Patient case: 50-year-old male with non-small cell lung cancer; genetic feature: EGFR (T790M)

Clinical trial: Induction Therapy With Intercalated Tyrosine Kinase Inhibitor (TKI) and Chemotherapy in NSCLC With Activating Epidermal Growth Factor Receptor (EGFR) Mutation in Stages II-IIIB

Summary: This study is designed as a single arm, un-controlled, open-label, multi-center hypothesis generating two-stage phase II trial. It is based on the assumption that the proposed treatment scheme doubles the rate of pathologic complete remission in Mutated epidermal growth factor receptor (EGFRmt) + NSCLC patients compared to historical control data from standard treatments.
  Patients with NSCLC and activating EGFR mutation in stages II, IIIA and IIIB eligible for induction therapy with docetaxel and cisplatin and gefitinib
  Patients will be treated for 12 days with gefitinib 250 mg/day p.o. (d -12 to -1) and induced with chemotherapy docetaxel 75 mg/m2 and cisplatin 50 mg/m2 d1+2 and intercalated gefitinib 250 mg/day d4-20 (cycle 1 and 2) and d4-17 (for cycle3). Surgery is planned in the 4th week after d1 of the last cycle.

Detailed description: Based on the notion that neoadjuvant combination of Chemotherapy (CTx) and intercalated TKI is clinically beneficial, which can be inferred from prior study data and single case reports, this study aims to generate additional information on feasibility, safety and efficacy of this treatment approach in a larger group of EGFR mutated NSCLC patients. This study is a hypothesis generating two-stage trial for future phase III studies of neoadjuvant CTx with intercalated TKI. Hence, the study design relies entirely on a single treatment arm. To demonstrate efficacy it is sufficient to compare to historical data of the conventional treatments of NSCLC.

Eligibility: Inclusion Criteria:
  1. Patients with histologically or cytologically confirmed non-squamous non-small-cell lung cancer (NSCLC) stage II, IIIA and IIIB detected preoperatively by adequate methods and activating EGFR mutation in exons 18-21 and deemed to be able to undergo curative surgery after induction therapy. Stage should be confirmed by PET-CT as well as adequate mediastinal staging. MRI of the brain to exclude CNS metastases is mandatory.
  2. At least one unidimensionally measurable lesion meeting RECIST criteria (version 1.1);
  3. Performance status of 0 to 1 on the ECOG scale;
  4. Estimated life expectancy of at least 12 weeks;
  5. Patients aged ≥ 18 years;
  6. Adequate organ function including the following:
  1. Adequate bone marrow reserve:
  -  absolute neutrophils (segmented and bands) count (ANC) ≥1.5x109/L;
  -  platelets ≥100x109/L;
  -  haemoglobin ≥9 g/dL.
  2. Hepatic:
  -  bilirubin ≤ 1xULN;
  -  alkaline phosphatase (AP);
  -  aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 2.5xULN.
  3. Renal:
  -  serum creatinine ≤ 1.3 mg/dL
  -  glomerular filtration rate (GFR) ≥ 70 mL/min for cisplatinum based CTx;
  -  If contraindications including GFR below 70mL/minagainst cisplatin exist, carboplatin may also be used;
  -  glomerular filtration rate ≥ 30 mL/min (calculated) if carboplatin is to be used
  7. Adequate lung function tests as assessed by body plethysmography, diffusion test and if necessary spiro-ergometry.
  8. Cooperation and willingness to complete all aspects of the study;
  -  Written informed consent to participate in the study.
  Exclusion Criteria:
  1. EGFR wild type configuration;
  2. EGFR resistance mutations (i.e. T790M);
  3. Significant cardiovascular disease, such as uncontrolled hypertension, myocardial infarction within the last 6 months, unstable angina pectoris, CHF ≥ NYHA 2, serious arrhythmia, significant peripheral vascular disease;
  4. Pre-existing neuropathic ≥ grade 2;
  5. Patients with confirmed HIV infection. HIV testing is not mandatory.
  6. Prior history of malignancy except for basal cell carcinoma or carcinoma in situ of the cervix, and with the exception of other malignancies after curative treatment with an interval of at least 3 years.
  7. Lactating or pregnant woman, woman of child-bearing potential who do not agree to the usage of highly effective contraception methods (allowed methods of contraception, meaning methods with a rate of failure of less than 1% per year are implants, injectable contraceptives, combined oral contraceptives, intrauterine devices (only hormonal devices), sexual abstinence or vasectomy of the partner). Woman of childbearing potential must have a negative pregnancy test (serum β-HCG) at visit 1.
  8. Any other chemotherapy at start;
  9. Treatment with other experimental drugs during the course of the study or within the last 30 days or 7 half-lifes, whatever is of longer duration, prior study start;
  10. Any psychiatric illness that would affect the patient's ability to understand the demands of the clinical trial;
  11. Parallel participation in another clinical trial or participation in another clinical trial within the last 30 days or 7 half-lifes, whatever is of longer duration, prior study start;
  12. Patient has already been included in this trial;
  13. Patients who do not understand the nature, the scope and the consequences of the clinical trial;
  14. Affected persons who might be dependent on the sponsor or the investigator.

Relevance to patient case: definitely relevant