A phase II trial of gefitinib monotherapy in pretreated patients with advanced non-small cell lung cancer not harboring activating EGFR mutations: implications of sensitive EGFR mutation test

Gefitinib sensitization of cisplatin-resistant wild-type EGFR non-small cell lung cancer cells

Purpose

The usual first-line strategy of wild-type EGFR (wtEGFR) non-small cell lung cancer (NSCLC) remains cisplatin-based chemotherapy. However, cisplatin often loses effectiveness because most tumors acquire drug resistance over time. As EGFR is the most important pro-survival/proliferation signal receptor in NSCLC cells, we aimed at investigating whether cisplatin resistance is related to EGFR activation and further evaluating the combined effects of cisplatin/gefitinib (EGFR-tyrosine kinase inhibitor, EGFR-TKI) on cisplatin-resistant wtEGFR NSCLC cells.

Materials and methods

EGFR activation was analysed in parental and cisplatin-resistant wtEGFR NSCLC cell lines (H358 and H358^R, A549 and A549^R). Cellular proliferation and apoptosis of H358^R/A549^R cells treated with cisplatin or gefitinib, alone or in combination were investigated, and the related effector protein was detected by western blot analysis. Anti-tumor effect of two drugs combined was evaluated in animal models of H358^R xenografts in vivo.

Results

EGFR was significantly phosphorylated in cisplatin-resistant wtEGFR NSCLC cells H358^R and A549^R than their parental cells. In H358^R and A549^R cells, anti-proliferative ability of gefitinib was further improved, and gefitinib combined with cisplatin enhanced inhibition of cellular survive/proliferation, and promotion of apoptosis in vitro. The combined effects were also associated with the inhibition of EGFR downstream effector proteins. Similarly, in vivo, gefitinib and cisplatin in combination significantly inhibited tumor growth of H358^R xenografts.

Conclusion

Abnormal activation of EGFR may induce wtEGFR NSCLC cell resistance to cisplatin. The combined effects of cisplatin/gefitinib suggest that gefitinib, as a combination therapy for patients with cisplatin-resistant wtEGFR NSCLC should be considered.

Apatinib with EGFR-TKIs in advanced wild gene-type NSCLC: A case report

RATIONALE

For advanced non-small-cell lung cancer (NSCLC), targeted therapy and chemoradiotherapy are recommended as the first-line treatment. For patients with a performance status (PS) score over 2 and without gene mutation, however, only supportive treatment is provided and survival time is extremely short. We believe that more can be done to improve the patient's survival time and their quality of life.

PATIENT CONCERNS AND DIAGNOSES

A 65-year-old female came to our hospital due to "cough and pain and lack of movement in the left leg". The diagnosis was advanced wild gene-type lung adenocarcinoma and PS score over 2.

INTERVENTIONS AND OUTCOMES

She was treated in our clinic with apatinib and erlotinib and has had no progression of the disease for 15.4 months. Except for the presence of hand-foot syndrome and diarrhea, no other serious adverse reactions were seen.

LESSONS

For patients in poor physical condition and unacceptable of chemo-radiotherapy, apatinib combined with an epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) is a safe and effective therapeutic method for advanced wild gene-type NCSCL.

Pneumonitis in advanced non-small-cell lung cancer patients treated with EGFR tyrosine kinase inhibitor: Meta-analysis of 153 cohorts with 15,713 patients: Meta-analysis of incidence and risk factors of EGFR-TKI pneumonitis in NSCLC

PURPOSE

Pneumonitis is a significant toxicity of EGFR tyrosine kinase inhibitors (EGFR-TKI) in non-small-cell lung cancer (NSCLC) patients. We studied the incidence of pneumonitis in clinical trials of EGFR-TKI published in 2003-2017, and performed subgroups analyses to identity predisposing factors.

METHODS

Ovid-MEDLINE and EMBASE search up to 4/17/17 using the keywords, "erlotinib", "gefitinib", "afatinib", "osimertinib", and "lung cancer", resulted in a total of 153 eligible trial cohorts with 15,713 advanced NSCLC patients treated with EGFR-TKI. The pooled incidence of all-grade, high-grade, and grade 5 pneumonitis was obtained. Subgroup analyses were performed with meta-regression using study-level covariates.

RESULTS

Among the patients without prior exposure to EGFR-TKI, the overall incidence was 1.12% (95% CI:0.79-1.58%) for all-grade, 0.61% (95% CI:0.40-0.93%) for high-grade, and 0.20% (95% CI:0.11-0.38%) for grade 5 pneumonitis. The incidence was significantly higher in Japanese studies compared to studies of non-Japan origin, for all-grade (4.77% vs. 0.55%, p < 0.001), high grade (2.49% vs. 0.37%, p < 0.001), and grade 5 pneumonitis (1.00% vs. 0.18%, p < 0.001). Multivariate analyses demonstrated higher odds of pneumonitis in Japanese studies for all-grade (odds ratio [OR]: 5.04; 95% CI:3.14-8.11, p < 0.001), high-grade (OR: 4.45; 95% CI:2.50-7.93, p < 0.001), and grade 5 pneumonitis (OR: 4.55; 95% CI:2.20-9.44, p < 0.001) compared to others, after adjusting for types of EGFR-TKI and lines of therapy. In patients with EGFR retreatment analyzed separately, the pooled incidence was 1.13% (95% CI:0.40-3.15%) for all-grade, 0.49% (95% CI:0.21-1.11%) for high-grade, and 0.16% (95% CI:0.04-0.65%) for grade 5 pneumonitis.

CONCLUSIONS

The overall incidence of EGFR-TKI pneumonitis was 1.12% in patients without prior exposure to EGFR-TKI, and 1.13% in EGFR-TKI retreatment group. The cohorts from Japan had significantly higher incidence of pneumonitis, providing insights for further mechanistic studies.

Antitumor activity of high-dose pulsatile gefitinib in non-small-cell lung cancer with acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have demonstrated efficacy in the treatment of advanced non-small cell lung cancer (NSCLC). However, their clinical efficacy is limited by acquired resistance. Drug resistance may be mediated by EGFR transduction, and a number of clinical trials have demonstrated that high-dose pulsatile TKIs may be effective at treating patients with acquired resistance, though their underlying mechanisms of action remain unknown. The aim of the present study was to investigate the antitumor activity of high-dose pulsatile gefitinib in NSCLC model cell lines, namely the EGFR-TKI-sensitive cell line PC9, as a control group, and the EGFR-TKI-resistant cell lines H1975 and H1650. The cell lines were administered with different doses of gefitinib and cell viability was measured using an MTT assay. Cell apoptosis and cycling were also determined by flow cytometry and the expression of phospho (p)-EGFR, EGFR, p-AKT and AKT were measured by western blot analysis. It was observed that the apoptotic rate of H1975 cells treated with high-dose pulsatile gefitinib significantly increased, while levels of p-EGFR and p-AKT were decreased. However, there was no significant difference in the apoptotic rate or level of p-AKT in gefitinib-treated H1650 cells, while p-EGFR levels decreased. By contrast, the EGFR-TKI-sensitive cell line PC9 exhibited sensitivity to gefitinib. It was demonstrated that the apoptosis rates were markedly increased when treated with high dose pulsatile gefitinib in PC9 cell line, while a decrease was noted in p-EGFR and p-AKT. These data suggest that high-dose pulsatile gefitinib treatment may overcome acquired resistance in NSCLC, though its efficacy is dependent on the type of drug resistance mutation(s) present. Furthermore, high-dose pulsatile gefitinib may inhibit tumor growth and induce cell apoptosis by blocking the EGFR signaling pathway. Therefore, if the signaling pathways involved in drug resistance are not activated by the EGFR gene, high-dose pulsatile gefitinib may have little efficacy in the treatment of NSCLC.

[Clinical Experience of Gefitinib in the Treatment of 32 Lung Adenocarcinoma Patients with Brain Metastases]

背景与目的

脑转移是晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）常见的转移部位，预后欠佳。吉非替尼是一种表皮生长因子受体（epithelial growth factor receptor, EGFR）酪氨酸激酶抑制剂，用于治疗晚期NSCLC。本研究旨在探讨吉非替尼治疗肺腺癌脑转移的疗效及毒副反应。

方法

回顾性分析32例肺腺癌脑转移患者的临床资料，所有患者均口服吉非替尼250 mg Qd，直到疾病进展或发生不可耐受的毒副反应。

结果

全组32例患者的中位生存时间（median overall survival, mOS）和中位无进展生存时间（median progression-free survival, mPFS）分别为24.7个月和11.2个月，有效率（response rate, RR）和疾病控制率（disease control rate, DCR）分别为62.5%和93.8%。吉非替尼用于初治患者的mOS和mPFS分别为35.6个月和11.3个月，RR和DCR分别为75.0%和100.0%。吉非替尼用于复治患者的mOS和mPFS分别为18.6个月和6.7个月，RR和DCR分别为50.0%和83.3%。EGFR敏感性突变患者的mOS和mPFS分别为24.8个月和10.8个月，RR和DCR分别为75.0%和100.0%。EGFR突变状态不明患者的mOS和mPFS分别为35.6个月和12.3个月，RR和DCR分别为53.3%和86.7%。全组患者耐受性好，未观察到严重毒副反应。常见的毒副反应包括：皮疹15例（46.9%）、腹泻7例（21.9%）、口腔溃疡1例（3.1%）。

结论

吉非替尼对肺腺癌脑转移患者有效率较高且耐受性好，可以作为肺腺癌脑转移患者的一种治疗选择。

Pulmonary Toxicities of Gefitinib in Patients With Advanced Non-Small-Cell Lung Cancer: A Meta-Analysis of Randomized Controlled Trials

Gefitinib is a selective tyrosine kinase inhibitor of the epidermal growth factor receptor (EGFR) used to treat adults with EGFR mutation-positive non-small-cell lung cancer (NSCLC). Clinical benefits of gefitinib administration in NSCLC patients have been observed in clinical practice, but the extent of the pulmonary toxicity of gefitinib in patients with advanced NSCLC remains unclear. The aim of this systematic review was to evaluate the overall incidence and risk of gefitinib-related pulmonary toxicity in advanced NSCLC patients. Relevant trials were identified from the databases of Pubmed, Embase, Cochrane Library, and the clinicaltrials.gov of the U.S. National Institutes of Health. The outcomes included the overall incidence, odds ratios (ORs), and 95% confidence intervals (CIs). Fixed-effects models were used in the statistical analyses according to the heterogeneity of the included studies. According to the data from the included trials, the overall incidence of high-grade hemoptysis, pneumonia, pneumonitis, and interstitial lung disease (ILD) was 0.49% (95% CI: 0.24%-0.99%), 2.33% (95% CI: 1.47%-3.66%), 2.24% (95% CI: 1.34%-3.72%), and 1.43% (95% CI: 0.98%-2.09%), respectively. The pooled ORs of high-grade hemoptysis, pneumonia, pneumonitis, and ILD were 1.73 (95% CI: 0.46-6.52; P = 0.42), 0.99 (95% CI: 0.66-1.49; P = 0.95), 4.70 (95% CI: 1.48-14.95; P = 0.0087), and 2.64 (95% CI: 1.22-5.69; P = 0.01), respectively. Gefitinib was associated with a significantly increased risk of high-grade/fatal ILD and pneumonitis compared with the controls, whereas the risk of other high-grade pulmonary events (pneumonia and hemoptysis) was not significant. Careful surveillance of gefitinib-related pulmonary toxicity is critical for the safe use of this drug.