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Abstract
Leptomeningeal metastases represent an aggressive stage of cancer with few durable treatment options. Improved understanding of cancer biology, neoplastic reliance on oncogenic driver mutations, and complex immune system interactions have resulted in an explosion in cancer-directed therapy in the last two decades to include small molecule inhibitors and immune checkpoint inhibitors. Most of these therapeutics are underexplored in patients with leptomeningeal metastases, limiting extrapolation of extracranial and even intracranial efficacy outcomes to the unique leptomeningeal space. Further confounding our interpretation of drug activity in the leptomeninges is an incomplete understanding of drug penetration through the blood-cerebrospinal fluid barrier of the choroid plexus. Nevertheless, a number of retrospective studies and promising prospective trials provide evidence of leptomeningeal activity of several small molecule and immune checkpoint inhibitors and underscore potential areas of further therapeutic development for patients harboring leptomeningeal disease.
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Affiliation(s)
- Jessica A Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Adrienne A Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
- Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Shetty V, Babu S. Management of CNS metastases in patients with EGFR mutation-positive NSCLC. Indian J Cancer 2020; 56:S31-S37. [PMID: 31793440 DOI: 10.4103/ijc.ijc_455_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Central nervous system (CNS) metastases are a frequent and severe complication associated with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). The first- and second-generation EGFR tyrosine kinase inhibitors (TKIs) have shown considerable efficacy in EGFR-mutated NSCLC. However, their limited potential to cross the blood-brain barrier (BBB) renders them less effective in the management of CNS metastases in NSCLC. Osimertinib, a third-generation irreversible EGFR-TKI with good potential to cross the BBB, has shown significant clinical activity and acceptable safety profile in patients with EGFR-positive NSCLC brain and leptomeningeal metastases. The progression-free survival (PFS) of up to 15.2 months in CNS metastases patients in the FLAURA trial and the CNS objective response rates (ORRs) of 54% and 43% in the AURA/AURA2 and BLOOM trials, respectively, have established the role of osimertinib in patients with NSCLC with CNS metastases. The AURA3 trial also reported a PFS of 8.5 months and overall ORR of 71%. These data have supported osimertinib to be recognized as a "preferred" first-line treatment for EGFR-positive metastatic NSCLC by the National Comprehensive Cancer Network (NCCN). With limited treatment options available, upfront administration of osimertinib in patients with NSCLC irrespective of EGFR T790M and CNS metastases may improve the overall response rate and potentially reduce the adverse effects of radiotherapy. Our review focuses on the management of EGFR-mutated NSCLC CNS metastases in the context of recent NCCN guidelines.
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Affiliation(s)
- Vijith Shetty
- Department of Medical Oncology, K.S. Hegde Medical Academy, Mangalore, Karnataka, India
| | - Suresh Babu
- Medical Oncologist, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
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Higuchi T, Oshiro H, Zhang Z, Miyake K, Sugisawa N, Katsuya Y, Yamamoto N, Hayashi K, Kimura H, Miwa S, Igarashi K, Zhao M, Bouvet M, Singh SR, Tsuchiya H, Hoffman RM. Osimertinib Regresses an EGFR-Mutant Cisplatinum- Resistant Lung Adenocarcinoma Growing in the Brain in Nude Mice. Transl Oncol 2019; 12:640-645. [PMID: 30807997 PMCID: PMC6393699 DOI: 10.1016/j.tranon.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/29/2019] [Indexed: 12/23/2022] Open
Abstract
The goal of the present study was to determine the efficacy of osimertinib (AZD9291), a third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor for the treatment of aggressive EGFR-mutant non-small cell lung cancer (NSCLC), compared to cisplatinum (CDDP) + pemetrexed (PEM). The NSCLC cell line PC-9 expressing green fluorescence protein (PC-9-GFP) was implanted in the brain of nude mice and was treated with CDDP + PEM or AZD9291. Tumors were observed by non-invasive fluorescence imaging. AZD9291 treatment caused tumor regression in contrast to CDDP + PEM which had only a slight inhibitory effect. These results suggest that AZD9291 is a promising clinical option for NSCLC patients with brain metastasis.
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Affiliation(s)
- Takashi Higuchi
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA; Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Hiromichi Oshiro
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Zhiying Zhang
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Kentaro Miyake
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Norihiko Sugisawa
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Yuki Katsuya
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Kimura
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan
| | - Ming Zhao
- AntiCancer, Inc., San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California, San Diego, CA, USA.
| | - Shree Ram Singh
- Basic Research Laboratory, National Cancer Institute, Frederick, MD, USA.
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan.
| | - Robert M Hoffman
- AntiCancer, Inc., San Diego, CA, USA; Department of Surgery, University of California, San Diego, CA, USA.
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Wang H, Zhang L, Hu P, Zheng X, Si X, Zhang X, Wang M. Penetration of the blood–brain barrier by avitinib and its control of intra/extra-cranial disease in non-small cell lung cancer harboring the T790M mutation. Lung Cancer 2018; 122:1-6. [DOI: 10.1016/j.lungcan.2018.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/07/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
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Fogli S, Polini B, Del Re M, Petrini I, Passaro A, Crucitta S, Rofi E, Danesi R. EGFR-TKIs in non-small-cell lung cancer: focus on clinical pharmacology and mechanisms of resistance. Pharmacogenomics 2018; 19:727-740. [PMID: 29785875 DOI: 10.2217/pgs-2018-0038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The clinical introduction of EGFR-TKIs within the oncologic armamentarium has changed the therapeutic landscape of non-small-cell lung cancer (NSCLC) creating widespread expectations both in patients and clinicians. However, several gaps in current understanding leave open important questions regarding the use of these drugs in clinical practice. For instance, there is uncertainty in regard to which EGFR-TKI should be given first in naive patients with EGFR-driven malignancies since different generations of drugs are available with different pharmacological profiles. Furthermore, acquired drug resistance may limit the therapeutic potential of EGFR-TKIs and the choice of the best treatment strategy after first-line treatment failure is still debated. This review article is aimed at describing the pharmacological properties of EGFR-TKIs and the current treatment options for NSCLC patients who develop acquired resistance. This information might be useful to design new rational and more effective pharmacological strategies in patients with EGFR-mutant NSCLC.
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Affiliation(s)
- Stefano Fogli
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
| | - Beatrice Polini
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
| | - Marzia Del Re
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
| | - Iacopo Petrini
- General Pathology, Department of Translational Research & New Technologies in Surgery & Medicine, University of Pisa, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
| | - Stefania Crucitta
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
| | - Eleonora Rofi
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
| | - Romano Danesi
- Clinical Pharmacology & Pharmacogenetics Unit, Department of Clinical & Experimental Medicine, University of Pisa, Italy
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Kong LL, Wang LL, Xing LG, Yu JM. Current progress and outcomes of clinical trials on using epidermal growth factor receptor-tyrosine kinase inhibitor therapy in non-small cell lung cancer patients with brain metastases. Chronic Dis Transl Med 2017; 3:221-229. [PMID: 29354805 PMCID: PMC5747498 DOI: 10.1016/j.cdtm.2017.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Indexed: 01/13/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) continues to be one of the major causes of cancer-related deaths worldwide, and brain metastases are the major cause of death in NSCLC patients. With recent advances in understanding the underlying molecular mechanism of NSCLC development and progression, mutations in epidermal growth factor receptor (EGFR) have been recognized as a key predictor of therapeutic sensitivity to EGFR tyrosine kinase inhibitors (TKIs). Using EGFR-TKI alone or in combination with standard treatments such as whole-brain radiotherapy and surgery has been an effective strategy for the management of brain metastasis. Particularly, a newer generation of EGFR-TKIs, including osimertinib and AZD3759, has been developed. These new EGFR-TKIs can cross the blood-brain barrier and potentially treat EGFR-TKI resistance and improve prognosis. In this article, current progress and outcomes of clinical trials on the use of EGFR-TKIs for treating NSCLC patients with brain metastasis will be reviewed.
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Affiliation(s)
- Ling-Ling Kong
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong 250117, China
- Key Laboratory of Radiation Oncology of Shandong Province, Shandong Academy of Medical Sciences, Jinan, Shandong 250001, China
| | - Lin-Lin Wang
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong 250117, China
- Key Laboratory of Radiation Oncology of Shandong Province, Shandong Academy of Medical Sciences, Jinan, Shandong 250001, China
| | - Li-Gang Xing
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong 250117, China
- Key Laboratory of Radiation Oncology of Shandong Province, Shandong Academy of Medical Sciences, Jinan, Shandong 250001, China
| | - Jin-Ming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong 250117, China
- Key Laboratory of Radiation Oncology of Shandong Province, Shandong Academy of Medical Sciences, Jinan, Shandong 250001, China
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Bui N, Woodward B, Johnson A, Husain H. Novel Treatment Strategies for Brain Metastases in Non-small-cell Lung Cancer. Curr Treat Options Oncol 2017; 17:25. [PMID: 27085533 DOI: 10.1007/s11864-016-0400-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OPINION STATEMENT Brain metastases are common in patients with non-small cell lung cancer (NSCLC), and due to associated poor prognosis, this field is an important area of need for the development of innovative medical therapies. Therapies including local approaches through surgical intervention and/or radiation and evolving systemic therapies have led to improvements in the treatment of brain metastases in patients with lung cancer. Strategies that consider applying advanced radiation techniques to minimize toxicity, intervening early with effective systemic therapies to spare radiation/surgery, testing radiosensitization combinations, and developing drug penetrant molecules have and will continue to define new practice patterns. We believe that in carefully considered asymptomatic patients, first-line systemic therapy may be considered before radiation therapy and small-molecule targeted therapy may provide an opportunity to defer radiation therapy for recurrence or progression of disease. The next several years in oncology drug development will see the reporting on of brain penetrant molecules in oncogene-defined non-small cell lung cancer. Ongoing studies will evaluate immunotherapies in patients with brain metastases with associated endpoints. We hope that continued drug development and carefully designed clinical trials may afford an opportunity to improve the lives of patients with brain metastases.
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Affiliation(s)
- Nam Bui
- Division of Hematology and Oncology, University of California, San Diego School of Medicine, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Brian Woodward
- Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Anna Johnson
- Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA
| | - Hatim Husain
- Division of Hematology and Oncology, University of California, San Diego School of Medicine, UCSD Moores Cancer Center, San Diego, CA, USA. .,Center for Personalized Cancer Therapy, UCSD Moores Cancer Center, San Diego, CA, USA. .,, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA.
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Sullivan I, Planchard D. Osimertinib in the treatment of patients with epidermal growth factor receptor T790M mutation-positive metastatic non-small cell lung cancer: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10:549-565. [PMID: 27784815 PMCID: PMC5933598 DOI: 10.1177/1753465816670498] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Patients with advanced epidermal growth factor receptor (EGFR)
mutant non-small cell lung cancer (NSCLC) are particularly sensitive to
treatment with first- or second-generation EGFR tyrosine kinase
inhibitors such as gefitinib, erlotinib and afatinib, which block the
cell-signaling pathways that drive the growth of tumor cells. Unfortunately, the
majority of patients develop resistance to them after a median duration of
response of around 10 months, and in over half of these patients the emergence
of the EGFR T790M resistance mutation is detected. Osimertinib
is an oral, highly selective, irreversible inhibitor of both
EGFR-activating mutations and the T790M-resistance
mutation, while sparing the activity of wild-type EGFR. This
article reviews clinical trial development of osimertinib in patients with
NSCLC, presenting efficacy and safety evidence for its value in the
EGFR T790M mutation-positive population and in different
settings, including patients with metastatic disease. The preclinical background
of clinically acquired resistance to osimertinib is presented and the
combination tactics being investigated in an attempt to circumvent this are
addressed.
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Affiliation(s)
- Ivana Sullivan
- Medical Oncology Department, Gustave Roussy, Villejuif, France
| | - David Planchard
- Medical Oncology Department, Gustave Roussy, 114 rue Édouard Vaillant, 94800 Villejuif, France
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Remon J, Alvarez-Berdugo D, Majem M, Moran T, Reguart N, Lianes P. miRNA-197 and miRNA-184 are associated with brain metastasis in EGFR-mutant lung cancers. Clin Transl Oncol 2015. [DOI: 10.1007/s12094-015-1347-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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