Multimodality treatment of unresectable stage III non–small cell lung cancer: Interim analysis of a phase II trial with preoperative gemcitabine and concurrent radiotherapy

The therapeutic potential of mesenchymal stem cells in lung cancer: benefits, risks and challenges

BACKGROUND

Lung cancer is one of the most challenging diseases to treat. In the past decades standard therapy including surgery, chemo- and radiation therapy, alone or in combination has not changed the high mortality rate and poor prognosis. In recent years, mesenchymal stem cells (MSCs) have emerged as putative therapeutic tools due to their intrinsic tumor tropism, anti-tumor and immunoregulatory properties. MSCs release biomolecules that are thought to exert the same beneficial effects as their cellular counterparts and, as such, they may offer practical possibilities of using MSC-secreted products. Owing to their innate affinity to home to tumor sites, MSCs have also gained interest as selective vehicles for the delivery of anti-cancer agents. However, MSCs are also known to confer pro-oncogenic effects, rendering them into double-sword weapons against neoplastic diseases.

CONCLUSIONS

Here, we present published data on the cell- and secretome-based therapeutic competences of MSCs, as well as on their potential as engineered delivery vectors for the treatment of lung cancer. Despite the controversial role of MSCs in the context of lung cancer therapy, current findings support hopeful perspectives to harness the potential of MSC-based regimens that may augment current treatment modalities in lung cancer.

Oral vinorelbine: a feasible and safe partner for radiotherapy in the treatment of locally advanced non-small cell lung cancer

Background

Concurrent chemoradiotherapy (CCRT) using cisplatin-based doublets represents the standard of care for locally advanced non-small cell lung cancer (NSCLC), having shown good efficacy and activity in clinical trials. Locally advanced NSCLC occurs frequently in the elderly population, which is often excluded by platinum-based CCRT administration, due to severe associated toxicities. This limitation has been overcome using new-generation drugs such as gemcitabine, docetaxel, paclitaxel, and vinorelbine, which have shown not only to be efficacious but also to have a favorable toxicity spectrum, both in association with cisplatin and as single agents. Vinorelbine is a vinca alkaloid that binds to tubulin, thus inhibiting mitotic microtubule polymerization. Previous studies have clearly demonstrated that vinorelbine acts as a radiosensitizing agent when administered intravenously or orally. Moreover, oral administration of vinorelbine has shown a good clinical safety profile in both elderly and younger patients.

Methods

A comprehensive review of the literature data regarding use of oral vinorelbine concurrently with radiotherapy in NSCLC was done.

Conclusion

Single-agent oral vinorelbine may represent an effective therapy option for elderly patients with locally advanced lung cancer. This review has described the use of oral vinorelbine both as a monochemotherapy and in combination with cisplatin in the context of CCRT.

A clinical score, including biohumoral parameters, is a useful pretest index to discriminate pulmonary infections from radiation damage in chemoradiation-treated lung cancer patients

To obtain an easy and prompt differential diagnosis between lower airways infections and acute radiation pneumonitis in chemoradiation lung cancer patients. From 303 patients treated, only patients with severe pulmonary symptoms were hospitalized. Clinical and radiation scores were calculated evaluating clinical, biohumoral, dosimetric parameters. Out of 36 patients hospitalized, infections and acute radiation pneumonitis were reported in 66.7% and 33.3%, respectively. Patients with clinical score ≥ 2 had an Odds Ratio of 3.4 (1.4-8.3; p = .006) to have infectious pneumonia, while radiation score was not predictive.

Neoadjuvant chemoradiotherapy for stage III (N2/3) non-small-cell lung cancer: a review of prospective studies

SUMMARY Trimodality therapy, a maximal combination of chemotherapy, radiotherapy and surgical resection, for stage III non-small-cell lung cancer promises improved outcomes through optimizing local, regional and distant control. Phase II trials of neoadjuvant chemoradiotherapy have explored a number of different radiotherapy dose and fractionation schemes, and have identified an important subset of patients who achieve mediastinal nodal clearance and may achieve long-term survival. Phase III trials of various combinations of chemotherapy, radiotherapy and surgery have demonstrated mixed results with regard to each modality’s impact on progression-free or overall survival. In this review, we focus on the historical lessons learned from prospective trials of trimodality therapy completed over the last 30 years and set the stage for future studies of neoadjuvant chemoradiotherapy for stage III non-small-cell lung cancer.

Multimodality treatment of stage III non-small cell lung cancer: analysis of a phase II trial using preoperative cisplatin and gemcitabine with concurrent radiotherapy

INTRODUCTION

We report the results of a phase II trial exploring the efficacy and the feasibility of combination of gemcitabine and cisplatin concurrent with radiotherapy followed by surgery in patients with stage III non-small cell lung cancer.

METHODS

Patients with histocytologically confirmed non-small cell lung cancer were treated with cisplatin 80 mg/sqm/wk of 1 and 4 or 20 mg/sqm/d of weeks 1 and 4 and weekly gemcitabine at 300 to 350 mg/m2 plus involved field radiotherapy. A 3D-conformal radiotherapy was delivered up to 50.4 Gy, with daily fractionation of 1.8 Gy. After clinical, radiologic, and pneumological reassessment, patients who reentered criteria for resectability were operated.

RESULTS

The stage at diagnosis was IIIA-N2 in 29 patients and IIIB-T4N0-2 for vascular direct infiltration for the remaining 21. Fifteen patients (30%) experienced acute grade 3 to 4 hematological toxicity, whereas acute grade 3 esophageal toxicity was recorded in three patients (6%). One patient developed a grade 4 pulmonary toxicity (2%). Clinical response was 40 (80%) partial response, one (2%) stable disease, and nine (18%) progressive disease. Thirty-six patients (72%) underwent surgery. Final pathology showed a downstaging to stage 0 to I in 25 cases (50%). Median overall survival for all patients was 21.8 months, with a 3-year survival of 40.2%.

CONCLUSIONS

The results of this phase II trial confirm the feasibility and the efficacy of concurrent chemoradiotherapy followed by surgery.

Adding ipsilateral V20 and V30 to conventional dosimetric constraints predicts radiation pneumonitis in stage IIIA-B NSCLC treated with combined-modality therapy

PURPOSE

To determine lung dosimetric constraints that correlate with radiation pneumonitis in non-small-cell lung cancer patients treated with three-dimensional radiation therapy and concurrent chemotherapy.

METHODS AND MATERIALS

Between June 2002 and December 2006, 97 patients with locally advanced non-small-cell lung cancer were treated with concomitant radiochemotherapy. All patients underwent complete three-dimensional treatment planning (including dose-volume histograms), and patients were treated only if the percentage of total lung volume exceeding 20 Gy (V(20)) and 30 Gy (V(30)), and mean lung dose (MLD) had not exceeded the constraints of 31%, 18%, and 20 Gy, respectively. The total and ipsilateral lung dose-volume histogram parameters, planning target volume, and total dose delivered were analyzed and correlated with pneumonitis incidence.

RESULTS

If dose constraints to the total lung were respected, the most statistically significant factors predicting pneumonitis were the percentage of ipsilateral lung volume exceeding 20 Gy (V(20)ipsi), percentage of ipsilateral lung volume exceeding 30 Gy (V(30)ipsi), and planning target volume. These parameters divided the patients into low- and high-risk groups: if V(20)ipsi was 52% or lower, the risk of pneumonitis was 9%, and if V(20)ipsi was greater than 52%, the risk of pneumonitis was 46%; if V(30)ipsi was 39% or lower, the risk of pneumonitis was 8%, and if V(30)ipsi was greater than 39%, the risk of pneumonitis was 38%. Actuarial curves of the development of pneumonitis of Grade 2 or higher stratified by V(20)ipsi and V(30)ipsi were created.

CONCLUSIONS

The correlation between pneumonitis and dosimetric constraints has been validated. Adding V(20)ipsi and V(30)ipsi to the classical total lung constraints could reduce pulmonary toxicity in concurrent chemoradiation treatment. V(20)ipsi and V(30)ipsi are important if the V(20) to the total lung, V(30) to the total lung, and mean lung dose have not exceeded the constraints of 31%, 18%, and 20 Gy, respectively.

Induction cisplatin-gemcitabine-paclitaxel plus concurrent radiotherapy and gemcitabine in the multimodality treatment of unresectable stage IIIB non-small cell lung cancer

BACKGROUND

To evaluate feasibility and safety of induction three-drugs combination chemotherapy and concurrent radio-chemotherapy in stage IIIB NSCLC.

PATIENTS AND METHODS

Patients with stage IIIB NSCLC were treated with three courses of induction chemotherapy, cisplatin 50 mg/m(2), paclitaxel 125 mg/m(2) and gemcitabine 1000 mg/m(2) on days 1,8 of every 21 day cycle. Patients without distant progressive disease were then treated with radiotherapy and concurrent weekly gemcitabine (250 mg/m(2)). Toxicity and response of radio-chemotherapy treatment have been assessed.

RESULTS

Between Jan 01 and Nov 02, 46 patients were enrolled. Grade 3+ hematological and non-hematological toxicity during the induction phase were 41.3% and 13.1%, respectively. In 38 patients a Clinical Response or Stable Disease was recorded and these patients underwent to concurrent radio-chemotherapy. Grade 3+ hematological and non-hematological toxicities were 8.2% in this group. Further response was observed in 66% of patients. Overall median survival time was 17.8 months, with a 3-year survival rates of 23%.

CONCLUSION

Three-drugs induction chemotherapy and concurrent radio-chemotherapy with weekly gemcitabine in locally advanced stage IIIB NSCLC is feasible and safe.

Chemo-radiotherapy in non-small cell lung cancer: the role of gemcitabine

Gemcitabine (2'-2'-difluorodeoxycytidine) is a well-known cytotoxic drug and a potent radio-enhancer. We herein report the in vitro evidence of its activity, and the clinical experiences when this drug is administered concurrently with radiation. The phase I-II trials are analyzed, focusing on the recent ability to deliver irradiation with low incidence of side effects.