A Phase II Study of Bevacizumab With Etoposide and Cisplatin in Breast Cancer Patients With Brain and/or Leptomeningeal Metastasis
Brain metastases are increasingly important causes of morbidity and mortality in breast
cancer patients. Whole brain radiotherapy (WBRT) and surgery remains the standard treatment
for brain metastases. However, the median overall survival after brain and leptomeningeal
metastasis were only 8.5 months and 16 weeks respectively There is lack of standard
treatment for brain metastasis progression post WBRT. Chemotherapy was considered mostly
poor for treatment response because of the blood brain barrier. However, this has been
questioned because tumor can disrupt the normal function of blood brain barrier. For
example, etoposide and cisplatin had been used for treatment for breast cancer patients with
brain metastasis. The overall response rate of central nervous system (CNS) was 39 %,
disease control rate was 60%, although the median overall survival was 31 weeks only. The
role of targeted therapies is actively being assessed. Recently, a phase II study of
lapatinib in patients with brain metastases from HER2-positive breast cancer showed that CNS
objective response rates were 6% to lapatinib monotherapy and 20% to lapatinib plus
capecitabine. Although the result is promising, the treatment population is limited in the
HER2 overexpression breast cancer.
Bevacizumab, an anti-angiogenic agent, has been approved to combine with several
chemotherapy agents in breast, lung and colon cancer. It was once considered contraindicated
in patients with brain metastases due to the possibility of intracranial bleeding. However,
two studies involving the use of bevacizumab for treating brain metastatic tumors of
non-squamous or peripherally located squamous lung cancer showed no report of brain
hemorrhage. In addition, bevacizumab has been approved to treat primary brain aggressive
tumors recently.
In the institution, the investigators treated three breast cancer patients with multiple
brain metastases using bevacizumab plus etoposide and cisplatin (B-EP). All of them have
been treated for at least two lines of chemotherapy before brain metastases occurred. All of
them received WBRT for brain metastases and one of them also received craniotomy with brain
tumor resection plus local stereotactic radiosurgery. The follow up magnetic resonance
imaging (MRI) had revealed recurrent metastatic brain tumors in one patients, and recurrence
of leptomeningeal metastasis in another two patients. One patient who has multiple brain
parenchyma metastases showed objective response on MRI after two cycle of B-EP treatment,
and remained progression free for more than 5 months. The other two patients with
leptomeningeal metastasis had intrathecal and intraventricular (via Ommaya reservoir)
methotrexate treatment for more than eight doses. They were near stupor before B-EP
treatment. Both had best clinical response of full recovery of consciousness and absence of
cancer cells in cerebrospinal fluid. One survived eight months after the diagnosis
leptomeningeal metastasis, and the other two were still alive six months after the diagnosis
of leptomeningeal metastasis .
Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) has been used in various
studies for evaluation of anti-angiogenic condition. In breast cancer, DCE-MRI has been used
as an early predictive marker for response. Glioblastoma patients have also been evaluated
with DCE-MRI to determine reduction of vessel permeability after bevacizumab treatment.
Proton magnetic resonance spectroscopy (1H-MRS) has been used to different benign brain
tumors from malignant ones. The utilization of 1H-MRS, especially in human brain tumors,
coupled to both routine MRI and functional MRI techniques provides greater information
concerning tumor grading and extension and characterization of the normal surrounding tissue
than what is possible with any other imaging technique alone. To analyze proton spectroscopy
before and after bevacizumab may give us further information about the mechanism of B-EP on
CNS metastasis.
Therefore, the investigators propose to conduct a phase II clinical trial to test the
efficacy of B-EP regimen in breast cancer patients with CNS metastasis along with brain
DCE-MRI to demonstrate the antiangiogenesis efficacy.
Interventional
Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
Response rate of central nervous system (CNS) metastasis
The response criteria for brain parenchymal metastasis is measured according to the volumetric response criteria with modification. CNS lesion(s) which have a ≧ 50% volumetric reduction of in the absence of progressive neurologic signs and symptoms will be considered as responsive. The response criteria for leptomeningeal metastasis is defined as disappearance of carcinoma cells of three consecutive cytology examination of cerebrospinal fluid (CSF) after chemotherapy. For patients with both brain and leptomeningeal metastases, both criteria need to be met to be considered as responsive.
1 year
No
Yen-Shen Lu, MD, PhD
Principal Investigator
Department of Oncology, National Taiwan University Hospital
Taiwan: Department of Health
201010077M
NCT01281696
January 2011
December 2013
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