Chemotherapy of small cell lung cancer

Immunoassay of Neuron-Specific Enolase (Nse) and Serum Fragments of Cytokeratin 19 (Cyfra 21.1) as Tumor Markers in Small Cell Lung Cancer: Clinical Evaluation and Biological Hypothesis

NSE is a biochemical marker for small cell lung cancer (SCLC) diagnosis and management. CYFRA 21.1 is a newly developed immunoassay to detect the serum fragments of cytokeratin 19 which are also expressed in SCLC with or without neurofilaments. The aim of this study was to evaluate the diagnostic performance and prognostic role of the two markers in SCLC and their contribution to chemotherapy monitoring and patient follow-up. We studied 62 patients with pathologically proven SCLC: 28 with limited disease (LD) and 34 with extensive disease (ED), and 100 patients with non-malignant pulmonary disease. Immunoradiometric assays (IRMA) were employed to test NSE and CYFRA 21.1 in patients and control subjects. For each patient subset results were expressed as median and interquartile distribution range. NSE and CYFRA 21.1 sensitivity was 0.52 (33/62) and 0.56 (35/62), respectively. In the group of patients with LD, NSE and CYFRA 21.1 sensitivity was 0.42 (12/28) and 0.54 (15/28) and in patients with ED, NSE and CYFRA 21.1 were positive in 0.62 (21/34) and 0.59 (20/34) of cases, respectively. Combining the two markers, a sensitivity of 0.78 (22/28) in LD, 0.82 (28/34) in ED and a global sensitivity of 0.80 (50/62) was obtained. Only NSE was significantly linked to the extension of disease (Mann-Whitney U test p = 0.002) while CYFRA 21.1 did not correlate. The analysis of survival and the evaluation of the two markers at diagnosis showed CYFRA 21.1 to be strongly linked to the patients’ outcome, independently of both clinical prognostic factors and NSE levels (log rank and Cox's model). The markers’ performance during chemotherapy was tested in a group of 33 patients with at least one marker above cut-off. NSE can be considered a reliable marker of tumor mass modifications under chemotherapy, while CYFRA 21.1 expression seems to be relatively independent of tumor volume modifications. An applicable model of biomarkers in SCLC could be the concurrent assay of NSE and CYFRA 21.1 in pre-therapeutic assessment and therapy planning. CYFRA 21.1 does not play an important role during therapy monitoring and follow-up; in these phases NSE alone may be employed.

Novel Doublets in Extensive-Stage Small-Cell Lung Cancer: A Randomized Phase II Study of Topotecan Plus Cisplatin or Paclitaxel (CALGB 9430)

Chemotherapy for extensive-stage small-cell lung cancer (E-SCLC) produces high response rates and improved survival but few cures. We tested three new regimens for E-SCLC that might merit further investigation in a subsequent phase III trial. Cancer and Leukemia Group B 9430 was a randomized phase II study evaluating 4 treatment arms in 57 evaluable, previously untreated E-SCLC patients. Each arm consisted of the following: Arm 1: cisplatin plus topotecan; Arm 2: cisplatin plus paclitaxel; Arm 3: paclitaxel 230 mg/m2 plus topotecan; and Arm 4: paclitaxel 175 mg/m2 plus topotecan. Because of an accrual time difference, Arm 2 will not be discussed in this manuscript. Arm 1 (12 patients) produced 1 complete response (CR, 8%) and an overall response rate (ORR) of 42%. Toxicity was excessive, with 3 deaths (25%). Arm 3 (13 patients) produced no CRs, 7 partial responses (PRs, 54%), median survival of 13.8 months, and failure-free survival (FFS) of 7.41 months, with 3 toxic deaths (25%). Among 32 evaluable patients on Arm 4, there were 2 CRs (6%) and 20 PRs (63%) for an ORR of 69%, median survival of 9.9 months, FFS of 5.21 months, and 1-year survival of 40%. There was 1 possible treatment-related death (3%). Topotecan plus cisplatin, in the doses and schedule employed, produced excessive toxicity and modest efficacy in E-SCLC patients. Paclitaxel (230 mg/m2 on day 1) plus topotecan (1 mg/m2 on days 1-5) produced excessive toxicity that was ameliorated with an attenuated paclitaxel dose (175 mg/m2). With the latter regimen (Arm 4) in patients with a performance status of 0/1, CR rates, FFS, overall survival, and 1-year survival were similar to standard etoposide plus cisplatin chemotherapy. Further exploration of topoisomerase inhibitors and taxanes in SCLC patients is warranted.

Is there a case for cisplatin in the treatment of small-cell lung cancer? A meta-analysis of randomized trials of a cisplatin-containing regimen versus a regimen without this alkylating agent

Chemotherapy is the backbone of small-cell lung cancer therapy. However, optimal drug combinations and schedules remain to be defined and there is hitherto no world-wide accepted standard regimen. Cisplatin, an alkylating agent with high putative toxicity is currently widely used although its effectiveness in this disease has not been established firmly. We conducted a meta-analysis of published data reporting trials randomizing a cisplatin-containing regimen versus a regimen without this alkylating agent in order to determine possible differences in survival response and toxicity. Nineteen trials have been identified in medical literature (4054 evaluable patients). Ten trials randomized patients to receive a cisplatin-etoposide regimen versus a regimen without any of these two drugs. A subgroup analysis was, therefore, carried out in the nine remaining trials that randomly allocated patients between two regimens differing in the absence or presence of cisplatin, whereas etoposide was given (or not given) in both arms (1579 evaluable patients). The DerSimonian and Laird method was used to estimate the size effects and the Peto and Yusuf method was used in order to generate the odds ratios (OR) of reduction in risk of death and the increase in probability of being responders to chemotherapy. There was no significant difference between the cisplatin-containing regimen and the regimen without this drug when the risk of toxic-death was taken into account with respective probabilities of 3.1 and 2.7% (NS). Patients randomized in a cisplatin-containing regimen had an increase in probability of being responders with an OR of 1.35, 95% confidence interval (CI) of 1.18-1.55; P < 10(-5) corresponding to an increase of objective (partial plus complete) response rate from 0.62 to 0.69 (a result taking into account a significant heterogeneity). Patients treated with a cisplatin-containing regimen benefited from a significant reduction of risk of death at 6 months and 1 year with respective OR 0.87, 95% CI 0.75-0.98, P = 0.03, and or 0.80, 95% CI 0.69-0.93, P = 0.002 (no statistical heterogeneity). This corresponded to a significant increase in the probability of survival of 2.6% and 4.4% at 6 months and 1 year respectively. The meta-analysis restricted to the subset of nine trials without etoposide treatment imbalance reached similar conclusions. A cisplatin-containing regimen yields a higher response rate and probability of survival than does a chemotherapy containing others alkylating agents without a perceptible increase in risk of toxic-death.

Markov model and markers of small cell lung cancer: assessing the influence of reversible serum NSE, CYFRA 21-1 and TPS levels on prognosis

High serum NSE and advanced tumour stage are well-known negative prognostic determinants of small cell lung cancer (SCLC) when observed at presentation. However, such variables are reversible disease indicators as they can change during the course of therapy. The relationship between risk of death and marker level and disease state during treatment of SCLC chemotherapy is not known. A total of 52 patients with SCLC were followed during cisplatin-based chemotherapy (the median number of tumour status and marker level assessments was 4). The time-homogeneous Markov model was used in order to analyse separately the prognostic significance of change in the state of the serum marker level (NSE, CYFRA 21-1, TPS) or the change in tumour status. In this model, transition rate intensities were analysed according to three different states: alive with low marker level (state 0), alive with high marker level (state 1) and dead (absorbing state). The model analysing NSE levels showed that the mean time to move out of state 'high marker level' was short (123 days). There was a 44% probability of the opposite reversible state 'low marker level' being reached, which demonstrated the reversible property of the state 'high marker level'. The relative risk of death from this state 'high marker level' was about 2.24 times greater in comparison with that of state 0 'low marker level' (Wald's test; P < 0.01). For patients in state 'high marker level' at time of sampling, the probability of death increased dramatically, a transition explaining the rapid decrease in the probability of remaining stationary at this state. However, a non-nil probability to change from state 1 'high marker level' to the opposite transient level, state 0 'low marker level', was observed suggesting that, however infrequently, patients in state 1 'high marker level' might still return to state 0 'low marker level'. Almost similar conclusions can be drawn regarding the three-state model constructed using the tumour response status. For the two cytokeratin markers, the Markov model suggests the lack of a true reversible property of these variables as there was only a very weak probability of a patient returning to state 'low marker level' once having entered state 'high marker level'. In conclusion, The Markov model suggests that the observation of an increase in serum NSE level or a lack of response of the disease at any time during follow-up (according to the homogeneous assumption) was strongly associated with a worse prognosis but that the reversion to a low mortality risk state remains possible.

Combination chemotherapy with low doses of weekly Carboplatin and oral Etoposide in poor risk small cell lung cancer

Sixty patients with poor prognostic features, either with extensive disease (ED) or limited disease (LD) small cell lung cancer (SCLC), were treated on an out-patient basis with Carboplatin 80 mg/m2 weekly for 3 weeks and oral Etoposide, at a dose of 100 mg, every other day for 21 days. The treatment was repeated every 5 weeks. Responding patients with LD were also treated with thoracic irradiation and those who achieved complete response (CR) received prophylactic cranial radio-therapy. The overall response rate (RR) was 32.1% with 8.9% CR. The responses were better for LD (RR 58.3%, CR 25%, partial response, PR 33.3%), than those for ED (RR 25%, CR 4.5%, PR 20.5%). The median time to progression (TTP) was 4.8 months and the median survival 5.5 months. These poor results could be attributed to the bad performance status and the presence of visceral and brain metastases in this group of patients. The results could also be due to the lower maximum concentration (Cmax) and higher T1/2 of Etoposide, as measured in the blood and urine probably due to the modified regimen used in our study and to the organ insufficiency in this selected group of patients. Although, toxicity was generally mild and manageable, two toxic deaths occurred. In conclusion, this regimen appears to have a lower efficacy in terms of response and survival than that obtained in other studies using Cisplatin or Carboplatin plus Etoposide in a similar way. Therapy with this regimen, though less toxic, may not be a reliable alternative in elderly patients with visceral metastases and ECOG performance status > or = 2.

[Evaluation of tumor response during chemotherapy of bronchial cancer]

Chemotherapy of lung cancer is still an experimental approach requiring careful evaluation. Tumour response (marker of anticancer activity) is not perfectly correlated to survival (marker of chemotherapy efficacy), but its evaluation remains a milestone inasmuch as reporting a wrong tumour response rate might lead to the rejection of active new treatments. This review deals with the method of tumour response measurements and its use during a chemotherapy protocol. Recommendations drawn from the analysis of the literature are: 1) to assess and classify all lesions which can be identified at the beginning of the treatment; 2) to define the target lesions, mainly the ones which can be bidimensionally measured; 3) to use the World Health Organization recommendations for reporting the overall response; 4) to confirm complete response by negative rebiopsies; 5) to avoid second fiberoptic bronchoscopy to patients with stable or progressive disease on CT-scan, and finally; 6) to assess response quality by evaluating response duration and improvement of quality of life.

Is carboplatin and oral etoposide an effective and feasible regimen in patients with small cell lung cancer?

The combination of carboplatin and etoposide is an active and well-tolerated regimen in the treatment of small cell lung cancer (SCLC). The aim of the study was to confirm whether the efficacy could be maintained if etoposide was administered orally. 106 consecutive, unselected, and untreated patients with SCLC (limited disease (LD) 44; extensive disease (ED) 62) were treated with a combination of carboplatin 300 mg/m2 intravenously (i.v.) day 1 and etoposide 240 mg/m2 orally days 1-3 every 4 weeks for six courses or until progression. If oral treatment was inconvenient, i.v. etoposide (120 mg/m2 days 1-3) was allowed. Thoracic irradiation (45 Gy in 22 fractions, split course) was given after three courses of chemotherapy to 29 patients with LD. Objective response (complete and partial) was seen in 89% (confidence interval (CI) 75-97) of patients with LD and in 53% (CI 40-66) with ED. Complete response was seen in 41% (CI 26-57) of patients with LD and in 8% (CI 2-18) with ED. Median time to progression for responders was 11 months and 6 months for patients with LD and ED, respectively. Corresponding median survival was 15 months (range 1-45 months) and 8.5 months (0-26 months). Myelosuppression comprised the main toxicity. Leucopenia (WHO III-IV) was observed in 20% and thrombocytopenia (WHO III-IV) in 16% of the cases. One patient died of sepsis during leucopenia. Oral treatment was convenient for most patients and therapy well tolerated. However, 9 patients (20%; CI 9-36%) with LD and 26 patients (42%; CI 29-56%) with ED received at least part of the etoposide treatment i.v.. The present study shows that the combination of carboplatin and oral etoposide is active and well tolerated, and may be used on an outpatient basis in patients with small cell lung cancer.

Randomized comparison of etoposide-cisplatin vs. etoposide-carboplatin and irradiation in small-cell lung cancer. A Hellenic Co-operative Oncology Group study

PURPOSE

To compare the efficacy and toxicity of etoposide and cisplatin (EP) with etoposide and carboplatin (EC) in combination with irradiation in small-cell lung cancer (SCLC).

METHODS

Previously untreated patients (pts) with SCLC and measurable or evaluable disease were randomized to receive either cisplatin 50 mg/m2 on days 1-2 or carboplatin 300 mg/m2 on day 1, both combined with etoposide 300 mg/m2 on days 1-3 every 21 days for 6 treatment cycles. The vast majority of responding limited disease (LD) pts and complete responders (CR) with extensive disease (ED), also received thoracic irradiation (TI) and prophylactic cranial irradiation (PCI) concurrently with the third cycle.

RESULTS

Of the 147 patients registered, 143 were eligible; median performance status (PS, WHO) was 1, and tumour stage was LD in 41 pts of each treatment group. The mean delay between cycles was 8 days in the EP group and 9 in the EC group increasing in both arms with the number of treatment courses. The drug dose administered per unit time as a proportion of the protocol dose was 74% and 80% for the two groups respectively. Leukopenia, neutropenic infections, nausea, vomiting, neurotoxicity and hyperergic reactions were more frequent and/or severe in the EP group. The CR rates were 57% and 58% for EP and EC respectively. Median survival for all pts was 12.5 and 11.8 months, respectively.

CONCLUSION

Both treatments proved to be effective, with no differences in response and survival between the two treatment arms. The EC regimen was associated with significantly less toxicity.

[Treatment of small cell bronchopulmonary cancers]

nn small cell lung cancer, the main treatment modality is chemotherapy, combinated with early thoracic radiation therapy for patients with complete response. The treatment of relapse with chemotherapy is efficient. The precocity of the response after initiating multimodality treatment is the main prognosis factor. The prophylactic cranial irradiation reduce the frequency of brain metastases, but has no significant effect on survival. Patients with very limited small cell lung cancer (TNM stage I and II) can be managed by surgery. Association with colony stimulating factors can lessen the severity of neutropenic and infectious episodes. The role of maintenance therapy by interferon alpha in clinically disease free patients is suggested.

Glutathione and glutathione linked enzymes in human small cell lung cancer cell lines

Glutathione levels and several glutathione-linked enzyme activities have been variably correlated with cisplatin chemosensitivity in cultured neoplastic cells. In order to determine the relative contribution of the glutathione-linked enzymes towards mediating inherent cisplatin resistance in cancer cells, we have measured the chemosensitivity to cisplatin, glutathione levels and activities of glutathione S-transferase, glutathione peroxidase, glutathione reductase and glucose-6-phosphate dehydrogenase in 8 cultured human small cell lung cancer (SCLC) cell lines with widely differing cisplatin sensitivities. Of these parameters, only glutathione S-transferase activity correlated with degree of cisplatin resistance in a linear fashion.

Immunohistochemical study of P-glycoprotein distribution in lung cancer

Indirect immunoperoxidase was used to determine the reactivity of C219 (P-glycoCHEK C219, Centocor Diagnostics, Malvern, PA), a monoclonal antibody (Mab) with high affinity for an internal epitope of the P-glycoprotein encoded by the multidrug resistance (MDR1) gene, in 40 surgically resected primary lung tumours. C219 reactivity was qualitatively classified in seven small cell lung cancers (SCLC), 29 non small cell lung cancers (NSCLC), and four carcinoid tumours. Ploidy was analysed by means of static cytometry using a computer-assisted image processor following Feulgen staining of cytologic prints of 32/40 lung tumours. Indirect immunoperoxidase reactivities of Mabs S-L 11.14 and MOC-1 were also studied to characterize the expression of cluster 1 lung cancer antigens and hence to determine among the NSCLC those which expressed the neural cell adhesion molecule (NCAM). Eighteen (45%) lung tumours strongly expressed P-glycoprotein as an immunostaining of many islets of malignant cells or almost all malignant cells. In addition, 8/40 tumours (20%) showed a weak reactivity (few immunostained cells) and 14/40 (35%) no reactivity. There was no difference of reactivity when NSCLC were compared with SCLC. The expression of P-glycoprotein in NSCLC did not vary significantly when the stage of disease was considered. Among the 29 NSCLC, 10 (36%) expressed S-L 11.14 and MOC-1. The NCAM positive NSCLC did not show any difference of P-glycoprotein expression in comparison with NCAM negative ones. Finally, C219 immunoperoxidase reactivity did not significantly differ according to the ploidy status. In conclusion, the internal epitope of the P-glycoprotein encoded by the MDR1 gene is frequently expressed by lung tumours of any histological type. This expression is not higher in Stage III and IV lung cancers in comparison with Stage I and II ones, or in NSCLC in comparison with SCLC either. Thus, the C219 related epitope seems to have a weak implication in the lower chemosensitivity of both advanced stages and NSCLC.

Neural cell adhesion molecule and prognosis of surgically resected lung cancer

The prognostic significance of the expression of neural cell adhesion molecule (NCAM), a neuroendocrine antigen in lung cancer, was analyzed by an indirect immunoperoxidase method in 97 surgically treated patients. Reactivity of MOC-1 and S-L 11.14, both cluster-1 monoclonal antibodies directed against NCAM, was positive in all nine small-cell lung cancers and in 16 of 88 (18%) non-small-cell lung cancers. For the latter group, this expression demonstrated a phenotypic heterogeneity that was mainly observed in poorly differentiated squamous cell carcinomas and in stage N2 non-small-cell lung cancers. Patients with NCAM-positive non-small-cell lung cancer proved to have a shorter survival than those with NCAM-negative disease. In Cox's model for multivariate analysis, nodal status and histology were the main independent determinants of prognosis. We therefore concluded that NCAM expression in non-small-cell lung cancer is correlated to nodal status and that it indicates a poor prognosis. These findings confirm that the diversification of lung cancer phenotype leads to tumor progression and brings a negative prognosis to surgically resected non-small-cell lung cancer. However, nodal status remains the most important prognostic variable, suggesting that NCAM expression is only one of numerous biological events that promote tumor progression.

Chest tumor response during lung cancer chemotherapy. Computed tomography vs fiberoptic bronchoscopy

Tumor response is one of the most important criteria in the analysis of chemotherapy. A chest computed tomographic (CT) scan and fiberoptic bronchoscopy (FOB) might give different results, as they analyze different aspects of the effects of chemotherapy on lung cancer. The response of the chest tumor in 103 patients with stage III or IV lung cancer (35 with small-cell lung cancer [SCLC] and 68 with non-small-cell lung cancer [NSCLC]) who prospectively entered chemotherapy trials was studied in order to determine the concordance between the chest CT scan and FOB. The chest CT scan allowed an assessment of tumor response in almost all patients, whereas FOB was not able to evaluate this response in 15 of the 103. The frequency of an evaluable endobronchial lesion did not depend on histology (SCLC, 97 percent; NSCLC, 93 percent; chi 2 = 0.85; not significant [NS]) or tumor T classification (T1-2, 83 percent; T3, 94 percent; T4, 97 percent; chi 2 = 1.49; NS). Tumor location in the bronchial airway did not differ when SCLC and NSCLC were compared. Thus, it is not possible to predict a subgroup of patients in whom FOB may be optional. In the group of 88 patients who were evaluable for response using both FOB and CT scan, a statistical concordance of the response classification was observed. The response was overevaluated by CT scan in 22 patients for whom data obtained by FOB appeared to be critical in the evaluation of tumor response. The concordance of response data obtained when the 2 methods were used was lower in NSCLC in comparison with SCLC. Thus, the use of FOB in the analysis of tumor response might be important, especially for NSCLC, inasmuch as FOB modulates the CT-evaluated response.