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Xu M, Shao K, Wang Y, Hao Y, Song Z. Comparison of the efficacy and safety of anlotinib monotherapy or anlotinib plus immune checkpoint inhibitor for advanced small cell lung cancer with brain metastases. Clin Transl Oncol 2024; 26:1687-1695. [PMID: 38363527 DOI: 10.1007/s12094-024-03390-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Anlotinib, as a salvage treatment for patients after failure of third-line or later-line treatments for small cell lung cancer (SCLC), has shown efficacy in patients with brain metastases (BMs). However, the efficacy and safety of anlotinib alone or in combination with immunotherapy for SCLC with BMs remain unclear. METHOD Patients treated with anlotinib alone or in combination with an immune checkpoint inhibitor (ICI) at the Zhejiang Cancer Hospital between April 2019 and February 2023 were identified. Kaplan-Meier curves were used to describe the progression-free survival (PFS) and intracranial PFS (iPFS). A waterfall diagram was used to indicate changes in intracranial lesions. RESULTS A total of 48 patients were included; 29 received anlotinib alone, and 19 were administered anlotinib plus ICI. Combination therapy, compared with anlotinib, was associated with significantly longer PFS and iPFS (PFS: 8.1 months vs. 2.5 months, P < 0.001; iPFS: 8.1 months vs. 2.5 months, P = 0.004). Similar results were observed in patients with multiple BMs (PFS: 8.1 months vs. 1.9 months, P = 0.001; iPFS: 8.1 months vs. 1.9 months, P = 0.002). After third-line or later-line treatments, patients treated with ICI plus anlotinib also achieved significant PFS and iPFS benefits (PFS: 8.4 months vs. 2.1 months, P < 0.001; iPFS: 9.2 months vs. 2.1 months, P = 0.002). No new or severe adverse events were observed with combination therapy. CONCLUSION The combination of anlotinib and ICI has promising intracranial and extracranial efficacy with tolerable toxicity, and may be a therapeutic option for SCLC patients with BMs.
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Affiliation(s)
- Manyi Xu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310000, China
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China
| | - Keda Shao
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310018, Zhejiang, China
| | - Yanhua Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310000, China
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China
| | - Yue Hao
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310000, China.
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China.
| | - Zhengbo Song
- Department of Clinical Trial, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, China.
- Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, 310018, Zhejiang, China.
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Buczek D, Zaucha R, Jassem J. Neurotoxicity-sparing radiotherapy for brain metastases in breast cancer: a narrative review. Front Oncol 2024; 13:1215426. [PMID: 38370347 PMCID: PMC10869626 DOI: 10.3389/fonc.2023.1215426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/19/2023] [Indexed: 02/20/2024] Open
Abstract
Breast cancer brain metastasis (BCBM) has a devastating impact on patient survival, cognitive function and quality of life. Radiotherapy remains the standard management of BM but may result in considerable neurotoxicity. Herein, we describe the current knowledge on methods for reducing radiation-induced cognitive dysfunction in patients with BCBM. A better understanding of the biology and molecular underpinnings of BCBM, as well as more sophisticated prognostic models and individualized treatment approaches, have appeared to enable more effective neuroprotection. The therapeutic armamentarium has expanded from surgery and whole-brain radiotherapy to stereotactic radiosurgery, targeted therapies and immunotherapies, used sequentially or in combination. Advances in neuroimaging have allowed more accurate screening for intracranial metastases, precise targeting of intracranial lesions and the differentiation of the effects of treatment from disease progression. The availability of numerous treatment options for patients with BCBM and multidisciplinary approaches have led to personalized treatment and improved therapeutic outcomes. Ongoing studies may define the optimal sequencing of available and emerging treatment options for patients with BCBM.
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Yang HY, Xia YQ, Hou YJ, Xue P, Zhu SJ, Lu DR. Chemotherapy combined with bevacizumab for small cell lung cancer with brain metastases: A case report. World J Clin Cases 2024; 12:405-411. [PMID: 38313643 PMCID: PMC10835696 DOI: 10.12998/wjcc.v12.i2.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Small cell lung cancer (SCLC) is a common and aggressive subtype of lung cancer. It is characterized by rapid growth and a high mortality rate. Approximately 10% of patients with SCLC present with brain metastases at the time of diagnosis, which is associated with a median survival of 5 mo. This study aimed to summarize the effect of bevacizumab on the progression-free survival (PFS) and overall survival of patients with brain metastasis of SCLC. CASE SUMMARY A 62-year-old man was referred to our hospital in February 2023 because of dizziness and numbness of the right lower extremity without headache or fever for more than four weeks. The patient was diagnosed with limited-stage SCLC. He received 8 cycles of chemotherapy combined with maintenance bevacizumab therapy and achieved a PFS of over 7 mo. CONCLUSION The combination of bevacizumab and irinotecan effectively alleviated brain metastasis in SCLC and prolonged PFS.
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Affiliation(s)
- Hong-Yu Yang
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
- Department of Oncology, Tianjin University of Chinese Medicine, Tianjin 300000, China
| | - Yu-Qing Xia
- Department of Electrothermal Acupuncture, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
- Department of Acupuncture and Moxibustion, Sihui Hospital of Traditional Chinese Medicine, Beijing 100102, China
| | - Yu-Jia Hou
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Peng Xue
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Shi-Jie Zhu
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Dian-Rong Lu
- Department of Oncology, Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing 100102, China
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Shiraishi Y, Shimose T, Tsuchiya-Kawano Y, Ishii H, Daga H, Ito K, Saruwatari K, Okamoto I. Forthcoming Phase II Study of Durvalumab (MEDI4736) Plus Chemotherapy for Small Cell Lung Cancer with Brain Metastases. Cancer Manag Res 2022; 14:3449-3453. [PMID: 36540201 PMCID: PMC9760036 DOI: 10.2147/cmar.s391220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/19/2022] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The standard of care for extensive-stage small cell lung cancer (ES-SCLC) is an immune checkpoint inhibitor (ICI) combined with platinum-etoposide (PE) chemotherapy. At initial diagnosis, about 25% of ES-SCLC patients have brain metastases, which are associated with a poor prognosis. The decision as to whether to treat brain metastases with local therapies such as surgery or radiotherapy before initiation of systemic chemoimmunotherapy is based on symptoms due to the brain lesions and the general condition of the patient. Subset analysis of the CASPIAN study showed that combination therapy with PE plus durvalumab (MEDI4736) is promising for ES-SCLC with brain metastases. However, data required in daily clinical practice, such as intracranial response rate and duration of intracranial response, are insufficient for such patients. PATIENTS AND METHODS We have designed a single-arm phase II trial of durvalumab plus PE for patients aged ≥20 years with chemotherapy-naïve ES-SCLC and at least one brain metastasis ≥5 mm in size that has not been previously treated. Patients receive durvalumab intravenously combined with four cycles of PE. Enrollment of 50 patients over 2 years at 25 oncology facilities in Japan is planned. The primary endpoint is intracranial response rate. CONCLUSION This is the first prospective study to evaluate the effects of an ICI with PE specifically in ES-SCLC patients with brain metastases. If it demonstrates intracranial efficacy, this regimen will be a potential treatment option for such individuals, and radiation therapy or surgery for brain metastases can be avoided or postponed.
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Affiliation(s)
- Yoshimasa Shiraishi
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Shimose
- Department of Statistics and Data Center, Clinical Research Support Center Kyushu, Fukuoka, Japan
| | - Yuko Tsuchiya-Kawano
- Department of Respiratory Medicine, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Hidenobu Ishii
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Haruko Daga
- Department of Medical Oncology, Osaka City General Hospital, Osaka, Japan
| | - Kentaro Ito
- Respiratory Center, Matsusaka Municipal Hospital, Mie, Japan
| | - Koichi Saruwatari
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Isamu Okamoto
- Department of Respiratory Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Zhu Y, Cui Y, Zheng X, Zhao Y, Sun G. Small-cell lung cancer brain metastasis: From molecular mechanisms to diagnosis and treatment. Biochim Biophys Acta Mol Basis Dis 2022; 1868:166557. [PMID: 36162624 DOI: 10.1016/j.bbadis.2022.166557] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/27/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022]
Abstract
Lung cancer is the most malignant human cancer worldwide, also with the highest incidence rate. However, small-cell lung cancer (SCLC) accounts for 14 % of all lung cancer cases. Approximately 10 % of patients with SCLC have brain metastasis at the time of diagnosis, which is the leading cause of death of patients with SCLC worldwide. The median overall survival is only 4.9 months, and a long-tern cure exists for patients with SCLC brain metastasis due to limited common therapeutic options. Recent studies have enhanced our understanding of the molecular mechanisms leading to meningeal metastasis, and multimodality treatments have brought new hopes for a better cure for the disease. This review aimed to offer an insight into the cellular processes of different metastatic stages of SCLC revealed by the established animal models, and into the major diagnostic methods of SCLC. Additionally, it provided in-depth information on the recent advances in SCLC treatments, and highlighted several new models and biomarkers with promises to improve the prognosis of SCLC.
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Affiliation(s)
- Yingze Zhu
- Department of Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, School of Clinical Medicine, Affiliated Hospital, School of Public Health, North China University of Science and Technology, Tangshan, Hebei 063000, China
| | - Yishuang Cui
- Department of Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, School of Clinical Medicine, Affiliated Hospital, School of Public Health, North China University of Science and Technology, Tangshan, Hebei 063000, China
| | - Xuan Zheng
- Department of Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, School of Clinical Medicine, Affiliated Hospital, School of Public Health, North China University of Science and Technology, Tangshan, Hebei 063000, China
| | - Yue Zhao
- Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, China.
| | - Guogui Sun
- Department of Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, School of Clinical Medicine, Affiliated Hospital, School of Public Health, North China University of Science and Technology, Tangshan, Hebei 063000, China.
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Nieder C, Aanes SG, Haukland E. Primary systemic therapy for patients with brain metastases from lung cancer ineligible for targeted agents. J Cancer Res Clin Oncol 2022; 148:3109-3116. [PMID: 35020043 PMCID: PMC9508211 DOI: 10.1007/s00432-022-03919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study was to evaluate overall survival after systemic therapy, largely chemotherapy, in patients with small cell or non-small cell lung cancer and brain metastases. After completion of systemic therapy, some patients received planned brain irradiation, while others were followed. Methods Retrospective cohort study. Results Thirty-eight patients were included (28 small cell, 20 followed with imaging). Six of these 20 patients (30%) received delayed radiotherapy during follow-up. Planned radiotherapy (n = 18, intention-to-treat) was associated with longer survival from diagnosis of brain metastases, median 10.8 versus 6.1 months, p = 0.025. Delayed radiotherapy still resulted in numerically better survival than no radiotherapy at all (median 8.8 versus 5.3 months, not significant). If calculated from the start of delayed radiotherapy, median survival was only 2.7 months. In a multivariable analysis, both Karnofsky performance status ≥ 70 (p = 0.03) and planned radiotherapy (p = 0.05) were associated with better survival. Conclusion In patients ineligible for targeted agents, planned radiotherapy in a modern treatment setting was associated with longer survival compared to no radiotherapy. Timing and type of radiotherapy in such patients should be evaluated in prospective trials to identify patients who might not need planned radiotherapy.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, 9037, Tromsø, Norway.
| | - Siv G Aanes
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway
| | - Ellinor Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, 9037, Tromsø, Norway.,SHARE-Center for Resilience in Healthcare, Faculty of Health Sciences, Department of Quality and Health Technology, University of Stavanger, 4036, Stavanger, Norway
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Rittberg R, Banerji S, Kim JO, Rathod S, Dawe DE. Treatment and Prevention of Brain Metastases in Small Cell Lung Cancer. Am J Clin Oncol 2021; 44:629-638. [PMID: 34628433 DOI: 10.1097/coc.0000000000000867] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Central nervous system (CNS) metastasis will develop in 50% of small cell lung cancer (SCLC) patients throughout disease course. Development of CNS metastasis poses a particular treatment dilemma due to the accompanied cognitive changes, poor permeability of the blood-brain barrier to systemic therapy and relatively advanced state of disease. Survival of patients with untreated SCLC brain metastases is generally <3 months with whole brain radiotherapy used as first-line management in most SCLC patients. To prevent development of CNS metastasis prophylactic cranial irradiation (PCI) is recommended in limited stage disease, after response to chemotherapy and radiation, while PCI may be considered in extensive stage disease after favorable response to upfront treatment. Neurocognitive toxicity with whole brain radiotherapy and PCI is a concern and remains difficult to predict. The mechanism of toxicity is likely multifactorial, but a potential mechanism of injury to the hippocampus has led to hippocampal sparing radiation techniques. Treatment of established non-small cell lung cancer CNS metastases has increasingly focused on using stereotactic radiotherapy (SRS) and it is tempting to extrapolate these results to SCLC. In this review, we explore the evidence surrounding the prediction, prevention, detection, and treatment of CNS metastases in SCLC. We further review whether existing evidence supports extrapolating less toxic treatments to SCLC patients with CNS metastases and discuss trials that may shed more light on this question.
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Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
| | - Shantanu Banerji
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
| | | | | | - David E Dawe
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
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Ren W, Wu P, Tian J, Chen D, Li S, Liu B. Anti-PD-1 therapy plus chemotherapy showed superior and durable survival benefit in a patient with small cell esophageal cancer: A case report. Thorac Cancer 2020; 12:264-267. [PMID: 33174677 PMCID: PMC7812062 DOI: 10.1111/1759-7714.13735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022] Open
Abstract
The prognosis of the small cell esophageal cancer (SCEC) patient in our study was poor due to lack of treatment options which were limited to surgery and chemotherapies, with a median overall survival (OS) of only 11.1 months according to previous studies. Herein, we adopted the regimen of immunotherapy plus chemotherapy, which exerted superior and durable benefit (OS > 19 months) in the patient in our study. Immunotherapy plus chemotherapy might therefore be a reasonable option for selected SCEC patients. In addition, well‐designed trials for better evidence are required to verify the findings in this study.
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Affiliation(s)
- Wei Ren
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Puyuan Wu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Jing Tian
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd, Nanjing, China
| | - Dongsheng Chen
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd, Nanjing, China
| | - Si Li
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd, Nanjing, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University & Clinical Cancer Institute of Nanjing University, Nanjing, China
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Pattern-of-failure and salvage treatment analysis after chemoradiotherapy for inoperable stage III non-small cell lung cancer. Radiat Oncol 2020; 15:148. [PMID: 32517716 PMCID: PMC7285541 DOI: 10.1186/s13014-020-01590-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/03/2020] [Indexed: 12/16/2022] Open
Abstract
Background Loco-regional and distant failure are common in inoperable stage III non small-cell lung cancer (NSCLC) after chemoradiotherapy (CRT). However, there is limited real-world data on failure pattern, patient prognosis and salvage options. Methods We analysed 99 consecutive patients with inoperable stage III NSCLC treated with CRT between 2011 and 2016. Follow up CT scans from date of the first-site failure were matched with the delivered radiation treatment plans. Intra-thoracic loco-regional relapse was defined as in-field (IFR) vs. out-of-field recurrence (OFR) [in- vs. outside 50Gy isodose line in the involved lung], respectively. Extracranial distant (DMs) and brain metastases (BMs) as first site of recurrence were also evaluated. Using the Kaplan-Meier method, impact of salvage surgery (sS), radiotherapy (sRT), chemotherapy (sCT) and immunotherapy (sIO) on patient survival was assessed. Results Median follow-up was 60.0 months. Median PFS from the end of CRT for the entire cohort was 7.5 (95% CI: 6.0–9.0 months) months. Twenty-six (26%) and 25 (25%) patients developed IFR and OFR. Median time to diagnosis of IFR and OFR was 7.2 and 6.2 months. In the entire cohort, onset of IFR and OFR did not influence patient outcome. However, in 73 (74%) patients who survived longer than 12 months after initial diagnosis, IFR was a significant negative prognostic factor with a median survival of 19.3 vs 40.0 months (p < 0.001). No patients with IFR underwent sS and/or sRT. 18 (70%) and 5 (19%) patients with IFR underwent sCT and sIO. Three (12%) patients with OFR underwent sS and are still alive with 3-year survival rate of 100%. 5 (20%) patients with OFR underwent sRT with a median survival of 71.2 vs 19.1 months (p = 0.014). Four (16%) patients with OFR received sIO with a numerical survival benefit (64.6 vs. 26.4 months, p = 0.222). DMs and BMs were detected in 27 (27%) and 16 (16%) patients after median time of 5.8 and 5.13 months. Both had no impact on patient outcome in the entire cohort. However, patients with more than three BMs showed significantly poor OS (9.3 vs 26.0 months; p = 0.012). Conclusions After completion of CRT, IFR was a negative prognostic factor in those patients, who survived longer than 12 months after initial diagnosis. Patients with OFR benefit significantly from salvage local treatment. Patients with more than three BMs as first site of failure had a significantly inferior outcome.
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Systemic therapy for brain metastases. Crit Rev Oncol Hematol 2019; 142:44-50. [PMID: 31357143 DOI: 10.1016/j.critrevonc.2019.07.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/30/2019] [Accepted: 07/14/2019] [Indexed: 02/07/2023] Open
Abstract
Metastases from cells outside of the central nervous system are the most common cancer found in the brain and are commonly associated with poor prognosis. Although cancer treatment is improving overall, central nervous system metastases are becoming more prevalent and require finesse to properly treat. Physicians must consider the biology of the primary tumor and the complex neurological environment that the metastasis resides in. This can be further complicated by the fact that the practice of cancer management is constantly evolving and therapy that works outside of the blood-brain barrier may not be effective inside of it. Therefore, this review seeks to update the reader on recent advancements made on the three most common sources of brain metastases: lung cancer, breast cancer, and melanoma. Each of these malignancies has been the subject of intriguing and novel avenues of therapy which are reviewed here.
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Risk factors for brain metastasis in patients with small cell lung cancer without prophylactic cranial irradiation. Strahlenther Onkol 2018; 194:1152-1162. [DOI: 10.1007/s00066-018-1362-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 08/20/2018] [Indexed: 11/25/2022]
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Abstract
OPINION STATEMENT Treatment options for leptomeningeal metastases are expanding with greater tolerability and efficacy than in the past. Improved knowledge of molecular subtypes of some cancers can guide in choosing more effective therapeutic options; however, physicians should be mindful that these molecular types can be different in the central nervous system compared to the rest of the body. This is particularly true in breast and lung cancer, in which some patients now can live for many months or even years after diagnosis of leptomeningeal metastases. Options for intrathecal therapies are expanding, but physicians should be mindful that this is a passive delivery system that relies on normal CSF flow, so therapies will not penetrate bulky or parenchymal disease sites, especially in the presence of abnormal CSF flow. When chemotherapeutic options are lacking or unsuccessful, focal radiosurgery which can provide symptomatic relief and proton craniospinal radiation remain effective options. Hopefully more formal studies will be conducted in the future to verify which treatments are indeed most effective for particular types of cancer.
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Affiliation(s)
- Jerome J Graber
- Department of Neurology, Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Neuroscience Institute, Seattle, WA, 98122-4470, USA.
| | - Santosh Kesari
- Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Pacific Neuroscience Institute, Providence Saint John's Health Center, Santa Monica, CA, 90404, USA.
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Abstract
Central nervous system metastases cause grave morbidity in patients with advanced malignancies. Lung cancer, breast cancer, and melanoma are the three most common causes of brain metastases. Although the exact incidence of brain metastases is unclear, there appears to be an increasing incidence which has been attributed to longer survival, better control of systemic disease, and better imaging modalities. Until recently surgical resection of solitary or symptomatic brain metastases, and radiation therapy (either whole-brain radiation therapy or stereotactic radiation) were the mainstay of treatment for patients with brain metastases. The majority of traditional chemotherapies have shown limited activity in the central nervous system, which has been attributed to the blood-brain barrier and the molecular structure of the used agents. The discovery of driver mutations and drugs targeting these mutations has changed the treatment landscape. Several of these targeted small-molecule tyrosine kinase inhibitors do cross the blood-brain barrier and/or have shown activity in the central nervous system. Another major advance in the care of brain metastases has been the advent of new immunotherapeutic agents, for which initial studies have shown intracranial activity. In this chapter, we will review the unique challenges in the treatment of brain metastases. The pertinent clinical studies of chemotherapy in brain metastases will be discussed. The currently reported clinical trials and evidence for use of targeted therapies and immunotherapeutic agents will be emphasized.
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Lukas RV, Gondi V, Kamson DO, Kumthekar P, Salgia R. State-of-the-art considerations in small cell lung cancer brain metastases. Oncotarget 2017; 8:71223-71233. [PMID: 29050358 PMCID: PMC5642633 DOI: 10.18632/oncotarget.19333] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/03/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Small cell lung cancer (SCLC) frequently leads to development of brain metastases. These unfortunately continue to be associated with short survival. Substantial advances have been made in our understanding of the underlying biology of disease. This understanding on the background of previously evaluated and currently utilized therapeutic treatments can help guide the next steps in investigations into this disease with the potential to influence future treatments. DESIGN A comprehensive review of the literature covering epidemiology, pathophysiology, imaging characteristics, prognosis, and therapeutic management of SCLC brain metastases was performed. RESULTS SCLC brain metastases continue to have a poor prognosis. Both unique aspects of SCLC brain metastases as well as features seen more universally across other solid tumor brain metastases are discussed. Systemic therapeutic studies and radiotherapeutic approaches are reviewed. CONCLUSIONS A clearer understanding of SCLC brain metastases will help lay the framework for studies which will hopefully translate into meaningful therapeutic options for these patients.
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Affiliation(s)
- Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Chicago Proton Center, Northwestern University, Warrenville, IL, USA
| | - David O. Kamson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Priya Kumthekar
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Ravi Salgia
- Department of Medical Oncology and Therapeutics, City of Hope, Duarte, CA, USA
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Waqar SN, Morgensztern D, Govindan R. Systemic Treatment of Brain Metastases. Hematol Oncol Clin North Am 2017; 31:157-176. [PMID: 27912831 DOI: 10.1016/j.hoc.2016.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lung cancer continues to be the leading cause of cancer-related mortality in the United States. Brain metastases are a significant problem in patients with lung cancer and have conventionally been treated with whole-brain radiation. This article reviews the data for systemic chemotherapy to treat brain metastasis from lung cancer and examines the activity of small molecule tyrosine kinase inhibitors for the targeted therapy for brain metastases from EGFR-mutant and ALK-rearranged non-small cell lung cancer. Future directions for evaluating the role of immunotherapy in treating brain metastasis are also discussed.
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Affiliation(s)
- Saiama N Waqar
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA.
| | - Daniel Morgensztern
- Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA
| | - Ramaswamy Govindan
- Section of Medical Oncology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8056, St Louis, MO 63110, USA
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Fu L, Liu F, Fu H, Liu L, Yuan S, Gao Y, Fu Z, Yu J. Circulating tumor cells correlate with recurrence in stage III small-cell lung cancer after systemic chemoradiotherapy and prophylactic cranial irradiation. Jpn J Clin Oncol 2014; 44:948-55. [PMID: 25135984 DOI: 10.1093/jjco/hyu109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We investigated the correlation between circulating tumor cells and the incidence of brain metastases as a first site of recurrence among patients with small-cell lung cancer after systemic chemoradiotherapy and prophylactic cranial irradiation. In addition, we assessed the contribution of circulating tumor cells for planning the appropriate total dose of prophylactic cranial irradiation for small-cell lung cancer. METHODS Patients (n = 112) with diagnosed Stage III small-cell lung cancer were treated with four cycles of platinum-based regimen and concurrent chest irradiation, and then prophylactic cranial irradiation. Blood samples for circulating tumor cell analysis were obtained before the initiation of chemotherapy and after the first and fourth cycle of chemotherapy. RESULTS Circulating tumor cells after the first cycle of chemotherapy correlated with tumor response after completion of chemotherapy (P = 0.012). Patients with brain as the first site suffered a higher rate of further metastases to other organs, and local recurrence, compared with those whose first site was the other organs (P < 0.001), and their survival rates were worse. Circulating tumor cells at baseline were the sole independent prognostic factor for specific progression-free survival. Receiver operating characteristic curves based on median specific progression-free survival revealed a circulating tumor cell cutoff at baseline of 218, and circulating tumor cells ≤218 at baseline correlated with significantly higher progression-free survival (P = 0.007), specific progression-free survival (P = 0.001) and overall survival (P = 0.001). CONCLUSIONS Circulating tumor cells prior to the initiation of chemotherapy are a valuable predictor of specific progression-free survival in Stage III small-cell lung cancer. For patients with circulating tumor cells >218, prophylactic cranial irradiation at a total dose of 30 Gy in 15 fractions is insufficient.
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Affiliation(s)
- Lei Fu
- Shandong University, Shandong Cancer Hospital, Jinan
| | | | - Hui Fu
- Department of Surgery, Shandong Cancer Hospital, Shandong University, Jinan
| | - Liqing Liu
- Department of Surgery, Shandong Cancer Hospital, Shandong University, Jinan
| | - Shuanghu Yuan
- Shandong University, Shandong Cancer Hospital, Jinan
| | - Yongsheng Gao
- Department of Pathology, Shandong Cancer Hospital, Shandong University, Jinan
| | - Zheng Fu
- Department of Nuclear Medicine, Shandong Cancer Hospital, Shandong University, Jinan, China
| | - Jinming Yu
- Shandong University, Shandong Cancer Hospital, Jinan
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Abstract
Neurologic complications of lung cancer are a frequent cause of morbidity and mortality. Tumor metastasis to the brain parenchyma is the single most common neurologic complication of lung cancer, of any histologic subtype. The goal of radiation therapy and in some cases surgical resection for patients with brain metastases is to improve or maintain neurologic function, and to achieve local control of the brain lesion(s). Metastasis of lung cancer to the spinal epidural space requires urgent evaluation and treatment. Early diagnosis and modern surgical and radiotherapy techniques improve neurologic outcome for most patients. Leptomeningeal metastasis is a less common but ominous occurrence in patients with lung cancer. Lung carcinomas can also occasionally metastasize to the brachial plexus, skull base, dura, or pituitary. Paraneoplastic neurologic disorders are uncommon but important complications of lung carcinoma, and are generally the presenting feature of the tumor. Paraneoplastic disorders are believed to be caused by an autoimmune humoral or cellular attack against shared "onconeural" antigens. The most frequent paraneoplastic disorders in patients with lung cancer are Lambert-Eaton myasthenic syndrome, and multifocal paraneoplastic encephalomyelitis, both mainly occurring in association with small-cell lung carcinoma. There is a variety of other paraneoplastic disorders affecting the central and peripheral nervous systems. Some affected patients have a good neurologic outcome, while others are left with severe permanent neurologic disability.
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Affiliation(s)
- Edward J Dropcho
- Department of Neurology, Indiana University Medical Center, Indianapolis, IN, USA.
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18
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Poli GL, Bianchi C, Virotta G, Bettini A, Moretti R, Trachsel E, Elia G, Giovannoni L, Neri D, Bruno A. Radretumab radioimmunotherapy in patients with brain metastasis: a 124I-L19SIP dosimetric PET study. Cancer Immunol Res 2013; 1:134-43. [PMID: 24777501 DOI: 10.1158/2326-6066.cir-13-0007] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Radioimmunotherapy (RIT) with (131)I-labeled L19SIP (radretumab; a small immunoprotein format antibody directed against the ED-B domain of fibronectin; ∼ 80 kDa molecular weight) has been investigated in several clinical trials. Here, we describe the use of immuno-PET imaging with iodine-124 ((124)I)-labeled L19SIP to predict doses delivered to tumor lesions and healthy organs by a subsequent radretumab RIT in patients with brain metastases from solid cancer. Bone marrow doses were evaluated both during the diagnostic phase and posttherapy, measuring activities in blood (germanium detector) and whole body (lanthanum bromide detector). Expected doses for radretumab administration (4,107 MBq/m(2)) were calculated from data obtained after administration of an average of 167 MBq (124)I-L19SIP to 6 patients. To assess lesion average doses, the positron emission tomography (PET) scanner was calibrated for the use of (124)I with an International Electrotechnical Commission (IEC) Body Phantom and recovery coefficients were calculated. The average dose to bone red marrow was 0.21 Gy/GBq, with high correlation between provisional and actual posttherapy doses. Although the fraction of injected activity in normal organs was similar in different patients, the antibody uptake in the neoplastic lesions varied by as much as a factor of 60. Immuno-PET with (124)I-labeled L19SIP offers significant advantages over conventional (131)I imaging, in particular accuracy of dosimetric results. Furthermore, the study indicates that antibody uptake can be highly variable even in different lesions of the same patient and that immuno-PET procedures may guide product development with armed antibodies.
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Affiliation(s)
- Gian Luca Poli
- Authors' Affiliations: Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland
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Nakazaki K, Higuchi Y, Nagano O, Serizawa T. Efficacy and limitations of salvage gamma knife radiosurgery for brain metastases of small-cell lung cancer after whole-brain radiotherapy. Acta Neurochir (Wien) 2013; 155:107-13; discussion 113-4. [PMID: 23065044 DOI: 10.1007/s00701-012-1520-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 09/28/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The efficacy and limitations of salvage gamma knife surgery (GKS) have not been thoroughly described. This study evaluated the efficacy of GKS for treating brain metastases associated with small-cell lung cancer (SCLC) after whole-brain radiotherapy (WBRT) as the first-line radiation therapy. METHODS Forty-four patients with recurrent or new SCLC-associated brain metastases underwent GKS after receiving WBRT (median age, 62 years; median duration between WBRT and first GKS, 8.8 months). The median Karnofsky performance status (KPS) score was 100 (range, 40-100), and the median number of brain metastases at the first GKS was five. Ten patients who partially or completely responded to chemotherapy received prophylactic cranial irradiation (PCI) for limited disease. RESULTS The median prescribed dose and number of lesions treated with the initial GKS were 20.0 Gy and 3.5, respectively, and the tumor control rate was 95.8 % (median follow-up period, 4.0 months). The 6-month new lesion-free survival, functional preservation rates, and overall survival were 50.0 %, 94.7 %, and 5.8 months, respectively. Neurological death occurred in 17.9 % of cases. The poor prognostic factors for new lesion-free survival time and functional preservation were >5 brain metastases and carcinomatous meningitis, respectively. Poor prognostic factors for survival time were KPS <70, >10 brain metastases, diameter of the largest tumor >20 mm, and carcinomatous meningitis. Median overall survival time from brain metastasis diagnosis was 16.9 months. CONCLUSIONS GKS may be an effective option for controlling SCLC-associated brain metastases after WBRT and for preventing neurological death in patients without carcinomatous meningitis.
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Affiliation(s)
- Kiyoshi Nakazaki
- Department of Neurosurgery, Brain Attack Center, Ota Memorial Hospital, 3-6-28 Okinogami, Fukuyama, Hiroshima, 720-0825, Japan.
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Traitements systémiques des métastases cérébrales (MC) des cancers bronchiques à petites cellules (CPC). Bull Cancer 2013; 100:89-93. [DOI: 10.1684/bdc.2012.1687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Chen AY, Chen PMT, Chen YJ. DNA topoisomerase I drugs and radiotherapy for lung cancer. J Thorac Dis 2012; 4:390-7. [PMID: 22934142 DOI: 10.3978/j.issn.2072-1439.2012.07.12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 07/12/2012] [Indexed: 01/18/2023]
Abstract
Lung cancer represents the most common cause of cancer-related mortality in the United States and around the world. DNA topoisomerase I (TOP1) drugs such as irinotecan and topotecan represent a unique class of chemotherapeutic agents that exhibit not only potent cytotoxic effect, but also tumor-selective radiation-sensitizing effect. The mechanism of cytotoxicity and radiation sensitization by TOP1 drugs has been intensely investigated. Modern radiotherapy, aided by improved imaging and treatment delivery technology, is capable of targeting tumors more precisely, while sparing surrounding critical structures. Clinical trials with camptothecin derivatives and radiotherapy have been conducted in lung cancers. Combined modality therapy with TOP1 drugs and radiotherapy offers a new frontier for lung cancer therapy. We review the present state of TOP1-targeted chemotherapy and modern radiotherapy for lung cancer.
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Kyritsis AP, Markoula S, Levin VA. A systematic approach to the management of patients with brain metastases of known or unknown primary site. Cancer Chemother Pharmacol 2011; 69:1-13. [DOI: 10.1007/s00280-011-1775-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/20/2011] [Indexed: 12/13/2022]
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Combined chemotherapy with carboplatin plus irinotecan showed favorable efficacy in a patient with relapsed small cell carcinoma of the prostate complicated with meningeal carcinomatosis. Int J Clin Oncol 2009; 14:468-72. [PMID: 19856060 DOI: 10.1007/s10147-008-0869-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 12/04/2008] [Indexed: 10/20/2022]
Abstract
We report the case of a 65-year-old man with recurrent prostate cancer who presented with meningeal carcinomatosis. In September 2007, he had been diagnosed with mixed type small cell carcinoma and adenocarcinoma at clinical stage T4N1M1 (primary prostate tumor with multiple bone, liver, and lymph node metastases) and hormonal therapy had been administered. Following an increase in the level of pro-gastrin-releasing peptide (ProGRP), combined chemotherapy with cisplatin plus etoposide was implemented and showed efficacy in targeting the small cell carcinoma. In March 2008, he presented with signs of meningeal irritation; his condition deteriorated quickly and multiple brain metastases were confirmed by magnetic resonance imaging (MRI). A sample of cerebrospinal fluid collected by lumbar puncture showed cancer cells and an elevated level of ProGRP. Small cell carcinoma of the prostate complicated with meningeal carcinomatosis was diagnosed. A different chemotherapy regimen was then administered, consisting of a combination of carboplatin plus irinotecan, which is one of the most common first-line treatments for extensive-stage small cell lung carcinoma. From day 20 after the initiation of this therapy, he gradually recovered from the signs of meningeal irritation, and brain MRI showed nearly normal findings; also, the serum level of ProGRP was reduced. In conclusion, we report the efficacy of combined treatment with carboplatin plus irinotecan for small cell carcinoma of the prostate complicated with meningeal carcinomatosis. Because this clinical condition is extremely rare, a gold standard treatment has yet to be established.
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Chen G, Huynh M, Fehrenbacher L, West H, Lara PN, Yavorkovsky LL, Russin M, Goldstein D, Gandara D, Lau D. Phase II trial of irinotecan and carboplatin for extensive or relapsed small-cell lung cancer. J Clin Oncol 2009; 27:1401-4. [PMID: 19204194 PMCID: PMC2668551 DOI: 10.1200/jco.2008.20.2127] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 11/21/2008] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The regimens of weekly irinotecan with platinum have been used for treatment of metastatic small-cell lung cancer (SCLC). We conducted a multi-institution phase II trial to evaluate a novel 21-day schedule of irinotecan and carboplatin in patients with relapsed or extensive SCLC. PATIENTS AND METHODS Eighty patients were enrolled with the following characteristics: 39 male patients, 41 female patients; median age, 65 years; and Zubrod performance status, 0 to 1 in 85% and 2 in 15% of patients. Dosing schemas were based on the maximum-tolerated dose derived in a previous phase I study. Chemotherapy-naive patients with extensive SCLC were treated with irinotecan 200 mg/m(2) and carboplatin area under the curve (AUC) of 5 (arm A). Patients, who had previously been treated with chemotherapy and had relapsed disease received irinotecan 150 mg/m(2) and carboplatin AUC of 5 (arm B). In each study arm, the treatment was given every 21 days for up to six cycles. RESULTS The most common grade 3 to 4 toxicities included neutropenia (54%), thrombocytopenia (22%), anemia (13%), diarrhea (22%), and nausea/emesis (11%) in both study arms. There were three treatment-related deaths owing to neutropenic sepsis. Among 72 assessable patients, response rates of 65% and 50% were observed, respectively, for arm A and arm B. The median survival for both study arms was identical at 10 months (95% CI, 6 to 14 months). A response rate of 65% was observed in the intracranial disease of 14 patients with known brain metastases. CONCLUSION This 21-day regimen of irinotecan and carboplatin seems promising for the treatment of relapsed SCLC.
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Affiliation(s)
- Gigi Chen
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Minh Huynh
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Lou Fehrenbacher
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Howard West
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Primo N. Lara
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Leonid L. Yavorkovsky
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Michael Russin
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Desiree Goldstein
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - David Gandara
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
| | - Derick Lau
- From the University of California, Davis Cancer Center, Sacramento; Veteran Administration Northern California Health System, Mather; Kaiser Permanente of Northern California, Oakland, CA; and Swedish Institute of Seattle, Seattle, WA
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Current world literature. Trauma and rehabilitation. Curr Opin Neurol 2008; 21:762-4. [PMID: 18989123 DOI: 10.1097/wco.0b013e32831cbb85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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