Second and third line treatment in non-small cell lung cancer

Gambogic acid potentiates gemcitabine induced anticancer activity in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the most frequent type of lung cancer accounting up to 80-85% of all lung cancer (LC) cases. Gemcitabine (Gem), a pyrimidine nucleoside antimetabolite, is widely used chemotherapy offering several months survival benefit in patients with NSCLC. The emergence of Gem resistance is a main clinical concern in cancer treatment and thus a continuous demand for development of new therapeutic strategies to improve its antitumor activity. Hence, we report an adjuvant therapeutic regimen based on natural compound, gambogic acid (GA) which has been shown to enhanced Gem induced inhibition of cancer cell growth, arrest cell cycle, and induce apoptosis by enhanced accumulation of Gem. The in vitro cell viability, clonogenicity, invasion, and migration assays demonstrated a significant higher therapeutic effect of Gem when it was combined with GA in A549 and H1299 cells. A better access of internalization of drug molecules achieved in rhodamine 123 assay when GA was used as adjuvant treatment. Further, GA and Gem combination significantly reduced tubular formation of HUVEC cells indicates lowering angiogenesis potential. Microarray and Western blot studies confirm that GA + Gem co-treatment strategy promotes cancer cell death by downregulating anti-apoptotic proteins, chemoresistance-associated proteins, and upregulation of apoptosis proteins. More importantly, a significant higher therapeutic benefit was noticed for GA and Gem combination in A549 xenograft mice model. Together, these results offer a rationale to evaluate the clinical translational possibility of GA as adjuvant therapy to overcome Gem resistance. This combination regimen can be a new therapeutic concept to eradicate this devastating disease.

[Study on the Metabolic Reprogramming of Lung Cancer Cells Regulated by Docetaxel Based on Metabolomics]

背景与目的

多西他赛是一种临床常用的抗肿瘤药物，是晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）的一线用药。然而，多西他赛抗NSCLC作用的分子机制尚不明确。研究表明肿瘤细胞的代谢重编程在肿瘤发生发展过程中发挥重要作用。本研究旨在通过结合代谢组学分析及生物学手段来探讨多西他赛所影响的NSCLC细胞代谢通路。

方法

首先，通过CCK-8实验分析多西他赛对NSCLC细胞活力的影响，筛选合适药物浓度。接下来，通过基于气相色谱质谱联用（gas chromatography-mass spectrometry, GC-MS）的代谢组学技术分析多西他赛处理和未处理的A549和H1299细胞。并通过统计学计算得到处理组和未处理组间的差异代谢物。最后，通过蛋白质免疫印迹分析（Western blot）多西他赛对其所调控的相关代谢途径中关键酶蛋白质表达水平的影响。

结果

多西他赛可时间依赖和浓度依赖地抑制A549和H1299细胞活力。随着多西他赛处理时间延长，凋亡敏感蛋白质多聚二磷酸腺苷核糖聚合酶[Poly(ADP-)Polymerase, PARP]逐渐被激活裂解形成P89片段。代谢组学分析发现，药物处理后的A549和H1299细胞内，8种代谢物均发生显著变化，主要集中于三羧酸（tricarboxylic acid, TCA）循环代谢通路。同时，药物处理后，TCA循环关键调控酶异柠檬酸脱氢酶蛋白质表达水平显著下降。

结论

多西他赛诱导NSCLC增殖抑制及凋亡的效应可能与下调异柠檬酸脱氢酶，进而抑制三羧酸循环代谢途径有关。

Japanese subgroup analysis of a phase III study of S-1 versus docetaxel in non-small cell lung cancer patients after platinum-based treatment: EAST-LC

Introduction

The East Asia S-1 Trial in Lung Cancer (EAST-LC) was a randomized phase III study conducted in East Asia that demonstrated the non-inferiority of S-1 to docetaxel in previously treated patients with advanced non-small cell lung cancer (NSCLC). Here, we reported the results of the Japanese subgroup treated with docetaxel 60 mg/m², the standard dosage in Japan.

Patients and methods

Patients were randomized 1:1 to receive either S-1 or docetaxel. The primary endpoint was overall survival (OS); the secondary endpoints included progression-free survival (PFS), response rate (RR), quality of life (QOL), and safety.

Results

Patient characteristics in the Japanese subgroup (n = 724) were similar to those in the overall EAST-LC population. Median OS was 13.4 months in the S-1 group and 12.6 months in the docetaxel group. In pemetrexed-pretreated patients, OS with S-1 was similar to that with docetaxel. Median PFS was 2.9 and 3.0 months in the S-1 and docetaxel groups, respectively. RR was 9.4% and 10.3% in the S-1 and docetaxel groups, respectively. The QOL of patients treated with S-1 was better compared with that of patients treated with docetaxel. Decreased appetite and diarrhea were more common in the S-1 group, whereas the frequency of neutropenia and febrile neutropenia was markedly higher in the docetaxel group.

Conclusions

This Japanese subgroup analysis showed that S-1 had similar efficacy to docetaxel in patients with previously treated advanced NSCLC. These results are similar to those of the overall EAST-LC population.

Electronic supplementary material

The online version of this article (10.1007/s10147-019-01396-z) contains supplementary material, which is available to authorized users.

Differences in the efficacy of S-1 monotherapy according to histological type in pretreated patients with advanced non-small cell lung cancer

BACKGROUND

S-1 is a novel antimetabolic agent that inhibits thymidylate synthase. The expression of thymidylate synthase is higher in squamous (Sq) non-small cell lung cancer (NSCLC) than in non-Sq NSCLC. The aim of this retrospective study was to assess the efficacy of S-1 monotherapy for advanced NSCLC according to the histological subtype.

METHODS

We reviewed the clinical records of patients with advanced NSCLC treated with S-1 monotherapy as second- or third-line therapy between May 2005 and July 2012 at the Shizuoka Cancer Center.

RESULTS

A total of 71 patients were included in this retrospective study. Patient characteristics were similar in the Sq NSCLC (n = 15) and non-Sq NSCLC (n = 56) groups, except with regard to gender and smoking status. The overall response rates were 0% (95% confidence interval [CI] 0-17%) for Sq NSCLC and 11% (95% CI 3-19%) for non-Sq NSCLC (P = 0.33). For Sq NSCLC and non-Sq NSCLC, the median progression-free survival times were 2.1 and 2.8 months (P = 0.02), respectively, and the median overall survival times were 6.1 and 10.1 months (P = 0.01), respectively.

CONCLUSION

S-1 monotherapy may be more effective in patients with non-Sq NSCLC than in those with Sq NSCLC.

Effectiveness and safety of pemetrexed-based doublet versus pemetrexed alone as second-line treatment for advanced non-small-cell lung cancer: a systematic review and meta-analysis

BACKGROUND

To compared pemetrexed-based doublet with single-agent pemetrexed as second-line treatment for advanced non-small-cell lung cancer

METHODS

We systematically searched for randomized clinical trials that compared pemetrexed-based doublet with single-agent pemetrexed in patients with histologically proven non-small-cell lung cancer. The primary end point was overall survival. Secondary end points were progression-free survival, overall response rate and grade 3 or 4 toxicity. Data were extracted from the studies by 2 independent reviewers. The meta-analysis was performed by Stata version 10.0 software (Stata Corporation, College Station, Texas, USA).

RESULTS

Five randomized clinical trials (totally 1,186 patients) were eligible. Meta-analysis showed that there was significant improvement in PFS (HR 0.82, 95% CI 0.71-0.95, P = 0.007) and overall response rate (OR 2.39, 95% CI 1.58-3.62, P = 0.000) in pemetrexed-based doublet group, compared with pemetrexed alone, though the pooled HR for overall survival (HR 0.89, 95% CI 0.76-1.04; P = 0.129) showed no significant difference between the two groups. However, there were more incidences of grade 3 or 4 neutropenia (OR 2.3, 95% CI 1.4-3.77, P = 0.001), thrombocytopenia (OR 6.41, 95% CI 2.57-16.0, P = 0.000), and leucopenia (OR 2.45, 95% CI 1.13-5.34, P = 0.024) in pemetrexed-based doublet group. With regard to the risk of grade 3 or 4 anemia (OR 0.71, 95% CI 0.17-2.91, P = 0.629) and fatigue (OR 1.47, 95% CI 0.92-2.35, P = 0.104), there was no significant difference between the two groups.

CONCLUSION

Pemetrexed-based doublet therapy didn't gain any benefit in survival but significantly improved PFS and better ORR compared with single-agent pemetrexed as second-line therapy for advanced non-small-cell lung cancer. However, more incidences of grade 3 or 4 neutropenia, thrombocytopenia, and leucopenia were observed in pemetrexed-based doublet group.

Phase II study of erlotinib as third-line monotherapy in patients with advanced non-small-cell lung cancer without epidermal growth factor receptor mutations

OBJECTIVE

There are few standard therapeutic options beyond second-line treatment. We aimed to evaluate the efficacy and safety of erlotinib monotherapy as third-line chemotherapy in patients with advanced non-small-cell lung cancer without epidermal growth factor receptor mutations.

METHODS

In this phase II trial, patients who did not have epidermal growth factor receptor mutations and who had previously received two cytotoxic chemotherapy regimens containing platinum were treated with erlotinib (150 mg, per os) until disease progression or unacceptable toxicity.

RESULTS

Twenty patients were eligible for the assessment of efficacy and safety. Three cases showed a partial response, and eight cases showed stable disease with an overall response rate of 15.0% (95% confidence interval: 5.2-36.0%) and a disease control rate of 55.0% (95% confidence interval: 34.2-74.2%). Median progression-free survival and overall survival time were 2.1 and 6.7 months, respectively. Although dose reduction was required in one patient because of skin toxicity, grade 3/4 toxicity or pulmonary disease was not observed.

CONCLUSIONS

Erlotinib as third-line therapy showed an acceptable response rate, survival time and toxicity. It could be a potential third-line therapy for patients without epidermal growth factor receptor mutations.

High response of second-line chemotherapy with pemetrexed or gemcitabine combined with carboplatin in patients with non-small-cell lung cancer experiencing progression following 6 months after concluding platinum-based chemotherapy

Because of improved therapeutic results after first-line platinum-based chemotherapy in patients with stage IV non-small-cell lung cancer (NSCLC), second-line chemotherapy may be considered for a growing number of patients. Approximately, 10% of patients have an interval time after concluding first-line platinum-based chemotherapy greater than 6 months. These patients may achieve high tumor responses when platinum is again used in second-line treatment. Twenty-three patients experiencing progression following 6 months after concluding platinum-based chemotherapy were managed with second-line treatment with carboplatin combined with gemcitabine or pemetrexed. Overall response, progression-free survival (PFS), and overall survival (OS) after initiation of second-line treatment were calculated for all patients. Median PFS after first-line treatment was 12.6 months (95% confidence interval [95% CI], 10.4-14.7 months). Partial response was achieved in 7 of 23 patients, resulting in an overall response of 30.4% (95% CI, 11.6-49.0). Following initiation of second-line chemotherapy, median PFS was 5.9 months (95% CI, 1-10.9 months) and median OS was 12.5 months (95% CI, 3.5-21.5 months). The 1-year survival rate for all patients was 61.0% (95% CI, 29.5-82.0). Adding these results to those of the 10 previously published trials, 75 of 326 patients, 23%, (95% CI, 18.7-27.3) presented an overall response with the use of second-line platinum-based chemotherapy. The use of platinum combinations as second-line chemotherapy seems to have a place in the management of patients with advanced NSCLC, especially those with an interval time to progression greater than 6 months.