Final results of the IFCT-0803 study, a phase II study of cetuximab, pemetrexed, cisplatin, and concurrent radiotherapy in patients with locally advanced, unresectable, stage III, non-squamous, non-small-cell lung cancer

PURPOSE

Roughly 20% of patients with non-small-cell lung cancer exhibit locally advanced, unresectable, stage III disease. Concurrent platinum-based chemoradiotherapy is the backbone treatment, which is followed by maintenance immunotherapy, yet with poor long-term prognosis. This phase II trial (IFCT-0803) sought to evaluate whether adding cetuximab to cisplatin and pemetrexed chemoradiotherapy would improve its efficacy in these patients.

MATERIALS AND METHODS

Eligible patients received weekly cetuximab (loading dose 400mg/m² day 1; subsequent weekly 250mg/m² doses until two weeks postradiotherapy). Chemotherapy comprised cisplatin (75mg/m²) and pemetrexed (500mg/m²), both delivered on day 1 of a 21-day cycle of maximally four. Irradiation with maximally 66Gy started on day 22. Disease control rate at week 16 was the primary endpoint.

RESULTS

One hundred and six patients were included (99 eligible patients). Compliance exceeded 95% for day 1 of chemotherapy cycles 1 to 4, with 76% patients receiving the 12 planned cetuximab doses. Maximal grade 3 toxicity occurred in 63% patients, and maximal grade 4 in 9.6%. The primary endpoint involving the first 95 eligible patients comprised two (2.1%) complete responses, 57 (60.0%) partial responses, and 27 (28.4%) stable diseases. This 90.5% disease control rate (95% confidence interval [95% CI]: 84.6%-96.4%) was achieved at week 16. After median 63.0-month follow-up, one-year and two-year survival rates were 75.8% and 59.5%. Median overall survival was 35.8months (95% CI: 23.5-NR), and median progression-free survival 14.4months (95% CI: 11.2-18.8), with one-year and two-year progression-free survival rates of 57.6% and 34.3%.

CONCLUSION

These survival rates compare favourably with published data, thus justifying further development of cetuximab-based induction chemoradiotherapy.

Weekly paclitaxel plus bevacizumab versus docetaxel as second- or third-line treatment in advanced non-squamous non-small-cell lung cancer: Results of the IFCT-1103 ULTIMATE study

PURPOSE

Second-line chemotherapy regimens have demonstrated poor benefit after failure of platinum-based chemotherapy in advanced non-squamous non-small-cell lung cancer (nsNSCLC).

METHODS

In this multicentre, open-label phase III trial, patients with advanced nsNSCLC treated with one or two prior lines, including one platinum-based doublet, were centrally randomised to receive 90 mg/m² of paclitaxel (D1, D8, D15) plus 10 mg/kg of bevacizumab (D1, D15) every 28 days or docetaxel (75 mg/m²) every 21 days; crossover was allowed after disease progression. Primary end-point was progression-free survival (PFS). ClinicalTrials.gov registration number: NCT01763671.

RESULTS

One hundred sixty six patients were randomised (paclitaxel plus bevacizumab: 111, docetaxel: 55). The median PFS was longer in patients receiving paclitaxel plus bevacizumab than in patients receveing docetaxel [5·4 months versus 3·9 months, adjusted hazard ratio (HR) 0·61 (95% confidence interval [CI]: 0·44-0·86); p = 0·005]. Objective response rates (ORRs) were 22·5% (95% CI: 14·8-30·3) and 5·5% (95% CI: 0·0-11·5) (p = 0·006), respectively. Median overall survivals were similar (adjusted HR 1·17; p = 0·50). Crossover occurred in 21 of 55 (38·2%) docetaxel-treated patients. Grade III-IV adverse events (AEs) were reported in 45·9% and 54·5% of patients treated with paclitaxel and bevacizumab or docetaxel, respectively (p = NS), including neutropenia (19·3% versus 45·4%), neuropathy (8·3% versus 0·0%) and hypertension (7·3% versus 0·0%). Three patients died due to treatment-related AEs (1·8% in each group).

CONCLUSION

Weekly paclitaxel plus bevacizumab as second- or third-line improves PFS and ORR compared with docetaxel in patients with nsNSCLC, with an acceptable safety profile. These results place weekly paclitaxel plus bevacizumab as a valid option in this population.

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01763671.

New insights into stage and prognosis in small cell lung cancer: an analysis of 968 cases

Background

The French College of General Hospital Respiratory Physicians conducted two studies that consecutively included all patients followed in participating general hospitals for primary small cell (SCLC) or non-small cell (NSCLC) lung cancer diagnosed in 2000 and 2010. These studies allow descriptive statistics and outcome assessment for SCLC and NSCLC separately and comparison over a 10-year period.

Methods

A standardised form was completed for each patient at inclusion. Then, vital status was collected.

Results

In 2000 and 2010, 948 (15.5% female) and 968 (23.3%) SCLC patients, mainly heavy active- or former-smoker seniors, participated in these studies. One-year survival rate was 35.8% for SCLC vs. 44.8% for NSCLC in 2010 and 33.1% for SCLC in 2000. In 2010, in reference to stage 0-IIB (4.1% of SCLCs), the hazard ratio was 0.92 [95% confidence interval (CI): 0.6-1.5; P=0.76], 1.8 (95% CI: 1.1-2.8; P=0.019), and 3.4 (95% CI: 2.2-5.3; P<0.001) for stage IIIA (10.2%), IIIB (14.5%), and IV (71.2%). Positron emission tomography (PET)-scan use, which has increased in 10 years, was frequent in patients with limited disease.

Conclusions

One-year survival in SCLC patients was poor in 2010 and dependent of SCLC stage. TNM classification reintroduction and new diagnostic techniques (e.g., PET-scan) should allow lung oncologists to tailor treatment based on disease stage at diagnosis.

Study KBP-2010-CPHG: Characteristics and management of 7,051 new cases of lung cancer managed in French general hospitals in 2010

1574

Background: An initial epidemiologic study was performed in 2000 by the French College of General Hospital Respiratory Physicians (Study KBP-2000-CPHG). Over the last 10 years, lung cancer management changed: new drugs such as targeted therapies appeared; new diagnostic techniques such as exploration for genetic mutations in the tumour have been developed; a new TNM classification has been drawn up. The aims of this study were to describe patient characteristics, first-line management, 1, 4 and 5-year survival rates and to compare the results with those of Study KBP-2000-CPHG. Methods: A prospective multi-centre study included all patients ≥18 years presenting with a new case of primary lung cancer, histologically or cytologically diagnosed between 1 January and 31 December 2010 and managed by one of the participating centers. A standardised form was completed for each patient. A steering committee checked the exhaustivity of data’s collection. Results: 7,610 patients from 119 general hospitals were included between 1 January and 31 December 2010. The main patient characteristics were: mean age 65.5 years (+/-11.3); 24.3% female; 10.9% non-smokers, 39.9% ex-smokers, 49.2% current smokers; 68.9% performance status 0 and 1; 9.1% of patients had lost >10 kg within the previous 3 months. The main tumour characteristics were: 13.7% small-cell lung cancer; 46.2% adenocarcinoma, 26.8% squamous-cell carcinoma; EGFR mutation, explored in 30.5% of cases, were found in 10.5% of cases; 16.4% stage IA to IIB, 13.4% stage IIIA, 10.2% stage IIIB and 60.0% stage IV. First-line treatments were: curative surgery, 16.6%; chemotherapy, 63.4%; radiotherapy alone, 17.8%; combined radio-chemotherapy, 8.8%; and supportive care, 11.1%. Targeted therapy was used in 6.6% of patients treated by chemotherapy. Conclusions: In 10 years, characteristics of lung cancer patients changed with an significantly increase of women, non-smokers, adenocarcinoma histology and stage IV at diagnosis.

Postoperative follow-up of lung cancer: Randomized trial comparing two follow-up programs in completely resected non-small cell lung cancer (IFCT-0302)

TPS7111

Background: There are no robust data published on the follow-up after surgery for non-small cell lung cancer (NSCLC). Current international guidelines are informed by expert opinion. Most of them recommend regular follow-up with clinic visit and thoracic imaging, either chest X-ray of Chest CT-scan. The IFCT-0302 trial addresses the question whether a surveillance program with chest CT-scan and fiberoptic bronchoscopy can improve survival compared to a follow-up only based on physical examination and chest x-ray. There is no such trial ongoing over the world. Methods: The IFCT-0302 trial is a multicenter open-label controlled randomized phase III trial. The objective of the trial is to compare two follow-up programs after surgery for stage I-IIIa NSCLC. The primary endpoint is overall survival. Patients are randomly assigned to arm 1, minimal follow-up, including physical examination and chest x-ray; or arm 2, a follow-up consisting of physical examination and chest x-ray plus chest CT scan and fiberoptic bronchoscopy (optional for adenocarcinomas). In both arms, follow-up procedures are performed every 6 months during the first two postoperative years, and every year between the third and the fifth years. The main eligibility criteria include: completely resected stage I-IIIA (6th UICC TNM classification) or T4 (in case of nodules in the same lobe as the tumor) N0 M0 NSCLC, surgery within the previous 8 weeks. Patients who have received and/or who will receive pre/post-operative chemotherapy and/or radiotherapy are eligible. Statistical considerations: 1,744 patients is required. Accrual status: 1,568 patients from 119 French centers had been included. The end of accrual can be expected for September 2012. Ancillary study: Blood samples are collected in 1000 patients for genomic high density SNP micro-array analysis. This collection will contribute to the French genome wide association study (gwas) of lung cancer gene susceptibility, and the genetic factors predictive of survival and lung cancer recurrence will be analyzed.

[Primary non-small-cell lung cancer: analysis of 419 T1 (<or=3 cm) tumors in the KBP-2000-CPHG study]

T1 tumors have the best prognosis among primary non-small-cell lung cancers, basically because surgery is generally possible. Among 5.667 patients with primary lung cancer included in the KBP-2000-CPHG study, we examined the characteristics of 419 T1 tumors, i.e. 9.2% of the non-small-cell cancers. Compared with the group of patients with non-T1 tumors, patients with T1 tumors were younger (p=0.0007). They had an equivalent percentage of squamous-cell tumors but more adenocarcinomas (40.3% versus 35.5%, p=0.05). TNM staging showed that 27.6% of the T1 tumors were metastatic at diagnosis (stage IV) with 12.4% T1N0M1 nad 15.2% T1N1-3M1. For the M0 tumors, 52.2% were T1N0 (stage IA) and 20.1% were T1N1-3. Squamous-cell tumors were significantly more frequent among the T1M1 tumors (p=0.07). More than one quarter (27.6%) of the T1 tumors were in stage IV, pointing out the importance of the initial work-up. This findings suggests we should revisit strategies in order to take into account new diagnostic possibilities. Likewise for the therapeutic strategy. Combinations using chemotherapy, surgery and radiotherapy should be better defined for this group of tumors.

[Lung volume reduction surgery in emphysema]

Lung volume reduction surgery in emphysema has, as an objective, the reduction of dyspnoea and an increase in the exercise tolerance in patients with respiratory insufficiency suffering from diffuse emphysema. In principle the resection of the most diseased areas of emphysema leads to improvement in the mechanical properties of the emphysematous lung and correct pulmonary hyperinflation. The respiratory function benefits both objective and subjective, produced by surgery are real but transitory and inconstant depending in particular on the evolutionary profile of the emphysematous disease. The indications should be further refined and an objective comparison of different surgical techniques has not been achieved. The impact on the quality of life for these patients is unknown.

Progressive obstructive lung disease associated with microscopic polyangiitis

Small airway involvement and progressive severe airflow obstruction are unexpected features in patients with microscopic polyangiitis. We report the case of a patient with microscopic polyangiitis and circulating anti-neutrophil cytoplasmic antibodies (ANCA), who developed pulmonary hyperinflation and airflow obstruction over a 7-yr period. Systemic manifestations of this vasculitis improved under corticosteriods and cyclophosphamid therapy, a treatment that did not influence either the very high level of anti-myeloperoxidase antibodies or the ventilatory impairment. Small airway involvement was suspected on the basis of pathologic small airway lesions and a mild emphysematous pattern on computed tomography (CT) scan, which was out of proportion with the severity of the obstructive lung disease.

[Pulmonary emphysema: surgical indications]

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Refractory hypoxemia during liver cirrhosis. Hepatopulmonary syndrome or "primary" pulmonary hypertension?

We report an uncommon mechanism of severe hypoxemia in two cirrhotic patients under long-term beta-blocker therapy. Our patients presented with profound hypoxemia refractory to oxygen therapy, normal lung radiography and pulmonary function tests, and evidence of right-to-left anatomic shunt. Although these features are highly suggestive of hepatopulmonary syndrome, pulmonary hypertension was present, and a right-to-left shunt through a patent foramen ovale was demonstrated by contrast-enhanced echocardiography. No cause of pulmonary hypertension other than portal hypertension was identified. Pulmonary hypertension and intracardiac right-to-left shunt eventually regressed after discontinuation of beta-blocker therapy. We conclude that "primary" pulmonary hypertension associated with portal hypertension may because of severe hypoxemia during liver cirrhosis. Differential diagnosis of hepatopulmonary syndrome relies upon contrast-enhanced echocardiography and may be of critical importance because of possible therapeutic implications.

Clinical significance of the pulmonary vasodilator response during short-term infusion of prostacyclin in primary pulmonary hypertension

BACKGROUND

The short-term vasodilator response to prostacyclin (PGI2) in patients with primary pulmonary hypertension (PPH) is not only unpredictable but also extremely variable in magnitude. In this retrospective study, we attempted to evaluate in a nonselected population of patients with PPH the degree of vasodilatation achieved during short-term infusion of PGI2 and to investigate whether patients with PPH differed in terms of baseline characteristics and prognoses, according to the level of vasodilatation achieved during initial testing with PGI2.

METHODS AND RESULTS

Between 1984 and 1992, 91 consecutive patients with PPH underwent catheterization of the right side of the heart with a short-term vasodilator trial with PGI2 (5 to 10 ng.kg-1.min-1). According to the level of vasodilatation achieved during PGI2 infusion, patients were divided into three groups: nonresponding (NR, n = 40), moderately responding (MR, n = 42), and highly responding (HR, n = 9) patients. All three groups were defined by a decrease in total pulmonary resistance index (TPRi) of < 20%, between 20% and 50%, and > 50%, respectively, relative to control values. Prolonged oral vasodilator therapy was subsequently started only in MR and HR patients. All patients had long-term oral anticoagulant therapy. The survival rate at 2 years (transplant recipients excluded) was significantly higher in HR patients compared with NR and MR patients (62% versus 38% and 47% survivors, respectively; P < .05). Comparisons between groups showed no significant differences in baseline hemodynamics or clinical characteristics except for a longer time between onset of symptoms and diagnosis (ie, first catheterization) of PPH in HR patients than in NR and MR patients (71 +/- 61 versus 35 +/- 34 and 21 +/- 21 months, respectively; P < .05).

CONCLUSIONS

In this study, patients with PPH exhibiting a decrease in TPRi > 50% during short-term PGI2 challenge at the time of diagnosis had longer disease evolutions and better prognoses than patients with a lower vasodilator response.

Mucosal T-lymphocytes in central airways of lung transplant recipients

The immunohistochemical profile of mucosal lymphocytes was investigated in the central airways of lung transplant recipients. Bronchial and transbronchial biopsies (BB and TBB, respectively) and bronchoalveolar lavage for culture of bacteria and viruses were performed during a fibroscopic procedure in patients without evidence of chronic rejection, 3 to 10 mo after surgery. Analysis was restricted to samples without concurrent airway infection: 23 pairs of BB and TBB from 18 transplant recipients were analyzed. An immunohistochemical technique was used to identify and score mucosal cells that reacted with monoclonal antibodies against CD4, CD8, CD45-Ro (memory T-cells), and HLA-DR molecules. The same procedure was applied in nine nonsmoking control subjects (NS group). Data from transplant recipients were allocated to R+ (n = 11) or R- groups (n = 12), depending on the presence or absence of histologic evidence of acute rejection on TBB. A statistically significant depletion of every immunoreactive cell subset was observed in the R+ and the R- groups, but not in the NS group. Conversely, no significant difference for either score of immunoreactive cells were found between R+ and R- groups. The immunosuppressive regimen is suspected to play to play a major role in this depletion of bronchial mucosal T-cells. The acute lung rejection process does not appear to affect concurrently the immunohistochemical profile of immunoreactive cells in the bronchial mucosa.

Pulmonary reimplantation response in single-lung transplantation

We studied the characteristics of the pulmonary reimplantation response (PRR) in single-lung transplantation (SLT), and detailed the occurrence, evolution, prognosis and risk factors of this complication. Forty single-lung transplant recipients were studied. Twenty four patients developed hypoxaemia and allograft infiltrates consistent with the PRR. In 40% of the cases hypoxaemia was severe, precluding weaning and requiring prolonged mechanical ventilation with high fractional inspiratory oxygen (FIO2). The mean duration of ventilation was 7 days (range 1-19 days). Clearing of the chest radiographs was progressive, with complete resolution between 6 and 21 days. In all cases, the pulmonary arterial wedge pressure was normal (6 +/- 2 mmHg) suggesting low pressure oedema. Sampling of the pulmonary oedema fluid revealed that the ratio of protein concentration in oedema fluid to that in serum exceeded 0.5. In patients with severe PRR (40% of cases) clinical, radiographic and haemodynamic abnormalities were identical to adult respiratory distress syndrome (ARDS), but the prognosis was more favourable with no death directly related to PRR in our patients. The mean duration of graft ischaemia of the oedematous grafts (241 +/- 103 min) was significantly longer than that of nonoedematous grafts (155 +/- 71 min). These date suggest that prolongation of graft ischaemia increased the incidence of PRR.

[Severe acute asthma in adults]

Despite a better understanding of the physiopathology of asthma and the availability of potent drugs, severe acute asthma is still a frequent cause of death (1500 to 2000 patients die each year of asthma in France). Among the different clinical presentations, hyperacute attack with an attack duration (period from onset of attack to mechanical ventilation or to fatality) of less than 3 hours has to be individualized. The agents of choice in the treatment of acute life-threatening asthma are oxygen, beta-adrenergic sympathomimetic amines given intravenously or by nebulization, and corticosteroids. Theophylline is not any more the first choice of treatment but should not be rejected. Anticholinergics given by nebulization in combination with sympathomimetic agents are effective. Beside these treatment, hydratation and antibiotics are important adjunctive treatment. Mechanical ventilation is rarely necessary but has to be instituted either in emergency in case of near fatal asthma or electively because of deterioration of clinical status and blood gases, despite full medical treatment.