Multicenter phase II trial of paclitaxel, cisplatin, and etoposide with concurrent radiation for limited-stage small-cell lung cancer

A pharmacovigilance study of etoposide in the FDA adverse event reporting system (FAERS) database, what does the real world say?

Introduction: Etoposide is a broad-spectrum antitumor drug that has been extensively studied in clinical trials. However, limited information is available regarding its real-world adverse reactions. Therefore, this study aimed to assess and evaluate etoposide-related adverse events in a real-world setting by using data mining method on the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods: Through the analysis of 16,134,686 reports in the FAERS database, a total of 9,892 reports of etoposide-related adverse drug events (ADEs) were identified. To determine the significance of these ADEs, various disproportionality analysis algorithms were applied, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms. Results: As a result, 478 significant disproportionality preferred terms (PTs) that were identified by all four algorithms were retained. These PTs included commonly reported adverse events such as thrombocytopenia, leukopenia, anemia, stomatitis, and pneumonitis, which align with those documented in the drug's instructions and previous clinical trials. However, our analysis also uncovered unexpected and significant ADEs, including thrombotic microangiopathy, ototoxicity, second primary malignancy, nephropathy toxic, and ovarian failure. Furthermore, we examined the time-to-onset (TTO) of these ADEs using the Weibull distribution test and found that the median TTO for etoposide-associated ADEs was 10 days (interquartile range [IQR] 2-32 days). The majority of cases occurred within the first month (73.8%) after etoposide administration. Additionally, our analysis revealed specific high-risk signals for males, such as pneumonia and cardiac infarction, while females showed signals for drug resistance and ototoxicity. Discussion: These findings provide valuable insight into the occurrence of ADEs following etoposide initiation, which can potentially support clinical monitoring and risk identification efforts.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Effect of Segmental Abutting Esophagus-Sparing Technique to Reduce Severe Esophagitis in Limited-Stage Small-Cell Lung Cancer Patients Treated with Concurrent Hypofractionated Thoracic Radiation and Chemotherapy

The aim of the current study is to evaluate the effect of segmental abutting esophagus-sparing (SAES) radiotherapy on reducing severe acute esophagitis in patients with limited-stage small-cell lung cancer treated with concurrent chemoradiotherapy. Thirty patients were enrolled from the experimental arm (45 Gy in 3 Gy daily fractions in 3 weeks) of an ongoing phase III trial (NCT02688036). The whole esophagus was divided into the involved esophagus and the abutting esophagus (AE) according to the distance from the edge of the clinical target volume. All dosimetric parameters were significantly reduced for the whole esophagus and AE. The maximal and mean doses of the esophagus (47.4 ± 1.9 Gy and 13.5 ± 5.8 Gy, respectively) and AE (42.9 ± 2.3 Gy and 8.6 ± 3.6 Gy, respectively) in the SAES plan were significantly lower than those (esophagus 48.0 ± 1.9 Gy and 14.7± 6.1 Gy, AE 45.1 ± 2.4 Gy and 9.8 ± 4.2 Gy, respectively) in the non-SAES plan. With a median follow-up of 12.5 months, only one patient (3.3%) developed grade 3 acute esophagitis, and no grade 4-5 events happened. SAES radiotherapy has significant dosimetric advantages, which are successfully translated into clinical benefits and provide good feasibility for dose escalation to improve local control and prognosis in the future.

Efficacy of chemotherapy in limited-disease small-cell lung cancer

SUMMARY Small-cell lung cancer (SCLC) accounts for approximately 13% of all lung cancers, and limited-disease SCLC is defined as a disease that can be encompassed within a tolerable radiation field. Concurrent chemoradiotherapy is considered to be the standard treatment for limited-disease SCLC. In both concurrent and consolidation chemoradiotherapies, the combination of etoposide and cisplatin is considered to be a standard chemotherapy regimen. To develop novel treatment for SCLC, several clinical trials of molecular-targeted therapy or immunotherapy have been reported. However, no molecular-targeted drug has shown clinical activity in limited-disease SCLC. In future studies, understanding the molecular profile of SCLC will be necessary for the development of molecular-targeted therapies for SCLC. This review provides an overview of chemotherapy regimens for limited-disease SCLC.

Prophylactic cranial irradiation for patients with limited-stage small-cell lung cancer with response to chemoradiation

BACKGROUND

Previous clinical studies have generally reported that prophylactic cranial irradiation (PCI) was given to patients with a complete response (CR) to chemotherapy and chest radiotherapy in limited-stage small-cell lung cancer (SCLC). It is not clear if those with incomplete response (IR) would benefit from PCI.

PATIENTS AND METHODS

The Saskatchewan experience from 1981 through 2007 was reviewed. Patients were treated with chest radiotherapy and chemotherapy with or without PCI (typical doses: 2500 cGy in 10 fractions over 2 weeks, 3000 cGy in 15 fractions over 3 weeks, or 3000 cGy in 10 fractions over 2 weeks).

RESULTS

There were 289 patients treated for curative intent, 177/289 (61.2%) of whom received PCI. For the whole group of 289 patients, PCI resulted in significant overall survival (OS) and cause-specific survival (CSS) benefit (P = .0011 and 0.0005, respectively). The time to symptoms of first recurrence at any site with or without PCI was significantly different: 16.9 vs. 13.2 months (P = .0006). PCI significantly delayed the time to symptoms of first recurrence in the brain: 20.7 vs. 10.6 months (P < .0001). The first site of metastasis was the brain for 12.5% and 45.5% patients with CR with and without PCI, respectively (P = .02) and in 6.1% and 27.6% of patients with IR with and without PCI, respectively (P = .05). For the 93 patients with IR, PCI did not confer OS or CSS benefit (P = .32 and 0.39, respectively).

CONCLUSIONS

Patients with IR benefited from PCI, with a reduced rate of and a delayed time for the development of brain metastases, although without significant OS or CSS benefit. PCI could be considered for all patients with limited-stage SCLC responding to chemoradiation.

Limited-stage small cell lung cancer: current chemoradiotherapy treatment paradigms

In the U.S., the prevalence of small cell lung cancer (SCLC) is declining, probably reflecting the decreasing prevalence of tobacco use. However, a significant number of patients will receive a diagnosis of SCLC, and approximately 40% of patients with SCLC will have limited-stage (LS) disease, which is potentially curable with the combination of chemotherapy and radiation therapy. The standard therapy for LS-SCLC is concurrent chemoradiotherapy, and the 5-year survival rate observed in clinical trials is approximately 25%. The standard chemotherapy remains cisplatin and etoposide, but carboplatin is frequently used in patients who cannot tolerate or have a contraindication to cisplatin. Substantial improvements in survival have been made through improvements in radiation therapy. Concurrent chemoradiotherapy is the preferred therapy for patients who are appropriate candidates. The optimal timing of concurrent chemoradiotherapy is during the first or second cycle, based on data from meta-analyses. The optimal radiation schedule and dose remain topics of debate, but 1.5 Gy twice daily to a total of 45 Gy and 1.8-2.0 Gy daily to a total dose of 60-70 Gy are commonly used treatments. For patients who obtain a near complete or complete response, prophylactic cranial radiation reduces the incidence of brain metastases and improves overall survival. The ongoing Radiation Therapy Oncology Group and Cancer and Leukemia Group B and the European and Canadian phase III trials will investigate different radiation treatment paradigms for patients with LS-SCLC, and completion of these trials is critical.

A phase II study of paclitaxel + etoposide + cisplatin + concurrent radiation therapy for previously untreated limited stage small cell lung cancer (E2596): a trial of the Eastern Cooperative Oncology Group

INTRODUCTION

To determine the 1-year survival, response rate, and toxicity for patients with limited stage small cell lung cancer treated with the combination of cisplatin plus etoposide plus paclitaxel with delayed concurrent (starting with cycle 3) high dose thoracic radiotherapy.

PATIENTS AND METHODS

Patients with previously untreated limited stage small cell lung cancer, Easter Cooperative Oncology Group performance status of 0-2 and adequate organ function were eligible. Cycles 1 and 2 of chemotherapy consisted of paclitaxel 170 mg/m intravenous day 1, etoposide 80 mg/m intravenous days 1 to 3, and cisplatin 60 mg/m intravenous day 1 followed by filgrastim 5 microg/kg subcutaneously days 4 to 13. Cycles 3 and 4 of chemotherapy consisted of a reduced dose of paclitaxel 135 mg/m intravenous day 1, and the same dose of etoposide and cisplatin with concurrent thoracic radiation therapy 1.8 Gy in 35 fractions (total 63 Gy) administered over 7 weeks.

RESULTS

Sixty-three patients were entered, 61 patients were eligible. The most common grade 4 toxicity seen was granulocytopenia (62%). Nonhematologic toxicities included febrile neutropenia in 19% of patients, grade 3 and 4 esophagitis in 32% of patients, and grade 3 peripheral neuropathy in 14% of patients. Two patients suffered lethal toxicities. The overall response rate was 79%. The 1-year survival rate was 64%. The median overall survival was 15.7 months, and the median progression-free survival was 8.6 months.

CONCLUSIONS

The combination of cisplatin plus etoposide plus paclitaxel chemotherapy and concurrent delayed thoracic radiotherapy as administered in this trial provide no apparent advantage with respect to response, local control, or survival compared with historical controls.

Limited-stage small-cell lung cancer: the current status of combined-modality therapy

Limited-stage (LS) small-cell lung cancer (SCLC) remains a therapeutic challenge to medical and radiation oncologists. The treatment of LS-SCLC has evolved significantly over the last two decades with combined-modality therapy now the standard of care. The addition of thoracic radiotherapy (TRT) to standard chemotherapy has led to improvements in long-term survival in this population. However, many questions remain about the optimal way to deliver chemoradiotherapy. In a landmark trial, twice-daily TRT to a dose of 45 Gy increased 5-year survival by 10% compared with once-daily TRT administered to the same dose. This suggests that more intensive TRT regimens may lead to further survival gains, assuming they can be delivered safely in this setting. Strategies currently under investigation include higher total daily doses delivered once daily or novel concurrent boost techniques allowing more intensive treatments over shorter periods of time. Several trials and meta-analyses have evaluated the timing of TRT with chemotherapy, with the weight of evidence suggesting that early and concurrent TRT with chemotherapy is optimal. Novel cytotoxic chemotherapy combinations have failed thus far to provide an advantage over standard etoposide-cisplatin combinations. Prophylactic cranial irradiation in near or complete responders to induction chemoradiotherapy has also been shown to improve long-term survival rates. LS-SCLC has been a model cancer in terms of the potential benefit of combined chemoradiotherapy strategies in improving patient outcomes.

A phase I/II study of docetaxel, etoposide, and carboplatin before concurrent chemoradiotherapy with cisplatin and etoposide in limited-stage small cell lung cancer

Limited stage small cell lung cancer (LS-SCLC) is an infrequent but aggressive tumor. No major advances in the treatment of this disease have been achieved in recent years. This study was conducted to determine the maximum-tolerated dose (MTD) and efficacy of docetaxel, etoposide, and carboplatin (DEC) given before definitive chest radiotherapy with concurrent cisplatin and etoposide. Seventeen untreated LS-SCLC patients received docetaxel 50 mg/m2, etoposide 50-80 mg/m2, and carboplatin AUC = 5-6, intravenously on day 1 followed by etoposide 100-160 mg/m2 orally on days 2 and 3 every 21 days for two cycles followed by once daily radiotherapy to a total dose of 50 Gy given concurrently with cisplatin (60 mg/m2, d1) and etoposide (120 mg/m2, d1 and 240 mg/m2 day 2-3) for 2 cycles. All patients were assessable for toxicity and 15 for response. The most frequent toxicity was grade 3 and 4 neutropenia in 41% of patients during DEC and in 57% with chemoradiation. The MTD for DEC was docetaxel 50 mg/m2 plus carboplatin AUC = 5 and etoposide 50/100 mg/m2 with growth factor support. Significant nonhematologic toxicities were primarily radiation-related esophagitis (43%). One patient (6%) died from toxicity. The overall response rate was 82% with 10 patients (59%) achieving a complete response. The median survival was 12.1 months (95% CI, 6.4-17.8 months) and the 1-year survival rate was 47%. This novel approach produced similar efficacy results to current two drug regimens but was associated with significant neutropenia. Alternative strategies to increase complete response rates and survival are needed.

Cisplatin plus etoposide chemotherapy followed by thoracic irradiation and paclitaxel plus cisplatin consolidation therapy for patients with limited stage small cell lung carcinoma

PURPOSE

To evaluate the efficacy and tolerance of a cisplatin plus etoposide regimen followed by thoracic radiotherapy (TRT) and paclitaxel plus cisplatin consolidation chemotherapy in patients with limited stage small cell lung cancer (SCLC).

PATIENTS AND METHODS

Thirty-nine patients with limited SCLC were enrolled onto this study. Patients received three courses of cisplatin 75 mg/m2 i.v., day 1 and etoposide 100 mg/m2 i.v., days 1-3 (EP regimen), followed by TRT (45-56 Gy administered in 15 fractions), and three courses of paclitaxel 175 mg/m2 i.v., day 1 and cisplatin, as previously, on day 2 (PP regimen); cycles were repeated every 21 days.

RESULTS

All patients were evaluable for toxicity and 34 for response. The overall response rate was 67% (CR: 26%; PR: 41%; intention-to-treat analysis) (95% CI: 53.0-84.2%). After a median follow-up period of 15 months, the median survival time was 15 months, the median time to tumor progression 8.3 months and the 1-year survival rate 53.8%. Grade 3/4 neutropenia occurred in 39% and 36% of patients receiving EP and PP regimens, respectively. The incidence of febrile neutropenia was 5% and 3% for EP and PP regimens, respectively. Other hematologic and non-hematologic toxicities were mild, with the exception of esophagitis occurring in 36% of patients during and/or immediately after radiotherapy.

CONCLUSION

Consolidation therapy with PP after sequential EP and thoracic radiotherapy is feasible and well-tolerated; however, the efficacy results are comparable with those previously obtained in the same patients' population using a combination of EP and TRT.

Current and evolving treatment options for limited stage small cell lung cancer

PURPOSE OF REVIEW

About one-third of small cell lung cancer cases are classified as limited stage. Trials have attempted to establish the most effective, least toxic regimen of combined modality treatment. Recently, issues like the role of the positron emission tomography scan, elderly patient management and the timing and delivery of radiotherapy have been addressed. Several targeted agents have also been evaluated. This review will highlight the data that have greatly impacted on the standard of limited stage small cell lung cancer care.

RECENT FINDINGS

Trials have concluded that small cell lung cancer is fluorodeoxy-D-glucose avid and that positron emission tomography has potential for utility in staging and radiation therapy planning, though it is not recommended. Recent trials confirm no benefit to adding chemotherapeutic agents to standard cisplatin and etoposide. To date, all targeted therapies have failed to show impressive results. Two analyses of outcomes in elderly patients argue that combined modality therapy should be considered, with patients carefully monitored. Two meta-analyses demonstrate thoracic radiotherapy should be delivered, with increased dose and schedule intensity.

SUMMARY

Current data demonstrate that combined modality therapy with early administration of thoracic radiotherapy remains the care standard in limited stage small cell lung cancer care. Cisplatin and etoposide continue to be the chosen cytotoxic agents. Targeted therapies and advances in the radiotherapy technological aspects represent opportunities for improved outcomes in the future management of this aggressive disease.

Tratamento do câncer de pequenas células de pulmão: doença limitada: resultados de uma única instituição

OBJETIVO: Relatar os resultados de tratamento de pacientes com câncer de pulmão de pequenas células com doença limitada (CPPC-DL), num período de dez anos, numa única instituição, para controle de qualidade e comparação com dados de literatura. MATERIAIS E MÉTODOS: Entre janeiro de 1992 e dezembro de 2002, 101 pacientes portadores de CPPC-DL completaram tratamento em nossa instituição. Seus resultados foram revistos e incluíram quimioterapia, radioterapia, a seqüência dos dois tratamentos e o uso de irradiação profilática cerebral (PCI). A radiação foi administrada com dose mediana de 45 Gy em 1,8 a 2 Gy por fração. A dose mediana de PCI foi de 25 Gy em dez frações. RESULTADOS: O seguimento mediano foi de 50,6 meses e a idade mediana dos pacientes foi de 63 anos. Houve 85 mortes confirmadas, 5 pacientes foram perdidos de seguimento e 11 estavam vivos. O tempo de sobrevida mediano foi de 11 meses, a sobrevida global em dois e cinco anos foi de 25,5% e 10%, respectivamente. Não houve diferença significante na sobrevida global em dois ou cinco anos segundo a idade e sexo dos pacientes. Também não houve diferença significante na sobrevida global entre os pacientes que realizaram PCI ou não, ou foram tratados em dois períodos diferentes (1997-2002 vs. 1992-1996). CONCLUSÃO: Os resultados de tratamento dos pacientes portadores de CPPC-DL na nossa instituição refletem as constantes mudanças no manuseio do CPPC. Nossa sobrevida global em dois anos de 25,5% é semelhante a outros resultados uni-institucionais publicados, mas menor que os resultados de 47% a 54% recentemente publicados por grupos cooperativos.

Study of Paclitaxel, Etoposide, and Cisplatin Chemotherapy Combined With Twice-Daily Thoracic Radiotherapy for Patients With Limited-Stage Small-Cell Lung Cancer: A Radiation Therapy Oncology Group 9609 Phase II Study

Purpose

To determine the response rate, progression-free survival and overall survival, and toxicity of paclitaxel, etoposide, and cisplatin combined with accelerated hyperfractionated thoracic radiotherapy in patients with limited-disease (LD) small-cell lung cancer (SCLC).

Patients and Methods

LD-SCLC patients with measurable disease, Karnofsky performance score of ≥ 70, and adequate organ function who were previously untreated were eligible for the study. Treatment was as follows. In cycle 1 of chemotherapy, concurrent thoracic radiation therapy was administered. In cycles 2 to 4, chemotherapy was administered alone. In cycle 1, chemotherapy consisted of paclitaxel 135 mg/m2 intravenous over 3 hours on day 1, etoposide 60 mg/m2 intravenous on day 1 and 80 mg/m2 orally on days 2 and 3, and cisplatin 60 mg/m2 intravenous on day 1. In cycles 2 to 4, the paclitaxel dose was increased to 175 mg/m2, with the etoposide and cisplatin doses remaining the same as in cycle 1. The thoracic radiation therapy consisted of 1.5 Gy in 30 fractions (total dose, 45 Gy) administered 5 days a week for 3 weeks.

Results

Fifty-five patients were enrolled onto the study, and 53 were assessable. The major toxicities included grade 3 and 4 acute neutropenia (32% and 43%, respectively) and grade 3 and 4 esophagitis (32% and 4%, respectively). Two patients died as a result of therapy (one died of acute respiratory distress syndrome, and one died of sepsis). There was one late fatal pulmonary toxicity. The median survival time was 24.7 months. The 2-year survival rate was 54.7%. The median progression-free survival time was 13 months, with a 2-year progression-free survival rate of 26.4%.

Conclusion

Although this therapeutic regimen is effective in the treatment of patients with LD-SCLC, it is unlikely that the three-drug combination with thoracic radiation therapy will improve the survival times compared with the etoposide plus cisplatin chemotherapy regimen with thoracic radiation therapy in LD-SCLC patients.

Combined Chemoradiotherapy in Small Cell Lung Cancer

Combined chemoradiotherapy is the established standard of care for limited stage small cell lung cancer; it provides cure in 15% to 25% of patients. Early concurrent therapy imparts a 5% long-term survival benefit compared with sequential therapy. Hyperfractionated delivery of radiotherapy may provide a small incremental benefit when compared with standard fractionation. Radiotherapy dose escalation and reduced radiotherapy volumes are feasible; however, survival benefit has not been confirmed. Cisplatin and etoposide remain the preferred chemotherapy agents. New chemotherapeutic agents and novel treatment approaches are under intense investigation.

Double-platinum chemotherapy combined with etoposide in metastatic brain tumor from small cell lung carcinoma

The platinum-based chemotherapeutic agents, such as cisplatin (CDDP) and carboplatin (CBDCA), are effective for small cell lung carcinoma (SCLC). However, high dose treatment of these agents required for advanced-stage SCLC is often associated with severe toxicity. The authors used combination of lower doses of both cisplatin and carboplatin combined with etoposide (VP-16) to minimize side effects of these agents. This goal was accomplished by utilizing the facts that each agent has its own toxicity that can be controlled individually. Two patients (60- and 71-year old men) with multiple metastatic brain tumors from SCLC were treated by our chemotherapeutic regimen. After fourth chemotherapy, remarkable shrinking of brain masses was associated with significant decrease the size of original lung lesions in both cases. The two patients were discharged without any side effects of the treatment, and neurological deficits subsided in both cases. Each course provided the following schedules: carboplatin 200 mg/m2 x 1 day, cisplatin 25 mg/m2 x 2 days (intravenous administration), and etoposide 25 mg oral x 14 days. After second chemotherapy, the patient of Case 1 was irradiated to both brain and chest lesions, and only to brain in Case 2. The authors concluded from our two cases that the combination of these agents extremely effective to treat this malignancy with less toxicity. We named this double platinum chemotherapy as 'PEC', abbreviated from cisplatin, etoposide, and carboplatin. m

Should aggressive surgery ever be part of the management of small cell lung cancer?

CMT with surgery and chemotherapy is feasible, the toxicity is manageable, and postoperative morbidity and mortality rates are acceptable. Patient selection is important, and the results of the LCSG trial indicate that surgical resection will not benefit most patients who have limited SCLC. The chances of long-term survival and cure are strongly correlated with pathologic TNM stage. Consideration of surgery for patients who have SCLC should be limited to those with stage I disease and perhaps some patients with stage II tumors. Therefore, before surgery is undertaken, patients should undergo extensive radiologic staging with CT, MRI, and perhaps even positron emission tomographic scanning and mediastinoscopy, even if the radiologic assessment of the mediastinum is negative. Surgery may be considered for patients with T1-T2 NO SCLC tumors, and whether it is offered as the initial treatment or after induction chemotherapy remains controversial [40,43]. If SCLC is identified unexpectedly at the time of thoracotomy, complete resection and mediastinal lymph node resection should be undertaken, if possible. Chemotherapy is recommended postoperatively for all patients, even those with pathologic stage I tumors. Surgery likely has very little role to play for most patients with stage II disease and virtually no role for patients with stage III tumors. Even though chemotherapy can result in dramatic shrinkage of bulky mediastinal tumors, the addition of surgical resection does not contribute significantly to long-term survival for most patients, as shown conclusively by the LCSG trial. The final group of patients who may benefit from surgical resection are those with combined small cell and non-small cell tumors. If a mixed-histology cancer is identified at diagnosis, the initial treatment should be chemotherapy to control the small cell component of the disease, and surgery should be considered for the non-small cell component. For patients who demonstrate an unexpectedly poor response to chemotherapy, and for patients who experience localized late relapse after treatment for pure small cell tumors, a repeat biopsy should be performed. Surgery may be considered if residual NSCLC is confirmed.

Limited-disease small-cell lung cancer

Substantial improvements in treatment outcome for limited-disease small-cell lung cancer (LD SCLC) have been achieved in the last two decades owing to the introduction of chemotherapy (CHT) consisting of cisplatin and etoposide (PE), and the understanding that thoracic radiation therapy (TRT) is an essential component in improving treatment outcome. In addition, a recent metaanalysis confirmed the importance of prophylactic cranial irradiation (PCI) in general treatment plans for patients who show a complete response to treatment. However, numerous questions remain unanswered regarding this disease. While TRT/PE/PCI is considered to be the standard treatment in the majority of centers worldwide, the emergence of new and effective drugs (e.g., topoisomerase I inhibitors and paclitaxel) for the treatment of LD SCLC will likely affect therapy strategies in the near future. Important issues regarding optimal doses and fractionation regimens, as well as the timing of TRT, remain to be resolved. While most centers currently use b.i.d. fractionation as a result of the Intergroup findings, high-dose standard TRT may also be beneficial. TRT volumes are also considered an important issue, since they likely relate to the incidence of both local failure and toxicity. Finally, the optimization of PCI (total dose, fractionation regimen, and timing) is already under way. The value of surgery is limited to peripheral tumors and poorly responding cancer, and to confirm histology or improve local control and survival.

Phase I/II study of altered schedule of cisplatin and etoposide administration and concurrent accelerated hyperfractionated thoracic radiotherapy for limited-stage small-cell lung cancer

To improve the efficacy of a combination of cisplatin and etoposide and concurrent accelerated twice-daily thoracic radiotherapy against limited-stage small-cell lung cancer, we conducted a phase I/II study using an altered schedule of chemotherapy administration. Chemotherapy consisted of four cycles of cisplatin (days 1 and 8) and etoposide (days 1, 2, 8, and 9) every 4 weeks. Accelerated hyperfractionated thoracic radiation (1.5 Gy twice daily x 30 fractions, total dose of 45 Gy) was concurrently given with the first cycle of chemotherapy. The recommended doses of cisplatin and etoposide determined in the phase I study were 40 and 80 mg/m(2), respectively. In the phase II study, the overall response rate was 100% (complete response: 32%, partial response: 68%). By a median follow-up time of 29 months, median radiation-outfield progression-free survival was 13.4 months, while radiation-infield progression-free survival did not reach median value. The median overall survival time was 22.9 months, with survival rate of 48.4% at 2 years. Major toxicities were leukopenia and neutropenia (>/=grade 3, 92% each). The local control and overall survival demonstrated in this study were excellent. However, the insufficient distant control suggests a need for development of more active chemotherapy regimens.

Lung cancer 5: state of the art radiotherapy for lung cancer

Radiotherapy has a key role in curative and palliative treatments of patients with lung cancer. Important advances are described in the technique of treatment delivery and its integration with chemotherapy.

Pharmacokinetics and pharmacodynamics of oral etoposide in children with relapsed or refractory acute lymphoblastic leukemia

PURPOSE

To study the pharmacokinetics and pharmacodynamics of once- versus twice-daily oral etoposide in children with relapsed or refractory acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Fifty-eight patients were randomly assigned to etoposide at 50 mg/m(2)/d with once- versus twice-daily doses for 22 days. On day 8, vincristine, asparaginase, and dexamethasone were started. Etoposide pharmacokinetics and pharmacodynamics were studied for 47, 28, and 26 patients on day 1, 8, and 22, respectively, of remission reinduction therapy.

RESULTS

Of 48 patients with pharmacokinetic data, 42 (87.5%) achieved complete remission, three (6.3%) failed to achieve remission, and three (6.3%) died during induction. Median etoposide day 8 area under concentration-time curve (AUC) and cumulative AUC tended to be greater (P =.06 and P =.07, respectively) in patients (n = 23) who achieved complete remission (24 and 522 micro mol/L x h, respectively) than in patients (n = 3) who did not (14 and 303 micro mol/L x h, respectively). Three of eight patients with plasma concentrations exceeding 1.7 micro M (1 micro g/mL) for more than 8 hours daily, compared with one of 20 patients with concentrations exceeding 1.7 micro M for <or= 8 hours daily, were unable to receive all 22 days of etoposide because of toxicity. There was no difference in the AUC at day 1 or day 8 with once- versus twice-daily doses (P =.55 and P =.86, respectively).

CONCLUSION

A pharmacodynamic relationship exists between systemic etoposide exposure and response to therapy when oral etoposide is used as part of remission induction regimens for relapsed or refractory childhood ALL.

The value of prognostic factors in small cell lung cancer: results from a randomised multicenter study with minimum 5 year follow-up

We have evaluated the prognostic value of 22 pretreatment attributes in 436 small cell lung cancer (SCLC) patients included in a prospective multicenter study with a minimum 5-year follow-up. Pretreatment clinical and laboratory parameters were registered. Possible prognostic factors were evaluated by univariate analysis (log rank test) and by the Cox multivariate regression model. In the univariate analysis of all patients, only age, nodal metastasis, and skin metastasis were not associated with survival. The multivariate Cox model identified gender, extent of disease, performance status (PS), weight loss, platelet count, LDH, and NSE as independent prognostic factors. In subset multivariate analyses according to extent of disease, we found haemoglobin level, PS, NSE, and total WBC as significant prognostic indicators for survival in limited-stage disease (LD-SCLC), while PS, weight loss, LDH, number of metastases, liver metastases, and brain metastases were identified as independent prognostic factors in extensive-stage disease (ED-SCLC). There was a significant correlation between serum LDH and NSE levels. In conclusion, gender, extent of disease, PS, weight loss, haemoglobin, WBC count, platelet count, LDH, and NSE were all found to be independent prognostic factors for SCLC survival. However, the prognostic value of these factors depends highly on whether all or subsets of SCLC patients are studied.

Chemotherapy for small cell lung cancer

There were approximately 42,000 new cases of small cell lung cancer (SCLC) in 2002. Despite its initial sensitivity to chemotherapy, only 10% of all SCLC patients will have significant long-term survival. Studies have yet to show significant survival advantages for maintenance chemotherapy, and it appears that four to six cycles of chemotherapy is as effective as longer durations. As yet, there is no defined role for dose escalation in the treatment of SCLC. No one chemotherapy combination has exhibited a definitive survival advantage in extensive disease, although it appears that single-agent oral etoposide may be inferior to combination intravenous chemotherapy. In limited disease, however, cisplatin plus etoposide alone or in alternation with cyclophosphamide/doxorubicin/vincristine is superior to other approaches. There are several new agents with significant activity in SCLC awaiting further study.

Surgical treatment of small cell lung cancer

Chemoradiotherapy remains a gold standard in the treatment of limited-disease small cell lung cancer. Currently, three indications for the surgical treatment of very limited disease (stage I, II, or highly selected IIIa) small cell lung cancer can be identified: (1) primary surgery in peripheral clinical N0 lesions followed by adjuvant chemotherapy or chemoradiotherapy; (2) primary chemotherapy or chemoradiotherapy followed by surgery +/- radiotherapy in patients with a good response to initial treatment; and (3) salvage operations in patients who recur or persist at the primary site but still have resectable disease. The value of these approaches has been assessed in retrospective analyses and prospective nonrandomized trials. A large prospective randomized trial failed to prove any added value for surgery in the multidisciplinary treatment of limited-disease small cell lung cancer, but very few very-limited-disease patients were included.

Phase I study of irinotecan and cisplatin with concurrent split-course radiotherapy in limited-disease small-cell lung cancer

We conducted a phase I study of irinotecan (CPT-11) and cisplatin with concurrent split-course radiotherapy in limited-disease small-cell lung cancer (LD-SCLC). This study aimed to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of this therapy. Four chemotherapy cycles of CPT-11 (days 1, 8 and 15) and cisplatin (day 1) were repeated every 28 days. Radiotherapy of 2 Gy/day commenced on day 2 of each chemotherapy cycle with 20 Gy administered from the first to the third cycles (a total of 60 Gy). 17 patients were enrolled at three dose levels (CPT-11/cisplatin: 40/60, 50/60 and 60/60 mg/m(2)), and 16 were evaluable for toxicity and outcome. 2 of 4 patients at 60/60 mg/m(2) refused continuation of therapy because of general fatigue, and the relative dose intensity of CPT-11 at 50/60 mg/m(2) was approximately 50%. These levels were considered as the MTD. Tumour responses included four complete responses (CR), 11 partial responses (PR) and one no change (NC), and the overall response rate was 93.8% (95% confidence interval: (CI) 71.7-98.9%). This combined modality is tolerable, and CPT-11/cisplatin of 40/60 mg/m(2) in this modality is recommended for phase II study.

Reversal of P-glycoprotein-mediated paclitaxel resistance by new synthetic isoprenoids in human bladder cancer cell line

We isolated a paclitaxel-resistant cell line (KK47/TX30) from a human bladder cancer cell line (KK47/WT) in order to investigate the mechanism of and reversal agents for paclitaxel resistance. KK47/TX30 cells exhibited 700-fold resistance to paclitaxel and cross-resistance to vinca alkaloids and topoisomerase II inhibitors. Tubulin polymerization assay showed no significant difference in the ratio of polymerized alpha- and beta-tubulin between KK47/WT and KK47/TX30 cells. Western blot analysis demonstrated overexpression of P-glycoprotein (P-gp) and lung resistance-related protein (LRP) in KK47/TX30 cells. Drug accumulation and efflux studies showed that the decreased paclitaxel accumulation in KK47/TX30 cells was due to enhanced paclitaxel efflux. Cell survival assay revealed that verapamil and cepharanthine, conventional P-gp modulators, could completely overcome paclitaxel resistance. To investigate whether new synthetic isoprenoids could overcome paclitaxel resistance, we synthesized 31 isoprenoids based on the structure of N-solanesyl-N,N'-bis(3,4-dimethoxybenzyl)ethylenediamine (SDB), which could reverse multidrug resistance (MDR), as shown previously. Among those examined, trans-N,N'-bis(3,4-dimethoxybenzyl)-N-solanesyl-1,2-diaminocyclohexane (N-5228) could completely reverse paclitaxel resistance in KK47/TX30 cells. N-5228 inhibited photoaffinity labeling of P-gp by [(3)H]azidopine, suggesting that N-5228 could bind to P-gp directly and could be a substrate of P-gp. Next, we investigated structural features of these 31 isoprenoids in order to determine the structural requirements for the reversal of P-gp-mediated paclitaxel resistance, suggesting that the following structural features are important for overcoming paclitaxel resistance: (1) a basic structure of 8 to 10 isoprene units, (2) a cyclohexane ring or benzene ring within the framework, (3) two cationic sites in close proximity to each other, and (4) a benzyl group with 3,4-dimethoxy functionalities, which have moderate electron-donating ability. These findings may provide valuable information for the development of P-gp-mediated MDR-reversing agents.