Nonsurgical combined modality therapies in non-small cell lung cancer

Modified weekly regimen with vinorelbine as a single agent in unresectable non-small cell lung cancer

After a 26% response rate was reported with a 20/mg/m2/week vinorelbine (VRL) dose, a multicenter phase II trial of a modified weekly VRL treatment protocol (30 mg/m2 days 1 and 8 every 21 days) for unresectable non-small cell lung cancer (NSCLC) was designed to determine its clinical activity, toxicity, and survival of treated patients. As myelotoxicity frequently precludes the administration of VRL, by suppressing the dose that would correspond to day 15 of a weekly protocol, we allowed bone marrow recovery to take place and avoided the administration of the drug at the nadir of the cycle. The trial included 71 consecutive, previously untreated patients with unresectable and measurable disease. A total of 297 three-week treatment courses were administered with an average of 4 courses per patient (range 1-11). Results showed that in spite of attaining a median dose intensity of 19 mg/m2/week, this modified weekly VRL treatment regimen has a low level of activity (7.5% response rate) in NSCLC. Although a more tolerable level of toxicity is achieved, in order to maintain its antitumor activity, the recommended dose of VRL when given alone for NSCLC treatment (30 mg/m2/weekly) should not be decreased.

A phase II study of cisplatin, 5-fluorouracil, leucovorin, and etoposide in advanced non-small-cell lung cancer

The aim of this study was to define the efficacy of a combination of cisplatin, 5-fluorouracil (5-FU), leucovorin, and etoposide (VP-16) in locally advanced or metastatic non-small-cell lung cancer (NSCLC). From September 1991 to November 1994, 28 patients were treated with cisplatin, 100 mg/m2 i.v. on day 1; 5-FU and leucovorin, 500 mg/m2 on days 1, 2, 3, and 4 by i.v. continuous infusion; and VP-16, 70 mg/m2 i.v. on days 1, 2, 3, and 4 (combination, PFL-VP-16). Cycles were repeated every 3 weeks. There were 22 men and six women. The median age was 58 (range, 41-76). All had measurable diseases (one was stage IIIA, six were IIIB, and 21 were IV). None had previously received chemotherapy for metastatic disease. There was one complete response and six partial responses, for an overall response rate of 25% (95% confidence interval 9-41%). The median response duration and the overall survival were 8 and 9 months, respectively. Limiting toxicity was myelosuppression and oral mucositis. Grade 3 or 4 leucopenia was observed in 20% of all of the 95 cycles administered, and oral mucositis in 13%. No grade 3 or 4 renal toxicity occurred, and neurologic toxicities were limited (3% of the 28 patients experienced grade 3). PFL-VP-16 is active and can easily be administered to patients with advanced NSCLC. However, according to the results obtained with this schedule, VP-16 does not increase either response rate or survival compared with the regimen previously described by Vokes et al. (PFL).

Multicenter Phase II trial of intermediate dose cisplatin and vinorelbine in inoperable non-small cell lung cancer patients

Vinorelbine (VNB) and cisplatin (CDDP) combination regimen was found active in the treatment of advanced non-small cell lung cancer (NSCLC) patients, but significant toxicity was observed. We evaluated the activity and toxicity of this combination administered at lower doses than previously reported. From March 1992 to March 1994, 99 patients (pts) were enrolled in a multicentric Phase II study and received intravenous CDDP at 80 mg/m2 on day 1, associated with intravenous VNB at 25 mg/m2 on days 1 and 8. Cycles were repeated every 3 weeks. The reduced doses led to a consistently lower myelotoxicity (8% Grade III-IV leukopenia) in comparison to two related Phase III studies, recently published. Conversely, the incidence of neurological toxicity was superimposable. Considering all eligible patients, the overall response rate was 28.3%, and this is similar to the results commonly observed employing the most active CDDP containing regimens. In conclusion, CDDP and VNB combination chemotherapy at the schedule performed in the present study led to a reduction of hematologic toxicity, while an appreciable activity was maintained.

The antitumor activity of radiation therapy is reduced in patients with non-small-cell carcinoma of the lung refractory to chemotherapy

Some in vitro studies demonstrate cross-resistance between chemotherapy (CT) and radiation therapy (RT) but there is no in vivo data showing the same effect. Several studies have estimated the response rate to chemotherapy following radiation, but the question of radiation responsiveness in chemotherapy-refractory tumors has not been examined. Between 1982 and 1988, 162 patients with stage IIIA, IIIB and IV non-small-cell lung cancer (NSCLC) received chemotherapy on various protocols at the National Cancer Center. All were treated until progression or the occurrence of unacceptable toxicity. Forty patients developed local progression on chemotherapy and were given radiation therapy (50 to 60 Gy). Nine responders (22.5%: 95% confidence limit, 9.5-35.5%) were seen in this group, a rate substantially lower than was to be expected with primary radiation treatment. The univariate logistic regression analysis with RT response as the outcome demonstrated that there was significant heterogeneity in response for T and N status between responders and non-responders. Also the odd ratio for radiation dose was strong (OR = 0.20), indicating that a low dose was less likely to produce response although this was not statistically significant. Hematologic toxicity was mild, but 11 patients (27.5%) developed evidence of acute radiation pneumonitis. These results suggest that some chemotherapy-refractory NSCLC may show cross-resistance to radiation therapy which consequently has marginal antitumor activity in this setting.

Phase I-II study of vinorelbine (Navelbine) plus cisplatin in advanced non-small cell lung cancer

32 patients with advanced non-small cell lung cancer previously untreated by chemotherapy were included in a phase I-II study in order to determine the feasibility of the combination of vinorelbine and cisplatin, each administered at its optimal dose, i.e. 30 mg/m2 weekly and 120 mg/m2 every 4-6 weeks, respectively. There were 27 males and 5 females with a mean age of 55 years and a median performance status of 80%. 13 had locally advanced disease and 19 had distant metastases at the time of inclusion. Our study demonstrated the feasibility of this protocol. Dose intensities could be maximised by adapting vinorelbine doses rather than by postponing treatment in the event of neutropenia. Both response rate (33%) and overall survival of the population (median 11 months) justify further studies.

A randomized prospective study of radiation versus radiation plus ACNU in inoperable non-small cell carcinoma of the lung. Japan Radiation-ACNU Study Group

Between February 1983 and January 1986, 77 evaluable patients with non-small cell lung cancer were randomized to receive radiotherapy with or without nimustine hydrochloride (ACNU) according to a centralized resistration system using a telephone call. The randomization was for radiation 50 to 60 Gy/5 to 6 weeks with or without ACNU (30 mg/m2 x 4 times) during irradiation. There were no significant differences in the patient characteristics of either group. The complete response rates to both regimens were statistically significantly different: 55% in radiation plus ACNU and 13.6% in radiation alone for squamous cell carcinoma. In addition, there were statistically significant differences in Stage III. The median survival time for radiation plus ACNU was 47.7 weeks, compared with 41.9 weeks for radiation alone. Overall survival did not significantly differ in either group. There was a significant decrease in the incidence of leukocyte nadirs below 2000/ml (5.7%) and platelet 50,000/ml (14.3%) with ACNU. This study confirmed that radiation with ACNU in the treatment of non-small cell lung cancer was effective and superior as compared to radiation alone.