Phase i study of 'dose-dense' pemetrexed plus carboplatin/radiotherapy for locally advanced non-small cell lung carcinoma

Decitabine Sensitizes the Radioresistant Lung Adenocarcinoma to Pemetrexed Through Upregulation of Folate Receptor Alpha

Chemotherapy is the backbone of subsequent treatment for patients with lung adenocarcinoma (LUAD) exhibiting radiation resistance, and pemetrexed plays a critical role in this chemotherapy. However, few studies have assessed changes in the sensitivity of LUAD cells to pemetrexed under radioresistant circumstances. Therefore, the objectives of this study were to delineate changes in the sensitivity of radioresistant LUAD cells to pemetrexed and to elucidate the related mechanisms and then develop an optimal strategy to improve the cytotoxicity of pemetrexed in radioresistant LUAD cells. Our study showed a much lower efficacy of pemetrexed in radioresistant cells than in parental cells, and the mechanism of action was the significant downregulation of folate receptor alpha (FRα) by long-term fractionated radiotherapy, which resulted in less cellular pemetrexed accumulation. Interestingly, decitabine effectively reversed the decrease in FRα expression in radioresistant cells through an indirect regulatory approach. Thereafter, we designed a combination therapy of pemetrexed and decitabine and showed that the activation of FRα by decitabine sensitizes radioresistant LUAD cells to pemetrexed both in vitro and in xenografts. Our findings raised a question regarding the administration of pemetrexed to patients with LUAD exhibiting acquired radioresistance and accordingly suggested that a combination of pemetrexed and decitabine would be a promising treatment strategy.

Phase II Study of Concurrent Pemetrexed, Cisplatin, and Radiation Therapy for Stage IIIA/B Unresectable Non-Small Cell Lung Cancer

INTRODUCTION

Concurrent thoracic radiation and platinum-based chemotherapy is the standard of care for treatment of unresectable stage IIIA-IIIB non-small-cell lung cancer (NSCLC), but the optimal drug regimen has not been established.

PATIENTS AND METHODS

In the present single-arm phase II trial, patients with previously untreated, unresectable stage IIIA-IIIB NSCLC (all histologic types) were treated with pemetrexed-cisplatin (500 mg/m(2) intravenously on days 1 and 22, 20 mg/m(2) intravenously on days 1-5 and days 22-26) concurrent with radiotherapy (61-66 Gy in 31-35 fractions), followed by 2 cycles of consolidation pemetrexed-cisplatin (75 mg(2)) therapy. The primary endpoint was the 1-year overall survival (OS) rate. The study treatment was considered active if the 1-year OS rate was ≥ 70%.

RESULTS

A total of 39 patients, including 6 from the previous phase I trial who had been treated at the recommended phase II dose, were eligible for analysis. The most common drug-related grade 3 to 4 adverse events during the concurrent phase were hematologic and 5.1% of patients experienced grade 3 esophagitis. The response rate was 45.9% (17 of 37 patients), with no complete responses. The 1-, 2-, and 3-year OS survival rates were 79.5%, 56.4%, and 46.2%, respectively. The median OS, time to progressive disease, and progression-free survival was 30.3, 13.7, and 11.8 months, respectively.

CONCLUSION

Full-dose cisplatin and pemetrexed can be administered concurrently with conventional doses of thoracic radiation. The median and 1-year OS rates were favorable compared with published clinical trials in this setting. The regimen was tolerable, and the toxicity profile was consistent with the known toxicity profiles of pemetrexed, cisplatin, and radiation.

Concurrent pemetrexed and radiation therapy in the treatment of patients with inoperable stage III non-small cell lung cancer: a systematic review of completed and ongoing studies

Current standard for locally advanced non-small cell lung cancer (NSCLC) is combined concurrent therapy with a platinum-based regimen. Preclinical synergistic activity of pemetrexed with radiation therapy (RT) and favorable toxicity profile has led to clinical trials evaluating pemetrexed in chemoradiation regimens. This literature search of concurrent pemetrexed and RT treatment of patients with stage III NSCLC included MEDLINE database, meeting abstracts, and the clinical trial registry database. Nineteen unique studies were represented across all databases including 11 phase I studies and eight phase II studies. Of the six phase II trials with mature data available, median overall survival ranged from 18.7 to 34 months. Esophagitis and pneumonitis occurred in 0-16% and 0-23% of patients, respectively. Of the ongoing trials, there is one phase III and four phase II trials with pemetrexed in locally advanced NSCLC. Pemetrexed can be administered safely at full systemic doses with either cisplatin or carboplatin concomitantly with radical doses of thoracic radiation therapy. While results from the ongoing phase III PROCLAIM trial are needed to address definitively the efficacy of pemetrexed-cisplatin plus RT in stage III NSCLC, available results from phase II trials suggest that this regimen has promising activity with an acceptable toxicity profile.

Phase 2 study of pemetrexed plus carboplatin, or pemetrexed plus cisplatin with concurrent radiation therapy followed by pemetrexed consolidation in patients with favorable-prognosis inoperable stage IIIA/B non-small-cell lung cancer

INTRODUCTION

There is no consensus chemotherapy regimen with concurrent radiotherapy (RT) for inoperable stage IIIA/B non-small-cell lung cancer. This trial evaluated pemetrexed with carboplatin (PCb) or cisplatin (PC) with concurrent RT followed by consolidation pemetrexed.

METHODS

In this open-label, noncomparative phase II trial, patients with inoperable stage IIIA/B non-small-cell lung cancer (initially all histologies, later restricted to nonsquamous) were randomized (1:1) to PCb or PC with concurrent RT (64-68 Gy over days 1-45). Consolidation pemetrexed monotherapy was administered every 21 days for three cycles. Primary endpoint was 2-year overall survival (OS) rate.

RESULTS

From June 2007 to November 2009, 98 patients were enrolled (PCb: 46; PC: 52). The 2-year OS rate was PCb: 45.4% (95% confidence interval [CI], 29.5-60.0%); PC: 58.4% (95% CI, 42.6-71.3%), and in nonsquamous patients was PCb: 48.0% (95% CI, 29.0-64.8%); PC: 55.8% (95% CI, 38.0-70.3%). Median time to disease progression was PCb: 8.8 months (95% CI, 6.0-12.6 months); PC: 13.1 months (95% CI, 8.3-not evaluable [NE]). Median OS (months) was PCb: 18.7 (95% CI, 12.9-NE); PC: 27.0 (95% CI, 23.2-NE). The objective response rates (ORRs) were PCb: 52.2%; PC: 46.2%. Grade 4 treatment-related toxicities (% PCb/% PC) were: anemia, 0/1.9; neutropenia, 6.5/3.8; thrombocytopenia, 4.3/1.9; and esophagitis, 0/1.9. Most patients completed scheduled chemotherapy and RT during induction and consolidation phases. No drug-related deaths were reported during chemoradiotherapy.

CONCLUSIONS

Because of study design, efficacy comparisons cannot be made. However, both combinations with concurrent RT were active and well tolerated.

Effect analysis of chemoradiotherapy after operation in patients with stage III A non-small cell lung cancer

OBJECTIVE

To investigate the effect of chemoradiotherapy after surgery on III A stage non-small cell lung cancer (NSCLC).

METHODS

A total of 156 NSCLC patients undergoing total pneumonectomy or pulmonary lobectomy were included in this study. The chemotherapy group (n=75) received the protocol of cisplatin (DDP) + gemcitabine (GEM) / docetaxel (DOC) / vinorelbine (NVB); the radiotherapy + chemotherapy group (n=81) received sequential chemoradiotherapy. The response rate, local control rate in 1 to 2 years, overall survival (OS), progression-free survival (PFS) and adverse reactions were evaluated.

RESULTS

The overall response rate was obviously higher in radiotherapy + chemotherapy group (79.4%) than in chemotherapy group (56.8%) (P<0.01). The 1 year local control rates for chemotherapy group and radiotherapy + chemotherapy group were (69.1±7.9)% and (77.8±8.2)% respectively and the difference reached statistical significance (P<0.001). The 2 year local control rates were (42.1±6.1)% and (61.5±6.9)% respectively (P<0.001). The difference in median follow-up time between the two groups did not reach statistical meaning (P>0.05), while the median PFS of two groups were 10.8 months and 16.9 months respectively (P<0.001). 1-year and 3-year survival rates were obviously higher in radiotherapy + chemotherapy group than in chemotherapy group, and the difference reached statistical significance (P<0.05 or P<0.01). The adverse reactions manifested as hematological toxicity and digestive tract reaction in the two groups. In the radiotherapy + chemotherapy group, incidences of radiation-induced esophagus injury and lung injury were 24.7% and 34.6% respectively, all occurring within 2 to 6 weeks after the start of radiation and both below grade 2.

CONCLUSIONS

Chemoradiotherapy after surgery can improve local control rate and reduce or prevent distant metastasis, but there are still many controversies. In clinical work, we should carefully evaluate each patient's age, lung function, basic physical condition scoring and complications to choose a therapeutic schedule that is suitable for the patient.

Duodenal perforation in a patient with non-small cell lung cancer receiving Pemetrexed-Cisplatin combination

Pemetrexed is increasingly used in combination with platinum antineoplastic agents for the treatment of certain lung malignancies. Its use was associated with favorable hematological adverse reaction compared to standard regimens. Non-hematological life-threatening complications such as gastrointestinal perforations are extremely rare with pemetrexed use and tend to develop in the distal bowel in patients at risk.

We report the case of a 56-years old Arab male, heavy smoker newly diagnosed with Stage IV non-small cell lung cancer with no comorbidities, treated with pemetrexed-cisplatin combination. Four days after the first cycle of chemotherapy, the patient developed a small duodenal perforation that required emergency laparoscopy repair.

Clinicians should have a high index of suspicion should be taken for alimentary tract perforation in patients presenting with acute abdominal pain during pemetrexed therapy.