Patterns of Progression and Feasibility of Re-biopsy After First-line Erlotinib for Advanced EGFR Mutation-positive Non-small-cell Lung Cancer

AIM

To assess the patterns of disease progression in advanced/metastatic epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer (NSCLC) on first-line treatment with erlotinib and identify potential prognostic factors for progression-free survival (PFS).

PATIENTS AND METHODS

Patients with stage IIIB/IV EGFR-mutation-positive NSCLC receiving first-line erlotinib were followed-up until 24 months after the last patient was enrolled or until premature withdrawal for any cause.

RESULTS

A total of 127 evaluable patients were enrolled. The median PFS and overall survival were 8.8 and 19.1 months, respectively. Disease progression was asymptomatic in 57.6% of patients and 53.3% developed new sites of metastasis. The presence of liver metastasis was identified as an independent prognostic factor for poor PFS.

CONCLUSION

Metastatic progression with asymptomatic disease seems to be the predominant pattern of disease progression on first-line erlotinib in real-life practice in patients with advanced/metastatic EGFR-mutant NSCLC. Additionally, the presence of liver metastases may negatively affect PFS in these patients.

EGFR testing and clinical management of advanced NSCLC: a Galician Lung Cancer Group study (GGCP 048-10)

Purpose

This study aimed to assess the incidence of mutations in the epidermal growth factor receptor (EGFR) gene in non-small-cell lung cancer (NSCLC) patients in the Galician region of Spain and the clinical management and outcome of patients carrying EGFR mutations.

Patients and methods

All newly diagnosed advanced or metastatic NSCLC patients were screened for EGFR mutations in matched tumor samples (tissue or cytology specimens) and serum samples.

Results

Of 198 patients screened for EGFR mutations in tumor samples, 184 had evaluable data and, of these, 25 (13.6%) had EGFR mutations (84% sensitizing mutations). EGFR mutation was found in serum in 14 (8.1%) patients (of 174 evaluable). Compared to matched tumor tissue, serum EGFR mutation testing specificity and sensitivity were 99% and 52%, respectively. All but two patients received gefitinib. Median progression-free survival and overall survival were 10 (95% confidence interval: 4.8–15.3) months and 17.8 (95% confidence interval: 13.9–21.6) months, respectively, in patients carrying sensitizing mutations.

Conclusion

The incidence of EGFR mutations in Galicia is consistent with previous data in Spain. Our results also support the feasibility of EGFR testing to guide treatment decision making using tumor tissue or cytology samples, or serum samples if tumor specimens are unavailable. These findings also confirm that first-line gefitinib is an active treatment option in Caucasians with EGFR mutation-positive NSCLC.

A phase II randomized trial of gemcitabine-docetaxel versus gemcitabine-cisplatin in patients with advanced non-small cell lung carcinoma

PURPOSE

To test efficacy and tolerability of non-platinum regimens for advanced non-small-cell lung cancer (NSCLC).

METHODS

Chemonaive patients with measurable stage IIIB/IV NSCLC treated with gemcitabine and cisplatin (GC), or gemcitabine and docetaxel (GD), maximumsix cycles in a phase IIB trial.

RESULTS

A total of 108 patients were randomized. Response rates (GC vs. GD, respectively): complete 3.6/2.0%, Partial 30.9/38.0%. Median Overall Survival (OS): 8.9 months in both groups (P = 0.53); and median time to progression (TTP): 6.2/5.5 months respectively (P = 0.61). Toxicities included (GC vs. GD, respectively): grade 3-4 neutropenia 49.1/41.2%; grade 3 thrombocytopenia 30.9/3.9%; grade 3 anemia 14.5/3.9%. Non-haematological toxicity was similar, except for nausea and vomiting, (16.3/2%); renal toxicity (3.7/0%) and hepatic toxicity (5.6/12.7%).

CONCLUSIONS

With a higher overall response rate and lower toxicity, GD is a good first treatment option for advanced NSCLC.

Biweekly administration of docetaxel and vinorelbine as second-line chemotherapy for patients with stage IIIB and IV non-small cell lung cancer: a phase II study of the Galician Lung Cancer Group (GGCP 013-02)

The current report aims to evaluate the efficacy and safety profile of a biweekly administration of docetaxel and vinorelbine to patients with advanced non-small cell lung cancer, who had previously been treated for this disease. In a prospective, multicenter, open-label, phase II trial, patients received 40 mg/m of docetaxel and 20 mg/m of vinorelbine on days 1 and 15, every 28 days. Treatment continued for up to a maximum of six cycles, unless disease progression or unacceptable toxicity occurred, or consent was withdrawn. Fifty patients were enrolled in the study and they received 174 cycles of chemotherapy, with a median of three cycles per patient. All patients were evaluated for efficacy and toxicity in an intention-to-treat analysis. The overall response rate was 10% [95% confidence interval (CI): 1-19], including one complete response (2%) and four partial responses (8%). Previous chemotherapy of 80% of the responders included paclitaxel. Median time to disease progression was 2.7 months (95% CI: 2.2-4.3) and median overall survival was 6.5 months (95% CI: 2.5-9.2). The survival rates at 1 and 2 years were 18% (95% CI: 7-29) and 4% (95% CI: 0-10), respectively. The most frequent severe toxicities were neutropenia (20% of patients) and leukopenia (8% of patients). Other toxicities appeared in 4% or fewer of the patients. Biweekly administration of docetaxel and vinorelbine is feasible as a second-line treatment for non-small cell lung cancer patients, but its level of activity and toxicity does not suggest any advantage compared with the results obtained with single-agent docetaxel in the same setting.

Biweekly docetaxel as second-line chemotherapy of patients with advanced non-small cell lung cancer: a phase II study of the Galician Lung Cancer Group (GGCP 006-00)

This phase II trial assessed the antitumoral activity and toxicity of docetaxel 50 mg/m (1-h i.v. infusion) administered every 2 weeks as second-line treatment in 45 patients with advanced non-small cell lung cancer (NSCLC). A total of 251 infusions (median 4 per patient) were administered. The actual and relative median dose intensity values were 24.2 mg/m/week and 0.97, respectively. Thirty-seven patients were evaluable for tumor response. The overall response rate was 20% [95% confidence interval (CI) 8-32%] and included one complete response (2%) and eight partial responses (18%). Stable disease was found in seven patients (16%). With a median follow-up of 4 months, the median time to disease progression was 2.8 months (95% CI 1.9-3.7), the median overall survival was 4.0 months (95% CI 3.4-4.6) and the 1-year survival rate was 23% (95% CI 9-37). The every-2-weeks docetaxel schedule was well tolerated. Grade 3/4 non-hematological toxicities showed rates of 5% or less of patients and 2% or less of cycles. The main grade 3/4 hematological toxicity was neutropenia (16% of patients and 8% of cycles). No febrile neutropenia was found. Nevertheless, one toxic death was reported. We conclude that the biweekly docetaxel schedule showed an antitumoral activity similar to that found with the every-3-weeks or weekly docetaxel schedule in a second-line setting for advanced NSCLC. This antitumoral effect was associated with a marked reduction in hematological toxicity, therefore suggesting that this new docetaxel schedule might be useful in the design of combined second-line schedules for treating NSCLC.

Gemcitabine, cisplatin and vinorelbine as induction chemotherapy followed by radical therapy in stage III non-small-cell lung cancer: a multicentre study of galician-lung-cancer-group

PURPOSE

To determine the effectiveness of a gemcitabine-cisplatin-vinorelbine combination in patients with stage III non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients (n=46) with stage III NSCLC and naive of therapy were recruited into the trial to receive gemcitabine (G, 1000 mg/m(2)) on days 1 and 8, cisplatin (C, 100 mg/m(2)) on day 1 and vinorelbine (V, 25 mg/m(2)) on days 1 and 8 every 21 days for three cycles.

RESULTS

Two patients achieved complete response (CR) and 23 partial response (PR), overall response 52%. Subsequent radical surgery included nine patients of whom four were non-resectable and five were resected and with 1 CR. Radiotherapy was administered to 31 patients, and two achieved CR. The median time to progression and overall survival were 37 and 50 weeks, respectively. Grade 3-4 neutropenia and thrombocytopenia occurred in 35% of cycles, with two toxic deaths. Severe non-haematological toxicity was uncommon.

CONCLUSIONS

This GCV combination is effective in patients with stage III NSCLC, and with an acceptable toxicity.

Phase II study of irinotecan as first-line chemotherapy for patients with advanced colorectal carcinoma

BACKGROUND

The objective of this multicenter, open-labeled, Phase II study performed in Spain was to assess the efficacy and safety of irinotecan (CPT-11) as first-line chemotherapy for patients suffering from advanced colorectal carcinoma (CRC).

METHODS

Patients with histologically proven CRC and at least one bidimensionally measurable lesion, ages 18-70 years, with a performance status < or = 2, normal analytical values, and no prior chemotherapy or only adjuvant chemotherapy completed before study entry were selected. The treatment schedule was CPT-11 350 mg/m(2) intravenously administered once every 3 weeks. Both tumor response and toxicity were assessed using the World Health Organization and National Cancer Institute common toxicity criteria. Changes in performance status, weight, and symptoms also were measured.

RESULTS

Sixty-five patients (44 chemotherapy-naïve patients and 21 patients who completed prior adjuvant treatment) were enrolled. Of these, 24.7% of patients responded to the treatment, and 41.5% of patients had stable disease. Patients who had not received prior adjuvant chemotherapy had a lower rate of progression on therapy (27.3%) compared with those who had received prior adjuvant chemotherapy (42.9%). The median survival was 19.9 months (range, 0.3-29.3 months). No significant differences were found in the median survival between chemotherapy-naïve patients and patients who had received previous chemotherapy. Grade 3-4 diarrhea and neutropenia were the most frequent severe toxic events, which were observed in 23.1% and 30.8% of patients and in 5.9% and 10.9% of the cycles, respectively.

CONCLUSIONS

The current antitumor efficacy results show that 350 mg/m(2) of CPT-11 administered every 3 weeks is an active and feasible first-line chemotherapy regimen for patients with CRC. Finally, the overall safety data confirmed that CPT-11 is a well tolerated treatment.

[Isolated primary hyperaldosteronism caused by adrenocortical carcinoma]

OBJECTIVE

To report a case of adrenocortical carcinoma and primary aldosteronism as the sole endocrine manifestation.

METHODS/RESULTS

A 39-year-old male with adrenocortical carcinoma and primary aldosteronism is presented. Following complete hormonal and radiological evaluation, right adrenalectomy and nephrectomy were performed (pT2pN0M0, stage II). Blood pressure, serum potassium and aldosterone levels returned to normal. The patient received adjuvant therapy with carboplatin and etoposide. After 15 months' disease-free interval, lung metastasis was diagnosed, without evidence of local recurrence until 5 months later, when hypertension and primary hyperaldosteronism reappeared. There were no other endocrine disorders. Treatment with spironolactone, 5-FU and adriamycin was instituted with no tumor response and the patient died 3 years later from complications of endobronchial metastasis.

CONCLUSION

Adrenocortical carcinoma with isolated primary hyperaldosteronism is uncommon and consequently there is no wide experience in regard to its diagnosis and treatment. Although randomized studies are not available, adjuvant therapy using other agents instead of mitotane (o,p-DDD), such as the combination of cisplatin and etoposide (VP-16), seems reasonable in the locally advanced stages. Mitotane may be useful when hypercortisolism is present, but its efficacy as an antitumor agent has been controversial.

Age: a critical factor in cancer management. A prospective comparative study of 400 patients

BACKGROUND

older people are often excluded from cancer treatments solely on the grounds of age.

AIMS

to compare cancer treatment in older and younger patients.

PATIENTS AND METHODS

between June 1992 and September 1994, 400 cancer patients were included in this prospective comparative study. The factors compared between younger and older subjects were performance status, associated chronic diseases, delay in diagnosis, stage of disease and initial treatment.

RESULTS

54 patients (25.5%) under 70 years of age were asymptomatic at the time of diagnosis, in comparison with 25 (12.5%) of the 200 older patients (P < 0.001). Associated chronic pathologies were more frequent in the older patients (55% vs 18.5%, P < 0.001). There were no statistical differences between both groups in diagnostic delay. Localized disease was found in 127 (63%) of the younger patients and in 109 (54%) of the older patients, the difference not being significant. The percentage of patients who underwent oncological treatment was higher in the younger than the older group (87.5% vs 56%, P < 0.001). The main cause of therapeutic exclusion in both groups was poor performance status; however, in the older group other variables--such as the presence of chronic disease and patients' or relatives' wishes and doctors' opinions--influenced the decision not to give specific treatment.

CONCLUSIONS

this study confirms that the clinical characteristics and treatment of aged people with cancer are different from those of younger patients. Nevertheless, there is considerable doubt about whether an arbitrary age limit should continue to be accepted as a discriminatory factor in some diagnostic and therapeutic procedures in cancer patients.

Follow-up study in head and neck cancer: cure rate according to tumor location and stage

The purpose of this clinical study was to analyze a long-term follow-up of all the patients with head and neck cancer in our institution. Between 1973 and 1993, 1,355 consecutive cases of head and neck cancerwere diagnosed, treated and followed up regularly. All were subjected to a multidisciplinary approach, and followed up until death or for 10 years with no event of disease. The local relapse rate was 20% and the node-regional relapse rate 15%. Distant metastases were observed in 6% of the patients mainly arising from the nasopharynx (23%) followed by the hypopharynx (11%). The main organ involved was the lung (50%). Median follow-up of the group was 10 years (range 4 months to 15 years). Cancer cure was observed after 5 years in glottic and supraglottic laryngeal carcinoma, oral and nasopharyngeal cancer and after 2.5 years in patients with cancer of the oropharynx and hypopharynx. The highest cure rate was 80% in the glottis, followed by 70% in the supraglottic area, 45% in the mouth, 30% in the nasopharynx, 25% in the oropharynx, and 20% in the hypopharynx. A second primary tumor was observed in 7% of the patients and a third primary in 0.6% of the patients. Only in 7 patients, the second or third primary was seen after 5 years of follow-up. Curability should be observed after 5 years from definitive therapy of glottic, supraglottic, oral and nasopharyngeal and earlier in oropharyngeal and hypopharyngeal cancer. Further follow-up should be discontinued. Second and third neoplasias are the main problems after 5 years of follow-up but their incidence is low.

Calcium supplementation and ototoxicity in patients receiving cisplatin

We have studied the effect on ototoxicity of maintaining serum calcium concentration by calcium gluconate infusion in cancer patients receiving high-dose cisplatin in a randomized study in two groups: 11 patients received calcium gluconate, 4 mg kg-1 i.v. infusion during cisplatin therapy; 11 other patients without any calcium supplementation served as controls. All of them received the first course of chemotherapy, based on cisplatin, 120 mg m2 with a hydration schedule. An audiogram was performed in each patient just before cisplatin and repeated after 1 day and 3 weeks. Mean total calcium concentration in control patients before and after chemotherapy was 2.2 +/- 0.14 (95% confidence interval 1.9-2.5) and 2.0 +/- 0.13 (95% CI 1.7-2.24) mmol 1(-1) respectively (P = 0.0004) and for ionized calcium 1.22 +/- 0.52 (95% CI 0.21-2.23) and 1.11 +/- 0.07 (95% CI 0.97-1.25) mmol 1(-1) respectively (P = 0.0005). Serum magnesium levels were maintained or increased by magnesium supplementation. Although there was no change in serum total or ionized calcium, or serum magnesium in the calcium infusion group, no differences in hearing loss between the groups were observed. High-dose cisplatin chemotherapy for cancer patients induces an acute decrease of serum total calcium and serum ionized calcium and audiometric changes. Maintenance of calcium serum levels by calcium gluconate infusion did not protect against ototoxicity in those patients.

Survival after chemotherapy with cisplatin and infusion of bleomycin prior to local-regional treatment in pyriform sinus cancer

AIMS AND BACKGROUND

The purpose of this study was to retrospectively compare different approaches including neoadjuvant chemotherapy.

METHODS

Ninety-six consecutive patients with pyriform sinus squamous cell carcinoma with no distant metastases were entered. The first 48 patients were treated with surgery plus postoperative radiation therapy (50-60 Gy) over cervical lymphatics. The next 48 patients were treated by induction chemotherapy with two courses of cisplatin, 120 mg/m2 i.v. day one, plus bleomycin, 20 mg/m2/day for 5 consecutive days in 24-hr i.v. perfusion followed by definitive surgery and postoperative radiation therapy as in the first therapeutic group.

RESULTS

Definitive surgery was performed in 38 control vs 39 neoadjuvant patients. Complete response was observed in 9 (18.7%) and partial response in 32 (66.7%) of 48 chemotherapy-treated patients. Partial plus complete response was seen in 41 (85.4%) of the 48 patients. Comparison between controls versus chemotherapy-treated groups showed persistence of the disease in 10 vs 9 patients; local-regional relapses in 21 versus 14 patients; and distant metastases in 4 vs 2 patients. Median survival was 12 vs 40 months. Survival curves were statistically better in neoadjuvants than in controls (P < 0.025).

CONCLUSIONS

Multidisciplinary therapy slightly decreases the rate of local-regional relapses and distant metastases and should improve survival in this set of pyriform sinus cancer patients.