Randomized phase III trial of cisplatin/irinotecan versus cisplatin/etoposide in patients with extensive-stage small-cell lung cancer

Randomized phase 2 study comparing irinotecan versus amrubicin as maintenance therapy after first-line induction therapy for extensive disease small cell lung cancer (HOT1401/NJLCG1401)

Background

A cisplatin plus irinotecan (CPT‐11) regimen is used for patients with extensive disease small cell lung cancer (ED‐SCLC). Amrubicin (AMR) is primarily used for relapsed SCLC. The HOT1401/NJLCG1401 trial, an open‐label randomized phase II trial, was designed to assess the benefit of maintenance therapy in patients with ED‐SCLC who responded to induction therapy.

Methods

Patients with histologically‐ or cytologically‐confirmed ED‐SCLC were included and were treated with an induction therapy of four cycles of cisplatin (60 mg/m² on day 1) plus CPT‐11 (60 mg/m² on days 1, 8, and 15) every four weeks. After induction therapy, patients who had nonprogressive disease were randomized to receive either maintenance CPT‐11 (60 mg/m² on days 1 and 8) every three weeks, or AMR (35 mg/m² on days 1–3) every three weeks.

Results

A total of 34 patients were enrolled; 20 patients had progressive disease or received incomplete induction chemotherapy. Finally, 14 patients were randomly assigned to receive CPT‐11 (n = 7) or AMR (n = 7). This study was terminated prematurely because of low patient accrual. The overall objective response rate was 73%, the median PFS was 5.7 months (95% confidence interval [CI]: 3.6–11.8), and the median overall survival was 20.1 months (95% CI: 13.7–not reached). No statistically significant difference in progression‐free survival (PFS) were noted between patients treated with CPT‐11 and those treated with AMR. There were no treatment‐related deaths in this study.

Conclusions

Maintenance therapy with CPT‐11 or AMR after induction therapy might be effective in some patients.

Randomized-controlled phase II trial of salvage chemotherapy after immunization with a TP53-transfected dendritic cell-based vaccine (Ad.p53-DC) in patients with recurrent small cell lung cancer

Small cell lung cancer TP53 mutations lead to expression of tumor antigens that elicits specific cytotoxic T-cell immune responses. In this phase II study, dendritic cells transfected with wild-type TP53 (vaccine) were administered to patients with extensive-stage small cell lung cancer after chemotherapy. Patients were randomized 1:1:1 to arm A (observation), arm B (vaccine alone), or arm C (vaccine plus all-trans-retinoic acid). Vaccine was administered every 2 weeks (3 times), and all patients were to receive paclitaxel at progression. Our primary endpoint was overall response rate (ORR) to paclitaxel. The study was not designed to detect overall response rate differences between arms. Of 69 patients enrolled (performance status 0/1, median age 62 years), 55 were treated in stage 1 (18 in arm A, 20 in arm B, and 17 in arm C) and 14 in stage 2 (arm C only), per 2-stage Simon Minimax design. The vaccine was safe, with mostly grade 1/2 toxicities, although 1 arm-B patient experienced grade 3 fatigue and 8 arm-C patients experienced grade 3 toxicities. Positive immune responses were obtained in 20% of arm B (95% confidence interval [CI], 5.3-48.6) and 43.3% of arm C (95% CI 23.9-65.1). The ORRs to the second-line chemotherapy (including paclitaxel) were 15.4% (95% CI 2.7-46.3), 16.7% (95% CI 2.9-49.1), and 23.8% (95% CI 9.1-47.5) for arms A, B, and C, with no survival differences between arms. Although our vaccine failed to improve ORRs to the second-line chemotherapy, its safety profile and therapeutic immune potential remain. Combinations with the other immunotherapeutic agents are reasonable options.

Comparing the adverse effects of platinum in combination with etoposide or irinotecan in previously untreated small-cell lung cancer patients with extensive disease: A network meta-analyses

BACKGROUND

The safety of front-line chemotherapies for the treatment of extensive stage small-cell lung cancer (ED-SCLC) is uncertain. We carried out a network meta-analysis to compare the toxicity of different therapies for ED-SCLC.

METHODS

We searched EMBASE, PubMed, CENTRAL and clinicaltrials.gov. We performed network meta-analysis on hematological (anemia, leukopenia, neutropenia, and thrombocytopenia) and non-hematological toxicities (diarrhea, infection, and nausea and vomiting).

RESULTS

Nine studies with 2317 patients were included. Etoposide with carboplatin (EC) was associated with a higher incidence of anemia (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.13-3.63), leukopenia (OR 2.67, 95% CI 1.25-5.72), neutropenia (OR 12.08, 95% CI 2.13-68.66), and thrombocytopenia (OR 2.73, 95% CI 1.27-5.85) compared with irinotecan with carboplatin (IC). Similarly, etoposide with cisplatin (EP) was associated with a higher incidence of anemia (OR 1.70, 95% CI 1.13-2.56), leukopenia (OR 2.65, 95% CI 1.34-5.28), neutropenia (OR 5.70, 95% CI 2.93-11.10), and thrombocytopenia (OR 3.26, 95% CI 1.66-6.38) compared with irinotecan with cisplatin (IP). EC was associated with a lower incidence of diarrhea (OR 0.26, 95% CI 0.10-0.68) compared with IC, and EP was associated with a lower incidence of diarrhea (OR 0.09, 95% CI 0.03-0.25) and nausea and vomiting (OR 0.53, 95% CI 0.33-0.84) than IP.

CONCLUSIONS

Hematological toxicities were most common in EC-treated patients, while the lowest incidence occurred with IP treatment. The IP regimen was associated with the highest incidence of toxicities of the digestive tract, while the lowest incidence occurred with EC treatment.

[First-line Chemotherapy for Extensive-disease Small Cell Lung Cancer: A Network Meta-analysis]

BACKGROUND

Regimens that combine irinotecan or etoposide with cisplatin or carboplatin have been recommended as first-line regimen for extensive-disease small cell lung cancer (ED-SCLC). In our network meta-analysis, we synthesized the direct and indirect lines of evidence to rank the short-term efficacies of these recommended chemotherapy regimens.

METHODS

We searched databases, including EMBASE, PubMed, CENTRAL and clinicaltrial.gov, for relevant randomized controlled trials (RCTs) that compared the efficacies of these treatments. A risk of bias tool was used to evaluate the quality of the included studies, whereas Stata 13.1 was used for statistical synthesis.

RESULTS

Our study included 10 RCTs that involved 2,378 patients. Compared with that of the regimen that combined etoposide and carboplatin, the complete remission rate was significantly higher in the group treated with irinotecan combined with carboplatin. The efficacy of the regimen that combined irinotecan with carboplatin was significantly superior over that of the combination of etoposide and cisplatin.

CONCLUSIONS

Our data presented here suggest that the effect of Irinotecan combination with Carboplatin is remarkably superior.

Platinum versus non-platinum chemotherapy regimens for small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a very fast growing form of cancer and is characterised by early metastasis. As a result, chemotherapy is the mainstay of treatment. A number of different platinum-based chemotherapy regimens and non-platinum-based chemotherapy regimens have been used for the treatment of SCLC, with varying results. This review was conducted to analyse the data from these studies in order to compare their effectiveness.

OBJECTIVES

To determine the effectiveness of platinum chemotherapy regimens compared with non-platinum chemotherapy regimens in the treatment of SCLC with respect to survival, tumour response, toxicity and quality of life.

SEARCH METHODS

We searched the biomedical literature databases CENTRAL (TheCochrane Library 2014, Issue 7), MEDLINE, EMBASE and CINAHL from 1966 to August 2014. In addition, we handsearched reference lists from relevant resources.

SELECTION CRITERIA

All randomised controlled trials involving patients with pathologically confirmed SCLC (including both limited-stage disease and extensive-stage disease) and the use of a platinum-based chemotherapy regimen in at least one treatment arm and a non-platinum-based chemotherapy regimen in a separate arm.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. Two authors independently assessed search results. We assessed included studies for methodological quality and recorded the following outcome data: survival, tumour response, toxicity and quality of life. We combined the results of the survival, tumour response and toxicity data in a meta-analysis. Quality-of-life data were analysed individually.

MAIN RESULTS

A total of 32 studies involving 6075 patients with SCLC were included in this systematic review. The majority of studies were multi-centre randomised controlled trials conducted throughout Europe, North America and Asia with the earliest study publishing data in 1981 and the latest in 2014. The duration of studies ranged from 12 to 72 months with a median of 32 months. The median age of patients in the vast majority of studies was between 60 and 65 years of age. Eighteen studies presented data on extensive-stage disease. Nine studies presented data on limited-stage disease. Eleven studies did not present data based on the disease stage. These data were analysed separately in subgroup analyses. Sixteen (50%) studies were of good quality with a low risk of bias and the data from these studies were analysed separately in a heterogeneity analysis.There was no statistically significant difference between treatment groups in terms of survival at 6 months, 12 months and 24 months. There was also no statistically significant difference in terms of overall tumour response. However, platinum-based treatment regimens did have a significantly higher rate of complete response. Platinum-based chemotherapy regimens had significantly higher rates of nausea and vomiting and thrombocytopenia toxicity. Four trials presented quality-of-life data, but, due to the different systems used to measure quality of life this data could not be combined in a meta-analysis.

AUTHORS' CONCLUSIONS

Platinum-based chemotherapy regimens did not offer a statistically significant benefit in survival or overall tumour response compared with non-platinum-based regimens. However, platinum-based chemotherapy regimens did increase complete response rates, at the cost of higher adverse events including nausea and vomiting, anaemia and thrombocytopenia toxicity. These data suggest non-platinum chemotherapy regimens have a more advantageous risk-benefit profile. This systematic review highlights the lack of quality-of-life data in trials involving chemotherapy treatment for SCLC. With poor long-term survival associated with both treatment groups, the issue of the quality of the survival period takes on even more significance. It would be beneficial for future trials in this area to include a quality-of-life assessment.

High-grade neuroendocrine carcinoma of the colon, long-term survival in advanced disease

A 72-year-old man was diagnosed with a poorly differentiated hepatic flexure mass seen on routine screening colonoscopy. He underwent a right hemicolectomy and biopsy of a liver lesion noted at laparotomy. Pathology revealed a high-grade neuroendocrine carcinoma in the primary tumor and the liver lesion. Post-operative imaging revealed an isolated FDG avid liver metastases which had not been appreciated pre-operatively. He was treated with combination platinum and etoposide for extensive stage small-cell carcinoma of the colon. After 6 cycles of chemotherapy, the isolated liver lesion remained FDG avid, albeit less than baseline. Radiofrequency ablation of the avid liver lesion was performed. Further, chemotherapy was given as the lesion remained FDG avid. Ablation was repeated and a subsequent biopsy was positive. Chemotherapy resumed for a total of 10 cycles. Repeat PET scan became negative and the patient remains disease-free 7 years from an initial diagnosis of extensive stage small-cell colon cancer with a negative PET scan. Aggressive locoregional treatment is an option in patients with extensive stage small-cell carcinoma of the colon who are left with an oligometastasis after platinum-based systemic chemotherapy.

Features of potentially predictive biomarkers of chemotherapeutic efficacy in small cell lung cancer

INTRODUCTION

One-size-fits-all chemotherapy does not improve survival in patients with small cell lung cancer (SCLC). Excision repair cross-complementing group 1 (ERCC1), ribonucleotide reductase 1 (RRM1), thymidylate synthase (TS), and topoisomerase 2alpha (Topo2alpha) expression levels are predictive of chemotherapeutic efficacy in some malignancies. Our aim was to determine the expression levels of these proteins to assess their potential clinical utility in SCLC.

METHODS

We used an immunofluorescence-based automated quantitative technique to score RRM1, ERCC1, TS, and Topo2alpha levels in tumor specimens from 100 patients with SCLC and immunohistochemistry to semiquantitatively score levels of TS, 5-phosphoribosyl-glycinamide formyl-transferase, and folyl-polyglutamate synthase expression. Confocal microscopy was used for subcellular localization in SCLC cells.

RESULTS

RRM1, ERCC1, and Topo2alpha staining was predominantly nuclear and TS mainly cytoplasmic. Using immunohistochemistry, we found that TS (antibody 106) and TS (antibody 4H4) scores were strongly correlated (r = 0.82, p < 0.0001). By automated quantitative technique, RRM1 and Topo2alpha levels were highly correlated (r = 0.56, p < 0.0001). ERCC1 and TS levels had a narrow and low range of expression. There was no correlation between any of these biomarkers and patients' age or sex.

CONCLUSION

Considering this clinical evidence, expression levels of RRM1 and Topo2alpha may have utility for chemotherapy customization. Clinical validation of their predictive power is desirable in a prospective clinical trial.

Platinum versus non-platinum chemotherapy regimens for small cell lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is a very fast growing form of cancer and is characterised by early metastasis. As a result, chemotherapy is the mainstay of treatment. A number of different platinum-based chemotherapy regimens and non-platinum-based chemotherapy regimens have been used for the treatment of SCLC, with varying results. This review was conducted to analyse the data from these trials in order to compare their effectiveness.

OBJECTIVES

To determine the effectiveness of platinum chemotherapy regimens compared with non-platinum chemotherapy regimens in the treatment of SCLC with respect to survival, tumour response, toxicity and quality of life.

SEARCH STRATEGY

We searched the biomedical literature databases CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE and CINAHL from 1966 to April 2007. In addition, we handsearched reference lists from relevant resources.

SELECTION CRITERIA

All randomised controlled trials involving patients with pathologically confirmed (cytological or histological) SCLC and the use of a platinum-based chemotherapy regimen in at least one treatment arm and a non-platinum-based chemotherapy regimen in a separate arm.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed search results. We assessed included studies for methodological quality and recorded the following outcome data: survival, tumour response, toxicity and quality of life. We combined the results of the survival, tumour response and toxicity data in a meta-analysis.

MAIN RESULTS

A total of 29 trials involving 5530 patients were included in this systematic review. There was no statistically significant difference between treatment groups in terms of survival at 6 months, 12 months and 24 months. There was also no statistically significant difference in terms of overall tumour response. However, platinum-based treatment regimens did have a significantly higher rate of complete response. Platinum-based chemotherapy regimens had significantly higher rates of nausea and vomiting, anaemia and thrombocytopenia toxicity. Three trials presented quality of life data but the data presented were not complete and therefore could not be combined in a meta-analysis.

AUTHORS' CONCLUSIONS

Platinum-based chemotherapy regimens did not offer a statistically significant benefit in survival or overall tumour response compared with non-platinum-based regimens. However, platinum-based chemotherapy regimens did increase complete response rates, at the cost of higher adverse events including nausea and vomiting, anaemia and thrombocytopenia toxicity. These data suggest non-platinum chemotherapy regimens have a more advantageous risk-benefit profile. This systematic review highlights the lack of quality of life data in trials involving chemotherapy treatment for SCLC. With poor long-term survival associated with both treatment groups, the issue of the quality of the survival period takes on even more significance. It would be beneficial for future trials in this area to include a quality of life assessment.

Novel systemic therapies for small cell lung cancer

A diagnosis of small cell lung cancer (SCLC) today confers essentially the same terrible prognosis that it did 25 years ago, when common use of cisplatin-based chemotherapy began for this disease. In contrast to past decades of research on many other solid tumors, studies of combination chemotherapy using later generation cytotoxics and targeted kinase inhibitors have not had a significant impact on standard care for SCLC. The past few years have seen suggestions of incrementally improved outcomes using standard cytotoxics, including cisplatin-based combination studies of irinotecan and amrubicin by Japanese research consortia. Confirmatory phase III studies of these agents are ongoing in the United States. Antiangiogenic strategies are also of primary interest and are in late-phase testing. Several novel therapeutics, including high-potency small molecule inhibitors of Bcl-2 and the Hedgehog signaling pathway, and a recently discovered replication-competent picornavirus, have shown remarkable activity against SCLC in preclinical models and are currently in simultaneous phase I clinical development. Novel therapeutic approaches based on advances in understanding of the biology of SCLC have the potential to radically change the outlook for patients with this disease.