Management of small-cell lung cancer

Toripalimab Plus Chemotherapy as a First-Line Therapy for Extensive-Stage Small Cell Lung Cancer: The Phase 3 EXTENTORCH Randomized Clinical Trial

Importance

Patients with extensive-stage small cell lung cancer (ES-SCLC) have poor prognoses and unmet medical needs.

Objective

To evaluate the efficacy and safety of toripalimab plus etoposide and platinum-based chemotherapy (EP) vs placebo plus EP as a first-line treatment for patients with ES-SCLC.

Design, Setting, and Participants

This multicenter, double-blind, placebo-controlled phase 3 randomized clinical trial (EXTENTORCH study) enrolled patients from September 26, 2019, to May 20, 2021, and was conducted at 49 sites in China. Eligible patients had histologically or cytologically confirmed ES-SCLC without previous systemic antitumor therapy for ES-SCLC. Data were analyzed between May 6, 2023, and June 1, 2024.

Interventions

Patients were randomized (1:1) to receive toripalimab, 240 mg, or placebo plus EP every 3 weeks for up to 4 to 6 cycles, followed by maintenance with toripalimab or placebo until disease progression, intolerable toxic effects, or up to 2 years of treatment.

Main Outcomes and Measures

The primary end points were investigator-assessed progression-free survival (PFS) and overall survival (OS). Whole-exome sequencing results identified correlative biomarkers for clinical efficacy.

Results

Among 595 screened patients, 442 eligible patients were randomized (median [range] age, 63 [30-77] years; 366 [82.8%] male); 223 patients were randomized to toripalimab plus EP, and 219 to placebo plus EP. By April 20, 2023, the median (range) survival follow-up was 13.7 (0.0-42.7) months. Compared with placebo, toripalimab improved investigator-assessed PFS (hazard ratio [HR], 0.67 [95% CI, 0.54-0.82]; P < .001), and significantly reduced the risk of death (HR, 0.80 [95% CI, 0.65-0.98]; P = .03). The median OS was 14.6 (95% CI, 12.9-16.6) months in the toripalimab group vs 13.3 (95% CI, 11.8-14.4) months in the placebo group. Whole-exome sequencing results from 300 patients identified low intratumor heterogeneity, HLA-A11+ HLA-B62- haplotype, wild-type KMT2D and COL4A4, or sequence variations in CTNNA2 or SCN4A correlated with favorable PFS and OS in the toripalimab group. No new safety signals were observed. Grade 3 or higher treatment-emergent adverse event incidence was similar between the toripalimab and placebo safety set groups (199 of 222 patients [89.6%] vs 193 of 216 patients [89.4%], respectively).

Conclusions and Relevance

In this phase 3 randomized clinical trial, adding toripalimab to first-line chemotherapy demonstrated significant improvements in PFS and OS for patients with ES-SCLC. The treatment exhibited an acceptable safety profile, supporting this combination regimen as a new treatment option for patients with ES-SCLC.

Trial Registration

ClinicalTrials.gov Identifier: NCT04012606.

Study design and rationale for IFCT- 2203 TAXIO: A study that aims to evaluate the effectiveness of a first-line chemotherapy regimen without etoposide, combined with durvalumab, for patients with extensive disease small cell lung cancer

BACKGROUND

Studies have shown improvement in overall survival with anti-PD1/PD-L1 molecules in combination with cisplatin/carboplatin and etoposide as a first-line treatment for Small Cell Lung Cancer (SCLC). However, first-line efficacy remains limited and well below that observed in Non-Small Cell Lung Cancer (NSCLC). Etoposide may have a detrimental effect on lymphocyte activation, which could explain the limited benefit of immunotherapy in the first line and the lack of benefit in the second line for patients previously exposed to high levels of etoposide.

METHODS

We initiated a multicenter, single-arm, open-label phase II study of a chemotherapy regimen with durvalumab, combined with carboplatin and paclitaxel for extensive disease SCLC. Eligible patients will receive durvalumab plus carboplatin and paclitaxel every 3 weeks for up to 4 cycles, followed by durvalumab every 4 weeks until progression or unacceptable toxicity. A total of 67 patients will be enrolled in this study, with a 12-month enrollment period and 36-month follow-up. The primary endpoint is Overall Survival (OS) rate at 12 months. Secondary endpoints are best response rate, OS, OS at 24- and 36 months, progression free survival (PFS), duration of response, quality of life and safety.

RESULTS

This study aims to establish the efficacy of durvalumab combined with carboplatin and paclitaxel in patients with extensive disease Small Cell Lung Cancer.

CLINICAL TRIAL REGISTRATION

EU CT: 2023-504670-38-00.

Prognostic value of pre-treatment red blood cell distribution width in lung cancer: a meta-analysis

Objective: In recent years, increasing studies found that pre-treatment red blood cell distribution width (RDW) could predict clinical outcomes in various cancers. However, the prognostic value of pre-treatment RDW in lung cancer was inconsistent. Therefore, we performed a meta-analysis to determine prognostic value of pre-treatment RDW in lung cancer.Methods: We performed a search in PubMed, The Cochrane Library, EMBASE (via OVID), Web of Science, CNKI, Wanfang, VIP, SinoMed databases, then we identified all records up to February 15, 2019. Outcomes of interest were overall survival (OS) and disease-free survival (DFS). Hazard ratios (HRs) and corresponding 95% confidence intervals (95% CIs) were calculated to assess the relevance of pre-treatment RDW to OS in lung cancer.Results: We included ten articles in total. Pooled results revealed that elevated pre-treatment RDW was significantly associated with poor OS (HR = 1.55, 95% CI: 1.26-1.92, p < 0.001) and DFS (HR = 1.53, 95% Cl: 1.15-2.05; p = 0.004) in lung cancer. Further subgroup analysis manifested that lung cancer patients with elevated pre-treatment RDW had worse prognosis.Conclusions: A higher value of pre-treatment RDW indicated worse survival of patients with lung cancer. RDW may serve as a reliable and economical marker for prediction of lung cancer prognosis.

Comparative effectiveness of combined therapy inhibiting EGFR and VEGF pathways in patients with advanced non-small-cell lung cancer: a meta-analysis of 16 phase II/III randomized trials

BACKGROUND & AIMS

Combined therapy inhibiting EGFR and VEGF pathways is becoming a promising therapy in the treatment of advanced non-small-cell lung cancer (NSCLC), however, with controversy. The study aims to compare the efficacy of combined inhibition therapy versus control therapy (including placebo, single EGFR inhibition and single VEGF inhibition) in patients with advanced NSCLC.

MATERIALS AND METHODS

An adequate literature search in EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), American Society of Clinical Oncology (ASCO) and European Society of Medical Oncology (ESMO) was conducted. Phase II or III randomized controlled trials (RCTs) that compared effectiveness between combined inhibition therapy and control therapy in patients with advanced NSCLC were eligible. The endpoint was overall response rate (ORR), progression free survival (PFS) and overall survival (OS).

RESULTS

Sixteen phase II or III RCTs involving a total of 7,109 patients were included. The results indicated that the combined inhibition therapy significantly increased the ORR (OR = 1.59, 95% CI = 1.36-1.87, p<0.00001; I2 = 36%) when compared to control therapy. In the subgroup analysis, the combined inhibition therapy clearly increased the ORR (OR = 2.04, 95% CI = 1.60-2.60, p<0.00001; I2 = 0%) and improved the PFS (HR = 0.78, 95% CI = 0.71-0.85, p<0.00001;I2 = 0%) when compared with the placebo, and similar results was detected when compared with the single EGFR inhibition in terms of ORR (OR = 1.39, 95% CI = 1.12-1.74, p = 0.003; I2 = 30%) and PFS (HR = 0.73, 95% CI = 0.67-0.81, p<0.0001; I2 = 50%). No obvious difference was found between the combined inhibition therapy and single VEGF inhibition in term of ORR, however, combined inhibition therapy significantly decreased the PFS when compared to the single VEGF inhibition therapy (HR = 1.70, 95% CI = 1.34-2.17, p<0.0001; I2 = 50%). Besides, no significant difference was observed between the combined inhibition therapy and control therapy in term of OS (including placebo, single EGFR inhibition and single VEGF inhibition) (HR = 0.98, 95% CI = 0.92-1.04, p = 0.41; I2 = 0%).

CONCLUSIONS

Combined inhibition therapy was superior to placebo and single EGFR inhibition in terms of ORR, PFS for advanced NSCLC, however, no statistical difference were found in term of OS. Besides, combined inhibition therapy was not superior to single VEGF inhibition in terms of ORR, PFS and OS. Therefore, combined inhibition therapy is recommended to treat advanced NSCLC patients.

The prognostic value of excision repair cross-complementation group 1 (ERCC1) in patients with small cell lung cancer (SCLC) receiving platinum-based chemotherapy: evidence from meta-analysis

Recently, the correlation between the efficacy of platinum-based chemotherapy and ERCC1 expression in patients with SCLC has attracted wide-spread attention, and a lot of investigations have been conducted, whereas conflicting results were presented. Therefore, we performed the present meta-analysis of eligible studies to derive a more precise evaluation of the association between ERCC1 expression and the clinical outcome in SCLC patients receiving platinum-based chemotherapy. A literature search for relevant studies was conducted in the electronic databases of PubMed, EMBASE and Web of Science. The inclusive criteria were SCLC patients treated by platinum-based chemotherapy, and evaluated the relationship between ERCC1 expression and the clinical outcomes [including overall response rate (ORR), overall survival (OS) or progression-free survival (PFS)]. Odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI) was calculated to assess the risk. A total of nine studies including 1129 patients were included in final analysis. Our analysis indicated that positive/high ERCC1 expression was associated with unfavorable OS (HR = 1.18, 95%CI = 1.02–1.37) and PFS (HR = 1.46, 95%CI = 1.14–1.88). Subgroup analysis according to disease stage suggested the significant relationship was found in limited stage (LS-SCLC), but not in extensive stage (ES-SCLC). However, no significant association was found between ERCC1 expression and ORR. Our analysis suggested ERCC1 expression may be a prognostic factor in SCLC patients receiving platinum-based chemotherapy, especially for LS-SCLC.

Phase II study of oral etoposide maintenance for patients with extensive stage small cell lung cancer who have responded to the induction on an EP regimen

BACKGROUND

Maintenance therapy for extensive stage small cell lung cancer (ES-SCLC) is still under debate. Many new agents fail during the maintenance course. As an active agent for SCLC, oral etoposide is worth being re-evaluated.

METHODS

This phase II study was performed to evaluate the toxicity/efficacy of the maintenance of patients with oral etoposide with ES-SCLC responding (complete remission [CR] + partial remission [PR]) to the induction of four cycles of etoposide plus cisplatin (EP) chemotherapy. Maintenance therapy with oral etoposide (50 mg/m² , day 1-14, repeated every 21 days until disease progression or unacceptable toxicity occurs) was administered. The primary endpoints were grade 3 and 4 toxicities and progression free survival (PFS).

RESULTS

Fifty-four patients with ES-SCLC received standard EP regimens as induction therapy; 31 responding patients were administered oral etoposide as the maintenance treatment. The most common hematological and non-hematological toxicity of the maintenance course was neutropenia and fatigue, respectively. Median PFS was nine months (95% confidence interval (CI): 8.33∼9.67 months), median overall survival (OS) was 14 months (95% CI: 11.58∼16.42 months). Significantly better PFS and OS were seen in patients responding to the induction EP chemotherapy.

CONCLUSIONS

Oral etoposide maintenance is safe and effective for patients with ES-SCLC who responded to the induction of EP chemotherapy. Significant survival benefit was revealed in patients completely responding to an EP regimen. Further randomized control study is warranted.

External Qi of Yan Xin Qigong induces cell death and gene expression alterations promoting apoptosis and inhibiting proliferation, migration and glucose metabolism in small-cell lung cancer cells

Small-cell lung cancer (SCLC) is a highly malignant carcinoma with poor long-term survival. Effective treatment remains highly demanded. In the present study, we demonstrated that External Qi of Yan Xin Qigong (YXQ-EQ) exerted potent cytotoxic effect towards SCLC cell line NCI-H82 via induction of apoptosis. Global gene expression profiling identified 39 genes whose expression was altered by YXQ-EQ in NCI-82 cells. Among them, semi-quantitative RT-PCR and real-time qPCR analyses confirmed that the gene expression levels of apoptotic proteins death-associated protein kinase 2 and cell death-inducing DFFA-like effector b were upregulated, whereas that of oncoproteins DEK and MYCL1, cell migration-promoting proteins CD24 and integrin-alpha 9, and glycolytic enzyme aldolase A were downregulated. These findings suggest that YXQ-EQ may exert anticancer effect through modulating gene expression in a way that facilitates cancer cell apoptosis while represses proliferation, metastasis, and glucose metabolism.

Hyponatremia as prognostic factor in small cell lung cancer--a retrospective single institution analysis

PURPOSE

The aim of this retrospective study is to present data on clinical significance of hyponatremia in an unselected contemporary patient population with small cell lung cancer (SCLC) with limited disease (LD) and extensive disease (ED).

PATIENTS AND METHODS

Our electronic database was searched for patients with newly diagnosed SCLC from June 2004 to December 2008. 395 cases were identified. We collected data on patient characteristics including clinical performance status, serum sodium values, serum LDH values, metastatic sites, chemotherapy regimens and response, radiotherapy and survival.

RESULTS

Hyponatremia (sodium <135 mmol/l) was present in 18.9% of all cases. Severe hyponatremia (sodium <129 mmol/l) was detected in 8.8%. Hyponatremia was present in 58 out of 241 (24%) patients with ED SCLC and 17 of 154 (11%) patients with LD SCLC. Hyponatremia was associated with significantly shorter median survival (SCLC all patients: 9.0 vs. 13.0 months, p < 0.001, LD SCLC: 9.0 vs. 17.0, p = 0.050, ED SCLC 9.0 vs. 10.0, p = 0.135). After adjustment for age, gender, LDH and performance status hyponatremia was an independent predictor of mortality in patients with ED and LD SCLC.

CONCLUSION

According to the extensive statistical analyses in our comprehensive unselected patient population, hyponatremia seems to constitute an independent prognostic factor in patients with SCLC.

A phase I trial of pan-Bcl-2 antagonist obatoclax administered as a 3-h or a 24-h infusion in combination with carboplatin and etoposide in patients with extensive-stage small cell lung cancer

Background:

Bcl-2 family genes are frequently amplified in small cell lung cancer (SCLC). A phase I trial was conducted to evaluate the safety of obatoclax, a Bcl-2 family inhibitor, given in combination with standard chemotherapy.

Methods:

Eligible patients (3–6 per cohort) had extensive-stage SCLC, measurable disease, ⩽1 before therapy, Eastern Cooperative Oncology Group performance status 0 or 1, and adequate organ function. Patients were treated with escalating doses of obatoclax, either as a 3- or 24-h infusion, on days 1–3 of a 21-day cycle, in combination with carboplatin (area under the curve 5, day 1 only) and etoposide (100 mg m⁻², days 1–3). The primary endpoint was to determine the maximum tolerated dose of obatoclax.

Results:

Twenty-five patients (56% male; median age 66 years) were enrolled in three dose cohorts for each schedule. Maximum tolerated dose was established with the 3-h infusion at 30 mg per day and was not reached with the 24-h infusion. Compared with the 24-h cohorts, the 3-h cohorts had higher incidence of central nervous system (CNS) adverse events (AEs); dose-limiting toxicities were somnolence, euphoria, and disorientation. These CNS AEs were transient, resolving shortly after the end of infusion, and without sequelae. The response rate was 81% in the 3-h and 44% in the 24-h infusion cohorts.

Conclusion:

Although associated with a higher incidence of transient CNS AEs than the 24-h infusion, 3-h obatoclax infusion combined with carboplatin–etoposide was generally well tolerated at doses of 30 mg per day. Though patient numbers were small, there was a suggestion of improved efficacy in the 3-h infusion group. Obatoclax 30 mg infused intravenously over 3 h on 3 consecutive days will be utilised in future SCLC studies.

Endoglin (CD105) expression and angiogenesis status in small cell lung cancer

It is well established that angiogenesis is crucial for tumor development and progression. Among the angiogenesis immunomarkers defined to date, endoglin (CD105) has been shown to be a useful marker of angiogenesis. To investigate the degree of angiogenesis status in small cell lung cancer (SCLC) tissue, we assessed 35 cases of SCLC at autopsy using immunohistochemical staining of CD31 and CD105. The intratumoral area, peritumoral area, and background pulmonary alveoli were then observed under low magnification, and the microvessel density (MVD) for each area was determined. The MVD-CD31 was the highest in the background alveoli, followed by the intratumoral and peritumoral areas. The MVD-CD105 was highest in the intratumoral area, followed by the peritumoral area and the background lung. The ratio of CD105/CD31 revealed that almost 78% of the intratumoral area, 63% of the peritumoral area, and 4.6% of the background lung alveoli were newly formed and expressed CD105. This result indicated that SCLC is predominantly supported by newly formed vessels that are generated by CD105-mediated angiogenesis. These findings suggest that anti-angiogenic therapy, especially CD105-targeting, may prove an effective form of SCLC treatment.

Characteristics, treatment patterns and outcomes of patients with small cell lung cancer--a retrospective single institution analysis

PURPOSE

The aim of this retrospective study is to present data on patient characteristics, treatment patterns, and treatment results in an unselected contemporary patient population with small cell lung cancer (SCLC) in limited disease (LD) and extensive disease stage (ED).

PATIENTS AND METHODS

From June 2004 to December 2008, our electronic database including all in-patient and out-patient contacts was searched for patients with newly diagnosed lung cancer. 397 patients were found having SCLC. We collected data on patient characteristics, chemotherapy, side effects, response on treatment and survival.

RESULTS

39% of all patients had LD SCLC. Median age was 63 years. The response rate (RR) reached 76%. Stable disease was the result of first line therapy in 16%. Consecutive thoracic radiotherapy was given in 72%. Additional prophylactic cranial irradiation (PCI) was administered to 33%. 43% received second line therapy. Median survival was 18.8 months. In 61% of cases, ED SCLC was diagnosed. Median age was 61 years. Main metastatic sites were liver, bone, brain and adrenal glands. RR was 69%. Stable disease and progressive disease were the result of first line chemotherapy both in 12%. 15% received palliative cranial irradiation, 3% PCI. 51% were treated with second line therapy. Median survival reached 10.6 months.

CONCLUSION

We provide a comprehensive analysis of a contemporary patient population. Treatment patterns and survival data fit well in the context of current international trials on more selected patients. Multivariate analyses confirmed extend of disease, performance status and LDH serum levels as independent prognostic factors for survival. Age and gender reached no statistical significance.

Retinoblastoma tumor suppressor gene expression determines the response to sequential flavopiridol and doxorubicin treatment in small-cell lung carcinoma

PURPOSE

Small-cell lung cancers (SCLC) are defective in many regulatory mechanisms that control cell cycle progression, i.e., functional retinoblastoma protein (pRb). Flavopiridol inhibits proliferation and induces apoptosis in SCLC cell lines. We hypothesized that the sequence flavopiridol followed by doxorubicin would be synergistic in pRb-deficient SCLC cells.

EXPERIMENTAL DESIGN

A H69 pRb-deficient SCLC cell line, H865, with functional pRb and H865 pRb small interfering RNA (siRNA) knockdown cells were used for in vitro and in vivo experiments. The in vivo efficiencies of various sequential combinations were tested using nude/nude athymic mice and human SCLC xenograft models.

RESULTS

Flavopiridol then doxorubicin sequential treatment was synergistic in the pRB-negative H69 cell line. By knocking down pRb with specific siRNA, H865 clones with complete pRb knockdown became sensitive to flavopiridol and doxorubicin combinations. pRb-deficient SCLC cell lines were highly sensitive to flavopiridol-induced apoptosis. pRb-positive H865 cells arrested in G0-G1 with flavopiridol exposure, whereas doxorubicin and all flavopiridol/doxorubicin combinations caused a G2-M block. In contrast, pRb-negative SCLC cells did not arrest in G0-G1 with flavopiridol exposure. Flavopiridol treatment alone did not have an in vivo antitumor effect, but sequential flavopiridol followed by doxorubicin treatment provided tumor growth control and a survival advantage in Rb-negative xenograft models, compared with the other sequential treatments.

CONCLUSIONS

Flavopiridol and doxorubicin sequential treatment induces potent in vitro and in vivo synergism in pRb-negative SCLC cells and should be clinically tested in tumors lacking functional pRB.

Expression of breast cancer resistance protein is associated with a poor clinical outcome in patients with small-cell lung cancer

BACKGROUND

ATP-binding cassette (ABC) transporter and DNA excision repair proteins play a pivotal role in the mechanisms of drug resistance. The aim of this study was to investigate the expression of ABC transporter and DNA excision repair proteins, and to elucidate the clinical significance of their expression in biopsy specimens from patients with small-cell lung cancer (SCLC).

METHODS

We investigated expression of the ABC transporter proteins, P-glycoprotein (Pgp), multidrug resistance associated-protein 1 (MRP1), MRP2, MRP3, and breast cancer resistance protein (BCRP), and the DNA excision repair proteins, excision repair cross-complementation group 1 (ERCC1) protein and breast cancer susceptibility gene 1 (BRCA1) protein, in tumor biopsy specimens obtained before chemotherapy from 130 SCLC patients who later received platinum-based combination chemotherapy, and investigated the relationship between their expression and both response and survival.

RESULTS

No significant associations were found between expression of Pgp, MRP1, MRP2, MRP3, ERCC1, or BRCA1 and either response or survival. However, there was a significant association between BCRP expression and both response (p=0.026) and progression-free survival (PFS; p=0.0103).

CONCLUSIONS

BCRP expression was significantly predictive of both response and progression-free survival (PFS) in SCLC patients receiving chemotherapy. These findings suggest that BCRP may play a crucial role in drug resistance mechanisms, and that it may serve as an ideal molecular target for the treatment of SCLC.

Small-cell lung cancer: 8 years experience of a single multidisciplinary team

Aims. We have audited the changes in treatment practice for small-cell lung cancer (SCLC) presented to a single multidisciplinary team (MDT) at Doncaster and Bassetlaw Hospitals between January 1998 and December 2005. Materials and Methods. The MDT database was used to identify all patients with SCLC. Anonymised demographic, treatment, and outcome details were extracted from the database supplemented by patient records. Results. 235 patients were identified. 112 (48%) had limited disease at presentation. Chemotherapy was the initial treatment for 195 patients, 77% of whom had a documented radiological response with a complete response in 24%. Chemotherapy regimes evolved during the study period with the increasing use of platinum-based chemotherapy. Anthracycline-based chemotherapy was most used before 2004 and was given to 57% of all patients. 42% received consolidation thoracic radiotherapy and 24% prophylactic cranial irradiation. The median and 2-year survival were 8 months and 18%, respectively, for patients with limited disease and 5 months and 5%, respectively, for extensive disease. Conclusion. We have documented changes in treatment practice and service delivery of SCLC over the 8 years during which the MDT has been operating. However, there has not achieve any significant improvement in outcome for the population of patients with SCLC.

Activity of the Bcl-2 family inhibitor ABT-263 in a panel of small cell lung cancer xenograft models

PURPOSE

The purpose of this study was to characterize the activity of the Bcl-2 protein family inhibitor ABT-263 in a panel of small cell lung cancer (SCLC) xenograft models.

EXPERIMENTAL DESIGN

A panel of 11 SCLC xenograft models was established to evaluate the efficacy of ABT-263. Single agent activity was examined on a continuous dosing schedule in each of these models. The H146 model was used to further evaluate dose and schedule, comparison to standard cytotoxic agents, and induction of apoptosis.

RESULTS

ABT-263 exhibited a range of antitumor activity, leading to complete tumor regression in several models. Significant regressions of tumors as large as 1 cc were also observed. The efficacy of ABT-263 was also quite durable; in several cases, minimal tumor regrowth was noted several weeks after the cessation of treatment. Antitumor effects were equal or superior to that of several clinically approved cytotoxic agents. Regression of large established tumors was observed through several cycles of therapy and efficacy was retained in a Pgp-1 overexpressing line. Significant efficacy was observed on several dose and therapeutic schedules and was associated with significant induction of apoptosis.

CONCLUSIONS

ABT-263 is a potent, orally bioavailable inhibitor of Bcl-2 family proteins that has recently entered clinical trials. The efficacy data reported here suggest that SCLC is a promising area of clinical investigation with this agent.

Somatostatin receptor scintigraphy in thoracic diseases

Somatostatin (SS) receptor scintigraphy is useful for the diagnosis of lesions with high density of SS receptors, and above all neuroendocrine tumors. For several years, only indium-labeled octreotide has been applied to visualise in vivo tissues with SS receptor overexpression. Radiolabeled octreotide became the gold standard for the detection of neuroendocrine tumors. More recently, however, several new SS analogues with varying affinity for SS receptor subtypes have been developed, and different radionuclides as radiolabels have been introduced. Moreover, significant improvements have been made by the introduction of hybrid machines, such as single photon emission computed tomography/ computed tomography (SPECT/CT) or positron emission tomography (PET)/CT that enable to perform whole-body imaging quickly and with high anatomical resolution in several body areas, including the chest. The development of more specific radiopharmaceuticals, together with the modern technique of imaging, may provide excellent quality images with high contrast, allowing to depict very small lesions and making them easy to interpret. Indeed, in the management of SS receptor-positive lesions, the contribution of nuclear medicine is essential in several clinical settings, such as initial diagnosis, disease staging, follow-up, treatment planning, and treatment monitoring. In addition, the tracer uptake might be used as a prognostic parameter and as a predictor of treatment response. In the chest, apart in (neuro)endocrine tumors, SS receptors have been demonstrated in granulomatous diseases, like sarcoidosis and other immune-mediated disorders, such as anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis. In this paper we review and discuss the role of SS receptor scintigraphy in diagnosis, staging or follow- up of thoracic SS receptor-positive lesions.

Available treatment options for the management of Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome is a rare, but reasonably well-understood, antibody-mediated autoimmune disease that is caused by serum auto-antibodies and results in muscle weakness and autonomic dysfunction. One half of the patients have an idiopathic form, the other half a tumour-associated form of the disease. Three randomised trials and a large number of smaller clinical studies have resulted in a number of drugs becoming available for the treatment of Lambert-Eaton myasthenic syndrome. Several drugs are available for the symptomatic treatment of the disease, including guanidine, aminopyridines or acetylcholinesterase inhibitors. Other therapies aim to deplete the serum autoantibodies or to suppress the immune system. For this purpose, immunomodulating strategies, such as intravenous immunoglobulins or plasmapheresis, or several immunosuppressive agents are available. Chemotherapy has successfully ameliorated the course of disease in Lambert-Eaton myasthenic syndrome patients with an underlying tumour.

Current status of second-line treatment and novel therapies for small cell lung cancer

Despite high response rates to first-line standard treatment, the great majority of patients with small cell lung cancer (SCLC) will relapse and succumb to their disease rather quickly. In the context of salvage therapy, symptom palliation and quality-of-life improvements, besides survival prolongation, are primary treatment endpoints. A variety of single-agent and multi-agent chemotherapy regimens have been tested with limited success in patients with recurrent SCLC. A number of combination regimens have demonstrated high response rates in second-line settings, but these can be considered only for patients with good performance status. Treatment outcome depends on many factors, including type of response to first-line therapy, treatment-free interval, and performance status. Currently, topotecan represents an effective, tolerable therapeutic option and is the only agent approved for this indication. The management of patients with recurrent disease remains an area of active research. This review provides an update of clinical research on second-line chemotherapy of SCLC and of recent results obtained with novel molecular targeted approaches in both first- and second-line therapy.

Phase III Double-Blind, Placebo-Controlled Study of Thalidomide in Extensive-Disease Small-Cell Lung Cancer After Response to Chemotherapy: An Intergroup Study FNCLCC cleo04–IFCT 00-01

Purpose

This randomized, double-blind, placebo-controlled phase III study aimed to determine whether thalidomide prolongs survival of patients with extensive-disease small-cell lung cancer (SCLC).

Patients and Methods

One hundred nineteen patients received two courses of etoposide, cisplatin, cyclophosphamide, and 4′-epidoxorubicin (PCDE). Responder patients who had recovered from chemotherapy toxicity were randomly assigned to receive four additional PCDE cycles plus thalidomide (400 mg daily) or placebo.

Results

After the first two PCDE cycles, objective response rate was 81.5%, and 92 patients were randomly assigned to placebo (n = 43) or thalidomide (n = 49). Median exposure duration to placebo was 4.5 months, and median exposure to thalidomide was 4.9 months. Patients treated with thalidomide had a longer survival compared with patients who received placebo, although the difference was not statistically significant (minimal follow-up, 3 years; median survival time, 11.7 v 8.7 months, respectively; log-rank test: hazard ratio [HR] = 0.74; 95% CI, 0.49 to 1.12; P = .16). Patients with a performance status (PS) of 1 or 2 who received thalidomide had a significantly longer survival (HR = 0.59; 95% CI, 0.37 to 0.92; P = .02). The disease also progressed slower in patients with PS of 1 or 2 receiving thalidomide (HR = 0.54; 95% CI, 0.36 to 0.87; P = .02), whereas the difference did not reach statistical significance for the whole population (HR = 0.74; 95% CI, 0.49 to 1.12; P = .15). Neuropathy occurred more frequently in the thalidomide group compared with the placebo group (33% v 12%, respectively).

Conclusion

Treatment with thalidomide was not associated with a significant improvement in survival of SCLC patients. There was pronounced heterogeneity in survival outcomes between groups of patients. Some benefit was observed among patients with a PS of 1 or 2 (exploratory analyses), deserving further studies targeting angiogenesis in this disease.

Prophylactic cranial irradiation in extensive small-cell lung cancer

BACKGROUND

We conducted a randomized trial of prophylactic cranial irradiation in patients with extensive small-cell lung cancer who had had a response to chemotherapy.

METHODS

Patients between the ages of 18 and 75 years with extensive small-cell lung cancer were randomly assigned to undergo prophylactic cranial irradiation (irradiation group) or receive no further therapy (control group). The primary end point was the time to symptomatic brain metastases. Computed tomography or magnetic resonance imaging of the brain was performed when any predefined key symptom suggestive of brain metastases was present.

RESULTS

The two groups (each with 143 patients) were well balanced regarding baseline characteristics. Patients in the irradiation group had a lower risk of symptomatic brain metastases (hazard ratio, 0.27; 95% confidence interval [CI], 0.16 to 0.44; P<0.001). The cumulative risk of brain metastases within 1 year was 14.6% in the irradiation group (95% CI, 8.3 to 20.9) and 40.4% in the control group (95% CI, 32.1 to 48.6). Irradiation was associated with an increase in median disease-free survival from 12.0 weeks to 14.7 weeks and in median overall survival from 5.4 months to 6.7 months after randomization. The 1-year survival rate was 27.1% (95% CI, 19.4 to 35.5) in the irradiation group and 13.3% (95% CI, 8.1 to 19.9) in the control group. Irradiation had side effects but did not have a clinically significant effect on global health status.

CONCLUSIONS

Prophylactic cranial irradiation reduces the incidence of symptomatic brain metastases and prolongs disease-free and overall survival. (ClinicalTrials.gov number, NCT00016211 [ClinicalTrials.gov].).

Could we expect to improve survival in small cell lung cancer?

Despite the very good response rate of small cell lung cancer (SCLC) to many anti-cancer agents, survival remains disappointing, particularly in extensive-stage (ES) disease. Many potentially beneficial regimens have achieved a median survival of less than 12 months in clinical trials, and so the standard regimen has remained cisplatin plus etoposide. Trials have shown that 3- and 4-drug regimens are no better than 2-drug regimens; alternating agents, dose-dense and high-dose regimens do not improve outcome, and non-platinum-based regimens are not superior to platinum-based regimens. A recent phase II trial demonstrated that pemetrexed/platinum-based doublets are active in ES-SCLC in the first-line setting. In combination with cisplatin or carboplatin, pemetrexed demonstrated a favourable toxicity profile. The ease of administration and convenient schedule of pemetrexed make these regimens attractive. Although further follow-up of patients in this trial is necessary to define response durability and survival, results so far have led to the initiation of phase III trials of pemetrexed-based regimens in ES-SCLC.

Serum level of arginine-vasopressin influences the prognosis of extensive-disease small-cell lung cancer

PURPOSE

The purpose of this study is to elucidate the influence of serum arginine-vasopressin (AVP) level on prognosis of extensive-disease small-cell lung cancer (ED-SCLC).

METHODS

We retrospectively investigated the clinical records of 163 patients with ED-SCLC, who were admitted to Okayama University Hospital or National Shikoku Cancer Center Hospital. The influence of 14 pretreatment variables on survival was analyzed.

RESULTS

In a multivariate analysis of 163 patients, elevation of serum LDH level (P = 0.028) and poor performance status (PS > or = 2, P = 0.002) were independent poor prognostic factors. In 34 patients whose serum AVP levels were available, high serum AVP level was related to the poor prognosis (P < 0.001). The serum-sodium level did not affect the survival. Median serum level of osmotic pressure in 34 patients was normal (284.9 mOsm/kg), although, serum osmotic pressure was low in four of six patients with high serum AVP level. In all patients with high serum AVP level, serum LDH level was elevated.

CONCLUSIONS

The data from the current study suggested that serum LDH level and PS were the poor prognostic factors for ED-SCLC. But we additionally identified the prognostic significance of serum AVP level, which may be a more useful factor than serum-sodium level.

Determination of the small cell lung cancer associated biomarker pro-gastrin-releasing peptide (ProGRP) using LC-MS

Small cell lung cancer is a rapidly growing neoplasm with high mortality. A recently discovered biomarker, pro-gastrin-releasing peptide (ProGRP), is used as a specific diagnostic marker for the disease. The present methods of quantification are based on the immunoassay techniques RIA and ELISA. Our object was to develop an LC-MS method for the detection and quantification of ProGRP using specific tryptic digestion products from the recombinant peptide ProGRP (31-98), a sequence common to three isoforms of ProGRP. The conditions for enzymatic cleavage were optimized and MS compatibility was obtained. Digestion of ProGRP (31-98) yielded an array of peptide products and these were evaluated for further method development. The peptide product NLLGLIEAK proved to be the preferable candidate to monitor ProGRP due to signal intensity, column retention, and peptide specificity. The identity of this product was verified by means of LC-MS/MS and the linearity of the calibration curve evaluated. LOD was calculated to be 13.9 pg on column (O.C.). Plasma samples spiked with ProGRP (31-98) prior to digestion verified the suitability of this digest product for the determination of ProGRP. LC-MS may prove to be a valuable tool for biomarker mediated diagnosis in the future.

Clinical review – Small cell carcinoma of the bladder

OBJECTIVES

To review the published literature on the diagnosis and management of small cell carcinoma of the bladder (SCCB).

METHODS

Papers were identified by searches of PubMed using the terms "small cell", "bladder" and "carcinoma". Additional papers were identified from review of references of relevant articles.

RESULTS

SCCB comprises less than 1% of bladder malignancies. It is an aggressive tumour that commonly presents at an advanced stage, in an elderly population. Consequently, patients are often not fit for anti-neoplastic therapy. In fit patients, the bedrock of treatment in the majority of cases is platinum-based systemic chemotherapy, which was the only factor predictive of improved outcome on multivariate analysis in one large review. The use of neoadjuvant chemotherapy has been associated with favourable results and may therefore be the preferred approach when scheduling treatment. Options for local management comprise surgery or radiotherapy (sequentially or concurrently with chemotherapy), both of which are potentially curative in selected cases. However, the subsequent frequent development of urothelial malignancies with bladder-sparing approaches should be considered when planning treatment, particularly in younger patients. Prognosis of SCCB overall is poor, the median survival of all cases varies from 4 to 23 months, and overall survival at 5 years from 10% to 40% of patients.

CONCLUSIONS

SCCB is a rare and aggressive tumour with a poor prognosis. Future efforts should be directed at its early detection and the development of more effective systemic therapies.