51
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Li WY, Zhao TT, Xu HM, Wang ZN, Xu YY, Han Y, Song YX, Wu JH, Xu H, Yin SC, Liu XY, Miao ZF. The role of EGFR mutation as a prognostic factor in survival after diagnosis of brain metastasis in non-small cell lung cancer: a systematic review and meta-analysis. BMC Cancer 2019; 19:145. [PMID: 30760227 PMCID: PMC6375157 DOI: 10.1186/s12885-019-5331-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 01/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background The brain is a common site for metastasis in non-small-cell lung cancer (NSCLC). This study was designed to evaluate the relationship between the mutational of the epidermal growth factor receptor (EGFR) and overall survival (OS) in NSCLC patients with brain metastases. Methods Searches were performed in PubMed, EmBase, and the Cochrane Library to identify studies evaluating the association of EGFR mutation with OS in NSCLC patients through September 2017. Results 4373 NSCLC patients with brain metastases in 18 studies were involved. Mutated EGFR associated with significantly improved OS compared with wild type. Subgroup analyses suggested that this relationship persisted in studies conducted in Eastern, with retrospective design, with sample size ≥500, mean age of patients ≥65.0 years, percentage male < 50.0%, percentage of patients receiving tyrosine kinase inhibitor ≥30.0%. Finally, although significant publication bias was observed using the Egger test, the results were not changed after adjustment using the trim and fill method. Conclusions This meta-analysis suggests that EGFR mutation is an important predictive factor linked to improved OS for NSCLC patients with brain metastases. It can serve as a useful index in the prognostic assessment of NSCLC patients with brain metastases. Electronic supplementary material The online version of this article (10.1186/s12885-019-5331-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wen-Ya Li
- Department of Thoracic Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ting-Ting Zhao
- Department of Breast Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Hui-Mian Xu
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Zhen-Ning Wang
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Ying-Ying Xu
- Department of Breast Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yunan Han
- Department of Breast Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yong-Xi Song
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Jian-Hua Wu
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Hao Xu
- Department of Medical Oncology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Song-Cheng Yin
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Xing-Yu Liu
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Zhi-Feng Miao
- Department of Surgical Oncology, First Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China.
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Protopapa M, Kouloulias V, Nikoloudi S, Papadimitriou C, Gogalis G, Zygogianni A. From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC. JOURNAL OF ONCOLOGY 2019; 2019:3267409. [PMID: 30853981 PMCID: PMC6378013 DOI: 10.1155/2019/3267409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.
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Affiliation(s)
- Maria Protopapa
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Vassilis Kouloulias
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 2nd Department of Radiology, Attikon University General Hospital, Greece
| | - Styliani Nikoloudi
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Christos Papadimitriou
- National and Kapodistrian University of Athens, Medical School, Medical Oncology Unit, 2nd Surgery Clinic, Aretaieion University Hospital of Athens, Greece
| | - Giannis Gogalis
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
| | - Anna Zygogianni
- National and Kapodistrian University of Athens, Medical School, Radiation Oncology Unit, 1st Department of Radiology, Aretaieion University Hospital, Greece
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Wrona A, Dziadziuszko R, Jassem J. Management of brain metastases in non-small cell lung cancer in the era of tyrosine kinase inhibitors. Cancer Treat Rev 2018; 71:59-67. [DOI: 10.1016/j.ctrv.2018.10.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 01/16/2023]
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54
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Ahluwalia MS, Becker K, Levy BP. Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors for Central Nervous System Metastases from Non-Small Cell Lung Cancer. Oncologist 2018; 23:1199-1209. [PMID: 29650684 PMCID: PMC6263119 DOI: 10.1634/theoncologist.2017-0572] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/22/2018] [Indexed: 12/14/2022] Open
Abstract
Central nervous system (CNS) metastases are a common complication in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), resulting in a poor prognosis and limited treatment options. Treatment of CNS metastases requires a multidisciplinary approach, and the optimal treatment options and sequence of therapies are yet to be established. Many systemic therapies have poor efficacy in the CNS due to the challenges of crossing the blood-brain barrier (BBB), creating a major unmet need for the development of agents with good BBB-penetrating biopharmaceutical properties. Although the CNS penetration of first- and second-generation EGFR tyrosine kinase inhibitors (TKIs) is generally low, EGFR-TKI treatment has been shown to delay time to CNS progression in patients with CNS metastases from EGFR-mutated disease. However, a major challenge with EGFR-TKI treatment for patients with NSCLC is the development of acquired resistance, which occurs in most patients treated with a first-line EGFR-TKI. Novel EGFR-TKIs, such as osimertinib, have been specifically designed to address the challenges of acquired resistance and poor BBB permeability and have demonstrated efficacy in the CNS. A rational, iterative drug development process to design agents that could penetrate the BBB could prevent morbidity and mortality associated with CNS disease progression. To ensure a consistent approach to evaluating CNS efficacy, special consideration also needs to be given to clinical trial endpoints. IMPLICATIONS FOR PRACTICE Historically, treatment options for patients who develop central nervous system (CNS) metastases have been limited and associated with poor outcomes. The development of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) has improved outcomes for patients with EGFR-mutated disease, and emerging data have demonstrated the ability of these drugs to cross the blood-brain barrier and elicit significant intracranial responses. Recent studies have indicated a role for next-generation EGFR-TKIs, such as osimertinib, in the treatment of CNS metastases. In the context of an evolving treatment paradigm, treatment should be individualized to the patient and requires a multidisciplinary approach.
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Affiliation(s)
| | - Kevin Becker
- Maimonides Medical Center, Brooklyn, New York, USA
| | - Benjamin P Levy
- Johns Hopkins University School of Medicine, Washington DC, USA
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55
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Wang W, Song Z, Zhang Y. Efficacy of brain radiotherapy plus EGFR-TKI for EGFR-mutated non-small cell lung cancer patients who develop brain metastasis. Arch Med Sci 2018; 14:1298-1307. [PMID: 30393484 PMCID: PMC6209704 DOI: 10.5114/aoms.2018.78939] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/19/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION To analyze the appropriate treatment methods or timing to use epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and brain radiation treatment (RT) for symptomatic and asymptomatic brain metastases (BM) in patients with EGFR mutation non-small cell lung cancer (NSCLC). MATERIAL AND METHODS We retrospectively studied patients diagnosed with EGFR gene mutated NSCLC who developed brain metastasis between June 2006 and December 2015 at Zhejiang Cancer Hospital. Treatment data were assessed in 181 patients with 49 symptomatic BM and 132 asymptomatic BM retrospectively. RESULTS In 49 symptomatic BM patients, the median OS of the stereotactic radiosurgery (SRS)-treated group was longer than in the whole brain radiotherapy (WBRT) group (37.7 vs. 21.1 months) (p = 0.194). In the group of 132 asymptomatic brain metastasis patients, the median overall survival (mOS) was longer in upfront brain radiotherapy compared with the upfront TKI group (24.9 vs. 17.4 months) (p = 0.035). In further analysis regarding the timing of using radiotherapy, out of all 74 patients, 33 underwent concurrent TKI and brain radiation, 13 received TKI after first-line RT treatment and 28 patients received radiotherapy after TKI failure. The intracranial progression free survival (iPFS) of the three groups was 11.1 months, 11.3 months and 8.1 months (p = 0.032), respectively. The mOS of the three groups was 21.9 months, 26.2 months and 17.1 months, respectively (p = 0.085). CONCLUSIONS Our research indicated that delayed brain RT may result in inferior iPFS in EGFR mutated NSCLC patients with asymptomatic brain metastases, but no OS benefit was obtained. In addition, our study revealed that patients treated with SRS had a significantly longer OS for symptomatic BM. Future prospective study of the optimal management strategy with WBRT or SRS and TKI for this patient cohort is urgently needed.
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Affiliation(s)
- Wenxian Wang
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
| | - Zhengbo Song
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yiping Zhang
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang province; Hangzhou, China
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Su PL, Wu YL, Chang WY, Ho CL, Tseng YL, Lai WW, Su WC, Lin CC, Yang SC. Preventing and treating brain metastases with three first-line EGFR-tyrosine kinase inhibitors in patients with EGFR mutation-positive advanced non-small cell lung cancer. Ther Adv Med Oncol 2018; 10:1758835918797589. [PMID: 30263066 PMCID: PMC6156208 DOI: 10.1177/1758835918797589] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/22/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Brain metastases (BM) are common in advanced non-small cell lung cancer (NSCLC), and the prognosis is poor with few therapeutic options. This study evaluated the efficacy of three epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in preventing and treating BM in patients with EGFR mutation-positive advanced NSCLC. Methods Patients with EGFR mutation-positive advanced NSCLC who visited a tertiary referral center from 1 December 2013 to 30 November 2017 were analyzed retrospectively. They received gefitinib, erlotinib, or afatinib until disease progression, death, or intolerable adverse events. The cumulative incidence of subsequent BM of initial non-BM patients, progression-free survival (PFS), and overall survival (OS) of the BM and non-BM patients were estimated and compared using the Kaplan-Meier and log-rank tests. Results 306 NSCLC patients were enrolled, with 116, 75, and 115 receiving first-line gefitinib, erlotinib, and afatinib, respectively. The afatinib group had a better PFS [12.7 versus 9.8 months; hazard ratio (HR) 0.59, p = 0.001] and OS (39.1 versus 22.0 months; HR 0.64, p = 0.035) than the gefitinib group. Afatinib tended to provide better BM prevention than gefitinib (BM cumulative incidence, HR 0.49; 95% confidence interval 0.34-0.71, p < 0.001) according to a Cox model adjusted for possible confounders. Patients with initial BM had a shorter PFS (p < 0.001) and OS (p = 0.015) than those without initial BM. Among the former, there were no differences in median PFS (p = 0.34) and median OS (p = 0.46) in the three EGFR-TKI groups. Conclusions Our data suggested that, compared with gefitinib, afatinib provided better benefits significantly in terms of PFS and OS. Both had the same effectiveness in preventing subsequent BM.
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Affiliation(s)
- Po-Lan Su
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Lin Wu
- Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wei-Yuan Chang
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Liang Ho
- Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yau-Lin Tseng
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wu-Chou Su
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chien-Chung Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan
| | - Szu-Chun Yang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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Krawczyk P, Duchnowska R, Nicoś M, Kowalski D, Wojas-Krawczyk K. Preventing central nervous system metastases in non-small cell lung cancer. Expert Rev Anticancer Ther 2018; 18:1077-1083. [PMID: 30198357 DOI: 10.1080/14737140.2018.1521273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION There are no effective central nervous system (CNS) metastases prevention methods in lung cancer patients. Prophylactic cranial irradiation has a limited effectiveness and relatively high toxicity. Systemic chemotherapy is not relevant in reducing the risk of CNS in lung cancer patients. The understanding of molecular background of brain metastases in non-small cell lung cancer (NSCLC) patients could contribute to the development of personalized treatments for such patients. Areas covered: This article summarizes the latest clinical trials concerning the use of radiotherapy, chemotherapy, molecularly targeted therapies, and immunotherapy in lung cancer patients, with particular consideration of brain lung cancer metastasis prevention. The literature search was undertaken via PubMed and EMBASE searches and relevant articles are included in this review. Expert commentary: The recent data supports that EGFR-TKIs and ALK inhibitors are clinically relevant for first-line treatment to prevent and treat CNS metastases in molecularly selected NSCLC patients. In the future, high hopes for the prevention of CNS metastases in NSCLC patients are associated with immunotherapy concerning immune check-points inhibitors.
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Affiliation(s)
- Paweł Krawczyk
- a Department of Pneumonology , Oncology and Allergology, Medical University of Lublin , Lublin , Poland
| | - Renata Duchnowska
- b Department of Oncology , Military Institute in Warsaw , Warszawa , Poland
| | - Marcin Nicoś
- a Department of Pneumonology , Oncology and Allergology, Medical University of Lublin , Lublin , Poland
| | - Dariusz Kowalski
- c Department of Lung and Chest Tumors , Oncology Centre - Institute in Warsaw , Warszawa , Poland
| | - Kamila Wojas-Krawczyk
- a Department of Pneumonology , Oncology and Allergology, Medical University of Lublin , Lublin , Poland
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Girard N, Cozzone D, de Leotoing L, Tournier C, Vainchtock A, Tehard B, Cortot AB. Extra cost of brain metastases (BM) in patients with non-squamous non-small cell lung cancer (NSCLC): a French national hospital database analysis. ESMO Open 2018; 3:e000414. [PMID: 30233822 PMCID: PMC6135444 DOI: 10.1136/esmoopen-2018-000414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 11/03/2022] Open
Abstract
Purpose To assess the incremental cost associated with the management of patients with primary non-squamous non-small cell lung cancer (NSCLC) with brain metastases at the time of diagnosis. Methods Data were extracted from the French Hospital medical information database (Programme de Médicalisation des Systèmes d'Information (PMSI)). Patients with non-squamous NSCLC were identified through a diagnosis of lung cancer and a prescription of bevacizumab or pemetrexed. All such patients hospitalised with lung cancer for the first time in 2013 and with metastases identified at the first hospitalisation were eligible. Two cohorts were identified, one with brain metastases (group B: n=971) and one with metastases at other sites (group A: n=1529). For each patient, total in-hospital medical resource consumption associated with the initial hospitalisation in 2013 and with any follow-up stays in the following 24 months was documented. Costs were attributed from official French national tariffs and expressed in 2017 euros. Results The mean number of hospitalisations per patient in the 24-moth follow-up period was 17 in group A and 21 in group B. >99% of patients in both groups received chemotherapy. 58% of patients in group B and 13% in group A were managed by radiotherapy. 37% in group B and 24% in group A received palliative care. The associated cost was €2979 per patient-month for patients in group B and €2426 for patients in group A, representing a differential cost of €553 per month. Radiotherapy (+€164/month) and palliative care (+€130/month) were the principal drivers of the incremental cost. Conclusions The presence of brain metastases at the time of diagnosis of non-squamous NSCLC carries a significant burden, and ways of lowering this burden are needed.
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Affiliation(s)
- Nicolas Girard
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.,Institut Curie, Paris, France
| | | | | | | | | | | | - Alexis B Cortot
- CHU Lille, Thoracic Oncology Department, Univ. Lille, Lille, France
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Reungwetwattana T, Nakagawa K, Cho BC, Cobo M, Cho EK, Bertolini A, Bohnet S, Zhou C, Lee KH, Nogami N, Okamoto I, Leighl N, Hodge R, McKeown A, Brown AP, Rukazenkov Y, Ramalingam SS, Vansteenkiste J. CNS Response to Osimertinib Versus Standard Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Patients With Untreated EGFR-Mutated Advanced Non-Small-Cell Lung Cancer. J Clin Oncol 2018; 36:JCO2018783118. [PMID: 30153097 DOI: 10.1200/jco.2018.78.3118] [Citation(s) in RCA: 466] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Purpose We report CNS efficacy of osimertinib versus standard epidermal growth factor receptor ( EGFR) tyrosine kinase inhibitors (TKIs) in patients with untreated EGFR-mutated advanced non-small-cell lung cancer from the phase III FLAURA study. Patients and Methods Patients (N = 556) were randomly assigned to osimertinib or standard EGFR-TKIs (gefitinib or erlotinib); brain scans were not mandated unless clinically indicated. Patients with asymptomatic or stable CNS metastases were included. In patients with symptomatic CNS metastases, neurologic status was required to be stable for ≥ 2 weeks after completion of definitive therapy and corticosteroids. A preplanned subgroup analysis with CNS progression-free survival as primary objective was conducted in patients with measurable and/or nonmeasurable CNS lesions on baseline brain scan by blinded independent central neuroradiologic review. The CNS evaluable-for-response set included patients with ≥ one measurable CNS lesion. Results Of 200 patients with available brain scans at baseline, 128 (osimertinib, n = 61; standard EGFR-TKIs, n = 67) had measurable and/or nonmeasurable CNS lesions, including 41 patients (osimertinib, n = 22; standard EGFR-TKIs, n = 19) with ≥ one measurable CNS lesion. Median CNS progression-free survival in patients with measurable and/or nonmeasurable CNS lesions was not reached with osimertinib (95% CI, 16.5 months to not calculable) and 13.9 months (95% CI, 8.3 months to not calculable) with standard EGFR-TKIs (hazard ratio, 0.48; 95% CI, 0.26 to 0.86; P = .014 [nominally statistically significant]). CNS objective response rates were 91% and 68% in patients with ≥ one measurable CNS lesion (odds ratio, 4.6; 95% CI, 0.9 to 34.9; P = .066) and 66% and 43% in patients with measurable and/or nonmeasurable CNS lesions (odds ratio, 2.5; 95% CI, 1.2 to 5.2; P = .011) treated with osimertinib and standard EGFR-TKIs, respectively. Probability of experiencing a CNS progression event was consistently lower with osimertinib versus standard EGFR-TKIs. Conclusion Osimertinib has CNS efficacy in patients with untreated EGFR-mutated non-small-cell lung cancer. These results suggest a reduced risk of CNS progression with osimertinib versus standard EGFR-TKIs.
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Affiliation(s)
- Thanyanan Reungwetwattana
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Kazuhiko Nakagawa
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Byoung Chul Cho
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Manuel Cobo
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Eun Kyung Cho
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Alessandro Bertolini
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sabine Bohnet
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Caicun Zhou
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ki Hyeong Lee
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Naoyuki Nogami
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Isamu Okamoto
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Natasha Leighl
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Rachel Hodge
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Astrid McKeown
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Andrew P Brown
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Yuri Rukazenkov
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Suresh S Ramalingam
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan Vansteenkiste
- Thanyanan Reungwetwattana, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Kazuhiko Nakagawa, Kindai University School of Medicine, Osaka; Naoyuki Nogami, National Hospital Organization Shikoku Cancer Center, Matsuyama; Isamu Okamoto, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Byoung Chul Cho, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul; Eun Kyung Cho, Gachon University Gil Medical Center, Incheon; Ki Hyeong Lee, Chungbuk National University Hospital, Cheong-ju, Republic of Korea; Manuel Cobo, Institute of Biomedical Research in Málaga, Málaga University Hospital Regional, Málaga, Spain; Alessandro Bertolini, Hospital of Sondrio, Sondrio, Italy; Sabine Bohnet, Universitätsklinik Schleswig-Holstein, Lübeck, Germany; Caicun Zhou, Pulmonary Hospital of Tongji University, Shanghai, People's Republic of China; Natasha Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Rachel Hodge, Astrid McKeown, Andrew P. Brown, and Yuri Rukazenkov, AstraZeneca, Cambridge, United Kingdom; Suresh S. Ramalingam, Winship Cancer Institute, Emory University, Atlanta, GA; and Johan Vansteenkiste, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
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Borghetti P, Bonù ML, Roca E, Pedretti S, Salah E, Baiguini A, Greco D, Triggiani L, Maddalo M, Levra NG, Alongi F, Magrini SM, Buglione M. Radiotherapy and Tyrosine Kinase Inhibitors in Stage IV Non-small Cell Lung Cancer: Real-life Experience. ACTA ACUST UNITED AC 2018; 32:159-164. [PMID: 29275314 DOI: 10.21873/invivo.11219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/08/2017] [Accepted: 11/13/2017] [Indexed: 12/18/2022]
Abstract
AIM To investigate the role of conventional radiotherapy (RT) and stereotactic body radiotherapy (SBRT) in patients with epidermal growth factor (EGFR)-mutant or anaplastic lymphoma kinase (ALK) rearrangement-positive metastatic non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Fifty patients with EGFR-mutated or ALK rearrangement-positive NSCLC were treated at our Institution. Radiotherapy was delivered before, after or concomitantly with tyrosine kinase inhibitors (TKIs). Acute toxicities and overall survival (OS) were assessed. RESULTS Radiotherapy was performed within 30 days before TKI, concomitantly with TKI and within 30 days after TKI in eight (16%), 33 (66%) and 9 (18%) cases, respectively. The median duration of TKI therapy in the whole series was 11.9 months. The median OS was 19.3 months and 1- and 2-year OS was 71.5% and 36.5%, respectively. The group treated with SBRT had a significant benefit in terms of OS (p=0.043). Only two grade 3 toxicities were reported. CONCLUSION RT concomitantly or close to TKI administration in stage IV NSCLC was shown to be feasible and safe. Intriguing data on OS were also reported.
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Affiliation(s)
- Paolo Borghetti
- Department of Radiation Oncology, Olindo Alberti Radiotherapy Institute, Brescia, Italy
| | | | - Elisa Roca
- Department of Medical Oncology, Spedali Civili Hospital, Brescia, Italy
| | - Sara Pedretti
- Department of Radiation Oncology, Olindo Alberti Radiotherapy Institute, Brescia, Italy
| | - Emiliano Salah
- Department of Radiation Oncology, Brescia University, Brescia, Italy
| | - Anna Baiguini
- Department of Radiation Oncology, Brescia University, Brescia, Italy
| | - Diana Greco
- Department of Radiation Oncology, Brescia University, Brescia, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, Brescia University, Brescia, Italy
| | - Marta Maddalo
- Department of Radiation Oncology, Olindo Alberti Radiotherapy Institute, Brescia, Italy
| | | | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Hospital, Negrar, Italy
| | - Stefano Maria Magrini
- Department of Radiation Oncology, Olindo Alberti Radiotherapy Institute, Brescia, Italy
| | - Michela Buglione
- Department of Radiation Oncology, Olindo Alberti Radiotherapy Institute, Brescia, Italy
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61
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Wu YL, Ahn MJ, Garassino MC, Han JY, Katakami N, Kim HR, Hodge R, Kaur P, Brown AP, Ghiorghiu D, Papadimitrakopoulou VA, Mok TSK. CNS Efficacy of Osimertinib in Patients With T790M-Positive Advanced Non-Small-Cell Lung Cancer: Data From a Randomized Phase III Trial (AURA3). J Clin Oncol 2018; 36:2702-2709. [PMID: 30059262 DOI: 10.1200/jco.2018.77.9363] [Citation(s) in RCA: 323] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose In patients with epidermal growth factor receptor ( EGFR) mutation-positive advanced non-small-cell lung cancer (NSCLC), there is an unmet need for EGFR-tyrosine kinase inhibitors with improved CNS penetration and activity against CNS metastases, either at initial diagnosis or time of progression. We report the first comparative evidence of osimertinib CNS efficacy versus platinum-pemetrexed from a phase III study (AURA3; ClinicalTrials.gov identifier: NCT02151981) in patients with EGFR T790M-positive advanced NSCLC who experience disease progression with prior EGFR-tyrosine kinase inhibitor treatment. Methods Patients with asymptomatic, stable CNS metastases were eligible for enrollment and were randomly assigned 2:1 to osimertinib 80 mg once daily or platinum-pemetrexed. A preplanned subgroup analysis was conducted in patients with measurable and/or nonmeasurable CNS lesions on baseline brain scan by blinded independent central neuroradiological review. The CNS evaluable for response set included only patients with one or more measurable CNS lesions. The primary objective for this analysis was CNS objective response rate (ORR). Results Of 419 patients randomly assigned to treatment, 116 had measurable and/or nonmeasurable CNS lesions, including 46 patients with measurable CNS lesions. At data cutoff (April 15, 2016), CNS ORR in patients with one or more measurable CNS lesions was 70% (21 of 30; 95% CI, 51% to 85%) with osimertinib and 31% (5 of 16; 95% CI, 11% to 59%) with platinum-pemetrexed (odds ratio, 5.13; 95% CI, 1.44 to 20.64; P = .015); the ORR was 40% (30 of 75; 95% CI, 29% to 52%) and 17% (7 of 41; 95% CI, 7% to 32%), respectively, in patients with measurable and/or nonmeasurable CNS lesions (odds ratio, 3.24; 95% CI, 1.33 to 8.81; P = .014). Median CNS duration of response in patients with measurable and/or nonmeasurable CNS lesions was 8.9 months (95% CI, 4.3 months to not calculable) for osimertinib and 5.7 months (95% CI, 4.4 to 5.7 months) for platinum-pemetrexed; median CNS progression-free survival was 11.7 months and 5.6 months, respectively (hazard ratio, 0.32; 95% CI, 0.15 to 0.69; P = .004). Conclusion Osimertinib demonstrated superior CNS efficacy versus platinum-pemetrexed in T790M-positive advanced NSCLC.
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Affiliation(s)
- Yi-Long Wu
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Myung-Ju Ahn
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Marina Chiara Garassino
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Ji-Youn Han
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Nobuyuki Katakami
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Hye Ryun Kim
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Rachel Hodge
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Paramjit Kaur
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Andrew P Brown
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Dana Ghiorghiu
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Vassiliki A Papadimitrakopoulou
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
| | - Tony S K Mok
- Yi-Long Wu, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China; Myung-Ju Ahn, Sungkyunkwan University School of Medicine; Hye Ryun Kim, Yonsei University College of Medicine, Seoul; Ji-Youn Han, National Cancer Center, Goyang, Republic of Korea; Marina Chiara Garassino, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Nobuyuki Katakami, Institute of Biomedical Research and Innovation, Kobe, Japan; Rachel Hodge, Paramjit Kaur, Andrew P. Brown, and Dana Ghiorghiu, AstraZeneca, Cambridge, United Kingdom; Vassiliki A. Papadimitrakopoulou, The University of Texas MD Anderson Cancer Center, Houston, TX; and Tony S.K. Mok, Chinese University of Hong Kong, Hong Kong
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Barriers to Effective Drug Treatment for Brain Metastases: A Multifactorial Problem in the Delivery of Precision Medicine. Pharm Res 2018; 35:177. [PMID: 30003344 DOI: 10.1007/s11095-018-2455-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/30/2018] [Indexed: 12/12/2022]
Abstract
The treatment of metastatic lesions in the brain represents a serious unmet medical need in the field of neuro-oncology. Even though many effective compounds have demonstrated success in treating peripheral (non-CNS) tumors with targeted agents, one aspect of this lack of success in the brain may be related to poor delivery of otherwise effective compounds. Many factors can influence the brain delivery of these agents, but one key barrier is a heterogeneously "leaky" BBB that expresses efflux transporters that limit the BBB permeability for many targeted agents. Future success in therapeutics for brain metastases must take into account the adequate delivery of "active, free drug" to the target, and may include combinations of targeted drugs that are appropriate to address each individual patient's tumor type. This review discusses some issues that are pertinent to precision medicine for brain metastases, using specific examples of tumor types that have a high incidence of brain metastases.
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O'Kane GM, Leighl NB. Systemic Therapy of Lung Cancer CNS Metastases Using Molecularly Targeted Agents and Immune Checkpoint Inhibitors. CNS Drugs 2018; 32:527-542. [PMID: 29799091 DOI: 10.1007/s40263-018-0526-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Central nervous system (CNS) metastases most commonly arise from lung cancer, with the majority of patients affected during their disease course. The prognosis for patients with untreated brain metastases is poor, with surgical resection and/or radiotherapy as classic therapeutic options. However, the value of systemic therapy in the management of CNS metastases from lung cancer is growing. Novel targeted agents for the treatment of non-small cell lung cancer (NSCLC) have demonstrated activity in treating patients with CNS involvement, and are potential alternatives to radiation and surgery. These agents include anaplastic lymphoma kinase (ALK) inhibitors such as alectinib, crizotinib, ceritinib, lorlatinib, and others; epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, including the recently developed third-generation inhibitor osimertinib, and even immune checkpoint inhibitors such as nivolumab, pembrolizumab, and atezolizumab. This review summarizes current activity of systemic agents in the management of CNS metastases from NSCLC, as well as potential mechanisms of action of these small and large molecules.
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Affiliation(s)
- Grainne M O'Kane
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 7W-389, 700 University Avenue, Toronto, ON, M5G 1Z5, Canada. Grainne.O'
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, 7W-389, 700 University Avenue, Toronto, ON, M5G 1Z5, Canada
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64
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Liao BC, Lin CC, Yang JCH. Treating brain metastases in non-small cell lung cancer patients: what have we learnt from pharmaceutical recent clinical trials? Expert Opin Pharmacother 2018; 19:851-864. [PMID: 29726292 DOI: 10.1080/14656566.2018.1472765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Brain metastases (BMs) develop in up to 40% of patients with non-small cell lung cancer (NSCLC). In many recent practice-changing clinical trials, patients with BM were included; however, only few trials reported intracranial efficacies in either post hoc or pre-planned analysis. Clinically meaningful intracranial efficacy data of novel agents have not been completely disclosed. AREAS COVERED The authors performed a systemic review of recent pharmaceutical clinical trials, mainly pivotal or practice-changing trials. Some of the prospective clinical trials focused on patients with NSCLC and BM. The authors collected and compared intracranial efficacy reports of chemotherapy, epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), ALK inhibitors, and immune checkpoint inhibitors. EXPERT OPINION Many clinical trials, especially those on 'brain-active' EGFR-TKIs and ALK inhibitors, have robust reports of intracranial efficacies either as post hoc or pre-planned analysis. Physicians should interpret this data with caution and apply the results to patients accordingly. For the design of future clinical trials, enrolling patients with only BM, incorporating novel risk classifications, pre-planning intracranial efficacy endpoints, reporting prior local brain therapies, and applying novel response evaluation criteria are emerging trends in this area.
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Affiliation(s)
- Bin-Chi Liao
- a Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,b National Taiwan University Cancer Center, College of Medicine, National Taiwan University , Taipei , Taiwan.,c Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University , Taipei , Taiwan
| | - Chia-Chi Lin
- a Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,c Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University , Taipei , Taiwan
| | - James Chih-Hsin Yang
- a Department of Oncology , National Taiwan University Hospital , Taipei , Taiwan.,b National Taiwan University Cancer Center, College of Medicine, National Taiwan University , Taipei , Taiwan.,c Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University , Taipei , Taiwan.,d Graduate Institute of Oncology, College of Medicine, National Taiwan University , Taipei , Taiwan
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Yomo S, Oda K. Impacts of EGFR-mutation status and EGFR-TKI on the efficacy of stereotactic radiosurgery for brain metastases from non-small cell lung adenocarcinoma: A retrospective analysis of 133 consecutive patients. Lung Cancer 2018; 119:120-126. [DOI: 10.1016/j.lungcan.2018.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 12/15/2022]
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Khandekar MJ, Piotrowska Z, Willers H, Sequist LV. Role of Epidermal Growth Factor Receptor (EGFR) Inhibitors and Radiation in the Management of Brain Metastases from EGFR Mutant Lung Cancers. Oncologist 2018; 23:1054-1062. [PMID: 29703765 DOI: 10.1634/theoncologist.2017-0557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/06/2018] [Indexed: 12/19/2022] Open
Abstract
The growth of genotype-directed targeted therapies, such as inhibitors of the epidermal growth factor receptor (EGFR), has revolutionized treatment for some patients with oncogene-addicted lung cancer. However, as systemic control for these patients has improved, brain metastases remain an important source of morbidity and mortality. Traditional treatment for brain metastases has been radiotherapy, either whole-brain radiation or stereotactic radiosurgery. The growing availability of drugs that can cross the blood-brain barrier and have activity in the central nervous system (CNS) has led to many studies investigating whether targeted therapy can be used in combination with or in lieu of radiation. In this review, we summarize the key literature about the incidence and nature of EGFR-mutant brain metastases (EGFR BMs), the data about the activity of EGFR inhibitors in the CNS, and whether they can be used as front-line therapy for brain metastases. Although initial use of tyrosine kinase inhibitors for EGFR BMs can often be an effective treatment strategy, multidisciplinary evaluation is critical, and prospective studies are needed to clarify which patients may benefit from early radiotherapy. IMPLICATIONS FOR PRACTICE Management of brain metastases in epidermal growth factor receptor (EGFR) mutant lung cancer is a common clinical problem. The question of whether to start initial therapy with an EGFR inhibitor or radiotherapy (either whole-brain radiotherapy or stereotactic radiosurgery) is controversial. The development of novel EGFR inhibitors with enhanced central nervous system (CNS) penetration is an important advance in the treatment of CNS disease. Multidisciplinary evaluation and evaluation of extracranial disease status are critical to choosing the best treatment option for each patient.
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Affiliation(s)
- Melin J Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Zofia Piotrowska
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lecia V Sequist
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Feng PH, Chen KY, Huang YC, Luo CS, Wu SM, Chen TT, Lee CN, Yeh CT, Chuang HC, Han CL, Lin CF, Lee WH, Kuo CH, Lee KY. Bevacizumab Reduces S100A9-Positive MDSCs Linked to Intracranial Control in Patients with EGFR-Mutant Lung Adenocarcinoma. J Thorac Oncol 2018; 13:958-967. [PMID: 29684573 DOI: 10.1016/j.jtho.2018.03.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION In vitro models have demonstrated immune-modulating effects of bevacizumab (BEV). Combinations of an EGFR tyrosine kinase inhibitor (TKI) with BEV improve progression-free survival (PFS) in patients with EGFR-mutated lung adenocarcinoma. How BEV confers this clinical effect and the underlying mechanisms of its effect are not clear. METHODS A total of 55 patients with stage 4 EGFR-mutated lung adenocarcinoma were enrolled. Myeloid-derived suppressor cells (MDSCs), type 1 and type 2 helper T cells, and cytotoxic T lymphocytes were analyzed by flow cytometry. Clinical data were collected for analysis. RESULT In all, 25 patients received EGFR TKI and BEV combination therapy (the BEV/TKI group) and 30 patients received EGFR TKI monotherapy (the TKI-only group). The BEV/TKI group had longer PFS (23.0 versus 8.6 months [p = 0.001]) and, in particular, better intracranial control rates (80.0% versus 43.0% [p = 0.03]), a longer time to intracranial progression (49.1 versus 12.9 months [p = 0.002]), and fewer new brain metastases (38.0% versus 71.0% [p = 0.03]) than the TKI-only group did. The BEV/TKI group had a lower percentage of circulating MDSCs (20.4% ± 6.5% before treatment versus 12.8% ± 6.6% after treatment, respectively [p = 0.02]), and higher percentages of type 1 helper T cells (22.9% ± 15.3% versus 33.2% ± 15.6% [p < 0.01]) and cytotoxic T lymphocytes (15.5% ± 7.2% versus 21.2% ± 5.6% [p < 0.01]) after treatment, changes that were not seen in the TKI-only group. Pretreatment percentage of MDSCs was correlated with PFS, with this correlation attenuated after BEV/TKI treatment. Percentage of MDSCs was also associated with shorter time to intracranial progression. CONCLUSION Combining a EGFR TKI with BEV extended PFS and protected against brain metastasis. Those effects were probably due to the reduction of circulating S100A9-positive MDSCs by BEV, which leads to restoration of effective antitumor immunity. Our data also support the rationale for a BEV-immune checkpoint inhibitor combination.
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Affiliation(s)
- Po-Hao Feng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China; Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kuan-Yuan Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China
| | - Yu-Chen Huang
- Division of Pulmonary Medicine, Department of Internal Medicine, Chang Gung Medical Foundation, Linko Branch, Taoyuan, Republic of China
| | - Ching-Shan Luo
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Shen Ming Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Tzu-Tao Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Chun-Nin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Chi-Tai Yeh
- Department of Medical Research and Education, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Hsiao-Chi Chuang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Republic of China
| | - Chia-Li Han
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, College of Pharmacy, Taipei Medical University, Taipei, Republic of China
| | - Chiou-Feng Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China
| | - Wei-Hwa Lee
- Department of Pathology, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China
| | - Chih-Hsi Kuo
- Division of Pulmonary Medicine, Department of Internal Medicine, Chang Gung Medical Foundation, Linko Branch, Taoyuan, Republic of China
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Republic of China; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Republic of China.
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Remon J, Besse B. Brain Metastases in Oncogene-Addicted Non-Small Cell Lung Cancer Patients: Incidence and Treatment. Front Oncol 2018; 8:88. [PMID: 29696132 PMCID: PMC5904204 DOI: 10.3389/fonc.2018.00088] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/14/2018] [Indexed: 12/11/2022] Open
Abstract
Brain metastases (BM) are common in non-small cell lung cancer patients including in molecularly selected populations, such as EGFR-mutant and ALK-rearranged tumors. They are associated with a reduced quality of life, and are commonly the first site of progression for patients receiving tyrosine kinase inhibitors (TKIs). In this review, we summarize incidence of BM and intracranial efficacy with TKI agents according to oncogene driver mutations, focusing on important clinical issues, notably optimal first-line treatment in oncogene-addicted lung tumors with upfront BM (local therapies followed by TKI vs. TKI monotherapy). We also discuss the potential role of newly emerging late-generation TKIs as new standard treatment in oncogene-addicted lung cancer tumors compared with sequential strategies.
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Affiliation(s)
- J. Remon
- Medical Oncology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Benjamin Besse
- Cancer Medicine Department, Institut Gustave Roussy, Villejuif, France
- University Paris-Sud, Orsay, France
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Yoon S, Kang J, Lee DH. Osimertinib, the winner, but cannot yet take it all. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:61. [PMID: 29611548 DOI: 10.21037/atm.2017.12.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shinkyo Yoon
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jihoon Kang
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dae Ho Lee
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Lazaro T, Brastianos PK. Immunotherapy and targeted therapy in brain metastases: emerging options in precision medicine. CNS Oncol 2018; 6:139-151. [PMID: 28425754 DOI: 10.2217/cns-2016-0038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Brain metastases (BM) continue to represent an unmet clinical need in oncology. Immunotherapy and targeted therapy hold great promise in the treatment of BM. Emerging data are confirming the activity of these agents in patients with BM. Genomic studies have confirmed that clinically actionable mutations are present in BM and they can be used in clinical studies to link targeted therapies with their genetic targets. Furthermore, as molecular signatures associated with sensitivity and resistance to immunotherapies are developed, we will better be able to select BM patients who will most benefit from these therapies. Understanding the genetic and immune evolution within BM should drive the next generation of immunotherapy and target therapy, as well as increase the accuracy of the selection process for these therapies.
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Affiliation(s)
- Tyler Lazaro
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, MA 02144, USA.,Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA 02144, USA
| | - Priscilla K Brastianos
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, MA 02144, USA.,Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA 02144, USA
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71
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Han G, Bi J, Tan W, Wei X, Wang X, Ying X, Guo X, Zhou X, Hu D, Zhen W. A retrospective analysis in patients with EGFR-mutant lung adenocarcinoma: is EGFR mutation associated with a higher incidence of brain metastasis? Oncotarget 2018; 7:56998-57010. [PMID: 27486770 PMCID: PMC5302968 DOI: 10.18632/oncotarget.10933] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/19/2016] [Indexed: 01/25/2023] Open
Abstract
Lung adenocarcinomas are more commonly associated with brain metastases (BM). Epidermal growth factor receptor (EGFR) mutations have been demonstrated to be both predictive and prognostic for patients with lung adenocarcinoma. We aimed to explore the potential association between EGFR mutation and the risk of BM in pulmonary adenocarcinoma patients. Data of 234 patients from 2007 to 2014 were retrospectively reviewed. A total of 108 patients had EGFR mutations in the entire cohort. Among them, 76 patients developed BM during their disease course. The incidence of BM was statistically higher in patients with EGFR mutations both at initial diagnosis (P=0.014) and at last follow-up (P<0.001). Multivariate logistic regression analysis revealed that EGFR mutation significantly increased the risk of BM at initial diagnosis (OR=2.515, P=0.022). In patients without BM at initial diagnosis, the accumulative rate of subsequent BM was significantly higher with EGFR mutations (P=0.001). Multivariate Cox regression analysis identified EGFR mutation as the only independent risk factor for subsequent BM (HR=3.036, P=0.001). Patients with EGFR mutations demonstrated longer overall survival (OS) after BM diagnosis than patients with wild-type EGFR (P=0.028). Our data suggest that EGFR mutation is an independent predictive and prognostic risk factor for BM and a positive predictive factor for OS in patients with BM.
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Affiliation(s)
- Guang Han
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Jianping Bi
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Wenyong Tan
- Department of Oncology, Shenzhen People Hospital, Shenzhen, China
| | - Xueyan Wei
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Xiaohong Wang
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Xiaofang Ying
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Xiaofang Guo
- Department of Radiology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Xiaoyi Zhou
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Desheng Hu
- Department of Radiation Oncology, Hubei Cancer Hospital, Wuhan, HB, China
| | - Weining Zhen
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Russo A, Franchina T, Ricciardi GRR, Fanizza C, Scimone A, Chiofalo G, Giordano A, Adamo V. Influence of EGFR mutational status on metastatic behavior in non squamous non small cell lung cancer. Oncotarget 2018; 8:8717-8725. [PMID: 28060728 PMCID: PMC5352435 DOI: 10.18632/oncotarget.14427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/01/2016] [Indexed: 12/25/2022] Open
Abstract
Epidermal Growth Factor Receptor (EGFR) mutated Non Small Cell Lung Cancers (NSCLCs) are a molecularly subgroup of patients with peculiar clinic-pathological characteristics. Previous studies have suggested a possible interaction between oncogene status and metastatic behavior in non squamous NSCLCs with conflicting results. The aim of this study was to compare the different metastatic patterns, at baseline and during the course of the disease, in a cohort of 137 Caucasian patients with non-squamous NSCLC according to the EGFR mutational status and survival differences according to the different metastatic behavior. We observed unique metastatic distributions between EGFR-mutated and EGFR wild type non-squamous NSCLCs. These data support the hypothesis that tumor bio-molecular characteristics and genotype may influence the metastatic process in NSCLC and might help the development of enrichment strategies for tumor genotyping in these tumors, especially in the presence of limited tissue availability.
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Affiliation(s)
- Alessandro Russo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology University of Messina, Italy
| | - Tindara Franchina
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology University of Messina, Italy
| | | | | | - Antonino Scimone
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology University of Messina, Italy
| | - Giuseppe Chiofalo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology University of Messina, Italy
| | - Antonio Giordano
- Department of Medicine, Surgery and Neuroscience, University of Siena and Istituto Toscano Tumori (ITT), Siena, Italy.,Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia PA, USA
| | - Vincenzo Adamo
- Medical Oncology Unit A.O. Papardo & Department of Human Pathology University of Messina, Italy
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Tsakonas G, Hellman F, Gubanski M, Friesland S, Tendler S, Lewensohn R, Ekman S, de Petris L. Prognostic factors affecting survival after whole brain radiotherapy in patients with brain metastasized lung cancer. Acta Oncol 2018; 57:231-238. [PMID: 28984492 DOI: 10.1080/0284186x.2017.1386799] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Whole-brain radiotherapy (WBRT) has been the standard of care for multiple NSCLC brain metastases but due to its toxicity and lack of survival benefit, its use in the palliative setting is being questioned. PATIENT AND METHODS This was a single institution cohort study including brain metastasized lung cancer patients who received WBRT at Karolinska University Hospital. Information about Recursive Partitioning Analysis (RPA) and Graded Prognostic Assessment (GPA) scores, demographics, histopathological results and received oncological therapy were collected. Predictors of overall survival (OS) from the time of received WBRT were identified by Cox regression analyses. OS between GPA and RPA classes were compared by pairwise log rank test. A subgroup OS analysis was performed stratified by RPA class. RESULTS The cohort consisted of 280 patients. RPA 1 and 2 classes had better OS compared to class 3, patients with GPA <1.5 points had better OS compared to GPA≥ 1.5 points and age >70 years was associated with worse OS (p< .0001 for all comparisons). In RPA class 2 subgroup analysis GPA ≥1.5 points, age ≤70 years and CNS surgery before salvage WBRT were independent positive prognostic factors. CONCLUSIONS RPA class 3 patients should not receive WBRT, whereas RPA class 1 patients should receive WBRT if clinically indicated. RPA class 2 patients with age ≤70 years and GPA ≥1.5 points should be treated as RPA 1. WBRT should be omitted in RPA 2 patients with age >70. In RPA 2 patients with age ≤70 years and GPA <1.5 points WBRT could be a reasonable option.
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Affiliation(s)
- Georgios Tsakonas
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Fatou Hellman
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Gubanski
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Signe Friesland
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Salomon Tendler
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Rolf Lewensohn
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Simon Ekman
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Luigi de Petris
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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Soria JC, Ohe Y, Vansteenkiste J, Reungwetwattana T, Chewaskulyong B, Lee KH, Dechaphunkul A, Imamura F, Nogami N, Kurata T, Okamoto I, Zhou C, Cho BC, Cheng Y, Cho EK, Voon PJ, Planchard D, Su WC, Gray JE, Lee SM, Hodge R, Marotti M, Rukazenkov Y, Ramalingam SS. Osimertinib in Untreated EGFR-Mutated Advanced Non-Small-Cell Lung Cancer. N Engl J Med 2018; 378:113-125. [PMID: 29151359 DOI: 10.1056/nejmoa1713137] [Citation(s) in RCA: 3126] [Impact Index Per Article: 521.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Osimertinib is an oral, third-generation, irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) that selectively inhibits both EGFR-TKI-sensitizing and EGFR T790M resistance mutations. We compared osimertinib with standard EGFR-TKIs in patients with previously untreated, EGFR mutation-positive advanced non-small-cell lung cancer (NSCLC). METHODS In this double-blind, phase 3 trial, we randomly assigned 556 patients with previously untreated, EGFR mutation-positive (exon 19 deletion or L858R) advanced NSCLC in a 1:1 ratio to receive either osimertinib (at a dose of 80 mg once daily) or a standard EGFR-TKI (gefitinib at a dose of 250 mg once daily or erlotinib at a dose of 150 mg once daily). The primary end point was investigator-assessed progression-free survival. RESULTS The median progression-free survival was significantly longer with osimertinib than with standard EGFR-TKIs (18.9 months vs. 10.2 months; hazard ratio for disease progression or death, 0.46; 95% confidence interval [CI], 0.37 to 0.57; P<0.001). The objective response rate was similar in the two groups: 80% with osimertinib and 76% with standard EGFR-TKIs (odds ratio, 1.27; 95% CI, 0.85 to 1.90; P=0.24). The median duration of response was 17.2 months (95% CI, 13.8 to 22.0) with osimertinib versus 8.5 months (95% CI, 7.3 to 9.8) with standard EGFR-TKIs. Data on overall survival were immature at the interim analysis (25% maturity). The survival rate at 18 months was 83% (95% CI, 78 to 87) with osimertinib and 71% (95% CI, 65 to 76) with standard EGFR-TKIs (hazard ratio for death, 0.63; 95% CI, 0.45 to 0.88; P=0.007 [nonsignificant in the interim analysis]). Adverse events of grade 3 or higher were less frequent with osimertinib than with standard EGFR-TKIs (34% vs. 45%). CONCLUSIONS Osimertinib showed efficacy superior to that of standard EGFR-TKIs in the first-line treatment of EGFR mutation-positive advanced NSCLC, with a similar safety profile and lower rates of serious adverse events. (Funded by AstraZeneca; FLAURA ClinicalTrials.gov number, NCT02296125 .).
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Affiliation(s)
- Jean-Charles Soria
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Yuichiro Ohe
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Johan Vansteenkiste
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Thanyanan Reungwetwattana
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Busyamas Chewaskulyong
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Ki Hyeong Lee
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Arunee Dechaphunkul
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Fumio Imamura
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Naoyuki Nogami
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Takayasu Kurata
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Isamu Okamoto
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Caicun Zhou
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Byoung Chul Cho
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Ying Cheng
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Eun Kyung Cho
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Pei Jye Voon
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - David Planchard
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Wu-Chou Su
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Jhanelle E Gray
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Siow-Ming Lee
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Rachel Hodge
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Marcelo Marotti
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Yuri Rukazenkov
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
| | - Suresh S Ramalingam
- From Gustave Roussy Cancer Campus and University Paris-Sud, Orsay, France (J.-C.S., D.P.); the Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo (Y.O.), the Department of Thoracic Oncology, Osaka International Cancer Institute (F.I.), and the Department of Thoracic Oncology, Kansai Medical University Hospital (T.K.), Osaka, the Department of Thoracic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama (N.N.), and the Research Institute for Diseases of the Chest, Graduate School of Medical Science, Kyushu University, Fukuoka (I.O.) - all in Japan; the Respiratory Oncology Unit, University Hospital KU Leuven, Leuven, Belgium (J.V.); Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok (T.R.), the Oncology Unit, Department of Medicine, Chiang Mai University, Chiang Mai (B.C.), and the Division of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai (A.D.) - all in Thailand; the Division of Medical Oncology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheong-ju (K.H.L.), the Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul (B.C.C.), and the Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon (E.K.C.) - all in South Korea; Pulmonary Hospital of Tongji University, Shanghai (C.Z.), and Jilin Provincial Cancer Hospital, Changchun (Y.C.) - both in China; Hospital Umum Sarawak, Kuching, Malaysia (P.J.V.); National Cheng Kung University, Tainan, Taiwan (W.-C.S.); the Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J.E.G.); the Department of Oncology, University College London Hospitals Biomedical Research Centre, and the Cancer Research UK Lung Cancer Centre of Excellence, London (S.-M.L.), and AstraZeneca, Cambridge (R.H., M.M., Y.R.) - all in the United Kingdom; and Emory University School of Medicine, Winship Cancer Institute, Atlanta (S.S.R.)
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Baek MY, Ahn HK, Park KR, Park HS, Kang SM, Park I, Kim YS, Hong J, Sym SJ, Park J, Lee JH, Shin DB, Cho EK. Epidermal growth factor receptor mutation and pattern of brain metastasis in patients with non-small cell lung cancer. Korean J Intern Med 2018; 33:168-175. [PMID: 27093978 PMCID: PMC5768530 DOI: 10.3904/kjim.2015.158] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 08/18/2015] [Accepted: 10/19/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIMS We investigated the time taken for patients with metastatic non-small cell lung cancer (NSCLC) to develop brain metastases (BM), as well as their subsequent overall median survival following diagnosis, considering the epidermal growth factor receptor (EGFR) mutational status. METHODS We retrospectively investigated the medical records of 259 patients diagnosed with advanced NSCLC from January 2010 to August 2013, who were tested for EGFR mutations. The time from the diagnosis of advanced NSCLC to the development of BM and the overall median survival after BM development (BM-OS) were evaluated and compared by EGFR mutational status. RESULTS Sixty-seven patients (25.9%) developed BM. Synchronous BM occurred more often in patients with EGFR mutation type (MT) (n = 20, 27.4%) compared with EGFR wild type (WT) (n = 27, 14.5%, p < 0.009). The median BM-OS was significantly longer in patients with EGFR MT than in those with EGFR WT (25.7 months vs. 3.8 months, p < 0.001), and a similar trend was noticed for patients with synchronous BM (25.7 months for EGFR MT vs. 6.8 months for EGFR WT, p < 0.001). However, in patients with metachronous BM development, the difference in BM-OS between patients with EGFR MT (14.6 months) and EGFR WT (2.5 months) did not reach statistical significance (p = 0.230). CONCLUSIONS Synchronous BM was more common in NSCLC patients with EGFR MT than in those with EGFR WT. However, EGFR mutations were associated with significantly longer median BM-OS, especially when the brain was the first metastatic site.
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Affiliation(s)
- Min Young Baek
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hee Kyung Ahn
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyu Ree Park
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwa-Sun Park
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Shin Myung Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Inkeun Park
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Saing Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Junshik Hong
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sun Jin Sym
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinny Park
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Hoon Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Dong Bok Shin
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Eun Kyung Cho
- Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
- Correspondence to Eun Kyung Cho, M.D. Division of Hematology and Oncology, Department of Internal Medicine, Gachon University Gil Medical Center, 21 Namdongdaero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-8507 Fax: +82-32-460-2391 E-mail:
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Li SH, Liu CY, Hsu PC, Fang YF, Wang CC, Kao KC, Tseng LC, Yang CT. Response to afatinib in treatment-naïve patients with advanced mutant epidermal growth factor receptor lung adenocarcinoma with brain metastases. Expert Rev Anticancer Ther 2017; 18:81-89. [PMID: 29172778 DOI: 10.1080/14737140.2018.1409623] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Brain metastases are observable in 20-40% of non-small cell lung cancer patients, but standard treatments for such metastases may be intolerable to some. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) were found to be effective against mutant-EGFR lung adenocarcinomas, but data regarding their effectiveness, especially for the second-generation EGFR-TKI afatinib, is limited. This study compared key outcomes for afatanib monotherapy versus afatinib combined with whole-brain radiotherapy (WBRT) in treatment-naïve lung adenocarcinoma patients harboring EGFR mutations. METHODS A retrospective review of 28 brain metastatic lung adenocarcinoma patients treated between June 2014 and December 2016 was conducted; 17 were treated with WBRT and maintenance afatinib therapy, while 11 received afatinib monotherapy. RESULTS The patients were predominantly female (n = 17, 60.7%) and non-smokers (78.6%). Almost all the patients (89.3%) had an Eastern Cooperative Oncology Group performance status of 0-2. The EGFR mutation type consisted of the del19 mutation in 57.1% of the patients (n = 16), while L858R mutations were found in 42.9% (n = 12). The mean number of brain metastases (6.1 ± 5.0) was higher among the patients treated with afatinib monotherapy, while the mean size of the largest brain metastasis (19.0 ± 10.5mm) was greater in the afatinib combined with WBRT group. The objective response rates for the afatinib monotherapy and combination therapy groups were 81.8% and 88.2%, respectively. However, the monotherapy group exhibited a significantly higher complete response rate for intracranial lesions (63.6% vs. 17.6%, p = 0.02), and there were no significant differences between the two treatment groups in overall survival or time to treatment failure. CONCLUSION Afatinib can provide therapeutic efficacy and a good response rate in treatment-naïve mutant-EGFR lung adenocarcinoma patients with brain metastases regardless of whether or not they also receive radiotherapy.
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Affiliation(s)
- Shih-Hong Li
- a Department of Thoracic Medicine , Chung Gung Memorial Hospital , Linkou , Taiwan
| | - Chien-Ying Liu
- a Department of Thoracic Medicine , Chung Gung Memorial Hospital , Linkou , Taiwan.,b College of Medicine , Chung Gung University , Taoyuan , Taiwan
| | - Ping-Chih Hsu
- a Department of Thoracic Medicine , Chung Gung Memorial Hospital , Linkou , Taiwan
| | - Yueh-Fu Fang
- a Department of Thoracic Medicine , Chung Gung Memorial Hospital , Linkou , Taiwan.,b College of Medicine , Chung Gung University , Taoyuan , Taiwan.,d Department of Thoracic Medicine , Department of Internal Medicine, Saint Paul's Hospital , Taoyuan , Taiwan
| | - Chun-Chieh Wang
- b College of Medicine , Chung Gung University , Taoyuan , Taiwan.,f Institute for Radiological Research , Chung Gung Memorial Hospital , Linkou , Taiwan
| | - Kuo-Chin Kao
- a Department of Thoracic Medicine , Chung Gung Memorial Hospital , Linkou , Taiwan.,b College of Medicine , Chung Gung University , Taoyuan , Taiwan
| | - Li-Chuan Tseng
- e Department of Nursing , Chung Gung Memorial Hospital , Linkou , Taiwan
| | - Cheng-Ta Yang
- b College of Medicine , Chung Gung University , Taoyuan , Taiwan.,c Department of Thoracic Medicine , Chung Gung Memorial Hospital , Taoyuan , Taiwan
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77
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Fernandes AW, Wu B, Turner RM. Brain metastases in non-small cell lung cancer patients on epidermal growth factor receptor tyrosine kinase inhibitors: symptom and economic burden. J Med Econ 2017; 20:1136-1147. [PMID: 28758857 DOI: 10.1080/13696998.2017.1361960] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE This study describes the symptom and economic burden associated with brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) receiving epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (EGFR-TKIs). METHODS This retrospective study included adults with ≥2 medical claims, within 90 days, for lung cancer and ≥1 administration of EGFR-TKIs. Based on ICD-9 codes, patients were stratified into cohorts by type of metastases (BM, other metastases [OM], or no metastases [NM]), and by when the metastasis diagnosis occurred (synchronous or asynchronous). RESULTS The population (synchronous BM [SBM] = 24, synchronous OM [SOM] = 23, asynchronous BM [ASBM] = 15, asynchronous OM [ASOM] = 49, NM = 85) was mostly female (57%), average age 69 years (SD = 11). SBM patients experienced more fatigue and nausea/vomiting compared with SOM and NM patients and more headaches and loss of appetite than NM patients. ASBM was associated with more fatigue, nausea/vomiting, headaches, pain/numbness, altered mental status, and seizures than NM, and more headaches and pain/numbness than ASOM. SBM patients experienced a greater increase in per-member-per-month all-cause total healthcare costs after diagnosis ($20,301) vs SOM ($9,131, p = .001) and NM ($2,493, p = .001). ASBM's cost increase between baseline and follow-up ($7,867) did not differ from ASOM's ($4,947, p = .195); both were larger than NM ($2,493, p = .001 and p = .009, respectively). LIMITATIONS EGFR mutation status was inferred based on EGFR-TKI treatment, not by molecular testing. Patients were from US commercial insurance plans; results may not be generalizable to other populations. CONCLUSIONS Among patients with EGFR-TKI-treated NSCLC, patients with BM experienced more symptoms and, when diagnosed synchronously, had significant increases in total medical costs vs patients with OM and NM. Therapeutic options with central nervous system activity may offer advantages in symptomatology and costs in EGFR-mutated patients with BM.
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Affiliation(s)
| | - Bingcao Wu
- b Janssen Pharmaceuticals, Inc. , Titusville , NJ , USA
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78
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Bohn JP, Pall G, Stockhammer G, Steurer M. Targeted Therapies for the Treatment of Brain Metastases in Solid Tumors. Target Oncol 2017; 11:263-75. [PMID: 26822319 DOI: 10.1007/s11523-015-0414-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality in cancer patients. While the mainstay treatment comprises surgery and radiation therapy, the role of systemic agents remains controversial. In general, it has been presumed that poor blood-brain barrier (BBB) penetration and inherently more resistant metastatic brain disease preclude a favorable systemic treatment approach. However, a better understanding of tumor biology and the subsequent development of targeted drugs have reawakened interest in systemic therapy. Despite still limited brain distribution, a variety of targeted drugs have demonstrated activity in brain metastases in early clinical trials. Nevertheless, disease progression commonly occurs, and it remains to be elucidated whether limited CNS drug distribution or the acquisition of resistant metastatic clones must be held responsible for this prognosis. Moreover, micrometastatic brain disease beyond an intact BBB-and ultimately prevention of brain metastasis formation-may generally remain inaccessible for first-generation targeted agents with poor CNS penetration. To overcome limited brain distribution and possibly emerging acquired resistance, highly potent next-generation targeted drugs with enhanced CNS distribution have been developed. In view of this emerging but yet undefined role of targeted therapies in the treatment of brain metastases from solid tumors, this review aims to summarize the current knowledge from clinical trials and discusses clinically relevant obstacles to overcome.
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Affiliation(s)
- Jan-Paul Bohn
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
| | - Georg Pall
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Guenther Stockhammer
- Department of Neurology and Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Steurer
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
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Arbour KC, Kris MG, Riely GJ, Ni A, Beal K, Daras M, Hayes SA, Young RJ, Rodriguez CR, Ahn L, Pao W, Yu HA. Twice weekly pulse and daily continuous-dose erlotinib as initial treatment for patients with epidermal growth factor receptor-mutant lung cancers and brain metastases. Cancer 2017; 124:105-109. [PMID: 28940498 DOI: 10.1002/cncr.30990] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND In a phase 1 study of pulse/continuous-dose erlotinib, no patient had disease progression in the central nervous system (CNS). This expansion cohort of the phase 1 study tested the same regimen in a cohort of individuals with epidermal growth factor receptor (EGFR)-mutant lung cancers with untreated brain metastases. METHODS Patients had not received EGFR tyrosine kinase inhibitors or radiation for brain metastases. All received 1200 mg of erlotinib on days 1 and 2 and 50 mg on days 3 to 7 weekly. The primary endpoints were the overall and CNS response rates (according to version 1.1 of the Response Evaluation Criteria in Solid Tumors). RESULTS Between May 2015 and August 2016, 19 patients were enrolled. Forty-two percent of the patients had target brain lesions, and the median size of the target brain lesions was 13 mm. Overall, 14 patients (74%; 95% confidence interval [CI], 51%-89%) had partial responses. The response rate in brain metastases was 75%. The overall median progression-free survival was 10 months (95% CI, 7 months to not reached). Only 3 patients (16%) had CNS progression. To date, 4 patients required CNS radiation at some time during their course. The adverse events (any grade) seen in 10% or more of the patients were rash, diarrhea, nausea, an increase in alanine aminotransferase, and fatigue. CONCLUSIONS Pulse/continuous-dose erlotinib produced a 74% overall response rate and a 75% response rate in brain metastases in patients with EGFR-mutant lung cancers and untreated brain metastases. CNS control persisted even after progression elsewhere. Although this regimen did not improve progression-free survival or delay the emergence of EGFR T790M, it prevented progression in the brain and could be useful in situations in which CNS control is critical. Cancer 2018;124:105-9. © 2017 American Cancer Society.
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Affiliation(s)
- Kathryn C Arbour
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Gregory J Riely
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ai Ni
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mariza Daras
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sara A Hayes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher R Rodriguez
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Ahn
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William Pao
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Helena A Yu
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
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80
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Niu H, Zhou J, Maan H, Markman M, Niu J. Treatment of Leptomeningeal Metastases in a Patient with Non-Small Cell Lung Cancer Harboring EGFR T790M Mutation. Case Rep Oncol 2017; 10:840-845. [PMID: 29070999 PMCID: PMC5649226 DOI: 10.1159/000480452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Leptomeningeal metastasis (LM) is an uncommon complication in patients with solid tumors, associated with poor survival. However, LM appears to be more frequent in lung cancer patients with EGFR mutations, posing a unique clinical challenge to treating physicians. CASE PRESENTATION We report the case of a 68-year-old Asian man with metastatic lung adenocarcinoma harboring an EGFR L858R mutation, which was initially treated with gefitinib. He developed disease progression 1 year later. Re-biopsy of the right lower lobe primary lesion revealed only an EGFR L858R mutation in the absence of a T790M mutation. The patient also experienced persistent confusion and generalized fatigue, and magnetic resonance imaging (MRI) of the brain demonstrated extensive LM. At this time, a liquid biopsy revealed an EGFR T790M mutation. Following initiation of treatment with osimertinib, the patient exhibited a rapid response with MRI of the brain showing substantial improvement of the LM after 6 months. Unfortunately, the LM recurred after 1 year at which time the patient declined further systemic chemotherapy. CONCLUSION To our knowledge, this is the second reported case of LM in a patient with lung cancer harboring an EGFR T790M mutation that was successfully treated with osimertinib.
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Affiliation(s)
- Hardy Niu
- Basis Scottsdale, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Junle Zhou
- Department of Pharmacy, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | | | - Maurie Markman
- Department of Medical Oncology, Cancer Treatment Centers of America, and Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jiaxin Niu
- Department of Medical Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
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81
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Nam JY, O’Brien BJ. Current chemotherapeutic regimens for brain metastases treatment. Clin Exp Metastasis 2017; 34:391-399. [DOI: 10.1007/s10585-017-9861-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 09/06/2017] [Indexed: 01/19/2023]
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82
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Bui N, Woodward B, Johnson A, Husain H. Novel Treatment Strategies for Brain Metastases in Non-small-cell Lung Cancer. Curr Treat Options Oncol 2017; 17:25. [PMID: 27085533 DOI: 10.1007/s11864-016-0400-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OPINION STATEMENT Brain metastases are common in patients with non-small cell lung cancer (NSCLC), and due to associated poor prognosis, this field is an important area of need for the development of innovative medical therapies. Therapies including local approaches through surgical intervention and/or radiation and evolving systemic therapies have led to improvements in the treatment of brain metastases in patients with lung cancer. Strategies that consider applying advanced radiation techniques to minimize toxicity, intervening early with effective systemic therapies to spare radiation/surgery, testing radiosensitization combinations, and developing drug penetrant molecules have and will continue to define new practice patterns. We believe that in carefully considered asymptomatic patients, first-line systemic therapy may be considered before radiation therapy and small-molecule targeted therapy may provide an opportunity to defer radiation therapy for recurrence or progression of disease. The next several years in oncology drug development will see the reporting on of brain penetrant molecules in oncogene-defined non-small cell lung cancer. Ongoing studies will evaluate immunotherapies in patients with brain metastases with associated endpoints. We hope that continued drug development and carefully designed clinical trials may afford an opportunity to improve the lives of patients with brain metastases.
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Affiliation(s)
- Nam Bui
- Division of Hematology and Oncology, University of California, San Diego School of Medicine, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Brian Woodward
- Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Anna Johnson
- Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Hatim Husain
- Division of Hematology and Oncology, University of California, San Diego School of Medicine, UCSD Moores Cancer Center, San Diego, CA, USA. .,Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA. .,, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA.
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McGranahan T, Nagpal S. A Neuro-oncologist's Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer. Curr Treat Options Oncol 2017; 18:22. [PMID: 28391420 PMCID: PMC5385200 DOI: 10.1007/s11864-017-0466-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited data to guide treatment decisions. Tumors with activating mutations in epidermal growth factor receptor (EGFRact+) have a higher incidence of BrM, but a longer overall survival. The high response rate of both systemic and BrM EGFRact+ NSCLC to tyrosine kinase inhibitors (TKIs) has led to the rapid incorporation of new therapies but is outpacing evidence-based decisions for BrM in NSCLC. While whole brain radiation therapy (WBRT) was the foundation of management of BrM, extended survival raises concerns for the subacute and late effects radiotherapy. We favor the use of TKIs and delaying the use of WBRT when able. At inevitable disease progression, we consider alternative dosing schedules to increase CNS penetration (such as pulse dosing of erlotinib) or advance to next generation TKI if available. We utilize local control options of surgery or stereotactic radiosurgery (SRS) for symptomatic accessible lesions based on size and edema. At progression despite available TKIs, we use pemetrexed-based platinum doublet chemotherapy or immunotherapy if the tumor has high expression of PDL-1. We reserve the use of WBRT for patients with more than 10 BrM and progression despite TKI and conventional chemotherapy, if performance status is appropriate.
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Affiliation(s)
- Tresa McGranahan
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
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84
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Péchoux CL, Sun A, Slotman BJ, De Ruysscher D, Belderbos J, Gore EM. Prophylactic cranial irradiation for patients with lung cancer. Lancet Oncol 2017; 17:e277-e293. [PMID: 27396646 DOI: 10.1016/s1470-2045(16)30065-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/20/2016] [Accepted: 04/05/2016] [Indexed: 01/20/2023]
Abstract
The incidence of brain metastases in patients with lung cancer has increased as a result of improved local and systemic control and better diagnosis from advances in brain imaging. Because brain metastases are responsible for life-threatening symptoms and serious impairment of quality of life, resulting in shortened survival, prophylactic cranial irradiation has been proposed in both small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) to try to improve incidence of brain metastasis, survival, and eventually quality of life. Findings from randomised controlled trials and a meta-analysis have shown that prophylactic cranial irradiation not only reduces the incidence of brain metastases in patients with SCLC and with non-metastatic NSCLC, but also improves overall survival in patients with SCLC who respond to first-line treatment. Although prophylactic cranial irradiation is potentially associated with neurocognitive decline, this risk needs to be balanced against the potential benefit in terms of brain metastases incidence and survival. Several strategies to reduce neurotoxicity are being investigated.
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Affiliation(s)
- Cécile Le Péchoux
- Department of Radiation Oncology, Gustave Roussy University Hospital, Villejuif, France.
| | - Alexander Sun
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands; Department of Oncology, Experimental Radiation Oncology, KU Leuven, Leuven, Belgium
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Elizabeth M Gore
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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85
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Treatment options for EGFR mutant NSCLC with CNS involvement—Can patients BLOOM with the use of next generation EGFR TKIs? Lung Cancer 2017. [DOI: 10.1016/j.lungcan.2017.02.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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86
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Patel SH, Rimner A, Foster A, Zhang Z, Woo KM, Yu HA, Riely GJ, Wu AJ. Patterns of initial and intracranial failure in metastatic EGFR-mutant non-small cell lung cancer treated with erlotinib. Lung Cancer 2017; 108:109-114. [PMID: 28625621 PMCID: PMC5477661 DOI: 10.1016/j.lungcan.2017.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Patients with metastatic EGFR-mutant (mEGFRmt) NSCLC have favorable survival when treated with erlotinib. We hypothesized that treatment failure in most patients is limited to initial sites of disease, in which case incorporating local therapy such as radiation might further delay progression. We therefore analyzed patterns and predictors of failure in a large cohort of such patients. MATERIALS AND METHODS We reviewed 189 patients treated with erlotinib for mEGFRmt NSCLC. We classified first pattern of failure as involving initial sites only (ISF), new sites only (NSF), or the combination (CSF), and used competing-risks regression to identify factors associated with ISF, progression and overall survival (OS). We also separately analyzed intracranial and intrathoracic failure. RESULTS Of 171 patients who progressed, 103 (60.2%) had ISF, 30 (17.5%) had NSF, and 38 (22.2%) had CSF. Younger age and lack of initial CNS involvement independently correlated with ISF, with a trend for higher T and N stage. Higher T and N stage was also a significant predictor of progression. Factors predicting shorter OS were female gender, weight loss, initial intracranial involvement, and ≥4 extracranial metastases. Intrathoracic progression was a component of first failure in 61%, and three-year cumulative incidence of brain metastasis was 30%. CONCLUSION The main pattern of progression in mEGFRmt NSCLC on erlotinib is in the initial sites of disease. Younger patients and those without brain involvement are particularly likely to develop ISF. This suggests a role for incorporating local therapy into treatment of selected patients with mEGFRmt NSCLC.
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Affiliation(s)
- Suchit H Patel
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Andreas Rimner
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Amanda Foster
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Zhigang Zhang
- Departments of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Kaitlin M Woo
- Departments of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Helena A Yu
- Departments of Thoracic Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Gregory J Riely
- Departments of Thoracic Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Abraham J Wu
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States.
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87
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Wong A. The Emerging Role of Targeted Therapy and Immunotherapy in the Management of Brain Metastases in Non-Small Cell Lung Cancer. Front Oncol 2017; 7:33. [PMID: 28424757 PMCID: PMC5380676 DOI: 10.3389/fonc.2017.00033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/24/2017] [Indexed: 02/03/2023] Open
Abstract
Lung cancer is the worldwide leading cause of cancer-related mortality in men and second leading in women. Brain metastases (BM) account for 10% of non-small cell lung cancer (NSCLC) patients at initial presentation, with another 25-40% developing BM during the course of their disease. In the last decade, the field of precision oncology has led to the discovery of a multitude of heterogenous molecular abnormalities within NSCLC as well as the development of tyrosine kinase inhibitors that target them. In this review, the focus will be on targeted therapy and immunotherapy that show efficacy in BM rather than conventional treatment for multiple BM (such as surgical resection, WBRT, or stereotactic radiosurgery).
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Affiliation(s)
- Annick Wong
- Medical Oncology, McGill University Health Centre, Montreal, QC, Canada.,Medical Oncology, Hôpital du Suroît, Valleyfield, QC, Canada
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88
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Li MX, He H, Ruan ZH, Zhu YX, Li RQ, He X, Lan BH, Zhang ZM, Liu GD, Xiao HL, Wu Y, Zhu B, Wang G, Yang ZZ. Central nervous system progression in advanced non-small cell lung cancer patients with EGFR mutations in response to first-line treatment with two EGFR-TKIs, gefitinib and erlotinib: a comparative study. BMC Cancer 2017; 17:245. [PMID: 28376735 PMCID: PMC5379522 DOI: 10.1186/s12885-017-3165-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/02/2017] [Indexed: 11/25/2022] Open
Abstract
Background Central nervous system (CNS) brain metastasis of advanced non-small cell lung cancer (NSCLC) patients confers a worse quality of life and prognosis. The efficacy comparison of two first-generation epidermal growth factor receptor (EGFR) inhibitors erlotinib or gefitinib as first-line treatment for CNS metastasis NSCLC patients with EGFR-sensitizing mutations is yet to be elucidated. Methods A retrospective analysis was done on cerebral metastasis rate after erlotinib or gefitinib as first-line treatment for advanced NSCLC patients with EGFR-sensitizing mutations. Time to neurological progression (nTTP) and median progression-free survival (mPFS) were calculated. Results The study involved 279 patients (erlotinib group: 108, gefitinib group: 171). After a median follow-up of 22 months, 27 patients (25%) in the erlotinib group and 60 patients (35.1%) in the gefitinib group showed CNS progression. The HR of CNS progression for erlotinib versus gefitinib was 0.695 [95% confidence interval (CI), 0.406–1.190], suggesting a risk reduction of 30.5% although not achieving statistical significance. The 6-, 12- and 18-month cumulative CNS progression rates were 0.9, 3.7 and 12% for erlotinib compared with corresponding rates of 5.8, 9.4 and 17% for gefitinib (P = 0.181). However, for those patients with preexisting brain metastases prior to EGFR-TKI treatment, erlotinib as first line treatment significantly extended the median nTTP in comparison to gefitinib (30 months vs 15.8 months, p = 0.024). Conclusions Our data show that nTTP can be effectively extended in preexisting brain metastases patients with EGFR-sensitizing mutations initially treated with erlotinib compared with gefitinib. If confirmed, our results indicate that erlotinib may play an important role in controlling CNS progression from EGFR mutation-positive NSCLC. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3165-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meng-Xia Li
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Hao He
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhi-Hua Ruan
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, 400037, People's Republic of China
| | - Yu-Xi Zhu
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Rong-Qing Li
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan, People's Republic of China
| | - Xiao He
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Bao-Hua Lan
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhi-Min Zhang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Guo-Dong Liu
- Eighth Department, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Hua-Liang Xiao
- Department of Pathology, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Yan Wu
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Bo Zhu
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, People's Republic of China
| | - Ge Wang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhen-Zhou Yang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China.
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Tsakonas G, De Petris L, Ekman S. Management of brain metastasized non-small cell lung cancer (NSCLC) – From local treatment to new systemic therapies. Cancer Treat Rev 2017; 54:122-131. [DOI: 10.1016/j.ctrv.2017.02.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/31/2017] [Accepted: 02/07/2017] [Indexed: 01/24/2023]
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Yu HA, Sima C, Feldman D, Liu LL, Vaitheesvaran B, Cross J, Rudin CM, Kris MG, Pao W, Michor F, Riely GJ. Phase 1 study of twice weekly pulse dose and daily low-dose erlotinib as initial treatment for patients with EGFR-mutant lung cancers. Ann Oncol 2017; 28:278-284. [PMID: 28073786 PMCID: PMC5834093 DOI: 10.1093/annonc/mdw556] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Patients with EGFR-mutant lung cancers treated with EGFR tyrosine kinase inhibitors (TKIs) develop clinical resistance, most commonly with acquisition of EGFR T790M. Evolutionary modeling suggests that a schedule of twice weekly pulse and daily low-dose erlotinib may delay emergence of EGFR T790M. Pulse dose erlotinib has superior central nervous system (CNS) penetration and may result in superior CNS disease control. Methods We evaluated toxicity, pharmacokinetics, and efficacy of twice weekly pulse and daily low-dose erlotinib. We assessed six escalating pulse doses of erlotinib. Results We enrolled 34 patients; 11 patients (32%) had brain metastases at study entry. We observed 3 dose-limiting toxicities in dose escalation: transaminitis, mucositis, and rash. The MTD was erlotinib 1200 mg days 1-2 and 50 mg days 3-7 weekly. The most frequent toxicities (any grade) were rash, diarrhea, nausea, fatigue, and mucositis. 1 complete and 24 partial responses were observed (74%, 95% CI 60-84%). Median progression-free survival was 9.9 months (95% CI 5.8-15.4 months). No patient had progression of an untreated CNS metastasis or developed a new CNS lesion while on study (0%, 95% CI 0-13%). Of the 18 patients with biopsies at progression, EGFR T790M was identified in 78% (95% CI 54-91%). Conclusion This is the first clinical implementation of an anti-cancer TKI regimen combining pulse and daily low-dose administration. This evolutionary modeling-based dosing schedule was well-tolerated but did not improve progression-free survival or prevent emergence of EGFR T790M, likely due to insufficient peak serum concentrations of erlotinib. This dosing schedule prevented progression of untreated or any new central nervous system metastases in all patients.
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Affiliation(s)
- H. A. Yu
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - C. Sima
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York
| | - D. Feldman
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - L. L. Liu
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - B. Vaitheesvaran
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Sloan Kettering Institute, Sloan Kettering Cancer Center, New York
| | - J. Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Sloan Kettering Institute, Sloan Kettering Cancer Center, New York
| | - C. M. Rudin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - M. G. Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - W. Pao
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - F. Michor
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - G. J. Riely
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
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91
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Cedrych I, Kruczała MA, Walasek T, Jakubowicz J, Blecharz P, Reinfuss M. Systemic treatment of non-small cell lung cancer brain metastases. Contemp Oncol (Pozn) 2016; 20:352-357. [PMID: 28373815 PMCID: PMC5371701 DOI: 10.5114/wo.2016.64593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/27/2015] [Indexed: 12/02/2022] Open
Abstract
In the systemic treatment of brain metastases from non-small cell lung cancer (BMF-NSCLC) chemo- and targeted therapy are used. Response rates after platinum-based chemotherapy, range from 23% to 45%. Development of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs): gefitinib or erlotinib, was an improvement in treatment of advanced NSCLC patients. EGFR mutations are present in 10-25% of NSCLC (mostly adenocarcinoma), and up to 55% in never-smoking women of East Asian descent. In the non-selected group of patients with BMF-NSCLC, the overall response rates after gefitinib or erlotinib treatment range from 10% to 38%, and the duration of response ranges from 9 to 13.5 months. In the case of present activating EGFR mutation, the response rate after EGRF-TKIs is greater than 50%, and in selected groups (adenocarcinoma, patients of Asian descent, never-smokers, asymptomatic BMF-NSCLC) even 70%. Gefitinib or erlotinib treatment improves survival of BMF-NSCLC patients with EGFR mutation in comparison to cases without the presence of this mutation. There is no data on the activity of the anti-EML4-ALK agent crizotinib. Bevacizumab, recombinant humanised monoclonal antibody anti-VEGF, in the treatment of advanced non-squamous NSCLC patients is a subject of intense research. Data from a clinical trial enrolling patients with pretreated or occult BMF-NSCLC proved that the addition of bevacizumab to various chemotherapy agents or erlotinib is a safe and efficient treatment, associated with a low incidence of CSN haemorrhages. However, the efficacy and safety of bevacizumab used for therapeutic intent, regarding active brain metastases is unknown.
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Affiliation(s)
- Ida Cedrych
- Department of Systemic and Generalised Malignancies, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
| | - Maksymilian A. Kruczała
- Department of Systemic and Generalised Malignancies, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
| | - Tomasz Walasek
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
| | - Jerzy Jakubowicz
- Department of Oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
| | - Paweł Blecharz
- Department of Gynecologic Oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
| | - Marian Reinfuss
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Krakow Branch, Poland
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92
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Buttigliero C, Bertaglia V, Novello S. Anti-angiogenetic therapies for central nervous system metastases from non-small cell lung cancer. Transl Lung Cancer Res 2016; 5:610-627. [PMID: 28149756 DOI: 10.21037/tlcr.2016.09.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Central nervous system (CNS) metastases are common in patients with advanced non-small cell lung cancer (NSCLC), occurring in 24% to 44% of patients in the course of their disease and confer significant morbidity and mortality. Systemic therapies have been deemed ineffective in brain metastases (BM) under the hypothesis that the blood-brain barrier (BBB) limits their delivery to the brain. Angiogenesis, which is mainly mediated by vascular endothelial growth factor (VEGF) pathway, is crucial for tumor survival, growth and invasion both in primary and metastatic brain lesions. Two major categories of agents have been developed to target this pathway: antibody-based agents and VEGF receptor tyrosine kinase inhibitors (TKIs). Clinical benefits have been shown with anti-angiogenetic therapies in the treatment of metastatic NSCLC. However, patients with CNS metastases were often excluded from trials with these agents, due to concerns about a potentially greater risk of cerebral haemorrhage and thromboembolic disease. Therefore, the overall efficacy and safety of angiogenetic agents in patients with BM from NSCLC are yet to be clarified. This paper aims to review available data about the efficacy and safety of anti-angiogenetic therapies for CNS metastases in NSCLC patients.
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Affiliation(s)
- Consuelo Buttigliero
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Valentina Bertaglia
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
| | - Silvia Novello
- Department of Oncology, San Luigi Hospital, University of Turin, Orbassano, Turin, Italy
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93
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Silva APS, Coelho PV, Anazetti M, Simioni PU. Targeted therapies for the treatment of non-small-cell lung cancer: Monoclonal antibodies and biological inhibitors. Hum Vaccin Immunother 2016; 13:843-853. [PMID: 27831000 PMCID: PMC5404364 DOI: 10.1080/21645515.2016.1249551] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The usual treatments for patients with non-small-cell lung cancer (NSCLC), such as advanced lung adenocarcinoma, are unspecific and aggressive, and include lung resection, radiotherapy and chemotherapy. Recently, treatment with monoclonal antibodies and biological inhibitors has emerged as an effective alternative, generating effective results with few side effects. In recent years, several clinical trials using monoclonal antibodies presented potential benefits to NSCLC, and 4 of them are already approved for the treatment of NSCLC, such as cetuximab, bevacizumab, nivolumab and pembrolizumab. Also, biological inhibitors are attractive tolls for biological applications. Among the approved inhibitors are crizotinib, erlotinib, afatinib and gefitinib, and side effects are usually mild to intense. Nevertheless, biological molecule treatments are under development, and several new monoclonal antibodies and biological inhibitors are in trial to treat NSCLC. Also under trial study are as follows: anti-epidermal growth factor receptor (EGFR) antibodies (nimotuzumab and ficlatuzumab), anti-IGF 1 receptor (IGF-1R) monoclonal antibody (figitumumab), anti-NR-LU-10 monoclonal antibody (nofetumomab) as well as antibodies directly affecting the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) molecule (ipilimumab and tremelimumab), to receptor activator of nuclear factor-kappa B ligand (RANKL) (denosumab) or to polymerase enzyme (veliparib and olaparib). Among new inhibitors under investigation are poly-ADP ribose polymerase (PARP) inhibitors (veliparib and olaparib) and phosphatidylinositol 3-kinase (PI3K) inhibitor (buparlisib). However, the success of immunotherapies still requires extensive research and additional controlled trials to evaluate the long-term benefits and side effects.
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Affiliation(s)
- Ana P S Silva
- a Department of Biomedical Science , Faculty of Americana , Americana , SP , Brazil
| | - Priscila V Coelho
- a Department of Biomedical Science , Faculty of Americana , Americana , SP , Brazil
| | - Maristella Anazetti
- a Department of Biomedical Science , Faculty of Americana , Americana , SP , Brazil.,b Department of Health Science , Faculty DeVry Metrocamp , Campinas , SP , Brazil
| | - Patricia U Simioni
- a Department of Biomedical Science , Faculty of Americana , Americana , SP , Brazil.,c Department of Genetics , Evolution and Bioagents, Institute of Biology, University of Campinas (UNICAMP) , Campinas , SP , Brazil.,d Department of Biochemistry and Microbiology , Institute of Biosciences, Universidade Estadual Paulista, UNESP , Rio Claro , SP , Brazil
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94
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Pechoux CL, Dhermain F, Besse B. Whole brain radiotherapy in patients with NSCLC and brain metastases. Lancet 2016; 388:1960-1962. [PMID: 27604505 DOI: 10.1016/s0140-6736(16)31391-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Cécile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94800, France.
| | - Frederic Dhermain
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif 94800, France
| | - Benjamin Besse
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif 94800, France; Faculté de Médecine, Université Paris Sud, Le Kremlin-Bicêtre, France
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Dagogo-Jack I, Gill CM, Cahill DP, Santagata S, Brastianos PK. Treatment of brain metastases in the modern genomic era. Pharmacol Ther 2016; 170:64-72. [PMID: 27773784 DOI: 10.1016/j.pharmthera.2016.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Development of brain metastasis (BM) portends a dismal prognosis for patients with cancer. Melanomas and carcinomas of the lung, breast, and kidney are the most common malignancies to metastasize to the brain. Recent advances in molecular genetics have enabled the identification of actionable, clinically relevant genetic alterations within primary tumors and their corresponding metastases. Adoption of genotype-guided treatment strategies for the management of systemic malignancy has resulted in dramatic and durable responses. Unfortunately, despite these therapeutic advances, central nervous system (CNS) relapses are not uncommon. Although these relapses have historically been attributed to limited blood brain barrier penetration of anti-neoplastic agents, recent work has demonstrated genetic heterogeneity such that metastatic sites, including BM, harbor relevant genetic alterations that are not present in primary tumor biopsies. This improved insight into molecular mechanisms underlying site specific recurrences can inform strategies for targeting these oncogenic drivers. Thus, development of rational, genomically guided CNS-penetrant therapies is crucial for ongoing therapeutic success.
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Affiliation(s)
- Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Corey M Gill
- Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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96
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Khalifa J, Amini A, Popat S, Gaspar LE, Faivre-Finn C. Brain Metastases from NSCLC: Radiation Therapy in the Era of Targeted Therapies. J Thorac Oncol 2016; 11:1627-43. [PMID: 27343440 DOI: 10.1016/j.jtho.2016.06.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/02/2016] [Accepted: 06/09/2016] [Indexed: 02/07/2023]
Abstract
Brain metastases (BMs) will develop in a large proportion of patients with NSCLC throughout the course of their disease. Among patients with NSCLC with oncogenic drivers, mainly EGFR activating mutations and anaplastic lymphoma receptor tyrosine kinase gene (ALK) rearrangements, the presence of BM is a common secondary localization of disease both at the time of diagnosis and at relapse. Because of the limited penetration of a wide range of drugs across the blood-brain barrier, radiotherapy is considered the cornerstone of treatment of BMs. However, evidence of dramatic intracranial response rates has been reported in recent years with targeted therapies such as tyrosine kinase inhibitors and has been supported by new insights into pharmacokinetics to increase rates of tyrosine kinase inhibitors' penetration of the cerebrospinal fluid (CSF). In this context, the combination of brain radiotherapy and targeted therapies seems relevant, and there is a strong radiobiological rationale to harness the radiosentizing effect of the drugs. Nevertheless, to date, there is a paucity of high-level clinical evidence supporting the combination of brain radiotherapy and targeted therapies in patients with NSCLC and BMs, and there are often methodological biases in reported studies, such as the lack of stratification by mutation status. Moreover, among asymptomatic patients not suitable for ablative treatment, this strategy is challenged by the promising results associated with the administration of targeted therapies alone. Herein, we review the biological rationale to combine targeted therapies and brain radiotherapy for patients with NSCLC and BMs, report the clinical data available to date, and discuss future directions to improve outcome in this group of patients.
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Affiliation(s)
- Jonathan Khalifa
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom.
| | - Arya Amini
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Sanjay Popat
- Lung Cancer Unit, Royal Marsden Hospital, London, United Kingdom
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie National Health Service Foundation Trust, Manchester, United Kingdom; Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester, Manchester, United Kingdom
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97
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Crisan A, Badulescu F, Popescu M, Andrei I. Therapeutical Attitude and Analysis of Results in Brain Metastases. CURRENT HEALTH SCIENCES JOURNAL 2016; 42:372-384. [PMID: 30581592 PMCID: PMC6269615 DOI: 10.12865/chsj.42.04.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/16/2016] [Indexed: 11/12/2022]
Abstract
Objectives - The aim of this study is to assess therapeutic outcomes in patients presenting with brain metastases as the first manifestation of malignancies either as a final stage in the evolution of malignancies. Materials and methods - We've performed a complex retrospective study on a total of 81 patients with brain metastases treated in Medical Oncology Clinic of the Emergency County Hospital Craiova between 1 January 2005-31 December 2010. Results - The average age of women (55 years) was statistically significantly low compared to men (64 years) (p = 0.000). The most affected age group was 51-60 years in women with maximum frequency of breast cancer and 61-70 years for men, with predominance of lung cancer. Most cases were presented with multiple metastases (90.12%) and the average latency-free interval from primary tumor detection to onset of symptoms was 29.8 months. Clinical manifestations, in most cases, occurred in less than 6 months after diagnosis of the primary tumor being a consequence of the evolution of disease at distance (36 patients / 62 patients in oncological evidence 58.06%) and 12 months after diagnosis survival rate was low being detected in patients with a controlled primary tumor and distant resumption of the disease (14 patients / 62 patients in oncological evidence-22.58%).Median survival in patients with irradiated brain metastases was 7 months. Multivariate statistical analysis of the survival rate has detected statistically significant differences depending on the type of the primary tumor (p = 0.000) and the manner of the onset of brain metastases as the first manifestation or evolution of neoplastic disease (p = 0.000).Survival was affected, without statistical significance threshold, by the number of metastases, patient gender and the loco-regional status of the primary tumor.
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Affiliation(s)
- A Crisan
- Department of Medical Oncology, University of Medicine and Pharmacy Craiova, Clinical Emergency County Hospital, Craiova
| | - F Badulescu
- Department of Medical Oncology, University of Medicine and Pharmacy Craiova, Clinical Emergency County Hospital, Craiova
| | - M Popescu
- Department of Radiology, University of Medicine and Pharmacy Craiova, Clinical Emergency County Hospital, Craiova
| | - I Andrei
- VI year student, University of Medicine and Pharmacy, Craiova
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98
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Toyokawa G, Seto T, Takenoyama M, Ichinose Y. Insights into brain metastasis in patients with ALK+ lung cancer: is the brain truly a sanctuary? Cancer Metastasis Rev 2016; 34:797-805. [PMID: 26342831 PMCID: PMC4661196 DOI: 10.1007/s10555-015-9592-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Anaplastic lymphoma kinase (ALK) has been identified to exert a potent transforming activity through its rearrangement in non-small cell lung cancer (NSCLC), and patients (pts) with ALK rearrangement can be treated more successfully with ALK inhibitors, such as crizotinib, alectinib, and ceritinib, than with chemotherapy. Despite the excellent efficacy of ALK inhibitors, resistance to these drugs is inevitably encountered in most ALK-rearranged pts. Cases of resistance are subtyped into three groups, i.e., systemic, oligo, and central nervous system (CNS) types, with the CNS being used to be considered a sanctuary. With regard to the management of CNS lesions in pts with ALK+ NSCLC, a growing body of evidence has gradually demonstrated the intracranial (IC) efficacy of ALK inhibitor (ALKi) in ALK+ NSCLC pts with brain metastases (BMs). Although the efficacy of crizotinib for the CNS lesions remains controversial, a recent retrospective investigation of ALK+ pts with BM enrolled in PROFILE 1005 and PROFILE 1007 demonstrated that crizotinib is associated with a high disease control rate for BM. However, BM comprises the most common site of progressive disease in pts with or without baseline BMs, which is a serious problem for crizotinib. Furthermore, alectinib can be used to achieve strong and long-lasting inhibitory effects on BM. In addition to alectinib, the IC efficacy of other next-generation ALK inhibitors, such as ceritinib, AP26113 and PF-06463922, has been demonstrated. In this article, we review the latest evidence regarding the BM and IC efficacy of ALK inhibitors in pts with ALK+ NSCLC.
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Affiliation(s)
- Gouji Toyokawa
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan.
| | - Takashi Seto
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
| | - Mitsuhiro Takenoyama
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
| | - Yukito Ichinose
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
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Arrieta O, Anaya P, Morales-Oyarvide V, Ramírez-Tirado LA, Polanco AC. Cost-effectiveness analysis of EGFR mutation testing in patients with non-small cell lung cancer (NSCLC) with gefitinib or carboplatin-paclitaxel. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:855-863. [PMID: 26338546 DOI: 10.1007/s10198-015-0726-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 08/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Assess the cost-effectiveness of an EGFR-mutation testing strategy for advanced NSCLC in first-line therapy with either gefitinib or carboplatin-paclitaxel in Mexican institutions. METHODS Cost-effectiveness analysis using a discrete event simulation (DES) model to simulate two therapeutic strategies in patients with advanced NSCLC. Strategy one included patients tested for EGFR-mutation and therapy given accordingly. Strategy two included chemotherapy for all patients without testing. All results are presented in 2014 US dollars. The analysis was made with data from the Mexican frequency of EGFR-mutation. A univariate sensitivity analysis was conducted on EGFR prevalence. Progression-free survival (PFS) transition probabilities were estimated on data from the IPASS and simulated with a Weibull distribution, run with parallel trials to calculate a probabilistic sensitivity analysis. RESULTS PFS of patients in the testing strategy was 6.76 months (95 % CI 6.10-7.44) vs 5.85 months (95 % CI 5.43-6.29) in the non-testing group. The one-way sensitivity analysis showed that PFS has a direct relationship with EGFR-mutation prevalence, while the ICER and testing cost have an inverse relationship with EGFR-mutation prevalence. The probabilistic sensitivity analysis showed that all iterations had incremental costs and incremental PFS for strategy 1 in comparison with strategy 2. CONCLUSION There is a direct relationship between the ICER and the cost of EGFR testing, with an inverse relationship with the prevalence of EGFR-mutation. When prevalence is >10 % ICER remains constant. This study could impact Mexican and Latin American health policies regarding mutation detection testing and treatment for advanced NSCLC.
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Affiliation(s)
- Oscar Arrieta
- Unit of Thoracic Oncology, Instituto Nacional de Cancerología (INCan), San Fernando #22, Col. Sección XVI, Tlalpan, 14080, México City, Mexico.
| | | | - Vicente Morales-Oyarvide
- Unit of Thoracic Oncology, Instituto Nacional de Cancerología (INCan), San Fernando #22, Col. Sección XVI, Tlalpan, 14080, México City, Mexico
| | - Laura Alejandra Ramírez-Tirado
- Unit of Thoracic Oncology, Instituto Nacional de Cancerología (INCan), San Fernando #22, Col. Sección XVI, Tlalpan, 14080, México City, Mexico
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100
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Jin Y, Xin T. [Research Progress of EGFR-TKI Therapy for Patients with Central Nervous System
Metastases from Non-small Cell Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2016; 19:496-500. [PMID: 27561797 PMCID: PMC5972986 DOI: 10.3779/j.issn.1009-3419.2016.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Approximately half of all patients with non-small cell lung cancer (NSCLC) develop central nervous system metastases during the course of their disease which indicate poor prognosis. A part of NSCLC patients demonstrates activating epidermal growth factor receptor gene (EGFR) mutations who represent effectiveness and well tolerance of EGFR-specific tyrosine kinase inhibitors (TKIs) therapy. Although the systemic efficacy of targeted agents is established, the efficacy of central nervous system (CNS) metastases is not as well characterized. In this article, we review recent data on the use of EGFR inhibitors for treatment of patients with NSCLC and CNS metastases.
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Affiliation(s)
- Yinghua Jin
- The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Tao Xin
- The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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