Teniposide (VM26): an effective treatment for brain metastases of small cell carcinoma of the lung

Chemotherapy and targeted molecular therapies for brain metastases

As therapy for systemic cancers improves, an increasing number of patients are developing brain metastases. Although conventional therapy with surgery, radiation therapy and radiosurgery has improved the outcome of a significant number of patients, many develop multiple lesions that are not amenable to standard treatments. In this review, the current role of chemotherapy and targeted molecular agents for brain metastases is summarized and future directions are discussed.

Response to topotecan of symptomatic brain metastases of small-cell lung cancer also after whole-brain irradiation. a multicentre phase II study

The purpose of this multicentre phase II study was to evaluate the efficacy and toxicity of topotecan in pretreated patients with small-cell lung cancer (SCLC) who relapsed with symptomatic brain metastases. 30 patients with a median age of 62 years were entered into the study. 22 patients received the initially planned dose of 1.5 mg/m(2) topotecan as a 30-min intravenous (i.v.) infusion for 5 consecutive days every 3 weeks. Due to the observed thrombocytopenia, the dose was reduced to 1.25 mg/m(2) in the last 8 patients. All 30 patients were pretreated with chemotherapy: 14 with one and 16 with at least two protocols. 8 patients had prior whole-brain iradiation (WBI): 7 in the prophylactic and 1 in the palliative setting. Concomitant systemic metastases were recorded in 24 patients at the time of brain relapse. Cerebral metastases responded in 33% of patients (10/30; three complete responses (CR) and seven partial responses (PR)). Noteworthy is the fact that response was achieved in 4 of 8 patients pretreated by WBI (3 in prophylactic and 1 in palliative setting). The systemic response rate was 29% (7/24). Median time to progression was 3.1 months (range 0.25-14.2+ months), median survival from the beginning of this study was 3.6 months (range 0.25-14.2+ months). Therapy was generally well tolerated, with myelotoxicity being the most common adverse event. Grade 3 leucocytopenia according to the Common Toxicity Criteria (CTC) occurred in 28% (23/83) of the courses and grade 4 in 22% (18/83). Grade 3 thrombocytopenia was observed in 17% of the courses (14/83) and grade 4 in 11% (9/83). 17% of patients (5/30) had a documented grade 3 infection. These results using topotecan are promising in heavily pretreated patients with SCLC brain metastases and merit further evaluation.

The role of systemic chemotherapy in the treatment of brain metastases from small-cell lung cancer

Brain is the most common site of metastatic spread in small-cell lung cancer (SCLC). Approximately 10% of SCLC patients have brain metastases (BM) already at diagnosis and an additional 40% will develop central nervous system (CNS) involvement during their disease course. Although whole brain radiotherapy and corticosteroids is considered the treatment of choice, accumulating evidence suggests that systemic chemotherapy may also play an important role. The concept of the brain as a pharmacologic sanctuary site for established metastases is in contrast with recent clinical observations of frequent BM responses with systemic chemotherapy. During the last decade, several reports about the effect of systemic chemotherapy on BM from SCLC have been published. Pooled data from five studies report 66% response rate (RR) in 64 patients with initial BM. In addition, an average RR of 36% is derived from five studies including 135 patients with delayed BM treated with systemic single agent chemotherapy. Among new drugs with activity in patients with SCLC brain metastases, camptothecin analog topotecan is one of the most promising with a 52% RR. Although whole brain radiation remains the standard treatment of established BM in SCLC there is an emerging role for systemic chemotherapy, particularly with the use of new active drugs as part of combined modality treatments.

Treatment of brain metastases of small-cell lung cancer: comparing teniposide and teniposide with whole-brain radiotherapy--a phase III study of the European Organization for the Research and Treatment of Cancer Lung Cancer Cooperative Group

PURPOSE

Approximately 60% of patients with small-cell lung cancer (SCLC) develop brain metastases. Whole-brain radiotherapy (WBRT) gives symptomatic improvement in more than 50% of these patients. Because brain metastases are a sign of systemic progression, and chemotherapy was found to be effective as well, it becomes questionable whether WBRT is the only appropriate therapy in this situation.

PATIENTS AND METHODS

In a phase III study, SCLC patients with brain metastases were randomized to receive teniposide with or without WBRT. Teniposide 120 mg/m(2) was given intravenously three times a week, every 3 weeks. WBRT (10 fractions of 3 Gy) had to start within 3 weeks from the start of chemotherapy. Response was measured clinically and by computed tomography of the brain.

RESULTS

One hundred twenty eligible patients were randomized. A 57% response rate was seen in the combined-modality arm (95% confidence interval [CI], 43% to 69%), and a 22% response rate was seen in the teniposide-alone arm (95% CI, 12% to 34%) (P<.001). Time to progression in the brain was longer in the combined-modality group (P=.005). Clinical response and response outside the brain were not different. The median survival time was 3.5 months in the combined-modality arm and 3.2 months in the teniposide-alone arm. Overall survival in both groups was not different (P=.087).

CONCLUSION

Adding WBRT to teniposide results in a much higher response rate of brain metastases and in a longer time to progression of brain metastases than teniposide alone. Survival was poor in both groups and not significantly different.

Treatment of Brain Metastases in Patients with Small-Cell Lung Cancer: Lessons from Treatment of Other Tumors

Brain metastases are common in patients with small-cell lung cancer (SCLC) and are usually fatal. About half of all patients who develop brain metastases will remain symptomatic at their time of death, even if the immediate cause of death is not neurologic. While it has been argued that the obtundation that sometimes comes with brain metastases may be a relatively easy way to die, studies which have examined the quality of life of individuals developing brain metastases dispute this. For most patients and their families, the impairment of physical, cognitive, and affective function which accompanies most brain metastases is highly distressing and can be seen as a "loss" of the patient even before his/her death. Thus, improved treatment of overt brain metastases will be of palliative value, and eradication of microscopic disease in the brain may cure patients whose disease in other sites has been eradicated. Prophylactic cranial irradiation (PCI) for patients who have achieved a complete response to induction therapy markedly reduces the risk of central nervous system relapse and modestly but significantly improves survival. Despite the use of PCI, many patients with SCLC will develop brain metastases, and there is increasing interest in surgical treatment of patients with solitary lesions and the use of systemic chemotherapy in treating patients, with both SCLC and non small-cell lung cancer, who have multifocal brain metastases which are minimally symptomatic, particularly when these patients also have extracranial metastatic disease.

Chemotherapy for brain metastases of lung cancer: a review

In lung cancer patients brain metastases develop with a high frequency. For years radiotherapy has been the standard treatment for these patients. Here we review the experience with chemotherapy for brain metastases in lung cancer patients. The concept of the brain as pharmacological sanctuary site when brain metastases are present is challenged and it is argued that chemotherapy does play a role in this situation. Recent clinical trials indicate that the combination of chemotherapy and radiotherapy may become the standard treatment for lung cancer patients with brain metastases. It is unclear whether for micrometastatic disease to the brain, blood brain barrier function is of importance for the outcome of chemotherapy in lung cancer patients with respect to the development of overt brain metastases. Areas of improvement of delivery of cytotoxic agents to the brain when brain metastases have not yet developed are discussed.

Is it time to reevaluate our approach to the treatment of brain metastases in patients with non-small cell lung cancer?

Brain metastases from non-small cell lung cancer develop in approximately one-third of patients. If not treated, neurological deterioration occurs quickly. Treatment with whole brain irradiation is advisable to palliate symptoms but despite this treatment, survival remains poor at 3-6 months. Recently, aggressive approaches with surgical resection and stereotactic radiosurgery have dramatically improved the control of brain metastases resulting in a meaningful survival advantage for a subset of eligible patients. New evidence also suggests a possible role for chemotherapy in the treatment of brain metastases. With several options now available to treat brain metastases proper patient selection is needed. This article will stratify patients with brain metastases and discuss the treatment modalities for each category.

Chemotherapy with cisplatin and teniposide for cerebral metastases in non-small cell lung cancer

Twenty-three patients with brain metastases from non-small cell lung cancer (NSCLC) (median age 62 years, Karnofsky PS 50-100) were treated with cisplatin (100 mg/m2, day 1) and teniposide (80 mg/m2, days 1, 3 and 5) every 3 weeks. Response was evaluated by contrast-enhanced brain CT every two to three cycles of treatment. The objective response rate of brain metastases was 35% (8/23); three patients achieved complete response (CR) and five partial response (PR). The median response duration was 24 weeks for CR patients and 32 weeks for PR patients. The median survival was 21 weeks overall and 45 weeks for responding patients. Grade 3/4 leukocytopenia and thrombocytopenia were seen in 28 and 9%, respectively. Two patients died from infections while in neutropenia. Cisplatin and teniposide seems an active regimen against brain metastases in NSCLC. These data may indicate the need for reconsideration of the role of chemotherapy for brain metastases of NSCLC.

Teniposide for meningeal carcinomatosis of small cell lung cancer

A female patient with small cell lung cancer and extensive bone marrow metastases achieved a complete response after combination chemotherapy including etoposide. During maintenance therapy meningeal carcinomatosis was diagnosed. After intravenous administration of teniposide she improved dramatically during 3 months.

High dose etoposide for brain metastases of small cell lung cancer. A phase II study. The EORTC Lung Cancer Cooperative Group

Symptomatic brain metastases are found in about 40% of patients with small cell lung cancer. Cranial irradiation is the first line treatment for this form of metastatic disease. Frequently brain metastases recur after this treatment or develop after prophylactic cranial irradiation. For these patients no effective antitumour therapy is available. In this study the efficacy of high dose etoposide 1.5 g m-2 was evaluated. In 10 (43%) out of 23 evaluable patients a response was seen. Toxicity was severe with five aplasia-related deaths. For palliative purposes this regimen is too toxic in heavily pretreated patients.

Podophyllotoxins for brain metastases of small cell lung cancer

A patient with brain metastases of small cell lung cancer (SCLC) responded initially to cranial irradiation. Recurrences were subsequently successfully treated with high-dose intravenous etoposide (VP 16-213) and teniposide (VM 26). Epipodophyllotoxins are potentially useful for CNS metastases of SCLC.