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Attili I, Corvaja C, Spitaleri G, Del Signore E, Trillo Aliaga P, Passaro A, de Marinis F. New Generations of Tyrosine Kinase Inhibitors in Treating NSCLC with Oncogene Addiction: Strengths and Limitations. Cancers (Basel) 2023; 15:5079. [PMID: 37894445 PMCID: PMC10605462 DOI: 10.3390/cancers15205079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Tyrosine kinase inhibitors (TKIs) revolutionized the treatment of patients with advanced or metastatic non-small cell lung cancer (NSCLC) harboring most driver gene alterations. Starting from the first generation, research rapidly moved to the development of newer, more selective generations of TKIs, obtaining improved results in terms of disease control and survival. However, the use of novel generations of TKIs is not without limitations. We reviewed the main results obtained, as well as the ongoing clinical trials with TKIs in oncogene-addicted NSCLC, together with the biology underlying their potential strengths and limitations. Across driver gene alterations, novel generations of TKIs allowed delayed resistance, prolonged survival, and improved brain penetration compared to previous generations, although with different toxicity profiles, that generally moved their use from further lines to the front-line treatment. However, the anticipated positioning of novel generation TKIs leads to abolishing the possibility of TKI treatment sequencing and any role of previous generations. In addition, under the selective pressure of such more potent drugs, resistant clones emerge harboring more complex and hard-to-target resistance mechanisms. Deeper knowledge of tumor biology and drug properties will help identify new strategies, including combinatorial treatments, to continue improving results in patients with oncogene-addicted NSCLC.
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Affiliation(s)
- Ilaria Attili
- Division of Thoracic Oncology, European Institute of Oncology IRCCS, Via G. Ripamonti 435, 20141 Milan, Italy
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2
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Therapeutic Monitoring of Orally Administered, Small-Molecule Anticancer Medications with Tumor-Specific Cellular Protein Targets in Peripheral Fluid Spaces-A Review. Pharmaceutics 2023; 15:pharmaceutics15010239. [PMID: 36678867 PMCID: PMC9864625 DOI: 10.3390/pharmaceutics15010239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/29/2022] [Accepted: 12/30/2022] [Indexed: 01/13/2023] Open
Abstract
Orally administered, small-molecule anticancer drugs with tumor-specific cellular protein targets (OACD) have revolutionized oncological pharmacotherapy. Nevertheless, the differences in exposure to these drugs in the systemic circulation and extravascular fluid compartments have led to several cases of therapeutic failure, in addition to posing unknown risks of toxicity. The therapeutic drug monitoring (TDM) of OACDs in therapeutically relevant peripheral fluid compartments is therefore essential. In this work, the available knowledge regarding exposure to OACD concentrations in these fluid spaces is summarized. A review of the literature was conducted by searching Embase, PubMed, and Web of Science for clinical research articles and case reports published between 10 May 2001 and 31 August 2022. Results show that, to date, penetration into cerebrospinal fluid has been studied especially intensively, in addition to breast milk, leukocytes, peripheral blood mononuclear cells, peritoneal fluid, pleural fluid, saliva and semen. The typical clinical indications of peripheral fluid TDM of OACDs were (1) primary malignancy, (2) secondary malignancy, (3) mental disorder, and (4) the assessment of toxicity. Liquid chromatography-tandem mass spectrometry was most commonly applied for analysis. The TDM of OACDs in therapeutically relevant peripheral fluid spaces is often indispensable for efficient and safe treatments.
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3
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Brain Metastases Management in Oncogene-Addicted Non-Small Cell Lung Cancer in the Targeted Therapies Era. Int J Mol Sci 2022; 23:ijms23126477. [PMID: 35742920 PMCID: PMC9223862 DOI: 10.3390/ijms23126477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
The therapeutic landscape in patients with advanced non-small-cell lung cancer harboring oncogenic biomarkers has radically changed with the development of targeted therapies. Although lung cancers are known to frequently metastasize to the brain, oncogene-driven non-small-cell lung cancer patients show a higher incidence of both brain metastases at baseline and a further risk of central nervous system progression/relapse. Recently, a new generation of targeted agents, highly active in the central nervous system, has improved the control of intracranial disease. The intracranial activity of these drugs poses a crucial issue in determining the optimal management sequence in oncogene-addicted non-small-cell lung cancer patients with brain metastases, with a potential change of paradigm from primary brain irradiation to central nervous system penetrating targeted inhibitors.
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Yi XF, Song J, Gao RL, Sun L, Wu ZX, Zhang SL, Huang LT, Ma JT, Han CB. Efficacy of Osimertinib in EGFR-Mutated Advanced Non-small-Cell Lung Cancer With Different T790M Status Following Resistance to Prior EGFR-TKIs: A Systematic Review and Meta-analysis. Front Oncol 2022; 12:863666. [PMID: 35785185 PMCID: PMC9242653 DOI: 10.3389/fonc.2022.863666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Epidermal growth factor receptor (EGFR) T790M-negative/unknown advanced non-small cell lung cancer (NSCLC) patients lack subsequent approved targeted therapies. This meta-analysis aimed to assess the efficacy of osimertinib in advanced NSCLC patients with different T790M status after resistance to prior first- or second-generation EGFR-tyrosine kinase inhibitors (EGFR-TKIs) and to predict the subgroups that may benefit beside T790M-positive disease. Methods PubMed, Embase, Web of Science, and Cochrane Library databases were searched for relevant trials. Meeting abstracts were also reviewed to identify appropriate studies. Studies evaluating the efficacy and/or survival outcomes of osimertinib in patients with different T790M status (positive, negative, or unknown) after resistance to prior first- or second-generation EGFR-TKIs were enrolled, and data were pooled to assess hazard ratios (HRs) or relative risk ratios (RRs) in terms of overall survival (OS), progression-free survival (PFS), and objective response rate (ORR). Results A total of 1,313 EGFR-mutated NSCLC patients from 10 retrospective and one prospective studies treated with osimertinib after resistance to first- or second-generation EGFR-TKIs were included. In overall groups, T790M-positive patients showed an improved OS (HR=0.574, p=0.015), PFS (HR = 0.476, p = 0.017), and ORR (RR = 2.025, p = 0.000) compared with T790M-negative patients. In the brain metastases subgroup, no significant difference in OS was observed between T790M-positive and T790M-negative patients (HR = 0.75, p = 0.449) or between T790M-positive and T790M-unknown patients (HR = 0.90, p = 0.673). In the plasma genotyping subgroup, PFS was similar between T790M-positive and T790M-negative patients (HR = 1.033, p = 0.959). Conclusion Patients with progressive brain metastases on first- or second-generation EGFR-TKIs can benefit from subsequent osimertinib therapy regardless of T790M status. Patients with plasma T790M-negative status and lack of tissue genotyping should be allowed to receive osimertinib treatment.
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Pisano C, De Filippis M, Jacobs F, Novello S, Reale ML. Management of Oligoprogression in Patients with Metastatic NSCLC Harboring ALK Rearrangements. Cancers (Basel) 2022; 14:cancers14030718. [PMID: 35158987 PMCID: PMC8833409 DOI: 10.3390/cancers14030718] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The growing efficacy and availability of new targeted systemic therapies have markedly improved the prognosis of metastatic lung cancer patients harboring ALK rearrangements. The use of effective targeted therapies capable of maintaining a prolonged control of disease, for as long as possible, is paramount to ensure the best survival outcomes. In this regard, in cases of oligoprogression, “beyond progression” systemic treatment added to local ablative therapies is considered a feasible option in an attempt to improve the quality and quantity of patients’ lives, even if based on retrospective data. Certainly, treatment of ALK rearranged lung cancer patients with oligoprogressive disease must be individualized and based on multidisciplinary decisions. Above all, when further molecular targeted therapies are available, options must always be evaluated, especially in case of cerebral progression. In this review, we provide an updated and comprehensive overview of the main treatment strategies in cases of ALK rearranged oligoprogression. Abstract Personalized treatment based on driver molecular alterations, such as ALK rearrangement, has revolutionized the therapeutic management of advanced oncogene-addicted NSCLC patients. Multiple effective ALK tyrosine kinase inhibitors (TKIs), with the amelioration of the activity at central nervous system level, are now available, leading to substantial prognosis improvement. The exposure to TKIs triggers resistance mechanisms and the sequential administration of other TKIs and chemotherapy is, for the most part, not targeted. In this context, extending the benefit deriving from precision medicine is paramount, above all, when disease progression occurs in a limited number of sites. Retrospective data indicate that, in oligoprogressive disease, targeted therapy beyond progression combined with definitive local treatment of the progressing site(s) is an effective alternative. In these cases, a multidisciplinary approach becomes essential for an integrated treatment strategy, depending on the site of disease progression, in order to improve not only survival, but also quality of life. In this review we provide an updated and comprehensive overview of the main treatment strategies in cases of ALK rearranged oligoprogression, including systemic treatment as well as local therapy, and report a real-world clinical story, with the final aim of identifying the most promising management for this subset of patients.
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McLean LS, Faisal W, Parakh S, Kao SC, Lewis CR, Chin MT, Voskoboynik M, Itchins MJ, Jennens RR, Broad AR, Morris TA, Solomon BJ. Standard-Dose Osimertinib in EGFR-Mutated Non-Small-Cell Lung Adenocarcinoma With Leptomeningeal Disease. JCO Precis Oncol 2022; 5:561-568. [PMID: 34994604 DOI: 10.1200/po.20.00464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Leptomeningeal disease (LMD) in epidermal growth factor receptor (EGFR)-mutant lung adenocarcinoma is associated with a poor prognosis and limited treatment options. Osimertinib is a potent third-generation EGFR tyrosine kinase inhibitor with confirmed CNS penetration. This study reports on outcomes of patients with EGFR-mutated non-small-cell lung cancer who developed LMD and were subsequently treated with osimertinib. METHODS We identified patients treated with osimertinib 80 mg PO daily under a compassionate access scheme across nine tertiary Australian institutes between July 2017 and July 2020. Patient demographics, tumor characteristics, and treatment history were collected. Median overall survival, median progression-free survival, disease control rates (DCR), and overall response rates (ORR) were assessed. Kaplan-Meier analysis was performed and descriptive statistics were used. RESULTS Thirty-nine patients were analyzed of which 74% were female. Exon 19 deletions (49%) and L858R point mutations (41%) were the most common EGFR mutations. Forty-nine percentage of patients were Eastern Cooperative Oncology Group 1. The median duration of osimertinib therapy was 6 months. The extracranial DCR and ORR were 60% and 54%, and the intracranial DCR and ORR were 68% and 53%, respectively. Median overall survival was 10.5 months (95% CI, 8.17 to 15.05 months). CONCLUSION There are limited treatment options for LMD in EGFR-positive lung cancer, and osimertinib at a dose of 80 mg daily is an active therapeutic option for these patients.
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Affiliation(s)
- Luke S McLean
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Wasek Faisal
- Department of Medical Oncology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Sagun Parakh
- Department of Medical Oncology, Austin Health, Melbourne, Victoria, Australia
| | - Steven C Kao
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Craig R Lewis
- Department of Medical Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Melvin T Chin
- Department of Medical Oncology, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Voskoboynik
- Department of Medical Oncology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Malinda J Itchins
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Ross R Jennens
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medical Oncology, Epworth Health, Melbourne, Victoria, Australia
| | - Adam R Broad
- Department of Medical Oncology, Andrew Love Cancer Centre, Geelong, Victoria, Australia
| | - Tessa A Morris
- Southern Blood and Cancer Service, Dunedin, New Zealand.,Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Benjamin J Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Li D, Song Z, Dong B, Song W, Cheng C, Zhang Y, Zhang W. Advances in targeted therapy in non-small cell lung cancer with actionable mutations and leptomeningeal metastasis. J Clin Pharm Ther 2021; 47:24-32. [PMID: 34309914 DOI: 10.1111/jcpt.13489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE?: Leptomeningeal metastasis (LM) is a serious complication of advanced non-small cell lung cancer (NSCLC) that is diagnosed in approximately 3%-5% of patients. LM occurs more frequently in patients with NSCLC harbouring epidermal growth factor receptor (EGFR) mutations or anaplastic lymphoma kinase (ALK) rearrangements and is usually accompanied by a poor prognosis, with a median overall survival (OS) of several months if patients receive conventional treatments. However, tyrosine kinase inhibitor (TKI) therapy after LM diagnosis is an independent predictive factor for extended survival. Here, we aim to summarize the latest advances in targeted therapy for LM and provide patients with better treatment options. METHODS: By reviewing the recent progress of targeted therapy in NSCLC with LM, especially the efficacy of newer generation TKIs, we aim to provide clinicians with a reference to further optimize patient treatment plans. RESULTS AND DISCUSSION: Osimertinib was confirmed to have a several-fold higher CNS permeability than other EGFR-TKIs and was recommended as the preferred choice for patients with EGFR-positive LM whether or not they harboured the T790M mutation. Second-generation ALK-TKIs have a higher rate of intracranial response and can be positioned as front-line drugs in NSCLC with LM. However, the sequence in which ALK-TKIs are administered for effective disease control requires further evaluation. In addition, targeted therapy revealed a potential choice in patients with LM and rare mutations, such as ROS1 and BRAF. WHAT IS NEW AND CONCLUSIONS?: The development of therapeutic agents with greater CNS penetration is vital for the management of CNS metastasis from NSCLC, particularly in the EGFR-mutant and ALK-rearranged subtypes. Systemic therapy with newer generation TKIs is preferred as the initial intervention. This is because newer generation TKIs are designed to penetrate the blood-brain barrier and possess significantly higher intracranial activities. However, their further effectiveness is limited by inadequate blood-brain barrier penetration and acquired drug resistance. Further studies are needed to further understand the mechanisms underlying resistance to treatment.
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Affiliation(s)
- Ding Li
- Department of Pharmacy, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.,Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Zhengzhou, China
| | - Zhenguo Song
- Department of Pharmacy, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.,Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Zhengzhou, China
| | - Bingqi Dong
- Department of Urology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Wenping Song
- Department of Pharmacy, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.,Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Zhengzhou, China
| | - Cheng Cheng
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yongna Zhang
- Department of Pharmacy, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.,Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Zhengzhou, China
| | - Wenzhou Zhang
- Department of Pharmacy, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.,Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Zhengzhou, China
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Miyawaki T, Kenmotsu H, Yabe M, Kodama H, Nishioka N, Miyawaki E, Mamesaya N, Kobayashi H, Omori S, Wakuda K, Ono A, Deguchi S, Mitsuya K, Naito T, Murakami H, Mori K, Harada H, Hayashi N, Takahashi K, Takahashi T. Rechallenge with previously administered epidermal growth factor receptor-tyrosine kinase inhibitors in EGFR-mutated non-small cell lung cancer with leptomeningeal metastasis. Invest New Drugs 2021; 39:1732-1741. [PMID: 34259953 DOI: 10.1007/s10637-021-01140-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
Objectives In EGFR-mutated non-small cell lung cancer (NSCLC) patients, approximately 80-90% of leptomeningeal metastasis (LM) develops after failed initial treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (EGFR-TKI). However, the efficacy of rechallenging with previously administered EGFR-TKIs in patients with EGFR-mutated NSCLC and the LM that develops following EGFR-TKI treatment failure remains unknown. Materials and methods We retrospectively reviewed medical records of patients with EGFR-mutated NSCLC and LM, from November 2011 to August 2019. The patients were classified according to the LM treatment type: switched to previously unadministered EGFR-TKIs (Switch-TKI) or rechallenge with previously administered EGFR-TKIs (Rechallenge-TKI). Results In total, 50 patients treated with EGFR-TKI after LM diagnosis were included; 35 were treated with Switch-TKI and 15 with Rechallenge-TKI. The median overall survival (OS) from the time of LM diagnosis was 6.2 months in all study patients. According to the treatment type, the median OS from the time of LM diagnosis was 6.9 months in Switch-TKI patients and 4.9 months in Rechallenge-TKI patients. There was no significant difference in the OS between the Switch-TKI and Rechallenge-TKI groups (P = 0.864). Thirty-five patients were treated with erlotinib and 15 with osimertinib; Regardless of the type for EGFR-TKI, there was no significant difference in OS between patients treated with Switch-TKI and those treated with Rechallenge-TKI. Conclusion Rechallenge of previously administered EGFR-TKIs may be a therapeutic option for LM development after EGFR-TKI treatment failure in patients with EGFR-mutated NSCLC, not only switching to previously unadministered EGFR-TKIs.
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Affiliation(s)
- Taichi Miyawaki
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Michitoshi Yabe
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroaki Kodama
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Naoya Nishioka
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Eriko Miyawaki
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nobuaki Mamesaya
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Haruki Kobayashi
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shota Omori
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akira Ono
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shoichi Deguchi
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Koichi Mitsuya
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Haruyasu Murakami
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keita Mori
- Division of Clinical Research Management Office, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nakamasa Hayashi
- Division of Neurosurgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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9
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Zhou Y, Yu F, Zhao Y, Zeng Y, Yang X, Chu L, Chu X, Li Y, Zou L, Guo T, Zhu Z, Ni J. A narrative review of evolving roles of radiotherapy in advanced non-small cell lung cancer: from palliative care to active player. Transl Lung Cancer Res 2021; 9:2479-2493. [PMID: 33489808 PMCID: PMC7815368 DOI: 10.21037/tlcr-20-1145] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiotherapy, along with other loco-regional interventions, is conventionally utilized as a palliative approach to alleviate symptoms and mitigate oncological emergencies in advanced non-small cell lung cancer (NSCLC). Thanks to the ongoing improvement of medical treatments in the last decade, such as targeted therapy and immunotherapy, the survival of patients with advanced NSCLC has been considerably prolonged, making it feasible and clinically beneficial for radiotherapy to play a more active role in highly selected subpopulations. In this review, we will focus on the evolving roles of radiotherapy in advanced NSCLC. First of all, among patients who are initially unable to tolerate aggressive treatment due to severe symptoms caused by metastases and/or tumor emergencies, timely radiotherapy could significantly improve their performance status (PS) and general condition, thus giving them a chance for intensive treatment and prolonged survival. The efficacy, potential candidates, and optimal dose-fractionation regimens of radiotherapy in this clinical scenario will be discussed. Additionally, radiotherapy can play a curative role as a concurrent therapy, consolidation therapy, and salvage therapy for patients with oligo-metastatic, oligo-residual, and oligo-progressive disease, respectively. Accumulating evidence from recent clinical trials, basic research, and translational investigations regarding the potentially curative roles of radiotherapy in NSCLC patients with oligo-metastatic disease will be summarized. Moreover, with the advent of various small molecular tyrosine kinase inhibitors (TKIs), the treatment efficacy and overall survival of oncogene-addicted NSCLC with brain metastases have been significantly improved, and the clinical value and optimal timing of cranial radiotherapy have become topics of much debate. Finally, synergistic antitumor interactions between radiotherapy and immunotherapy have been repeatedly demonstrated. Thus, the immune sensitizing role of radiotherapy in advanced NSCLC is also highlighted in this review.
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Affiliation(s)
- Yue Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Fan Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yang Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ya Zeng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yida Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tiantian Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Institute of Thoracic Oncology, Fudan University, Shanghai, China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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10
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Schoenmaekers JJAO, Paats MS, Dingemans AMC, Hendriks LEL. Central nervous system metastases and oligoprogression during treatment with tyrosine kinase inhibitors in oncogene-addicted non-small cell lung cancer: how to treat and when? Transl Lung Cancer Res 2020; 9:2599-2617. [PMID: 33489821 PMCID: PMC7815343 DOI: 10.21037/tlcr-20-459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Up to 70% of non-small cell lung cancer (NSCLC) patients develop central nervous system (CNS) metastases during the course of their disease, especially those with oncogenic drivers treated with a first-generation tyrosine kinase inhibitor (TKI), because of the relatively poor CNS penetration. CNS metastases are associated with a negative impact on quality of life and survival. As, with the introduction of newer generation TKIs, the survival rates are increasing in this particular population, treatment and/or prevention of CNS metastases becomes even more relevant and the TKI with the best CNS efficacy should be selected. Unfortunately, CNS efficacy data in clinical trials are not fully comparable. Furthermore, oligoprogression to the brain without extracranial progression regularly occurs in the oncogenic driver population and both local therapy and switch of systemic therapy are possible treatment options. However, the best order of systemic and local therapy is still not precisely known. In this narrative review, we will summarize incidence and treatment of CNS metastases in oncogene driven NSCLC, including the optimal treatment of CNS oligometastatic disease (synchronous as well as oligoprogressive).
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Affiliation(s)
- Janna Josephus Anna Oda Schoenmaekers
- Department of Pulmonary Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands;,Department of Pulmonary Diseases GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marthe Sentijna Paats
- Department of Pulmonary Diseases, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Anne-Marie Clasina Dingemans
- Department of Pulmonary Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands;,Department of Pulmonary Diseases GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands;,Department of Pulmonary Diseases, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Lizza Elisabeth Lucia Hendriks
- Department of Pulmonary Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands;,Department of Pulmonary Diseases GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
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11
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Zhao S, Zhang Z, Fang W, Zhang Y, Zhang Z, Hong S, Ma Y, Zhou T, Yang Y, Huang Y, Zhao H, Zhang L. Efficacy and Tolerability of Erlotinib 100 mg/d vs. Gefitinib 250 mg/d in EGFR-Mutated Advanced Non-small Cell Lung Cancer (E100VG250): An Open-Label, Randomized, Phase 2 Study. Front Oncol 2020; 10:587849. [PMID: 33244458 PMCID: PMC7683781 DOI: 10.3389/fonc.2020.587849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Erlotinib-based combination therapy leads to increased efficacy but also toxicity for EGFR-mutated NSCLC. Reducing the dose of erlotinib could improve treatment tolerability, but few evidences are available regarding its efficacy at reduced dose. This randomized phase-2 study intends to compare the efficacy and tolerability between lower dose erlotinib (100 mg/d) and standard dose gefitinib (250 mg/d) in EGFR-mutated NSCLC. Methods: Patients with EGFR-mutated advanced NSCLC were randomized at 1:1 ratio to receive erlotinib 100 mg/d or gefitinib 250 mg/d until disease progression or unacceptable toxicity. The primary endpoint was disease control rate (DCR). Results: Between April 2013 and September 2018, 171 patients were randomized to receive erlotinib (n = 85) and gefitinib (n = 86); 74 in the erlotinib group and 83 in the gefitinib group were include in analysis. DCR with erlotinib and gefitinib were 91% [95% CI 81.7-95.3] and 93% [85.1-96.6], respectively (P = 0.613). Response rate was 62% [50.8-72.4] in the erlotinib group and 53% [42.4-63.4] in the gefitinib group (P = 0.247). No significant difference was observed between erlotinib and gefitinib in median progression-free survival [10.1 vs. 11.3 months, HR = 1.295 [0.893-1.879], P = 0.171] and median overall survival [26.6 vs. 28.7 months, HR = 0.999 [0.637-1.569], P = 0.998]. Subgroup analyses by line of treatment, EGFR subtypes and status of central nervous system (CNS) metastasis found similar results. More toxicity [any-grade, 80 [96%] vs. 66 [89]; grade 3-4, 11 [13%] vs. 4 [5%]] and toxicity-related discontinuation [10 [12%] vs. 3 [4%]] occurred with gefitinib compared with erlotinib. But no significant difference was observed. Conclusion: Lower dose erlotinib (100 mg/d) achieved comparable efficacy compared with standard dose gefitinib (250 mg/d) in EGFR-mutated NSCLC. Clinical Trial Registration: https://clinicaltrials.gov, identifier: NCT01955421.
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Affiliation(s)
- Shen Zhao
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhen Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Wenfeng Fang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yaxiong Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhonghan Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shaodong Hong
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yuxiang Ma
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ting Zhou
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yunpeng Yang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yan Huang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hongyun Zhao
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Li Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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12
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Nagano T, Tachihara M, Nishimura Y. Molecular Mechanisms and Targeted Therapies Including Immunotherapy for Non-Small Cell Lung Cancer. Curr Cancer Drug Targets 2020; 19:595-630. [PMID: 30526458 DOI: 10.2174/1568009619666181210114559] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/21/2018] [Accepted: 11/28/2018] [Indexed: 12/21/2022]
Abstract
Lung cancer is the leading cause of cancer death worldwide. Molecular targeted therapy has greatly advanced the field of treatment for non-small cell lung cancer (NSCLC), which accounts for the majority of lung cancers. Indeed, gefitinib, which was the first molecular targeted therapeutic agent, has actually doubled the survival time of NSCLC patients. Vigorous efforts of clinicians and researchers have revealed that lung cancer develops through the activating mutations of many driver genes including the epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS1), v-Raf murine sarcoma viral oncogene homolog B (BRAF), and rearranged during transfection (RET) genes. Although ALK, ROS1, and RET are rare genetic abnormalities, corresponding tyrosine kinase inhibitors (TKIs) can exert dramatic therapeutic effects. In addition to anticancer drugs targeting driver genes, bevacizumab specifically binds to human vascular endothelial growth factor (VEGF) and blocks the VEGF signaling pathway. The VEGF signal blockade suppresses angiogenesis in tumor tissues and inhibits tumor growth. In this review, we also explore immunotherapy, which is a promising new NSCLC treatment approach. In general, antitumor immune responses are suppressed in cancer patients, and cancer cells escape from the immune surveillance mechanism. Immune checkpoint inhibitors (ICIs) are antibodies that target the primary escape mechanisms, immune checkpoints. Patients who respond to ICIs are reported to experience longlasting therapeutic effects. A wide range of clinical approaches, including combination therapy involving chemotherapy or radiation plus adjuvant therapy, are being developed.
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Affiliation(s)
- Tatsuya Nagano
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Motoko Tachihara
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiro Nishimura
- Division of Respiratory Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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13
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Irurzun-Arana I, McDonald TO, Trocóniz IF, Michor F. Pharmacokinetic Profiles Determine Optimal Combination Treatment Schedules in Computational Models of Drug Resistance. Cancer Res 2020; 80:3372-3382. [PMID: 32561532 PMCID: PMC7442591 DOI: 10.1158/0008-5472.can-20-0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 12/21/2022]
Abstract
Identification of optimal schedules for combination drug administration relies on accurately estimating the correct pharmacokinetics, pharmacodynamics, and drug interaction effects. Misspecification of pharmacokinetics can lead to wrongly predicted timing or order of treatments, leading to schedules recommended on the basis of incorrect assumptions about absorption and elimination of a drug and its effect on tumor growth. Here, we developed a computational modeling platform and software package for combination treatment strategies with flexible pharmacokinetic profiles and multidrug interaction curves that are estimated from data. The software can be used to compare prespecified schedules on the basis of the number of resistant cells where drug interactions and pharmacokinetic curves can be estimated from user-provided data or models. We applied our approach to publicly available in vitro data of treatment with different tyrosine kinase inhibitors of BT-20 triple-negative breast cancer cells and of treatment with erlotinib of PC-9 non-small cell lung cancer cells. Our approach is publicly available in the form of an R package called ACESO (https://github.com/Michorlab/aceso) and can be used to investigate optimum dosing for any combination treatment. SIGNIFICANCE: These findings introduce a computational modeling platform and software package for combination treatment strategies with flexible pharmacokinetic profiles and multidrug interaction curves that are estimated from data.
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Affiliation(s)
- Itziar Irurzun-Arana
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain
| | - Thomas O McDonald
- Department of Data Sciences, Dana-Farber Cancer Institute, and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Massachusetts
- Center for Cancer Evolution, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Iñaki F Trocóniz
- Pharmacometrics and Systems Pharmacology, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdisNA), University of Navarra, Pamplona, Spain
| | - Franziska Michor
- Department of Data Sciences, Dana-Farber Cancer Institute, and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Massachusetts
- Center for Cancer Evolution, Dana-Farber Cancer Institute, Boston, Massachusetts
- The Broad Institute of Harvard and MIT, Cambridge, Massachusetts
- The Ludwig Center at Harvard, Boston, Massachusetts
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14
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Nosaki K, Yamanaka T, Hamada A, Shiraishi Y, Harada T, Himeji D, Kitazaki T, Ebi N, Shimose T, Seto T, Takenoyama M, Sugio K. Erlotinib for Non-Small Cell Lung Cancer with Leptomeningeal Metastases: A Phase II Study (LOGIK1101). Oncologist 2020; 25:e1869-e1878. [PMID: 32654250 DOI: 10.1634/theoncologist.2020-0640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/28/2020] [Indexed: 01/06/2023] Open
Abstract
LESSONS LEARNED This phase II trial evaluated the efficacy of erlotinib for patients with non-small cell lung cancer with leptomeningeal metastasis. The 17 cerebrospinal fluid specimens that were available for epidermal growth factor receptor mutation analysis were all negative for the resistance-conferring T790M mutation. The cytological objective clearance rate was 30.0% (95% confidence interval: 11.9%-54.3%). The median time to progression was 2.2 months. The rate of cerebrospinal fluid penetration among these patients was equivalent to those in previous reports regarding leptomeningeal metastasis. BACKGROUND Leptomeningeal metastases (LM) occur in approximately 5% of patients with non-small cell lung cancer (NSCLC) and are associated with a poor prognosis. However, no prospective study has identified an active chemotherapeutic drug in this setting. METHODS Patients were considered eligible to receive erlotinib if they had NSCLC with cytologically confirmed LM. The objective cytological clearance rate, time to LM progression (TTP), overall survival (OS), quality of life outcomes, and pharmacokinetics were analyzed. This study was closed because of slow accrual at 21 of the intended 32 patients (66%). RESULTS Between December 2011 and May 2015, 21 patients (17 with activating epidermal growth factor receptor [EGFR] mutations) were enrolled. The 17 cerebrospinal fluid specimens available were all negative for the T790M mutation, which confers erlotinib resistance. The clearance rate was 30.0% (95% confidence interval [CI]: 11.9%-54.3%), the median TTP was 2.2 months, and the median OS was 3.4 months. Significantly longer TTP and OS times were observed in patients with mutant EGFR (p = .0113 and p < .0054, respectively). The mean cerebrospinal fluid penetration rate was 3.31% ± 0.77%. There was a good correlation between plasma and cerebrospinal fluid (CSF) concentrations, although there was no clear correlation between pharmacokinetic parameters and clinical outcome. CONCLUSION Erlotinib was active for LM and may be a treatment option for patients with EGFR-mutated NSCLC and LM.
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Affiliation(s)
- Kaname Nosaki
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University, Yokohama, Japan
| | - Akinobu Hamada
- Division of Molecular Pharmacology, National Cancer Center Research Institute, Tokyo, Japan
| | - Yoshimasa Shiraishi
- Department of Respiratory Disease, National Hospital Organization Fukuoka-Higashi Medical Center, Koga, Japan
| | - Taishi Harada
- Department of Respiratory Medicine, Japan Community Health Care Organization (JCHO) Kyushu Hospital, Kitakyushu, Japan
| | - Daisuke Himeji
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Takeshi Kitazaki
- Department of Respiratory Disease, Japan Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Noriyuki Ebi
- Department of Respiratory Oncology, Iizuka Hospital, Iizuka, Japan
| | | | - Takashi Seto
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Mitsuhiro Takenoyama
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Kenji Sugio
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
- Department of Thoracic and Breast Surgery, Oita University, Yufu, Japan
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15
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Hossain JA, Latif MA, Ystaas LAR, Ninzima S, Riecken K, Muller A, Azuaje F, Joseph JV, Talasila KM, Ghimire J, Fehse B, Bjerkvig R, Miletic H. Long-term treatment with valganciclovir improves lentiviral suicide gene therapy of glioblastoma. Neuro Oncol 2020; 21:890-900. [PMID: 30958558 DOI: 10.1093/neuonc/noz060] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Suicide gene therapy for malignant gliomas has shown encouraging results in the latest clinical trials. However, prodrug application was most often restricted to short-term treatment (14 days), especially when replication-defective vectors were used. We previously showed that a substantial fraction of herpes simplex virus thymidine kinase (HSV-TK) transduced tumor cells survive ganciclovir (GCV) treatment in an orthotopic glioblastoma (GBM) xenograft model. Here we analyzed whether these TK+ tumor cells are still sensitive to prodrug treatment and whether prolonged prodrug treatment can enhance treatment efficacy. METHODS Glioma cells positive for TK and green fluorescent protein (GFP) were sorted from xenograft tumors recurring after suicide gene therapy, and their sensitivity to GCV was tested in vitro. GBM xenografts were treated with HSV-TK/GCV, HSV-TK/valganciclovir (valGCV), or HSV-TK/valGCV + erlotinib. Tumor growth was analyzed by MRI, and survival as well as morphological and molecular changes were assessed. RESULTS TK-GFP+ tumor cells from recurrent xenograft tumors retained sensitivity to GCV in vitro. Importantly, a prolonged period (3 mo) of prodrug administration with valganciclovir (valGCV) resulted in a significant survival advantage compared with short-term (3 wk) application of GCV. Recurrent tumors from the treatment groups were more invasive and less angiogenic compared with primary tumors and showed significant upregulation of epidermal growth factor receptor (EGFR) expression. However, double treatment with the EGFR inhibitor erlotinib did not increase therapeutic efficacy. CONCLUSION Long-term treatment with valGCV should be considered as a replacement for short-term treatment with GCV in clinical trials of HSV-TK mediated suicide gene therapy.
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Affiliation(s)
- Jubayer A Hossain
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Md A Latif
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Lars A R Ystaas
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Sandra Ninzima
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Kristoffer Riecken
- Research Department Cell and Gene Therapy, Department of Stem Cell Transplantation, University Medical Center, Hamburg, Germany
| | - Arnaud Muller
- Bioinformatics Team, Center for Quantitative Biology, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Francisco Azuaje
- Bioinformatics Team, Center for Quantitative Biology, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Justin V Joseph
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | | | - Jiwan Ghimire
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Boris Fehse
- Research Department Cell and Gene Therapy, Department of Stem Cell Transplantation, University Medical Center, Hamburg, Germany
| | - Rolf Bjerkvig
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Norlux Neuro-Oncology Laboratory, Department of Oncology, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Hrvoje Miletic
- Department of Biomedicine, University of Bergen, Bergen, Norway.,Department of Pathology, Haukeland University Hospital, Bergen, Norway
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16
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Sands JM, Daly ME, Lee EQ. Neurologic complications of lung cancer. Cancer 2020; 126:4455-4465. [PMID: 33460079 DOI: 10.1002/cncr.32772] [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] [Received: 09/03/2019] [Revised: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/07/2022]
Abstract
Lung cancer and its associated treatments can cause various neurologic complications, including brain and leptomeningeal metastases, epidural spinal cord compression, cerebrovascular events, and treatment-related neurotoxicities. Lung cancer care has significantly changed in the last 5 to 10 years, with novel therapies that have affected aspects of neurologic complication management. Herein, the authors review the potential neurologic complications of lung cancer, including important clinical and therapeutic aspects of care.
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Affiliation(s)
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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17
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Lee J, Choi YL, Han J, Park S, Jung HA, Su JM, Lee SH, Ahn JS, Park K, Ahn MJ. Osimertinib Improves Overall Survival in Patients With EGFR-Mutated NSCLC With Leptomeningeal Metastases Regardless of T790M Mutational Status. J Thorac Oncol 2020; 15:1758-1766. [PMID: 32652216 DOI: 10.1016/j.jtho.2020.06.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Osimertinib, a third-generation EGFR tyrosine kinase inhibitor, efficiently penetrates the blood-brain barrier. This study explored whether treatment with osimertinib leads to improved overall survival (OS) for patients with EGFR-mutated NSCLC with leptomeningeal metastases (LM) compared with those not treated with osimertinib. METHODS From October 2008 to October 2019, patients with EGFR-mutated NSCLC and cytologically confirmed LM were retrospectively analyzed for OS according to osimertinib treatment and T790M mutational status. The OS was defined as the time from the diagnosis of LM to death. RESULTS For the 351 patients with LM included in the analysis, the median OS (mOS) was 8.1 months (95% confidence interval [CI]: 7.2-9.0). T790M mutation was detected in 88 of 197 patients tested, and a total of 110 patients were treated with osimertinib after LM. No difference in mOS according to T790M mutational status (10.1 mo [95% CI: 4.31-15.82] versus 9.0 [95% CI: 6.81-11.21], p = 0.936) was found. Nevertheless, patients treated with osimertinib had a superior OS of 17.0 months (95% CI: 15.13-18.94) compared with those not treated with osimertinib who had a mOS of 5.5 months (95% CI: 4.34-6.63), regardless of T790M mutational status (hazard ratio: 0.36 [95% CI: 0.28-0.47], p < 0.001). This was also considerably longer even than the mOS of 8.7 months (95% CI: 7.01-10.39) of those who were never treated with osimertinib but had first- or second-generation EGFR tyrosine kinase inhibitors. CONCLUSIONS Osimertinib is a promising treatment option for EGFR-mutated NSCLC with LM regardless of T790M mutational status.
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Affiliation(s)
- Jiyun Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon La Choi
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joungho Han
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sehhoon Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Ae Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Mu Su
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keunchil Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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18
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Shriyan B, Patil D, Gurjar M, Nookala M, Patil A, Kannan S, Patil V, Joshi A, Noronha V, Prabhash K, Gota V. Safety and CSF distribution of high-dose erlotinib and gefitinib in patients of non-small cell lung cancer (NSCLC) with brain metastases. Eur J Clin Pharmacol 2020; 76:1427-1436. [PMID: 32529316 DOI: 10.1007/s00228-020-02926-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/01/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients of non-small cell lung cancer (NSCLC) with brain metastases have limited treatment options. High-dose erlotinib (HDE) and gefitinib (HDG) have been tried in the past. This study investigates the cerebrospinal fluid (CSF) disposition and safety of both, high-dose erlotinib and gefitinib regimens. METHODS Eleven and nine patients were treated with erlotinib and gefitinib, respectively. All patients received 1 week of standard dose of erlotinib (150 mg OD) or gefitinib (250 mg OD), followed by the high dose (1500 mg weekly for erlotinib and 1250 mg OD for gefitinib) from day 8. Blood and CSF samples were collected on days 7 and 15, 4 h after the morning dose and drug levels determined using LC-MS/MS. Adverse events were documented as per CTCAE 4.03 till day 15. RESULTS Pulsatile HDE and daily HDG resulted in 1.4- and 1.9-fold increase in CSF levels, respectively. A constant 2% CSF penetration rate was observed across both doses of erlotinib, while for gefitinib the penetration rate for high dose was half that of the standard dose suggesting a nonlinear disposition. Three patients on HDE treatment discontinued treatment after the first dose due to intolerable toxicities, whereas HDG was better tolerated with no treatment discontinuations. Since CSF disposition of gefitinib followed saturable kinetics, a lower dose of 750 mg was found to achieve CSF concentrations comparable to that of the 1250 mg dose. CONCLUSIONS HDG was better tolerated than HDE. CSF disposition of gefitinib was found to be saturable at a higher dose. Based on these findings, the dose of 750 mg OD should be considered for further evaluation in this setting.
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Affiliation(s)
- Bharati Shriyan
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Deepali Patil
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Murari Gurjar
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Manjunath Nookala
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Anand Patil
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Sadhana Kannan
- Department of Biostatistics, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, 400012, India
- Homi Bhabha National Institute, Mumbai, 400094, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, 400012, India
- Homi Bhabha National Institute, Mumbai, 400094, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, 400012, India
- Homi Bhabha National Institute, Mumbai, 400094, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, 400012, India
- Homi Bhabha National Institute, Mumbai, 400094, India
| | - Vikram Gota
- Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Kharghar, Navi Mumbai, Maharashtra, 410210, India.
- Homi Bhabha National Institute, Mumbai, 400094, India.
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19
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Spagnuolo A, Muto M, Monaco F, Colantuoni G, Gridelli C. The optional approach of oncogene-addicted non-small cell lung cancer with brain metastases in the new generation targeted therapies era. Transl Lung Cancer Res 2019; 8:1134-1151. [PMID: 32010591 PMCID: PMC6976372 DOI: 10.21037/tlcr.2019.12.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/13/2019] [Indexed: 12/11/2022]
Abstract
In recent years, the study of the molecular characteristics of non-small cell lung cancer (NSCLC) has highlighted a specific role of some genes that represent important therapeutic targets, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene 1 (ROS-1) and v-Raf murine sarcoma viral oncogene homolog B1 (BRAF). Patients with oncogene-addicted cancer benefit more from therapy with tyrosine kinase inhibitors (TKIs) than from chemotherapy. The brain is a preferred site for tumor spread in these patients. In addition, given greater control of extracranial disease and prolonged survival, the brain is often the first site of progression. Therefore, there is great interest in therapeutic approaches that optimize the control of intracranial disease associated with systemic drugs that, by penetrating the blood-brain barrier (BBB), may improve local control. On the latter, radiotherapy provides excellent efficacy but following the results of clinical trials with new brain penetrant drugs, the question of how and especially when to perform brain radiotherapy in patients with oncogene-addicted NSCLC remains open. Prospective studies may indicate which patients are most likely to benefit from combined use or in what sequence they will undergo systemic and radiotherapy treatment. Due to the heterogeneity of patients and the introduction of new generation TKIs, a multidisciplinary assessment for the best management of therapies in NSCLC patients with molecular driver alterations and brain metastases (BM) is required.
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Affiliation(s)
- Alessia Spagnuolo
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | - Matteo Muto
- Division of Radiotherapy, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | - Fabio Monaco
- Division of Radiation Protection, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | | | - Cesare Gridelli
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
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An N, Wang H, Zhu H, Yan W, Jing W, Kong L, Zhang Y, Yu J. Great efficacy of afatinib on a patient with lung adenocarcinoma harboring uncommon EGFR delE709_T710insD mutations: a case report. Onco Targets Ther 2019; 12:7399-7404. [PMID: 31686847 PMCID: PMC6752199 DOI: 10.2147/ott.s221638] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/25/2019] [Indexed: 12/18/2022] Open
Abstract
EGFR)-targeted drugs have been the first-line treatment for patients with EGFR-mutant non-small cell lung cancer (NSCLC), especially exon 19 deletions and L858R mutation in exon 21. However, there is insufficient evidence for other less common types of EGFR mutations, such as delE709_T710insD (del 18). Recent studies have revealed that these rare genotypes could be targetable if appropriate mutations, such as delE709_T710insD (del 18). Recent studies have revealed that these rare genotypes could be targetable if appropriate EGFR tyrosine kinase inhibitors are selected. Here we reported a stage Ⅳ NSCLC patient with delE709_T710insD mutation who responded well to afatinib, a second-generation TKI. Afatinib had taken good control of the patient’s brain metastasis with a progression-free survival of 11 months and an overall survival exceeded 21 months, although he had received multi-line therapy. This case demonstrates EGFR delE709_T710insD is a rare but potentially afatinib responsive mutation in NSCLC, which may contribute to changes in clinical practice and further research into the precise detection and treatment of rare mutations in EGFR.
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Affiliation(s)
- Ning An
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, People's Republic of China
| | - Haoyi Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Weiwei Yan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Wang Jing
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Yan Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
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Lin CY, Chang CC, Su PL, Lin CC, Tseng YL, Su WC, Yen YT. Brain MRI imaging characteristics predict treatment response and outcome in patients with de novo brain metastasis of EGFR-mutated NSCLC. Medicine (Baltimore) 2019; 98:e16766. [PMID: 31415376 PMCID: PMC6831109 DOI: 10.1097/md.0000000000016766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Patients with non-small cell lung cancer (NSCLC) and de novo brain metastasis (BM) have poor prognosis. We aim to investigate the characteristic of brain magnetic resonance (MR) imaging and the association with the treatment response of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) for lung cancer with BM.EGFR-mutated NSCLC patients with BM from October 2013 to December 2017 in a tertiary referral center were retrospectively analyzed. Patient's age, sex, cell type, EGFR mutation status, treatment, and characteristics of BM were collected. Survival analysis was performed using Kaplan-Meier method. The efficacy of different EGFR-TKIs were also analyzed.Among the 257 eligible patients, 144 patients with Exon 19 deletion or Exon 21 L858R were included for analysis. The erlotinib group had the best progression free survival (PFS) (median PFS 13 months, P = .04). The overall survival (OS) revealed no significant difference between three EGFR-TKI groups. Brain MR imaging features including tumor necrosis, rim enhancement and specific tumor locations (frontal lobe, putamen or cerebellum) were factors associated with poor prognosis. Patients with poor prognostic imaging features, the high-risk group, who received erlotinib had the best PFS (median PFS 12 months, P < .001). However, the OS revealed no significant difference between 3 EGFR-TKI groups. The low risk group patients had similar PFS and OS treated with three different EGFR-TKIs.In NSCLC patients with common EGFR mutation and de novo BM, those with poor prognostic brain MR characteristics, erlotinib provided better PFS than afatinib or gefitinib.
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Affiliation(s)
| | - Chao-Chun Chang
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University
| | | | - Chien-Chung Lin
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University
| | - Wu-Chou Su
- Department of Internal Medicine and Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yi-Ting Yen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University
- Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
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Chang X, Liu Z, Man S, Roys A, Li Z, Zuo D, Wu Y. Metastasis manners and the underlying mechanisms of ALK and ROS1 rearrangement lung cancer and current possible therapeutic strategies. RSC Adv 2019; 9:17921-17932. [PMID: 35520562 PMCID: PMC9064669 DOI: 10.1039/c9ra02258a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 06/01/2019] [Indexed: 11/21/2022] Open
Abstract
The rearrangements of anaplastic lymphoma kinase (ALK) and the c-ros oncogene 1 (ROS1) have both been important driving factors in non-small-cell lung cancer (NSCLC). They have already been defined in 3-5% of NSCLC patients. ALK and ROS1 rearrangements are associated with unique clinical and pathological features, especially patients are usually younger, with milder or never smoking history, and adenocarcinoma histology. Also, they have both been found to contribute to the metastasis of NSCLC by cell migration and invasion. It has recently been recognized that the brain can be considered as a primary site for metastasis in cancers with ALK or ROS1 rearrangements. The present review summarizes the current status of NSCLC metastasis and possible mechanisms based on available evidence, and then we list possible therapeutic strategies so that an increase in control of ALK and ROS1 rearrangement of NSCLC metastases by combination therapy can be translated in an increase in overall survival and prognosis.
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Affiliation(s)
- Xing Chang
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Zi Liu
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Shuai Man
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Annie Roys
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Zengqiang Li
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Daiying Zuo
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
| | - Yingliang Wu
- Department of Pharmacology, Shenyang Pharmaceutical University 103 Wenhua Road, Shenhe District Shenyang 110016 China
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Venur VA, Cohen JV, Brastianos PK. Targeting Molecular Pathways in Intracranial Metastatic Disease. Front Oncol 2019; 9:99. [PMID: 30886831 PMCID: PMC6409309 DOI: 10.3389/fonc.2019.00099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
The discovery and clinical application of agents targeting pivotal molecular pathways in malignancies such as lung, breast, renal cell carcinoma, and melanoma have led to impressive improvements in clinical outcomes. Mutations in epidermal growth factor receptor (EGFR), and rearrangements of anaplastic lymphoma kinase (ALK) are targetable in lung cancer, while BRAF mutations have been successfully targeted in metastatic melanoma. Targeting estrogen receptors, cyclin dependent kinases, and HER2 (Human Epidermal Receptor) have resulted in improvement in survival in breast cancer. Major strides have been made in the management of metastatic renal cell carcinoma by targeting the vascular endothelial growth factor (VEGF) pathway. However, intracranial metastases remain a major hurdle in the setting of targeted therapies. Traditional treatment options for brain metastases include surgery, whole brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). Surgery is effective in symptomatic patients with dominant lesions or solitary intracranial metastases, however, recovery time can be prolonged, often requiring an interruption in systemic treatment. WBRT and SRS provide symptomatic relief and local control but data on improving overall survival is limited. Most targeted therapies which provide extracranial control have limited penetration through the blood brain barrier. Given the limited therapeutic options and increasing prevalence of brain metastases, finding new strategies for the management of intracranial metastatic disease is critical. Genomic analysis of brain metastases has led to a better understanding of variations in the driver mutations compared to the primary malignancy. Furthermore, newer generations of targeted agents have shown promising intracranial activity. In this review, we will discuss the major molecular alterations in brain metastases from melanoma, lung, breast, and renal cell carcinoma. We will provide an in-depth review of the completed and ongoing clinical trials of drugs targeting the molecular pathways enriched in brain metastases.
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Affiliation(s)
| | | | - Priscilla K. Brastianos
- Divisions of Neuro-Oncology and Hematology/Oncology, Departments of Neurology and Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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From Whole-Brain Radiotherapy to Immunotherapy: A Multidisciplinary Approach for Patients with Brain Metastases from NSCLC. JOURNAL OF ONCOLOGY 2019; 2019:3267409. [PMID: 30853981 PMCID: PMC6378013 DOI: 10.1155/2019/3267409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/15/2019] [Indexed: 12/25/2022]
Abstract
Non-small cell lung cancer patients with brain metastases have a multitude of treatment options, but there is currently no international and multidisciplinary consensus concerning their optimal treatment. Local therapies have the principal role, especially in symptomatic patients. Advances in surgery and radiation therapy manage considerable local control. Systemic treatments have shown effect in clinical trials and in real life clinical settings; yet, at present, this is restricted to patients with asymptomatic or stable intracranial lesions. Targeted agents can have a benefit only in patients with EGFR mutations or ALK rearrangement. Immunotherapy has shown impressive results in patients with PD-L1 expression in tumor cells. Its effects can be further enhanced by a synergy with radiotherapy, possibly by increasing the percentage of responders. The present review summarizes the need for more effective systemic treatments, so that the increased intracranial control achieved by local treatments can be translated in an increase in overall survival.
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Kim M, Laramy JK, Mohammad AS, Talele S, Fisher J, Sarkaria JN, Elmquist WF. Brain Distribution of a Panel of Epidermal Growth Factor Receptor Inhibitors Using Cassette Dosing in Wild-Type and Abcb1/Abcg2-Deficient Mice. Drug Metab Dispos 2019; 47:393-404. [PMID: 30705084 DOI: 10.1124/dmd.118.084210] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/28/2019] [Indexed: 01/03/2023] Open
Abstract
Tyrosine kinase inhibitors that target the epidermal growth factor receptor (EGFR) have had success in treating EGFR-positive tumors, including non-small-cell lung cancer (NSCLC). However, developing EGFR inhibitors that can be delivered to the brain remains a challenge. To identify optimal compounds for brain delivery, eight EGFR inhibitors [afatinib, 6-[4-[(4-ethylpiperazin-1-yl)methyl]phenyl]-N-(1-phenylethyl)-7H-pyrrolo[2,3-day]pyrimidin-4-amine (AEE788), [4-(3-chloro-2-fluoroanilino)-7-methoxyquinazolin-6-yl] (2R)-2,4-dimethylpiperazine-1-carboxylate (AZD3759), erlotinib, dacomitinib, gefitinib, osimertinib, and vandetanib] were evaluated for distributional kinetics using cassette dosing with the ultimate goal of understanding the brain penetrability of compounds that share the same molecular target in an important oncogenic signaling pathway for both primary brain tumors (glioblastoma) and brain metastases (e.g., NSCLC). Cassette dosing was validated by comparing the brain-to-plasma ratios obtained from cassette-dosing to discrete-dosing studies. The brain-to-blood partition coefficients (Kp,brain) were calculated following cassette dosing of the eight EGFR inhibitors. The comparison of Kp,brain in wild-type and transporter-deficient mice confirmed that two major efflux transporters at the blood-brain barrier (BBB), P-glycoprotein and breast cancer resistance protein, play a crucial role in the brain distribution of seven out of eight EGFR inhibitors. Results show that the prediction of brain distribution based on physicochemical properties of a drug can be misleading, especially for compounds subject to extensive efflux transport. Moreover, this study informs the choice of EGFR inhibitors, i.e., determining BBB permeability combined with a known target potency, that may be effective in future clinical trials for brain tumors.
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Affiliation(s)
- Minjee Kim
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - Janice K Laramy
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - Afroz S Mohammad
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - Surabhi Talele
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - James Fisher
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - Jann N Sarkaria
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
| | - William F Elmquist
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy (M.K., J.K.L., A.S.M., S.T., W.F.E.) and Clinical Pharmacology and Analytical Services Laboratory, Department of Experimental and Clinical Pharmacology (J.F.), University of Minnesota, Minneapolis, Minnesota; and Radiation Oncology, Mayo Clinic, Rochester, Minnesota (J.N.S.)
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Yun J, Hong MH, Kim SY, Park CW, Kim S, Yun MR, Kang HN, Pyo KH, Lee SS, Koh JS, Song HJ, Kim DK, Lee YS, Oh SW, Choi S, Kim HR, Cho BC. YH25448, an Irreversible EGFR-TKI with Potent Intracranial Activity in EGFR Mutant Non–Small Cell Lung Cancer. Clin Cancer Res 2019; 25:2575-2587. [DOI: 10.1158/1078-0432.ccr-18-2906] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/31/2018] [Accepted: 01/16/2019] [Indexed: 11/16/2022]
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27
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Wrona A, Dziadziuszko R, Jassem J. Management of brain metastases in non-small cell lung cancer in the era of tyrosine kinase inhibitors. Cancer Treat Rev 2018; 71:59-67. [DOI: 10.1016/j.ctrv.2018.10.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 10/11/2018] [Accepted: 10/19/2018] [Indexed: 01/16/2023]
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28
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Han Y, Zhang X, Lu Y, Dong Y, Fu H, Zhang B, Gao Y. Elemene treatment for NSCLC with multiple CNS metastases: a case report and literature review. Onco Targets Ther 2018; 11:6377-6382. [PMID: 30323615 PMCID: PMC6174310 DOI: 10.2147/ott.s160970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CNS metastases are common in patients with non-small-cell lung cancer (NSCLC) and is associated with poor prognosis. In NSCLC patients with EGFR mutations, and ALK fusion oncogene, chemotherapy is ineffective; however, targeted and pulse therapies may be used as alternative treatment options. Elemene can cross the blood-brain barrier and enter the brain tissue. In this paper, treatment consisting of elemene injections in a case of NSCLC with brain metastases, spinal metastases and a possible complication of leptomeningeal metastases is reported, and the efficacy of elemene in treating NSCLC with CNS metastases was investigated.
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Affiliation(s)
- Yushan Han
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China, ;
| | - Xia Zhang
- Department of Oncology, The Fifth People's Hospital of Dalian, Dalian, People's Republic of China
| | - Yishan Lu
- Queen Mary University of London, London, UK
- Nanchang University, Nanchang, People's Republic of China
| | - Yan Dong
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China, ;
| | - Hong Fu
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China, ;
| | - Bin Zhang
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China, ;
| | - Yajie Gao
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China, ;
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29
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Wang W, Song Z, Zhang Y. Efficacy of brain radiotherapy plus EGFR-TKI for EGFR-mutated non-small cell lung cancer patients who develop brain metastasis. Arch Med Sci 2018; 14:1298-1307. [PMID: 30393484 PMCID: PMC6209704 DOI: 10.5114/aoms.2018.78939] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/19/2016] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION To analyze the appropriate treatment methods or timing to use epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) and brain radiation treatment (RT) for symptomatic and asymptomatic brain metastases (BM) in patients with EGFR mutation non-small cell lung cancer (NSCLC). MATERIAL AND METHODS We retrospectively studied patients diagnosed with EGFR gene mutated NSCLC who developed brain metastasis between June 2006 and December 2015 at Zhejiang Cancer Hospital. Treatment data were assessed in 181 patients with 49 symptomatic BM and 132 asymptomatic BM retrospectively. RESULTS In 49 symptomatic BM patients, the median OS of the stereotactic radiosurgery (SRS)-treated group was longer than in the whole brain radiotherapy (WBRT) group (37.7 vs. 21.1 months) (p = 0.194). In the group of 132 asymptomatic brain metastasis patients, the median overall survival (mOS) was longer in upfront brain radiotherapy compared with the upfront TKI group (24.9 vs. 17.4 months) (p = 0.035). In further analysis regarding the timing of using radiotherapy, out of all 74 patients, 33 underwent concurrent TKI and brain radiation, 13 received TKI after first-line RT treatment and 28 patients received radiotherapy after TKI failure. The intracranial progression free survival (iPFS) of the three groups was 11.1 months, 11.3 months and 8.1 months (p = 0.032), respectively. The mOS of the three groups was 21.9 months, 26.2 months and 17.1 months, respectively (p = 0.085). CONCLUSIONS Our research indicated that delayed brain RT may result in inferior iPFS in EGFR mutated NSCLC patients with asymptomatic brain metastases, but no OS benefit was obtained. In addition, our study revealed that patients treated with SRS had a significantly longer OS for symptomatic BM. Future prospective study of the optimal management strategy with WBRT or SRS and TKI for this patient cohort is urgently needed.
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Affiliation(s)
- Wenxian Wang
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
| | - Zhengbo Song
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yiping Zhang
- Department of Chemotherapy, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang province; Hangzhou, China
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Barriers to Effective Drug Treatment for Brain Metastases: A Multifactorial Problem in the Delivery of Precision Medicine. Pharm Res 2018; 35:177. [PMID: 30003344 DOI: 10.1007/s11095-018-2455-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/30/2018] [Indexed: 12/12/2022]
Abstract
The treatment of metastatic lesions in the brain represents a serious unmet medical need in the field of neuro-oncology. Even though many effective compounds have demonstrated success in treating peripheral (non-CNS) tumors with targeted agents, one aspect of this lack of success in the brain may be related to poor delivery of otherwise effective compounds. Many factors can influence the brain delivery of these agents, but one key barrier is a heterogeneously "leaky" BBB that expresses efflux transporters that limit the BBB permeability for many targeted agents. Future success in therapeutics for brain metastases must take into account the adequate delivery of "active, free drug" to the target, and may include combinations of targeted drugs that are appropriate to address each individual patient's tumor type. This review discusses some issues that are pertinent to precision medicine for brain metastases, using specific examples of tumor types that have a high incidence of brain metastases.
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31
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Lazaro T, Brastianos PK. Immunotherapy and targeted therapy in brain metastases: emerging options in precision medicine. CNS Oncol 2018; 6:139-151. [PMID: 28425754 DOI: 10.2217/cns-2016-0038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Brain metastases (BM) continue to represent an unmet clinical need in oncology. Immunotherapy and targeted therapy hold great promise in the treatment of BM. Emerging data are confirming the activity of these agents in patients with BM. Genomic studies have confirmed that clinically actionable mutations are present in BM and they can be used in clinical studies to link targeted therapies with their genetic targets. Furthermore, as molecular signatures associated with sensitivity and resistance to immunotherapies are developed, we will better be able to select BM patients who will most benefit from these therapies. Understanding the genetic and immune evolution within BM should drive the next generation of immunotherapy and target therapy, as well as increase the accuracy of the selection process for these therapies.
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Affiliation(s)
- Tyler Lazaro
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, MA 02144, USA.,Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA 02144, USA
| | - Priscilla K Brastianos
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Boston, MA 02144, USA.,Department of Neurology, Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA 02144, USA
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Abstract
Central nervous system metastases cause grave morbidity in patients with advanced malignancies. Lung cancer, breast cancer, and melanoma are the three most common causes of brain metastases. Although the exact incidence of brain metastases is unclear, there appears to be an increasing incidence which has been attributed to longer survival, better control of systemic disease, and better imaging modalities. Until recently surgical resection of solitary or symptomatic brain metastases, and radiation therapy (either whole-brain radiation therapy or stereotactic radiation) were the mainstay of treatment for patients with brain metastases. The majority of traditional chemotherapies have shown limited activity in the central nervous system, which has been attributed to the blood-brain barrier and the molecular structure of the used agents. The discovery of driver mutations and drugs targeting these mutations has changed the treatment landscape. Several of these targeted small-molecule tyrosine kinase inhibitors do cross the blood-brain barrier and/or have shown activity in the central nervous system. Another major advance in the care of brain metastases has been the advent of new immunotherapeutic agents, for which initial studies have shown intracranial activity. In this chapter, we will review the unique challenges in the treatment of brain metastases. The pertinent clinical studies of chemotherapy in brain metastases will be discussed. The currently reported clinical trials and evidence for use of targeted therapies and immunotherapeutic agents will be emphasized.
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Nolan C, Deangelis LM. Overview of metastatic disease of the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2018; 149:3-23. [PMID: 29307359 DOI: 10.1016/b978-0-12-811161-1.00001-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In 2016, the American Society of Clinical Oncology reported that 1.7 million Americans were diagnosed with cancer; this number will rise to 2.3 million in the United States and 22 million worldwide in 2030. This rising need is being met by an explosion of new cancer therapies, including: immune checkpoint inhibitors, T-cell therapies, tumor vaccines, antiangiogenic therapies, and various targeted therapies. This armamentarium of targeted therapies has led to better systemic control of disease and longer patient overall survival (OS). The incidence of metastatic disease to the central nervous system (CNS) is rising as patients are living longer with these more effective systemic therapies. Prolonged OS allows increased time to develop CNS metastases. The CNS is also a sanctuary for metastatic tumor cells that are protected from full exposure to therapeutic concentrations of most anticancer agents by the blood-brain barrier, the tumor microenvironment, and immune system. In addition, CNS metastases often develop late in the course of the disease, so patients are frequently heavily pretreated, resulting in drug resistance. Although genomic profiling has led to more effective therapies for systemic disease, the same therapy may not be effective in treating CNS disease, not only due to failure of blood-brain barrier penetration, but from discordance between the molecular profile in systemic and CNS tumor.
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Affiliation(s)
- Craig Nolan
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Lisa M Deangelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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34
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Bohn JP, Pall G, Stockhammer G, Steurer M. Targeted Therapies for the Treatment of Brain Metastases in Solid Tumors. Target Oncol 2017; 11:263-75. [PMID: 26822319 DOI: 10.1007/s11523-015-0414-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Brain metastases are a major cause of morbidity and mortality in cancer patients. While the mainstay treatment comprises surgery and radiation therapy, the role of systemic agents remains controversial. In general, it has been presumed that poor blood-brain barrier (BBB) penetration and inherently more resistant metastatic brain disease preclude a favorable systemic treatment approach. However, a better understanding of tumor biology and the subsequent development of targeted drugs have reawakened interest in systemic therapy. Despite still limited brain distribution, a variety of targeted drugs have demonstrated activity in brain metastases in early clinical trials. Nevertheless, disease progression commonly occurs, and it remains to be elucidated whether limited CNS drug distribution or the acquisition of resistant metastatic clones must be held responsible for this prognosis. Moreover, micrometastatic brain disease beyond an intact BBB-and ultimately prevention of brain metastasis formation-may generally remain inaccessible for first-generation targeted agents with poor CNS penetration. To overcome limited brain distribution and possibly emerging acquired resistance, highly potent next-generation targeted drugs with enhanced CNS distribution have been developed. In view of this emerging but yet undefined role of targeted therapies in the treatment of brain metastases from solid tumors, this review aims to summarize the current knowledge from clinical trials and discusses clinically relevant obstacles to overcome.
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Affiliation(s)
- Jan-Paul Bohn
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
| | - Georg Pall
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Guenther Stockhammer
- Department of Neurology and Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Steurer
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
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Abstract
The expanding spectrum of both established and candidate oncogenic driver mutations identified in non-small-cell lung cancer (NSCLC), coupled with the increasing number of clinically available signal transduction pathway inhibitors targeting these driver mutations, offers a tremendous opportunity to enhance patient outcomes. Despite these molecular advances, advanced-stage NSCLC remains largely incurable due to therapeutic resistance. In this Review, we discuss alterations in the targeted oncogene ('on-target' resistance) and in other downstream and parallel pathways ('off-target' resistance) leading to resistance to targeted therapies in NSCLC, and we provide an overview of the current understanding of the bidirectional interactions with the tumour microenvironment that promote therapeutic resistance. We highlight common mechanistic themes underpinning resistance to targeted therapies that are shared by NSCLC subtypes, including those with oncogenic alterations in epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS1 proto-oncogene receptor tyrosine kinase (ROS1), serine/threonine-protein kinase b-raf (BRAF) and other less established oncoproteins. Finally, we discuss how understanding these themes can inform therapeutic strategies, including combination therapy approaches, and overcome the challenge of tumour heterogeneity.
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Affiliation(s)
- Julia Rotow
- Department of Medicine, Division of Hematology and Oncology, University of California San Francisco, 505 Parnassus Avenue, Box 1270, San Francisco, California 94143, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, Box 0981, San Francisco, California 94143, USA
| | - Trever G Bivona
- Department of Medicine, Division of Hematology and Oncology, University of California San Francisco, 505 Parnassus Avenue, Box 1270, San Francisco, California 94143, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, Box 0981, San Francisco, California 94143, USA
- Cellular and Molecular Pharmacology, University of California San Francisco, Box 2140, San Francisco, California 94158, USA
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Arbour KC, Kris MG, Riely GJ, Ni A, Beal K, Daras M, Hayes SA, Young RJ, Rodriguez CR, Ahn L, Pao W, Yu HA. Twice weekly pulse and daily continuous-dose erlotinib as initial treatment for patients with epidermal growth factor receptor-mutant lung cancers and brain metastases. Cancer 2017; 124:105-109. [PMID: 28940498 DOI: 10.1002/cncr.30990] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND In a phase 1 study of pulse/continuous-dose erlotinib, no patient had disease progression in the central nervous system (CNS). This expansion cohort of the phase 1 study tested the same regimen in a cohort of individuals with epidermal growth factor receptor (EGFR)-mutant lung cancers with untreated brain metastases. METHODS Patients had not received EGFR tyrosine kinase inhibitors or radiation for brain metastases. All received 1200 mg of erlotinib on days 1 and 2 and 50 mg on days 3 to 7 weekly. The primary endpoints were the overall and CNS response rates (according to version 1.1 of the Response Evaluation Criteria in Solid Tumors). RESULTS Between May 2015 and August 2016, 19 patients were enrolled. Forty-two percent of the patients had target brain lesions, and the median size of the target brain lesions was 13 mm. Overall, 14 patients (74%; 95% confidence interval [CI], 51%-89%) had partial responses. The response rate in brain metastases was 75%. The overall median progression-free survival was 10 months (95% CI, 7 months to not reached). Only 3 patients (16%) had CNS progression. To date, 4 patients required CNS radiation at some time during their course. The adverse events (any grade) seen in 10% or more of the patients were rash, diarrhea, nausea, an increase in alanine aminotransferase, and fatigue. CONCLUSIONS Pulse/continuous-dose erlotinib produced a 74% overall response rate and a 75% response rate in brain metastases in patients with EGFR-mutant lung cancers and untreated brain metastases. CNS control persisted even after progression elsewhere. Although this regimen did not improve progression-free survival or delay the emergence of EGFR T790M, it prevented progression in the brain and could be useful in situations in which CNS control is critical. Cancer 2018;124:105-9. © 2017 American Cancer Society.
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Affiliation(s)
- Kathryn C Arbour
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Gregory J Riely
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ai Ni
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mariza Daras
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sara A Hayes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher R Rodriguez
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Linda Ahn
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William Pao
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Helena A Yu
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
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Attarian S, Rahman N, Halmos B. Emerging uses of biomarkers in lung cancer management: molecular mechanisms of resistance. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:377. [PMID: 29057237 DOI: 10.21037/atm.2017.07.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Management of patients with advanced non-small cell lung cancer (NSCLC) has recently been transformed by molecularly targeted and immunotherapeutic agents. In patients with EGFR/ALK/ROS mutated NSCLC, first line molecular therapy is the standard of care. Moreover, immune checkpoint inhibitors are revolutionary treatment options for advanced NSCLC and are now the standard of care in front-line or later line settings. Both classes of agents have led to improved patient outcomes, however, primary resistance and development of acquired resistance to both targeted and immunotherapeutic agents is commonly observed, limiting the use of these agents in clinical settings. In this review, we will discuss the most recent advances in understanding the mechanisms of primary and acquired resistance, progress in the spectrum of assays detecting causative molecular events and the development of new generations of inhibitors to overcome acquired resistance.
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Affiliation(s)
- Shirin Attarian
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Numa Rahman
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Balazs Halmos
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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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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McGranahan T, Nagpal S. A Neuro-oncologist's Perspective on Management of Brain Metastases in Patients with EGFR Mutant Non-small Cell Lung Cancer. Curr Treat Options Oncol 2017; 18:22. [PMID: 28391420 PMCID: PMC5385200 DOI: 10.1007/s11864-017-0466-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of non-small cell lung cancer (NSCLC) with brain metastasis (BrM) has been revolutionized by identification of molecular subsets that have targetable oncogenes. Historically, survival for NSCLC with symptomatic BrM was weeks to months. Now, many patients are surviving years with limited data to guide treatment decisions. Tumors with activating mutations in epidermal growth factor receptor (EGFRact+) have a higher incidence of BrM, but a longer overall survival. The high response rate of both systemic and BrM EGFRact+ NSCLC to tyrosine kinase inhibitors (TKIs) has led to the rapid incorporation of new therapies but is outpacing evidence-based decisions for BrM in NSCLC. While whole brain radiation therapy (WBRT) was the foundation of management of BrM, extended survival raises concerns for the subacute and late effects radiotherapy. We favor the use of TKIs and delaying the use of WBRT when able. At inevitable disease progression, we consider alternative dosing schedules to increase CNS penetration (such as pulse dosing of erlotinib) or advance to next generation TKI if available. We utilize local control options of surgery or stereotactic radiosurgery (SRS) for symptomatic accessible lesions based on size and edema. At progression despite available TKIs, we use pemetrexed-based platinum doublet chemotherapy or immunotherapy if the tumor has high expression of PDL-1. We reserve the use of WBRT for patients with more than 10 BrM and progression despite TKI and conventional chemotherapy, if performance status is appropriate.
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Affiliation(s)
- Tresa McGranahan
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
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Jiang BY, Li YS, Guo WB, Zhang XC, Chen ZH, Su J, Zhong WZ, Yang XN, Yang JJ, Shao Y, Huang B, Liu YH, Zhou Q, Tu HY, Chen HJ, Wang Z, Xu CR, Wang BC, Wu SY, Gao CY, Zhang X, Wu YL. Detection of Driver and Resistance Mutations in Leptomeningeal Metastases of NSCLC by Next-Generation Sequencing of Cerebrospinal Fluid Circulating Tumor Cells. Clin Cancer Res 2017; 23:5480-5488. [PMID: 28606923 DOI: 10.1158/1078-0432.ccr-17-0047] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/27/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Leptomeningeal metastases are more common in non-small cell lung cancer (NSCLC) with EGFR mutations. The diagnosis is difficult by traditional imaging only, and leads to poor understanding of resistance mechanisms of leptomeningeal metastases.Experimental Design: We compared the CellSearch Assay, the Thinprep cytologic test (TCT), and brain magnetic resonance imaging (MRI) in 21 NSCLC patients with suspected leptomeningeal metastases. Next-generation sequencing that included 416 cancer-associated genes was also performed on cerebrospinal fluid circulating tumor cells (CSFCTC) of 19 patients.Results: Twenty-one patients were diagnosed with leptomeningeal metastases, and CSFCTCs were captured by CellSearch in 20 patients (median, 969 CSFCTCs/7.5 mL; range, 27-14,888). CellSearch had a sensitivity of 95.2% for leptomeningeal metastases diagnosis, which was higher than that of TCT (12/21, 57.1%), MRI (10/21, 47.6%), and MRI plus TCT (19/21, 90.5%), respectively. CTCs were found only in 5 of 14 patients (median, 2 CTCs/7.5 mL; range, 2-4), which was a much lower ratio than CSFCTCs. Genetic profiles of CSFCTCs were highly concordant with molecular mutations identified in the primary tumor (17/19, 89.5%). The resistance gene EGFR T790M was detected in 7 of 9 patients with extracranial lesions, but was detected in only 1 of 14 CSFCTC samples. Other potential resistant mutations, such as MET amplification and ERBB2 mutation, were also identified in CSFCTCs.Conclusions: CSFCTCs captured by CellSearch may be a more sensitive and effective way to diagnose leptomeningeal metastases, and may serve as a liquid biopsy medium for gene profiles in NSCLC patients with leptomeningeal metastases. Clin Cancer Res; 23(18); 5480-8. ©2017 AACR.
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Affiliation(s)
- Ben-Yuan Jiang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yang-Si Li
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei-Bang Guo
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xu-Chao Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi-Hong Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Su
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen-Zhao Zhong
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xue-Ning Yang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin-Ji Yang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yang Shao
- Geneseeq Biotechnology, Inc., Nanjing, China
| | - Biao Huang
- Department of Radiology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yan-Hui Liu
- Department of Pathology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qing Zhou
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hai-Yan Tu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hua-Jun Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhen Wang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chong-Rui Xu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bin-Chao Wang
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shu-Yu Wu
- Geneseeq Biotechnology, Inc., Nanjing, China
| | - Cun-Yi Gao
- Geneseeq Biotechnology, Inc., Nanjing, China
| | - Xian Zhang
- Geneseeq Biotechnology, Inc., Nanjing, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China.
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Li MX, He H, Ruan ZH, Zhu YX, Li RQ, He X, Lan BH, Zhang ZM, Liu GD, Xiao HL, Wu Y, Zhu B, Wang G, Yang ZZ. Central nervous system progression in advanced non-small cell lung cancer patients with EGFR mutations in response to first-line treatment with two EGFR-TKIs, gefitinib and erlotinib: a comparative study. BMC Cancer 2017; 17:245. [PMID: 28376735 PMCID: PMC5379522 DOI: 10.1186/s12885-017-3165-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/02/2017] [Indexed: 11/25/2022] Open
Abstract
Background Central nervous system (CNS) brain metastasis of advanced non-small cell lung cancer (NSCLC) patients confers a worse quality of life and prognosis. The efficacy comparison of two first-generation epidermal growth factor receptor (EGFR) inhibitors erlotinib or gefitinib as first-line treatment for CNS metastasis NSCLC patients with EGFR-sensitizing mutations is yet to be elucidated. Methods A retrospective analysis was done on cerebral metastasis rate after erlotinib or gefitinib as first-line treatment for advanced NSCLC patients with EGFR-sensitizing mutations. Time to neurological progression (nTTP) and median progression-free survival (mPFS) were calculated. Results The study involved 279 patients (erlotinib group: 108, gefitinib group: 171). After a median follow-up of 22 months, 27 patients (25%) in the erlotinib group and 60 patients (35.1%) in the gefitinib group showed CNS progression. The HR of CNS progression for erlotinib versus gefitinib was 0.695 [95% confidence interval (CI), 0.406–1.190], suggesting a risk reduction of 30.5% although not achieving statistical significance. The 6-, 12- and 18-month cumulative CNS progression rates were 0.9, 3.7 and 12% for erlotinib compared with corresponding rates of 5.8, 9.4 and 17% for gefitinib (P = 0.181). However, for those patients with preexisting brain metastases prior to EGFR-TKI treatment, erlotinib as first line treatment significantly extended the median nTTP in comparison to gefitinib (30 months vs 15.8 months, p = 0.024). Conclusions Our data show that nTTP can be effectively extended in preexisting brain metastases patients with EGFR-sensitizing mutations initially treated with erlotinib compared with gefitinib. If confirmed, our results indicate that erlotinib may play an important role in controlling CNS progression from EGFR mutation-positive NSCLC. Electronic supplementary material The online version of this article (doi:10.1186/s12885-017-3165-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meng-Xia Li
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Hao He
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhi-Hua Ruan
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, 400037, People's Republic of China
| | - Yu-Xi Zhu
- Department of Oncology, First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Rong-Qing Li
- Department of Radiation Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan, People's Republic of China
| | - Xiao He
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Bao-Hua Lan
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhi-Min Zhang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Guo-Dong Liu
- Eighth Department, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Hua-Liang Xiao
- Department of Pathology, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Yan Wu
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Bo Zhu
- Institute of Cancer, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, People's Republic of China
| | - Ge Wang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China
| | - Zhen-Zhou Yang
- Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, 10 Changjiang Zhilu, Daping Yuzhong District, Chongqing, 400042, People's Republic of China.
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How J, Mann J, Laczniak AN, Baggstrom MQ. Pulsatile Erlotinib in EGFR-Positive Non-Small-Cell Lung Cancer Patients With Leptomeningeal and Brain Metastases: Review of the Literature. Clin Lung Cancer 2017; 18:354-363. [PMID: 28245967 DOI: 10.1016/j.cllc.2017.01.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/24/2017] [Accepted: 01/31/2017] [Indexed: 02/08/2023]
Abstract
Patients with epidermal growth factor receptor (EGFR)-positive (EGFR+) non-small-cell lung cancer (NSCLC) show improved response rates when treated with tyrosine kinase inhibitors (TKIs) such as erlotinib. However, standard daily dosing of erlotinib often does not reach therapeutic concentrations within the cerebrospinal fluid (CSF), resulting in progression of central nervous system (CNS) disease. Intermittent, high-dose administration of erlotinib reaches therapeutic concentrations within the CSF and is well tolerated in patients. Experience with "pulsatile" dosing, however, is limited. We review the literature on the pharmacology and clinical outcomes of pulsatile erlotinib in the treatment of EGFR+ NSCLC with brain and leptomeningeal metastases, and include available data on the use of next-generation TKIs in CNS progression. We also provide our institution's experience with patients treated with pulsatile erlotinib for CNS metastasis, and propose clinical criteria for its use. Pulsatile erlotinib is a reasonable alternative in EGFR+ patients with new or worsening CNS disease, without evidence of systemic progression, and without confirmed T790M resistance mutations within the CNS.
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Affiliation(s)
- Joan How
- Barnes-Jewish Hospital, St Louis, MO
| | - Janelle Mann
- Mallinckrodt Institute of Radiology at Washington University, St Louis, MO
| | - Andrew N Laczniak
- Division of Pharmacology, Washington University School of Medicine, St Louis, MO
| | - Maria Q Baggstrom
- Division of Oncology, Washington University School of Medicine, St Louis, MO.
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Yu HA, Sima C, Feldman D, Liu LL, Vaitheesvaran B, Cross J, Rudin CM, Kris MG, Pao W, Michor F, Riely GJ. Phase 1 study of twice weekly pulse dose and daily low-dose erlotinib as initial treatment for patients with EGFR-mutant lung cancers. Ann Oncol 2017; 28:278-284. [PMID: 28073786 PMCID: PMC5834093 DOI: 10.1093/annonc/mdw556] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Patients with EGFR-mutant lung cancers treated with EGFR tyrosine kinase inhibitors (TKIs) develop clinical resistance, most commonly with acquisition of EGFR T790M. Evolutionary modeling suggests that a schedule of twice weekly pulse and daily low-dose erlotinib may delay emergence of EGFR T790M. Pulse dose erlotinib has superior central nervous system (CNS) penetration and may result in superior CNS disease control. Methods We evaluated toxicity, pharmacokinetics, and efficacy of twice weekly pulse and daily low-dose erlotinib. We assessed six escalating pulse doses of erlotinib. Results We enrolled 34 patients; 11 patients (32%) had brain metastases at study entry. We observed 3 dose-limiting toxicities in dose escalation: transaminitis, mucositis, and rash. The MTD was erlotinib 1200 mg days 1-2 and 50 mg days 3-7 weekly. The most frequent toxicities (any grade) were rash, diarrhea, nausea, fatigue, and mucositis. 1 complete and 24 partial responses were observed (74%, 95% CI 60-84%). Median progression-free survival was 9.9 months (95% CI 5.8-15.4 months). No patient had progression of an untreated CNS metastasis or developed a new CNS lesion while on study (0%, 95% CI 0-13%). Of the 18 patients with biopsies at progression, EGFR T790M was identified in 78% (95% CI 54-91%). Conclusion This is the first clinical implementation of an anti-cancer TKI regimen combining pulse and daily low-dose administration. This evolutionary modeling-based dosing schedule was well-tolerated but did not improve progression-free survival or prevent emergence of EGFR T790M, likely due to insufficient peak serum concentrations of erlotinib. This dosing schedule prevented progression of untreated or any new central nervous system metastases in all patients.
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Affiliation(s)
- H. A. Yu
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - C. Sima
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York
| | - D. Feldman
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - L. L. Liu
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - B. Vaitheesvaran
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Sloan Kettering Institute, Sloan Kettering Cancer Center, New York
| | - J. Cross
- Donald B. and Catherine C. Marron Cancer Metabolism Center, Sloan Kettering Institute, Sloan Kettering Cancer Center, New York
| | - C. M. Rudin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - M. G. Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
| | - W. Pao
- Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - F. Michor
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - G. J. Riely
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Weill Cornell Medical College, New York
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Miller JA, Kotecha R, Ahluwalia MS, Mohammadi AM, Suh JH, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Chao ST. The impact of tumor biology on survival and response to radiation therapy among patients with non-small cell lung cancer brain metastases. Pract Radiat Oncol 2017; 7:e263-e273. [PMID: 28254368 DOI: 10.1016/j.prro.2017.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/03/2016] [Accepted: 01/01/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE To investigate the natural history and response to radiation therapy among ALK-rearranged, EGFR-mutated, wild-type adenocarcinoma, and squamous cell non-small cell lung cancer (NSCLC) brain metastases. METHODS AND MATERIALS Patients with NSCLC brain metastasis diagnosed from 1989 through 2014 at a single tertiary-care institution were included. The primary outcome was overall survival, whereas secondary outcomes included local failure, distant intracranial failure, and radiation necrosis. Cox proportional hazards regression was used to model overall survival; multivariate competing risks regression was used to model secondary outcomes. RESULTS Within the study period, 1920 patients presented with 6312 brain metastases. Squamous histology was associated with poorer median survival compared with adenocarcinomas (5.4 vs 8.8 months, P < .01). Median survival was greatest among ALK+ patients (49.2 months), followed by EGFR+ (20.3 months), and wild-type adenocarcinomas (10.0 months, P < .01). Treatment with estimated glomerular filtration rate inhibitors (hazard ratio [HR], 0.66; P < .01) and vascular endothelial growth factor antibodies (HR, 0.65; P < .01) increased survival independent of mutational status. Among 2056 lesions treated with stereotactic radiosurgery, the 12-month cumulative incidence of local failure was significantly greater among squamous cell carcinomas relative to adenocarcinomas (15% vs 10%, HR, 1.26; P = .04). Patients with ALK+ metastases experienced higher rates of local failure (10%; HR, 2.00; P = .05), distant failure (39%; HR, 2.94; P < .01), and radiation necrosis (18%; HR, 5.77; P < .01), whereas EGFR+ patients experienced the lowest rates of local failure (5%; HR, 0.46; P = .04) and distant failure (3%; HR, 0.13; P = .04). CONCLUSIONS Advances in precision medicine have increased survival among select patients with NSCLC. In the present investigation, ALK+ and EGFR+ status were associated with improved survival. However, patients with ALK+ metastases have poor intracranial control relative to EGFR+ metastases, possibly because of limited intracranial penetration of crizotinib compared with estimated glomerular filtration rate inhibitors. Future investigations are warranted to determine the optimal management of ALK+ brain metastases with the introduction of second-generation ALK inhibitors.
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Affiliation(s)
- Jacob A Miller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio; Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio; Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.
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46
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Chamberlain MC, Baik CS, Gadi VK, Bhatia S, Chow LQM. Systemic therapy of brain metastases: non-small cell lung cancer, breast cancer, and melanoma. Neuro Oncol 2017; 19:i1-i24. [PMID: 28031389 PMCID: PMC5193029 DOI: 10.1093/neuonc/now197] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Brain metastases (BM) occur frequently in many cancers, particularly non-small cell lung cancer (NSCLC), breast cancer, and melanoma. The development of BM is associated with poor prognosis and has an adverse impact on survival and quality of life. Commonly used therapies for BM such as surgery or radiotherapy are associated with only modest benefits. However, recent advances in systemic therapy of many cancers have generated considerable interest in exploration of those therapies for treatment of intracranial metastases.This review discusses the epidemiology of BM from the aforementioned primary tumors and the challenges of using systemic therapies for metastatic disease located within the central nervous system. Cumulative data from several retrospective and small prospective studies suggest that molecularly targeted systemic therapies may be an effective option for the treatment of BM from NSCLC, breast cancer, and melanoma, either as monotherapy or in conjunction with other therapies. Larger prospective studies are warranted to further characterize the efficacy and safety profiles of these targeted agents for the treatment of BM.
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Affiliation(s)
- Marc C Chamberlain
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Christina S Baik
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Vijayakrishna K Gadi
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Shailender Bhatia
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
| | - Laura Q M Chow
- Seattle Cancer Center Alliance, Seattle, Washington (M.C.C., C.S.B., V.K.G., S.B., L.Q.M.C.); Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (C.S.B., V.K.G., L.Q.M.C.); Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington (M.C.C.); Division of Medical Oncology, University of Washington, Seattle, Washington (C.S.B., V.K.G., S.B., L.Q.M.C)
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Kawaguchi Y, Hanaoka J, Hayashi H, Mizusaki N, Iihara H, Itoh Y, Sugiyama T. Clinical Efficacy of Afatinib Treatment for a Patient with Leptomeningeal Carcinomatosis. Chemotherapy 2016; 62:147-150. [PMID: 28030859 DOI: 10.1159/000454727] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
Abstract
Leptomeningeal metastases occur in 1% of patients with non-small-cell lung cancer. There have been several reports on the treatment of leptomeningeal metastases with afatinib. Our patient was a 41-year-old woman who had never smoked and was diagnosed with stage IV adenocarcinoma of the lung with an epidermal growth factor receptor (EGFR) mutation. She was treated with afatinib for the recurrence of leptomeningeal metastases. After the treatment with afatinib was initiated, the neurological symptoms dramatically regressed, and she achieved progression-free survival for 7 months. The concentration of afatinib in the cerebrospinal fluid (CSF) ranged from 0.05 to 0.14 ng/mL, and the penetration rate of afatinib from the plasma to the CSF ranged from 0.28 to 0.40%. This concentration might be sufficient to achieve a clinical effect for leptomeningeal carcinomatosis. Therefore, afatinib administered at the usual doses may be an effective treatment for leptomeningeal carcinomatosis of EGFR-mutated or EGFR-tyrosine kinase inhibitor-sensitive lung adenocarcinoma.
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Affiliation(s)
- Yo Kawaguchi
- Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science, Otsu City, Japan
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Toimela T, Huttala O, Sabell E, Mannerström M, Sarkanen JR, Ylikomi T, Heinonen T. Intra-laboratory validated human cell-based in vitro vasculogenesis/angiogenesis test with serum-free medium. Reprod Toxicol 2016; 70:116-125. [PMID: 27915012 DOI: 10.1016/j.reprotox.2016.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/11/2016] [Accepted: 11/28/2016] [Indexed: 01/27/2023]
Abstract
Vasculogenesis and angiogenesis are the processes by which new blood vessels are formed. We have developed a serum-free human adipose stromal cell and umbilical cord vein endothelial cell based vasculogenesis/angiogenesis test. In this study, the test was validated in our GLP laboratory following the OECD Guidance Document 34 [1] using erlotinib, acetylic salicylic acid, levamisole, 2-methoxyestradiol, anti-VEGF, methimazole, and D-mannitol to show its reproducibility, repeatability, and predictivity for humans. The results were obtained from immunostained tubule structures and cytotoxicity assessment. The performance of the test was evaluated using 26 suspected teratogens and non-teratogens. The positive predictive value was 71.4% and the negative predictive value was 50.0%, indicating that inhibition of vasculogenesis is a significant mechanism behind teratogenesis. In conclusion, this test has great potential to be a screening test for prioritization purposes of chemicals and to be a test in a battery to predict developmental hazards in a regulatory context.
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Affiliation(s)
- T Toimela
- FICAM, University of Tampere, Finland.
| | - O Huttala
- FICAM, University of Tampere, Finland
| | - E Sabell
- FICAM, University of Tampere, Finland
| | | | - J R Sarkanen
- Cell Biology, University of Tampere, Finland; Science Center, Tampere University Hospital, Finland
| | - T Ylikomi
- Cell Biology, University of Tampere, Finland; Science Center, Tampere University Hospital, Finland
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Terada T. Pharmaceutical Investigation for Individualized and Optimal Cancer Pharmacotherapy. YAKUGAKU ZASSHI 2016; 136:1469-1476. [PMID: 27803477 DOI: 10.1248/yakushi.16-00181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
After the year 2000, the treatment of cancer remarkably changed, including the development of outpatient cancer chemotherapy. Meanwhile, we have encountered many clinical problems related to cancer patient pharmacy services. To resolve these problems, I have tried to establish the individualized and optimal cancer pharmacotherapy utilizing the findings of basic research. In this review, three topics of my research will be introduced. 1) In 2005, information regarding the genetic polymorphism of UGT1A1*28 was described in the package insert of the drug irinotecan in the United States. At that time, however, there was little similar information for Japanese patients. Through clinical research, we demonstrated that UGT1A1*6 was a significant factor for neutropenia, as induced by irinotecan. 2) Tyrosine kinase inhibitors are mainly used at a fixed dose, but wide interpatient variability has been observed relative to their pharmacokinetics and/or pharmacodynamics. To overcome these variations, clinical and basic pharmacological research on erlotinib, sorafenib and sunitinib was carried out. Especially, in sunitinib therapy, we demonstrated that the breast cancer resistant protein in the intestine functions as a limiting factor for oral absorption, and that therapeutic drug monitoring could be helpful for avoiding severe toxicities, resulting in prolonged progression-free survival. 3) We quantitatively assessed side effect management by pharmacist intervention for outpatient chemotherapy. We calculated the improvement ratio between before and after pharmacist intervention, and found that 135 suggestions (50.8%) led to significant improvements, indicating that pharmacist intervention could be useful for attenuating the side effects of cancer chemotherapies.
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Affiliation(s)
- Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital
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50
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Dagogo-Jack I, Gill CM, Cahill DP, Santagata S, Brastianos PK. Treatment of brain metastases in the modern genomic era. Pharmacol Ther 2016; 170:64-72. [PMID: 27773784 DOI: 10.1016/j.pharmthera.2016.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Development of brain metastasis (BM) portends a dismal prognosis for patients with cancer. Melanomas and carcinomas of the lung, breast, and kidney are the most common malignancies to metastasize to the brain. Recent advances in molecular genetics have enabled the identification of actionable, clinically relevant genetic alterations within primary tumors and their corresponding metastases. Adoption of genotype-guided treatment strategies for the management of systemic malignancy has resulted in dramatic and durable responses. Unfortunately, despite these therapeutic advances, central nervous system (CNS) relapses are not uncommon. Although these relapses have historically been attributed to limited blood brain barrier penetration of anti-neoplastic agents, recent work has demonstrated genetic heterogeneity such that metastatic sites, including BM, harbor relevant genetic alterations that are not present in primary tumor biopsies. This improved insight into molecular mechanisms underlying site specific recurrences can inform strategies for targeting these oncogenic drivers. Thus, development of rational, genomically guided CNS-penetrant therapies is crucial for ongoing therapeutic success.
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Affiliation(s)
- Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Corey M Gill
- Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Daniel P Cahill
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Priscilla K Brastianos
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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