1
|
Abstract
Despite significant recent progress in precision medicine and immunotherapy, conventional chemotherapy remains the cornerstone of the treatment of most cancers. Chemotherapy-induced lung toxicity represents a serious diagnostic challenge for health care providers and requires careful consideration because it is a diagnosis of exclusion with significant impact on therapeutic decisions. This review aims to provide clinicians with a valuable guide in assessing their patients with possible chemotherapy-induced lung toxicity.
Collapse
Affiliation(s)
- Paul Leger
- Division of Internal Medicine, Vanderbilt University Medical Center, T1218 Medical Center North, Nashville, TN 37232-2650, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, T1218 Medical Center North, Nashville, TN 37232-2650, USA.
| |
Collapse
|
2
|
Jones C, Perryman L, Hargrave D. Paediatric and adult malignant glioma: close relatives or distant cousins? Nat Rev Clin Oncol 2012; 9:400-13. [PMID: 22641364 DOI: 10.1038/nrclinonc.2012.87] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gliomas in children differ from their adult counterparts by their distribution of histological grade, site of presentation and rate of malignant transformation. Although rare in the paediatric population, patients with high-grade gliomas have, for the most part, a comparably dismal clinical outcome to older patients with morphologically similar lesions. Molecular profiling data have begun to reveal the major genetic alterations underpinning these malignant tumours in children. Indeed, the accumulation of large datasets on adult high-grade glioma has revealed key biological differences between the adult and paediatric disease. Furthermore, subclassifications within the childhood age group can be made depending on age at diagnosis and tumour site. However, challenges remain on how to reconcile clinical data from adult patients to tailor novel treatment strategies specifically for paediatric patients.
Collapse
Affiliation(s)
- Chris Jones
- Divisions of Molecular Pathology and Cancer Therapeutics, The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, UK
| | | | | |
Collapse
|
3
|
Levin VA, Ictech S, Hess KR. Impact of phase II trials with progression-free survival as end-points on survival-based phase III studies in patients with anaplastic gliomas. BMC Cancer 2007; 7:106. [PMID: 17587447 PMCID: PMC1919386 DOI: 10.1186/1471-2407-7-106] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 06/22/2007] [Indexed: 12/04/2022] Open
Abstract
Background To assess progression-free survival (PFS) as the appropriate end-point for phase II trials for anaplastic gliomas (AGs) and to determine the impact of PFS on survival-based phase III trials. Methods Combined data from 16 phase II studies (N = 529 patients) were analyzed to determine progression-free survival (PFS) at 6, 9, and 12 months and the impact of age, Karnofsky performance score (KPS), number of prior chemotherapies, and response to treatment on PFS. Results The specific chemotherapy used was the major effector of PFS at 6, 9, and 12 months. Age, KPS, treatment response rate, and number of prior chemotherapies did not affect PFS to the same extent. Hierarchical cluster analyses and linear least squares fitting of PFS9 v PFS12 demonstrated the existence of three therapeutic efficacy groups with PFS rates at 6, 9, and 12 months ranging from lowest (A) to highest (C). The PFS6 was 15% in group A and 41% in group C (p < .0001); the PFS12 was 9% in group A and 33% in group C (p < .0001). Further, 80% of patients at recurrence had a 23% likelihood that each chemotherapy would provide > 1 year of additional life. Conclusion Based on PFS rates at 6, 9, and 12 months for AG patients, a differential of 1.5 to 2 years is the norm and could invalidate overall survival as an end-point for phase III studies in patients with AG. PFS is a more reliable end-point because it reflects the true antitumor benefit of the chemotherapy.
Collapse
Affiliation(s)
- Victor A Levin
- Department of Neuro-Oncology, Unit 431, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas, 77030, USA
| | - Sandra Ictech
- Department of Neuro-Oncology, Unit 431, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas, 77030, USA
| | - Kenneth R Hess
- Department of Biostatistics & Applied Math, Unit 447, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas, 77030, USA
| |
Collapse
|
4
|
Ballman KV, Buckner JC, Brown PD, Giannini C, Flynn PJ, LaPlant BR, Jaeckle KA. The relationship between six-month progression-free survival and 12-month overall survival end points for phase II trials in patients with glioblastoma multiforme. Neuro Oncol 2007; 9:29-38. [PMID: 17108063 PMCID: PMC1828103 DOI: 10.1215/15228517-2006-025] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 09/01/2006] [Indexed: 11/19/2022] Open
Abstract
Common end points for phase II trials in patients with glioblastoma multiforme (GBM) are six-month progression-free survival (PFS6) and 12-month overall survival (OS12). OS12 can be accurately measured but may be confounded with subsequent therapies upon progression, whereas the converse is true for PFS6. Our goal was to assess the relationship between these end points separately for phase II trials in patients with newly diagnosed GBM and patients with recurrent GBM. Data were pooled from 11 North Central Cancer Treatment Group trials for patients with newly diagnosed GBM (n = 1348). All patients received radiotherapy and pharmaceutical therapy (before, during, or after radiotherapy). Data were pooled from 16 trials that used various pharmaceuticals in treating patients for recurrent GBM (n = 345). All trial regimens were declared nonefficacious by predefined criteria. Overall per-patient concordance was estimated with a kappa statistic. The relationship between OS12 and PFS6 across study arms was assessed by weighted linear regression and Pearson's correlation. Simulation was used to determine the agreement of study outcomes when using PFS6 versus OS12 end points. Cox models with progression status as a time-dependent variable and Kaplan-Meier estimators were used to ascertain the association between progression-free survival status and overall survival. At present, 97% of the patients with newly diagnosed GBM and 95% of those with recurrent GBM have died. The PFS6 and OS12 were 43% and 41%, respectively, for patients with newly diagnosed disease and 9% and 14% for patients with recurrent disease. There was only moderate concordance between the end points on both the patient level and the study level. For the simulation studies, we established phase II efficacy criteria for each end point by using the pooled estimates of OS12 (PFS6) as historical controls. The study decisions made using PFS6 and OS12 were in agreement 88% and 90% of the time for the trials of newly diagnosed and recurrent disease, respectively. Finally, there was a strong association between progression-free survival status and overall survival. PFS6 seems to be a reasonable end point for phase II trials in patients with recurrent glioblastoma.
Collapse
Affiliation(s)
- Karla V Ballman
- Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | | | | | | | | | | | | |
Collapse
|
5
|
Lee DP, Skolnik JM, Adamson PC. Pediatric Phase I Trials in Oncology: An Analysis of Study Conduct Efficiency. J Clin Oncol 2005; 23:8431-41. [PMID: 16293874 DOI: 10.1200/jco.2005.02.1568] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine the efficacy and safety of pediatric phase I oncology trials in the era of dose-intensive chemotherapy and to analyze how efficiently these trials are conducted. Methods Phase I pediatric oncology trials published from 1990 to 2004 and their corresponding adult phase I trials were reviewed. Dose escalation schemes using fixed 30% dose increments were studied to theoretically determine whether trials could be completed utilizing fewer patients and dose levels. Results Sixty-nine pediatric phase I oncology trials enrolling 1,973 patients were identified. The pediatric maximum-tolerated dose (MTD) was strongly correlated with the adult MTD (r = 0.97). For three-fourths of the trials, the pediatric and adult MTD differed by no more than 30%, and for more than 85% of the trials, the pediatric MTD was less than or equal to 1.6 times the adult MTD. The median number of dose levels studied was four (range, two to 13). The overall objective response rate was 9.6%, the likelihood of experiencing a dose-limiting toxicity was 24%, and toxic death rate was 0.5%. Conclusion Despite the strong correlation between the adult and pediatric MTDs, more than four dose levels were studied in 40% of trials. There appeared to be little value in exploring dose levels greater than 1.6 times the adult MTD. Limiting pediatric phase I trials to a maximum of four doses levels would significantly shorten the timeline for study conduct without compromising safety.
Collapse
Affiliation(s)
- Debra P Lee
- Division of Clinical Pharmacology & Therapeutics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | | |
Collapse
|
6
|
Affiliation(s)
- E Galanis
- Division of Medical Oncology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
| | | |
Collapse
|
7
|
Abstract
Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.
Collapse
Affiliation(s)
- B Zachariah
- Department of Radiology, University of South Florida College of Medicine, USA
| | | |
Collapse
|
8
|
Newton HB, Turowski RC, Stroup TJ, McCoy LK. Clinical presentation, diagnosis, and pharmacotherapy of patients with primary brain tumors. Ann Pharmacother 1999; 33:816-32. [PMID: 10466912 DOI: 10.1345/aph.18353] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To briefly review the clinical presentation and diagnosis of patients with primary brain tumors, followed by an in-depth survey of the pertinent pharmacotherapy. DATA SOURCES A detailed search of the neurologic, neurosurgical, and oncologic literature for basic science research, clinical studies, and review articles related to chemotherapy and pharmacotherapy of primary brain tumors. STUDY SELECTION Relevant studies on tissue culture systems, animals, and humans examining the mechanisms of action, pharmacokinetics, clinical pharmacology, and treatment results of chemotherapeutic agents for primary brain tumors. In addition, studies of pharmacologic agents administered for supportive care and symptom control are reviewed. DATA SYNTHESIS Primary brain tumors derive from cells within the intracranial cavity and generally present with headache, seizure activity, cognitive changes, and weakness. They are diagnosed most efficiently with magnetic resonance imaging. After diagnosis, the most common supportive medications include corticosteroids, gastric acid inhibitors, and anticonvulsants. Chemotherapy is adjunctive treatment for patients with malignant tumors and selected recurrent or progressive benign neoplasms. In general, the most effective chemotherapeutic drugs are alkylating agents such as the nitrosoureas, procarbazine, cisplatin, and carboplatin. Other agents used include cyclophosphamide, methotrexate, vincristine, and etoposide. Angiogenesis inhibitors and gene therapy comprise some of the novel therapeutic strategies under investigation. CONCLUSIONS The efficacy of chemotherapy for primary brain tumors remains modest. Novel agents must be discovered that are more specific and attack tumor cells at the molecular level of tumorigenesis. Furthermore, strategies must be developed to counteract the pervasive problem of brain tumor chemoresistance.
Collapse
Affiliation(s)
- H B Newton
- Department of Neurology, The Ohio State University, Columbus 43210, USA.
| | | | | | | |
Collapse
|
9
|
van den Bent MJ, Schellens JH, Vecht CJ, Sillevis Smit PA, Loosveld OJ, Ma J, Tijssen CC, Jansen RL, Kros JM, Verweij J. Phase II study on cisplatin and ifosfamide in recurrent high grade gliomas. Eur J Cancer 1998; 34:1570-4. [PMID: 9893630 DOI: 10.1016/s0959-8049(98)00138-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
27 patients with recurrent high grade glioma following surgery and radiation therapy were treated with 100 mg/m2 cisplatin and 6 g/m2 ifosfamide per cycle, administered on days 1-3 in 4 week cycles, for a maximum of six cycles. Toxicity was assessed after every cycle. Response was assessed following every second cycle, and a 50% decrease of the largest cross-sectional tumour area on contrast enhanced magnetic resonance imaging or computed tomography scan was considered a partial response (PR). A total of 95 cycles was administered; 26 patients were evaluable for response. In 5 patients (19%), a PR was obtained (median time to progression (TTP): 34 weeks). Stable disease was observed in 6 patients (23%, median TTP: 22 weeks). The most frequent toxicity was haematological: 37% of cycles were complicated by a grade 3 or 4 leucopenia. 1 patients died, probably as a consequence of increased cerebral oedema induced by the cisplatin hydration schedule. Determination of the cisplatin concentration in this patient showed a 10-fold increase in the tumour concentration as compared with that in normal brain tissue, demonstrating the absence of a blood-brain barrier in the tumour. In conclusion, generally this schedule was well tolerated, but it is of moderate activity for recurrent glioma.
Collapse
Affiliation(s)
- M J van den Bent
- Department of Neuro-Oncology, Rotterdam Cancer Institute, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Sanson M, Ameri A, Monjour A, Sahmoud T, Ronchin P, Poisson M, Delattre JY. Treatment of recurrent malignant supratentorial gliomas with ifosfamide, carboplatin and etoposide: a phase II study. Eur J Cancer 1996; 32A:2229-35. [PMID: 9038603 DOI: 10.1016/s0959-8049(96)00299-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Thirty-six patients previously treated with surgery, radiation therapy and chemotherapy with a nitrosourea for malignant supratentorial gliomas received a combination of ifosfamide, carboplatin and etoposide (ICE) at tumour progression. Carboplatin and etoposide were both given at a dose of 75-100 mg/m2/day for 3 days, whereas ifosfamide doses ranged from 750 mg/m2/day to 1500 mg/m2/ day for 3 days, according to haematological tolerance. Treatment was repeated every 4 weeks. A minimum of three courses was required to evaluate the response unless the patient had rapid tumour progression. Grade III and IV haematological toxicity occurred in 15 patients (42%) and was lethal in one patient. Grade II hepatic toxicity was observed in one patient. Five complete (CR) and five partial responses (PR) were noted. 9 patients had stable disease (SD) after a minimum of three courses. CR + PR + SD was 53% (19/36). The median time to tumour progression (MTTP) was 13 weeks. Median survival (MST) was 29 weeks (44 weeks for R + S patients and 17 weeks for patients with progressing disease). This study suggests that the ICE combination is active in recurrent supratentorial malignant gliomas after failure of surgery, radiation therapy and chemotherapy, but at the cost of substantial haematological toxicity.
Collapse
Affiliation(s)
- M Sanson
- Department of Neurology, Hôpital de la Pitié Salpêtrière, Paris, France
| | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
First-line treatment of malignant gliomas invariably includes surgery when feasible, and often adjuvant radiotherapy with or without chemotherapy; at progression or recurrence, the only remaining possibility is chemotherapy. While the role of first-line treatment has been established by many randomized studies, second-line treatment is not as well defined. To analyze the difficulties encountered with cytotoxic drugs in relation to both the blood-brain barrier and drug resistance, we examined the results obtained by single-agent chemotherapy, drug combinations, and biological response modifiers. Our findings confirmed that the nitrosoureas are the most active substances at the time of recurrence; these agents give an approximately 30% global response rate, with about 20 weeks' survival. Although no comparative randomized studies regarding single- versus multiple-agent chemotherapy are available, the latter approach, including nitrosourea, can obtain an up to 40% rate of response, with survival ranging from 30 to 50 weeks. The role of interferons has been very controversial; individually, alpha- and beta-interferons seem to give a 20% response rate, with 20 weeks' survival. To date, they have never been used in combination with cytotoxic drugs, but they may prove synergistic without increasing toxicity. Studies addressing the quality of life of these patients are not available, and it is clear that we need more basic research in this field.
Collapse
Affiliation(s)
- A A Brandes
- Department of Oncology, Ospedale Civile, Padua, Italy
| | | |
Collapse
|
12
|
Heideman RL, Douglass EC, Langston JA, Krischer JP, Burger PC, Kovnar EH, Kun LE, Friedman HS, Kadota R. A phase II study of every other day high-dose ifosfamide in pediatric brain tumors: a Pediatric Oncology Group Study. J Neurooncol 1995; 25:77-84. [PMID: 8523093 DOI: 10.1007/bf01054726] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite reported activity in many other solid tumors, high-dose ifosfamide produces few objective responses in recurrent pediatric brain tumors. Alkylating agents such as cyclophosphamide (CYCLO) possess good activity in many of solid tumors, including brain tumors. Although Ifosfamide (IFOS), a structural congener of CYCLO, has been suggested to have greater activity in several tumors, its activity in brain tumors is uncertain. We conducted a phase II trial of every-other day IFOS (3 gm/M2/qod x 3) in 87 recurrent pediatric brain tumors. Responses were evaluable in 71 patients. Partial responses occurred in 1/6 patients with low grade astrocytoma, 1/16 with malignant glioma, 1/16 with medulloblastoma, 1/3 with pineoblastoma and 1/12 patients with ependymoma. No responses occurred among 10 patients with brain stem gliomas or 8 patients with other brain tumors. Despite the poor objective response rate, 23/71 patients were clinically and imaging stable for periods of 8-62 weeks. There was no relationship between prior CYCLO treatment and subsequent response or failure with IFOS. The predominant toxicity was myelosuppression. Although generally reversible, prolonged suppression and sepsis were responsible for the deaths of 3 heavily pretreated patients. Renal toxicity was uncommon; 2 patients had grade III, and one grade IV renal tubular dysfunction. One patient had grade IV hematuria. Neurotoxicity was less common than in studies of daily ifosfamide; only 1 patient had grade IV neurotoxicity. Three patients had grade III or IV IFOS related hyponatremia. Despite the good stable disease rate, the poor rate of objective response suggests that IFOS monotherapy possesses little clinically meaningful activity in brain tumors.
Collapse
Affiliation(s)
- R L Heideman
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
A review of single agent trials of cytotoxic agents in adults with high grade gliomas is presented. The rationale for testing these agents in patients with brain tumors was variable and is discussed. The criteria to evaluate responses were also variable ranging from subjective evaluation of clinical improvement with a stable radiographic assessment to the same objective response criteria utilized for solid tumors. Trials of agents specifically designed for brain tumors such as AZQ and spiromustine have been disappointing. There are encouraging results being seen in early trials of newer agents which await confirmation in larger trials but which hold promise for improving the disappointing results seen so far with chemotherapy in primary brain tumors.
Collapse
Affiliation(s)
- S A Taylor
- University of Kansas Medical Center, Kansas City
| |
Collapse
|
14
|
Pratt CB, Douglass EC, Kovnar EH, Heideman R, Kun L, Avery L, Kellie SJ. A phase I study of ifosfamide given on alternate days to treat children with brain tumors. Cancer 1993; 71:3666-9. [PMID: 8490915 DOI: 10.1002/1097-0142(19930601)71:11<3666::aid-cncr2820711132>3.0.co;2-e] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ifosfamide with Mesna, given every other day over a 5-day period, was evaluated in 20 children with recurrent or progressive primary brain tumors. METHODS The patients were assigned to dosage cohorts separated on the basis of prior exposure to cisplatin (n = 10) or the absence of such exposure (n = 10). The initial dose in each treatment arm was 2133 mg/m2 every other day for three doses, which represented 80% of the total dose delivered in our prior study of ifosfamide given daily over 5 days. The dose was escalated by 20% in each of the two subsequent cohorts (2560 mg/m2 and 3072 mg/m2 every other day for three doses). RESULTS The hematologic toxicity was dose limiting. Prior exposure to cisplatin did not seem to increase the hematologic toxicity. The most frequent and significant metabolic disturbance was hyponatremia, resulting in self-limited seizure activity in three patients. This complication was prevented in subsequent patients by changing the post-ifosfamide hydration fluids from 5% dextrose in quarter normal saline to 5% dextrose in normal saline. CONCLUSIONS Although no child achieved a complete response, the activity of ifosfamide was demonstrated for a variety of tumors. The recommended dose of ifosfamide in a Phase II study for brain tumors is 3000 mg/m2 given with Mesna every other day for three doses.
Collapse
Affiliation(s)
- C B Pratt
- Department of Hematology/Oncology, St. Jude Children's Research Hospital, TN 38101-0318
| | | | | | | | | | | | | |
Collapse
|
15
|
Zachariah SB, Zachariah B, Wang T, Balducci L. Primary brain tumors in the older patient: an annotated review. J Am Geriatr Soc 1992; 40:1265-71. [PMID: 1447446 DOI: 10.1111/j.1532-5415.1992.tb03654.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|