Metastatic pattern in non-resectable non-small cell lung cancer

This study describes the metastatic pattern at autopsy in patients with non-resectable non-small cell lung cancer (NSCLC) and evaluates the impact of various pretreatment variables and treatment outcomes on the metastatic spread. In eight phase II chemotherapy trials from 1985 through 1993, 337 patients were treated and 51 autopsies were performed (autopsy rate 15%). The male/female ratio was 31/20, median age 56 years (range 36-71), response rate to chemotherapy 8%, and median survival 88 days (range 3-899). Histologic types included adenocarcinoma, 31 cases (60%), squamous cell carcinoma, 9 cases (18%), large cell carcinoma, 9 cases (18%), and unclassified NSCLC, 2 cases (4%). Patients who were autopsied had a shorter median survival than patients without autopsy (p = 0.002, log-rank test). Most commonly involved metastatic sites found at autopsy were mediastinal lymph nodes (84%), pleura (51%), liver (47%), bone (34%), brain (32%), pericardium (29%), adrenals (29%). The median number of involved organs was 5 (range 1-16), with a median of 3 intrathoracic sites (range 1-8) and 2 extrathoracic sites (range 0-11). Patients who initially had metastatic NSCLC also had significantly more metastatic sites at autopsy both extrathoracic (p = 0.004) and totally (p = 0.03) compared to patients with locally advanced disease. No other relation to pretreatment variables was found.

Small bowel metastases in non-small cell lung cancer

A case report of stage I adenocarcinoma of the lung in a 43-year-old female with recurrence in the small bowel and liver 11 months after pneumonectomy is presented. In addition, a cohort of 733 patients with non-small cell lung cancer (NSCLC) in all pretreatment stages (stages I-IV) with a total of 218 autopsies are evaluated, and the literature on the topic is reviewed, in order to define the frequency of metastases from NSCLC to the small bowel. There were 10 cases with and 208 cases without small bowel involvement among 218 consecutive autopsies (autopsy rate, 30%,). The frequency of small bowel involvement was 4.6% (95%, confidence interval, 2.2-8.3%), and all were in patients with adenocarcinoma of the lung. All patients with small bowel involvement at autopsy had also other concurrent metastatic sites as well and the following were the most frequent: adrenals (90%, of cases), mediastinal lymph nodes (80%), liver (70%), pleura (60%), contralateral lung (60%), bones (60%), and brain (50%). Significantly more metastatic sites were observed in patients with than without small bowel involvement, both totally (P = 0.0001) and with respect to number of extrathoracic (P = 0.0001) and intrathoracic (P = 0.01) metastatic sites. In conclusion, small bowel involvement in NSCLC is relatively infrequent. As a unique finding, over-representation of patients with poorly differentiated tumors (P = 0.03) and patients having solid carcinoma with mucus formation after histologic subtyping (P = 0.04) among cases with small bowel involvement was observed. This indicates, that small bowel metastases is an epiphenomonen of NSCLC tumors with certain biological characteristics, although as yet undiscovered, which leads to a high metastatic potential. If such biological characteristics could be identified, they may be used in the selection of treatment options for individual patients, e.g. indicating a need for adjuvant or neoadjuvant chemotherapy in addition to surgery in resectable or marginally resectable NCSLC patients.

Paclitaxel, gemcitabine, and cisplatin in non-resectable non-small-cell lung cancer

BACKGROUND

Paclitaxel, gemcitabine, and cisplatin are each active in non-small-cell lung cancer (NSCLC), and with different modes of action. Hence, a phase II study combining these drugs were conducted.

PATIENTS AND METHODS

Treatment was paclitaxel 110 mg/m2 and cisplatin 60 mg/m2 day 1 and 15, with gemcitabine 800 mg/m2 day 1, 8, and 15, every four weeks. Patients had previously untreated NSCLC, measurable disease, age 18-70 years, performance status < or = 2, and no brain metastases.

RESULTS

Among 49 patients, 6 (group 1) received chemotherapy as described above, while 43 patients (group 2) did not receive gemcitabine day 8. In group 1, all experienced grade 4 neutropenia and four achieved a partial response (67%). In group 2, neutropenia grade 4 occurred in 58%, with one episode of febrile neutropenia and no toxic death. No other grade 4 toxicities occurred, while grade 3 toxicity occurred with respect to thrombocytopenia (9%), nausea/vomiting (12%), neurotoxicity (12%), and nephrotoxicity (7%). There were 3 complete and 20 partial responses (response rate 54%, 95% confidence limits 38%-69%), median response duration 29 weeks (range 10-66+), median time to progression 28 weeks (range 4-66+), median survival 46 weeks (4-89+) and one-year survival rate 42%.

CONCLUSION

This regimen of paclitaxel, gemcitabine, and cisplatin has neutropenia as dose limiting toxicity, but septicemic episodes were rare and toxic death did not occur. Other grade 4 toxicities than neutropenia did not occur. The regimen appears safe and with a noteworthy activity both in terms of response rate, time to progression, and survival.

Metastatic pattern at autopsy in non-resectable adenocarcinoma of the lung--a study from a cohort of 259 consecutive patients treated with chemotherapy

A cohort of 259 consecutive patients with non-resectable adenocarcinoma of the lung (ACL) received chemotherapy and were followed until death with 124 cases examined by autopsy (autopsy rate 48%). Metastatic sites were identified and the following localisations were affected in 40% or more of patients post mortem: lungs, mediastinal lymph nodes, liver, pleura, adrenals, brain, and bones. Significant more metastatic sites were observed in patients who responded to the chemotherapy compared with non-responders (p = 0.04), in patients aged below the median of 58 years compared with older patients (p = 0.002), and, as expected, in patients with initial extensive disease compared with limited disease (p = 0.03). In contrast, no differences in metastatic pattern at autopsy could be detected with regard to other variables, such as initial TNM-stages, degree of histological differentiation, histologic subtypes, performance status, or LDH.

Metastatic pattern in adenocarcinoma of the lung. An autopsy study from a cohort of 137 consecutive patients with complete resection

A cohort of 137 patients with completely resected stage I or II adenocarcinoma of the lung was observed from the time of operation; the metastatic pattern determined at autopsy is described in relation to clinical, histologic, and laboratory variables. The pretreatment variables evaluated were performance status, age, gender, lactate dehydrogenase, stage, degree of differentiation, and histologic subtype of adenocarcinoma of the lung. Patients who survived longer than 30 days after operation were eligible for analysis, and 35 autopsies were performed in this patient group (autopsy rate: 39.8%). The most common intrathoracic metastatic sites were mediastinal lymph nodes (43%), lung (31%), pleura (20%), pericardium (9%), and heart (6%). The most common extrathoracic sites were liver (37%), brain (33%), bones (21%), adrenals (17%), and kidneys (17%). Patients undergoing resection for stage I disease had significantly fewer intrathoracic metastases than patients with stage II disease (p = 0.01). Patients who survived less than 1 year had significantly more extrathoracic metastases than patients who survived for a longer period (p = 0.01). Patients with highly differentiated tumors had fewer extrathoracic metastases than patients with less differentiated tumors. No other statistically significant differences were observed. Overall, patients with stage I adenocarcinoma of the lung had better local control of the disease at autopsy than those with stage II disease, but distant metastases are a large problem despite the favorable prognosis of this patient group. The extrathoracic metastatic potential was greatest for less differentiated tumors. An active adjuvant systemic therapy after resection is needed in selected patients with poorly differentiated adenocarcinomas of the lung, even in those with stage I disease.

Toremifene and tamoxifen in advanced breast cancer--a double-blind cross-over trial

Toremifene (TOR) is a triphenylethylene derivative related to tamoxifen (TAM). TOR has antitumor activity, not dependent on estrogen receptors, and responses with TOR have been observed in patients with progressive disease during TAM-treatment. To elucidate possible cross-resistance between these two antiestrogens, we compared their anti-tumor activity in a randomized, double-blind, cross-over study. 66 postmenopausal women with advanced estrogen receptor positive or unknown breast cancer and a median age of 63 years (range 38-82) were included. Patients were randomized to TAM 40 mg/day or TOR 240 mg/day. Treatment continued until progressive disease, when cross-over to the alternative treatment was done. The response rate with first line TOR was 29% (95% confidence limits 10-41%) and with TAM 42% (95% confidence limits 25-61%). Response rates and response durations, survival and toxicity were not significantly different between the two treatments. 44 patients progressing on first line TAM or TOR were evaluable for second line TOR or TAM treatment. As no responses were observed, the possibility of over-looking a response rate of 20% or more is less than 1%. In conclusion, this study strongly indicates that TOR and TAM are clinically cross-resistant in patients with advanced breast cancer.