Chemotherapy improves low performance status lung cancer patients

The aim of the present study was to determine the potential benefit of conventional cisplatin-based chemotherapy on patients with advanced nonsmall cell lung cancer (NSCLC) and poor performance status (PS), defined as 60-70 on the Karnofsky scale. Retrospective analysis was carried out of a randomised trial performed in advanced NSCLC where 485 patients received three courses of gemcitabine+ifosfamide+cisplatin induction chemotherapy. Of the patients, 80% had good PS (Karnofsky 80-100) and 20% poor PS. Response rates were 38 and 28%, respectively. Clinical improvement, defined as achieving a good PS during chemotherapy, was observed overall in 25% of the poor PS patients, with rates of 38, 20 and 14%, respectively, in case of response, no change and progression. PS improved more quickly in the responders. Survival of patients with poor PS was significantly worse, but survival of responders was similar, irrespective of the initial poor or good PS. Although nonfatal toxicity was almost similar, there were more toxic deaths (including vascular and cardiac fatalities) in the poor PS patients (9.2 versus 2.1%). In conclusion, combination chemotherapy is associated with clinical improvement in a substantial number of patients with advanced nonsmall cell lung cancer of poor performance status.

A phase III randomised trial comparing sequential chemotherapy using cisplatin-based regimen and paclitaxel to cisplatin-based chemotherapy alone in advanced non-small-cell lung cancer

BACKGROUND

The purpose of this study is to determine whether in advanced non-small-cell lung cancer (NSCLC), the sequential administration of cisplatin-based chemotherapy and paclitaxel (Taxol) is superior to a cisplatin-based chemotherapy, followed by paclitaxel as salvage treatment.

PATIENTS AND METHODS

A total of 485 chemotherapy naive patients with advanced NSCLC were treated with three courses of GIP (gemcitibine + ifosfamide + cisplatin), consisting of cisplatin 50 mg/m(2) on day 1, ifosfamide 3 g/m(2) on day 1 and gemcitabine 1 g/m(2) on days 1 and 8. Patients with nonprogressive disease were then randomised to further similar courses of GIP or courses of paclitaxel (225 mg/m(2) over 3 h every 3 weeks).

RESULTS

Objective response or nonprogression after induction GIP occurred in 174 and 115 patients, respectively. After randomisation, there were 140 patients in the GIP arm and 141 in the paclitaxel arm. In terms of postrandomisation survival, there was no statistically significant difference (P = 0.17) between the two arms. Median times were 9.7 [95% confidence interval (CI) 7.8-11.6] and 11.9 (95% CI 9.4-14.3) months for paclitaxel and GIP, respectively. Multivariate analysis demonstrated that sex and haemoglobin were independent prognostic factors. After adjustment for these factors, the observed hazard ratio was 0.81 (95% CI 0.63-1.04) in favour of GIP (P = 0.10). Toxicity was tolerable; there was a significantly higher rate of grades III/IV thrombocytopenia with GIP and more alopecia with paclitaxel.

CONCLUSION

Sequential chemotherapy using cisplatin-based regimen followed by paclitaxel does not result in better outcome than cisplatin-based chemotherapy using taxane as salvage treatment.

Second-line paclitaxel in non-small cell lung cancer initially treated with cisplatin: a study by the European Lung Cancer Working Party

In the context of a phase III trial comparing in advanced non-small cell lung cancer (NSCLC) sequential to conventional administration of cisplatin-based chemotherapy and paclitaxel, we evaluated the activity of paclitaxel as second-line chemotherapy and investigated any relation of its efficacy with the type of failure after cisplatin. Patients received three courses of induction GIP (gemcitabine, ifosfamide, cisplatin). Non-progressing patients were randomised between three further courses of GIP or three courses of paclitaxel. Second-line paclitaxel was given to patients with primary failure (PF) to GIP and to those progressing after randomisation to further GIP (secondary failure or SF). One hundred sixty patients received second-line paclitaxel. Response rates were 7.7% for PF and 11.6% for SF (P=0.42). Median survival times (calculated from paclitaxel start) were 4.1 and 7.1 months for PF and SF (P=0.002). In multivariate analysis, three variables were independently associated with better survival: SF (hazard ratio (HR)=1.55, 95% confidence interval (CI) 1.08–2.22; P=0.02), normal haemoglobin level (HR=1.56, 95% CI 1.08–2.26; P=0.02) and minimal weight loss (HR=1.79, 95% CI 1.26–2.55; P=0.001). Paclitaxel in NSCLC patients, whether given for primary or for SF after cisplatin-based chemotherapy, demonstrates activity similar to other drugs considered active as second-line therapy.

Hypothermia and Hodgkin's disease: case report and review of the literature

We reported the case of a patient with stage IV Hodgkin's disease (involving the nodes and Liver) presenting with paraneoplastic fever and who subsequently developed hypothermia during chemotherapy administration. We also reviewed the 12 other cases of hypothermia in Hodgkin's disease reported in the literature and discussed the most probable physiopathologic aetiologies.

Prognostic role of thyroid transcription factor-1 in stage III non-small cell lung cancer

Stage III NSCLC represents a heterogeneous group and the ISS remains unsatisfactory in term of prognosis prediction. The aim of the present study was to determine the role of TTF-1 as prognostic factor in stage III NSCLC in addition to other known clinical factors. All stage III NSCLC patients treated in our hospital were retrieved and searched for biopsy specimens. TTF-1 was assessed by immunohistochemistry (Novocastra SPT24). Between 01/1987 and 07/2003, 108 assessable stage III NSCLC patients were included in the study. Their principal characteristics were: median age 64 years (range 37-83), male/female 81/27, squamous/non squamous 52/56, IIIA/IIIB 44/64, median Karnofsky PS 80 (range 20-100). Forty-four patients were positive for TTF-1 (squamous 25.0% versus non-squamous 55.4%). In multivariate analysis, only three factors were statistically significantly associated with better survival: good PS, surgery and creatinine level.

CONCLUSION

In stage III NSCLC patients, good PS, resectability and low creatinine level but not TTF-1 are prognostic factors for survival.

Mitomycin, ifosfamide, cisplatin for non-small cell lung cancer: an implementation study

BACKGROUND

The MIP regimen (mitomycin, ifosfamide, cisplatin) demonstrated its effectiveness as first-line chemotherapy in phase II and III trials in NSCLC. We aimed to determine whether these results could be confirmed in a hospital population.

METHODS

Between 1987 and 2004, 204 patients with NSCLC received MIP in our institution. Patients treated in and off trials received the same combination of cisplatin (50 mg/m2), ifosfamide (3 g/m2) and mitomycin C (6 mg/m2) every three weeks and were staged and followed in a similar way.

RESULTS

Response rates for patients treated in or outside trials were 36.8% and 40.7%, respectively. After multiple logistic regressions, the only statistically significant factor predicting objective response was stage. The median survival time was 54.6 and 43.7 weeks respectively for patients treated in and outside trials. In multivariate analysis, four factors were statistically significantly associated with better survival: good performance status (p = 0.003), normal LDH value (p < 0.001), early stage (p = 0.01) and active smoking (p = 0.03).

CONCLUSION

Participation in a clinical trial was not associated with a significant difference in efficacy. This implementation study thus confirms the activity of the MIP regimen when used in the routine management of patients with NSCLC.

EGFR, c-erbB-2 and ki-67 in NSCLC and preneoplastic bronchial lesions

BACKGROUND

The relationships between EGF-R and c-erbB-2 with other factors involved in tumour regulation are not well understood. The aim of this study was to correlate the expression of these markers with tumour proliferation.

MATERIALS AND METHODS

The presence of EGF-R, c-erbB-2 and Ki-67 was evaluated by immunohistochemistry in non-small cell lung cancer (NSCLC) and preneoplastic lesions.

RESULTS

Forty-two percent of the tumours were positive for EGF-R, 22% for c-erbB-2 and 97% for Ki-67. No statistically significant correlation was found between EGF-R and Ki-67, EGF-R and c-erbB-2 or between c-erbB-2 and Ki-67. With regards to Ki-67, a significant difference in survival was noted in favour of patients who did not express the marker. In preneoplastic lesions, most of the low-grade lesions showed neither EGF-R nor Ki-67 staining. In contrast, most of the high-grade lesions stained positively for these proteins.

CONCLUSION

EGF-R and c-erbB-2 do not seem to be correlated with Ki-67 in NSCLC.

A phase II study evaluating the cisplatin and epirubicin combination in patients with unresectable malignant pleural mesothelioma

Few chemotherapeutic agents have demonstrated their efficacy in malignant mesothelioma. The cisplatin plus doxorubicin combination has one of the highest response rates. Epirubicin is an anthracyclin, analogous to doxorubicin, with a different toxicologic pattern. As there are no data on the activity of the combination cisplatin plus epirubicin in malignant mesothelioma, the European Lung Cancer Working Party (ELCWP) designed a phase II study with response rate as primary objective. Sixty-nine eligible patients with malignant pleural mesothelioma were centrally registered. The majority of the patients were male (n=59), had a Karnofsky performance status of 80 or more (n=62) and presented with an epithelial histologic subtype (n=43). Median age was 62 years. In nine patients, metastases were documented at the initial work-up, mainly in bone, lung and skin. Three hundred and twenty-four cycles of chemotherapy were administered. The main toxicities were nausea and vomiting, neutropenia and alopecia. Among 63 assessable patients, response rate was 19.0% (95% confidence interval [CI] 9-29%). Median survival was 13.3 months. In multivariate analysis, poor prognostic factors for survival were neutrophil count and CALGB groups 4-6. In conclusion, cisplatin plus epirubicin appears as an effective regimen in malignant mesothelioma, with a favourable toxicity profile. However, it does not demonstrate superior activity to other active regimens in this disease.

Correction of hyponatremia by urea in a patient with heart failure

A 84 year-old woman presenting with evolving breast cancer was admitted in the intensive care unit for malaise. Profound hyponatremia in the context of symptomatic heart failure was documented. Intravenous infusion of NaCl 0.9% was unsuccessful. Treatment with oral urea was begun and sodium level returned to nearly normal values 5 days later.

Is there a relationship between c-erbB-1 and c-erbB-2 amplification and protein overexpression in NSCLC?

In order to analyse the genetic abnormalities and protein expression of c-erbB-1 and -2, we have performed fluorescence in situ hybridisation (FISH) and immunohistochemistry (IHC) in resected non-small cell lung carcinoma (NSCLC). By IHC (106 patients), 11% of the patients were positive both for c-erbB-1 and -2 protein expression and 47% negative for both proteins. FISH (69 patients) showed a balanced disomy for both c-erbB-1 and -2 in 38%, all other cases had genetic abnormalities in at least one of both genes. c-erbB-2 gene was amplified in less than 10% of the tumours and c-erbB-1 gene was never amplified. c-erbB-2 protein overexpression was observed in only three out of the six cases showing c-erbB-2 amplification. The negative predictive value (NPV) of IHC for gene abnormalities was high for both markers. Median survival time (MST) was respectively of 76 and 174 weeks for patients with or without c-erbB-2 overexpression. Patients with c-erbB-2 amplification had a shorter survival: 125 weeks versus 165 weeks. MST was respectively of 109 and 196 weeks for patients with or without EGFR overexpression and patients with EGFR gene abnormalities had also a shorter survival with MST 136 weeks versus 189 weeks. These differences were not significant. In conclusion, if the majority of NSCLC showed genetic abnormalities in the c-erbB-1 and/or c-erbB-2 gene receptor, amplification could be observed only in a few tumours and was not strictly correlated with protein expression. Finally, survival of patients expressing EGFR and/or c-erbB-2 was slightly shorter.

Survival improvement in resectable non-small cell lung cancer with (neo)adjuvant chemotherapy: Results of a meta-analysis of the literature

The recent publication of many randomised trials about (neo)adjuvant chemotherapy in resectable non-small cell lung cancer (NSCLC) has prompted our group to update a prior meta-analysis of the literature. Randomised studies published in French and English between 1965 and June 2004 were included in this analysis. A qualitative assessment of each trial was first performed using the European lung cancer working party (ELCWP) and the Chalmers' scales. In absence of statistically significant quality difference between positive and negative trials, a quantitative aggregation (meta-analysis) of the individual results was performed. Two trials for which data were available on ASCO virtual meeting website were also included in the meta-analysis. Twenty-five studies eligible for this analysis assessed chemotherapy as induction (n = 6) or adjuvant to surgery (n = 19). No quality difference was detected between positive and negative trials according to the two scores, whatever all trials were combined or only adjuvant chemotherapy studies were considered. The overall meta-analysis showed that the hazard ratio (HR) of the combined results was 0.66 (95% CI 0.48-0.93) in favour of the addition of induction chemotherapy to a standard surgical procedure and 0.84 (95% CI 0.78-0.89) in favour of adjuvant chemotherapy. The effect was significant for adjuvant chemotherapy in stages I and II with a HR of 0.88 (95% CI 0.83-0.94). It was not statistically significant in stage III although the trend was in favour of chemotherapy whatever adjuvant (HR = 0.85; 95% CI 0.69-1.04) or (neo)adjuvant (HR = 0.65; 95% CI 0.41-1.04) chemotherapy was tested. In conclusion, our meta-analysis shows the efficacy of adjuvant chemotherapy in stages I and II resected NSCLC. More data are needed to confirm such a role for induction chemotherapy. Further trials should separate stage III disease from earlier stages.

B-cell lymphoma presenting with renal failure associated to spontaneous tumor lysis syndrome and urinary tract obstruction

The acute tumor lysis syndrome (ATLS) may be a dramatic complication of anticancer treatment. It occurs mostly in haematological malignancies and less commonly in solid tumors. Spontaneous tumor lysis syndrome (STLS) has been reported more frequently in Burkitt's lymphomas than in other haematological tumors, and exceptionally in solid tumors like small-cell lung carcinoma and germ-cell tumors. We report on the case of a patient with a diffuse large B-cell lymphoma (DLBCL) of the urinary tract involved by acute renal failure due to STLS and complicated by obstructive uropathy subsequent to neoplastic infiltration of the bladder. Hyperhydration, urine alkalinization, urate oxidase administration and continuous veno-venous haemodiafiltration (CVVHDF) permitted to control the initial renal failure and to administer chemotherapy. The patient then developed chemotherapy-induced tumor lysis syndrome (TLS) controlled by urate oxidase administration, hyperhydration and urine alkalinization. The treatment of TLS and the differences between ATLS and STLS are discussed.

Non-invasive ventilation for cancer patients with life-support techniques limitation

GOALS OF WORK

The study was conducted to determine the usefulness and efficacy of non-invasive ventilation (NIV) in cancer patients with "life-support techniques limitation" admitted for an acute respiratory distress, in terms of intensive care unit (ICU) and hospital discharges.

PATIENTS AND METHODS

A total of 18 consecutive cancer patients (17 with solid tumours and one with haematological malignancy) with "life-support techniques limitation" in acute respiratory failure and who benefited from NIV were included. NIV was provided with a standard face mask by the BiPAP Vision ventilator (Respironics Inc.). Variables related to the demographic parameters, SAPS II score, cancer characteristics, intensive care data and hospital discharge were recorded.

MAIN RESULTS

Complications leading to NIV were hypoxemic respiratory failure in 11 patients and hypercapnic respiratory failure in seven. Total median duration of NIV was 29 h. NIV was applied during a median of 2.5 days with a median of 16 h per day. Total median ICU stay was 7 days (range 1-21). Fourteen and ten patients were discharged from ICU and from hospital, respectively.

CONCLUSION

NIV appears to be an effective ventilation support for cancer patients with "life-support techniques limitation".

Prognostic role of epidermal growth factor receptor in stage III nonsmall cell lung cancer

New biological factors have not been extensively studied in stage III nonsmall cell lung cancer (NSCLC). The aim of the present retrospective study was to determine the role of epidermal growth factor receptor (EGF-R) as a prognostic factor in stage III NSCLC, in addition to the stage and other known clinical factors. Clinical characteristics were retrieved from the patients' charts. Membrane immunostaining for EGF-R was evaluated by three independent observers. The Cox multivariate model, including all variables with a p-value of <0.2 in univariate analysis, was used to assess the impact of clinical and biological factors on patients survival. Between January 1987 and July 2002, 99 assessable stage III NSCLC patients were included in the study. A total of 23 patients were positive for EGF-R (squamous 39.6% versus nonsquamous 7.8%). In multivariate analysis, only three factors were statistically significantly associated with survival: performance status, surgery and creatinine. In conclusion, good performance status, surgical resection and creatinine were found to be independent favourable prognostic factors for survival in a retrospective analysis of stage III nonsmall cell lung cancer, while epidermal growth factor receptor was not even in the univariate analysis.

[Docetaxel as salvage treatment for non-small cell lung cancer: implementation study]

Salvage treatment with docetaxel after failure of cisplatin-based chemotherapy in non-small cell lung cancer (NSCLC) has already been tested in the context of clinical prospective trials but only dealing with selected patients. The aim of the present study is to assess the generalizability of these results in an unselected population. We retrospectively analysed the data of all patients not included in clinical studies and treated at the Jules Bordet Institute between September 1996 and July 2003 by docetaxel after a previous chemotherapy containing platinum. Patients were separated in two groups: eligible or not studies according to the selection criteria of the published phase II and III prospective trials. There were 27 patients treated by docetaxel after relapse or failure of prior first-line platinum-based chemotherapy. Among them, 15 were ineligible according to the criteria of published phase II and III trials. The global response rate was 7.41%. All responders had a partial response to first line chemotherapy. Toxicity consisted mainly in grade III/IV neutropenia and was similar between the two group of patients. The median survival time was 25 weeks. In conclusion, our implementation study confirms the activity of docetaxel as salvage therapy after failure of first line cisplatin-based chemotherapy in an unselected population of patients with NSCLC, with a response rate similar to that obtained in propective trials.

Does c-erbB-2 play a role in the first steps of lung carcinogenesis?

BACKGROUND

The 1999 WHO/IASLC histological classification of preneoplastic bronchial lesions has been shown to be reproducible, but little is known about its biological significance. The EGFR expression rate increases from normal epithelium to carcinoma in situ (CIS) with a significant difference between mild versus severe dysplasia. C-erbB-2, another member of the erbB family, is overexpressed in lung carcinomas, suggesting that this mechanism may play a role in carcinogenesis. We evaluated the correspondence between the morphological changes of the bronchial epithelium and the c-erbB-2 expression.

MATERIALS AND METHODS

Nine normal bronchial epithelia, 16 hyperplasia, 12 metaplasia, 12 mild dysplasia, 8 severe dysplasia, 11 CIS and 6 microinvasive tumours were evaluated. Immunostaining was performed using anti-c-erbB-2 antibodies (clone CBI ).

RESULTS

No immunostaining was found whatever the bronchial lesions evaluated.

CONCLUSION

C-erbB-2 does not seem to be involved in the first step of carcinogenesis of squamous cell carcinoma. These findings suggest that there is no place for chemoprevention by anti-c-erbB-2 drugs such as trastuzumab in lung cancer.

Prognostic role of p53 in stage III non-small cell lung cancer

BACKGROUND

New biological factors have not been extensively studied in stage III non-small cell lung cancer (NSCLC). We aimed to determine the role of p53 as a prognostic factor in such patients.

MATERIALS AND METHODS

p53 expression was assessed by immunohistochemistry and evaluated by three independent observers. The Cox model was used to assess the impact of clinical and biological factors on patient survival.

RESULTS

Between 01/1987 and 07/2002, 93 stage III NSCLC patients were included. Twenty-eight had a p53-positive tumour. There was no survival difference among patients with p53-positive and -negative tumours (p = 0.46). In multivariate analysis, 3 factors were statistically significantly associated with survival: surgical resection (p = 0.009), good performance status (p = 0.02) and low creatinine level (p = 0.02).

CONCLUSION

Good performance status, surgical resection and low creatinine level were independent favourable prognostic factors for survival in stage III NSCLC, while p53 was not, even in univariate analysis.

Synchronous lesions detected by autofluorescence bronchoscopy in patients with high-grade preinvasive lesions and occult invasive squamous cell carcinoma of the proximal airways

The cancerization field concept implies that lung cancer multicentricity may be a frequent event and primary studies using white-light bronchoscopy (WLB) have reported a high prevalence of multicentricity in patients with roentgenographically occult lung cancer. We have used autofluorescence bronchoscopy (AFB) to reassess the prevalence of synchronous lesions in patients referred for the staging and/or treatment of occult lesions initially detected during WLB. All the patients referred with high-grade preinvasive lesions (severe dysplasia, DYS S and carcinoma in situ, CIS) and occult invasive squamous cell carcinoma (CIV) of the bronchus initially detected during WLB at other centers, underwent AFB. Data were prospectively collected and retrospectively analyzed to assess the prevalence of synchronous occult lesions. From January 1996 to December 2001, 28 patients (26 males, 2 females; mean age: 65 +/- 11) were assessed. After re-evaluation, in two cases, the referred lesions corresponded only to metaplasia and were discarded from analysis. The 26 other patients were referred for 28 lesions (3 DYS S, 19 CIS and 6 CIV; 2 patients were referred with two synchronous lesions). AFB revealed, in these 26 patients, six additional lesions (1 DYS S, 4 CIS and 1 CIV). Multicentricity in this group, initially estimated to amount to 7% with WLB alone, raised to 23% by using AFB. The high prevalence of synchronous lesions in this series of patients with occult DYS S, CIS and occult CIV suggests that AFB may be a useful adjunct in the pretreatment evaluation.

Survival is better predicted with a new classification of stage III unresectable non-small cell lung carcinoma treated by chemotherapy and radiotherapy

The 1997 International staging system (ISS) classification separated stage III non-small cell lung cancer (NSCLC) into stages IIIA and IIIB. In a previous study including unresectable NSCLC initially treated with chemotherapy, we analysed survival according to tumour (T) and node (N) stages and derived a classification into stages IIIbeta (T3-4N3) and IIIalpha (other TN stage III) that had a better discrimination on survival distribution. The aim of this study was to validate these results in a further set of patients. Patients with unresectable stage III NSCLC included in a phase III trial assessing the role of increased dose chemotherapy (SuperMIP: mitomycin 6 mg/m2, ifosfamide 4.5 g/m2, cisplatin 60 mg/m2, carboplatin 200 mg/m2) in comparison to standard chemotherapy MIP (mitomycin 6 mg/m2, ifosfamide 3 g/m2, cisplatin 50 mg/m2), before thoracic irradiation (60 Gy in 30 fractions over 6 weeks) were the subject of this study. Survival distributions were assessed by the method of Kaplan-Meier. Survival comparisons were made by the log-rank test. Multivariate analyses using Cox regression models, included all potential prognostic factors for survival with a P-value <0.2 in univariate analysis. According to the 1997 International staging system classification, 328 eligible patients were included in the study. There was no imbalance between the two arms. Five parameters were significantly associated (P < or = 0.05) with survival in univariate analysis: European lung cancer working party (ELCWP) staging (IIIalpha[n = 294 pts] versus IIIbeta [n = 46]), Karnofsky index, weight loss, platelet count and haemoglobin level. These variables as well as the 1997 ISS staging, white blood cell (WBC) count, LDH and sodium levels were included in a multivariate analysis. Two models were constructed, including either the ELCWP or the 1997 ISS. In model 1 (ISS included), Karnofsky index (HR 0.69; 95% confidence interval (CI) 0.47-1.00; P = 0.05) and haemoglobin (HR 1.49; 95% CI 1.11-1.99; P = 0.007) were found significant. In model 2, including ELCWP staging, two variables were associated with survival: ELCWP staging (HR 1.68; 95% CI 1.20-2.35; P = 0.002) and haemoglobin (HR 1.54; 95% CI 1.15-2.07; P = 0.01).

CONCLUSION

In initially unresectable stage III NSCLC treated by chemotherapy and radiotherapy, we validated the results of our previous study. The classification into stages IIIbeta (T3-4N3M0) and IIIalpha (other TN stage III) better discriminates the patients in term of survival than the 1997 ISS classification.