International Tailored Chemotherapy Adjuvant (ITACA) trial, a phase III multicenter randomized trial comparing adjuvant pharmacogenomic-driven chemotherapy versus standard adjuvant chemotherapy in completely resected stage II-IIIA non-small-cell lung cancer

BACKGROUND

Several strategies have been investigated to improve the 4% survival advantage of adjuvant chemotherapy in early-stage non-small-cell lung cancer (NSCLC). In this investigator-initiated study we aimed to evaluate the predictive utility of the messenger RNA (mRNA) expression levels of excision repair cross complementation group 1 (ERCC1) and thymidylate synthase (TS) as assessed in resected tumor.

PATIENTS AND METHODS

Seven hundred and seventy-three completely resected stage II-III NSCLC patients were enrolled and randomly assigned in each of the four genomic subgroups to investigator's choice of platinum-based chemotherapy (C, n = 389) or tailored chemotherapy (T, n = 384). All anticancer drugs were administered according to standard doses and schedules. Stratification factors included stage and smoking status. The primary endpoint of the study was overall survival (OS).

RESULTS

Six hundred and ninety patients were included in the primary analysis. At a median follow-up of 45.9 months, 85 (24.6%) and 70 (20.3%) patients died in arms C and T, respectively. Five-year survival for patients in arms C and T was of 65.4% (95% CI (confidence interval): 58.5% to 71.4%) and 72.9% (95% CI: 66.5% to 78.3%), respectively. The estimated hazard ratio (HR) was 0.77 (95% CI: 0.56-1.06, P value: 0.109) for arm T versus arm C. HR for recurrence-free survival was 0.89 (95% CI: 0.69-1.14, P value: 0.341) for arm T versus arm C. Grade 3-5 toxicities were more frequently reported in arm C than in arm T.

CONCLUSION

In completely resected stage II-III NSCLC tailoring adjuvant chemotherapy conferred a non-statistically significant trend for OS favoring the T arm. In terms of safety, the T arm was associated with better efficacy/toxicity ratio related to the different therapeutic choices in the experimental arm.

Impact of TP53 mutation status on systemic treatment outcome in ALK-rearranged non-small-cell lung cancer

Background

We analyzed whether co-occurring mutations influence the outcome of systemic therapy in ALK-rearranged non-small-cell lung cancer (NSCLC).

Patients and methods

ALK-rearranged stage IIIB/IV NSCLC patients were analyzed with next-generation sequencing and fluorescence in situ hybridization analyses on a centralized diagnostic platform. Median progression-free survival (PFS) and overall survival (OS) were determined in the total cohort and in treatment-related sub-cohorts. Cox regression analyses were carried out to exclude confounders.

Results

Among 216 patients with ALK-rearranged NSCLC, the frequency of pathogenic TP53 mutations was 23.8%, while other co-occurring mutations were rare events. In ALK/TP53 co-mutated patients, median PFS and OS were significantly lower compared with TP53 wildtype patients [PFS 3.9 months (95% CI: 2.4–5.6) versus 10.3 months (95% CI: 8.6–12.0), P < 0.001; OS 15.0 months (95% CI: 5.0–24.9) versus 50.0 months (95% CI: 22.9–77.1), P = 0.002]. This difference was confirmed in all treatment-related subgroups including chemotherapy only [PFS first-line chemotherapy 2.6 months (95% CI: 1.3–4.1) versus 6.2 months (95% CI: 1.8–10.5), P = 0.021; OS 2.0 months (95% CI: 0.0–4.6) versus 9.0 months (95% CI: 6.1–11.9), P = 0.035], crizotinib plus chemotherapy [PFS crizotinib 5.0 months (95% CI: 2.9–7.2) versus 14.0 months (95% CI: 8.0–20.1), P < 0.001; OS 17.0 months (95% CI: 6.7–27.3) versus not reached, P = 0.049] and crizotinib followed by next-generation ALK-inhibitor [PFS next-generation inhibitor 5.4 months (95% CI: 0.1–10.7) versus 9.9 months (95% CI: 6.4–13.5), P = 0.039; OS 7.0 months versus 50.0 months (95% CI: not reached), P = 0.001).

Conclusions

In ALK-rearranged NSCLC co-occurring TP53 mutations predict an unfavorable outcome of systemic therapy. Our observations encourage future research to understand the underlying molecular mechanisms and to improve treatment outcome of the ALK/TP53 co-mutated subgroup.

Everolimus with paclitaxel and carboplatin as first-line treatment for metastatic large-cell neuroendocrine lung carcinoma: a multicenter phase II trial

Background

Large-cell neuroendocrine carcinoma of the lung (LCNEC) is a rare disease with poor prognosis and limited treatment options. Neuroendocrine tumors frequently show overactivation of the mTOR pathway. Based on the good activity of the mTOR inhibitor everolimus in different types of neuroendocrine tumors and the results of a previous phase I trial, we evaluated the efficacy and safety of everolimus in combination with carboplatin and paclitaxel as upfront treatment for patients with advanced LCNEC.

Patients and methods

In this prospective, multicenter phase II trial chemotherapy-naive patients with stage IV LCNEC received 5 mg everolimus daily combined with paclitaxel 175 mg/m2 and carboplatin AUC 5 every 3 weeks for a maximum of four cycles followed by maintenance everolimus 5 mg daily until progression. Efficacy parameters were determined based on central radiologic assessment.

Results

Forty-nine patients with a mean age of 62 ±9 years and a predominance of male (71%) smokers (98%) were enrolled in 10 German centers. The overall response rate was 45% (95% confidence interval [CI] 31%-60%), the disease control rate 74% (CI 59%-85%), the median progression-free survival 4.4 (CI 3.2-6) months and the median overall survival 9.9 (CI 6.9-11.7) months. The progression-free survival rate at 3 months (primary end point) was 76% (CI 64%-88%) according to Kaplan-Meier. Grade-3/4 toxicities occurred in 51% of patients and mainly consisted of general physical health deterioration (8%), cytopenias (24%), infections (10%) and gastrointestinal problems (8%). Typical everolimus-related adverse events, like stomatitis, rash and ocular problems occurred only in a minority of patients (<15%) and were exclusively of grade 1-2.

Conclusion

Everolimus in combination with carboplatin and paclitaxel is an effective and well-tolerated first-line treatment for patients with metastatic LCNEC.

Registered clinical trial numbers

EudraCT number 2010-022273-34, NCT01317615.

[Employing tyrosine kinase inhibitors in the first line treatment of EGFR-positive metastatic NSCLC - state of the art and recent developments]

In this review article we present an overview of recent developments in EGFR TKIs in lung cancer therapy. Besides the approved drugs erlotinib and gefitinib, clinical data on second-generation irreversible TKIs including afatinib, dacomitinib, neratinib, pelitinib, and canertinib are mentioned; these drugs not only inactivate EGFR but show a broader range of activity. We also report on NSCLC data of TKI that are known and approved in other indications, such as lapatinib and vandetanib. We stress the importance of quality of life in the treatment of patients with TKIs, an important aspect of the treatment that should also be considered in the selection of the appropriate NSCLC therapy in advanced stages.

[Gender-specific difference in lung cancer]

More and more differences in lung cancer are being detected between men and women. Lung cancer, at the beginning of the last century a rare disease in women, has a growing incidence in women, in particular in young females. Lung cancer is a leading cause of cancer death in women in developed countries with different histological types and adenocarcinomas are more frequent in women than in men. Cigarette smoking is the most prevalent cause of lung cancer in women, in addition susceptibility to carcinogens may differ between the sexes. As more non-smoking women than men develop lung cancer, it is likely that they are exposed to excessive environmental carcinogens such as second-hand-smoking, in-house-radon or cooking fumes. Furthermore, genetic and hormonal influences play a role in lung cancer etiology for women. Taken together, women have a better overall survival than men with lung cancer. Differences in molecular susceptibility patterns are observed between men and women, and show that molecular targets such as EGFR or ALK more frequent in women.

Randomized phase 2 trial on refinement of early-stage NSCLC adjuvant chemotherapy with cisplatin and pemetrexed versus cisplatin and vinorelbine: the TREAT study

BACKGROUND

Adjuvant chemotherapy is beneficial in non-small-cell lung cancer (NSCLC). However, balancing toxicity and efficacy mandates improvement.

PATIENTS AND METHODS

Patients with completely resected stages IB-pT3N1 NSCLC were randomly assigned to either four cycles cisplatin (C: 50 mg/m(2) day (d)1 + 8) and vinorelbine (V: 25 mg/m(2) d1, 8, 15, 22) q4 weeks or four cycles cisplatin (75 mg/m(2) d1) and pemetrexed (Px: 500 mg/m(2) d1) q3 weeks. Primary objective was the clinical feasibility rate (no grade (G)4 neutropenia/thrombocytopenia or thrombocytopenia with bleeding, no G3/4 febrile neutropenia or non-hematological toxicity; no premature withdrawal/death). Secondary objectives were drug delivery and efficacy.

RESULTS

One hundred and thirty two patients were randomized (stages: 38% IB, 10% IIA, 47% IIB, 5% pT3pN1; histology: 43% squamous, 57% non-squamous). The feasibility rates were 95.5% (cisplatin and pemetrexed, CPx) and 75.4% (cisplatin and vinorelbine, CVb) (P = 0.001); hematological G3/4 toxic effects were 10% (CPx) and 74% (CVb) (P < 0.001), non-hematological toxic effects were comparable (33% and 31%, P = 0.798). Delivery of total mean doses was 90% of planned with CPx, but 66% (cisplatin) and 64% (vinorelbine) with CVb (P < 0.0001). The median number of cycles [treatment time (weeks)] was 4 for CPx (11.2) and 3 for CVb (9.9). Time to withdrawal from therapy differed significantly between arms favoring CPx (P < 0.001).

CONCLUSION

Adjuvant chemotherapy with CPx is safe and feasible with less toxicity and superior dose delivery compared with CVb.

Cetuximab combined with either gemcitabine (G) followed by docetaxel (D) or carboplatin/gemcitabine (CP/G) in chemotherapy-naive patients (pts) with advanced non-small cell lung cancer (NSCLC): Safety profile from the ongoing phase II/III GemTax IV trial

8048

Background: The EGFR-targeting antibody cetuximab is undergoing broad clinical investigation in NSCLC. Our randomized trial assesses the safety of cetuximab combined with 2 different chemotherapy (CT) regimens in pts with advanced NSCLC. Phase II results are reported. Methods: Pts with histologically confirmed stage IIIB or IV NSCLC, WHO PS 0–2, and no prior CT received cetuximab 400 mg/m2 loading dose followed by 250 mg/m2 weekly either combined with G 1000 mg/m2 days 1 + 8 for 2 cycles (3qw) followed by D 75 mg/m2 day 1 for 2 cycles (q3w) (arm A) or CP AUC5 day 1 and G 1200 mg/m2 days 1 + 8 for 4 cycles (q3w) (arm B). Maintenance cetuximab was administered until disease progression or unacceptable toxicity. Results: 229 pts evaluable for safety received 1810 infusions of cetuximab combined with CT and 1216 infusions of maintenance cetuximab. 35 pts in arm A received 1–26 cycles (median 4) of maintenance cetuximab and 6 pts received ≥10 cycles; 50 pts in arm B received 1–22 cycles (median 3) and 7 pts ≥10 cycles. Grade 1 or 2 skin reactions related to study medication occurred in 84% of pts in arm A and 77% in arm B. In general, toxicity was more common in pts receiving CP (leukopenia and neutropenia 10%; pneumonia and fever 10%). In arm B, thrombopenia developed in 14% of pts and allergic reactions in 8%. Toxicities requiring clinical intervention are shown below. Updated results will be presented for 320 pts. Conclusions: Cetuximab does not significantly increase CT toxicity in the induction phase and is well tolerated in the maintenance phase. Notably, ∼75% of pts developed skin rash (grade 3/4 in ∼5% of pts).

[Table: see text]

[Table: see text]

[Modern endoscopic procedures for diseases of the respiratory tract]

Bronchoscopy is the most important diagnostic procedure for the work-up of central bronchial processes and parenchymal lung diseases, such as lung cancer, pneumonias or diffuse lung diseases. Recent progress - ultrasound, navigation systems or ultrathin bronchoscopes - was made to achieve a better yield in the diagnosis of peripheral and peribronchial lesions. Bronchial recanalisation by thermal ablation or stenting is mainly performed with rigid instruments; these procedures as well as brachytherapy in local anaesthesia should be restricted to specialized centers. If pleuracentesis does not provide the etiology of pleural effusion, thoracoscopy in local anaesthesia is the method of choice. The procedure does not only provide a definite diagnosis for almost all of the patients, it also allows the immediate option for talcum poudrage in case of pleural malignancy.

Pemetrexed in second-line therapy in patients with malignant pleural mesothelioma

18198

Introduction: Based on the study of Vogelzang (2003) standard treatment in patients with malignant pleural mesothelioma (MPM) is pemetrexed cisplatin with a medium survival of 12 months compared to 9 months with cisplatin therapy. As this treatment prolongs survival, but is not a curative treatment, many patients will relapse during the course of their disease. In sensitive relapses (within more than 3 months) our policy was to reintroduce pemetrexed therapy in unselected consecutive patients. Methods: Retrospective analysis of 17 consecutive patients treated in our hospital. Patient characteristics: 17 patients (pat), 14 males, 3 females, with MPM were included between April 2004 and November 2006 with an age between 45 and 82 years, with a median age of 65 years. Histologic subtypes were: 16 epithelial, 1 biphasic MPM. Pretreatment: 8 pat. had undergone palliative debulcing surgery (pleurectomy) 1 pat. underwent EPP. All patients were pretreated with platinum /pemetrexed, 5 pat. were pretreated with platinum/Gemcitabine before the availability of pemetrexed. 2nd line chemotherapy: 9 pat. were treated with carboplatin AUC5 / pemetrexed 500 mg/m2, 1 patient had cisplatinum 75 mg/m2/Pemetrexed 500 mg/m2 and 7 patients had pemetrexed single agent therapy (500 mg/m2 d1, WH d21), repeated on day 22 respectively. Results: Response: 6% (n=1) PR, MR: 12% (n=2 )., NC: 47% (n=8)., PD: 35% (n= 6), clinical benefit (PR, MR, NC) was seen in 65% of ou pat. Toxicity: Pemetrexed/Carboplatin or pemetrexed therapy were well tolerated, toxicity was mild: one patient developed mild sensory neurotoxicity (peripheral sensory neuropathy) (WHO II) under 6 cycles pemetrexed, 35% developed mild fatigue (Who I and II), one patient had mild renal impairment, no alopecia was seen. Survival: Only 3 patients had still died, median survival from start of second-line pemetrexed-therapy was not reached, time to progression was between 25 and 630 days, 4 pat. had not progressed until now. Conclusion: Second line therapy in MPM is not yet standard of care. Nevertheless patients with progressive disease following pemetrexed/platinum therapy may benefit from second line pemetrexed reintroduction therapy. Clinical benefit was seen in 65% with low toxicity.

No significant financial relationships to disclose.

Multimodale Therapie des kleinzelligen und nichtkleinzelligen Lungenkarzinoms

Lung cancer is divided into two types: non-small cell and small cell lung cancer. Small-cell lung cancer is a very aggressive rapid growing tumour type treated primarily with chemotherapy and, in the minority of patients with limited disease, with radiotherapy. Non-small cell lung cancer is treated in a multidisciplinary way with surgery, radiotherapy and chemotherapy depending on stage. Surgery is the mainstay of treatment for early stage non-small cell lung cancer patients. Adjuvant therapy has become state of the art in stage II and IIIA patients and must be considered in stage IB. Stage III patients should be treated in a multimodal way with radiotherapy and chemotherapy, and, if possible, with surgery. Treatment for every stage III patient should be discussed in a multidisciplinary team. Stage IV patients in good performance status will benefit from a combination chemotherapy, preferably platinum-based. Second line therapy has become standard and targeted therapies are under evaluation and are common in second line chemotherapy.