Induction chemotherapy followed by concurrent standard radiotherapy and daily low-dose cisplatin in locally advanced non-small-cell lung cancer

Clinical Studies on Ultrafractionated Chemoradiation: A Systematic Review

Aim

The efficacy of low-dose fractionated radiotherapy (LDFRT) and chemotherapy (CHT) combination has large preclinical but little clinical evidence. Therefore, the aim of this review was to collect and analyze the clinical results of LDRT plus concurrent CHT in patients with advanced cancers.

Methods

A systematic literature search was conducted on PubMed using the PRISMA methodology. Only studies based on the combination of LDFRT (< 1 Gy/fraction) and CHT were included. Endpoints of the analysis were tumor response, toxicity, and overall survival, with particular focus on any differences between LDFRT-CHT and CHT alone.

Results

Twelve studies (307 patients) fulfilled the selection criteria and were included in this review. Two studies were retrospective, one was a prospective pilot trial, six were phase II studies, two were phase I trials, and one was a phase I/II open label study. No randomized controlled trials were found. Seven out of eight studies comparing clinical response showed higher rates after LDFRT-CHT compared to CHT alone. Three out of four studies comparing survival reported improved results after combined treatment. Three studies compared toxicity of CHT and LDFRT plus CHT, and all of them reported similar adverse events rates. In most cases, toxicity was manageable with only three likely LDFRT-unrelated fatal events (1%), all recorded in the same series on LDFRT plus temozolomide in glioblastoma multiforme patients.

Conclusion

None of the analyzed studies provided level I evidence on the clinical impact of LDFRT plus CHT. However, it should be noted that, apart from two small series of breast cancers, all studies reported improved therapeutic outcomes and similar tolerability compared to CHT alone.

Systematic Review Registration

www.crd.york.ac.uk/prospero/, identifier CRD42020206639.

Angiogenesis at the Interface between Basic and Clinical Research

The field of antiangiogenesis has shown a remarkably rapid evolution from the discovery at the bench to translation into the clinic. Currently a wide variety of compounds are in clinical trial as inhibitors of angiogenesis, and new compounds are being frequently added. The target cell of most angiogenesis inhibitors is the endothelial cell, with inhibitors that selectively affect a number of endothelial cell functions acquired during angiogenesis, including activation, proliferation, migration, invasion and survival. The endothelial cell may also be targeted by chemotherapeutic agents currently in use. The high doses and intermittent treatment schedules used to fight resistant tumor cells may be altered towards lower doses and chronic administration to obtain selective inhibition of angiogenic factor-stimulated endothelial cells as adjuvant therapy. Finally, gene therapy is a promising route for the delivery of novel protein inhibitors of angiogenesis, and is actively being investigated.

The predictive value of 18F-FDG PET-CT for assessing the clinical outcomes in locally advanced NSCLC patients after a new induction treatment: low-dose fractionated radiotherapy with concurrent chemotherapy

Background

Patients with locally advanced non-small-cell lung cancer (LA-NSCLC) have poor prognosis despite several multimodal approaches. Recently, low-dose fractionated radiotherapy concurrent to the induction chemotherapy (IC-LDRT) has been proposed to further improve the effects of chemotherapy and prognosis. Until now, the predictive value of metabolic response after IC-LDRT has not yet been investigated. Aim: to evaluate whether the early metabolic response, assessed by ¹⁸F-fluoro-deoxyglucose positron emission-computed tomography (¹⁸F-FDG PET-CT), could predict the prognosis in LA-NSCLC patients treated with a multimodal approach, including IC-LDRT.

Methods

Forty-four consecutive patients (35males, mean age: 66 ± 7.8 years) with stage IIIA/IIIB NSCLC were retrospectively evaluated. Forty-four patients underwent IC-LDRT (2 cycles of chemotherapy, 40 cGy twice daily), 26/44 neo-adjuvant chemo-radiotherapy (CCRT: 50.4Gy), and 20/44 surgery. ¹⁸F-FDG PET-CT was performed before (baseline), after IC-LDRT (early) and after CCRT (final), applying PET response criteria in solid tumours (PERCIST). Patients with complete/partial metabolic response were classified as responders; patients with stable/progressive disease as non-responders. Progression free survival (PFS) and overall survival (OS) were assessed using Kaplan-Meyer analysis; the relationship between clinical factors and survivals were assessed using uni-multivariate regression analysis.

Results

Forty-four out of 44, 42/44 and 23/42 patients underwent baseline, early and final PET-CT, respectively. SUL_peak of primary tumour and lymph-node significantly (p = 0.004, p = 0.0002, respectively) decreased after IC-LDRT with a further reduction after CCRT (p = 0.0006, p = 0.02, respectively). At early PET-CT, 20/42 (47.6%) patients were classified as responders, 22/42 (52.3%) as non-responders. At final PET-CT, 19/23 patients were classified as responders (12 responders and 7 non-responders at early PET-CT), and 4/23 as non-responders (all non-responders at early PET-CT). Early responders had better PFS and OS than early non-responders (p ≤ 0.01). Early metabolic response was predictive factor for loco-regional, distant and global PFS (p = 0.02, p = 0.01, p = 0.005, respectively); surgery for loco-regional and global PFS (p = 0.03, p = 0.009, respectively).

Conclusions

In LA-NSCLC patients, ¹⁸F-FDG metabolic response assessed after only two cycles of IC-LDRT predicts the prognosis. The early evaluation of metabolic changes could allow to personalize therapy. This multimodality approach, including both low-dose radiotherapy that increases the effects of induction chemotherapy, and surgery that removes the disease, improved clinical outcomes. Further prospective investigation of this new induction approach is warranted.

Chemoradiation and adjuvant chemotherapy in advanced cervical adenocarcinoma

PURPOSE

The optimal treatment of women with advanced adenocarcinoma of uterine cervix is still undefined. We compared concurrent chemoradiation (CCRT) and adjuvant cisplatin-based chemotherapy with CCRT alone for advanced cervical adenocarcinoma in a randomized trial at the Hunan Provincial Tumor Hospital in China.

METHODS

From 1998 to 2007, 880 patients with clinical FIGO stages IIB-IVA cervical adenocarcinoma were randomized to receive either CCRT or chemoradiation with one cycle of neo-adjuvant chemotherapy with Paclitaxel (135 mg/m(2))+Cisplatin (75 mg/m(2)) before receiving radiation and two cycles of consolidation chemotherapy with the same drugs after radiotherapy in 3-week intervals. The disease control and survival rates were calculated using the Kaplan-Meier method.

RESULTS

All patients completed the treatment plan. 340 patients have relapsed, with a median follow-up duration of 60 months. Patients who received chemoradiation with adjuvant chemotherapy showed a significantly longer disease-free (P<.05), cumulative survival (P<.05) and long-term local tumor control (P<.05). Patients who received CCRT alone had significantly more distant metastasis and pelvic failure than those who received chemoradiation with adjuvant chemotherapy (P<.05).

CONCLUSION

Incorporating neo-adjuvant and consolidation chemotherapy with Paclitaxel and Cisplatin into concomitant chemoradiation is highly effective, safe and may be a very promising treatment protocol for advanced cervical adenocarcinoma.

Phase I study of cisplatin and irinotecan combined with concurrent hyperfractionated accelerated thoracic radiotherapy for locally advanced non-small cell lung carcinoma

BACKGROUND

Irinotecan, when combined with cisplatin, is an effective treatment for advanced non-small cell lung cancer (NSCLC). This constitutes a rationale for conducting a phase I study of chemoradiotherapy including this combination for locally advanced NSCLC.

PATIENTS AND METHODS

Patients with locally advanced NSCLC and a performance status of 0 or 1 were eligible. The protocol consisted of escalating doses of irinotecan on days 1 and 15, and daily low-dose cisplatin (6 mg/m(2) daily for a total dose of 120 mg/m(2)) combined with concurrent hyperfractionated accelerated thoracic irradiation (1.5 Gy twice daily for a total dose of 60 Gy).

RESULTS

The maximum tolerable dose was 50 mg/m(2) of irinotecan, and the dose-limiting toxicity was esophagitis. Tumor response was observed in 50% of cases, and the median survival time of the 12 patients enrolled was 10.1 months, including two patients with 5-year disease-free survival. A pharmacokinetics study demonstrated an accumulation of total platinum, but not of free platinum, during the 26-day treatment period.

CONCLUSION

The recommended dose for phase II studies was determined.

Induction Chemotherapy With Carboplatin–Paclitaxel Followed by Standard Radiotherapy With Concurrent Daily Low-Dose Cisplatin Plus Weekly Paclitaxel for Inoperable Non-Small-Cell Lung Cancer

Both induction chemotherapy and concurrent platinating agents have been shown to improve results of thoracic irradiation in the treatment of locally advanced non-small-cell lung cancer (NSCLC). This phase II study investigated activity and feasibility of a novel chemoradiation regimen, including platinum and paclitaxel, both as induction chemotherapy and concurrently with thoracic radiotherapy. Previously untreated patients with histologically/cytologically proven unresectable stage I-III NSCLC were eligible. Induction chemotherapy consisted of 2 courses of 200 mg/m2 paclitaxel and carboplatin at AUC of 6 mg/mL/min every 3 weeks. From day 43, continuous thoracic irradiation (60 Gy in 30 fractions radiotherapy for 6 weeks) was given concurrently with daily cisplatin at a dose of 5 mg/m2 intravenously and weekly paclitaxel at a dose of 45 mg/m2 for 6 weeks. Fifteen patients were accrued in the first stage of the trial. According to the previous statistical considerations, accrual at the second stage of the study was halted as a result of the achievement an insufficient number of successes. Major toxicity of combined chemoradiation was grade III-IV esophagitis requiring hospitalization for artificial nutrition, which occurred in 58% of patients. Other toxicities included grade II-IV fatigue in 75% of patients and grade I-IV neuromuscular toxicity in 67%. Only 7 patients completed the treatment program as scheduled. Eight patients (53.3%; 95% confidence interval, 26.5-78.7%) had a major response (5 partial response, 3 complete response), 2 patients had disease progression, and 1 was stable at the end of treatment. Four patients died early. With a median follow up of 38 months, the median survival was 12 months. A combined chemoradiation program, including platinum and paclitaxel, appears difficult to deliver at full dose as a result of toxicity, mainly esophagitis. More active and less toxic combined modality treatments need to be developed for inoperable NSCLC.

Chemo-radiotherapy for stage III unresectable non-small cell lung cancer—long-term results of a prospective study

INTRODUCTION

Combined-modality treatment is considered standard of care in the treatment of stage III non-small-cell lung cancer (NSCLC). This study was designed to assess the efficacy and tolerability of induction paclitaxel/carboplatin followed by concurrent thoracic radiotherapy and weekly paclitaxel.

MATERIALS AND METHODS

Patients with unresectable stage III NSCLC were treated prospectively with two cycles of paclitaxel (175 mg/m2) and carboplatin (area under the curve of 6) followed by radiotherapy (60-66 Gy) concurrent with 6 weekly doses of paclitaxel (60 mg/m2). Response was determined 8 weeks after the completion of treatment and treatment-related toxicities were assessed at each visit during treatment and follow-up.

RESULTS

Sixty-three patients were treated, 5 had complete response and 33 had partial response, giving a response rate of 60%. Thirty-seven percent of patients developed grade 3 or 4 neutropenia; 48% had significant esophagitis requiring the use of narcotic analgesics. Two patients developed esophageal stricture subsequently. The median survival was 51 months and 12 months for stage IIIA and IIIB patients, respectively. Progression-free survival was 16 months and 11 months respectively.

CONCLUSIONS

The response rate was encouraging. Esophagitis was a significant morbidity and should prompt modification of treatment regimen, either in the chemotherapy schedule or by adjusting the radiotherapy treatment planning.

Induction chemotherapy and radiotherapy in locally advanced non–small cell lung cancer

The position for induction chemotherapy has shifted somewhat in the past few years. This approach has the ability to reduce distant failure and is relatively easy to administer. There are patients who would benefit from and could be offered induction chemotherapy--specifically, those who would not tolerate concurrent chemoradiotherapy or those who might benefit from more intensive therapy combing induction and concurrent strategies. The latter platform, however, should be undertaken with caution, ideally in a clinical trial setting.

Randomized double-blind trial of combined modality treatment with or without amifostine in unresectable stage III non-small-cell lung cancer

PURPOSE

Greater toxicities have been recognized to be a consequence of combined chemotherapy and radiotherapy in the treatment of locally advanced non-small-cell lung cancer (NSCLC). This study was designed to determine if the use of amifostine could reduce treatment-related toxicities associated with the use of paclitaxel plus carboplatin and thoracic radiotherapy.

PATIENTS AND METHODS

Sixty patients with unresectable stage III NSCLC were treated with two cycles of paclitaxel 175 mg/m2 and carboplatin (area under the time-concentration curve = 6), followed by thoracic radiotherapy (64 Gy) with concurrent weekly paclitaxel 60 mg/m2. Patients were randomly assigned to receive 740 mg/m2 of amifostine (arm A) or placebo (arm B) before each dose of paclitaxel and carboplatin. Treatment-related toxicities were evaluated at each visit and nerve conduction tests were performed before and after treatment for the objective assessment of neurotoxicity.

RESULTS

There was no significant difference between arms A and B in grade 3 to 4 neutropenia. In all 72 neurophysiological parameters measured, there was no significant difference between the two treatment arms, although there was a trend toward fewer patients showing deterioration in arm A for six of the parameters. Grade 2 to 3 esophagitis occurred in 43% of patients in arm A and in 70% of patients in arm B. The difference of -27% (95% confidence limit = -50%, 0.4%) was not statistically significant. Response rates and survival were also not significantly different between the two arms.

CONCLUSION

Pretreatment with amifostine showed a trend toward reducing the severity of esophagitis associated with concurrent chemoradiotherapy, but it did not reach statistical significance. There was no significant protective effect on hematologic or neurologic toxicities induced by paclitaxel and carboplatin.

Surgically Proven Complete Response of Stage III Non-Small Cell Lung Cancer after Cisplatin-Enhanced Radiotherapy. Clinical Implications and Long-Term Results

Aims and Background

Pathologic complete response in locally advanced non-small cell lung cancer is the main end point of combined therapies (chemotherapy and/or radiotherapy). Surgery after an induction treatment can improve local control, allowing the histologic assessment of treatment activity by means of resection or extensive biopsies.

Methods

Thirty patients surgically assessed without viable tumor after concurrent radiotherapy and continuous infusion of low-dose cisplatin, owing to an initially unresectable stage III non-small-cell lung cancer, were the object of evaluation to assess clinical implications, short- and long-term surgical results.

Results

The specificity rate of the preoperative restaging was 36.6%. The surgical procedures consisted of 22 resections and of extensive biopsies in 8 cases. The operative mortality was 4% (1/25) for procedures other than right pneumonectomy (3/5). No patient received postoperative chemotherapy. Eleven distant progressions, 4 local recurrences, and 4 new primary tumors were assessed as initial failures. The 8-year overall survival was 36%.

Conclusions

Pathologic complete response after cisplatin-enhanced radiotherapy cannot be satisfactorily assessed by clinical means. Surgery is required to obtain a reliable evaluation; however, right pneumonectomy should be contraindicated because of prohibitive risk. Although an effective local treatment can cure patients with advanced stage III disease, the addition of chemotherapy seems advisable to improve tumor relapse control.

Concomitant chemoradiation versus neoadjuvant chemotherapy in locally advanced cervical carcinoma: results from two consecutive phase II studies

BACKGROUND

Randomized studies comparing induction chemotherapy followed by surgical resection with radiation alone found that the neoadjuvant approach produces better results. So far, this latter modality has not been compared with standard concomitant chemoradiation. The objective of this report was to compare the results of two consecutive phase II studies: neoadjuvant chemotherapy followed by surgery or chemoradiation for the unresectable cases versus standard cisplatin-based chemoradiation.

PATIENTS AND METHODS

From February 1999 to July 1999, 41 patients with cervical carcinoma, stages IB2-IIIB, were treated with neoadjuvant chemotherapy. Treatment consisted of three 21-day courses of cisplatin 100 mg/m(2) on day 1 and gemcitabine 1000 mg/m(2) on days 1 and 8, followed by either surgery or concomitant chemoradiation for the non-operable cases. From August 1999 to December 1999, an equal number of patients having comparable clinicopathological characteristics were treated with six weekly courses of cisplatin 40 mg/m(2) during standard pelvic radiation.

RESULTS

A total of 82 patients were analyzed. Both groups were similar with regard to age, histology, International Federation of Gynecology and Obstetrics (FIGO) stage, tumor size, pretreatment hemoglobin levels, parametrial infiltration and performance status. In the neoadjuvant arm the overall response rate to induction chemotherapy was 95% (95% confidence interval 88% to 100%). Twenty-three patients had surgery and 14 underwent chemoradiation. In the definitive chemoradiation study, 38 patients completed treatment, the median number of cisplatin courses was six for a dose intensity of 33 mg/m(2)/week. Doses to points A and B were 85 Gy (range 68-95) and 55 Gy (range 51-65), respectively. Chemoradiation was delivered in 44.6 (range 28-113) days. Complete response rates after all treatment were similar: 97% and 87% in the neoadjuvant and chemoradiation groups, respectively. At a median follow-up of 28 (range 2-33) and 24 (range 3-30) months, respectively, there were no differences in overall survival. To date, 15 and 13 patients in the neoadjuvant and chemoradiation groups, respectively, have died of disease (P = 0.8567).

CONCLUSIONS

The results of this non-randomized comparison suggest that induction chemotherapy followed by surgery or chemoradiation is at least as effective in terms of response and survival as standard cisplatin-based chemoradiation. A randomized study is needed to confirm these findings.

Advanced non-small cell lung cancer: induction chemotherapy and chemoradiation before operation

BACKGROUND

Induction chemotherapy before operation is beneficial for patients with advanced locoregional non-small cell lung cancer. However, no optimal regimen has been established. This study assesses feasibility, response, resectability, and survival of chemotherapy followed by chemoradiation before operation in patients with non-small cell lung cancer.

METHODS

Fifty-seven stage IIIA and selected IIIB patients with non-small cell lung cancer received 2/3 cycles of cisplatin and oral etoposide, followed in 3/4 weeks by chemoradiation with daily cisplatin before each radiation fraction. Patients achieving a resectable status underwent operation.

RESULTS

Response to induction treatment was documented in 73%; 69% achieved a resectable status and 53% underwent operation. Median survival was 16 months. The 1-, 2-, and 3-year survival rates were 65%, 35% and 22%, respectively. There was no difference in survival between stage IIIA and IIIB disease. Myelotoxicity was moderate to severe (grade III/IV in 61% of patients). Three patients died of late complications of pneumonectomy.

CONCLUSIONS

Our presurgery chemotherapy and chemoradiation protocol yields high response and resectability rates, with moderate to severe myelotoxicity. Pneumonectomy is associated with a relatively high rate of late complications.

Induction chemotherapy followed by concurrent chemotherapy and definitive high-dose radiotherapy for patients with locally advanced non-small-cell lung cancer (stages IIIa/IIIb): a pilot phase I/II trial

BACKGROUND

Overall prognosis of patients with locally advanced non-small-cell lung cancer (LAD-NSCLC) is still unfavourable. Different attempts to improve treatment results have been made using combinations of chemotherapy and radiotherapy. The aim of this pilot phase I/II investigation was to test the feasibility and toxicity of a definitive multimodality protocol in patients with irresectable NSCLC stages IIIA (N2) and IIIB.

PATIENTS AND METHODS

Thirty LAD-NSCLC patients (stages IIIA/IIIB: 3/27; median age: 54 years, range 34-70; male/female: 17/13) who were consecutively enrolled onto our ongoing neoadjuvant multimodality protocol from October 1996 to February 1999 remained inoperable after induction treatment. Three cycles of cisplatin/etoposide (PE) were followed by hyperfractionated accelerated radiotherapy (HF-RTx: 1.5 Gy bid up to a total dose of 45 Gy in 3 weeks) concurrent with one cycle of PE. Definitive local treatment was completed with a small volume boost of 20 Gy (qd), adding up to a total dose of 65 Gy to the primary. Patients were routinely offered prophylactic cranial irradiation (PCI; 30 Gy; 2 Gy qd).

RESULTS

Overall toxicity of the definitive CTx/RTx protocol-the main endpoint of this investigation-turned out to be acceptable (oesophagitis grade 3/4: 6/4 patients; pneumonitis grade 3/4: 0/1 patients; no treatment-related deaths). Actuarial survival at 2 years was 31% with a loco-regional control rate of 21%.

CONCLUSIONS

This regimen turned out to be feasible with acceptable toxicity and will serve as a reference arm in a planned randomised trial in stage IIIB NSCLC, testing the value of surgery in this setting: preoperative induction CTx/RTx followed by surgery versus definitive CTx/RTx.

Radiosensitization with chemotherapeutic agents

The combination of low-dose chemotherapy and thoracic radiotherapy is one of the treatments proposed in an attempt to improve the prognosis of locally advanced non-small cell lung cancer. Chemotherapeutic drugs administered at subtoxic doses act by means of a radiosensitization mechanism. Platinum-derived drugs have been historically used as radiosensitizers, without cumulative unacceptable toxicity. Many new chemotherapeutic agents, which have shown promising results in terms of disease control in advanced non-small cell lung cancer, show also a radiosensitizing activity. However, the optimal dose and timing of such drugs when used concurrently to radiotherapy are unknown. This paper will review the results obtained using new chemotherapeutic drugs as radiosensitizers.

Failure-specific prognostic factors after continuous hyperfractionated accelerated radiotherapy (CHART) or conventional radiotherapy in locally advanced non-small-cell lung cancer: a competing risks analysis

The aim of this study was to identify possible failure-specific prognostic factors in non-small-cell lung cancer. Clinical outcome was analysed in 549 patients participating in the randomized controlled trial of CHART vs conventional radiotherapy. Local failure and distant failure with or without concurrent local relapse were subjected to a competing risk analysis using an accelerated failure-time model with a log-logistic hazard function. Randomization to CHART (2 P = 0.005), increasing age (2 P = 0.036) and female sex (2 P = 0.09) was all associated with a prolonged interval to failure. Advanced clinical stage was associated with a decreased interval to failure (2 P = 0.004) and a significantly increased risk (2 P = 0.009) of failing in distant rather than in local position. From this model, prognostic indices for local and distant failure were estimated for each individual patient. Competing risk analysis allows identification of patients with different failure patterns, and may provide a means of stratifying patients for intensified local or systemic therapy.

Combined modality therapy in NSCLC

Combined modality treatment has 'come out of age' and increasingly represents standard of care for a rapidly growing number of patients in locally advanced stages of NSCLC. Modern progress of treatment techniques as well as possibilities for supportive interventions will lead to lesser treatment toxicities, better patient's compliance to treatment protocols and combinations of different modalities with a more efficient outcome. This number will further increase, as more and more centres in Europe are setting up the logistics of multidisciplinary treatment groups for patients with lung cancer. Standard of care for most disease stages is currently under investigation in large randomised phase-III trials. Further research in the forthcoming years has to address questions of treatment individualisation (risks, prognosis, need for local control in the individual patient, biological evaluation of tumour aggressiveness, DNA-fingerprinting of tumours, evaluation of MRD-status, treatment in the community). New drugs or treatment principles with different mechanisms of action such as antiangiogenesis factors, signal-transduction inhibitors, immunotherapy, antisense-oligonucleotides or gene(replacement) therapy may stimulate further clinical research. This may eventually define 'new modalities of treatment' thus leading to modern 'second-generation combined-modality protocols' including some of the new principles.

Locally advanced non-small cell lung cancer

Locally advanced non-small cell lung cancer remains a paradoxical entity to manage. Although this type of cancer is confined to the thorax and is ostensibly curable, most patients presenting at this stage of disease eventually succumb to it. The accepted therapy presently includes chemotherapy and radiation. The exact agents, schedules, and combinations need to be defined further, although cisplatin has become the widely viewed standard cytotoxic drug in this setting. Notwithstanding, newer chemotherapeutic and biologic agents are being extensively tested to find less toxic options with greater efficacy. Drugs that are gaining widespread approval include carboplatin, paclitaxel, gemcitabine, and vinorelbine. At the same time, advances in radiation therapy are triggering a revolution in dose intensity and scheduling that will one day offer superlative local control.