Treatment of extensive stage small cell bronchogenic carcinoma. Effects of variation in intensity of induction chemotherapy

Superiority of high-dose platinum (cisplatin and carboplatin) compared to carboplatin alone in combination chemotherapy for small-cell lung carcinoma: a prospective randomised trial of 280 consecutive patients

PURPOSE

A prospective randomized trial in small-cell lung cancer (SCLC) was performed to determine if intensification of the platinum dose by giving cisplatin and carboplatin in combination to patients with SCLC yields higher response rates and survival, than carboplatin alone in a combination chemotherapy regimen.

PATIENTS AND METHODS

Between September 1992 and October 1997, 280 patients were included in a two armed prospective randomized trial, stratified by stage of disease, LDH and performance status. The treatment was in arm A: three courses induction chemotherapy with carboplatin (AUC = 4, day 1), cisplatin (35 mg/m2, days 2 and 3), teniposide (50 mg/m2, day 1-5), vincristine (1.3 mg/m2, day 1) every four weeks, followed by cyclophosphamide (3 g/m2, day 84), 4-epirubicin (4-epidoxorubicin) (150 mg/m2, day 112), and finally one course cisplatin, carboplatin, teniposide and vincristine, (days 140-144). Arm B also comprised a total of six courses, identical to those in arm A except for omission of cisplatin.

RESULTS

There were no significant differences in the overall treatment outcome for A vs. B, in terms of response rates (72% in both arms), complete response rates (40% and 34%, respectively), or median survival (314 days and 294 days, respectively). However, for patients with limited disease both the CR rate (54% vs. 37%, P < 0.05), overall survival (log-rank test, P < 0.05), and the two-year survival rate (11% vs. 6%, P < 0.05) were higher in the high-dose platinum arm compared to the carboplatin alone arm.

CONCLUSIONS

The intensification of platinum dose (cisplatin plus carboplatin) in combination chemotherapy significantly increased the complete response rate, overall survival and number of two-year survivors among SCLC patients with limited disease compared to combination therapy with carboplatin alone, suggesting that a more aggressive treatment to this category of patients is worthwhile, while no difference in treatment outcome was observed for patients with extensive disease.

Hematopoietic stem cell transplantation for small cell lung cancer

Treatment for small cell lung cancer has not improved substantially in the past 15 years. Some advances are being made in supportive care and by use of more intense concurrent thoracic radiotherapy. New agents such as the taxanes and the topoisomerase I inhibitors hold promise and are currently in phase III evaluation. The question whether dose intensity can improve the outcome of patients with small cell lung cancer has been raised for many years. Improving supportive care enhances our ability to test this question more thoroughly. This paper reviews the historical and current experience using high-dose therapy with hematopoietic stem cell support for the treatment of small lung cancer. Future directions are identified.

Autologous stem-cell transplantation for solid tumors in adults

Over the last decade, high-dose chemotherapy (HDC) with autologous stem-cell transplantation has been explored for a variety of solid tumors in adults, particularly breast cancer, ovarian cancer, and nonseminomatous germ-cell tumors. Response of phase II studies are encouraging in most cases, and, in certain settings, seem clearly superior to historical results of conventional-dose chemotherapy. The value of HDC for adult solid tumors is a highly controversial issue, currently being addressed in large randomized phase II trials. This article reviews the results of HDC in different diseases and depicts potential directions of future progress.

Dose-intensive therapy for limited-stage small-cell lung cancer: long-term outcome

PURPOSE

To determine progression-free survival (PFS) and overall long-term survival for limited-stage small-cell lung cancer (SCLC) patients aged 60 years or younger who respond to first-line chemotherapy followed by high-dose combination alkylating agents (cyclophosphamide 5,625 mg/m(2), cisplatin 165 mg/m(2), and carmustine 480 mg/m(2)) with hematologic stem-cell support and chest and prophylactic cranial radiotherapy.

PATIENTS AND METHODS

Patients were selected on the basis of their continued response to first-line therapy, their relative lack of significant comorbidity, and their ability to obtain financial clearance.

RESULTS

Of 36 patients with stage III SCLC, nine patients (25%) had achieved a complete response (CR), 20 had achieved a near-CR, and seven had achieved a partial response before undergoing high-dose therapy. Toxicity included three deaths (8%). For all patients, the median PFS was 21 months. The 2- and 5-year survival rates after dose intensification were 53% (95% confidence interval [CI], 39% to 72%), and 41% (95% CI, 28% to 61%). Of the 29 patients who were in or near CR before undergoing high-dose therapy, 14 remain continuously progression-free a median of 61 months (range, 40 to 139 months) after high-dose therapy. Actuarial 2- and 5-year PFS rates were 57% (95% CI, 41% to 79%) and 53% (95% CI, 38% to 76%). By multivariate analysis, short intensive induction chemotherapy was associated with favorable outcome (P <.05).

CONCLUSION

Use of high-dose systemic therapy with intensive local-regional radiotherapy was associated with manageable treatment-related morbidity and mortality. Patients who were in or near CR before intensification are enjoying an unmaintained 5-year PFS rate of 53%. Late complications were infrequent, and most patients returned to full-time work and activity. A randomized comparison of this approach and conventional-dose therapy should define the use of dose intensification with hematopoietic support in patients with responding limited-stage SCLC.

Dose-intensive therapy in small cell lung cancer

Basic to curative treatment for small cell lung cancer (SCLC) are the principles of dose response, combination chemotherapy, and combined-modality therapy. Theory and experimental and clinical data suggest that solid tumors recur, despite initially responding to chemotherapy due to drug resistance. Resistance to chemotherapy is potentially overcome by using 5- to 10-fold higher doses. To decrease the emergence of drug resistance, combinations of active non-cross-resistant agents are used. Hematopoietic stem cell support provides the opportunity to test dose response to the limits of organ tolerance. Dose-intensive therapy for lung cancer patients is complicated by the fact that this disease most often occurs in an older-aged population (median, 60 to 65 years) with underlying smoking-related comorbid disease, early metastatic spread, and enhanced risk of secondary smoking-related malignancies. In a phase II feasibility trial just activated, patients younger than 60 years of age with limited-stage SCLC are being treated with four cycles of cisplatin and etoposide and concurrent twice-daily chest radiotherapy to 45 Gy (150-cGy fractions). Those patients achieving complete or near-complete response will receive high-dose cyclophosphamide/cisplatin/ carmustine with autologous stem cell support. Upon recovery, prophylactic cranial irradiation will be given. Results could lead to a phase III trial testing the concept of dose intensification. This article reviews evidence for the contribution of dose intensification to response and survival in the treatment of SCLC, the adequacy of the clinical trial's design to address these relationships, and suggestions for future directions. The strategies of dose-intensive induction therapy, multicycle dose-intensive combination therapies, chest radiography, and stem cell purging trials will be discussed.

Outcome of patients with small-cell lung cancer during 20 years of clinical research at the US National Cancer Institute

OBJECTIVE

To determine the outcome of all patients with small-cell lung cancer (SCLC) treated at the US National Cancer Institute between April 1973 and April 1993.

DESIGN

We retrospectively analyzed a series of 594 consecutive patients with SCLC treated at a single institution during a 20-year period to assess changes in duration of survival and toxicity related to various treatment regimens.

MATERIAL AND METHODS

For analysis, patients were grouped by decade, and the duration of survival of patients with limited- and extensive-stage SCLC was examined to assess whether patients treated during the first decade of the study (1973 through 1983), when cyclophosphamide-based regimens were used, had different outcomes than those treated during the second decade (1983 through 1993), when cisplatin-based regimens were used. Patients had a minimal follow-up of 2 years.

RESULTS

No significant difference was found in the survival of patients with limited- or extensive-stage SCLC treated during the second decade in comparison with during the first decade of the study. Among patients with extensive-stage SCLC, performance status 3 or 4 and metastatic lesions of the liver and central nervous system had a significant adverse effect on survival in both the first and the second decade. Among patients with limited-stage disease, performance status 3 or 4 had the most significant adverse influence on survival during the overall study period. In addition, in a multivariate analysis, etoposide-cisplatin plus twice-daily chest radiotherapy was significantly associated with prolonged survival (P = 0.003).

CONCLUSION

We noted no significant change in the duration of survival of patients with either limited-or extensive-stage SCLC treated at our institution during a 20-year period. A multivariate analysis showed that patients with limited-stage SCLC given a cisplatin-based regimen plus chest radiotherapy lived modestly longer than similar patients given cyclophosphamide regimens at our institution. No evidence was found of changes in pretreatment factors that would affect survival.

Small cell lung cancer: state-of-the-art therapy in 1996

Small cell lung cancer (SCLC) occurs almost exclusively in smokers and represents 15 to 25% of all lung cancer histologic findings. It is distinguished from non-small cell lung cancer by its rapid tumor doubling time, high growth fraction, and early development of widespread metastases. Since patients with SCLC usually present with disseminated disease, treatment strategies have focused on systemic therapy. Single-agent and combination chemotherapy, as well as combined-modality therapy, have produced high response rates (80 to 100% for limited disease; 60 to 80% for extensive disease), but these tend to be short-lived (median duration, 6 to 8 months). Survival beyond 5 years occurs in only 3 to 8% of all patients with SCLC. At least 15 to 20 different chemotherapeutic agents have shown major activity against SCLC in both the untreated and relapsed settings, including etoposide, teniposide, cisplatin, carboplatin, ifosfamide, cyclophosphamide, vincristine, and doxorubicin. This paper reviews state-of-the-art treatment strategies being employed in the treatment of SCLC, including those incorporating high-dose intensive therapy, salvage therapy, new agents, thoracic radiotherapy, prophylactic cranial radiotherapy, surgical resection, and biologic response modifiers.

Retreatment of patients surviving cancer-free 2 or more years after initial treatment of small cell lung cancer

STUDY OBJECTIVE

To assess the outcome after retreatment of patients with small cell lung cancer (SCLC) who redevelop small cell cancer (SCC) 2 or more years after initial therapy.

DESIGN

Retrospective analysis.

SETTING

Single government institution: the National Cancer Institute.

PATIENTS

Twenty patients who redeveloped SCC among 65 patients who survived 2 or more years after starting treatment for their initial cancer.

MEASUREMENTS

The response rate of patients after retreatment, the survival duration from the time of redevelopment of SCC, and the toxicities of retreatment.

RESULTS

Twenty patients redeveloped SCC: 18 with a relapse and 2 with a second primary cancer. Sixteen received treatment after they redeveloped SCLC while four did not. Eleven patients were retreated with chemotherapy alone, two patients received chemotherapy plus chest radiotherapy, one patient received radiotherapy alone, one patient underwent lobectomy, and one patient was treated with a monoclonal antibody followed by chemotherapy. Nine of 16 patients (56%) treated after they redeveloped SCLC had an objective response (3 complete and 6 partial). The median survival of all 20 patients after they redeveloped SCC was 3.9 months (range, 0 to 46 months). The median survival of the patients who were retreated was 6.5 months (range, 1 to 46 months).

CONCLUSIONS

Patients who suffer relapses with SCLC 2 or more years from diagnosis are candidates for retreatment.

NCI-Navy Medical Oncology Branch cell line data base

The cell line data base described in this paper includes both clinical information about the patients from whom the cell lines were derived and information about the in vitro analyses performed of the cell lines. The cell line data base has evolved as a part of a systematic effort by a research group at the NCI since 1976 to generate human cell lines as biological tools to study cancer and other diseases. The cell lines were generated from clinical specimens obtained as part of a series of Institutional Review Board-approved clinical protocols. The preponderance of the data is on lung cancer cell lines, though a broad range of other cancers are represented. A bank of over 300 human cell lines including cancer cell and in some instances autologous B-lymphoblastoid cells from the NCI-VA and NCI-Navy Medical Oncology Branch are reposited at the American Type Culture Collection. The cell lines are available for the research community. The entire data base is available on the American Type Culture Collection Web Site (WWW:http:@www.atcc.org/).

Dose-intensive therapy for small cell lung cancer

Enhancement of dose and dose intensity increases tumor response and may enhance long-term progression-free survival in patients with small cell lung cancer. Several strategies are identified to intensify therapy safely: a traditional induction/intensification mode, in which high-dose therapy with hematopoietic stem cell support is used to treat patients responding to conventional-dose therapy; and multicycle dose-intensive approaches, in which higher-dose therapy is administered over multiple cycles at initiation of therapy. This paper reviews some of the recently completed and activated trials (particularly those developed at the Dana-Farber Cancer Institute) exploring these concepts.

High-dose combined alkylating agent therapy with autologous stem cell support and chest radiotherapy for limited small-cell lung cancer

Although initially responsive to chemotherapy, patients with small-cell lung cancer (SCLC) almost invariably suffer relapse. Recurrent SCLC responds poorly to treatment. Previous trials using high-dose chemotherapy with bone marrow support have commonly used single agents or combined alkylating agents without chest radiotherapy. Among patients with limited disease receiving dose-intensive chemotherapy, locoregional relapse remained the predominant site of first failure. Recent phase II trials using intensive locoregional therapy (aggressive concurrent chemoradiotherapy) have resulted in promising survival. Our trial used combined alkylating agents with autologous marrow support and chest radiotherapy in patients with limited disease in response to conventional-dose induction chemotherapy. Of 19 patients treated, the actuarial survival was 56% with a median follow-up of 18 months following high-dose therapy. Patients who achieved complete or near-complete response prior to high-dose therapy enjoyed the best prognosis. Continued evaluation of intensive systemic and local therapy for SCLC is indicated.

Female patients with small cell lung cancer live longer than male patients

PURPOSE

The incidence of lung cancer is rising in women in the United States, and recent reports have suggested that female patients treated for small cell lung cancer have an improved survival compared with their male counterparts. In view of these findings, we decided to determine if, in our patient population, women live longer than men and if a higher proportion of female patients are entering our trials.

PATIENTS AND METHODS

The survival of women entering therapeutic clinical trials for small cell lung cancer from 1973 through 1986 at the National Cancer Institute-Navy Medical Oncology Branch was evaluated and compared with the survival of similarly treated men during the same time period.

RESULTS

The survival of female patients was longer than that of male patients (median of 13 months versus 10 months). Cox proportional hazards modeling incorporating multiple prognostic factors indicated that women survived significantly longer than men (p = 0.002) when adjustment for other significant factors was made. This survival advantage for women was consistent in both early and late time periods analyzed. In addition, women constituted a larger proportion of patients entering clinical trials in the later time period, as is consistent with the rising incidence of lung cancer in women nationwide.

CONCLUSION

We believe it will be important that comparisons of current clinical trials with older trials that enrolled fewer women control for the favorable prognostic factor of the female sex.

Chemosensitivity testing of human lung cancer cell lines using the MTT assay

Thirty human lung cancer cell lines were tested for chemosensitivity using the semi-automated, non-clonogenic MTT assay. The tumour cell lines came from three major categories of patients: untreated small cell lung cancer (SCLC); SCLC relapsing on chemotherapy; and non-SCLC predominantly from untreated patients. From these data IC50 values were derived for each drug in each cell line. While some inter-experimental variability was observed, the rank order of chemosensitivity of each cell line within this panel was significantly correlated between experiments. These results show that tumour cell lines derived from untreated small cell lung cancer patients were the most chemosensitive for adriamycin, melphalan, vincristine and VP16 compared to the other cell types. In addition, untreated SCLC was more sensitive than non-SCLC to BCNU and cis-platin, while vincristine was the only drug to which treated SCLC was more sensitive compared to the non-SCLC lines. In contrast, no significant differences between the lung cancer types were observed for vinblastine. Thus, this panel of lung cancer cells exhibited a drug sensitivity profile paralleling that observed in clinical practice. These results suggest that this lung cancer cell line panel in combination with a relatively simple but reproducible chemosensitivity assay, such as the MTT assay, has potential for the testing of drug combinations and evaluating new anti-cancer agents in vitro.

Results of therapeutic cranial irradiation in small cell lung cancer

A large proportion of patients with small cell lung cancer develop intracranial metastases which are often severely disabling. The optimal radiotherapeutic program for treating these metastases is unknown. We therefore evaluated objective response rates, response duration, and survival after therapeutic cranial irradiation in 59 patients with proven brain metastases from small cell lung cancer. Objective responses to a variety of doses and schedules were observed in 37 (63%) patients. However, progression of intracranial disease after radiotherapy was common, with 24 responding patients having relapsed in the brain prior to death. The actuarial likelihood of remaining free of progressive brain tumor at 1 year was only 37% in complete and 0% in partial responders. Patients who received radiation doses of more than 40 Gy had longer response durations than those given lower doses, although patient selection could well explain this observation. Brain metastases presenting after initiation of systemic chemotherapy or occurring in conjunction with other sites of extrathoracic disease were associated with a poor prognosis. In patients who present with brain metastases as the sole site of metastatic disease, higher doses of cranial irradiation should be considered, in view of the high intracranial relapse rate associated with currently accepted dose and fractionation schedules.

Non-small-cell lung cancer. Major cause of late mortality in patients with small cell lung cancer

Among 360 patients with small cell lung cancer treated in National Cancer Institute therapeutic trials from 1973 to 1982, 40 were two-year cancer-free survivors. Of these 40 patients, six had later development of non-small-cell lung cancer at 3.5 to 8.0 years (median 5.1) after the diagnosis of small cell lung cancer. Three had the second malignant tumor in the contralateral lung, one in a different lobe, and two in the same lobe as the initial small cell lung cancer. Ten patients had relapses of small cell lung cancer at 2.1 to 6.2 years (median 3.2) from diagnosis. Three recurrences were in the same site or lobe as the initial lesion, four in the same lobe and in sites outside the thorax, and three solely in sites outside the thorax. It is concluded that these non-small-cell lung cancers usually represent second primary lung tumors and that most late small cell lung cancers represent relapses occurring up to 6.2 years from diagnosis. In this study, the risk of development of non-small-cell lung cancer after two years of disease-free survival following small cell lung cancer is 4.4 percent per person-year, approximately 10 times higher than the rate of 0.5 percent previously determined in screening studies of men at high risk for lung cancer. Non-small-cell lung cancer represents more than a third of lung cancer deaths in patients with small cell lung cancer surviving beyond two years from diagnosis and more than half of lung cancer deaths beyond three years. It is recommended that all patients treated for small cell lung cancer discontinue smoking.

Maintenance chemotherapy for anaplastic small cell carcinoma of the bronchus: a randomised, controlled trial

Since March 1980, 309 patients with anaplastic small cell carcinoma of the bronchus (ASCB) have received remission induction therapy prior to randomisation to maintenance (M) or no maintenance (NM) chemotherapy. Induction therapy consisted of six courses of vincristine, doxorubicin and cyclophosphamide (VAC) given IV every 3 weeks. Those with limited disease also received mediastinal irradiation. Consenting patients with no unequivocal residual disease were randomised to have no further treatment until relapse or a further eight courses of VAC, at a lower dosage, every 4 weeks. Patients failing to achieve randomisation status received palliative treatment only. The median survival for all patients with limited disease (LD) is 363 days and that for patients with extensive disease (ED) is 272 days (P less than 0.00001). Sixty-one patients with ED were randomised. Those having maintenance chemotherapy lived significantly longer (median 372 days) than those who did not continue therapy (median 259 days) (P = 0.006). An imbalance in the proportion of 'complete remitters' randomised to maintenance therapy does not account for this difference. There is no significant difference between the M and NM groups in the 32 randomised LD patients. Continuing treatment during remission with agents used to induce the remission can prolong survival in patients with extensive stage ASCB.

Small cell bronchogenic carcinoma

We have attempted to highlight the most important aspects of SCBC in this review. The significant strides made in a variety of areas have been associated with increased response rates and survival as well as with a prolonged disease-free interval in a fraction of patients. The consensus is that 50% or more of patients with LD can achieve a CR, with an overall objective response rate of 80% or greater and a median overall survival of 14 months or longer. Furthermore, 15% to 20% of such patients may expect a disease-free interval of at least three years that appears to be associated with cure in at least some of these patients. Patients with ED may experience a 20% or greater CR, an 80% or greater objective response, and have a median overall survival of at least seven months. Extensive research is ongoing in a variety of areas. Further refinements in developing more effective chemotherapeutic regimens are likely, as is obtaining new information concerning the intensity, duration, and selection of chemotherapeutic agents and their role in relationship to radiotherapy. Improvement in radiotherapy techniques may lead to improved therapeutic results. Only recently has a reevaluation of the role of surgery in SCBC begun to take place. Also, several new areas of investigation are on the horizon, ranging from improved staging with thoracic and abdominal computed tomography to the role of warfarin, monoclonal tumor antibodies, and several currently investigational chemotherapeutic and biologic response modifier agents.

Small cell carcinoma of the lung

Small cell lung cancer is a common, usually fatal neoplasm. Although palliative therapy is available for the majority of patients, only a very small minority enjoy long-term survival. Ironically, this neoplasm is nearly entirely preventable and a successful antismoking program is desperately needed. Our efforts to understand the basic biology of this tumor should continue, and, hopefully, will eventually translate into improvements in therapy. In addition to following the leads provided by basic research, a concerted clinical research effort needs to continue to build upon the advances already achieved.

Sequential hemibody and local irradiation with combination chemotherapy for small cell lung carcinoma: a preliminary analysis

Sequential hemibody irradiation (SHB) was integrated with combination chemotherapy and local irradiation (LRT) in the induction and consolidation phases of a therapeutic protocol for small cell lung carcinoma (SCLC). Forty-one previously untreated patients were entered into this program. Among 38 evaluable patients (20 with limited disease [LD] and 18 with extensive disease [ED], the overall response rate was 63% (90% in LD and 33% in ED patients). The estimated overall survival is 8.1 months. The major toxicity has been myelosuppression--especially thrombocytopenia. The frequency of previously described "acute radiation syndromes" and radiation pneumonitis associated with hemibody irradiation have been substantially decreased at the current dosage with premedication and shielding techniques. The integration of SHB as a systemic therapy with combination chemotherapy and LRT is a feasible program for sequential administration of non-cross-resistant agents in SCLC and may be beneficial in patients with limited disease.

Current status of therapy for small cell carcinoma of the lung

Small cell carcinoma of the lung (SCCL) is distinguished from other types of lung cancer by its propensity for early development of distant metastases and its rapidly fatal clinical course in the absence of treatment. The introduction of chemotherapy into the management of SCCL has led to a four- to five-fold improvement in median survival and to the cure of a small proportion of patients with this disease. Employment of three- or four-drug regimens with or without chest irradiation in moderately intensive doses for periods of 12 months or less has proven to be the optimal therapeutic strategy with currently available agents. Despite these substantial gains, it is obvious that the vast majority of SCCL patients are continuing to die from their cancer, and a slowing in the pace of treatment advances has become apparent over the past 5 years. This article reviews current areas of active clinical investigation in SCCL and some information developed in the cell biology laboratory that may have eventual application in the clinic.

Small cell lung cancer 1973-1983: early progress and recent obstacles

The recognition that the vast majority of patients with small cell lung cancer have distant metastatic disease at the time of diagnosis led to the use of systemic chemotherapy and consequent major improvements in survival in the early to mid-1970's. In the past five years, however, the pace of therapeutic advances has slowed. Recently evaluated treatment strategies, including more intensive induction chemotherapy, "late intensive" therapy of responding patients, alternation of chemotherapeutic regimens, integration of chest irradiation with drug therapy, large field irradiation, and reappraisal of the value of surgical resection, are discussed in this review. Advances in understanding of the cell biology of small cell lung cancer which may eventually lead to new forms of treatment are summarized.