Chemotherapeutic management of stage IV non-small cell lung cancer

Survival Benefit of Perioperative Systemic Chemotherapy for Patients With N0 to N1 NSCLC Having Synchronous Brain Metastasis

Introduction

In stage IV NSCLC with solitary or oligometastatic brain metastasis, surgical resection of the primary and definitive management of the brain metastasis is an accepted standard. However, the effect of systemic chemotherapy after surgical resection on overall survival is not well-established.

Methods

We used the National Cancer Database to retrospectively identify individuals with NSCLC as the primary tumor along with synchronous brain metastases who underwent thoracic resection with or without adjuvant chemotherapy. Chi-square and Wilcoxon rank sum tests were performed to compare categorical and continuous variables, respectively, across the treatment groups. Kaplan-Meier and Cox proportional modeling were done to determine the survival benefit.

Results

A total of 310 (71.9%) of the cohort received perioperative chemotherapy, most of whom (79.4%) received it in the adjuvant setting. Patients receiving chemotherapy were likely to be younger (p = 0.002), privately insured (p = 0.01), and receive radiation (p < 0.001). Perioperative chemotherapy was significantly associated with survival on both univariate (hazard ratio = 0.71[0.52 - 0.99]) and multivariable (hazard ratio = 0.66 [0.47 - 0.92]) in addition to age (p = 0.03), Charlson-Deyo score (p = 0.02), pathologic N stage (p = 0.02), and adenocarcinoma histology (p = 0.02). Kaplan-Meier analysis confirmed this result with a significantly better survival with perioperative chemotherapy (p = 0.02). Further subgroup analysis using pathologic N stage revealed similar effect in pN1 (p = 0.001), but not pN0 (p = 0.2) patients.

Conclusions

Perioperative chemotherapy for pN0-1 NSCLC with synchronous brain metastasis is associated with improved OS in this analysis.

Surface and mechanical properties of polyurethane central venous catheters after repeated contact with chemotherapy excipient solutions

This article investigates the impact of the interactions between polyurethane central venous catheters and solutions containing excipients used in cisplatin and paclitaxel formulations. Changes to the properties of catheters and the leaching of catheter additives into the infused solutions were studied while these solutions were infused cyclically for several months. Chemotherapy treatment was mimicked in vitro in compliance with hospital practices. The treatment cycle was repeated 10 times, using solutions containing only the excipients. After 10 treatment cycles, no physical or chemical degradation of the catheter was observed. Mechanical performances were stable, but surface modifications occurred, causing the surface to become more hydrophobic. A loss in polyurethane antioxidant amount was observed in part due to a leaching phenomenon.

Pharmaceutical care issues in lung cancer: can community pharmacists support patients receiving systemic anticancer therapy?

OBJECTIVES

Most patients receive systemic anticancer therapy (SACT) as day cases and toxicities, if they occur, are likely to appear first in primary care. Pharmaceutical care can be delivered by community pharmacists, but little is known about the epidemiology of SACT toxicities in the community and potential interventions to address these which raise the following questions: what are the typologies of SACT-associated toxicities experienced by community-based patients and what are the associated pharmaceutical care issues (PCIs)? The aim of this study was to identify toxicities and pharmaceutical care issues of patients prescribed SACT for lung cancer and understand the potential for community pharmacists to deliver aspects of cancer care including toxicity management.

METHODS

Retrospective analysis of clinical records of patients prescribed oral and parenteral SACT in 2013-14, to describe patient characteristics; SACT toxicity; PCIs and episodes of unscheduled care.

KEY FINDINGS

Twelve categories of toxicity and 13 categories of PCIs were identified from 50 patients. More PCIs were observed with oral SACT/oral-parenteral combinations than with parenteral regimens. The PCIs which could be managed by community pharmacists were mucositis; skin toxicity; gastrointestinal toxicity; reinforcing patient education and identification/prevention of drug interactions.

CONCLUSIONS

Community pharmacists are ideally placed to provide pharmaceutical care to patients with lung cancer prescribed SACT. Cancer specialists in secondary care can signpost patients to community pharmacists for early management of low-grade SACT toxicity.

The effects of traditional Chinese medicine combined with chemotherapy on immune function and quality of life in patients with non-small cell lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

This article will evaluate the effects of traditional Chinese medicine (TCM) combined with chemotherapy on the immune function and quality of life of patients with non-small cell lung cancer (NSCLC), and evaluate the published side effects.

METHODS

The systematic review and meta-analysis will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The databases we will search include: PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, China Biomedicine, Wan fang Data, and Technology Periodical Database. The search date is from inception to June 30, 2020. There are no restrictions on the document language. The literatures included in this study are randomized controlled trials. The main results include ratio of CD3, CD4, CD8, CD4/CD8, NK cells, the level of IgA, IgG, IgM, and Karnofsky performance status score. The secondary result is to evaluate various side effects during treatment. We will use the Cochrane Collaboration tool to evaluate each study and use Review Manager software (RevMan, version 5.3) to merge and analyze the data. The 2 researchers will independently cross-screen the literature, extract data, and evaluate the quality. If there are differences, we will resolve them through discussion or consultation with a third reviewer.

RESULTS

The results of this study will provide high-quality evidence for the effect of TCM combined with chemotherapy on the immune function and quality of life of patients with NSCLC.

CONCLUSION

This article will comprehensively evaluate the effects of TCM combined with chemotherapy on the immune function and quality of life of patients with NSCLC, and provide evidence-based evidence for clinical practice.

ETHICS

Since the data used in this study is based on previous trials and does not involve patient privacy, ethical approval is not required.

STUDY REGISTRATION NUMBER

INPLASY202070071.

Tolerance of Radical Radiotherapy Among Elderly Head and Neck Cancer Patients

Head and neck cancers usually occur in the elderly age group and about half of the cases occur at the age > 60 years with majority detected in an advanced stage with increased morbidity and decreasing compliance to therapy. Since there are limited data available for the adequate treatment of elderly head and neck cancer patients, we proposed a study to analyze tolerance and response based on age, site, modality of treatment received, and implication of nutrition vs weight loss during treatment. Fifty-five patients were enrolled in this study, which was conducted between November 2015 and April 2017, and those who met the eligibility criteria were evaluated with a detailed history and physical examination, and biochemical, pathological, and radiological investigations. Patients were staged based on TNM staging and treated as per the standard guidelines. Patients were assessed with the weekly routine blood investigation, weight loss, and toxicity. The response was assessed after 6 weeks and documented as per RECIST criteria. 52/55 (94.5%) patients completed the treatment, and 48/55 (92.3%) had a complete response at 6 weeks (p value 0.000) with a mean treatment duration of 46.67 days and mean weight loss of 5.44 kg with 55.4% having GR-II mucositis, 40% having GRIII mucositis at the time of completion of treatment. Sixty-eight percent having GRII and 38.2% having GR I dermatitis and 80% had moderate pain. Subgroup analysis was done based on age, site, and treatment modality. Patients were also assessed for nutrition vs weight loss. We concluded that elderly patients tolerate and respond well to radical treatment with acceptable toxicities; hence, age should not be a barrier to decide treatment.

[Evolution of the costs and management of lung cancer between 2004 and 2014]

BACKGROUND

Given its morbidity and mortality, lung cancer is a major public health issue. In recent years, it has benefited from several therapeutic innovations. The objective of this study was to compare, over two distinct periods of ten years, the impact on survival and the costs of lung cancer management.

METHODS

The monocentric study assessed survival and the direct costs of lung cancer management of patients diagnosed in Brest University hospital in 2004 and in 2014.

RESULTS

The analysis included 142 patients in 2004 and 156 in 2014. Most patients were smokers (72%), metastatic at diagnosis (60%) both in 2004 and in 2014. Median survival was not significantly improved between the 2 periods (9.7 versus 10.9 months), but there was a significant increase in the average cost of care per patient (€ 17,063 vs. € 29,264, P=<0.0001) between 2004 and 2014.

CONCLUSION

The significant increase in treatment costs did not translate into an improvement in the survival of patients with lung cancer between 2004 and 2014.

The Stage IV Shuffle: Elusiveness of Straight Talk About Advanced Cancer

During the initial consultation with a patient to communicate a diagnosis of late-stage cancer, the oncologist may refrain from giving survival statistics, redirecting the conversation from the bad news (incurability) to the practical aspects of the patient's care (treatments, timetables, appointments, and testing to monitor response to treatment). Whether conscious or unconscious, this diversion helps cushion the impact of the disturbing news. This paper shows that clinicians' gingerly handling of harsh facts when they talk with patients also applies to health educators and researchers when they write about late-stage cancer. As a result, these cancer patients typically lack an understanding of their poor prognosis and the limited effectiveness of most available treatments, possibly compromising their ability to make informed choices. To remedy this problem, I describe an approach to straight talk about late-stage cancer that can give a patient realistic hopes instead of false hopes that are apt to betray later on. I also propose an enhanced method of displaying and interpreting comparative efficacy data that can facilitate understanding and serve as a basis for shared decision making.

Survival nomogram for patients with initially diagnosed metastatic non-small-cell lung cancer: a SEER-based study

Aim: Prognosis of patients with metastatic non-small-cell lung cancer differ widely. Methods: All patients were randomly divided into training or validation cohort. Cox-regression analyses were conducted to select independent predictors. We built a nomogram by R code and evaluated the accuracy and the reliability of the model using C-index, calibration curves and decision curve analyses. We made a risk classification system based on the nomogram. Results: In the validation cohort, C-index was 0.729 and 0.738 for 1- and 2-year overall survival. Calibration plots and decision curve analyses presented great prognostic accuracy and clinical applicability. Its prognostic accuracy preceded the American Joint Committee on Cancer staging with evaluated integrated discrimination improvement. Conclusion: The model can be a practical tool in treatment decision and individual counseling.

Surgical treatment of intraperitoneal metastases from lung cancer: two case reports and a review of the literature

BACKGROUND

Peritoneal metastases are often reported in several abdominal tumors. Peritoneal diffusion from extra-abdominal tumors is thought to be rare. Lung cancer is one of the most common cancers in the world with early metastases and it is associated with poor prognosis in advanced stages. Peritoneal metastases from lung cancer are uncommon and the real mechanism of its diffusion to the peritoneum is unknown. However, its clinical behavior is similar to any other peritoneal metastasis from abdominal tumors.

CASE PRESENTATION

We present two Caucasian patients (a 44-year-old man and a 59-year-old man) with bowel obstruction from peritoneal metastases from non-small cell lung cancer who successfully underwent emergency cytoreductive surgery and had a good prognosis and survival.

CONCLUSIONS

In our patients with isolated peritoneal metastases from lung cancer, cytoreduction showed good prognosis with acceptable morbidity. This treatment option might be considered in highly selected cases to improve survival. Strict follow-up is mandatory to allow early diagnosis of peritoneal diffusion.

Quantitative 18F-FDG PET analysis in survival rate prediction of patients with non-small cell lung cancer

The aim of the present study was to investigate the prognostic value of quantitative [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) parameters for patients with non-small cell lung cancer (NSCLC). The present study conducted a retrospective review of the medical records of 203 patients with NSCLC, of which 193 patients underwent baseline 18F-FDG PET/CT prior to initial therapy. Multivariate analyses using Cox's proportional hazards regression were performed for the assessment of the association between initial PET/CT measurements and overall survival (OS). The multivariate models were adjusted for sex, age, smoking status, disease stage, standardized uptake value (SUV), standardized uptake value corrected for lean body mass (SUL), metabolic tumor volume (MTV), total lesion glycolysis (TLG) and standard deviation of SUV (SD). Kaplan-Meier (K-M) estimator curves were constructed following the formation of three approximately equal-sized groups using tertiles for each PET/CT measurement (n=65, 64 and 64). OS curves were plotted using K-M estimator curves. Results demonstrated significant associations between OS and MTVPET volume computerized assisted reporting (PETVCAR), MTV2.5, MTV25%, MTV42% and TLGPETVCAR; however, no significant associations were identified between OS and MTV50%, MTV75%, TLG2.5, all SUV and SUL. Subgroup analyses according to pathology demonstrated that there were statistically significant associations between OS and stage (P<0.001), MTV50% (P=0.002) and MTV42% (P=0.004) in the adenocarcinoma group, and SULmean (P=0.010), MTV25% (P=0.005) and MTV42% (P=0.001) in the squamous cell carcinoma group; however, no significant differences were identified between any other group. Furthermore, there was a significant association between OS and MTV42% (P=0.02) and MTV50% (P=0.04) in the early-stage group; however, no significant differences were identified in the advanced-stage group. K-M estimator curve analyses demonstrated that the pathology (P=0.01), stage (P<0.001) and all PET metabolic parameters with the exception of SD were significantly associated with OS (P<0.05). No significant associations were demonstrated between SD and OS. In conclusion, 18F-FDG PET/CT MTVPETVCAR, MTV2.5, MTV25%, MTV42% and TLGPETVCAR exhibit prognostic values with regard to OS. Overall, selection of appropriate metabolic parameters may predict NSCLC prognosis.

An updated and validated PET/CT volumetric prognostic index for non-small cell lung cancer

OBJECTIVES

Whole-body metabolic tumor volume (MTV_WB) and TNM staging are independent prognostic factors for overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to update and validate the PET/CT volumetric prognostic index (PVP index) using the new 8th edition TNM staging system to evaluate its prognostic power versus TNM staging and MTV_WB alone.

MATERIALS AND METHODS

This study was a retrospective analysis of 949 non-small cell lung cancer (NSCLC) patients diagnosed between 2004 and 2014. Clinical TNM stage, MTV_WB, age and gender, tumor histology type at the initial staging PET/CT exam, as well as treatment history and long-term survival data were obtained. Patients were randomly assigned to modeling or validation group. Univariate and multivariate Cox regression analyses were performed to compare PVP index, TNM stage, and MTV_WB in the validation group.

RESULTS

The updated PVP index included the 3 variables TNM stage, and MTV_WB and age. Univariate Cox models showed significant association of PVP index with overall survival (OS) in patients with NSCLC (with Hazard ratio HR = 2.88 in the validation group, p < 0.001). The C-statistic of the PVP index (C-statistic = 0.71 in the validation group) was significantly greater than that of 8th edition TNM staging (C-statistic = 0.68, p = 0.029), MTV_WB (C-statistic = 0.68, p = 0.001), and patient age (C-statistic = 0.53, p < 0.001). Multivariate Cox regression analyses demonstrated significant association of PVP index with OS (with HR = 2.80, p < 0.001) after adjusting patient's gender and tumor histology.

CONCLUSIONS

The updated PVP index provides a quantitative risk assessment for NSCLC patients using 8th edition TNM staging, MTV_WB, and age. The index provides a simple and practical way for the care team to incorporate the independent prognostic value of both the TNM stage and MTV_WB. This approach can further improve the accuracy of overall survival prognosis.

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients.

Variations in Oncologist Recommendations for Chemotherapy for Stage IV Lung Cancer: What Is the Role of Performance Status?

PURPOSE

Chemotherapy prolongs survival in patients with advanced non-small-cell lung cancer. However, few studies have included patients with poor performance status. This study examined rates of oncologists' recommendations for chemotherapy by patient performance status and symptoms and how physician characteristics influence chemotherapy recommendations.

METHODS

We surveyed medical oncologists involved in the care of a population-based cohort of patients with lung cancer from the CanCORS (Cancer Care Outcomes Research and Surveillance) study. Physicians were queried about their likelihood to recommend chemotherapy to patients with stage IV lung cancer with varying performance status (Eastern Cooperative Oncology Group performance status 0 [good] v 3 [poor]) and presence or absence of tumor-related pain. Repeated measures logistic regression was used to estimate the independent associations of patients' performance status and symptoms and physicians' demographic and practice characteristics with chemotherapy recommendations.

RESULTS

Nearly all physicians (adjusted rate, 97% to 99%) recommended chemotherapy for patients with good performance status, and approximately half (adjusted rate, 38% to 53%) recommended chemotherapy for patients with poor performance status (P < .001). Compared with patient factors, physician and practice characteristics were less strongly associated with chemotherapy recommendations in adjusted analyses.

CONCLUSION

Strong consensus among oncologists exists for chemotherapy in patients with advanced non-small-cell lung cancer and good performance status. However, the relatively high rate of chemotherapy recommendations for patients with poor performance status despite the unfavorable risk-benefit profile highlights the need for ongoing work to define high-value care in oncology and to implement and evaluate strategies to align incentives for such care.

First-Line Pemetrexed Plus Cisplatin Followed by Gefitinib Maintenance Therapy Versus Gefitinib Monotherapy in East Asian Never-Smoker Patients With Locally Advanced or Metastatic Nonsquamous Non-Small-cell Lung Cancer: Quality of Life Results From a Randomized Phase III Trial

BACKGROUND

The efficacy results from an open-label, randomized, multicenter study found no significant difference in progression-free survival between pemetrexed plus cisplatin followed by maintenance gefitinib (PC/G) and gefitinib monotherapy (G) in patients with advanced nonsquamous non-small-cell lung cancer (NSCLC) and unknown epidermal growth factor receptor (EGFR) mutation status (hazard ratio favored PC/G). The present report describes the quality of life (QoL) results from that trial.

PATIENTS AND METHODS

Chemotherapy-naive, East Asian, light ex-smokers or never-smokers with advanced nonsquamous NSCLC and unknown EGFR mutation status (n = 236) were randomly assigned (1:1) to PC/G or G. EGFR mutation status was subsequently determined for 74 patients. The symptoms and QoL were assessed using the Lung Cancer Symptom Scale (LCSS). The time to worsening of symptoms (TWS) was analyzed using the Kaplan-Meier method.

RESULTS

In the overall population, the TWS was generally longer in the G group (n = 109) than in the PC/G group (n = 109) for the LCSS symptoms classified as treatment-related (loss of appetite, fatigue) and tumor-related (cough, dyspnea, hemoptysis, pain). In the subgroup of patients with wild-type EGFR, the TWS was generally longer in the PC/G group (n = 13) than in the G group (n = 8) for the tumor-related LCSS symptoms.

CONCLUSION

In this study population clinically selected to respond to gefitinib, the LCSS scores were more favorable in the G group than in the PC/G group. Patients with wild-type EGFR tended to show greater improvement in tumor-related LCSS symptoms with chemotherapy than with gefitinib alone. These LCSS outcomes provide further evidence that patients with wild-type EGFR might not benefit from first-line treatment of advanced NSCLC with gefitinib.

[F-18] FDG-PET/CT parameters as predictors of outcome in inoperable NSCLC patients

Background

We evaluated the prognostic significance of standardized uptake value (SUVmax), metabolic tumour volume (MTV), and total lesion glycolysis (TLG) in [F-18] FDG PET/CT findings in patients with inoperable non-small-cell lung cancer (NSCLC).

Patients and methods.

One hundred and three patients (mean age, 65.6 ± 16 years) underwent [F-18] FDG PET/CT before the chemotherapy. The SUVmax value, the MTV (cm³; 42% threshold) and the TLG (g) were registered. The patients were followed up to 18 months thereafter (range 12–55 months). Failure to respond without progression, progression and/or disease-related death constituted surrogate end-points. The optimal SUVmax, MTV and TLG cut-off to predict the patients’ outcome were estimated. PET/CT results were then related to disease outcome (progression free survival; PFS).

Results

The Kaplan-Meier survival analysis for SUVmax showed a significant shorter PFS in patients presenting with lower values as compared to those with higher (p < 0.05, log-rank test). MTV and TLG were not suitable for predicting PFS apart from the subset of patients with mediastinal nodal involvement.

Conclusions

Despite the availability of new tools for the quantitative assessment of disease activity on PET/CT, the SUVmax rather than MTV and TLG remains the only predictor for PFS in NSCLC patients. MTV holds a value only when concomitant nodal involvement occurs.

Cell-free DNA as a prognostic marker in stage I non-small-cell lung cancer patients undergoing stereotactic body radiotherapy

OBJECTIVE

To evaluate whether plasma cell-free DNA (cfDNA) was related to clinical outcome in inoperable stage I non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiotherapy (SBRT).

MATERIALS AND METHODS

Plasma cfDNA was assessed at baseline, before the last day and 45 days after the end of SBRT, in 22 NSCLC patients. Twenty-two healthy controls were also evaluated.

RESULTS

Plasma cfDNA was higher in patients than in controls. An association with unfavourable disease-free survival was found for continuous baseline cfDNA increments (HR = 5.9, 95%CI: 1.7-19.8, p = 0.04).

CONCLUSION

Plasma cfDNA may be a promising prognostic biomarker in high-risk NSCLC patients.

A new PET/CT volumetric prognostic index for non-small cell lung cancer

OBJECTIVES

Whole-body metabolic tumor volume (MTVWB) has been shown of prognostic value for non-small cell lung cancer (NSCLC) beyond that of TNM stage, age, gender, performance status, and treatment selection. The current TNM staging system does not incorporate tumor volumetric information. We propose a new PET/CT volumetric prognostic (PVP) index that combines the prognostic value of MTVWB and TNM stage.

MATERIALS AND METHODS

Based on 328 consecutive NSCLC patients with a baseline PET/CT scan before treatment, from which MTVWB was measured semi-automatically, we estimated hazard ratios (HRs) for ln(MTVWB) and TNM stage from a Cox proportional hazard regression model that consisted of only ln(MTVWB) and TNM stage as prognostic variables of overall survival. We used the regression coefficients, which gave rise to the HRs, as weights to formulate the PET/CT volumetric prognostic (PVP) index. We also compared the prognostic value of the PVP index against that of TNM stage alone and ln(MTVWB) alone with univariate and multivariate survival analyses and C-statistics.

RESULTS

Univariate analysis C-statistic for the PVP index (C=0.71) was statistically significantly greater than those for TNM stage alone (C=0.67, p<0.01) and for ln(MTVWB) alone (C=0.69, p=0.033). Multivariate analyses showed that the PVP index yielded significantly greater discriminatory power (C=0.74) than similar models based on either TNM stage (C=0.72, p<0.01) or ln(MTVWB) (C=0.73, p<0.01). Lower values of the PVP index were associated with significantly better overall survival (adjusted HR=2.70, 95%CI [2.16, 3.37]).

CONCLUSION

The PVP index provides a practical means for clinicians to combine the prognostic value of MTVWB and TNM stage and offers significantly better prognostic accuracy for overall survival of NSCLC patients than the current TNM staging system or metabolic tumor burden alone.

Free flaps in head and neck reconstruction after oncologic surgery: expected outcomes in the elderly

OBJECTIVE

To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly.

DATA SOURCES

Medline, Isiweb, and Cochrane databases.

REVIEW METHODS

A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review.

CONCLUSIONS

Evaluation of the pertinent literature is hampered by a number of biases, such as a lack of general consensus of a definition of "elderly," differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our findings showed no differences in terms of free flap success, surgical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age.

IMPLICATION FOR PRACTICE

Microvascular reconstruction in the elderly can be performed with high success rates, even though medical complications can occur more frequently compared to younger patients. Minor and major surgical complications in the elderly appear to be comparable to those in the younger population and do not affect final outcome or the perioperative mortality rate. Flap outcome does not seem to be significantly affected by age. Careful preoperative assessment and postoperative monitoring are mandatory to prevent adverse events, and prompt management is warranted whenever present.

A comprehensive review of nongenetic prognostic and predictive factors influencing the heterogeneity of outcomes in advanced non-small-cell lung cancer

While there have been advances in treatment options for those with advanced non-small-cell lung cancer, unmet medical needs remain, partly due to the heterogeneity of treatment effect observed among patients. The goals of this literature review were to provide updated information to complement past reviews and to identify a comprehensive set of nongenetic prognostic and predictive baseline factors that may account for heterogeneity of outcomes in advanced non-small-cell lung cancer. A review of the literature between 2000 and 2010 was performed using PubMed, Embase, and Cochrane Library. All relevant studies that met the inclusion criteria were selected and data elements were abstracted. A classification system was developed to evaluate the level of evidence for each study. A total of 54 studies were selected for inclusion. Patient-related factors (eg, performance status, sex, and age) were the most extensively researched nongenetic prognostic factors, followed by disease stage and histology. Moderately researched prognostic factors were weight-related variables and number or site of metastases, and the least studied were comorbidities, previous therapy, smoking status, hemoglobin level, and health-related quality of life/symptom severity. The prognostic factors with the most consistently demonstrated associations with outcomes were performance status, number or site of metastases, previous therapy, smoking status, and health-related quality of life. Of the small number of studies that assessed predictive factors, those that were found to be significantly predictive of outcomes were performance status, age, disease stage, previous therapy, race, smoking status, sex, and histology. These results provide a comprehensive overview of nongenetic prognostic and predictive factors assessed in advanced non-small-cell lung cancer over the last decade. This information can be used to inform the design of future clinical trials by suggesting additional subgroups based on nongenetic factors that may be analyzed to further investigate potential prognostic and predictive factors.

Metastatic sites and survival in lung cancer

OBJECTIVES

Population-based data on metastatic sites and survival in site-specific metastases are lacking for lung cancer and for any cancer because most cancer registries do not record metastases. This study uses a novel population-based approach to identify metastases from both death certificates and national inpatient data to describe metastatic pathways in lung cancer patients.

MATERIALS AND METHODS

17,431 deceased lung cancer patients diagnosed 2002-2010 were identified from the nationwide Swedish Cancer Registry, which is based on compulsory reports. The influence of age at diagnosis, sex, and histological subtype on metastatic spread was investigated. Survival in metastatic lung cancer was assessed by histology and metastatic site.

RESULTS

The most frequent metastatic sites were the nervous system, bone, liver, respiratory system, and adrenal gland. Liver (35%) and nervous system (47%) metastases were common in patients with metastases from small cell lung cancer, and bone (39%) and respiratory system (22%) metastases in adenocarcinoma. Women (43% vs. 35%) and younger patients had more metastases to the nervous system. Median survival after diagnosis was 13 months for non-metastatic and five months for metastatic lung cancer. In this novel data, liver metastases conferred the worst prognosis (three months), especially for large cell histology. Bone metastases also featured poor survival, whereas survival in respiratory and nervous system metastases was better.

CONCLUSION

Metastatic sites and survival in metastatic lung cancer is influenced by sex, histological subtype, and age at diagnosis. Liver and bone metastases signal poor survival, compared with nervous system metastases.

PARAMOUNT: Descriptive subgroup analyses of final overall survival for the phase III study of maintenance pemetrexed versus placebo following induction treatment with pemetrexed plus cisplatin for advanced nonsquamous non-small-cell lung cancer

INTRODUCTION

The PARAMOUNT phase III trial demonstrated that pemetrexed continuation maintenance significantly reduced the risk of disease progression (hazard ratio = 0.62) and death (hazard ratio = 0.78) versus placebo in patients with advanced nonsquamous non-small-cell lung cancer. To further understand the survival data, descriptive subgroup analyses were undertaken.

METHODS

Nine hundred thirty-nine patients received induction therapy (four 21-day cycles pemetrexed 500 mg/m and cisplatin 75 mg/m), after which 539 nonprogressing patients with an Eastern Cooperative Oncology Group performance status (PS) of 0/1 were randomized (2:1) to maintenance pemetrexed (500 mg/m) cycles or placebo until disease progression.

RESULTS

Baseline characteristics of patients surviving for longer periods were comparable to patients surviving shorter periods, suggesting overall survival (OS) benefit for all subgroups of patients on maintenance therapy. An examination of type and severity of induction adverse events also found no association with survival duration. Response to induction (tumor response versus stable disease) was not determinate of pemetrexed maintenance OS outcome as assessed by waterfall plot and scattergrams and by the distribution of patients among various OS intervals. The length of the interval before beginning maintenance therapy (<7 days versus ≥7/≤30 days) also did not impact the survival results. PS, a known prognostic factor, was the only baseline characteristic associated with improved OS; however, both PS 0 and PS 1 patients exhibited a survival benefit from pemetrexed maintenance.

CONCLUSIONS

In PARAMOUNT, the OS benefit was seen across all subgroups. Other than PS, no baseline or clinical parameter clearly identified a subgroup more likely to benefit. Maintenance treatment decisions should be made on an individual basis.

Is the Evaluation of Quality of Life in NSCLC Trials Important? Are the Results to be Trusted?

The majority of patients with non-small cell lung cancer present at the time of diagnosis with stage IV metastatic disease and they experience 2 or more disease-related symptoms. These symptoms may have a negative impact on their health-related quality of life (HR QOL). Data has shown many of these patients prefer a therapy to improve their symptoms rather than receive a therapy which slightly prolongs their survival without improving their symptoms. The improvement of disease-related symptoms on a specific drug or regimen augments the significance of prolongation of the progression-free survival or the response rate as well as symptom worsening. The choice of the questionnaires to evaluate patients’ reported outcomes and HR QOL benefits and the methods of collecting the data and their interpretations are very important. Only if the data are collected and analyzed properly will they be meaningful and can then be viewed as components that add the total value to a treatment and provide a comprehensive picture of the benefits and risks of a certain anticancer therapy.

Long-term survival of more than 3 years among patients with advanced non-small cell lung cancer treated with chemotherapy

AIM: To evaluate the prognostic factors of long-term survival of more than 3 years in patients with advanced non-small cell lung cancer (NSCLC).

METHODS: We retrospectively analyzed the records of 474 patients with advanced IIIB/IV NSCLC who received chemotherapy as initial treatment between September 2002 and March 2007.

RESULTS: The median survival time (MST) was 12.5 mo and the 3 year and 5 year survival rates were 14.6% and 5.3%, respectively. Long-term survival of more than 3 and 5 years was observed in 65 and 16 patients, respectively. The MST for the 65 patients was 61.5 mo (range, 60.1-81.0 mo). In the 474 patients, a good performance status (PS), female sex, non-smoking status and adenocarcinoma histology were significantly associated with a favorable outcome. Furthermore, female sex, a good PS, non-smoking status and adenocarcinoma histology were significantly correlated with long-term survival of more than 3 years and most of these patients (89.2%, 58/65) received epidermal growth factor receptor-tyrosine kinase inhibitors as any line treatment. Survival analysis of long-term survivors showed that a PS of 0 was an independent prognostic factor for predicting favorable outcomes.

CONCLUSION: Our results suggest that a good PS and adenocarcinoma histology play an important role in long-term survival of more than 3 years. A PS of 0 was an independent prognostic factor for predicting favorable outcomes in patients with advanced NSCLC who survived for more than 3 years.

Are the data on quality of life and patient reported outcomes from clinical trials of metastatic non-small-cell lung cancer important?

Majority of the patients with advanced non-small-cell lung cancer (NSCLC) experience two or more disease related symptoms, which may have a negative impact on their health-related quality of life (HR QOL). These patients prefer a therapy that would improve disease related symptoms, as opposed or treatment that slightly prolongs their survival without improving symptoms. The improvements of the symptoms augment the significance of improved response rates or progression free survivals. The choice of the questionnaires to evaluate patients-reported outcomes (PROs) and HRQOL benefits and methods of collecting the data and their interpretations are very important and are discussed in this manuscript. PROs and HR QOL outcomes are important in patients with advanced NSCLC only when the data are collected and analyzed correctly. Then they can be viewed as components of the total value of a treatment, providing a comprehensive picture of the benefits and risks of anticancer therapies. Enabling the patients to feel during the last months of their lives more comfortable and not be dependent on their loved ones is a very important task in the treatment of advanced NSCLC.

Outcomes of patients with unresected stage III and stage IV non-small cell lung cancer: A single institution experience

Introduction:

To report on the demographic profile and survival outcomes of North Indian population affected with stage III and stage IV non-small cell lung cancer (NSCLC).

Materials and Methods:

From November 2008 to January 2012, 138 consecutively diagnosed NSCLC patients were included in this study. The patient, tumor and treatment related factors were analyzed. Median overall survival (OS), Kaplan-Meier survival plots, t-test, Cox proportional hazards models were generated by multivariate analysis [MVA]) and analyzed on SPSS software (version 19.0; SPSS, Inc., Chicago, IL).

Results:

Median OS of stage III patients was 9.26 ± 1.85 months and 2-year survival rate of 13% while stage IV patients had median OS of 5 ± 1.5 months with a 2-year survival rate of 8%. Cox regression modeling for MVA demonstrated higher biologically equivalent dose (BED) (P = 0.01) in stage III while in stage IV non-squamous histology (P = 0.01), administration of chemotherapy (P = 0.02), partial responders to chemotherapy (P = 0.001), higher BED (P = 0.02), and those with skeletal metastasis alone (P = 0.17) showed a better OS.

Conclusion:

Our data showed that a higher BED is associated with favorable outcomes, indicating a role of dose escalated radiation therapy to the primary lesion in both stage III and essentially in stage IV NSCLC. Additionally, optimal use of chemotherapy relates to better survival. The developing, resource restrained nations need to follow an economically feasible multimodality approach.

Phase II study of oral S-1 plus cisplatin with bevacizumab for advanced non-squamous non-small cell lung cancer

BACKGROUND

We conducted a phase II study to evaluate the efficacy and safety of S-1 plus cisplatin with bevacizumab followed by maintenance bevacizumab in patients with advanced non-squamous non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemotherapy-naïve patients received S-1 plus cisplatin with bevacizumab. S-1 (80 mg/m(2)) was administered orally twice daily for 14 days, cisplatin (60 mg/m(2)) on day 1, and bevacizumab (15 mg/kg) on day 1 and every 3 weeks for 4-6 cycles. Patients with an objective response or stable disease received maintenance bevacizumab every 3 weeks until disease progression.

RESULTS

Thirty patients were enrolled in this study. The median number of chemotherapy was four (range, 1-6 cycles), and the median number of bevacizumab alone was three (range, 1-31 cycles). The grade 3/4 toxicities were neutropaenia (23%), thrombocytopaenia (10%), febrile neutropaenia (3%), hypertension (17%), pneumonia (7%), and bowel perforation (3%). The objective response rate was 71% (95% CI, 55-88%) for a disease control rate of 100%. The median progression-free and overall survival times were 7.0 months and 20.0 months, respectively.

CONCLUSIONS

S-1 plus cisplatin with bevacizumab is an active and well-tolerated regimen in patients with chemotherapy-naïve non-squamous NSCLC.

ACR appropriateness criteria nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent

Radiation therapy plays a potential curative role in the treatment of patients with non-small-cell lung cancer with locoregional disease who are not surgical candidates and a palliative role for patients with metastatic disease. Stereotactic body radiation therapy is a relatively new technique in patients with early-stage non-small-cell lung cancer. A trial from RTOG(®) reported >97% local control at 3 years. For patients with locally advanced disease, thoracic radiation to a dose of 60 Gy remains the standard of care. Sequential chemotherapy or radiation alone can be used for patients with poor performance status who cannot tolerate more aggressive approaches. Chemotherapy should be used for patients with metastatic disease. Radiation therapy is useful for palliation of symptomatic tumors, and a dose of approximately 30 Gy is commonly used. Endobronchial brachytherapy is useful for patients with symptomatic endobronchial tumors. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Treatment of stage IV non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Stage IV non-small cell lung cancer (NSCLC) is a treatable, but not curable, clinical entity in patients given the diagnosis at a time when their performance status (PS) remains good.

METHODS

A systematic literature review was performed to update the previous edition of the American College of Chest Physicians Lung Cancer Guidelines.

RESULTS

The use of pemetrexed should be restricted to patients with nonsquamous histology. Similarly, bevacizumab in combination with chemotherapy (and as continuation maintenance) should be restricted to patients with nonsquamous histology and an Eastern Cooperative Oncology Group (ECOG) PS of 0 to 1; however, the data now suggest it is safe to use in those patients with treated and controlled brain metastases. Data at this time are insufficient regarding the safety of bevacizumab in patients receiving therapeutic anticoagulation who have an ECOG PS of 2. The role of cetuximab added to chemotherapy remains uncertain and its routine use cannot be recommended. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors as first-line therapy are the recommended treatment of those patients identified as having an EGFR mutation. The use of maintenance therapy with either pemetrexed or erlotinib should be considered after four cycles of first-line therapy in those patients without evidence of disease progression. The use of second- and third-line therapy in stage IV NSCLC is recommended in those patients retaining a good PS; however, the benefit of therapy beyond the third-line setting has not been demonstrated. In the elderly and in patients with a poor PS, the use of two-drug, platinum-based regimens is preferred. Palliative care should be initiated early in the course of therapy for stage IV NSCLC.

CONCLUSIONS

Significant advances continue to be made, and the treatment of stage IV NSCLC has become nuanced and specific for particular histologic subtypes and clinical patient characteristics and according to the presence of specific genetic mutations.

Identifying the target NSCLC patient for maintenance therapy: an analysis from a placebo-controlled, phase III trial of maintenance pemetrexed (H3E-MC-JMEN)

Background

This was a post hoc analysis of patients with non-squamous histology from a phase III maintenance pemetrexed study in advanced non-small cell lung cancer (NSCLC).

Patients and methods

The six symptom items' [average symptom burden index (ASBI)] mean at baseline was calculated using the lung cancer symptom scale (LCSS). Low and high symptom burden (LSB, ASBI < 25; HSB, ASBI ≥ 25) and performance status (PS: 0, 1) subgroups were analyzed for treatment effect on progression-free survival (PFS) and overall survival (OS) using the Cox proportional hazard models adjusted for demographic/clinical factors.

Results

Significantly longer PFS and OS for pemetrexed versus placebo occurred in LSB patients [PFS: median 5.1 versus 2.4 months, hazard ratio (HR) 0.49, P < 0.0001; OS: median 17.5 versus 11.0 months, HR 0.63, P = 0.0012] and PS 0 patients (PFS: median 5.5 versus 1.7 months, HR 0.36, P < 0.0001; OS: median 17.7 versus 10.3 months, HR 0.54, P = 0.0019). Significantly longer PFS, but not OS, occurred in HSB patients (median 3.7 versus 2.8 months, HR 0.50, P = 0.0033) and PS 1 patients (median 4.4 versus 2.8 months, HR 0.60, P = 0.0002).

Conclusions

ASBI and PS are associated with survival for non-squamous NSCLC patients, suggesting that maintenance pemetrexed is useful for LSB or PS 0 patients following induction.

Radiation therapy is well tolerated and produces excellent control rates in elderly patients with locally advanced head and neck cancers

PURPOSE

Management of locally advanced head and neck cancer (LAHNC) in the elderly is challenging due to multiple co-morbidities, poor organ function and performance status. The aim of this study was to evaluate efficacy of radiation therapy (RT) in elderly patients, defined as 65 years and older, with high-risk LAHNC.

MATERIALS AND METHODS

An IRB approved retrospective chart review of elderly patients was performed, of whom 73 patients were selected for analysis. The stages included were II/III-IV. Sites included were oropharynx, oral cavity, larynx, salivary gland, nasopharynx, nasal cavity, paranasal sinus, hypopharynx and unknown primary.

RESULTS

Median age was 74 years. Thirty nine (53%) patients received concurrent chemotherapy. Median time to completion of RT was 53 days. Median external beam radiotherapy (EBRT) dose was 66 Gy. With a median follow-up of 24 months, overall local control (LC) was 80% and distant metastasis (DM) was 12%. Sixty patients (82%) were alive at the time of study. Two-year overall survival (OS) was 96% (95% CI=87%, 99%). Chemotherapy did not improve LC [80% (chemo) vs 79% (no chemo), p=0.88] or DM [11% (chemo) vs 14% (no chemo), p=0.73]. Interestingly, patients receiving RT using intensity-modulated radiation therapy (IMRT) had a significantly higher rate of LC vs three-dimensional conformal radiotherapy (3DCRT) (94% vs 68%, respectively, p=0.008). Grade 2/3 toxicity was seen in 70/73 (96%) patients while grade 4 toxicity was seen in three patients (4%).

CONCLUSION

Elderly patients with LAHNC have high rates of LC and OS. Prospective studies can reveal more insight into this increasingly important clinical problem in elderly patients.

Metabolic Tumor Volume Measured by F-18 FDG PET/CT can Further Stratify the Prognosis of Patients with Stage IV Non-Small Cell Lung Cancer

PURPOSE

This study aimed to further stratify prognostic factors in patients with stage IV non-small cell lung cancer (NSCLC) by measuring their metabolic tumor volume (MTV) using F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT).

MATERIALS AND METHODS

The subjects of this retrospective study were 57 patients with stage IV NSCLC. MTV, total lesion glycolysis (TLG), and maximum standardized uptake value (SUVmax) were measured on F-18 FDG PET/CT in both the primary lung lesion as well as metastatic lesions in torso. Optimal cutoff values of PET parameters were measured by receiver operating characteristic (ROC) curve analysis. Kaplan-Meier survival curves were used for evaluation of progression-free survival (PFS). The univariate and multivariate Cox proportional hazards models were used to select the significant prognostic factors.

RESULTS

Univariate analysis showed that both MTV and TLG of primary lung lesion (MTV-lung and TLG-lung) were significant factors for prediction of PFS (P < 0.001, P = 0.038, respectively). Patients showing lower values of MTV-lung and TLG-lung than the cutoff values had significantly longer mean PFS than those with higher values. Hazard ratios (95 % confidence interval) of MTV-lung and TLG-lung measured by univariate analysis were 6.4 (2.5-16.3) and 2.4 (1.0-5.5), respectively. Multivariate analysis revealed that MTV-lung was the only significant factor for prediction of prognosis. Hazard ratio was 13.5 (1.6-111.1, P = 0.016).

CONCLUSION

Patients with stage IV NSCLC could be further stratified into subgroups of significantly better and worse prognosis by MTV of primary lung lesion.

Prevalence and characteristics of patients with metastatic cancer who receive no anticancer therapy

BACKGROUND

A subset of patients who present with metastatic solid tumors never receive anticancer therapy. Reasons may include poor functional status, comorbidities, and patient preference. To the authors' knowledge, the prevalence and characteristics of this population have not previously been described.

METHODS

The National Cancer Data Base was queried for patients diagnosed with metastatic (stage IV according to the American Joint Committee on Cancer) solid tumors (including those of the breast, cervix, colon, and kidney; small cell and nonsmall cell lung cancer [NSCLC]; and tumors of the prostate, rectum, and uterus) who received neither radiotherapy nor systemic therapy. Log-binomial regression analysis was used to estimate prevalence ratios (PRs) for the percentage of untreated to treated patients with stage IV cancer.

RESULTS

Between 2000 and 2008, 773,233 patients with stage IV cancer were identified, 159,284 of whom (20.6%; 95% confidence interval, 20.5%-20.7%) received no anticancer therapy. Patients with NSCLC accounted for 55% of the untreated population. Patients with cancers of the kidney and lung had the highest rates of no treatment at 25.5% and 24.0%, respectively, whereas patients with prostate cancer had the lowest rate of no treatment at 11.1%. Across all cancer types, older age (PR range, 1.37-1.49; all P < .001), black race (PR range, 1.05-1.32; all P < .001), lack of medical insurance (PR range, 1.47-2.46; all P < .001), and lower income (except for cancer of the uterus; PR range, 0.91-0.98 for every $10,000-increase in income [all P < .001]) were associated with a lack of treatment.

CONCLUSIONS

Approximately 20% of patients who present with stage IV solid tumors do not receive anticancer therapy. Although there are likely multiple reasons for this lack of treatment, including appropriate indications, these findings have potential implications with regard to health care policy and access to care.

Independent prognostic value of whole-body metabolic tumor burden from FDG-PET in non-small cell lung cancer

PURPOSE

To determine whether whole-body metabolic tumor burden, measured as either metabolic tumor volume (MTVWB) or total lesion glycolysis (TLGWB), using FDG-PET/CT is an independent prognostic marker in non-small cell lung cancer (NSCLC).

METHODS

328 patients with histologically proven NSCLC were identified for this retrospective analysis. This study was approved by our Institutional Review Board. All patients underwent baseline (18)F-FDG-PET/CT scan imaging before therapy. The MTVWB, TLGWB, maximum standardized uptake value (SUVmaxWB) and mean standardized uptake value (SUVmeanWB) of tumors throughout the whole body were measured from FDG-PET images with semi-automated 3D contouring software.

RESULTS

In univariate analysis, there was a statistically significant association of overall survival (OS) with the MTVWB (hazard ratio (HR) = 1.62, p < 0.001), TLGWB (HR = 1.47, p < 0.001). The patients with a MTVWB ≤ median of 65.7 ml and TLGWB ≤ median of 205.11 SUVmean * ml had a median OS of 41.1 and 35.4 months compared with 9.5 and 9.7 months for those with a MTVWB > 65.7 ml and TLGWB > 205.11 SUVmean * ml, respectively. From a series of multivariate Cox regression models, the MTVWB and TLGWB were significantly better than SUVmaxWB and SUVmeanWB at prognostication and significantly associated with patients' OS with HRs of 1.50 (p < 0.001) and 1.42 (p < 0.001), respectively, after adjustment for patient's age, gender and treatment intent as well as the tumor SUVmaxWB, histology and stage.

CONCLUSIONS

MTVWB and TLGWB as metabolic tumor burden measurements in (18)F-FDG-PET/CT are independent prognostic markers and are significantly better than SUVmaxWB and SUVmeanWB at prognostication.

Erlotinib in salvage treatment of patients with advanced non-small cell lung cancer: results of an expanded access programme in Poland

Aim of the study

Erlotinib and gefitinib are reversible EGFR-TKI administered orally. Results of the phase III study JBR.21 proved the clinical efficacy of erlotinib-based regimens as second- or third-line treatment of advanced NSCLC. We analyze efficacy of treatment with erlotinib in patients suffering from advanced stage NSCLC who participated in the multicentre, international phase IV study – MO 18109 TRUST (expanded access clinical program of Tarceva™ in patients with advanced stage IIIB/IV NSCLC). Our analysis was performed based on clinical data derived from centres with the largest number of patients who received erlotinib.

Material and methods

Between May and November 2005, a total of 56 patients (19 women and 37 men) with histologic or cytologic diagnosis of NSCLC were included in the study. The histological diagnosis was: squamous-cell (n = 23), adenocarcinoma (n = 20), broncho-alveolar carcinoma (n = 2). In 11 patients the type of NSCLC was not specified.

Results

Patients received erlotinib in a single dose of 150 mg per day. Partial response (PR), stable disease (SD) or progressive disease (PD) were observed in 5 (9%), 33 (59%) and 16 (29%) patients respectively. Median PFS was 16.0 weeks. In the study population adverse events (AE) were noted in 12 (21%) patients.

Conclusions

Results of the TRUST study in the Polish population confirmed the efficacy of erlotinib in advanced NSCLC after failure of prior platinum-based chemotherapy. Treatment with erlotinib was associated with longer PFS as compared to the JBR.2 study, whole TRUST study population and Italian population included in the TRUST study.

The Evolving Role of Maintenance Therapy Using Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors (EGFR TKIs) in the Management of Advanced Non-Small-Cell Lung Cancer

The epidermal growth factor receptor (EGFR) plays an important role in the development of many cancers, including non-small cell lung cancer. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) are a class of novel biologically-targeted agents widely used in the management of recurrent non-small cell lung cancer. Erlotinib, one of the EGFR TKIs, is currently FDA approved in second and third line therapy. However, recent studies showed that erlotinib is also effective as maintenance therapy after initial chemotherapy, improving disease free survival and possibly overall survival. Our current understanding of erlotinib's mechanism of action, with the discovery that EGFR mutation confers higher response rate, has propelled this agent into the first line setting. Advances in molecular testing and clinical research of this agent and other agents in this class will eventually change the way we utilize EGFR TKIs in the near future.

Hepatic arterial therapy with drug-eluting beads in the management of metastatic bronchogenic carcinoma to the liver: a multi-institutional registry

Introduction. There has been limited information reported on the use of hepatic arterial therapy in liver dominant hepatic metastases arising from lung cancer. The aim of this study was to evaluate the safety and efficacy of hepatic arterial therapy in the treatment of liver dominant hepatic metastases arising from lung cancer. Methods. Thirteen patients underwent a total of 30 treatment sessions with Drug-Eluting Beads. Eight of the thirteen received only doxorubicin DEB (17 of the total treatments), and four patients received Irinotecan DEB (7 of the total treatments). Results. The planned preprocedural dosage was a median of 75 mg (range 19–200), with total hepatic dose exposure being a median of 150 mg (range 0–458), with a technical success rate of 97% in all 29 treatments. There were 4 adverse events related to treatment, but no evidence of hepatic insufficiency. Overall 6-month and 12-month response rates were 50%. After a median followup of 24 months, the median overall survival in this cohort was 14 months (range 7–48 months). Conclusion. Drug-eluting beads loaded with doxorubicin (DEBDOX) or irinotecan (DEBIRI) can be safely and effectively used in treatment of patients with liver predominant metastatic disease from lung cancer.

Prognostic value of the quantitative metabolic volumetric measurement on 18F-FDG PET/CT in Stage IV nonsurgical small-cell lung cancer

RATIONALE AND OBJECTIVES

Stage IV non-small-cell lung cancer (NSCLC) consists of a heterogeneous group of patients with different prognoses. We assessed the prognostic value of baseline whole body tumor burden as measured by metabolic tumor volume (MTV), total lesion glycolysis (TLG), and standardized uptake values (SUV(max) and SUV(mean)) of all tumors in nonsurgical patients with Stage IV NSCLC.

MATERIALS AND METHODS

Ninety-two consecutive patients with newly diagnosed Stage IV NSCLC who had a pretreatment F-18 fludeoxyglucose positron emission tomography/computed tomography scan were retrospectively reviewed. The MTV, TLG, SUV(mean), and SUV(max) of whole-body (WB) tumors were measured with the MIMvista workstation with manual adjustment.

RESULTS

There was a statistically significant association between overall survival (OS) and ln(MTV)/ln(TLG) at the level of WB tumor burden (MTV(WB)) and of primary tumor (MTV(T)). The hazard ratio (HR) for a 1-unit increase of ln(MTV(WB)) and ln(MTV(T)) before and after adjusting for age and gender was 1.48/1.48 (both P < .001) and 1.25/1.25 (P = .006, .007), respectively. The HR for a 1-unit increase of ln(TLG(WB)) and ln(TLG(T)) before and after adjusting for age and gender was 1.37/1.37 (both P = .001) and 1.19/1.19 (P = .001, .017), respectively. There was no statistically significant association between OS and ln(SUV(max)) and ln(SUV(mean)) at WB tumor burden, primary tumor, nodal metastasis, or distant metastasis (P > .05). There was low interobserver variability between two radiologists with concordance correlation coefficients of 0.90 for ln(MTV(WB)) and greater than 0.90 for SUV(maxWB), SUV(meanWB), and ln(TLG(WB)).

CONCLUSION

Baseline WB metabolic tumor burden, as measured with MTV and TLG, is a prognostic measurement in patients within Stage IV NSCLC with low interobserver variability. This study also suggests pretreatment MTV and TLG measurements may be used to further stratify patients with Stage IV NSCLC and are better prognostic measures than SUV(max) and SUV(mean) measurements.

Immediate Versus Delayed Treatment with EGFR Tyrosine Kinase Inhibitors after First-line Therapy in Advanced Non-small-cell Lung CANCER

OBJECTIVE

To analyze the outcomes of patients who received TKI immediately after the first-line without progression as maintenance treatment (immediate group) vs. those received delayed treatment upon disease progression as second-line therapy (delayed group).

METHODS

The study included 159 no-small-cell lung cancer (NSCLC) patients who received gefitinib or erlotinib as maintenance treatment in the immediate group (85 patients) or as second-line therapy in the delayed group (74 patients). The primary end point was progression-free survival (PFS). EGFR mutation status was detected using denaturing high-performance liquid chromatography (DHPLC).

RESULTS

PFS was 17.3 and 16.4 months in the immediate and delayed groups, respectively (hazard ratio [HR], 0.99; 95% Confidence Interval [CI]: 0.69-1.42; P=0.947). In a subgroup analysis that included only patients with EGFR mutation, however, PFS was significantly longer in the immediate group than in the delayed group (HR, 0.48; 95% CI: 0.27-0.85; P=0.012). In patients with wild type EGFR, the risk for disease progression was comparable between the two groups (HR, 1.23; 95% CI: 0.61-2.51; P=0.564). No significant difference was demonstrated between the immediate and delayed group in terms of the overall survival (OS) (26.1 months vs. 21.6 months, respectively; HR=0.53; 95% CI: 0.27 to 1.06; P=0.072). There was also no difference in the incidence of adverse events between the two groups.

CONCLUSIONS

EGFR TKI maintenance improves PFS in patients with EGFR mutation. Prospectively designed clinical studies that compare TKI immediate vs. delayed treatment after first-line chemotherapy upon disease progression are needed.