1 Phase II trial of navelbine (NVB), in small cell lung cancer (SCLC)

Pilot Phase II Study of Gemcitabine and Vinorelbine in Patients with Recurrent or Refractory Small Cell Lung Cancer

The aim of this phase II study was to evaluate toxicity, response, time to progression, and overall survival in patients with recurrent or progressive small cell lung cancer (SCLC) receiving the combination of gemcitabine and vinorelbine. This two stages Simon design trial was stopped after 17 patients were enrolled and response rate did not reach a level to justify continuation to the second stage. One patient had received three previous chemotherapy combinations, 5 had two prior chemotherapy regimens, and the remaining 11 had been treated with one prior line of therapy. Their median age was 62 years (35-72). Vinorelbine was administered at 25 mg/m(2) followed by gemcitabine 1000 mg/m(2), on days 1 and 8, every 3 weeks. Sixteen patients were evaluable for toxicity and 11 for response. Grade 3 neutropenia was seen in 5 patients (33%) and 3 patients had grade 4 neutropenia (20%). Three patients had grade 3 thrombocytopenia. No grade 4 non-hematological toxicities were seen. A total of 85 infusions were given, with 1 patient (6%) obtaining a partial response (PR) for a duration of 148 days. Three additional patients had stable disease (19%), but only in 1 patient for longer than 24 weeks. The median time to progression was 47 days for all patients (range 25-196). After a median follow-up of 184 days, 13 patients died (76%). Median overall survival was 164 days. The combination of gemcitabine and vinorelbine has limited activity in relapsed SCLC.

Chemotherapy as treatment of primary and recurrent small cell lung cancer

Chemotherapy is the treatment of choice in metastatic stage of small-cell lung cancer (SCLC). Radiation therapy, surgery and other forms of therapy are only included in special treatment situations, particularly for different local problems. A wide range of chemotherapeutic agents have proven to be effective in SCLC, including carboplatin, cisplatin, cyclophosphamide, doxorubicin, epirubicin, etoposide, ifosfamide, teniposide and vincristine. However, treatment results could not be improved over the last 10 years and the median survival of patients with metastatic disease is limited to 7-10 months. New agents like docetaxel, gemcitabine, irinotecan, paclitaxel, topotecan and vinorelbine have shown promising results in phase-II investigations. Yet, no evidence is provided from randomized trials to employ these drugs in first line treatment. Clearly, polychemotherapy is superior to single agent treatment. Compared to the combination of cisplatin and etoposide, no other combination has clearly shown improved results in large phase-III randomised trials, yet. The combination of cisplatin and irinotecan has also shown promising results in a single randomised trial with the need to be confirmed in larger settings. Neither extending the initial treatment beyond the median number of six cycles, nor maintenance treatment have-so far-resulted in any increase in survival results for patients with metastasised SCLC. Nor has dose-intensification, which causes significantly higher toxicities in patients, shown a clear impact on the overall survival of these patients. Brain metastases represent a high frequent complication associated with SCLC. In these cases, the combination of chemotherapy and whole brain radiation therapy is advocated. Second-line treatment should always be considered in patients with relapse or failure to first-line therapy. In addition to a rechallenging with the prior drug combination or selecting a different potentially non-cross resistant one, monotherapy with topotecan proved to be effective as well. In summary, up to now, no standard chemotherapy combination exists for metastatic SCLC. The individual therapy strategy can only be selected by considering the clinically relevant conditions of the patient.

Treatment of extensive stage small cell lung cancer

Over the past twenty years combination chemotherapy has continued to produce small survival gains for patients with SCLC. We enter the next century enthusiastic about the array of new chemotherapeutic agents to evaluate and fascinated by the biological agents with the hope of achieving dramatic improvements in survival for our patients with SCLC.

Comparative prognostic value of lactate dehydrogenase and neuron-specific enolase in small-cell lung cancer patients treated with platinum-based chemotherapy

The influence of pretreatment serum levels of lactate dehydrogenase (LDH) and neuron-specific enolase (NSE) on survival was investigated in a series of 263 consecutive patients with small-cell lung cancer. LDH was elevated in one-half of the patients, NSE in 79%. Both were significantly higher when the disease was considered extensive than when it was limited. The markers were significantly correlated (r= 0.54, P=1.03 x 10(-20)), and both had a significant impact on survival in the univariate analysis. The multivariate survival analysis of the entire population showed that LDH, along with performance status, extent of disease, and albumin, was a more important prognostic factor than NSE. Only when LDH was removed from the model did NSE become an independent prognostic factor. In the separate multivariate survival analyses of limited and extensive disease, LDH remained an independent prognostic factor. For extensive disease, NSE did not even appear in the model when LDH was excluded; for limited stage disease, NSE did become a weak independent prognostic factor when LDH was excluded. In conclusion, LDH, which is less expensive to assay than NSE, is also a stronger independent prognostic factor for small-cell lung cancer and should be part of the initial work-up. In clinical trials, stratification for LDH levels should be considered because of its prognostic weight.

New chemotherapy agents for small cell lung cancer

BACKGROUND

Approximately 45,000 new cases of small cell lung cancer (SCLC) will be diagnosed in the United States this year. Combination chemotherapy is the cornerstone of treatment for all stages of this disease and results in high response rates (65 to 85%), leading to a meaningful survival advantage for these patients. Patients with limited-stage disease enjoy a median survival of 10 to 15 months with chemotherapy, as compared to 3 months without drug therapy. With addition of chest radiotherapy, survival is further prolonged to 12 to 20 months. Patients with extensive-stage disease experience an average survival of 1.5 months without chemotherapy and 7 to 11 months with chemotherapy. However, no further improvement in survival has been demonstrated since combination chemotherapy regimens were introduced in the late 1970s and early 1980s, despite evaluating numerous strategies; the 5-year survival for all patients remains dismal at 5%. Clearly, new chemotherapy agents with novel mechanisms of action are needed.

FOCUS

This article will review the experience to date with six new agents that are active against SCLC. It includes two taxanes (paclitaxel and docetaxel), vinorelbine, two camptothecin derivatives (topotecan and irinotecan), and gemcitabine. Single-agent activity as well as combination regimens with other agents and radiotherapy will be discussed. The role of maintenance therapy with oral matrix metalloproteinase inhibitors also is evaluated.