phase III randomised trial. Toxicity, mainly haematological, was tolerable. It consisted in neutropenia (IG) and both thrombopenia and neutropenia (CCG). The administration of carboplatin according to the AUC (AUC = 3) resulted in a significant reduction of haematological toxicity. A good number of responses were documented. These acceptable results urged our group to compare these regimens to the combination of cisplatin, carboplatin and if osfamide.

Carbonic anhydrase IX antigen differentiates between preneoplastic malignant lesions in non-small cell lung carcinoma

The MaTu interval (MN)/carbonic anhydrase (CA) IX tumour-associated antigen is a protein that is normally expressed in the gut and belongs to the carbonic anhydrase enzyme family (CA IX). It has been detected in tumour cell lines and in some solid tumours including cervical, oesophageal and clear cell renal carcinoma. This study determined MN/CA IX expression in 65 primary non-small cell lung cancer resected with curative intent and in 38 bronchial preneoplastic lesions, carcinoma in situ or microinvasive carcinoma as well as in normal bronchial tissue. The presence of MN/CA IX was detected using immunohistochemistry and Western blot analysis, whenever frozen material was available. Immunostaining was positive in 52/65 (80%) of the tumour samples. The staining was more often focal than diffuse. The percentage of stained cells in positive tumours was highly variable, ranging 1-85%. The pattern of immunostaining was predominantly cytoplasmic with a membranous reinforcement (87%). The intensity was mainly strong (69%). The presence of the protein in the tumour was confirmed by Western blot analysis in the eight samples tested. All the morphologically normal epithelia, except in close vicinity of tumours in some cases, as well as the preneoplastic bronchial lesions (basal cell hyperplasia, metaplasia and dysplasia) were immunonegative for MN/CA IX expression. In contrast, carcinoma in situ and microinvasive epithelioma showed the presence of MN-immunopositive tumoural cells in 5/7 and 4/5 of the samples, respectively. These data suggest that MN/CA IX is a useful marker for the differentiation between preneoplastic lesions and bronchial non-small cell lung cancer in the lung.

Phase II and III studies with new drugs for non-small cell lung cancer: a systematic review of the literature with a methodology quality assessment

We carried out a systematic review of new drugs active in non-small cell lung carcinoma (NSCLC). Fifty five phase II and III trials were reviewed (vinorelbine (19 trials), paclitaxel (15), gemcitabine (11), docetaxel (6), topotecan (2) or irinotecan (2)). The first four ones could be considered as active drugs when given as single agent. More information is required for the camptothecin derivatives. Four phase III randomised studies were available, all concerning vinorelbine. They showed that in combination with cisplatin, vinorelbine improved the response rate and perhaps survival, in comparison to vinorelbine alone and that vinorelbine was better than 5 fluorouracil and vindesine. A quantitative overview was impracticable, because of too few randomised trials. A qualitative overview was carried out using the European Lung Cancer Working Party score. The overall median quality score was 65.3%. There was no statistically significant difference between the drugs, but there was a positive correlation between the score and the number of patients. There was also an improvement of the quality score in favour of the randomised trials. Some important methodological aspects were often missing in the articles. In conclusion, gemcitabine, vinorelbine, paclitaxel and docetaxel are active against NSCLC but more good-quality data are required to define their exact role in the routine.

Detection of bronchial preneoplastic lesions and early lung cancer with fluorescence bronchoscopy: a study about its ambulatory feasibility under local anaesthesis

BACKGROUND

Autofluorescence bronchoscopy (AB) enhances the bronchoscopist's ability to diagnose bronchial preneoplastic lesions and early cancer. We undertook a study to assess its feasibility and performance under local anaesthesia on a real ambulatory mode.

METHODS

Thirty-four consecutive patients at very high risk for lung cancer were prospectively studied by AB under local anaesthesia, without any sedation. Lidocaine doses, time, oxygen saturation, peak expiratory flow (PEF) and the number of cough episodes were measured. Continuous assessment of the respiratory sensation was obtained with a visual analog scale. A total of 172 biopsies were performed in abnormal and normal areas.

RESULTS

The procedure was long-lasting (mean +/- SD: 26.6 +/- 6.0 min), required high total doses of Lidocaine (660 +/- 107 mg) without any significant side effect, and was associated with significant decreases in O2 saturation from 98.5 +/- 1.4 to 96.1 +/- 2.5% and in PEF from 380 +/- 96 to 310 +/- 78 l/min. However, the cough counts were moderate and the majority of patients reported no respiratory discomfort. 62 hyperplasia, metaplasia, dysplasia and carcinoma in situ (CIS) were detected and the relative sensitivity of AB +/- white-light bronchoscopy (WLB) versus WLB alone was 3.75 for intraepithelial lesions corresponding to moderate dysplasia or worse.

CONCLUSIONS

AB, a procedure that increases our ability to recognize preneoplastic lesions and early lung cancer, can be performed under local anaesthesia, without systemic sedation in patients at very high risk for lung cancer.

A comparison of methods of calculation for estimating carboplatin AUC with a retrospective pharmacokinetic-pharmacodynamic analysis in patients with advanced non-small cell lung cancer. European Lung Cancer Working Party

We retrospectively analysed the data obtained in a large randomised trial performed in 505 eligible patients with advanced non-small cell lung cancer. Its purpose had been to compare a combination of carboplatin (200 mg/m2) and cisplatin (60 mg/m2) with or without the addition of ifosfamide. The present retrospective analysis assessed two ways of dosing carboplatin: according to body surface area (mg/m2) or to the estimated targeted area under the concentration versus time curve (AUC). Two different methods were used in the latter calculation: the Calvert formula using the Cockroft approximation to evaluate the glomerular filtration rate and the Chatelut equation. There was an excellent linear correlation between them. With the Chatelut method, the calculated administered AUC were lower. Whichever method was used, carboplatin AUC was not significantly associated with antitumour response rate nor patient survival. A statistically significant increase in haematological toxicity, mainly thrombopenia, was observed with an increase in the AUC. This effect was observed whatever AUC variable was considered, i.e. total dosage at course one, total dosage during the first three chemotherapy courses or dose intensity during the first three courses. The effect remained highly significant after adjustment for treatment arm. We conclude that for a moderate carboplatin dose in non-small cell lung cancer, the therapeutic index could be improved if dosage is calculated according to the AUC.

A randomised phase III trial comparing consolidation treatment with further chemotherapy to chest irradiation in patients with initially unresectable locoregional non-small-cell lung cancer responding to induction chemotherapy. European Lung Cancer Working Party

PURPOSE

A phase III randomised trial was conducted in patients with non-metastatic unresectable non-small-cell lung cancer in order to compare, in responders to induction chemotherapy, consolidation treatment by further chemotherapy to chest irradiation.

PATIENTS AND METHODS

A total of 462 untreated NSCLC patients were eligible for three courses of induction chemotherapy (MIP) consisting of cisplatin (50 mg/m2), ifosfamide (3 g/m2) and mitomycin C (6 mg/m2). It was proposed that objective responders be randomised to either three further courses of MIP or to chest irradiation (60 Gy; 2 Gy per fraction given over six weeks).

RESULTS

An objective response rate of 35% was achieved; 115 patients (including 52% with initial stage IIIA and 44% with initial stage IIIB) were randomised to consolidation treatment, 60 of them to further chemotherapy and 55 to chest radiotherapy. There was no significant difference in survival between the two arms, with a respective median and two-year survival of 42 weeks (95% confidence intervals (95% CI: 35-51) and 18% (95% CI: 8-28) for chemotherapy and 54 weeks (95% CI: 43-73) and 22% (95% CI: 11-33) for irradiation. There was also no statistical difference for response duration between the two arms but chest irradiation was associated with a significantly greater duration of local control than chemotherapy (median duration times: 158 vs. 31 weeks, P = 0.0007).

CONCLUSIONS

For non-metastatic unresectable NSCLC treated by an induction chemotherapy regimen containing cisplatin and ifosfamide, if an objective response is obtained, consolidation treatments by further chemotherapy or by chest irradiation result in non-statistically different survival distributions, although a better local control duration is observed with radiotherapy.

[Anatomical-clinical conference: mediastinal mass]

A 56 years-old man developed a pneumonia. An anterior mediastinal mass is fortuitly found on the chest X-ray and the patient is hospitalised for further investigations. Differential diagnosis of mediastinal masses is discussed.

Evaluation of the TN sub-staging in patients with initially unresectable stage III non-small cell lung cancer treated by induction chemotherapy. The European Lung Cancer Working Party

PURPOSE

This study attempted to investigate, in a cohort of patients with clinical stage III initially unresectable non-small cell lung cancer (NSCLC) treated by the same induction chemotherapy regimen, the prognostic value of clinical T and N sub-groupings in order to validate the current International Staging System (ISS).

PATIENTS AND METHODS

All the eligible patients with stage III NSCLC (428 patients) registered in a clinical trial were included in the study investigating, after three courses of induction chemotherapy, the role, in responders, of chest irradiation in comparison to further chemotherapy. The chemotherapy regimen consisted of mitomycin C, ifosfamide and cisplatin.

RESULTS

Patients with ISS 1986 stage IIIA had a significantly better survival than those with stage IIIB (median survival 47 vs 36 weeks; P = 0.01). A RECPAM analysis showed that patients with T1-T2 N3 and T4 N0-1-2 stage had a more similar prognosis to those with stage IIIA. That result leads to define two new sub-groups: stage IIIlalpha (T3-T4 N0-N1; any T N2; T1-T2 N3) and IIIbeta (T3-T4 N3), with a highly significant difference in survival between them (median survival: 45 vs 29 weeks; P < 0.0001). The superiority of that new classification on the ISS documented in our series of stage III patients for discriminating survival and tumour response has to be confirmed on another series in a multivariate context.

CONCLUSION

For unresectable NSCLC treated by induction chemotherapy, stage III sub-classification by moving T4 N0-1 and T1-2 N3 tumours from stage IIIB to stage IIIA appeared to better correlate with prognosis. The usefulness of this new sub-division has to be tested in validation studies.

[Clinical pathological consultation: lung mass]

The anatomoclinical exercise consists in the discussion of the etiology of an isolated pulmonary nodule in an asymptomatic patient.

[Critical review of the randomized trials assessing the role of adjuvant thoracic irradiation and chemotherapy in the treatment of limited-stage small cell lung cancer]

The role of chest irradiation in the treatment of small cell lung cancer remains controversial. Two meta-analyses have shown a significant improvement of survival when this therapy is associated to chemotherapy but the controlled studies individually lead to contradictory conclusions. We have performed qualitative and quantitative evaluation of the literature on this topic in order to try to clarify this problem. On 15 published trials, 8 only give sufficient data allowing a meta-analysis. This does not show that chest irradiation improves statistically significantly survival in comparison to chemotherapy alone (odds ratio = 0.82; 95% CI: 0.63-1.07). The qualitative evaluation has been performed with the Chalmers and ELCWP scales. The scores obtained by both methods are highly correlated. There is no significant difference between the scores obtained by studies showing a survival improvement with irradiation or by negative studies. Very few trials report important criteria like definition of the primary end-point or the a priori estimate of the population size, attesting important methodological deficiencies. In conclusion, the quantitative aggregation of studies seems difficult to interpret because of the non optimal quality of the studies.

[Maintenance chemotherapy in the treatment of small cell lung cancer: the advocate's view]

The role of maintenance chemotherapy in the treatment of small cell lung cancer remains controversial. We have collected the arguments in favor of that approach by performing a quantitative and qualitative overview of the studies published on this topic in the French and English literatures since 1980. On the thirteen prospective randomized trials reported, six demonstrated a significant survival advantage in favor of maintenance, no difference was observed in 6 and 1 study had a significant survival advantage for no maintenance. Due to the heterogeneity of the study designs and to the lack of published data, no meta-analysis could be performed. A qualitative overview of the different trials showed that the quality scores of the positive trials was similar to the negative ones, allowing us to conclude that they could be considered at the same level. No negative trial with a similar design can be opposed to each particular positive trial that is thus not conterbalanced. Moreover the trials not in favor of maintenance could be falsely negative by a lack of power, the publications mentioning no statistical consideration. There are thus a series of arguments in favor of maintenance chemotherapy for small-cell lung cancer, which require to be confirmed by randomised trials of adequate quality.