Her2/EGFR-PDGFR pathway aberrations associated with tamoxifen response in metastatic breast cancer patients

Background

Metastatic breast cancer (MBC) is a major health problem worldwide. Some patients improve on tamoxifen and others do not respond to treatment. Therefore, the aim of the current study is to assess genetic aberrations in the Her2/EGFR-PDGFR pathway associated with tamoxifen response in MBC patients.

Methods

This is a retrospective cohort study, including 157 hormone receptors positive, locally recurrent inoperable and/or MBC patients on tamoxifen treatment. Patients were categorized into 78 (49.7%) tamoxifen responders and 79 (50.3%) tamoxifen non-responder patients. Genetic aberrations of 84 genes involved in the Her2/EGFR-PDGFR pathway were assessed in the tumor tissue samples obtained from the patients using SA-Bioscience assay. The identified panel was correlated to patients’ response to treatment, to detect the differentially expressed genes in tamoxifen responders and non-responders.

Results

One hundred twenty-three (78.3%) patients were estrogen receptor (ER) and progesterone receptor (PR) positive, 108 (68.8%) were ER only positive, and 78 (49.7%) were PR only positive. There were 56 genes overexpressed in the refractory group compared to responders. However, only five out of these 56 genes, Janus kinase 1 (JAK1), collagen type I alpha 1 (COL1A1), GRB2-associated binding protein 1 (GAB1), fibronectin-1 (FN1), and MAP kinase-interacting serine/threonine-protein kinase (MKNK1), showed statistical significance between the two groups. Patients with bone metastasis showed a better response to treatment compared to those with metastatic deposits in other sites such as visceral metastasis (P < 0.005).

Conclusions

Genetic profiling using simple quantitative real-time polymerase chain reaction (qRT-PCR) protocols could be used to assess response to tamoxifen treatment in MBC patients. According to our data, a five-gene panel in the EGFR pathway (JAK1, COL1A1, GAB1, FN1 and MKNK1) could be used to categorize MBC patients into groups according to treatment response.

Primary therapy of early breast cancer: Egyptian view of 2021 St. Gallen consensus

PURPOSE

The theme of the St. Gallen International Breast Cancer Conference 2021 held virtually for the first time, due to the COVID-19 pandemic, was on tailoring therapies for patients with early breast cancer. A monkey survey that included an Egyptian Panel voted on most of the questions of the original St. Gallen consensus, and some added new questions most relevant to oncology practice in the country, to be able to compare voting results that reflect differences in breast cancer management and decision making.

METHODS

The panel included 74 Egyptian scientists from different oncology specialties. Management issues including controversial diagnostic and therapeutic interventions were prepared by a small committee and then projected using the online monkey survey website: https://www.surveymonkey.com . The survey included 130 questions. Results were then analyzed, tabulated, and compared to the voting results of the original St. Gallen consensus.

RESULTS AND CONCLUSIONS

Voting questions and resulting percentages of answers from the Egyptian panel were summarized. There was no consensus between the Egyptian and the original St. Gallen panels on 28/130 statements. They mostly included genetic and pathologic aspects, specifically the routine use of gene signature assays and a few queries involving surgical, radiotherapeutic, and systemic interventions. Probably, available resources and healthcare system differences in Egypt compared to European and the USA were the cause of these differences. This would also be applicable to other low- and low-middle-income healthcare scenarios present in many countries, especially with the present constraints of the COVID-19 pandemic.

Real-World Data on the Prevalence of Anaplastic Lymphoma Kinase-Positive Non-Small-Cell Lung Cancer in the Middle East and North Africa

PURPOSE

Anaplastic lymphoma kinase (ALK) gene alterations are potent oncogenic drivers in non–small-cell lung cancer (NSCLC). Tyrosine kinase inhibitors targeting the ALK pathway are effective in treating ALK-positive NSCLC. Around 5% of Asian and White patients with NSCLC have ALK-positive tumors, but ALK rearrangement prevalence data in the Middle East and North Africa (MENA) region are limited.

METHODS

In this noninterventional epidemiology study, histologically confirmed nonsquamous NSCLC samples retained for < 5 years in tissue banks at six centers in MENA were retrospectively analyzed for ALK rearrangement using the VENTANA immunohistochemistry (IHC) method. Patient characteristics obtained were analyzed for association with ALK rearrangement. Concordance between IHC and Vysis fluorescence in situ hybridization (FISH) ALK detection methods was assessed in a subset of samples.

RESULTS

Four hundred forty-eight tissue samples were analyzed using IHC: 137 (30.6%) in Lebanon, 104 (23.2%) in Saudi Arabia, 97 (21.7%) in Egypt, 80 (17.9%) in the United Arab Emirates, and 30 (6.7%) in Morocco. On the basis of IHC, the prevalence was 8.7% (95% CI, 6.3 to 11.7) for ALK-positivity and 91.3% (95% CI, 88.3 to 93.7) for ALK-negativity. On the basis of FISH (n = 148), the prevalence was 5.4% positivity and 81.8% negativity (12.8% nonevaluable). Concordance between IHC and FISH (n = 129) was 98.4% (95% CI, 94.2 to 99.8) for negative agreement and 98.5% (95% CI, 94.5 to 99.8) for overall agreement. Univariate analysis showed that ALK rearrangement was significantly associated with epidermal growth factor receptor wild-type status (P = .03) but was not significantly associated with sex, race, smoking history, or histologic subtype.

CONCLUSION

Our findings suggest that ALK rearrangements are more prevalent in MENA than other geographic regions. High concordance was found between FISH and IHC. Except for epidermal growth factor receptor wild-type status, no clinicopathologic characteristics were associated with ALK-positive NSCLC.

Breast cancer in Egypt:a review of disease presentation and detection strategies

Carcinoma of the breast is the most prevalent cancer among Egyptian women and constitutes 29% of National Cancer Institute cases. Median age at diagnosis is one decade younger than in countries of Europe and North America and most patients are premenopausal. Tumours are relatively advanced at presentation. The majority of tumours are invasive duct subtype and the profile of hormone receptors is positive for estrogen receptors and /or progesterone receptors in less than half of cases. This overview examines genetic changes, potential and established predictive and prognostic markers and end results of surgery, radiotherapy and systemic therapy for early, locally advanced and metastatic disease stages. Disease presentations common to the region and early detection strategies are presented

Risk factors for inflammatory and non-inflammatory breast cancer in North Africa

PURPOSE

Studies of the etiology of inflammatory breast cancer (IBC), a rare but aggressive breast cancer, have been hampered by limited risk factor information. We extend previous studies by evaluating a broader range of risk factors.

METHODS

Between 2009 and 2015, we conducted a case-control study of IBC at six centers in Egypt, Tunisia, and Morocco; enrolled were 267 IBC cases and for comparison 274 non-IBC cases and 275 controls, both matched on age and geographic area to the IBC cases. We administered questionnaires and collected anthropometric measurements for all study subjects. We used multiple imputation methods to account for missing values and calculated odds ratios (ORs) and 95% confidence intervals (CIs) using polytomous logistic regression comparing each of the two case groups to the controls, with statistical tests for the difference between the coefficients for the two case groups.

RESULTS

After multivariable adjustment, a livebirth within the previous 2 years (OR 4.6; 95% CI 1.8 to 11.7) and diabetes (OR 1.8; 95% CI 1.1 to 3.0) were associated with increased risk of IBC, but not non-IBC (OR 0.9; 95% CI 0.3 to 2.5 and OR 0.9; 95% CI 0.5 to 1.6 for livebirth and diabetes, respectively). A family history of breast cancer, inflammatory-like breast problems, breast trauma, and low socioeconomic status were associated with increased risk of both tumor types.

CONCLUSIONS

We identified novel risk factors for IBC and non-IBC, some of which preferentially increased risk of IBC compared to non-IBC. Upon confirmation, these findings could help illuminate the etiology and aid in prevention of this aggressive cancer.

Afatinib in locally advanced/metastatic NSCLC harboring common EGFR mutations, after chemotherapy: a Phase IV study

Aim

The current study evaluated the efficacy and tolerability of second-line afatinib in patients with EGFR mutation-positive (EGFRm+) non-small-cell lung cancer (NSCLC) following chemotherapy.

Patients & methods

In this open-label, single-arm Phase IV study, patients with EGFRm+ (Del19/L858R) NSCLC who had progressed following platinum-based chemotherapy received afatinib (starting dose 40 mg/day). The primary end point was confirmed objective response.

Results

60 patients received afatinib for a median duration of 11.5 months. 50% of patients had a confirmed objective response, of median duration 13.8 months. Median progression-free survival was 10.9 months. The most common treatment-related adverse events were diarrhea (72%), rash (28%) and paronychia (23%).

Conclusion

Our data support the use of afatinib (40 mg/day) as an effective and well-tolerated second-line treatment in EGFRm+ NSCLC.

Abstract 1828: Genetic profiling of breast cancer confirms a pivotal role of EGFR pathway in the development of acquired resistance to tamoxifen

Background: Metastatic breast cancer (MBC) represents a major health problem in Egypt and worldwide. Prognostic and predictive factors for patients with MBC are highly needed, for better management and improved survival. The aim of this study was to assess the prognostic and predictive value(s) of CYP2D6 polymorphisms in MBC patients on Tamoxifen and to determine the genetic profile(s) of Tamoxifen responders and non-responders. Methods: We assessed 157 females with hormone receptor positive, locally recurrent inoperable and/or metastatic breast cancer (MBC) patients from Egypt for 1) CYP2D6 polymorphisms and 2) genetic aberrations in the EGFR pathway (92 genes). All patients received Tamoxifen and according to their response they were divided into Tamoxifen-responders and refractory. RNA was extracted from tumor and normal tissue samples and used to assess the genetic profiles of the patients using the SABioscience array (Qiagen) with four house-keeping genes. Results: 92(58.6%) patients were ER and PR positive, 51 (32.5%) were ER positive and 14 (8.9%) were PR positive. CYP2D6 *3/*4 was significantly prevalent in the refractory group (86.6%).Variants *10/*10 and *10/*3 were more common in the responders (85.5%) compared to refractory (P=0.027). CYP2D6 polymorphism associated significantly with Her-2 amplification (P&lt;0.001), and reduced overall survival rate of patients in both refractory and responder groups (P&lt; 0.001). Fifty-six genes were differentially over-expressed in the refractory group compared to responders, of which only JAK1, COL1A1, GAB1, FN1and MKNK1 showed a significant difference. In the refractory group 34 genes were differentially reduced compared to responders; none of them showed significant difference. Response to Tamoxifen associated significantly with disease site since patients with bone only disease showed better response than those with visceral metastases (P&lt;0.005). Conclusion: A panel of 5 genes in EGFR pathway (MJAK1, COL1A1, GAB1, FN1 and MKNK1) together with CYP2D6 polymorphism scan predict response to Tamoxifen in metastatic BC patients though this has to be verified in an extended study including larger sample.

Citation Format: Abeer A. Bahnnasy, Ibrahim Malash, Nasr Al-Lahlouby, Osman Mansour, Sabry Shaarawy, Mona S. Abdellateif, Hend Yousef, Mai M. Lotfy, Rabab Gaafar, Mohamed. elsesy, Abdel-Rahman N. Zekri. Genetic profiling of breast cancer confirms a pivotal role of EGFR pathway in the development of acquired resistance to tamoxifen [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1828.

Contributing factors to the outcome of primary malignant chest wall tumors

Background

Primary malignant chest-wall tumors (PMCWTs) are a heterogeneous group of tumors. They require a special experience in designing resection and reconstruction. They account for less than 1% of all primary malignant tumors. This study is designed to clarify different factors contributing to the outcome of patients with PMCWTs in our institution.

Methods

A retrospective study included 98 patients with pathology proven PMCWTs, treated at the National Cancer Institute (NCI), Cairo University, Egypt, during the past 10 years. Used variables were: age, sex, forced expiratory volume in the 1^st second (FEV1), site, size, multiplicity, pathologic subtype, tumor grade, safety margin (SM), excised ribs, complications, estimated blood loss (EBL), neo-adjuvant and adjuvant treatments, Overall and disease free survival (DFS) were obtained using Kaplan-Meier method and compared using Log rank test. Cox regression was used to identify DFS predictors.

Results

PMCWTs represented 10.5% of all thoracic malignancies in our institution. There were 51 females (52%). The median age was 39 years [interquartile range (IQR) =25-52.3)] years. Chondrosarcoma was the commonest tumor histology (20.4%). The median tumor size was 8 cm (IQR =5-14). Tumor multiplicity was found in 18.4% of patients. Bone resection was performed in 76 patients (78.3%), ribs resection was performed in 59 patients and the median number of resected ribs per patient was 3 (IQR =1-3) ribs. Sternal resection was done in 7 (7.1%) cases. R0 resection was achieved in 62.2% of patients. There was one operative related mortality (1.02%) and 17.3% patients suffered procedure related complications. Local recurrence developed in 35 (35.7%) patients. The overall survival (OS) at 1, 3 and 5 years was 73.9%, 45.6% and 34.6% respectively and the median OS was 33 months (95% CI, 21.8-44.2), while median DFS was 24 months (95% CI, 19.6-28.4). Predictors of better DFS were -ve SM (P<0.001), tumors <5 cm (P=0.039), low grade (P=0.033), lower EBL (P=0.003) and absence of adjuvant therapy (P=0.007); however, on multivariate analysis, only -ve SM was the only predictor (HR =0.54; 95% CI, 0.29-0.97, P=0.041).

Conclusions

In primary malignant CWTs (PMCWTs) achievement of wide resection margins is of great importance to minimize the local tumor recurrence that will have an adverse impact on long-term survival.

LUME-Meso: Design and Rationale of the Phase III Part of a Placebo-Controlled Study of Nintedanib and Pemetrexed/Cisplatin Followed by Maintenance Nintedanib in Patients With Unresectable Malignant Pleural Mesothelioma

Malignant pleural mesothelioma (MPM) is a rare but aggressive disease: median survival is 6 to 9 months if untreated. Standard first-line treatment for patients with unresectable MPM is cisplatin/pemetrexed, with a median overall survival (OS) of approximately 1 year. Improvements in first-line treatment options are needed. With the benefit of combining bevacizumab with standard therapy shown in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS), vascular endothelial growth factor (VEGF) pathway inhibition has gained renewed interest as a treatment approach. Nintedanib is an oral angiokinase inhibitor targeting multiple signaling pathways implicated in the pathogenesis of MPM, including the VEGF receptor. The phase III part of the international, phase II/III LUME-Meso study is evaluating the efficacy and safety of nintedanib plus pemetrexed/cisplatin in patients with unresectable epithelioid MPM. Originally, this was a double-blind, randomized, phase II exploratory study and was amended to include a confirmatory phase III part following the recommendation of an internal Data Monitoring Committee and review of phase II data. The phase III part plans to enroll 450 chemotherapy-naive patients, who will be randomized to receive pemetrexed/cisplatin on day 1 and nintedanib or placebo on days 2 to 21, for a maximum of 6 cycles. Patients without disease progression who are eligible to continue study treatment will receive maintenance treatment with nintedanib or placebo until disease progression or undue toxicity. The primary end point is progression-free survival; OS is the key secondary end point. The study will use an adaptive design, including an interim analysis to reassess the number of OS events required to ensure sufficient power for OS analysis. The study is currently enrolling patients.

Abstract 4258: Genetic profiling of breast cancer confirms a pivotal Role of EGFR pathway in the development of acquired resistance to Tamoxifen in locally recurrent and metastatic breast cancer patients

Background: Acquisition of resistance to Tamoxifen is a major drawback in the treatment of estrogen receptor (ER)-positive breast cancer (BC) patients. The role of CYP2D6 in predicting response to Tamoxifen is debatable. We assessed the involvement of aberrant EGFR pathway genes expressions and CYP2D6 polymorphism in predicting response to Tamoxifen in a cohort of BC patients from Egypt.

Patients and methods: This prospective study included 157 females with hormone receptor positive, locally recurrent inoperable and/or metastatic BC patients treated in the National Cancer Institute, Cairo. Patients were categorized according to their response to Tamoxifen into: responders and refractory groups. RNA and DNA were extracted from tumour and normal tissue samples obtained from all patients. The expression of 92 genes in the EGFR pathway was evaluated using the SABioscience array (Qiagen) with four house-keeping genes and CYP2D6 polymorphism was assessed by PCR.

Results: We found that 58.6% of the patients were ER/PR positive, 32.48% were ER positive and 8.91% were PR positive. Response to Tamoxifen correlated significantly with the site of the disease (patients with bone only disease demonstrated better and maintained response compared to those with visceral involvement; p. = 0.005) and CYP2D6 polymorphism (p. = 0.034). CYP2D6 *3, *4 were significantly prevalent in the refractory group (86.6%), whereas variants *10/*10 and *10/*3 were more common in the in the responders (85.5%) (p. = 0.027). RNA profiling of the EGFR pathway showed that 56 genes were differentially over-expressed in the refractory group compared to the responders, of which only JAK1, COL1A1, GAB1, FN1, MKNK1, AKT1, EGFR, NFKB1 and HGDC showed a significant difference between the groups (p&lt;0.05).. Thirty four genes were differentially reduced, of which only STAT5A, RHOA, MAPK9, MAPK10, CCND1 showed significant difference between groups (p&lt;0.05)..

Conclusion: The EGFR pathway contributes significantly to patients’ response to Tamoxifen in locally advanced/ metastatic breast cancer. A panel of 13 genes (JAK1, COL1A1, GAB1, FN1, MKNK1, EGFR, NFKB1, HGDC, STAT5A, RHOA, MAPK9, MAPK10, CCND1) in this pathway together with CYP2D6 polymorphisms can predict response to Tamoxifen though this has to be verified in a larger study.

Citation Format: Abdel-Rahman N. Zekri, Abeer Bahnassy, Ibrahim Malash, Mohammad Mansour,Sabry Shaarawy, Hoda Abdel-Raouf, Rabab Gaafar. Genetic profiling of breast cancer confirms a pivotal Role of EGFR pathway in the development of acquired resistance to Tamoxifen in locally recurrent and metastatic breast cancer patients. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4258. doi:10.1158/1538-7445.AM2015-4258

Abstract P2-17-01: Overall survival (OS) in the IMELDA randomized phase III trial of maintenance bevacizumab (BEV) with or without capecitabine (CAP) for HER2-negative metastatic breast cancer (mBC)

BACKGROUND The open-label randomized phase III IMELDA trial demonstrated that adding CAP to maintenance BEV until disease progression (PD) after initial BEV–docetaxel (DOC) provides statistically significant and clinically meaningful improvements in both progression-free survival (PFS [primary endpoint]; hazard ratio [HR] 0.38 [95% CI 0.27–0.55]; log-rank p&lt;0.001) and OS. We present OS in subgroups representing stratification factors and clinically important populations.

METHODS Patients (pts) with HER2-negative measurable mBC, ECOG PS &lt;2, and no prior chemotherapy for mBC were eligible. After 3–6 cycles of BEV–DOC, pts without PD were randomized to BEV alone or BEV–CAP (BEV 15 mg/kg q3w; CAP 1000 mg/m2 bid d1–14 q3w) until PD. Stratification factors were estrogen receptor (ER) status, visceral metastases, response status, and lactate dehydrogenase (LDH) concentration. OS from randomization was a secondary endpoint. The planned sample size of 360 enrolled pts (290 randomized) was calculated assuming a PFS HR of 0.70 (median PFS 5.8→8.3 months) with 80% power at 2-sided α=0.05 after 244 PFS events. Recruitment was stopped prematurely after regulatory withdrawal of the BEV–DOC combination but pts who had already been enrolled and randomized were followed as originally planned.

RESULTS Between Jun 2009 and Mar 2011, 284 pts were enrolled and treated. Of these, 99 were not eligible for randomization (most commonly due to PD [41%] or AEs/toxicity [31%]) and 185 (65%) were randomized. At the time of the primary PFS analysis, representing study closure, median follow-up (from randomization) was 31.6 months. Median OS from randomization was 23.7 months in the BEV arm and 39.0 months in the BEV–CAP arm (events in 36% of pts). The HR for OS in the two randomized arms showed consistency between subgroups, favoring the BEV–CAP arm in all subgroups analyzed.

SubgroupNo. of events/No. of pts (%)Unstratified HR (95% CI)1-y OS rate (%) BEVBEV–CAP BEVBEV–CAPAll53/94 (56)33/91 (36)0.43 (0.26-0.69)a7290&lt;65 y46/81 (57)27/77 (35)0.51 (0.32-0.82)7293≥65 y7/13 (54)6/14 (43)0.50 (0.16-1.60)6879Triple negative16/21 (76)10/25 (40)0.44 (0.19-0.99)6290Hormone receptor positive37/73 (51)23/66 (35)0.53 (0.31-0.89)7591ER positiveb36/69 (52)23/64 (364)0.53 (0.32-0.90)7590ER negativeb17/25 (68)10/27 (37)0.44 (0.20-0.99)6491&lt;3 metastatic organ sites17/40 (43)17/48 (35)0.75 (0.38-1.49)8193≥3 metastatic organ sites36/54 (67)16/43 (37)0.39 (0.22-0.71)6588Visceral metastasesb38/65 (58)23/62 (37)0.43 (0.26-0.73)7092No visceral metastasesb15/29 (52)10/29 (34)0.76 (0.34-1.70)7688Complete or partial responseb36/68 (53)24/68 (35)0.61 (0.37-1.03)7389Stable diseaseb14/22 (64)6/20 (30)0.22 (0.08-0.63)68100Non-measurableb3/4 (75)3/3 (100)0.30 (0.03-2.98)6767LDH ≤1.5×ULNb50/89 (56)30/85 (35)0.49 (0.31-0.76)7294LDH &gt;1.5×ULNb3/5 (60)3/6 (50)1.01 (0.20-5.00)6044aStratified analysis. bStratification factor.

CONCLUSIONS. Combining maintenance BEV with CAP until PD after initial BEV–DOC for mBC provides a statistically significant and clinically meaningful improvement in OS (secondary endpoint), seen consistently irrespective of baseline characteristics.

Citation Format: Joseph Gligorov, Jose Bines, Emilio Alba, Giorgio Mustacchi, Saverio Cinieri, Vineet Gupta, Jean-Yves Pierga, Hakan Bozcuk, Rabab Gaafar, Sudeep Gupta, Guillermo Lopez Vivanco, Xiaojia Wang, Romulo Costa, Kadri Altundag, Ewa Chmielowska, Sabine de Ducla, Ulrich Freudensprung, Paulo Cortes, Dinesh Doval. Overall survival (OS) in the IMELDA randomized phase III trial of maintenance bevacizumab (BEV) with or without capecitabine (CAP) for HER2-negative metastatic breast cancer (mBC) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-17-01.

Mistletoe preparation (Viscum Fraxini-2) as palliative treatment for malignant pleural effusion: a feasibility study with comparison to bleomycin

Background

Malignant pleural effusion is a common problem in patients with solid tumours. It has a significant impact on quality of life, and, hence, there is a substantial need to investigate new agents to treat it.

Patients and methods

This is a prospective randomised controlled study, including patients with symptomatic recurrent malignant pleural effusion of different primaries. Patients were randomised into two groups: the first group received five ampoules of mistletoe preparation with defined lectin content (Viscum Fraxini-2, ATOS Pharma) diluted in 10 cc glucose 5% solution. Re-instillation was repeated every week until complete dryness of the pleural fluid was achieved (the maximum duration of the therapy was eight weeks). The second group received 60 units of bleomycin once intrapleurally.

Aims

The primary aim of this paper was to evaluate the efficacy of mistletoe preparation as a palliative treatment for malignant pleural effusions in comparison with bleomycin. The secondary aim was to evaluate the tolerability of the mistletoe preparation.

Results

A total of 23 patients were included and followed up during the study from December 2007 to January 2012: 13 patients received mistletoe preparation, and ten patients received bleomycin. Overall clinical response was reported in 61.5% of the mistletoe preparation arm versus 30% in bleomycin arm (p = 0.2138), 95% CI = (–0.1203, 0.6325). The toxicity of both arms was mild and manageable; the mistletoe preparation arm included fever, chills, headache, malaise, and, in two cases, allergic reaction, which was controlled by discontinuation of the drug and steroid injection.

Conclusion

Mistletoe preparation is an efficient and well tolerated sclerosant agent which needs further investigation.

Plasma vascular endothelial growth factor 165 in advanced non-small cell lung cancer

Currently, there is no serum marker that is routinely recommended for lung cancer. Therefore, the aim of the present study was to demonstrate that plasma vascular endothelial growth factor 165 (VEGF 165) may be a potential marker for advanced lung cancer. Lung cancer is the leading cause of cancer-related mortality worldwide, therefore, it is important to develop novel diagnostic techniques. The present prospective case control study included two groups of patients; a control group of healthy volunteers and a second group of patients with advanced non-small cell lung cancer (NSCLC). The plasma VEGF 165 levels were measured at baseline by ELISA prior to the first-line gemcitabine-cisplatin regimen. The high VEGF 165 expression level cut-off was >703 pg/ml, and the primary endpoint was used to compare the plasma VEGF 165 levels between the NSCLC patients and the control group subjects. The secondary endpoint was used to identify the correlations between high VEGF 165 levels and; clinical response (CR), progression-free survival (PFS) and overall survival (OS) in the advanced NSCLC patients. In total, patients with advanced NSCLC (n=35) were compared with a control group of age- and gender-matched healthy subjects (n=34). The follow-up period was between Oct 2009 and Oct 2012, with a median follow-up time of 10.5 months. The median plasma VEGF 165 level was 707 pg/ml in the NSCLC patients versus 48 pg/ml in the healthy control subjects (P<0.001). However, no significant correlation was found between the plasma VEGF 165 levels and CR (P<0.5), median PFS (P=1.00) or OS (P=0.70). Therefore, it was concluded that plasma VEGF 165 may serve as a potential diagnostic marker for advanced NSCLC.

A randomized, phase 2 study comparing pemetrexed plus best supportive care versus best supportive care as maintenance therapy after first-line treatment with pemetrexed and cisplatin for advanced, non-squamous, non-small cell lung cancer

BACKGROUND

Maintenance therapy for non-small cell lung cancer (NSCLC) aims to extend disease control after first-line chemotherapy with active and well-tolerated agents. The utility of continuation maintenance therapy requires further research.

METHODS

This multicenter, randomized, phase 2 study compared continuation maintenance therapy with pemetrexed (500 mg/m2 every 21 days) and best supportive care (BSC) versus BSC alone in patients with advanced, non-squamous NSCLC who had not progressed after 4 cycles of induction chemotherapy with pemetrexed (500 mg/m2) and cisplatin (75 mg/m2). The primary endpoint was progression-free survival (PFS) from randomization, was analyzed using a Cox model, stratified for the tumor response at the end of induction therapy, at a one-sided alpha of 0.2. Secondary endpoints: response and disease control rates, overall survival (OS), one year survival rates, and treatment-emergent adverse events (TEAEs).

RESULTS

A total of 106 patients commenced induction therapy, of whom 55 patients were randomized to maintenance pemetrexed/BSC (n = 28) or BSC (n = 27). Although the median PFS time for maintenance phase for both arms was 3.2 months, the one-sided p-value for the PFS HR comparison was less than the prespecified limit of 0.2 (HR = 0.76, two-sided 95% confidence interval [CI]: 0.42 to 1.37; one-sided p-value = 0.1815), indicating that PFS was sufficiently long in the pemetrexed/BSC arm to warrant further investigation. Similar PFS results were observed for the overall study period (induction plus maintenance) and when the PFS analysis was adjusted for sex, baseline disease stage, and the ECOG PS prior to randomization. The median OS for the maintenance phase was 12.2 months (95%CI: 5.6 to 20.6) for the pemetrexed/BSC arm and 11.8 months (95% CI: 6.3 to 25.6) for BSC arm. The one-year survival probabilities were similar for both arms for the maintenance phase and the overall study period. Both the induction and continuation maintenance therapies were generally well-tolerated, and similar proportion of patients in each arm experienced at least 1 grade 3/4 TEAE (pemetrexed/BSC, 17.9%; BSC, 18.5%).

CONCLUSIONS

Continuation pemetrexed maintenance therapy resulted in promising PFS with an acceptable safety profile in a Middle Eastern population with advanced non-squamous NSCLC and is worthy of further investigation.

TRIAL REGISTRATION

NCT00606021.

A phase 2 study of the combination of gemcitabine and cisplatin in patients with locally advanced or metastatic breast cancer previously treated with anthracyclines with/without taxanes

BACKGROUND AND OBJECTIVES

Many patients with relapsed metastatic breast cancer are pre-treated with taxanes and anthracyclines, which are usually given in the neoadjuvant/adjuvant setting or as first-line treatment for metastatic disease. The primary objective of this study was to determine the overall response rate for combination treatment with gemcitabine and cisplatin in patients with locally advanced or metastatic breast cancer who had relapsed after receiving one adjuvant/neoadjuvant or first-line metastatic chemotherapy regimen containing an anthracycline with/without a taxane. Secondary endpoints included duration of response, time to progression, one-year survival probability, and toxicity.

DESIGN AND SETTING

A single-arm, open-label, phase 2 study conducted at 17 investigative sites in Egypt.

PATIENTS AND METHODS

treatment consisted of gemcitabine (1250 mg/m2) on Days 1 and 8 and cisplatin (70 mg/m2) on Day 1 of each 21-day cycle. Treatment continued until disease progression or a maximum of 6 cycles.

RESULTS

Of 144 patients all were evaluable for safety and 132 patients were evaluable for efficacy. The overall response rate was 33.3% and 45.5% of the patients with stable disease as their best response. The median time-to-progression was 5.1 months and the one-year survival probability was 73%. The most common grade 3/4 adverse events were nausea/vomiting (20.1%), neutropenia (19.4%), anemia (13.9%), asthenia (11.1%), diarrhea (9.7%), stomatitis (7.6%), leucopenia (7.6%), and thrombocytopenia (6.2%). twelve (8.3%) patients had serious adverse events.

CONCLUSIONS

The results of this study indicate that gemcitabine and cisplatin were active and generally well tolerated in pretreated patients with locally advanced or metastatic breast cancer.

Cancer education for medical students in developing countries: where do we stand and how to improve?

BACKGROUND

This article is a review of the literature regarding the state of oncology education for medical students in developing countries, and possible solutions to the problems at hand.

METHODS

Ovid MEDLINE, PubMed, ERIC, The Cochrane CENTRAL Register of Controlled Trials (CENTRAL) and Google Scholar were searched using the terms oncology, undergraduate, cancer, education and teaching.

RESULTS

The search resulted in 40 relevant articles in total. Ten articles showed that there is a lack of adequate knowledge in the scientific, clinical and psychological aspects of oncology and palliative care amongst students and physicians in developing countries. Eight articles describe the relevance and usefulness of summer schools, workshops and trainings. The rest of them discuss possible methods of addressing the issue, the most important of which is the inclusion of a clinical oncology rotation in the undergraduate syllabus.

CONCLUSION

Graduated physicians and medical students are a long way from reaching the standard knowledge and skills required in oncology. Thus, there is a pressing need to reform the undergraduate medical curricula in developing countries in order to increase cancer awareness for better graduated future physicians.

Patient-mediated factors predicting early- and late-stage presentation of breast cancer in Egypt

OBJECTIVE

Breast cancer fatality rates are high in low- and middle-income countries because of the late stage at diagnosis. We investigated patient-mediated determinants for late-stage presentation of breast cancer in Egypt.

METHODS

A case-case comparison was performed for 343 women with breast cancer, comparing those who had been initially diagnosed at Stage I or II with those diagnosed at Stage III or IV. Patients were recruited from the National Cancer Institute of Cairo University and Tanta Cancer Center in the Nile delta. Patients were either newly diagnosed or diagnosed within the year preceding the study. Interviews elicited information on disease history and diagnosis, beliefs and attitudes toward screening practices, distance to treatment facility, education, income, and reproductive history.

RESULTS

Forty-six per cent of the patients had presented at late stage. Women seen in Cairo were more likely to present at late stages than patients in Tanta (OR=5.05; 95% CI=1.30, 19.70). Women without any pain were more likely to present at later stage (OR=2.68; 95% CI=1.18, 6.08). Knowledge of breast self-examination increased the likelihood of women to present in early stages significantly (OR=0.24; 95% CI=0.06, 0.94).

CONCLUSIONS

Despite increasing numbers of cancer centers in Egypt during the past 20 years, additional regional facilities are needed for cancer management. In addition, increasing awareness about breast cancer will have significant long-term impact on breast cancer prevention.

Trimodality therapy for malignant pleural mesothelioma: results from an EORTC phase II multicentre trial

The European Organisation for Research and Treatment of Cancer (EORTC; protocol 08031) phase II trial investigated the feasibility of trimodality therapy consisting of induction chemotherapy followed by extrapleural pneumonectomy and post-operative radiotherapy in patients with malignant pleural mesothelioma (with a severity of cT3N1M0 or less). Induction chemotherapy consisted of three courses of cisplatin 75 mg·m⁻² and pemetrexed 500 mg·m⁻². Nonprogressing patients underwent extrapleural pneumonectomy followed by post-operative radiotherapy (54 Gy, 30 fractions). Our primary end-point was "success of treatment" and our secondary end-points were toxicity, and overall and progression-free survival. 59 patients were registered, one of whom was ineligible. Subjects' median age was 57 yrs. The subjects' TNM scores were as follows: cT1, T2 and T3, 36, 16 and six patients, respectively; cN0 and N1, 57 and one patient, respectively. 55 (93%) patients received three cycles of chemotherapy with only mild toxicity. 46 (79%) patients received surgery and 42 (74%) had extrapleural pneumonectomy with a 90-day mortality of 6.5%. Post-operative radiotherapy was completed in 37 (65%) patients. Grade 3-4 toxicity persisted after 90 days in three (5.3%) patients. Median overall survival time was 18.4 months (95% CI 15.6-32.9) and median progression-free survival was 13.9 months (95% CI 10.9-17.2). Only 24 (42%) patients met the definition of success (one-sided 90% CI 0.36-1.00). Although feasible, trimodality therapy in patients with mesothelioma was not completed within the strictly defined timelines of this protocol and adjustments are necessary.

Tissue and serum EGFR as prognostic factors in malignant pleural mesothelioma

BACKGROUND

Malignant pleural mesothelioma (MPM) is an asbestos related aggressive tumor. Asbestos causes genetic modifications and cell signaling events that favor resistance to chemotherapy. A variety of receptor tyrosine kinases have been identified to play a central role in various aspects of tumorigenesis. Epidermal growth factor receptor (EGFR) is overexpressed in a variety of epithelial malignancies including lung cancer in which EGFR aberrations not only predict response to EGFR tyrosine kinase inhibitors but also indicate tumor progression. However in MPM, the role of EGFR is less clear. This study was designed to identify serum and tissue EGFR levels in patients with MPM and to evaluate the relationship between serum and tissue EGFR levels and clinicao-pathological prognostic factors and survival.

METHODS

We investigated 71 cases of MPM for EGFR expression in tissue. Serum EGFR was assessed in 40 out of those 71 cases and 20 healthy subjects as a control. Pre-treatment serum EGFR levels were measured using quantitative enzyme-linked immunosorbent assay. Tissue EGFR protein overexpression was assessed by immunohistochemistry and gene amplification was assessed by the chromogen in situ hybridization (CISH) technique. Results were correlated with the clinical-pathological factors of the patients and overall survival (OS).

RESULTS

Out of the 71 patients included in the study, 19 had undergone extrapleural pneumonectomy. As for the rest of the patients, 46 received chemotherapy while 6 had only best supportive care. EGFR immuno-reactivity was detected in 74.6% of the cases, 37 (52.1%) cases were positive for EGFR gene amplification by CISH, 31 of them revealed moderate to high (++, +++) EGFR immuno-reactivity. Elevated serum EGFR >2.5 ng/ml (the median concentration of EGFR in MPM) was reported in 45% of the cases. The overall response rate (RR) for the 46 treated patients who received chemotherapy was 24.1%. After a median follow up of 29 months, the median overall survival (OS) was 10 months. Elevated serum and tissue EGFR is significantly associated with advanced disease stage. However neither EGFR overexpression in tissues nor high serum levels were associated with survival rates.

CONCLUSIONS

EGFR expression is a common feature in MPM patients. High pre-treatment levels of serum EGFR are associated with advanced stage but not with reduced OS. Detailed mutational analysis of EGFR on a larger number of patients is still needed to clarify the exact role of EGFR in MPM patients.

Phase II feasibility trial of induction chemotherapy (ICT) followed by extrapleural pneumonectomy (EPP) and postoperative radiotherapy (PORT) for cT3N1M0 or less malignant pleural mesothelioma (MPM) (EORTC 08031)

7509

Background: MPM is a highly lethal disease and the role of EPP in the treatment of early stage, potentially resectable MPM remains controversial. EORTC 08031 phase II trial investigated the feasibility of trimodality therapy (TMT) consisting of ICT followed by EPP and PORT. Methods: Eligibility criteria were cT3N1M0 or less, proven MPM, < 70 years, PS 0–1, fit for TMT. ICT consisted of 3 courses of cisplatin 75mg/m2 and pemetrexed 500mg/m2 q3weeks. Non-progressing patients (pts) underwent EPP followed by PORT (54Gy, 30 fractions). Primary endpoint was “success of treatment” defined as a patient receiving the full protocol treatment, still alive 90 days after end of treatment without progression and without grade (G) 3–4 toxicity. Using a one step Fleming design 52 patients and 26 successes were required. Secondary endpoints were toxicity of TMT, overall and progression-free survival. Results: 59 pts were registered between 07/26/05 and 08/24/07, 1 was ineligible. Median age was 57 years (range 26–67), M/F 46/12, all proven MPM (31 epithelial, 18 mixed, 9 other). All pts underwent mediastinoscopy, cT1/T2/T3: 36/16/6, cN0/N1: 57/1. 55 pts received 3 cycles of ICT. G3–4 toxicity related to ICT was rare. 46 pts (79%) were operated, 42 (74%) had EPP. R0/1/2: 30/10/3, 6 were re-operated, pT0/1/2/3/4: 2/5/19/15/4, pN0/1/2/3: 34/2/6/2, 90-day mortality: 3 pts (6.5%); in 38 pts (83%) postoperative complications occurred. PORT was initiated in 38 pts and completed in 37 (65%). After PORT 2 pts (3.5%) died due to infection. Persisting G3/4 toxicity after 90 days: 3 pts (5.3%) due to radiation pneumonitis and bronchopleural fistula. After median follow- up of 19.3 months (mos) median overall survival time was 18.4 mos (95% CI 14.8-NR) and median progression-free survival was 13.9 mos (95% CI 10.9–17.1). Only 24 pts (42%) met the definition of success (one-sided 90% CI 0.36–1.00). Conclusions: EORTC 08031 investigated the feasibility of TMT in pts with proven MPM. Due to the low proportion of “successes” this TMT is not considered to be feasible. Although overall results were similar to other series, adjustments to this TMT are necessary.

No significant financial relationships to disclose.

Soluble mesothelin-related protein in malignant pleural mesothelioma

BACKGROUND AND PURPOSE

Building-up evidence suggests that soluble mesothelinrelated protein (SMRP) carries a diagnostic and a prognostic value in malignant pleural mesothelioma (MPM). Egypt suffers endemic asbestosis and thus this study was conducted to evaluate the sensitivity and specificity of SMRP in patients with MPM and to correlate this marker with known clinicopathological prognostic factors.

MATERIAL AND METHODS

During the period from January 2006 till March 2008, Serum samples were obtained from MPM patients presenting to the Egyptian National Cancer Institute, Cairo University. Serum samples were provided from patients with breast cancer and from healthy individuals to function as controls. The SMRP was assayed using the ELISA technique and correlations were made with different clinico-pathological prognostic parameters.

RESULTS

83 patients (50 MPM and 33 breast cancer) as well as 22 healthy individuals were enrolled in this study. Serum SMRP levels were not different between patients with breast cancer and healthy controls (p > 0.05). However, there was a significant difference between MPM patients and the other two groups (p < 0.0001). ROC analysis showed an AUC = 0.765 for differentiating between the controls and MPM with a best statistical cut-off of 7.22nM/L (sensitivity = 66 % , specificity = 70.9 % ). The mean SMRP concentrations were significantly higher in patients with advanced disease (p = 0.038), poor performance status (p = 0.017) and high alkaline phosphatase (p = 0.015). The mean SMRP concentrations were also higher in males, elderly patients, asbestos-exposed patients, epithelioid subtypes and patients with high platelet and leucocytic counts. However, these differences did not reach statistical significance

CONCLUSIONS

This study confirms that SMRP is of considerable sensitivity and specificity in Egyptian patients with MPM. Higher levels are frequently seen in patients with high tumor burden, which could be helpful in monitoring response to therapy.

KEY WORDS

Malignant pleural mesothelioma (MPM) - Soluble mesothelin related protein (SMRP)- Sensitivity - Specificity - Asbestos.

Symptoms and patient-reported well-being: do they predict survival in malignant pleural mesothelioma? A prognostic factor analysis of EORTC-NCIC 08983: randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma

PURPOSE

Malignant pleural mesothelioma (MPM) is a rare disease. Unlike other advanced cancer types, little is known about patient-reported symptoms or health-related quality of life (HRQOL) and their possible prognostic value. This study reports an evaluation of the prognostic value of these factors using data gathered from a recent randomized controlled trial.

PATIENTS AND METHODS

Patients were entered onto this trial if they had a histologically proven unresectable MPM, not pretreated with chemotherapy, WHO performance status < or = 2, and adequate hematologic, renal, and hepatic function. Patients were randomly assigned to receive cisplatin 80 mg/m2 intravenously on day 1, without or with preceding infusion of raltitrexed 3 mg/m2. HRQOL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30/Lung Cancer 13 tool. The Cox proportional hazards regression model was used for the univariate and multivariate analyses of survival, along with a bootstrap validation technique. Included were the EORTC prognostic index (PI) composed of stage of disease, histology type, time since diagnosis, and WBC, and, in addition, 10 selected key symptoms and HRQOL scales.

RESULTS

Two hundred fifty patients were randomly assigned (80% male; median age, 58 years; WHO performance status 0, 1, 2 in 25%, 62%, and 13% of cases, respectively). Two hundred twenty-nine patients (91.6%) had a valid HRQOL assessment. The final multivariate model retained the PI, pain (P < .0001), and appetite loss (P = .0100) as independent prognostic indicators of survival.

CONCLUSION

Results suggest that the PI, pain, and appetite loss may be independent prognostic factors in patients with advanced MPM.

Evaluation of simian virus-40 as a biological prognostic factor in Egyptian patients with malignant pleural mesothelioma

The association between simian virus (SV40) and malignant pleural mesothelioma (MPM) suggests an etiological role for SV40. However, exact pathogenetic mechanisms and possible prognostic value are not clear. The purpose of the present paper was to investigate 40 Egyptian MPM patients for the presence of SV40 DNA, altered Rb expression and p53 gene status using immunohistochemistry and molecular techniques. The relation between SV40, asbestos exposure, Rb, p53 and their contribution to the overall survival (OS) were also assessed. SV40 DNA was detected in 20/40 patients and asbestos exposure in 31 patients; 18 of them were SV40 positive. Altered p53 and Rb expression were detected in 57.5% and 52.5%, respectively, with no p53 mutation. Univariate analysis showed a significant correlation between OS and stage (P = 0.03), performance status (P = 0.04), p53 overexpression (P = 0.05), asbestos exposure (P = 0.002) and SV40 (P = 0.001). Multivariate analysis showed that when SV40 and asbestos exposure were considered together, only combined positivity of both was an independent prognostic factor affecting the OS (P = 0.001). SV40 and asbestos exposure are common in Egyptian MPM, denoting a possible etiological role and a synergistic effect for both agents. Combined positivity for SV40 and asbestos exposure is an independent prognostic factor in MPM, having a detrimental effect on OS.

Phase II, open-label, randomized study (SIGN) of single-agent gefitinib (IRESSA) or docetaxel as second-line therapy in patients with advanced (stage IIIb or IV) non-small-cell lung cancer

Our objective was to evaluate gefitinib (IRESSA), an epidermal growth factor receptor tyrosine kinase inhibitor, versus docetaxel as second-line monotherapy for advanced non-small-cell lung cancer (NSCLC). SIGN (Second-line Indication of Gefitinib in NSCLC; code 1839IL/0503) was a multicenter, randomized, parallel-group, open-label, phase II trial that investigated oral gefitinib (250 mg/day) or i.v. docetaxel (75 mg/m2 every 3 weeks) in patients with advanced NSCLC who had previously received one chemotherapy regimen. The primary objective was assessment of symptom improvement (using the FACT-L Lung Cancer Subscale). Secondary objectives included quality of life (FACT-L total score), response rate (using RECIST), overall survival and safety. This trial recruited 141 patients (68 to gefitinib and 73 to docetaxel) who received treatment for a median duration of 3.0 (gefitinib) and 2.8 (docetaxel) months. Similar efficacy was observed with gefitinib and docetaxel, 36.8 and 26.0% symptom improvement rates, 33.8 and 26.0% quality-of-life improvement rates, 13.2 and 13.7% objective response rates, and 7.5 and 7.1 months median overall survival, respectively. Fewer drug-related adverse events were observed with gefitinib compared with docetaxel (all grades: 51.5 versus 78.9%; Common Toxicity Criteria grade 3/4: 8.8 versus 25.4%). There were no withdrawals or deaths due to drug-related adverse events with gefitinib, while three patients withdrew and three died due to adverse events in the docetaxel group that were possibly drug related. We conclude efficacy with gefitinib was similar to docetaxel, but with a more favorable tolerability profile, in the second-line treatment of advanced NSCLC. These results support further investigation of gefitinib in this disease setting.

Is a patient's self-reported health-related quality of life a prognostic factor for survival in non-small-cell lung cancer patients? A multivariate analysis of prognostic factors of EORTC study 08975

BACKGROUND

The aim of this prognostic factor analysis was to investigate if a patient's self-reported health-related quality of life (HRQOL) provided independent prognostic information for survival in non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Pretreatment HRQOL was measured in 391 advanced NSCLC patients using the EORTC QLQ-C30 and the EORTC Lung Cancer module (QLQ-LC13). The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap validation technique was used to assess the stability of the outcomes.

RESULTS

The final multivariate Cox regression model retained four parameters as independent prognostic factors for survival: male gender with a hazard ratio (HR) = 1.32 (95% CI 1.03-1.69; P = 0.03); performance status (0 to 1 versus 2) with HR = 1.63 (95% CI 1.04-2.54; P = 0.032); patient's self-reported score of pain with HR= 1.11 (95% CI 1.07-1.16; P < 0.001) and dysphagia with HR = 1.12 (95% CI 1.04-1.21; P = 0.003). A 10-point shift worse in the scale measuring pain and dysphagia translated into an 11% and 12% increased in the likelihood of death respectively. A risk group categorization was also developed.

CONCLUSION

The results suggest that patients' self-reported HRQOL provide independent prognostic information for survival. This finding supports the collection of such data in routine clinical practice.

Short-term treatment-related symptoms and quality of life: results from an international randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: an EORTC Lung-Cancer Group and National Cancer Institute, Canada, Intergroup Study

PURPOSE

For malignant pleural mesothelioma (MPM) patients with a poor prognosis, maintaining health-related quality of life (HRQOL) is important. This article compares the impact on HRQOL of first-line treatment with cisplatin versus raltitrexed and cisplatin.

PATIENTS AND METHODS

Patients with histologically-proven unresectable MPM, not pretreated with chemotherapy were randomly assigned to receive cisplatin 80 mg/m2 intravenously on day 1, with or without preceding infusion of raltitrexed 3 mg/m2. HRQOL was assessed with the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire C30 (EORTC QLQ-C30) and EORTC Lung Cancer Module (QLQ-LC13) tools. Assessments were conducted at baseline, immediately before every treatment cycle, at the end of treatment, and every six weeks for 12 months.

RESULTS

Two hundred fifty patients were randomly assigned, 80% were male with a median age of 58 years, WHO performance status 0, 1, and 2, in 25%, 62%, and 13% of cases. The clinical results found raltitrexed and cisplatin to be superior to cisplatin with regard to overall survival (P = .048). The global HRQOL scale was comparable at baseline on both treatment arms (P = .848); at no point was any significant difference apparent on this end point. Both treatments led to an improvement, over time, in dyspnoea. This effect is an important clinically meaningful reduction from baseline in the cisplatin/raltitrexed arm. However, the majority of scales of the EORTC QLQ-C30 or LC13 showed stabilization of HRQOL with few clinically significant differences between the treatment arms.

CONCLUSION

This study provides important information about the HRQOL of chemotherapy-treated MPM patients.

Randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: an intergroup study of the European Organisation for Research and Treatment of Cancer Lung Cancer Group and the National Cancer Institute of Canada

PURPOSE

We conducted a phase III trial to determine whether first-line treatment with raltitrexed, a thymidine synthase inhibitor, and cisplatin results in superior outcome compared with cisplatin alone in patients with malignant pleural mesothelioma (MPM).

PATIENTS AND METHODS

Eligible patients with histologically proven advanced MPM, not pretreated with chemotherapy, WHO performance status (PS) 0 to 2, and adequate hematological, renal, and hepatic function were randomly assigned to receive cisplatin 80 mg/m2 IV on day 1, alone (arm A) or combined with raltitrexed 3 mg/m2 (arm B). In patients with measurable disease, response was monitored using the Response Evaluation Criteria in Solid Tumors criteria. Health related quality of life (HRQOL) was measured using the European Organisation for Research and Treatment of Cancer QLQ-C30 and Lung Module (QLQ-LC13).

RESULTS

Two hundred fifty patients were randomized: 80% male; median age, 58 years; and WHO PS, 0, 1, 2 in 25, 62, and 13% of cases, respectively. There were no toxic deaths. The main grade 3 or 4 toxicities observed were neutropenia and emesis, reported twice as often in the combination arm. Among 213 patients with measurable disease, response rate was 13.6% (arm A) versus 23.6% (arm B; P = .056). No difference in HRQOL was observed on any of the scales. Median overall and 1-year survival in arms A and B were 8.8 (95% CI, 7.8 to 10.8) v 11.4 months (95% CI, 10.1 to 15), respectively, and 40% v 46%, respectively (P = .048).

CONCLUSION

A combination of raltitrexed and cisplatin improves overall survival compared with cisplatin alone. This study confirms that a combination of cisplatin and an antifolate is superior to cisplatin alone in patients with MPM, without harmful effect on HRQOL.