Patterns of relapse and prognosis after bevacizumab failure in recurrent glioblastoma

BACKGROUND

Bevacizumab has recently been approved by the US Food and Drug Administration for recurrent glioblastoma (GBM). However, patterns of relapse, prognosis, and outcome of further therapy after bevacizumab failure have not been studied systematically.

METHODS

We identified patients at Memorial Sloan-Kettering Cancer Center with recurrent GBM who discontinued bevacizumab because of progressive disease.

RESULTS

There were 37 patients (26 men with a median age of 54 years). The most common therapies administered concurrently with bevacizumab were irinotecan (43%) and hypofractionated reirradiation (38%). The median overall survival (OS) after progressive disease on bevacizumab was 4.5 months; 34 patients died. At the time bevacizumab was discontinued for tumor progression, 17 patients (46%) had an increase in the size of enhancement at the initial site of disease (local recurrence), 6 (16%) had a new enhancing lesion outside of the initial site of disease (multifocal), and 13 (35%) had progression of predominantly nonenhancing tumor. Factors associated with shorter OS after discontinuing bevacizumab were lower performance status and nonenhancing pattern of recurrence. Additional salvage chemotherapy after bevacizumab failure was given to 19 patients. The median progression-free survival (PFS) among these 19 patients was 2 months, the median OS was 5.2 months, and the 6-month PFS rate was 0%.

CONCLUSIONS

Contrast enhanced MRI does not adequately assess disease status during bevacizumab therapy for recurrent glioblastoma (GBM). A nonenhancing tumor pattern of progression is common after treatment with bevacizumab for GBM and is correlated with worse survival. Treatments after bevacizumab failure provide only transient tumor control.

Administration of sunitinib to patients with non-small cell lung cancer and irradiated brain metastases: A phase II trial

8077

Background: Sunitinib (SU), an oral, multitargeted inhibitor of VEGFRs, PDGFRs, KIT, FLT3, CSF-1R, and RET has promising single-agent antitumor activity in refractory non-small cell lung cancer (NSCLC) (Socinski JCO 2008). Brain metastases (BrMs) occur in ≥25% of NSCLC patients (pts); preclinical data suggest that VEGF signaling is required for the growth of BrMs, and that SU can cross the blood-brain barrier. This study assessed the safety and preliminary efficacy of SU in NSCLC pts with BrMs. Methods: NSCLC pts who had received ≤2 prior systemic therapies and prior whole brain radiation therapy (WBRT) were eligible to receive SU at a starting dose of 37.5 mg with continuous daily dosing (CDD) in 4-wk cycles. Antitumor efficacy was based on overall (RECIST) and intracranial (WHO) tumor assessments. Intracranial disease was assessed by MRI. Safety was assessed by monitoring adverse events (AEs) and health-related quality of life was assessed using FACT/NCCN Lung Symptom Index (FLSI) and Brain Symptom Index (FBrSI). Study termination was to occur when 3 cases of intracranial hemorrhage (ICH) associated with neurologic deficit were noted. Results: To date, 47 pts, including 28 with adenocarcinoma and 10 with squamous cell carcinoma, received SU for a median of 2 cycles (range: 1, 9). The median age of pts was 61 yrs (range: 35, 75), most were male (n=26, 55%), were ever smokers (n=36, 77%) and all had good performance status (ECOG 0/1). In total, 25 pts (53%) experienced non-neurologic grade (G) 3/4 AEs; the most frequent were fatigue/asthenia and dyspnea. Neurologic AEs occurred in 4 pts (9%), including intracranial pressure increased, mental impairment, and gait disturbance (each n=1 and G1) and 1 pt with G3 convulsion and peripheral motor neuropathy. Importantly, no cases of ICH were noted. Stable disease occurred in 7 (19%) of 36 measurable pts. Median PFS was 10.9 wks (95% CI: 6.4,15.4). Median OS was 19.6 wks (95% CI:13.1, NR). Mean change from baseline in FLSI and FBrSI scores did not differ significantly at any time point. Conclusions: Oral SU 37.5 mg on a CDD schedule had a manageable safety profile in NSCLC pts with BrMs. These data support the investigation of SU in combination with agents with known antitumor activity in pts with BrMs.

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Combination immunochemotherapy followed by reduced dose (rd) whole brain radiation therapy (WBRT) in an expanded cohort of patients with newly diagnosed primary central nervous system lymphoma (PCNSL)

2072

Background: High-dose methotrexate (M)-based chemotherapy combined with WBRT has improved survival in patients with PCNSL. However, disease recurrence and treatment-related neurotoxicity are significant problems. We conducted a prospective trial incorporating rituximab (R) and rdWBRT and previously demonstrated this was feasible. This study was extended to assess the long-term outcome of this approach in an expanded cohort. Methods: Patients were treated with R-MPV (d1 R 500mg/m2; d2 M 3.5gm/m2; vincristine 1.4mg/m2; d1–7 procarbazine 100 mg/m2/d on odd-cycles). Patients with a PR after five cycles received two additional cycles. Patients with a CR received rdWBRT (2340cGy), otherwise patients received standard WBRT (4500cGy). Patients then received two cycles of Ara-C 3gm/m2. Prospective neuropsychological evaluations were performed at baseline, before WBRT, and every 6 months thereafter. Results: From October 2002 to September 2008, 50 patients were enrolled (22 female, 28 male), median age 59.5 years (range 30–79 years). Due to neutropenia in two of the first five patients, all subsequent patients received G-CSF. 42 patients are assessable for response (4 patients died from progressive disease prior to completing the first cycle of treatment, 4 patients - treatment ongoing). 33 patients (79%) had a CR, of whom 29 received rdWBRT (3 refused, 1 died). At median follow-up of 3 years for survivors the median OS has not been reached and the estimated 2-year OS is 68%. Patients treated with rdWBRT have a median follow up of 38 months: 21 (72%) are alive with no evidence of disease, seven (24%) relapsed, and one died of unknown causes. Eight of 21 (38%) who are alive with no evidence of disease were age 60+ at diagnosis. The number of patients treated with rdWBRT alive with no evidence of disease at 3, 4, and 5 years is 12, 8, and 4 respectively. 9 patients have completed neuropsychological evaluations 24 months after rdWBRT with no significant cognitive decline detectable. Conclusions: Prolonged follow-up of an expanded cohort of patients treated with immunochemotherapy followed by rdWBRT for patients with an initial CR continues to support our initial conclusions that this approach results in excellent disease control with no observed treatment-related neurotoxicity.

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Phase II trial of temozolomide (TMZ) followed by myeloablative chemotherapy with autologous peripheral blood progenitor cell rescue (APBPCR) for newly diagnosed anaplastic oligodendroglioma: An Oligodendroglioma Study Group trial

2055

Background: Treatment of anaplastic oligodendroglioma (AO) and anaplastic oligoastrocytomas (AOA) is controversial. Radiotherapy (RT) remains the standard therapy, but not without toxicity. Exploiting the chemosensitivity of these tumors using myeloablative chemotherapy with APBPCR is a potential strategy to defer RT. We previously reported results using induction PCV chemotherapy; subsequently the induction regimen was changed to temozolomide (TMZ) which is reported here. Methods: Patients were treated with six cycles of TMZ at 200mg/m2 on standard 5/28 day schedule. MRI was performed after three cycles and then after six cycles. Patients with surgical gross total resection who maintained response or patients who responded to temozolomide (CR or PR defined as >50% reduction in tumor) were eligible for myeloablative chemotherapy with thiotepa 250mg/m2/day for three days followed by busulfan 3.2mg/kg/day for three days, followed by APBPCR. 1p19q status was analyzed prospectively; however, patients were enrolled without regard to deletion status. Results: 19 patients (16 AO, 2 AOA, 1 low-grade oligodendroglioma with radiographic features suggestive of high-grade tumor) with a median age of 42 (28–56) and KPS of 90 (70–100) were enrolled. 13 patients had co-deletion of 1p/19q, 2 had intact 1p/19q, 1 pt had biopsy without enough tissue, and pending in 3. Eleven patients were eligible for APBPCR: 10 patients either maintained surgical CR (9) or had a response to TMZ (1) and went on to transplant; one surgical CR pt refused transplant. Six patients were ineligible for transplant because best response of SD (2), PD (2, both 1p19q intact), insurance denial (2). Two patients are still receiving induction TMZ. Median progression-free (PFS) and overall survivals (OS) have not been reached at a median follow-up of 20 months. 2 of the 10 patients who underwent APBPCR recurred, one at 16.1 and one at 34.2 months. No veno-occlusive disease was observed during transplant and no treatment-related deaths occurred. Conclusions: TMZ followed by myeloablative chemotherapy with APBPCR can be safely administered to newly diagnosed AO patients.

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Phase II trial of oral gimatecan in adults with recurrent glioblastoma

2009

Background: Gimatecan is a highly lipophilic oral camptothecin analogue with impressive preclinical activity in glioma models. Methods: We conducted a multicenter two-stage phase II trial to evaluate the efficacy of gimatecan in adults with recurrent glioblastoma. Eligibility criteria included ≤1 prior treatment for recurrent disease, age ≥18, ECOG performance status 0 or 1, and normal organ function. Patients taking enzyme-inducing anti-seizure medications were excluded. Gimatecan 1.22 mg/m2 was given orally once daily for 5 consecutive days during each 28-day cycle. Radiographic response was evaluated by MRI after every second cycle. The primary endpoint of the study was 6 months PFS. A Simon's 2-stage design was used in which 19 patients were evaluated in the first stage, with an additional 36 patients accrued if > 4 patients in stage 1 achieved 6 month PFS. Results: A total of 29 patients were enrolled in the study, with median age of 58 years (range, 25–77 years); 58.6% female; all of whom had received prior surgery, radiation therapy, and at least one regimen of chemotherapy. The daily dose was reduced to 1.0 mg/m2 after four of the first 10 patients experienced grade 4 hematologic toxicity. One patient was removed from trial due to toxicity (grade 3 leukopenia and thrombocytopenia). Treatment delay occurred in 11 patients (38%) and dose reduction was necessary in eight patients (28%). Treatment-related grade 3/4 toxicities included thrombocytopenia (17.2%), leukopenia (17.2%), and neutropenia (10.3%). Only 1/19 patients treated with 1.0 mg/m2/day experienced grade 3/4 hematologic toxicity. The 18% reduction in the daily dose resulted in a 19% decrease in the concentration of total gimatecan in plasma prior to administration of the fifth daily dose (56 ± 23 vs. 45 ± 20 ng/mL) and a 33% decrease in the AUC for dose 5 (8.0±4.8 vs. 5.3±4.2 ng*h/mL). Only one patient had a partial radiographic response by the modified Macdonald criteria and stable disease was the best response in 13 patients. All other patients had progressive disease after two cycles of therapy. Only three patients (12%) were progression-free at 6 months. Median time to progression was 12.0 weeks (95% CI: 7.0, 17.0). Conclusions: Treatment with single-agent gimatecan 1.0 mg/m2/day for 5 days, repeated every 28-days showed minimal efficacy.

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Characteristics and outcomes of elderly patients with primary CNS lymphoma (PCNSL)

2070

Background: The incidence of PCNSL is increasing and is highest in those ≥ 65 years of age. Systemic chemotherapy (CT) ± radiotherapy (RT) improves survival, but treatment related toxicity is greatest in this population. The optimal treatment has yet to be determined. The aim of this study was to characterize older patients with PCNSL at our institution and identify outcomes related to treatment. Methods: We identified patients ≥ 65 years of age treated for PCNSL from 1986 to 2008. Charts were reviewed for demographics, treatment details, tumor progression, and survival. Approval for this study was obtained from the IRB at MSKCC. Results: 174 patients were identified with a median age of 72 years (range: 65–89). 60% of patients had a stereotactic biopsy for diagnosis; 93% had a histologic or cytologic diagnosis. 14 patients had evidence of systemic involvement with detailed staging evaluation. 82% of patients received a high-dose methotrexate (3.5g/m2) regimen, only 13% did not receive CT. Among the patients who received CT, 76% had a radiographic response (CR+PR), 3% had stable disease while 12% progressed. Only 26% had RT as part of initial therapy. CR rate to initial therapy was 67%, 52% of these patients eventually relapsed. Median time to progression was 24 months (range: 1–91). Among the patients who relapsed, 85% received salvage therapy consisting of CT (n = 42), RT (n = 14), or both (n = 7) while 15% received no further treatment. 48% of patients had a CR or PR to salvage therapy while 26% had PD; the remainder were not evaluated. Median overall survival for the entire cohort was 25 months (range: 0.5 to 177+) with a 3-year survival of 36%. 17% developed late treatment-related neurologic toxicity. Administration of RT was associated with the development of neurotoxicity (p < 0.0001). 39 patients remain alive with a median follow-up of 34 months (range: 0.5–177). Conclusions: Elderly patients can receive an aggressive chemotherapeutic regimen with good outcomes. Systemic staging is also valuable as a small subset of patients will have systemic involvement at diagnosis. Clinical trials to optimize treatments for this population are critical.

No significant financial relationships to disclose.

Phase II trials of erlotinib or gefitinib in patients with recurrent meningiomas

2062

Background: No effective treatment is available for recurrent meningiomas when surgical and radiation options are exhausted. The epidermal growth factor receptor (EGFR) is often over-expressed in meningiomas and may promote tumor growth. In open label, single arm phase II studies of the EGFR inhibitors gefitinib (NABTC 00–01) and erlotinib (NABTC 01–03) for recurrent malignant gliomas, we included exploratory subsets of recurrent meningioma patients. We have pooled the data and report the results here. Methods: Patients with recurrent histologically confirmed meningiomas and no more than two previous chemotherapy regimens were treated with gefitinib 500 mg/day or erlotinib 150 mg/day until tumor progression or unacceptable toxicity. Results: Twenty-five eligible patients were enrolled with median age 57 years (range 29–81) and median Karnofsky performance status (KPS) score 90 (range 60–100). Sixteen patients (64%) received gefitinib and nine (36%) erlotinib. Eight patients (32%) had benign tumors, 9 (36%) atypical, and eight (32%) malignant. For benign tumors, the 6-month progression-free survival (PFS6) was 29%, 12-month PFS (PFS12) 0%, 6-month overall survival (OS6) 63%, and 12-month OS (OS12) 50%. For atypical/malignant tumors, PFS6 was 25%, PFS12 19%, OS6 81%, and OS12 68%. There were no significant PFS or OS differences by histology. Of 21 evaluable patients, there were no responses; eight patients (38%) had stable disease, and 13 (62%) had progressive disease. Treatment was well-tolerated. Rash was not a significant predictor of PFS or OS. Conclusions: Neither gefitinib nor erlotinib appear to have significant activity against recurrent meningioma. The role of EGFR inhibitors in meningiomas is unclear but evaluation of EGFR inhibitors in combination with other targeted molecular agents may be warranted.

No significant financial relationships to disclose.

Phase I/II study of sorafenib and temsirolimus for patients with recurrent glioblastoma (GBM) (NABTC 05–02)

2006

Background: The activity of targeted molecular therapy with single agents has been disappointing in GBM. Combination therapy simultaneously targeting both the PI3k/Akt/mTOR and the MAP kinase pathway may be more effective. Methods: The North American Brain Tumor Consortium conducted a phase I/II study of sorafenib (VEGFR/PDGFR/Raf inhibitor) in combination with temsirolimus (mTOR inhibitor) in recurrent GBM. Eligibility criteria included histologically proven GBM, radiologic progression, > 18 years old, KPS > 60, adequate bone marrow reserve, and organ function. There was no limit on the number of prior relapses for phase I and no more than two prior relapses for phase II. No enzyme-inducing antiepileptic drugs were allowed. Dose-finding used a standard 3 + 3 design with the MTD defined as the dose with DLTs in 1/6 or fewer patients. The primary endpoint for the phase II component was PFS6 (p0 = 15%; p1 = 35%). A 2-stage design was used. If > 4 of the initial 19 patients achieved PFS6, an additional 14 patients would be accrued for a total of 33 patients. Results: In phase I, 13 patients were enrolled. Median age was 50 years (32–59); median prior chemotherapy 1 (1–3). The initial doses were sorafenib 200 mg bid and temsirolimus 25 mg intravenously once weekly. The MTD was 400 mg bid of sorafenib daily combined with 25 mg of temsirolimus weekly. At this dose 1/6 patients had a DLT (grade 3 thrombocytopenia). Other grade 3 or 4 toxicities included transaminitis, hypophosphatemia, fatigue, diarrhea, and hyperlipidemia. Pharmacokinetic data were similar to that for single agent sorafenib and temsirolimus suggesting that there were no significant interaction between the two drugs. In phase II, 19 patients were accrued to stage I. Median age 50 years (24–64); median prior relapses 1 (range 1–2). One patient was found not to have GBM on central review. No patient remained progression free at 6 months, although two patients stopped treatment prior to 26 weeks for other than progression (alternative therapy, cerebral ischemia). As result, the study was terminated and did not proceed to the second stage. Conclusions: The combination of sorafenib and temsirolimus was moderately well-tolerated but did not demonstrate sufficient efficacy in recurrent GBM to warrant further investigation.

No significant financial relationships to disclose.

Patterns of care and outcomes in patients with intracranial hemangiopericytomas: The Memorial Sloan-Kettering Cancer Center (MSKCC) experience

e13011

Background: Intracranial hemangiopericytomas are rare primary brain tumors with a tendency to metastasize. Available literature is restricted to small series of patients, and little is known regarding optimal clinical management and disease course, particularly in the targeted therapy era. Methods: Retrospective review of all patients with intracranial hemangiopericytoma seen at MSKCC from January 1, 1990 to December 31, 2008. Patients were included if histology was reviewed at MSKCC, and if clinical information was deemed sufficient for the analysis. Results: A total of 32 patients met inclusion criteria. The median age was 43 (range 24–68), median KPS was 80 (range 70–100), 17 were women. Disease was metastatic at presentation in only one patient. Initial treatment consisted of surgical resection in all patients (gross total resection: 14 patients, partial resection: 7, equivocal/unknown extent of surgery: 11). Adjuvant radiotherapy following surgery was given to 21 patients. The median progression-free survival was 65 months; median overall survival was 153 months and the 15-year survival was 48%. Treatment for recurrence included re-resection in 19 patients, additional radiotherapy in 17, and chemotherapy in 10. Regimens used included cytotoxic chemotherapy (6 patients) and targeted therapy (sorafenib: 3 patients; sunitinib: 3; imatinib: 2; erlotinib: 1; sirolimus: 1; bevacizumab: 1). Stable disease was the best observed response to these agents. Metastatic sites throughout disease course included lungs in 7 patients, bone in 10, liver in 3 and chest wall in 2. Immunohistochemistry and molecular analyses are ongoing and updated results will be presented. Conclusions: Hemangiopericytomas can be associated with late recurrences, even in patients completely resected and irradiated. Salvage treatment with surgery and radiotherapy seems effective, although the efficacy of chemotherapy remains to be determined. Given the slow growth rates, the meaning of stable disease while on chemotherapy is uncertain. Several patients in this series received agents targeting PDGFR or VGFR pathways, but such strategies need to be investigated further.

No significant financial relationships to disclose.

Primary CNS lymphoma with intraocular involvement: International PCNSL Collaborative Group Report

OBJECTIVE

To describe the demographics, diagnostic details, therapeutic management, and outcome in patients with primary CNS lymphoma (PCNSL) with ocular involvement.

METHODS

A retrospective study of 221 patients was assembled from 16 centers in seven countries. Only HIV-negative, immunocompetent patients with brain and ocular lymphoma were included; none had systemic lymphoma.

RESULTS

Median age at diagnosis was 60. Fifty-seven percent were women. Median Eastern Cooperative Oncology Group performance status was 2. Ocular disturbance and behavioral/cognitive changes were the most common presenting symptoms. Diagnosis of lymphoma was made by brain biopsy (147), vitrectomy (65), or CSF cytology (11). Diagnosis of intraocular lymphoma was made by vitrectomy/choroidal/retinal biopsy (90) or clinical ophthalmic examination (141). CSF cytology was positive in 23%. Treatment information was available for 176 patients. A total of 102 received dedicated ocular therapy (ocular radiotherapy 79, intravitreal methotrexate 22, and both 1) in addition to treatment for their brain lymphoma. Sixty-nine percent progressed at a median of 13 months; sites of progression included brain 52%, eyes 19%, brain and eyes 12%, and systemic 2%. Patients treated with local ocular therapy did not have a statistically significant decreased risk of failing in the eyes (p = 0.7). Median progression free survival and overall survival for the entire cohort were 18 and 31 months.

CONCLUSION

This is the largest reported series of primary CNS lymphoma (PCNSL) with intraocular involvement. Progression free and overall survival was similar to that reported with PCNSL. Dedicated ocular therapy improved disease control but did not affect overall survival.

Primary intraocular lymphoma: an International Primary Central Nervous System Lymphoma Collaborative Group Report

BACKGROUND

Primary intraocular lymphoma (PIOL) is an uncommon subset of primary central nervous system lymphoma. Because it is rare and difficult to diagnose, the natural history and optimal management are unknown.

PATIENTS AND METHODS

A retrospective study of 83 HIV negative, immunocompetent PIOL patients was assembled from 16 centers in seven countries.

RESULTS

Median age at diagnosis was 65. Median ECOG performance status was 0. Presenting symptoms included blurred vision, decreased visual acuity, and floaters. Median time to diagnosis was 6 months. Diagnosis was made by vitrectomy (74), choroidal/retinal biopsy (6) and ophthalmic exam (3). Eleven percent had positive CSF cytology. Initial treatment was categorized as focal in 23 (intra-ocular methotrexate, ocular radiotherapy) or extensive in 53 (systemic chemotherapy, whole brain radiotherapy). Six received none; details are unknown in one. Forty-seven relapsed: brain 47%, eyes 30%, brain and eyes 15%, and systemic 8%. Median time to relapse was 19 months. Focal therapy alone did not increase risk of brain relapse. Median progression free (PFS) and overall survival (OS) were 29.6 and 58 months, respectively, and unaffected by treatment type.

CONCLUSION

Treatment type did not affect relapse pattern, median PFS or OS. Focal therapy may minimize treatment toxicity without compromising disease control.

Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines

BACKGROUND

Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population.

DESIGN

In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified.

RESULTS

The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials.

CONCLUSION

The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.

A phase II trial of temozolomide and vinorelbine for patients with recurrent brain metastases

2050

Background: Temozolomide has shown modest efficacy in the treatment of recurrent brain metastases. We designed a regimen combining temozolomide with vinorelbine, a lipophilic agent that crosses the blood-brain barrier, trying to improve efficacy. Methods: This is a phase II trial with 28-day cycles using temozolomide (150 mg/m2, days 1–7 and 15–21) and vinorelbine on days 1 and 8. We previously reported a phase I trial that established an MTD of 30 mg/m2 of vinorelbine in this combination, but the dose was decreased to 25 mg/m2 in this phase II trial. The phase II component was planned as a two-stage clinical trial. Since two or more responses were observed after the 20 initial patients, 15 more assessable patients were required. This design had a 91% probability to detect a true response rate of 20% or more. The primary endpoint was objective radiographic response. Secondary endpoints include OS, PFS and toxicity. Patients = 18 years old with KPS = 60, adequate organ function and progressive or recurrent brain metastases were eligible. Results: Thirty-six patients (13 men, 23 women) with a median age of 56 years (range, 38–76) and median KPS of 80 were enrolled. The primary tumor sites were lung (n=19), breast (n=11), colon (n=2), bladder (n=1), endometrium (n=1), head/neck (n=1) and kidney (n=1). Prior therapies included whole-brain radiation therapy (81%), chemotherapy (97%), radiosurgery (42%) and brain metastasis resection (47%). Objective radiographic response was 7% (1 CR and 1 minor response); 4 patients had SD and 23 PD. Three patients withdrew consent and did not undergo follow-up scans, 2 patients did not receive the planned treatment and 2 patients recently began treatment and have not been assessed. The median follow-up was 12.3 weeks and 72% of patients have died. Median PFS and OS were 8.3 weeks and 5 months, respectively. Grade 3/4 toxicities were mainly hematological and 3 patients were removed from the study due to myelosuppression. Conclusions: In this heavily pretreated population of patients with brain metastases, adding vinorelbine to temozolomide does not seem to improve response rates as compared to temozolomide alone. Single-agent temozolomide also has a more favorable toxicity profile.

[Table: see text]

What is the role of whole brain radiation therapy (WBRT) and high-dose cytarabine (Ara-C) as consolidation treatment after initial chemotherapy for primary CNS lymphoma (PCNSL)?

2013

Background: Optimal management of PCNSL is not defined. To date the best outcomes have been achieved by combined modality therapy using methotrexate (MTX)-based chemotherapy and WBRT. However, WBRT carries a significant risk of neurotoxicity and may not be required in all patients. Methods: We retrospectively analyzed the data of 122 patients who had complete response (CR) after initial chemotherapy, from a total of 338 PCNSL patients treated in our institution since 1986. Descriptive variables including sex, age, KPS at diagnosis, histology, and extent of CNS involvement were reported. We specifically studied the benefit of consolidation therapy with WBRT and/or high dose Ara-C on OS and PFS. Results: The median age was 60 (19–89) years and a median KPS was 70. Men constituted 57% of the patients. Median follow up was 30 months. Histologically, 83% had diffuse large B cell lymphoma. Ocular and CSF involvements were 13%, and 27%, respectively. Most patients received MTX-based regimens (96%). Five-year OS was 43% and five-year PFS was 50% for all patients. There was no significant difference in OS, between patients who received consolidation therapy with Ara-C (n=35), WBRT (n=12), Ara-C + WBRT (n=28), or no consolidation (n=42) [data from 5 patients are missing]. There was a trend towards improved disease control for patients treated with WBRT; however, these patients were also younger than the other groups. Risk of neurotoxicity was significantly higher in patients who received WBRT (p=0.005). Conclusions: Consolidation therapy does not clearly improve survival in PCNSL patients with a CR to initial treatment. However other important prognostic factors including age and KPS may have been used in the decision making related to consolidation therapy.

[Table: see text]

No significant financial relationships to disclose.

Clinical outcome of glioblastoma multiforme patients with long-term survival

2069

Background: Glioblastoma multiforme (GBM) patients generally have a dismal prognosis with average survival of one year. Long-term survival of 3 years or more is rare and the clinical outcome of these patients has been poorly studied. Methods: Retrospective review of patients surviving 3 years or longer following diagnosis of GBM at our institution between 1985 and 2003. Clinical characteristics and long-term outcome were reviewed. Pathology was confirmed at our institution for all patients. Results: 39 long-term survivors of GBM were identified. Median age at diagnosis was 47 years (range: 14 - 69 years). Fifteen patients (pts) were older than 55 at time of diagnosis, and 5 were over 60. Presenting symptoms were headaches (56%), seizures (28%), hemiparesis (12%), aphasia (17%) or confusion (5%). Median KPS at diagnosis was 90 (range: 50–100). One patient (4%) underwent biopsy and X patients each (48%) underwent complete resection and incomplete resections. All patients received focal radiation therapy (RT) with a median dose of 5940 cGy (range: 4500 - 6120 cGy); 7 received concurrent temozolomide. Adjuvant chemotherapy in 35 pts consisted of temozolomide (54%), BCNU (38%), intra-arterial cisplatin (4%), or PCV (4%). Estimated median survival was 6.16 years (range: 3.1 - 18.2). After initial treatment, 11 pts had continuous clinical and radiographic remission, 28 relapsed, and 12 died. Median KPS at last follow-up was 70 (range 40 - 100). However, 19 pts (49%) developed delayed treatment-related complications at a median of 2.7 years (range: 1 -12 years) from initial diagnosis. Six (15%) developed RT necrosis (none of whom received concurrent temozolomide), 12 (31%) developed a subcortical dementia with associated leukoencephalopathy, and 9 (23%) developed strokes thought to be related to prior treatment. Conclusions: Long-term GBM survivors remain rare but occur in all age groups. These patients have a high risk of developing clinically significant long-term complications of their treatment.

No significant financial relationships to disclose.

A pilot study of bevacizumab and stereotactic intensity modulated re-irradiation for recurrent high grade gliomas

2028

Background: Bevacizumab is a humanized monoclonal antibody directed at vascular endothelial growth factor A (VEGF-A). Preclinical studies suggest that inhibition of VEGF-A improves glioma response to radiotherapy. The concurrent use of bevacizumab and cranial radiotherapy has not been investigated. The objective of this study is to determine the safety of this combination. Methods: Patients with recurrent glioblastoma multiforme (GBM) and anaplastic astrocytomas (AA) less than 3.5 cm received bevacizumab (10 mg/kg IV) every 2 weeks. MRI after cycle 1 (28 days) was done to reassess response and for RT planning. Patients then received stereotactic intensity modulated radiation therapy (IMRT): 30Gy in 5 fractions over 15 days. Bevacizumab treatment, given every 2 weeks, was administered during radiotherapy and continued until tumor progression. Brain MRI to assess response was performed after odd cycles. MR T1 and T2* perfusion were performed at baseline and after cycle 1. Results: 12 patients (10 GBM, 2 AA) with median age 53 (range, 30–61) and median KPS 90 (range, 80–100) received a median of 5.5 cycles of bevacizumab. In 1 patient, stereotactic IMRT could not be delivered safely to tumor. Grade III events occurred in 10 patients including hypertension, headache, seizures, neutropenia, hyponatremia and hypophosphatemia. There were no grade IV or V events, no dose limiting toxicities and no intracranial hemorrhage. 7/12 patients had objective responses (3 CR and 4 PR). In 5, SD was the best reported response. At last follow up, ten patients remain on study; 2 have come off for PD. Estimated 6 month PFS is 76%. MR perfusion imaging demonstrated a decrease in mean perfusion values after 1 cycle of bevacizumab. Conclusions: Bevacizumab in combination with RT is safe and well tolerated. Imaging responses and duration of disease control suggest that this regimen is active in this subset of recurrent glioma patients. Further investigations to determine efficacy and possible synergy of bevacizumab with radiotherapy are warranted.

[Table: see text]

A randomized phase II trial of concurrent temozolomide (TMZ) and radiotherapy (RT) followed by dose dense compared to metronomic TMZ and maintenance cis-retinoic acid for patients with newly diagnosed glioblastoma multiforme (GBM)

2031

Background: Metronomic and dose dense scheduling are alternatives to conventional TMZ regimens to overcome drug resistance in part by depleting O-6 methylguanine-DNA methyltransferase (MGMT). Furthermore, metronomic TMZ may inhibit endothelial recovery and act as an anti-angiogenic therapy; dose dense TMZ increases the intensity of drug delivery. Objective: To determine the overall (OS) and progression free survival (PFS) of patients with newly diagnosed GBM treated with concurrent TMZ and RT followed by dose dense or metronomic TMZ and maintenance cis-retinoic acid. Methods: Patients with newly diagnosed, histologically confirmed GBM underwent standard RT with TMZ. Upon completion of this treatment, patients were randomized to receive dose-dense TMZ (150mg/m2, days 1–7 and 15–21 of a 28 day cycle) or metronomic TMZ (50mg/m2 daily in 28 day cycles), for 6 cycles. Maintenance cis-retinoic acid was prescribed following the 6 cycles of adjuvant TMZ. OS and PFS were calculated from date of diagnosis. Prospective correlative tissue analysis of MGMT status is planned. A Simon minimax 2-stage design was used for each cohort. If either group has 70% survival probability at 1 year, further evaluation in a phase III trial will be recommended. Results: 51 patients were randomized: 24 to metronomic, and 27 to dose dense. Median age is 57, and median KPS 90. 26 patients have progression of disease (POD), with a median follow up of 5 months. Grade 3/4 hematologic toxicity occurred in 7 patients (14%), 3 in the metronomic and 4 in the dose dense arm. Conclusions: Our patient population is comparable to that of other upfront GBM treatment trials. Metronomic and dose dense TMZ appear to be well tolerated with equivalent toxicities. Early analysis suggests that patients on the dose dense regimen may have better PFS than those on the metronomic arm.

[Table: see text]

No significant financial relationships to disclose.

Prognostic model for primary CNS lymphoma (PCNSL): Recursive partitioning analysis (RPA) of the MSKCC PCNSL population

1531

Background: Increasingly there is a need to develop a simple prognostic score that can be used in the analysis and design of PCNSL studies as well as for clinical management. Recently the IELSG published a 3 group prognostic model incorporating patient age, performance status, serum LDH, location of brain lesions and CSF total protein; however, only 105 of their 378 patients had all of the variables available to develop this score. Methods: We analyzed 338 patients (median age 60; median KPS 70) seen and treated for PCNSL at MSKCC between 1983 and 2003. The median survival was 37 months and median follow up of surviving patients is 35 months. Univariate analysis of potential prognostic factors was performed using the Kaplan Meier product limit method. Significant univariate variables were included in a multivariate analysis using the Cox proportional hazards regression model. Patients were separately analyzed using the IELSG prognostic score. Finally, RPA was employed as an independent method of developing specific prognostic categories. Results: In the univariate analysis, age, hemiparesis, mental status changes, creatinine clearance and KPS were significant predictors of overall survival; in the multivariate model only age and KPS remained as significant predictors. 113 patients had adequate information (all 5 variables) to be analyzed using the IELSG prognostic score; while this correlated significantly with overall survival, the comparison between groups 2 and 3 was not statistically significant (p = 0.10). RPA of all 338 patients identified 3 subgroups: age ≤ 50 (median OS 9.2 y), age > 50 and KPS ≥ 70 (median OS 3.2 y) and age > 50 and KPS < 70 (median OS 1 y) that significantly separated our entire PCNSL population (p < 0.001). Conclusions: The use of RPA allows for easy discrimination of 3 prognostic groups of patients with PCNSL. In contrast to the IELSG score the MSK RPA classification includes information that is readily available on all patients and can be easily incorporated into the analysis or design of clinical research.

No significant financial relationships to disclose.

A phase I/II trial of RAD 001 with gefitinib in patients with castrate metastatic prostate cancer and glioblastoma multiforme

14520

Background: Inactivation of the Pten tumor suppressor gene, leading to constitutive activation of the PI3K/AKT/mTOR pathway, is correlated with resistance to EGFR-targeted therapies. This trial tested the concept that inhibition of mTOR by RAD 001 (NOVARTIS) will restore sensitivity to EGFR inhibition by gefitinib (ASTRA ZENECA), in patients with progressive PC and GBM. Methods: Phase I was designed to determine a safe and tolerable dose and the pharmacokinetics (PK) of RAD (30/ 50/ 70 mg po weekly) with a fixed dose of gefitinib (250 mg po qd) in patients with PC and GBM. Phase II evaluated the proportion of PC patients with no change or a decline in PSA at 12 weeks, without clinical or radiographic progression. FDG PET imaging and immunohistochemistry were included as correlative studies. Results: 12 patients (2 GBM, 10 PC) were treated in Phase I, and 22 of 27 PC patients have been treated in Phase II. (The GBM Phase II results are reported separately). 20/32 (63%) of PC patients had received prior chemotherapy. No dose limiting toxicities were observed in Phase I, and 70 mg of RAD 001 weekly with gefitinib 250 mg qd was studied as the Phase II dose. PK parameters estimated during a 3 week single agent lead-in phase and during subsequent combined therapy suggested no clinically relevant PK interactions between RAD and gefitinib. The most common drug-related grade 3/4 toxicities were lymphopenia (28%) and elevated ALT (7%). Serial FDG PET scans showed > 25% decline in SUV uptake in 9/23 evaluable patients during the first week of treatment; of these, 3 patients showed no progression at 12 weeks. Overall, 5/29 PC patients showed no progression at 12 weeks, 3 (60%) of whom had received prior chemotherapy. Conclusions: Combination therapy with RAD 70 mg weekly and gefitinib 250 mg daily appears to be safe and is associated with modest activity in metastatic prostate cancer. Support: Novartis Pharmaceuticals, Astra Zeneca Pharmaceuticals.

[Table: see text]

A pilot study to assess the tolerability and efficacy of RAD-001 (everolimus) with gefitinib in patients with recurrent glioblastoma multiforme (GBM)

1507

Background: The majority of GBMs overexpress EGFR and have PTEN loss leading to activation of AKT signaling. mTOR is a downstream target which is blocked by RAD-001. The addition of an mTOR inhibitor to EGFR blockade by gefitinib may augment downregulation of AKT. Methods: Nineteen patients with GBM were enrolled in a phase I/II protocol open to patients with either hormone refractory prostate cancer or recurrent GBM. Patients on enzyme inducing anti-epileptic drugs (EIAEDs) were excluded, but prior treatment with an EGFR inhibitor was allowed. All patients received gefitinib 250 mg daily. Two patients enrolled in a dose escalation arm received RAD-001 30 mg or 50 mg weekly; 17 patients received the maximum tolerated dose of RAD-001 70 mg weekly. Baseline and follow-up MRIs were reviewed by a neuro-radiologist. Primary endpoints were radiographic response and progression-free survival (PFS). Results: There were 11 men and 8 women with a median age of 53 years (range 22–72) and median KPS of 80 (range 70–100). Seventeen patients (89%) were treated at their second or greater recurrence. The most frequent grade 1 and 2 toxicities were thrombocytopenia, elevated ALT, rash, anemia, leukopenia, and diarrhea. Grade 3 lymphopenia occurred in 8 patients (42%); two patients (11%) had grade 4 seizures unrelated to the study drugs. Five patients (26%) had a partial radiographic response, including one treated at 3rd recurrence, 2 treated at 4th recurrence, and one who had progressed through prior gefitinib therapy. Two additional patients (11%) had disease stabilization for greater than 4 months. Median PFS was 2.6 months. Median overall survival has not been reached, with a median follow up of 5.4 months for surviving patients. Conclusions: The combination of RAD-001 and gefitinib demonstrated activity in 37% of patients with GBM (26% responded, 11% achieved stable disease). Most subjects were heavily pre-treated and expected to have resistant disease. Because disease control was not durable, alternate dosing, or treatment earlier in the course of disease should be considered in further studying this promising combination.

[Table: see text]

The role of systemic and cranial 18Fluorodeoxyglucose positron emission tomography (FDG PET) in primary central nervous system lymphoma (PCNSL)

1535

Background: The utility of body and brain FDG PET in staging and management of PCNSL is unknown. Methods: We performed a retrospective study of 166 PCNSL pts at Memorial Sloan-Kettering Cancer Center between January 2000 and August 2005. Pts. who underwent PET imaging were identified using the electronic medical record. PET reports and clinical data were reviewed to determine the reason for the study and impact on management. Results: 61 (37%) pts had ≥1 PET scans. Of 93 studies, 58 were body scans and 35 were brain scans. 72% (42/58) of body PET were done for systemic staging at diagnosis and 28% (16/58) at relapse. 19% (8/42) of scans done for initial staging had suspicious systemic foci. Lymphoma was found in 3 (37.5%), adrenal adenoma in 1 (12.5%), duodenal adenocarcinoma in 1 (12.5%) and non-diagnostic tissue in 1 (12.5%); biopsy was not pursued in 2 (25%). 31% (5/16) of scans done at relapse were abnormal. In 3 (19%) of these, biopsy revealed lymphoma; in 2 (12.5%), biopsy was not pursued. In 8% (4/50) of pts (SUV 12.8, 14.3, 22, 30.5), PET was the only study to demonstrate systemic lymphoma. 2 other pts found to have systemic disease had suspicious findings on conventional imaging in addition to positive body PET (SUV 3.8, 4.1). 43% (15/35) of brain PET were done at diagnosis and 57% (20/35) were done to evaluate residual MRI abnormalities after treatment. 14 brain PET at diagnosis were positive; SUV reported in 7 of these pts ranged from 7.5 to 26.8. The pt with a negative PET was receiving steroids. 10 brain PET done after treatment showed residual tumor and affected interpretation of MRI response. SUV reported in 7 of these pts. ranged from 8.1 to 29. Conclusions: Body PET imaging appears to be a sensitive tool for the detection of occult systemic lymphoma that may be missed with other diagnostics. While Brain PET at initial diagnosis did not yield incremental information, it may be useful in the interpretation of persistent MRI abnormalities after treatment.

No significant financial relationships to disclose.

Prospective analysis of expression of circulating levels of matrix metalloproteinase-9 (MMP-9) in the serum of patients with primary central nervous system lymphoma (PCNSL)

1532

Background: Matrix metalloproteinases have been associated with angiogenesis, tumor infiltration and metastases formation in systemic lymphoma. Disease status in PCNSL is determined by brain MRI; however it may be inconclusive and non-invasive tests to evaluate disease status would be useful. This study was designed to determine whether circulating levels of MMP-9 could be related to disease status in PCNSL. Methods: Circulating levels of MMP-9 were determined by ELISA and correlated with disease status assessed by MRI in a prospective longitudinal study. The disease status was classified as no evidence of disease (CR) versus active disease (AD). Results: We enrolled 18 PCNSL patients and obtained 93 blood samples (median 6 per patient, range 1–10) from August 2002 to December 2005. When in CR (12 patients, 59 samples), the mean MMP-9 level was 205.5 ± 19.1 ng/ml (median 162.3 ng/ml, range: 35.9–649.1 ng/ml). MMP-9 levels were significantly higher in AD (16 patients, 34 samples), with a mean MMP-9 of 638.2 ± 140.7 ng/ml (median 287.5 ng/ml, range 24.7–3340.6 ng/ml) (p = 0.0001). Paired samples obtained before and after therapy were obtained in 10 patients. Patients in AD had a mean of 1223.9 ± 336.5 ng/ml (median 770.1 ng/ml, range 284.1–3340.6 ng/ml) before treatment and levels fell to a mean of 143.5 ± 38.4 ng/ml (median 86.7 ng/ml, range 28.1–356.5 ng/ml) (p = 0.005) when CR was reached. During follow-up, 4 of the 18 patients developed recurrent disease (total 5 recurrences). MMP-9 levels increased from 154.22 ± 34.9 ng/ml (median 162.4 ng/ml, range 64.5–260.3 ng/ml) to 324.4 ± 98.5 ng/ml (median 251.5 ng/ml, range: 159.5–709.7 ng/ml) (p = 0.14) at relapse. Conclusions: PCNSL patients in CR have circulating MMP-9 levels that are significantly lower than in patients with AD. A significant drop in MMP-9 was seen after treatment compared to baseline. MMP-9 levels increased with disease recurrence but did not reach statistical significance in this small population. MMP-9 has the potential to complement neuroimaging to confirm remission or progression.

No significant financial relationships to disclose.

Vinorelbine combined with a protracted course of temozolomide for recurrent brain Metastases: a phase I trial

Temozolomide (TMZ) has shown modest efficacy in the treatment of recurrent brain metastasis (BM). We designed a new regimen utilizing dose-intensified, protracted course of TMZ in combination with vinorelbine, a lipophilic large-spectrum agent, in an attempt to improve the efficacy of TMZ. This phase I study was conducted to establish the maximum tolerated dose (MTD) of vinorelbine for this combination. Patients with recurrent or progressive BM were eligible. Chemotherapy consisted of 28-day cycles with TMZ (150 mg/m2, days 1-7 and 15-21) and vinorelbine (days one and eight at escalating doses). The starting dose was 15 mg/m2, with increments of 5 mg/m2 for each cohort of 3-6 patients, until MTD was reached (30 mg/m2). A total of 21 patients were enrolled; the median age was 59 (41-77). The primary tumor was lung cancer in 13 patients (NSCLC in 10, SCLC in 3), breast in 6, renal in 1 and endometrial in 1. Vinorelbine dose was 15 mg/m2 in seven patients, 20 mg/m2 in five, 25 mg/m2 in four and 30 mg/m2 in six. Grades 3 and 4 neutropenia developed in six patients, lymphopenia in nine, and thrombocytopenia in six; other toxicities were rare. No dose-limiting toxicity was seen. Out of 18 evaluable patients 2 had a radiographic response (one partial and one minor). Disease was stable in 6 of 18 patients and the median survival was 27 weeks. This regimen was well tolerated and a phase II trial using a dose of 30 mg/m2 of vinorelbine is warranted.

Proton magnetic resonance spectroscopy in immunocompetent patients with primary central nervous system lymphoma

BACKGROUND

Magnetic resonance spectroscopy imaging (MRSI) non-invasively evaluates the metabolic profile of normal and abnormal brain tissue. Primary central nervous system lymphoma (PCNSL) is a highly aggressive tumor responsive to high-dose methotrexate based regimens. Patients often have complete responses but relapses are common. We characterized the MR spectra of PCNSL patients, correlated MRSI with MRI and evaluated whether early recurrence could be detected by MRSI.

METHODS

Patients with PCNSL had multi-voxel MRSI before, during, and after treatment. The region of interest was defined using axial FLAIR images. Metabolites assessed were N-acetyl-aspartate (NAA), choline (Cho), creatine (Cr), lipid, and lactate. Ratios of Cho/Cr, NAA/Cho, and NAA/Cr were calculated and correlated with MRI. Overall survival (OS), progression free survival (PFS), and relative risks of each of the ratios were determined.

RESULTS

MRSI was performed on 11 men and seven women; median age of 59. Sixty-seven MRSI studies were performed, 17 baseline and 48 follow-up studies. Median ratios in 16 pretreated patients were Cho/Cr-1.90, NAA/Cho-0.39, and NAA/Cr-1.27. Two patients had lipid at baseline, five had lactate and two had both. MRSI correlated with tumor response or progression on MRI; in three patients MRSI suggested disease progression prior to changes on MRI. Univariate analysis of metabolite ratios, lipid, and lactate revealed that none significantly affected PFS or OS. Kaplan-Meier analysis of the presence or absence of lipid, lactate or both revealed a trend for increased PFS.

CONCLUSION

MRSI and MRI correlate with tumor response or progression and may allow early detection of disease recurrence. The presence or absence of lipid and/or lactate may have prognostic significance. Further research using MRSI needs to be done to validate our findings and determine the role of MRSI in PCNSL.

Cognitive functions in survivors of primary central nervous system lymphoma

BACKGROUND

The standard treatment for primary CNS lymphoma (PCNSL) involves high-dose methotrexate-based (MTX) chemotherapy and whole brain radiotherapy (WBRT). This combined regimen prolongs patient survival, but also carries a substantial risk for delayed neurotoxicity particularly in the elderly. However, cognitive outcome evaluations have not been included in most clinical trials.

OBJECTIVE

To assess cognitive functioning and quality of life in PCNSL survivors treated either with WBRT +/- MTX-based chemotherapy or chemotherapy alone.

METHODS

Twenty-eight PCNSL patients in disease remission received a post-treatment baseline neuropsychological evaluation, and a subset of patients were available for an 8-month follow-up evaluation. Assessment of quality of life and extent of white matter disease on MRI were also performed.

RESULTS

Patients displayed mild to moderate impairments across several cognitive domains. These were of sufficient severity to reduce quality of life in half of the patient sample. Comparisons according to treatment type revealed more pronounced cognitive impairment, particularly in the memory and attention/executive domains, among patients treated with WBRT +/- chemotherapy. Extent of white matter disease correlated with attention/executive, memory, and language impairment.

CONCLUSIONS

PCNSL survivors treated with WBRT +/- chemotherapy displayed more pronounced cognitive dysfunction than patients treated with MTX-based chemotherapy alone.

Temozolomide for treating brain metastases

The metastasis of solid tumors to the brain is associated with a poor prognosis despite aggressive treatment. Available treatment options are limited, as many chemotherapeutic agents do not penetrate the blood-brain barrier. Temozolomide (Temodar in the United States, Temodal globally; Schering Corporation, Kenilworth, NJ) is a novel chemotherapeutic agent with a good safety profile that crosses the blood-brain barrier and has shown activity against many human solid tumors. In two phase II trials of temozolomide in heavily pretreated patients with various solid tumor brain metastases, temozolomide was safe and generally well tolerated and showed clinical activity, with three partial responses and 19 disease stabilizations. Results of a third randomized phase II trial of concurrent administration of temozolomide and radiation therapy followed by adjuvant temozolomide therapy compared with radiation alone showed a higher rate of complete and partial responses (objective response of 96% v 67%) and significantly more complete responses (38% v 33%, P =.017), primarily in patients with newly diagnosed brain and lung metastases.