Randomized phase II trial of erlotinib (E) versus temozolomide (TMZ) or BCNU in recurrent glioblastoma multiforme (GBM): EORTC 26034

2005

Background: In 40–50% of GBM epidermal growth factor receptor (EGFR) is amplified, and often constitutively activated (EGFRvIII mutant). EGFR is therefore a potential therapeutic target. Previous studies suggested activity of EGFR tyrosine-kinase inhibitors in recurrent GBM, particularly in specific molecular subsets. This study explored erlotinib (E) activity in recurrent GBM. Methods: Randomized phase II trial. Eligibility criteria: histologically proven GBM, recurrent >3 months after radiotherapy, Karnofsky performance status (KPS) =70, no prior chemotherapy for recurrent disease, tissue sample for EGFR studies. Patients (pts) received E 150mg/day (300mg/day if on enzyme inducing anti-epileptic drugs [EIAEDs]), or control (TMZ 150–200mg/m2, day 1–5 q4wk or BCNU 60–80mg/m2 i.v., day 1–3 q8wk). If no significant toxicity, E was escalated to 200mg (500mg in patients on EIAEDs). The primary endpoint was 6 months’ PFS in =10/50 pts on E (20%); P0 was set at 15%, and P1 at 30%. Response was assessed with Macdonald’s criteria. EGFR amplification (FISH) and expression of EGFR, EGFRvIII and PTEN (immunohistochemistry [IHC]) were assessed. Results: 110 patients were randomized (54 E, 56 control: 27 TMZ; 29 BCNU). Median age 55 years; median KPS 90. All but 1 patient started treatment; median number of cycles was 2 for E, 4 for TMZ and 1 for BCNU. Grade 3/4 toxicities likely related to E: dermatological (5); hemorrhage (1). Grade 3/4 toxicities for control were mainly hematological (3 TMZ, 13 BCNU). Three pts discontinued E due to toxicity. Six-month PFS was 12% for E, 24% for control. Six and 12-month survival were 61% and 24% for E, and 63% and 26% for control. Two responses were seen on control; the best response on E was SD (n=6). Patients with EGFRvIII mutations (13 in E arm, 8 in control arm) had shorter PFS (p=0.007) and OS (p=0.004) regardless of treatment. Response to E was not correlated with EGFR expression, EGFR amplification or EGFRvIII mutation. Conclusions: This randomized, controlled phase II study did not find sufficient activity for erlotinib in the general population of recurrent GBM. The presence of EGFRvIII mutations was not predictive for response.

No significant financial relationships to disclose.

Guidelines for the treatment of oligodendroglioma: an evidence-based medicine approach

The sensitivity to chemotherapy of oligodendroglioma (OD) is the major clinical distinction between oligodendroglial and astrocytic tumours. In particular, chemotherapy with alkylating agents (PCV chemotherapy, temozolomide) in recurrent OD is of proven efficacy, with 50 to 70% of patients responding. The value of adjuvant chemotherapy in newly diagnosed tumours still remains to be proven. The efficacy of radiotherapy (RT) has never been proven in a phase III trial on OD, but based on historical phase III trials on anaplastic glioma this generally considered part of standard treatment of these tumours. Recent molecular biological studies show that OD are characterised by a combined loss of the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19 q). This combined loss of 1p and 19 q also identifies a group of tumours with a better response to chemotherapy and a longer survival after RT. It is expected that this knowledge will change the diagnostic criteria for OD and will help to select patients for specific treatments. However, improvement of the currently available treatments is needed, as the outcome of these patients remains dismal.

[Treatment results and the prognosis in patients with localization of non-Hodgkins-lymphoma in the central nervous system]

OBJECTIVE

A description of clinical features and treatment results in patients with a central nervous system (CNS) localization of systemic non-Hodgkin's lymphoma (NHL).

DESIGN

Retrospective.

SETTING

Department of Neuro-oncology and Haematology, Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands.

METHODS

All patients with NHL (but not primary CNS lymphoma) treated in the period January 1st, 1990-December 31st, 1996 at the department of neuro-oncology were reviewed for presence of CNS localizations. Clinical characteristics like malignancy grade, disease stage, presence of extranodal localizations, B-symptoms, serum LDH, neurological signs and symptoms, results of ancillary investigations, treatment and response were recorded.

RESULTS

In this period 25 patients were diagnosed with leptomeningeal lymphoma, 2 with an intracerebral lymphoma, and 7 with both. In almost all patients the CNS localization developed during systemic progression of the NHL. Most patients presented with a radicular syndrome, cranial nerve deficits, headache or encephalopathy. More than 80% of the patients showed clinical improvement after treatment with intrathecal chemotherapy, radiation therapy or a combination of both. The median survival was three and a half months, six month survival was 32%. Progression of systemic disease was the most frequent cause of death.

CONCLUSION

In most patients good palliation of neurological signs and symptoms could be obtained with intrathecal chemotherapy and radiation therapy. Survival in these patients was limited, however, in part because of the frequent concurrent progression of systemic disease. Patients with CNS localizations with chemotherapeutic treatment possibilities with a realistic chance of cure or longterm survival should be treated accordingly. Otherwise, treatment should consist of intrathecal chemotherapy or radiation therapy of involved areas only.