Comparison of single-agent chemotherapy and targeted therapy to first-line treatment in patients aged 80 years and older with advanced non-small-cell lung cancer

Effect of Perioperative Factors on Short-Term Outcomes in Patients with Non-Small Cell Lung Cancer Over 60 Years of Age

Background

People in China have gradually entered old age society, and the number of lung cancer cases is expected to increase annually among the elderly. This study aimed to retrospectively explore the association between perioperative factors and short-term outcomes in elderly patients with non-small cell lung cancer (NSCLC).

Methods

A total of 490 elderly patients with NSCLC between January 1, 2003, and December 31, 2009, were selected. Perioperative factors were grouped and analyzed according to postoperative complications (PPCs) and length of hospital stay. A logistic regression analysis model was used to screen for the independent predictors of patient prognosis. The primary endpoint was postoperative complications and the secondary endpoint was postoperative hospital stay.

Results

Of all patients, 344 (70.2%) developed postoperative complications, and the average length of stay after surgery was 14.0±5.6 days. Perioperative fentanyl equivalents>28.7μg/kg and duration of surgery>4.4h were associated were associated with an increased risk of postoperative complications (P < 0.05); intraoperative blood loss (IBL) > 200 mL was associated with extended hospital stay (P < 0.05).

Conclusion

This study suggested that Perioperative factors may affect the short-term prognosis of elderly NSCLC patients after surgery. Perioperative fentanyl equivalents>28.7μg/kg, surgery duration, and IBL may be independent predictors of short-term outcomes in elderly patients.

Development and Optimization of Osimertinib-loaded Biodegradable Polymeric Nanoparticles Enhance In-vitro Cytotoxicity in Mutant EGFR NSCLC Cell Models and In-vivo Tumor Reduction in H1975 Xenograft Mice Models

Osimertinib (OMB), a third-generation EGFR inhibitor, specifically and irreversibly inhibits EGFR_T790M mutant form. Nevertheless, its clinical use is limited due to poor solubility, low absorption, and oral bioavailability. To overcome the low therapeutic capabilities of the free drug, we developed OMB-loaded PCL or CHS nanoparticles and characterized them. Among fifteen devised nanoparticle formulations (Npfs), OMB-PCL-f3, f9, and OMB-CHS-f3 showed great characteristics such as particle size (ranges from 101.3 ± 8.2 to 119.7 ± 10.4 nm), zeta potential (-36.4 ± 3.2 to -31.7 ± 3.9 mV), and polydispersity index (0.227 ± 0.037 to 0.261 ± 0.025). The % entrapment (91.25 ± 5.84 to 95.25 ± 5.88) and drug loading (29.64 ± 2.38 to 33.59 ± 2.36) indicated the formulation optimization. OMB-CHS-f3 demonstrated long-term in-vitro release, with a % cumulative OMB release of 99.99 ± 2.67 within 24 h, and the cytotoxicity of OMB-CHS-f3 showed 2.6- and 2.4-fold superior activity in mutant EGFR harboring H1975 and PC-9 cells, respectively, compared to plain OMB. Quantitative assessment of OMB cellular uptake from OMB-CHS-f3 showed superior drug accumulation of 81.59 ± 5.8% and 77.31 ± 4.6% in H1975 and PC-9 cells which was more than OMB-CHS-f9 and plain OMB. Flow cytometric cell cycle analysis revealed that OMB-CHS-f3 triggered G2/M phase arrest greater than OMB-PCL-f9 and plain OMB. In vivo, OMB-CHS-f3 Npf treatment reduced tumor size and body weight gain compared to Tagrisso treatment (p < 0.05). These findings showed that chitosan-coated OMB Npfs might improve outcomes by overcoming complications, including resistance and disease recurrence in NSCLC patients.

125I Seed Brachytherapy Combined with Single-Agent Chemotherapy in the Treatment of Non-Small-Cell Lung Cancer in the Elderly: A Valuable Solution

Purpose

The aim of this study was to compare the effectiveness and safety of CT-guided ¹²⁵I seed brachytherapy combined with single-agent chemotherapy versus combined chemotherapy in the treatment of elderly NSCLC.

Materials and Methods

We retrospectively analyzed 110 patients (64 men and 46 women; mean age=71.25±7.14 years) who were diagnosed with NSCLC without distant metastases between January 2015 and May 2020. A total of 50 patients received ¹²⁵I brachytherapy combined with single-agent chemotherapy (group A), whereas 60 patients received combined chemotherapy (group B). The response to therapy and adverse effect were compared between groups. The local response rate was evaluated by CT. Progression-free survival (PFS) and overall survival (OS) data were obtained through clinical follow-up.

Results

All patients had been treated and were followed-up for 3-60 months. The median OS and PFS were 23.71±1.41 months (95% CI=20.95-26.47) vs 16.12±0.93 months (95% CI=14.31-17.93) (P<0.05) and 15.08±0.85 months (95% CI=13.42-16.74) vs 10.03±0.53 months (95% CI=9.01-11.06) (P<0.05) in group A and group B, respectively. The local response rate and clinical symptoms of patients in group A were significantly relieved when compared with group B. Severe complications were not observed in either group.

Conclusion

CT-guided ¹²⁵I seed brachytherapy combined with single-agent chemotherapy is an effective and safe therapy and shows promising results compared to combined chemotherapy alone for NSCLC in the elderly. A randomized study will be needed to assess the superiority of this combined modality treatment.

Delayed adverse events in phase I trials of molecularly targeted and cytotoxic agents

BACKGROUND

Grade 3 and 4 adverse events (AEs) during cycle 1 are traditionally used for dose escalation decisions in Phase I oncology trials. With molecularly targeted agents (MTAs), assessment of lower grade AEs and those in later cycles is considered increasingly relevant.

METHODS

We conducted a retrospective analysis of AEs in patients enrolled onto relevant phase I trials of MTAs and cytotoxic combinations (CCs) at our UK centre between 2006 and 2016. All AEs in the first six cycles deemed at least 'possibly related' were recorded.

RESULTS

A total of 912 AEs were identified in 127 patients across 15 trials. Mean AE totals for CCs or MTAs respectively was 4.7 versus 3.0 in cycle 1, 3.8 versus 2.8 in cycles 2-6. Patients on CCs had higher mean AEs in six cycles compared to those on MTAs (8.5 vs. 5.7, p = 0.0005). For patients experiencing grade 3 AEs, 58% (CCs) and 60% (MTAs) occurred for the first time after cycle 1.

CONCLUSION

Overall AE incidence was lower in MTAs than CCs across six cycles. For MTAs, more frequent incidence of first grade 3/4 AEs after cycle 1 supports incorporation of delayed AEs into recommendations for Phase 2 dosing.

Nanoformulated paclitaxel and AZD9291 synergistically eradicate non-small-cell lung cancers in vivo

AIM

This study aims to develop new nanoformulations of EGFR T790M targeted inhibitor AZD9291 and paclitaxel (PTX) for combination therapy of lung cancer.

MATERIALS & METHODS

We prepared and characterized PTX- and AZD9291-loaded disulfide cross-linking micelles (DCMs), and evaluate their combination effect and toxicity in vitro and in lung cancer-bearing mice.

RESULTS

Drug-loaded DCMs were relatively small in size, and possessed glutathione-responsive drug release. The combination of PTX-DCMs and AZD92921-DCMs exhibited strong synergistic effects in both cell line and in vivo without additional toxicity. Molecular studies demonstrated the synergistic modification in both IKB-α/NF-κB/Bcl-2 and EGFR/Akt pathways.

CONCLUSION

The combination of DCM-loaded AZD9291 and PTX could potentially offer more effective and less toxicity treatment options for lung cancer patients.

Clinical strategies for acquired epidermal growth factor receptor tyrosine kinase inhibitor resistance in non-small-cell lung cancer patients

Epidermal growth factor receptor (EGFR) mutations (EGFRm⁺) occur in 10–35% of non-small-cell lung cancer (NSCLC) cases and confer sensitivity to EGFR tyrosine kinase inhibitors (TKIs). EGFR TKIs are standard treatments for NSCLC patients harboring EGFR exon 19 deletions or exon 21 L858R point mutations. Despite initial benefit, most patients develop drug resistance, posing a challenge to oncologists. The secondary T790M point mutation in EGFR exon 20 contributes to approximately 60% of resistance cases. Optimum strategies for overcoming acquired EGFR TKI resistance are not clearly defined, although current common practice is to switch to platinum-based chemotherapy following resistance onset. While the second-generation EGFR TKIs, including afatinib, dacomitinib, and neratinib, exhibit promising preclinical activity against T790M mutants, dose-limiting toxicities in patients have limited clinical success. However, third generation EGFR TKIs appear able to overcome this mutation. Other treatment options aimed at EGFR TKI resistance include use of an EGFR TKI beyond progression, and chemotherapy plus an EGFR TKI. This review focuses on improved anticancer agents and therapy options for NSCLC patients with acquired EGFR TKI resistance.

Comparison of gefitinib as first- and second-line therapy for advanced lung adenocarcinoma patients with positive exon 21 or 19 del epidermal growth factor receptor mutation

OBJECTIVES

Gefitinib, a tyrosine kinase inhibitor (TKI) targeting epidermal growth factor receptor (EGFR), shows excellent clinical benefit in treating advanced non-small-cell lung cancer (NSCLC). The aim of this study was to compare the efficacy and toxicity of gefitinib as first-line therapy and second-line therapy for advanced lung adenocarcinoma patients with positive exon 21 (L858R) or exon 19 deletion of EGFR mutation.

METHODS

We retrospectively analyzed the clinical data of 60 EGFR-mutated advanced lung adenocarcinoma patients from July 2011 to November 2015 who have received oral gefitinib 250 mg once daily. Gefitinib was taken until disease progression, intolerable toxicity or death.

RESULTS

After a median follow-up of 792 days, one death had occurred. Among the 59 patients who survived, 17 patients progressed. Overall, the median progression-free survival (mPFS) was 10 months (95% confidence interval [CI]: 7.53-12.46 months, p<0.05). The response rate (RR) and disease control rate (DCR) were 33.33% and 71.66%, respectively. However, there was longer mPFS in the first line-therapy than that in the second-line therapy: in the first-line gefitinib therapy, mPFS was 12 months among 41 patients (95% CI: 9.58-14.41 months, p<0.05), and in the second-line therapy, mPFS was 7 months among 19 patients (95% CI: 1.31-12.68 months, p<0.05). Furthermore, in subgroup analyses examining different EGFR mutation types, we noted that mPFS was significantly longer for patients with exon 19 deletion than for those with positive exon 21in both the first-line therapy and second-line therapy.

CONCLUSION

Patients with advance lung adenocarcinoma who were selected by positive exon 21 or 19 deletion mutations had significantly longer mPFS in the first-line therapy than that in the second-line therapy when treated with gefitinib. EGFR mutation types may influence the response to gefitinib therapy.

Signaling pathways as therapeutic targets in biliary tract cancer

INTRODUCTION

The incidence of biliary tract cancer (BTC) is increasing, and the disease is frequently diagnosed during advanced stages, leading to poor overall survival. Limited treatment options are currently available and novel therapeutic approaches are needed. A number of completed clinical trials have evaluated the role of chemotherapy for BTC, demonstrating a marginal benefit. Thus, there is increased interest in applying targeted therapies for this disease. Areas covered: This review article summarizes the role of chemotherapeutic regimens for the treatment of BTC, and highlights key signal transduction pathways of interest for targeted inhibition. Of particular interest are the MEK or MAP2K (mitogen-activated protein kinase kinase), phosphatidylinositol-3 kinase (PI3K) and signal transducer and activator of transcription-3 (STAT3) pathways. We discuss the available data on several promising inhibitors of these pathways, both in the pre-clinical and clinical settings. Expert opinion: Future treatment strategies should address targeting of MEK, PI3K and STAT3 for BTC, with a focus on combined therapeutic approaches.

Three generations of epidermal growth factor receptor tyrosine kinase inhibitors developed to revolutionize the therapy of lung cancer

Lung cancer, ~80%–85% of which is non-small-cell lung cancer (NSCLC), is the leading cause of cancer-related mortality worldwide. Sensitizing mutations in epidermal growth factor receptor (EGFR) gene (EGFRm⁺), such as exon 19 deletions and exon 21 L858R point mutations, are the most important drivers in NSCLC patients. In this respect, small-molecule EGFR tyrosine kinase inhibitors (TKIs) have been designed and developed, which launched the era of targeted, personalized and precise medicine for lung cancer. Patients with EGFRm⁺ could achieve good responses to the treatment with the first-generation EGFR TKIs, such as erlotinib and gefitinib. However, most patients develop acquired drug resistance mostly driven by the T790M mutation occurring within exon 20. Although the second-generation EGFR TKIs, such as afatinib, dacomitinib and neratinib, demonstrated promising activity against T790M in preclinical models, they have failed to overcome resistance in patients due to dose-limiting toxicity. Recently, the third-generation EGFR TKIs have shown to be effective against cell lines and murine models harboring T790M mutations while sparing wild-type EGFR, which represents a promising breakthrough approach in overcoming T790M-mediated resistance in NSCLC patients. This article provides a comprehensive review of the therapy revolution for NSCLC with three generations of EGFR TKIs.

Osimertinib making a breakthrough in lung cancer targeted therapy

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are the evidence-based first-line treatment for advanced non-small-cell lung cancer that harbors sensitizing EGFR mutations (EGFRm(+)) such as exon 19 deletions and L858R substitutions in exon 21. However, acquired resistance to EGFR TKIs is mostly driven by a second-site EGFR T790M mutation, which negates their inhibitory activity. Osimertinib (AZD9291, Tagrisso™), an oral, third-generation EGFR TKI, has been designed to target the EGFR T790M mutation, while sparing wild-type EGFR. In this up-to-date review, focus is not only on the structure, mechanisms, and pharmacokinetics of osimertinib but also on summarizing clinical trials and making recommendations of osimertinib for patients with non-small-cell lung cancer.