Prevention of pulmonary recurrence of cancer with cisplatin lipid complexes

Abstract

The invention discloses a method for preventing lung relapse of cancer by using a cis-platinum lipid complex, and particularly discloses application of an inhalation type cis-platinum lipid complex (ILC) in preparation of a medicine for preventing or delaying osteosarcoma lung metastasis postoperative relapse or primary lung cancer postoperative relapse.

Description

[0001] This application is a divisional application of the invention application filed on September 4, 2013, with application number 201380045971.1 and invention title "Prevention of Lung Cancer Recurrence Using Cisplatin Lipid Complex". Cross-reference to related applications

[0002] This application claims priority to U.S. Provisional Patent Application Serial No. 61 / 743,398, filed September 4, 2012, the entire disclosure of which is incorporated herein by reference. Invention Field The invention described relates to a method and a compound for treating lung cancer. Background of the Invention lung The morphogenesis and repair of the lung are characterized by complex cell-cell interactions originating from the endoderm and mesoderm, resulting in the formation (or restoration) of an alveolar structure capable of efficient gas exchange between the pulmonary circulation and alveolar spaces. During development, the morphogenesis and differentiation of the interstitium specifically refer to the epithelium, and the entire respiratory epithelium (from the larynx to the distal bronchi) exhibits strong plasticity in its final phenotype, depending on the inducible signals it receives from the interstitium. (DeMayo F, Am. J. Physiol. Lung Cell Mole. Physiol. 283: L510-L517 (2002)). Distal lung epithelial phenotype-specific inducing factors are diffusive and active over short distances, and the regulation of lung epithelial growth and differentiation is multifactorial. (Ibid.)

[0003] During bronchial smooth muscle myogenesis in the embryonic lung (smooth muscle growth occurs at sites that maintain mechanical tension), at least partly, it involves the formation of the bronchial basement membrane by promoting the elongation of peribronchial cells from round to slender. The new epithelial-mesenchymal junctions generated during bronchial myogenesis stimulate the synthesis of laminin-α1 chains in both cell types. Ibid. Laminin-1 (a major component of the basement membrane) is then produced and polymerized at the epithelial-mesenchymal junction. The adjacent mesenchymal cells utilize this polymer for diffusion and elongation (leading to smooth muscle differentiation), further stimulating myogenesis. Ibid.

[0004] lung cancer Lung cancer is generally believed to originate in precancerous lesions in the bronchial endothelial cells and other parts of the lung (such as bronchioles or alveoli), initially affecting the DNA of these cells. Subsequently, abnormal cells can acquire other genetic alterations, which allow them to develop into true cancer. As the tumor develops, cancer cells can produce angiogenic factors that cause new blood vessels to form nearby (providing nutrients to the cancer cells), allowing the cancer cells to continue growing and form a tumor that can be seen on imaging examinations such as X-rays.

[0005] To some extent, cancer cells can detach from their original cells and spread (metastasize) to other parts of the body. Lung cancer is a life-threatening disease because it may have already spread in this way before imaging tests such as X-rays detect it.

[0006] Types of lung cancer The two main types of lung cancer are: (1) small cell lung cancer (SCLC) and (2) non-small cell lung cancer (NSCLC).

[0007] Small cell lung cancer Of all lung cancers, approximately 10-15% are small cell lung cancers (SCLC), named for the size of the cancer cells as observed under a microscope. Other names for SCLC include oat cell tumor, oat cell carcinoma, and small cell undifferentiated carcinoma.

[0008] SCLC typically begins in the bronchi near the center of the chest. It is a highly aggressive neuroendocrine subtype of lung cancer characterized by high rates of distant metastasis and poor prognosis. Zhang, Y and He, J, J. Thoracic Dis. 5(4): 538-548 (2013).

[0009] Non-small cell lung cancer Approximately 85%-90% of lung cancers are non-small cell lung cancer (NSCLC). There are three main subtypes of NSCLC: (1) adenocarcinoma, (2) squamous cell carcinoma, and (3) large cell carcinoma. Although the cells in these subtypes differ in size, shape, and chemical composition, they are grouped together because the treatment strategies and prognoses (prospects) are similar.

[0010] Other types of lung cancer Other tumors that develop in the lungs include, for example, lung carcinoids, adenocystic carcinomas, hamartomas, lymphomas, and sarcomas, as well as cancers that have spread to the lungs (i.e., metastases).

[0011] Lung carcinoids account for less than 5% of lung tumors. Most slow-growing tumors are called typical carcinoids. They are generally curable with surgery. Some typical carcinoids can spread, but they usually have a better prognosis than small cell lung cancer or non-small cell lung cancer. Atypical carcinoids are less common. The prognosis of these tumors sometimes falls between that of typical carcinoids and small cell lung cancer.

[0012] Other types of lung tumors, such as adenocystic carcinoma, hamartoma, lymphoma, and sarcoma, are rare and have different treatment modalities than common lung cancer.

[0013] Primary tumors in other organs (such as the breast, pancreas, kidneys, or skin) can sometimes spread (metastasize) to the lungs, but these are not lung cancer. For example, cancer that begins in the breast and spreads to the lungs is still breast cancer, not lung cancer. Treatment for metastatic cancer that has spread to the lungs needs to be based on the location of the primary cancer.

[0014] Risk factors for lung cancer Smoking is clearly the leading risk factor for lung cancer. At least 80% of lung cancer deaths are believed to be caused by smoking. Other risk factors include, for example: exposure to radon, asbestos, radioactive minerals such as uranium, inhaled chemicals or minerals such as arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, talc and talcum powder, and chloromethyl ether, air pollution, radiation therapy to the lungs, a personal or family history of lung cancer, and certain food additives.

[0015] Lung cancer detection Symptoms of lung cancer often don't appear until the disease has progressed to an advanced, untreatable stage. Even when symptoms do appear, they are often mistaken for other problems, such as infections or the long-term effects of smoking, thus delaying diagnosis.

[0016] Some lung cancers are diagnosed incidentally during examinations for other conditions. For example, lung cancer can be discovered in patients with heart disease, pneumonia, or other lung conditions during imaging examinations (such as chest X-rays or chest CT scans), bronchoscopy (using a flexible light tube to examine the inside of the lung airways), or sputum examination (microscopic examination of cells in coughed-up sputum).

[0017] Common signs and symptoms of lung cancer The most common symptoms of lung cancer include, for example: persistent or worsening cough, chest pain that worsens with deep breathing, coughing or laughing, hoarseness, weight loss and loss of appetite, coughing up blood or rusty sputum (saliva or phlegm), shortness of breath, fatigue or weakness, persistent or recurrent infections such as bronchitis and pneumonia, and new-onset wheezing.

[0018] When lung cancer spreads to distant organs, it can cause symptoms such as bone pain (back or hip pain), neurological changes (such as headaches, weakness or numbness in the arms or legs, dizziness, balance problems, or seizures), jaundice (yellowing of the skin and eyes), and lumps near the body surface, as the tumor spreads to the skin, cervical or supraclavicular lymph nodes (collections of immune system cells).

[0019] American Cancer Society Lung Cancer Screening Guidelines The American Cancer Society thoroughly reviewed lung cancer screening results and issued the following guidelines for physicians and other healthcare providers: Patients should be asked about their smoking history. Individuals meeting all of the following criteria are likely candidates for lung cancer screening: (1) age 55–74 years; (2) in relatively good health; (3) a history of smoking with a smoking index of more than 30 pack-years, and currently smoking or having quit within the last 15 years.

[0020] Imaging examination Chest X-ray examination Chest X-rays are typically the first examination performed to detect any lumps or spots in the lungs. They can be taken at imaging centers, hospitals, and doctors' offices.

[0021] Computed tomography (CT) scan CT (or CAT) scans (which are more likely to show lung tumors than a routine chest X-ray) can also provide accurate information about the size, shape, and location of any lung tumor and help detect enlarged lymph nodes caused by tumors that have spread from the lungs. This examination is also used to detect mass-like lesions that have metastasized from lung cancer to the adrenal glands, liver, brain, and other internal organs.

[0022] A CT scan is an examination that uses X-rays to create detailed cross-sectional images of the body. The CT scanner rotates around the subject while they lie flat on a table, acquiring numerous images. These images are then combined by a computer to create slice images of the parts of the body being examined. Unlike conventional X-ray examinations, CT scans produce detailed images of all the soft tissues in the body. Before a CT scan, contrast agents may be inhaled or injected to help better visualize the structures of the entire body.

[0023] Magnetic resonance imaging (MRI) scan MRI scans are most commonly used to detect the spread of lung cancer to the brain or spinal cord.

[0024] Like CT scans, MRI scans (which use radio waves and strong magnets instead of X-rays) produce detailed images of the entire body's soft tissues. Energy from the radio waves is absorbed and released in specific patterns depending on the type of tissue and disease. A computer then transforms these patterns into highly detailed whole-body images. Before the scan, a contrast agent (gadolinium) is typically injected intravenously to better visualize the details.

[0025] Positron emission tomography (PET) scan For PET scan imaging, fluorodeoxyglucose or FDG is injected into the bloodstream. Because cancer cells in the body grow rapidly, they absorb more radioactive FDG. The PET scanner displays an image of the radioactive areas throughout the body. While it doesn't provide the fine detail of a CT or MRI scan, it offers valuable information about your entire body.

[0026] Bone scan Bone scans can be used to show whether cancer has spread to the bones.

[0027] For this examination, a small amount of low-level radioactive material is injected intravenously (IV). This material settles over several hours in areas of bone change throughout the skeleton. A special camera detects this radioactivity and produces an image of the skeleton. Areas of active bone change absorb more radioactivity and appear as "hot spots." These areas suggest metastatic cancer, but arthritis or other bone diseases can also cause the same result. To differentiate between these conditions, other imaging techniques such as plain X-rays or MRI scans, or obtaining a bone biopsy sample, can be used.

[0028] Diagnostic examination Symptoms and specific test results can strongly suggest that someone has lung cancer, but the definitive diagnosis of non-small cell lung cancer requires examination of lung cells under a microscope.

[0029] Cells can be found in upper respiratory tract secretions (saliva or sputum), suspicious lesions (called a biopsy), or exudate removed from around the lungs (thoracentesis). The choice of which test(s) to use depends on the specific circumstances.

[0030] Sputum cytology Sputum (mucus coughed up from the lungs) samples are examined under a microscope to check for cancer cells. The best way to perform this test is to collect sputum samples in the morning for three consecutive days. This test is more likely to detect cancers originating in the main airways of the lungs, such as most squamous cell lung cancers. It may not be as useful for detecting other types of non-small cell lung cancer.

[0031] Needle aspiration biopsy Doctors typically use a hollow needle to obtain a small sample from a suspicious area (clump). In a fine-needle aspiration (FNA) biopsy, the doctor uses a syringe with a very fine hollow needle (finer than the needle used for blood tests) to aspirate (absorb) cells and small tissue fragments. In a core biopsy, a larger needle is used to cut one or more small columns (cores) of tissue. Core biopsies provide a larger volume of tissue than FNA biopsies.

[0032] Although needle aspiration biopsies do not require surgical incision, in some cases they may not provide enough sample for diagnosis and classification of DNA changes in cancer cells (which helps in the selection of anticancer drugs).

[0033] If the suspected tumor is peripheral to the lung, any type of biopsy needle can be inserted through the skin over the chest wall. This is called a percutaneous fine-needle aspiration biopsy. The insertion site can be locally anesthetized with anesthetic. The doctor then guides the needle into the suspected tumor while viewing the lung using fluoroscopy (images displayed on a screen, not film) or a CT scan. Unlike fluoroscopy, CT does not provide a constant image, so the needle is inserted towards the tumor and CT images are captured. The direction of the needle is guided by this image, and this process is repeated several times until the needle is located within the tumor.

[0034] A possible complication of this procedure is that leaked air from the lungs may enter the space between the lung and chest wall at the biopsy needle insertion site, causing partial lung collapse and difficulty breathing. This complication (called pneumothorax) usually resolves on its own without any treatment. If it does not improve, a thoracentesis can be performed for one or two days to suction the air from the chest cavity, after which it usually heals on its own.

[0035] FNA biopsy can also be used to examine interpulmonary lymph nodes for cancer. Transtracheal or transbronchial FNA is performed by inserting a thin needle through the walls of the trachea (the airway from the larynx to the lungs) or bronchi (the large airways leading to the lungs) during bronchoscopy or endobronchial ultrasound. In some cases, FNA biopsy is performed by inserting a thin needle through the esophageal wall during esophageal endoscopic ultrasound.

[0036] Bronchoscopy Bronchoscopy can help detect tumors or obstructions in the larger airways of the lungs.

[0037] For this examination, a flexible fiber optic tube (called a bronchoscope) is inserted through the mouth or nose and lowered into the trachea and bronchi. Small instruments can be used to pass the bronchoscope down to obtain biopsy specimens (tissue specimens). The physician can also use a small brush to sample cells from the inner lining of the airway (bronchial brushing) or by flushing the airway with sterile saline (bronchial lavage). These tissue and cell specimens are then examined under a microscope.

[0038] Intrabronchial ultrasound examination An ultrasound examination is an examination that uses sound waves to create images of the body's internal structures. For this examination, small microphone-like instruments (called transducers) emit sound waves and capture the echoes reflected from body tissues. These echoes are then converted into a black-and-white image on a computer screen.

[0039] For endobronchial ultrasound, the bronchoscope is fitted with an ultrasound transducer at its tip and transmitted downwards into the trachea. This examination is performed under local anesthesia and mild sedation.

[0040] The transducer can be pointed in different directions to observe structures in the lymph nodes and mediastinum (the region between the lungs). If suspicious areas, such as enlarged lymph nodes, are seen on ultrasound, a hollow needle can be used to locate these areas under the guidance of a bronchoscope to obtain a biopsy specimen. The specimen is then sent to the laboratory for microscopic examination.

[0041] Esophageal endoscopic ultrasound examination This examination is similar to endobronchial ultrasound, except that an endoscope (a flexible, light-illuminating microscope) is inserted down the larynx and into the esophagus (the tube connecting the pharynx and stomach). It is performed under local anesthesia and mild sedation.

[0042] The esophagus is located just behind the trachea and near some intrathoracic lymph nodes from which lung cancer may have spread. Similar to intrabronchial ultrasound, the transducer can be pointed in different directions to observe potentially cancerous lymph nodes and other structures within the chest. If enlarged lymph nodes are seen on ultrasound, a hollow needle can be inserted through the endoscope to aspirate a biopsy specimen. The specimen is then sent to the laboratory for microscopic examination.

[0043] Mediastinoscopy and mediastinotomy These examinations and procedures allow for more direct observation of the structures in the mediastinum (the region between the lungs) and the collection of specimens from them.

[0044] Mediastinoscopy is performed by making a small incision in the anterior neck and inserting a thin, hollow light tube behind the sternum and in front of the trachea to examine the area. Instruments can be used to collect lymph node tissue samples along the trachea and main bronchus through this tube. The samples are then examined under a microscope for the presence of cancer cells.

[0045] Mediastinotomy involves making a large incision (usually about 2 inches long) between the second and third ribs on the left side, close to the sternum. This allows the surgeon to visualize some lymph nodes that cannot be reached by mediastinoscopy.

[0046] Thoracentesis If fluid accumulates around the lungs (pleural effusion), doctors can use a thoracentesis to determine if it is caused by cancer spreading to the outer membrane of the lungs (pleura). Pleural effusion can also be caused by other conditions, such as heart failure or infection.

[0047] In this procedure, local anesthesia is administered first, and then a hollow needle is inserted between the ribs to drain the effusion. (In a similar procedure called pericardiocentesis, the effusion is drained from vesicles surrounding the heart.) The fluid is examined under a microscope for cancer cells. Chemical analysis of the fluid can sometimes be used to differentiate between malignant (cancerous) and benign (non-cancerous) pleural effusions.

[0048] If malignant pleural effusion is diagnosed, thoracentesis can be repeated to drain more fluid. Accumulated fluid can prevent the lungs from filling with air, so thoracentesis can help the patient breathe better.

[0049] Thoracoscopic examination Thoracoscopic examination can determine if cancer has spread to the space between the lung and the chest wall or its inner lining. It can also be used to sample tumors in the lateral portions of the lung, as well as surrounding lymph nodes and fluid, and to assess whether the tumor has grown into adjacent tissues or organs. This examination is often used not only to diagnose lung cancer, but also unless other examinations, such as fine-needle aspiration biopsy, cannot collect sufficient specimens for diagnosis.

[0050] Thoracoscopic examination is performed through a small incision (sometimes more than one) made in the side of the chest wall. A thin light tube with a small camera at the end is inserted through the incision to examine the space between the lung and the chest wall. Using this method, doctors can see potential masses on the inner lining of the lung or chest wall and take small pieces of tissue for microscopic examination. (When certain areas cannot be reached by thoracoscopy, surgeons may need to make a larger incision in the chest wall, a procedure called thoracotomy.) Thoracoscopic examination can also be used as part of treatment in some early-stage lung cancers by removing a small portion of the lung.

[0051] Immunohistochemical examination In this examination, very thin sections of the specimen are attached to a microscope slide. They are then treated with special proteins (antibodies) designed to bind only to specific substances present in cancer cells. If the patient's cancer cells contain this substance, the antibody will attach to the cell. A chemical is then added to cause the antibody attached to the cell to change color.

[0052] Molecular detection Some tests may detect specific gene alterations in cancer cells.

[0053] For example, epidermal growth factor receptor (EGFR) is a protein that is sometimes expressed at high levels on the surface of cancer cells and helps them grow. Some newer anticancer drugs that target EGFR appear to work best for lung cancers with specific EGFR gene alterations that are more common in certain populations, such as nonsmokers, women, and Asians. However, these drugs do not appear to be as effective in patients whose cancer cells have KRAS gene alterations. Many doctors now test for alterations in genes such as EGFR and KRAS to determine whether such treatments are beneficial.

[0054] It has been found that approximately 5% of NSCLC cases exhibit ALK gene rearrangements. This change is most common in non-smokers (or light smokers) with the adenocarcinoma subtype of NSCLC. Doctors can examine the ALK gene alterations in the tumor to determine if drugs targeting this alteration (such as crizotinib) are effective.

[0055] Approximately 1%-2% of NSCLC cases exhibit ROS1 gene rearrangements, which may enable the tumor to respond to the targeted drug crizotinib. RET gene rearrangements have a similar incidence. Targeting certain drugs with RET gene alterations may be another treatment option for these tumors.

[0056] Blood test Blood tests are not used to diagnose lung cancer, but they can help provide an assessment of a patient’s overall health, such as whether they are safe enough to undergo surgery.

[0057] A complete blood count (CBC) determines whether a subject's blood has a normal number of all cell types. For example, it can indicate whether a subject is anemic (low red blood cell count), has a bleeding tendency (low platelet count), or is at high risk of infection (low white blood cell count). Because chemotherapy can affect bone marrow's hematopoietic function, this test needs to be repeated periodically.

[0058] Blood chemistry tests can help monitor abnormal liver or kidney function. For example, if cancer has spread to the liver and bones, it can cause abnormal levels of lactate dehydrogenase (LDH).

[0059] Lung function test Pulmonary function tests (PFT) are typically used after a lung cancer diagnosis to assess lung function (e.g., the presence of emphysema or chronic bronchitis), thus informing surgeons whether surgery is the optimal choice and, if so, how much lung tissue can be safely removed. Determining whether surgery is the best option for treating the tumor is particularly important because lung resection means removing part or all of the lung tissue. Some people with impaired lung function (such as those with lung damage from smoking) do not have sufficient lung reserve to withstand partial lung removal.

[0060] Sometimes, PFT is combined with arterial blood gas analysis, which involves drawing blood from an artery (most blood tests are done from a vein) to measure the amount of oxygen and carbon dioxide in the blood.

[0061] Lung cancer staging There are two types of lung cancer staging: clinical staging and pathological staging. Clinical staging is based on the results of physical examination, biopsy, and imaging examinations (CT scan, chest X-ray, PET scan, etc.). Pathological staging is based on the same factors as clinical staging plus the pathological results after surgery.

[0062] Because many lung cancer patients do not undergo surgery, clinical staging is often used to describe this type of cancer. When available, pathological staging is likely to be more accurate than clinical staging because it incorporates additional information obtained at the time of surgery.

[0063] TNM Installment System The TNM staging system, used to describe the growth and spread of lung cancer, is also the American Joint Committee on Cancer (AJCC) staging system. The TNM system is based on three key information blocks: ■T indicates the size of the primary tumor and whether it has invaded adjacent tissues.

[0064] ■N indicates the spread to adjacent (regional) lymph nodes. Lymph nodes are collections of pea-shaped immune cells, and tumors often spread to lymph nodes before reaching other parts of the body.

[0065] ■M indicates whether the tumor has spread (metastasized) to other organs in the body. (The most common sites are the brain, bones, adrenal glands, liver, kidneys, and the contralateral lung.) Numbers or letters appear after T, N, and M to provide more details about these factors. Numbers 0-4 indicate progressively increasing severity.

[0066] T staging of lung cancer TX: The primary tumor cannot be evaluated, or cancer cells are found in sputum cytology or bronchoalveolar lavage fluid but no visible tumor.

[0067] T0: No evidence of primary tumor.

[0068] Tis: The tumor is found only in the apical cell layer of the inner airway. It has not invaded deeper lung tissue. This is also known as carcinoma in situ.

[0069] T1: The maximum diameter of the tumor is less than 3 cm to slightly less than 1 1 / 4 inches, surrounded by the lung or visceral pleura, and does not involve the main bronchus.

[0070] If the maximum diameter of the tumor is 2 cm (about 4 / 5 inch) or smaller, it is called T1a. If the maximum diameter of the tumor is greater than 2 cm but less than 3 cm, it is called T1b.

[0071] T2: The tumor has one or more of the following characteristics: ■ The maximum diameter is greater than 3cm but less than 7cm.

[0072] ■ The main bronchus is involved, but the distance from the carina (the location that divides the trachea into the left and right main bronchi) is greater than 2 cm (about 3 / 4 inch).

[0073] ■ Involving the visceral pleura.

[0074] ■ The tumor partially obstructs the airway, but does not cause atelectasis or obstructive pneumonia.

[0075] If the maximum diameter of the tumor is 5 cm or less, it is called T2a. If the maximum diameter of the tumor is greater than 5 cm (but less than 7 cm), it is called T2b.

[0076] T3: The tumor has one or more of the following characteristics: ■ Maximum diameter greater than 7cm.

[0077] ■ It has invaded the chest wall, the respiratory muscles separating the chest and abdomen (diaphragm), the membrane surrounding the two lungs (mediastinal pleura), or the capsule surrounding the heart (pericardium).

[0078] ■ It invades the main bronchus and is less than 2 cm (about 3 / 4 inch) from the carina, but does not invade the carina itself. ■ It invades the airways and causes total atelectasis or total obstructive pneumonia.

[0079] ■ Two or more independent tumor nodules exist in the same lobe of the lung.

[0080] T4: The tumor has one or more of the following characteristics: ■ Any tumor, regardless of size, growing in the space between the lungs (mediastinum), the heart, large blood vessels near the heart (such as the aorta), the trachea from the larynx to the lungs (trachea), the tube connecting the pharynx and the stomach (esophagus), the spine, or the carina.

[0081] ■ Two or more independent tumor nodules are present in different lobes of the same lung.

[0082] N-stage of lung cancer NX: Regional lymph nodes cannot be assessed.

[0083] N0: No spread to regional lymph nodes.

[0084] N1: Regional lymph nodes (hilar lymph nodes) that have spread into the lungs and / or into the lungs via the bronchi. The affected lymph nodes are on the same side as the primary tumor.

[0085] N2: The tumor has spread to the lymph nodes around the carina (the site that divides the trachea into the left and right bronchi) or between the lungs (mediastinum). The affected lymph nodes are on the same side as the primary tumor.

[0086] N3: The tumor has spread to the supraclavicular lymph nodes on either side and / or to the hilar or mediastinal lymph nodes on the opposite side.

[0087] M staging of lung cancer M0: No spread to distant organs or regions. This includes the contralateral lung, lymph nodes farther away than those mentioned in the N staging above, and other organs or tissues such as the liver, bone, or brain.

[0088] M1a: Any of the following: ■The tumor has spread to the contralateral lung.

[0089] ■ Cancer cells were found in the pleural effusion (called malignant neoplasm pleural effusion).

[0090] ■ Cancer cells were found in the pericardial effusion (called malignant neoplastic pericardial effusion).

[0091] M1b: The tumor has spread to distant lymph nodes or to other organs such as the liver, bones, or brain.

[0092] Lung cancer staging Once the T, N, and M categories are determined, they are combined to determine the overall stage: 0, I, II, III, or IV. This process is called staging. Some stages are further subdivided into A and B. Staging can identify tumors with similar prognoses and allow for similar treatment. Patients with lower stages tend to have better prognoses.

[0093] Hidden cancer TX, N0, M0: Cancer cells were found in sputum or other fluid accumulations, but no other tests detected cancer, so their location could not be determined.

[0094] 0th period Tis, N0, M0: The tumor is found only in the apical cell layer of the inner airway. It has not invaded other lung tissues or spread to regional lymph nodes or distant tissues.

[0095] Phase IA T1a / T1b, N0, M0: The tumor's maximum diameter is less than 3 cm, and it has not invaded the visceral pleura or the main bronchus. It has not spread to regional lymph nodes or distant tissues.

[0096] IB phase T2a, N0, M0: The tumor has one or more of the following characteristics: ■The maximum diameter of the main tumor is greater than 3cm but less than 5cm.

[0097] ■ The tumor invades the main bronchus, but is at least 2 cm (and no more than 5 cm) away from the carina.

[0098] ■ The tumor invades the visceral pleura and is no larger than 5 cm.

[0099] ■ The tumor partially obstructs the airway (and is no larger than 5 cm).

[0100] The tumor has not spread to regional lymph nodes or distant tissues.

[0101] IIA period This periodization is composed of three main combinations of periodizations.

[0102] T1a / T1b, N1, M0: Tumor maximum diameter not exceeding 3cm, not invading the visceral pleura or main bronchus. Spread to intrapulmonary and / or bronchial lymph nodes (hilar lymph nodes). These lymph nodes are ipsilateral to the primary lesion. No spread to distant tissues.

[0103] or T2a, N1, M0: Tumors exhibit one or more of the following characteristics: ■The maximum diameter of the main tumor is greater than 3cm but not greater than 5cm.

[0104] ■ The tumor has grown into the main bronchus, but is at least 2 cm (and no more than 5 cm) away from the carina.

[0105] ■ The tumor has grown into the visceral pleura and is no larger than 5 cm.

[0106] ■ The tumor partially obstructs the airway (and is no larger than 5 cm).

[0107] The tumor has spread to the lungs and / or the regional lymph nodes (hilar lymph nodes) where the bronchi enter the lungs. These lymph nodes are on the same side as the primary lesion. It has not spread to distant tissues.

[0108] or T2b, N0, M0: Cancer exhibits one or more of the following characteristics: ■The maximum diameter of the main tumor is greater than 5cm but not greater than 7cm.

[0109] ■ The tumor has invaded the main bronchus, but is at least 2 cm away from the carina (and its maximum diameter is between 5 and 7 cm).

[0110] ■ The tumor has invaded the visceral pleura and its maximum diameter is between 5 and 7 cm.

[0111] ■ The tumor partially obstructs the airway (and its maximum diameter is between 5-7 cm).

[0112] The tumor has not spread to regional lymph nodes or distant tissues.

[0113] IIB period This period is formed by the combination of two classifications.

[0114] T2b, N1, M0: The tumor has one or more of the following characteristics: ■The maximum diameter of the main tumor is greater than 5cm but not greater than 7cm.

[0115] ■ The tumor has invaded the main bronchus, but is at least 2 cm away from the carina (and its maximum diameter is between 5 and 7 cm).

[0116] ■ The tumor has invaded the visceral pleura and its maximum diameter is between 5 and 7 cm.

[0117] ■ The tumor partially obstructs the airway (and its maximum diameter is between 5-7 cm).

[0118] It has also spread to the intrapulmonary and / or bronchial lymph nodes (hilar lymph nodes) at the entry points of the bronchi into the lungs. These lymph nodes are on the same side as the primary lesion. It has not spread to distant tissues.

[0119] or T3, N0, M0: The main tumor has one or more of the following characteristics: ■ Maximum diameter greater than 7cm.

[0120] ■ It has invaded the chest wall, the respiratory muscles separating the chest and abdomen (diaphragm), the membrane surrounding the two lungs (mediastinal pleura), or the capsule surrounding the heart (pericardium).

[0121] ■ It invades the main bronchus and is less than 2 cm (about 3 / 4 inch) from the carina, but it does not invade the carina itself.

[0122] ■ It can invade the airways and cause atelectasis or obstructive pneumonia of the whole lungs.

[0123] ■ Two or more independent tumor nodules are present in the same lobe of the lung.

[0124] The cancer has not spread to regional lymph nodes or distant tissues.

[0125] Phase IIIA This periodization is composed of three main categories.

[0126] T1-T3, N2, M0: The primary tumor can be of any size. It has grown into the interpulmonary space (mediastinum), the heart, major blood vessels near the heart (such as the aorta), the trachea from the larynx to the lungs (trachea), the esophagus connecting the pharynx and stomach, the spine, or the carina. It has spread to different lobes of the same lung.

[0127] The tumor has spread to the lymph nodes around the carina (the site that divides the trachea into the left and right bronchi) or in the interpulmonary spaces (mediastinum). These lymph nodes are on the same side as the main lung tumor. The tumor has not spread to distant tissues.

[0128] or T3, N1, M0: The tumor has one or more of the following characteristics: ■ Maximum diameter greater than 7cm.

[0129] ■ It has invaded the chest wall, the respiratory muscles separating the chest and abdomen (diaphragm), the membrane surrounding the two lungs (mediastinal pleura), or the capsule surrounding the heart (pericardium).

[0130] ■ It invades the main bronchus and is less than 2 cm (about 3 / 4 inch) from the carina, but it does not invade the carina itself.

[0131] ■ Two or more independent tumor nodules are present in the same lobe of the lung.

[0132] ■ It can invade the airways and cause atelectasis or obstructive pneumonia of the whole lungs.

[0133] It has also spread to the intrapulmonary and / or bronchial lymph nodes (hilar lymph nodes) at the entry points of the bronchi into the lungs. These lymph nodes are on the same side as the primary lesion. It has not spread to distant tissues.

[0134] or T4, N0 or N1, M0: Cancer exhibits one or more of the following characteristics: ■ Any tumor of any size that has grown into the space between the lungs (mediastinum), the heart, large blood vessels near the heart (such as the aorta), the trachea from the larynx to the lungs (trachea), the tube connecting the pharynx and the stomach (esophagus), the spine, or the carina.

[0135] ■ Two or more independent tumor nodules are present in different lobes of the same lung.

[0136] It may or may not have spread to the intrapulmonary and / or bronchial lymph nodes (hilar lymph nodes). The affected lymph nodes are on the same side as the cancer. It has not spread to distant tissues.

[0137] Phase IIIB This period is formed by the combination of two classifications.

[0138] Any T, N3, M0: The tumor can be of any size. It may or may not invade adjacent structures or cause pneumonia or lung growth. It has spread to the supraclavicular lymph nodes on either side and / or to the hilar or mediastinal lymph nodes on the opposite side of the primary tumor. The tumor has not spread to distant tissues.

[0139] or T4, N2, M0: The tumor has one or more of the following characteristics: ■ Any tumor of any size that has grown into the space between the lungs (mediastinum), the heart, large blood vessels near the heart (such as the aorta), the trachea from the larynx to the lungs (trachea), the tube connecting the pharynx and the stomach (esophagus), the spine, or the carina.

[0140] ■ Two or more independent tumor nodules are present in different lobes of the same lung.

[0141] The tumor has spread to the lymph nodes around the carina (the site that divides the trachea into the left and right bronchi) or in the interpulmonary spaces (mediastinum). The affected lymph nodes are on the same side as the primary tumor. It has not spread to distant tissues.

[0142] Phase IV This period is formed by the combination of two classifications.

[0143] Any T, any N, M1a: The tumor can be of any size and may or may not invade adjacent tissues or regional lymph nodes. Additionally, any of the following conditions must be present: ■ It spread to the contralateral lung.

[0144] ■ Cancer cells were found in the pleural effusion (called malignant neoplasm pleural effusion).

[0145] ■ Cancer cells were found in the pericardial effusion (called malignant neoplastic pericardial effusion).

[0146] or Any T, any N, M1b: The tumor can be of any size and may or may not have invaded adjacent tissues or regional lymph nodes. It may have spread to distant lymph nodes or to other organs such as the liver, bones, or brain.

[0147] Treatment of lung cancer Treatment options for patients with lung cancer include surgery, radiation therapy, local treatment, chemotherapy, and targeted therapy.

[0148] Operation Surgical removal of the tumor (usually along with other treatments) can be an option for early-stage lung cancer. Types of lung surgery include, for example, pulmonary resection (removal of the entire lung), lobectomy (removal of an entire segment (lobe) of the lung), and segmentectomy or wedge resection (removal of a portion of a lobe).

[0149] radiotherapy Radiation therapy uses high-energy rays (such as X-rays) or microparticles to kill cancer cells. There are two types of radiation therapy – external beam radiation therapy and brachytherapy (internal beam radiation therapy).

[0150] External radiation therapy External beam radiation therapy (EBRT) focuses radiation from outside the body onto the tumor. It is the most common type of radiation therapy used to treat primary lung cancer or cancer that has spread to other organs.

[0151] This treatment is similar to an X-ray examination, but with a stronger radiation dose. The procedure itself is painless. Each treatment session lasts only a few minutes. Typically, radiation therapy for the lungs is performed 5 days a week for 5-7 weeks, but this can vary.

[0152] Standard (conventional) EBRT is used far less frequently than in the past. Newer technologies help doctors treat lung cancer more accurately while reducing radiation exposure to adjacent healthy tissues. These technologies can offer higher success rates and fewer side effects.

[0153] Three-dimensional conformal radiotherapy (3D-CRT): 3D-CRT uses a special computer to precisely locate the tumor. The radiation beam is shaped and directed at the tumor from multiple directions, making it less likely to damage normal tissue.

[0154] Intensity-Modulated Radiation Therapy (IMRT): IMRT is an advanced form of 3D radiotherapy. It uses a computer-driven instrument that moves around the patient while releasing radiation. The intensity (strength) of the radiation beam can be adjusted to limit the dose to the most sensitive normal tissues while shaping and directing the radiation beam towards the tumor from multiple directions. This technique is most commonly used if the tumor is close to vital structures such as the spinal cord. Many large hospitals and cancer centers now use IMRT.

[0155] Stereotactic body radiation therapy (SBRT): When surgery is not the optimal treatment option for a patient due to health concerns or in patients who do not wish to undergo surgery, SBRT, also known as stereotactic ablation radiation therapy (SABR), is sometimes used to treat very early-stage lung cancer. Instead of administering small doses of radiation daily over several weeks, SBRT delivers a very concentrated high dose of radiation in fewer treatment sessions (usually 1-5 sessions). Several beams of radiation are directed at the tumor from different angles. To ensure precise targeting, the patient is placed within a specially designed body frame during each treatment. This reduces movement of the lung tumor during breathing. Like other forms of external radiation, the treatment itself is painless.

[0156] SBRT has shown promising early results in the treatment of smaller lung cancers and appears to have a lower risk of complications. This method is also used for tumors that have spread to other parts of the body, such as bone or liver.

[0157] Stereotactic radiosurgery (SRS): SRS is a treatment that delivers stereotactic radiation over a specific session. Sometimes it can be used in place of surgery or in conjunction with surgery for single tumors that have spread to the brain. In this treatment, an instrument called the Gamma Knife® focuses approximately 200 beams of radiation from different angles onto the tumor for several minutes to several hours. The head is held in a fixed, consistent position by being placed within a rigid frame. In another form, a computer-controlled linear accelerator (the instrument that generates the radiation) moves around the head to deliver radiation to the tumor from many different angles. These treatments can be repeated if needed.

[0158] Brachytherapy (internal radiation therapy) Brachytherapy is sometimes used to shrink tumors in the airways to relieve symptoms in people with lung cancer, but it is not commonly used in lung cancer compared to other cancers such as head and neck cancer.

[0159] For this type of treatment, a small source of radioactive material (usually in the form of small particles) is placed directly into the tumor or in the airway near the tumor. The treatment is performed via bronchoscopy, but it can also be done during surgery. The radiation travels only a short distance from the source, thus limiting its impact on surrounding normal tissue. Less commonly, the small radioactive "seed" remains permanently in place, and the radiation weakens over several weeks.

[0160] Local treatment Radiofrequency ablation (RFA) This technique may be an option for some small lung tumors located near the outer edge of the lung, especially in patients who cannot or do not wish to undergo surgery. It uses high-energy radio waves to heat the tumor. A thin, needle-like probe is placed through the skin and moved forward until its tip is inside the tumor. The placement of the probe is guided by a CT scan. Once in place, an electric current is passed through the probe, which heats the tumor and destroys cancer cells.

[0161] Photodynamic therapy (PDT) Photodynamic therapy is sometimes used to treat very early-stage lung cancer confined to the outer layer of the lung airways when other treatments are not appropriate. It can also be used to help dilate airways obstructed by tumors, thereby helping patients breathe better.

[0162] For this technique, a photoactivated drug (Photofrin®) is injected intravenously. This drug is more likely to accumulate in cancer cells compared to normal cells. Several days later, a bronchoscope is inserted down the throat into the lungs. This procedure is performed under local and sedation or general anesthesia. A special laser at the tip of the bronchoscope is directed at the tumor, and the activating drug causes cell death. The dead cells are clamped out during bronchoscopy several days later. This treatment can be repeated if necessary.

[0163] Laser treatment Lasers can sometimes be used to treat very small lung cancers in the lining of the airway. They can also be used to dilate airways obstructed by larger tumors. The laser is placed at the end of a bronchoscope, which is passed down the throat and close to the tumor. The doctor then directs the laser beam at the tumor to burn it off. This treatment can be repeated if necessary.

[0164] bracket placement Lung tumors that grow into the airway can sometimes cause breathing or other problems. To help keep the airway open (usually after other treatments such as PDT or laser therapy), rigid silicone or metal tubes (called stents) can be placed in the airway via a bronchoscope.

[0165] Chemotherapy The most frequently used chemotherapy drugs for lung cancer are: ■cisplatin ■Carboplat ■Taxol® ■ Albumin-bound paclitaxel (nab-paclitaxel, Abraxane®) ■Taxotere® ■ Gemzathabine (Gemzar®) ■ Changchun Navelbine® ■ Irinotecan (Camptosar®) ■ Etoposide (VP-16®) ■ Vincryptine ■ Pemetrexed (Alimta®) Most commonly, lung cancer is treated with a combination of two chemotherapy drugs.

[0166] If combination chemotherapy is used, it typically includes cisplatin or carboplatin plus another drug. Sometimes combinations that do not include these drugs can be used, such as gemcitabine with vinorelbine or paclitaxel.

[0167] For individuals with advanced lung cancer who meet specific criteria, targeted therapies such as bevacizumab (Avastin®) or cetuximab (Erbitux®) can also be added to the treatment regimen. For advanced cancer, initial combination chemotherapy is typically administered for 4–6 cycles.

[0168] If initial treatment for advanced lung cancer is no longer effective, second-line therapy may be recommended. This therapy may include, for example, single-agent treatments such as taxane or pemetrexed.

[0169] Targeted therapy Drugs targeting tumor angiogenesis (angiogenesis) For tumors to grow, they must form new blood vessels to maintain their nutrient supply. Some targeted drugs block this new blood vessel growth (angiogenesis).

[0170] Bevacizumab (Avastin®): Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF). It has been shown to prolong survival in patients with advanced non-small cell lung cancer (NSCLC) when added to standard chemotherapy regimens as first-line treatment. Bevacizumab is administered via intravenous infusion every 2–3 weeks.

[0171] Drugs targeting EGFR Epidermal growth factor receptor (EGFR) is a protein found on the cell surface that helps with cell growth and division. Some NSCLC cells have an excess of EGFR, causing them to grow faster.

[0172] Erlotinib (Tarceva®): Erlotinib is a drug that blocks EGFR transmission of signals that promote cell growth. It has been shown to help control some lung cancers, particularly in women or non-smokers. It is used alone, primarily for advanced NSCLC, if initial therapy is no longer effective. It can also be used as first-line treatment in patients whose cancer has a mutation in the EGFR gene.

[0173] Cetuximab (Erbitux®): Cetuximab is a monoclonal antibody that targets EGFR. For patients with advanced NSCLC, some physicians may add it to standard chemotherapy as part of first-line treatment. Cetuximab is administered via intravenous infusion, usually once a week.

[0174] Afatinib (Gilotrif) TM Like erlotinib, afatinib blocks EGFR-indicating signals that guide cell growth. It was recently approved as a first-line treatment (without chemotherapy) for advanced NSCLC with a specific mutation in the EGFR gene.

[0175] Drugs targeting the ALK gene Approximately 5% of NSCLC cases show ALK gene rearrangement. This alteration is more common in non-smokers (or light smokers) with the adenocarcinoma subtype of NSCLC. ALK gene rearrangement produces the ALK protein, which leads to abnormal cell growth and spread.

[0176] Crizotinib (Xalkori®) (a drug that blocks the abnormal ALK protein) has been shown to shrink tumors in more than half of lung cancer patients with ALK gene alterations, even in patients who have already received chemotherapy. It is the first-line recommended treatment (alternative to chemotherapy) in patients with ALK gene rearrangements.

[0177] Although these are all treatment options, the median survival for SCLC patients with localized disease (LD) is 16–24 months, while that for patients with extensive disease (ED) is 7–12 months. Zhang, Y and He, J, J. Thoracic Dis. 5(4): 538–548 (2013). The median survival for NSCLC subjects who underwent video-assisted thoracotomy (VATS) lobectomy was reported to be 49.0 months in patients with only N2 metastases. Wang, S et al., Ann. Thorac. Med. 8(3): 170–175 (2013). The presence of distant metastases throughout the body significantly impacts survival outcomes, even after adjusting for other important variables in advanced non-squamous NSCLC. Lee DS et al., Cancer Res. Treat. 45(2): 95–102 (2013). Therefore, other adjuvant therapies are necessary to treat NSCLC and SCLC patients and prolong their survival.

[0178] osteosarcoma Osteosarcoma, the most common primary malignant tumor of bone, infiltrates and destroys the cortex of bone and extends into the surrounding soft tissues. Without treatment, they often progress locally or metastasize to distant sites. Prior to systemic chemotherapy, >90% of patients with osteosarcoma die from lung metastases (see Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii 320-325).

[0179] Osteosarcoma primarily occurs in the metaphysis of long bones, such as the distal femur, proximal tibia, and proximal humerus, between the ages of 10 and 20, and can have any of the following characteristics: (i) primary / local (i.e., originating from / limited to bone); (ii) metastatic (i.e., spreading from primary osteosarcoma to other organs or tissues); or (iii) recurrent / relapsed (i.e., recurrence of osteosarcoma after treatment and for a period of time after which osteosarcoma is undetectable).

[0180] The incidence of osteosarcoma in the general population is 2–3 per million per year, but it is higher in adolescents, with an annual incidence of 8–11 per million per year in those aged 15–19. Osteosarcoma accounts for 15% of all extracranial solid tumors in this age group, and the incidence is 1.4 times higher in males than in females (see Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii 320–325).

[0181] In children and young adults, osteosarcoma typically occurs in areas of rapidly growing bone, such as near the ends of long bones. Most tumors occur in the bones around the knee, in the distal femur or proximal tibia. However, osteosarcoma can occur in any bone, including the pelvis, shoulder, and jaw. This is especially true in older adults. The incidence of osteosarcoma is increased in several well-defined genetic disorders associated with germline alterations in tumor suppressor genes, such as hereditary retinoblastoma and Lifflaumin tumor family syndrome.

[0182] bone Generally speaking, bones can be divided into two types: loose, spongy or cavernous bone, and cortical, compact or dense bone.

[0183] Cortical bone, also known as compact bone or dense bone, is the hard outer layer of bone tissue, named for its minimal gaps and spaces. This tissue gives bone its smooth, white, and solid appearance. Cortical bone consists of Haver sites (cannulas through which blood vessels and connective tissue penetrate the bone) and osteoids (the basic units of cortical bone containing Haver cannulas and their concentrically arranged bone plates), ensuring that bone is surrounded by blood supply. Cortical bone has a porosity of approximately 5%–30% and constitutes about 80% of the total bone mass in the adult skeleton.

[0184] Cancellous bone (trabecular or spongy bone) Cancellous bone tissue (also known as lobulitic or spongy bone, an open, chamber-like porous network) fills the interior of bone and consists of rod- and plate-like structures that make the overall structure relatively light and provide space for blood vessels and bone marrow, thus allowing blood supply to surround the bone. Cancellous bone accounts for the remaining 20% ​​of total bone mass but has nearly ten times the surface area of ​​cortical bone. It does not contain Haver sites or osteoids and has a porosity of approximately 30%–90%.

[0185] The head of a bone, called the epiphysis, has a spongy appearance and is composed of elongated, irregular trabeculae or cords (which anastomose to form a lattice structure). Its spaces contain bone marrow, while the thin outer shell is dense. The irregular medullary spaces of the epiphysis become continuous with the central medullary cavity of the diaphysis (called the bone body), whose walls are formed by thin plates of cortical bone.

[0186] Cancellous bone and cortical bone share the same cell types and intercellular material, but they differ in the arrangement of their components and the ratio of medullary space to bone material. In cancellous bone, the medullary space is relatively large and irregularly arranged, and the bone material is in the form of elongated anastomotic trabeculae and pointed apex bones. In cortical bone, the spaces or channels are narrow and densely packed with bone.

[0187] In rare cases, both cortical and cancellous bone are present in every bone, but the amount and distribution of each type vary significantly. The diaphysis of long bones is primarily composed of cortical tissue; only the innermost layer directly surrounding the medullary cavity is cancellous bone. The flat bones of the skull consist of plates of two cortical bones bridging the medullary space, connected by irregular strips of cancellous bone. The epiphysis of long bones and most short bones consist of cancellous bone covered by a thin outer layer of cortical bone.

[0188] Each bone (except at its joint ends) is surrounded by an outer layer of vascular elastic fibers (periosteum). The so-called endosteum, or the inner periosteum of the medullary cavity or medullary space, is not a well-defined layer; it is composed of variable-component medullary reticular connective tissue (which contains osteoprogenitor cells in direct contact with bone tissue).

[0189] Bone components Bone is composed of bone cells, organic matter, inorganic substances, and intercellular matrix.

[0190] The organic components of bone consist of collagen, glycosaminoglycans, proteoglycans, and glycoproteins. The protein matrix of bone is mainly composed of collagen (a family of fibrous proteins capable of forming insoluble and rigid fibers). The main type of collagen in bone is type I collagen.

[0191] The inorganic components of bone (which constitute the rigid structure of bone and make up up to two-thirds of its fat-free dry weight) are primarily composed of calcium phosphate and calcium carbonate (in the form of hydroxyapatite), with small amounts of magnesium hydroxide, fluoride, and sulfate. The composition varies with age and various dietary factors. Bone minerals form long, fine crystals that increase the strength and rigidity of collagen fibers; the process of bone mineral deposition is called mineralization.

[0192] bone cells Four cell types are involved in the formation and maintenance of bone. They are 1) osteoprogenitor cells, 2) osteoblasts, 3) osteocytes, and 4) osteoclasts.

[0193] osteoprogenitor cells Osteoprogenitor cells originate from mesenchymal cells and are found within the periosteum and the endosteum of mature bone. They are discovered in the embryonic mesenchymal compartments where bone begins to form and in regions near the surface of growing bone. Structurally, osteoprogenitor cells differ from the mesenchymal cells that produce them. They are irregularly shaped, elongated cells with lightly stained cytoplasm and lightly stained nuclei. Osteoprogenitor cells (which proliferate through mitosis) are primarily identified by their relevance to osteoblasts through their location. Some osteoprogenitor cells differentiate into osteocytes. Although osteoblasts and osteocytes are no longer mitotic, osteoprogenitor cells have been shown to continuously undergo mitosis throughout their lives.

[0194] osteoblasts Osteoblasts, located on the surface of sutures (narrow regions on the surface of newly formed organic matrix bone that are not yet mineralized), originate from osteoprogenitor cells. They are immature, mononuclear osteoblasts that synthesize collagen and regulate mineralization. Osteoblasts can be morphologically distinguished from osteoprogenitor cells; generally, they are larger and have a more rounded nucleus, a more prominent nucleolus, and much more basophilic cytoplasm. Osteoblasts form a protein mixture called osteoid (which is mainly composed of type I collagen), which mineralizes to become bone. Osteoblasts also produce hormones such as prostaglandins, alkaline phosphatase (an enzyme that plays a role in bone mineralization), and matrix proteins.

[0195] bone cells Osteocytes (derived from osteoblasts, astral mature osteocytes, and the most abundant cells found in compact bone) maintain the structure of bone. Osteocytes, like osteoblasts, cannot undergo mitosis. They actively participate in bone matrix transformation and reside in small spaces, cavities, gaps, or depressions called lacunas. Osteocytes maintain the bone matrix, regulate calcium homeostasis, and are considered part of the cellular feedback mechanism that directs bone formation where it is most needed. Bone becomes stronger to withstand applied forces; osteocytes can contribute to bone formation through mechanical deformation and by mediating bone formation through osteoblasts.

[0196] osteoclasts Osteoclasts, derived from monocyte stem cell lineages and possessing macrophage-like phagocytic mechanisms, are typically found in bone depressions called Hauschka's lacunae. They are large, multinucleated cells involved in bone resorption. During resorption, osteoclasts seal off areas of the bone surface; then, upon activation, they release hydrogen ions to create a highly acidic environment that dissolves hydroxyapatite components. The number and activity of osteoclasts increase during calcium resorption upon stimulation with parathyroid hormone (PTH), while osteoclast activity is inhibited by injection of calcitonin (a hormone produced by parafollicular cells of the thyroid gland).

[0197] Bone matrix The bone matrix accounts for approximately 90% of the total weight of compact bone and is composed of microcrystalline calcium phosphate (60%), which is similar to hydroxyapatite, and fibrous type I collagen (27%). The remaining 3% consists of fewer types of collagen and other proteins (including osteocalcin, osteonectin, osteopontin, and osteosialin), as well as proteoglycans, glycosaminoglycans, and lipids.

[0198] The bone matrix is ​​also a major source of biological information that bone cells can receive and act upon. For example, extracellular matrix glycoproteins and proteoglycans in bone bind to a variety of growth factors and cytokines, acting as a reservoir of signals for osteoblasts and osteoclasts. Growth factors and cytokines present in the bone matrix include, but are not limited to, bone morphogenesis protein (BMP), epidermal growth factor (EGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), insulin-like growth factor-1 (IGF-1), transforming growth factor (TGF), bone-derived growth factor (BDGF), cartilage-derived growth factor (CDGF), bone growth factor (hSGF), interleukin-1 (IL-1), and macrophage-derived factor.

[0199] A recent understanding is that extracellular matrix molecules themselves can play a regulatory role, thereby providing direct biological effects on cells as well as important spatial and environmental information.

[0200] Periosteum and Endosteum The periosteum is a fibrous connective tissue lining of bone, except at the articular surfaces. Its adhesion to bone varies with location and age. In the bones of young people, the periosteum is easily detached. In the bones of adults, it adheres more firmly, especially at the insertion points of tendons and ligaments, where more periosteal fibers penetrate into the bone as perforating fibers (tufts of collagen fibers entering the peripheral bone plates). The periosteum consists of two layers: the outer layer is composed of coarse fibrous connective tissue containing fewer cells but more blood vessels and nerves; the inner layer (which contains fewer blood vessels but more cells) contains many elastic fibers. During growth, the osteogenic layer of the original connective tissue forms the inner layer of the periosteum. In adults, this appears only as a row of dispersed, flattened cells tightly adhering to the bone. The periosteum serves as a supporting bed for blood vessels and nerves entering the bone and for the fixation of tendons and ligaments. The osteogenic layer (which is considered part of the periosteum) is known to supply osteoblast growth and repair, and plays an important limiting role in controlling and restricting bone formation. Because both the periosteum and the bone it contains are regions of connective tissue compartments, they are not separated from each other or from other connective tissues by substrate material or basement membrane. Periosteal stem cells have been shown to be important in bone regeneration and repair (Zhang et al., 2005, J. Musculoskelet. Neuronal. Interact. 5(4): 360-362).

[0201] The inner layer of the endosteal membrane is the surface of the cavities (medullary cavity and central canal) within the bone and the surface of the trabeculae within the medullary cavity. In growing bone, it consists of a fine stroma (striatum) of bone marrow reticular connective tissue, beneath which lies a layer of osteoblasts. In adults, osteoprogenitor cells become flattened and cannot be distinguished as a separate layer. They can transform into osteoprogenitor cells in the presence of stimuli for bone formation (such as after a fracture).

[0202] marrow Bone marrow is the soft connective tissue that occupies all the spaces between the medullary cavity, the larger central canal, and the trabeculae of the spongy bones of long bones. It is composed of a fine network of connective tissue, within which various cells reside. Two types of bone marrow are generally recognized: red bone marrow and yellow bone marrow. Red bone marrow is the only type found in the bones of fetuses and young adults, but in adults, it is confined to the epiphyses of the vertebrae, sternum, ribs, skull, and long bones. It is the primary site of blood cell development in the adult body. Yellow bone marrow is primarily composed of fat cells that gradually replace other bone marrow components. Under certain conditions, the yellow bone marrow of elderly or emaciated individuals loses most of its fat and exhibits a reddish color and gel-like consistency, known as gelatinous bone marrow. With sufficient stimulation, yellow bone marrow can regain the properties of red bone marrow and become an active component in blood development.

[0203] Bone formation or ossification Osteogenesis, or ossification, is the process by which bone is formed. There are three distinct lineages of skeletal formation. Mesodermal segments form the axial skeleton, lateral plate mesoderm forms the limb skeleton, and cranial neural crests form the branchial arches, cranial surfaces, and cartilage. There are two main modes of bone formation or osteogenic development, both involving the transformation of pre-existing mesenchymal tissue into bone tissue. The direct transformation of mesenchymal tissue into bone is called intramembranous ossification. This process primarily occurs in the skull. In other cases, mesenchymal cells differentiate into cartilage, which is subsequently replaced by bone. The process of cartilage intermediate formation and replacement by osteocytes is called endochondral ossification.

[0204] Intramembrane ossification Intramembranous ossification is a characteristic process in the formation of flat bones in the scapula, skull, and tortoise shell. In intramembranous ossification, bone forms sheets of fibrous connective tissue. In intramembranous ossification of the skull, mesenchymal cells originating from the neural crest differentiate and aggregate into a tight structure. Some of these cells develop into capillaries; others change their shape to become osteoblasts, thus becoming osteoprogenitor cells. Osteoblasts secrete a collagen-proteoglycan matrix capable of binding calcium salts. Through this binding, the preosseous (osteoid) matrix becomes calcified. In most cases, osteoblasts are separated from the calcified area by the layer of osteoid matrix they secrete. Occasionally, osteoblasts remain in the calcified matrix and become osteocytes. As calcification progresses, spicules radiate outward from the area where ossification begins, and the entire area of ​​the calcified spicule becomes surrounded by a tight layer of mesenchymal cells forming the periosteum, and the cells on the inner surface of the periosteum also become osteoblasts and deposit osteoid matrix parallel to the existing spicule matrix. In this way, many layers of bone are formed.

[0205] Intramembranous ossification is characterized by capillary invasion into the interstitial region and the emergence and differentiation of mesenchymal cells into mature osteoblasts. Bone matrix continues to deposit, forming spicules, which grow and develop, eventually fusing with other spicules to form trabeculae. As the size and number of trabeculae increase, they become interconnected to form woven bone (a detissued, weak structure with a high proportion of osteocytes), which is eventually replaced by more tissued and stronger lamellar bone.

[0206] The molecular mechanisms of intramembranous ossification involve the activation of bone morphogenetic proteins (BMPs) and a transcription factor called CBFA1. BMPs from the scalp epidermis, such as BMP2, BMP4, and BMP7, are thought to direct the direct transformation of mesenchymal cells originating from the neural crest into osteoblasts. BMPs activate the Cbfa1 gene in mesenchymal cells. The CBFA1 transcription factor is known to convert mesenchymal cells into osteoblasts. Studies have shown that mouse CBFA1 mRNA is primarily confined to the formation of bone mesenchymal aggregates and is limited to the osteoblast lineage. CBFA1 is known to activate the genes for osteocalcin, osteopontin, and other bone-specific extracellular matrix proteins.

[0207] Intrachondral ossification (ossification within the cartilage) Endochondrial ossification (which involves the formation of cartilage tissue from aggregated mesenchymal cells and subsequent replacement of the cartilage tissue with bone) can be divided into five stages. The skeletal components of the spine, pelvis, and limbs are initially formed from cartilage and subsequently become bone.

[0208] First, mesenchymal cells are stereotyped into chondrocytes. This stereotype is induced by the expression of paracrine factors of two transcription factors (Paxl and Scleraxis) in nearby mesodermal cells. These transcription factors are known to activate cartilage-specific genes. For example, Scleraxis is expressed in the mesenchyme from osteophytes, in the facial mesenchyme that enables cartilaginous precursors to form bone, and in the mesenchyme of the extremities.

[0209] In the second stage of endochondrial ossification, mature mesenchymal cells aggregate into tightly bound cells and differentiate into chondrocytes (chondrocytes that produce and maintain the cartilage matrix, which is mainly composed of collagen and proteoglycans). Studies have shown that N-cadherin is important in the initiation of these aggregates, and N-CAM is important for maintaining them. In humans, the SOX9 gene (which encodes a DNA-binding protein) is expressed in prechondral aggregates.

[0210] In the third stage of endochondral ossification, chondrocytes rapidly differentiate to form the rudiments of bone. As they divide, chondrocytes secrete cartilage-specific extracellular matrix.

[0211] In the fourth stage, chondrocytes stop dividing and rapidly increase in size, becoming hypertrophic chondrocytes. These large chondrocytes alter the matrix they produce (by adding collagen X and more fibronectin) to make it mineralized by calcium carbonate.

[0212] The fifth stage involves vascular invasion of the cartilage rudimentary structure. The hypertrophic chondrocytes die through apoptosis, and this gap becomes bone marrow. As the chondrocytes die, the cell population surrounding the rudimentary structure differentiates into osteoblasts, which begin to form bone matrix on the partially degraded cartilage. Ultimately, all the cartilage is replaced by bone. Thus, cartilage tissue serves as the rudimentary form of subsequent bone.

[0213] Chondrocyte replacement by osteocytes depends on the mineralization of the extracellular matrix. Multiple processes lead to chondrocyte hypertrophy and mineralization, including the initial switch from aerobic to anaerobic respiration, which alters their cellular metabolism and mitochondrial energy potential. Hypertrophic chondrocytes secrete numerous small membrane-bound vesicles into the extracellular matrix. These vesicles contain active enzymes that produce calcium and phosphate ions and initiate the mineralization process within the cartilaginous matrix. Hypertrophic chondrocytes, their metabolism, and mitochondrial membranes undergo alterations, ultimately leading to cell death via apoptosis.

[0214] In the long bones of many mammals (including humans), endochondral ossification spreads outward from the center of the bone in two directions. Because the ossified front is close to the end of the rudimentary cartilage, the chondrocytes near the ossified front proliferate before hypertrophy, thus pushing the cartilaginous end of the bone outward. The cartilaginous region at the end of a long bone is called the epiphyseal growth plate. These plates contain three regions: a chondrocyte proliferation region, a mature chondrocyte region, and a hypertrophic chondrocyte region. As endochondral proliferation and the ossified front extend further outward, the cartilage retained in the epiphyseal growth plate proliferates. As long as the epiphyseal growth plate can produce chondrocytes, bone will continue to grow.

[0215] Bone Reconstruction In adults, bone is constantly being broken down by osteoclasts and remodeled by osteoblasts. Up to 18% of bone is reportedly recycled annually through a renewal process called bone remodeling, which maintains bone stiffness. The balance of this dynamic process shifts with age: in younger people, it favors bone formation, but in older people, it favors resorption.

[0216] As new bone material increases from the inner surface of the periosteum, cavitation occurs in the internal regions to form the medullary cavity. This destruction of bone tissue is caused by osteoclasts that enter the bone via blood vessels. Osteoclasts dissolve the inorganic and protein portions of the bone matrix. Each osteoclast expands into multiple cells into the matrix and pumps hydrogen ions to the surrounding structures, thereby acidifying and dissolving them. Blood vessels also supply blood-forming cells, which remain in the bone marrow during the organism's survival.

[0217] The number and activity of osteoclasts must be closely regulated. If there are too many active osteoclasts, too much bone will be dissolved, leading to osteoporosis. Conversely, if not enough osteoclasts are produced, bone will not cavitate and will remain in the bone marrow, leading to osteosclerosis (also known as osteopetrosis, a condition in which bone hardens and becomes denser).

[0218] Bone regeneration and fracture repair Like any traumatic injury, a fracture causes bleeding and tissue destruction. Therefore, the initial reparative changes exhibit the characteristics of reparative changes that occur in any soft tissue injury. Proliferating fibroblasts and capillary sprouts extend into the blood clot and the injured area, thus forming granulation tissue. This area is also invaded by polymorphonuclear leukocytes and macrophages that phagocytose tissue debris. The granulation tissue gradually becomes denser and forms cartilage. This newly formed connective tissue and cartilage is called callus tissue. It serves to temporarily stabilize the fractured bone and bind the fractured bones together. As this process proceeds, dormant osteoprogenitor cells in the periosteum enlarge and become active osteoblasts. On the outside of the fractured bone, bone tissue is deposited initially at a distance from the fracture. This formation of new bone continues towards the fracture ends and eventually forms a sheath-like layer of bone on the fibrocartilaginous callus. As bone mass increases, periosteal sprouts invade the fibrocartilaginous callus and replace it with bony tissue. Cartilage replaces the fibrocartilaginous callus, undergoing calcification and resorption, and intramembranous bone formation also occurs. The newly formed bone is primarily spongy rather than compact, and the healing tissue is smaller in diameter. While this subperiosteal bone formation is underway, bone is also forming within the medullary cavity. The medullary bone growing centripetally from each side of the fracture merges, thus aiding in bone healing.

[0219] Generally, the repair process is orderly, but it varies greatly depending on the displacement of the fractured bone ends and the degree of trauma suffered. Uneven or protruding surfaces gradually disappear, and the healed bone, especially in young individuals, restores its original contours.

[0220] Bone formation and angiogenesis Bone development and fracture repair involve the synergistic effects of multiple processes, such as the migration, differentiation, and activation of various cell types and tissues. The development of the microvascular system and microcirculation are crucial for homeostasis and regeneration of viable bone, which otherwise leads to tissue degeneration and death. Recent advances in the use of in vitro and in vivo models of bone development and fracture repair have provided a better understanding of the recruitment characteristics of the vascular system during bone development and repair.

[0221] The vascular system transports oxygen, nutrients, soluble factors, and various cell types to all tissues in the body. The growth and development of mature vascular structures is one of the earliest processes in organogenesis. In mammalian embryonic development, a new network of blood vessels occurs by the aggregation of newly generated vascular cells into a primitive vascular plexus (angiogenesis). This involves a complex remodeling process in which budding, bridging, and growth from existing blood vessels (angiogenesis) lead to the initiation of a functional circulatory system.

[0222] Factors and processes that lead to normal embryonic vascular system development are repeated in angiogenesis in adults. Multiple factors are involved in angiogenesis; these include, but are not limited to, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), members of the transforming growth factor β (TGFP) family, and hypoxia-inducible transcription factor (HIF). Other factors with angiogenic properties include angiopoietin (Ang-1), hepatocyte growth factor (HGF), platelet-derived growth factor (PDGF), insulin-like growth factor family (IGF-1, IGF-2), and neurotrophic factor (NGF).

[0223] VEGF and its corresponding receptors are key regulators in the molecular and cellular cascade of events that ultimately lead to the development of the vascular system (through angiogenesis, vascularization, or the formation of the lymphovascular system). While VEGF is a key regulator of physiological angiogenesis, it also plays a significant role in bone growth and repair.

[0224] In established, mature vascular systems, the endothelium plays a crucial role in homeostasis by providing a communication network with neighboring tissues to respond to demands when needed. Furthermore, the vascular system delivers growth factors, hormones, cytokines, chemokines, and metabolites as needed by surrounding tissues and acts as a barrier restricting molecular and cellular movement. Signaling and inducing factors expressed on the bone endothelium help recruit circulating cells (especially hematopoietic cells) to the bone marrow and coordinate with metastatic cells to target them to skeletal regions. Therefore, any alteration in the vascular connectivity of bone tissue can lead to pathological changes in the bone, such as osteonecrosis (bone death due to reduced blood supply to nourishing bone), osteomyelitis (bone or bone marrow infection by microorganisms), and osteoporosis (decreased bone mineral density). Several factors have been found to have significant effects on the pathology of the vascular system and bone, including osteoprotegerin (OPG), which inhibits NF-κB ligand receptor activator (RANKL)-induced osteoclastogenic bone resorption.

[0225] Intramembranous and intrachondral ossification occurs closely adjacent to the blood vessels. In intrachondral ossification, the coupling between chondrogenesis and osteogenesis, which determines the rate of ossification, depends on the level of vascularization of the growth plate. For example, vascular endothelial growth factor (VEGF) isoforms are essential for coordinating ossification during metaphyseal and epiphyseal vascularization, chondrogenesis, and intrachondral bone development. HIF-1 stimulates the transcription of VEGF genes (and other genes that require their products in oxygen-deficient conditions). VEGF proteins are secreted, diffuse through tissues, and act on adjacent endothelial cells.

[0226] Endothelial cell responses involve at least four components. First, the cell produces proteases to digest its pathway through the basement membrane of the mammary capillaries or venules. Second, endothelial cells migrate towards signaling sources. Third, cell proliferation occurs. Fourth, cells form tubules and differentiate. VEGF selectively acts on endothelial cells to stimulate this entire process. Other growth factors, including some members of the fibroblast growth factor family, can also stimulate angiogenesis, but they also affect other cell types besides endothelial cells. As new blood vessels form and deliver blood to tissues, oxygen concentration increases, HIF-1 activity decreases, VEGF production ceases, and angiogenesis stops.

[0227] Vascularization of cartilaginous regions in long bones occurs at different stages of development. In early embryonic development, blood vessels originating from the perichondrium enter the cartilaginous structures. After birth, capillaries invade the growth plates of long bones. In adulthood, angiogenesis can periodically switch during bone remodeling in bone trauma or pathophysiological conditions such as rheumatoid arthritis (RA) and osteoarthritis (OA).

[0228] Bone possesses a unique ability to regenerate without producing fibrous scars (a symptom of soft tissue wound healing). This is achieved through complex, interdependent stages of the healing process, which mimic tightly regulated skeletal development. Following trauma involving damage to the skeletal muscle system, disruption of the vascular system leads to acute necrosis and hypoxia of surrounding tissues. This disruption of circulation results in the activation of thrombotic factors in the coagulation cascade, thus leading to hematoma formation. Inflammatory responses and tissue destruction can activate factors (such as cytokines and growth factors) that recruit osteoprogenitor cells and mesenchymal cells to the fracture site. Stimulation of intraosseous circulation in the fractured bone allows mesenchymal cells associated with growing capillaries to enter the wound area from the endosteum and bone marrow. At the fracture margins, short-lived granulation tissue is replaced by fibrocartilage. Simultaneously, the periosteum undergoes direct intraosseous bone formation, resulting in external callus formation; while internally, tissue mineralization occurs to form woven bone. After the bone tissue and vascular system stabilize in a fracture, cells mediating the reconstruction cascade are activated, in which large callus are replaced by lamellar bone after osteoclast removal of necrotic bone, callus size decreases and normal vascular connections are restored.

[0229] Multiple mediators associated with fetal and postnatal bone development play significant roles in the cascade of fracture repair. These include, but are not limited to, BMP-2 and BMP-4, VEGF, bFGF, TGF-β, and PDGF. VEGF expression is detected on chondrocytes, osteoblasts, osteoprogenitors, and osteoblasts in the callus, and it is highly expressed in angiocytes, osteoprogenitors, and osteoblasts during the first seven days of healing, but decreases after day 11. Additionally, osteoclasts release enzymes that induce the release of active forms of VEGF from heparin, thereby activating not only angiogenesis but also osteoclast recruitment, differentiation, and activity, leading to callus remodeling during endochondral ossification. In some cases, fractures fail to repair or unite, resulting in fibrous-filled pseudoarthrosis. A variety of factors can contribute to nonunion or delayed union of fractures, such as, but not limited to, anti-inflammatory drugs, steroids, vitamin C, vitamin D and calcium deficiency, smoking, diabetes, and other physiological disorders.

[0230] The absence of a functional vascular network is also a significant factor contributing to the lack of bone healing in nonconnecting fractures. Studies have reported that angiogenic factors released from biomimetic skeletons can enhance bone regeneration, and a combined strategy of releasing both angiogenic and bone-forming factors can enhance bone regeneration capacity.

[0231] The key timing sequence of osteoclast differentiation and activation, angiogenesis, osteoprogenitor recruitment, and the release of growth factors such as BMP-2 in bone formation and fracture repair can be enhanced by synchronizing endogenous angiogenesis and the production of bone formation-related mediators. Studies of drill-hole injuries in the rat femur have demonstrated VEGF splice aberration and differential expression of its receptors, indicating their important role in bone healing. Other studies in osteodistraction models have shown that angiogenesis during bone elongation primarily occurs before the onset of osteogenesis.

[0232] Another angiogenesis-inducing growth factor, FGF-2, can accelerate fracture repair when exogenously supplemented during the early stages of bone healing. Although its mechanism is not fully elucidated, it has the ability to stimulate angiogenesis and osteoblast proliferation and differentiation, thereby contributing to fracture repair.

[0233] osteosarcoma Osteosarcoma is defined as the pathological production of precalcified osteoid (newly formed organic bone matrix). Significant variability exists in the matrix, leading to different histological subtypes, which are diagnosed based on the presence of malignant spindle cells and small osteoid regions. Whether the clinical features of osteosarcoma are determined by different cellular origins, the genetic events leading to transformation, the timing of these events, and factors related to osteoblast differentiation phenotypes remains inconclusive. (R. Gorlick, Cancer Treatment & Res. 152: 467-478 (2010)). In mouse models, osteosarcoma is shown to originate from mesenchymal stem cells via genomic deletion of the cdkn2 region. (Mohseny, AB et al., J. Pathol. 219(3): 294-305 (2009)).

[0234] Subtypes of osteosarcoma Advanced osteosarcoma High-grade osteosarcoma is the fastest-growing type of osteosarcoma and most commonly occurs in children and adolescents. Tumor cells in high-grade osteosarcoma exhibit marked nuclear pleomorphism, significant chromatin abnormalities, prominent nucleoli, and mitotic figures, some of which are atypical. High-grade osteosarcomas include osteoblastic, chondrocyte-mediated, fibroblastic, mixed, small-celled, telangiectatic, high-surface (near-cortical high-grade), osteomyelitis-like (tumors occurring in people with Paget's disease), extraosseous (tumors originating in parts of the body other than bone), and post-radiational (tumors originating in bone that has previously received radiation). In the fibrosarcomatous form of osteosarcoma, the matrix is ​​composed of spindle cells.

[0235] Intermediate osteosarcoma Intermediate-grade osteosarcoma is an uncommon tumor between high-grade and low-grade osteosarcoma, but it is treated similarly to low-grade osteosarcoma. An example of intermediate-grade osteosarcoma is the periosteal type (intermediate-grade osteosarcoma juxtacortical).

[0236] low-grade osteosarcoma Low-grade osteosarcoma is the slowest-growing type of osteosarcoma. These tumors appear as normal bone and have very few dividing cells when viewed under a microscope. There are two types of these tumors: extraperiosteal (near-cortical low-grade osteosarcoma) and well-differentiated intramedullary / intraosseous (low-grade central osteosarcoma).

[0237] Staging of osteosarcoma The treatment and diagnosis of osteosarcoma largely depend on the stage of cancer at the time of initial diagnosis.

[0238] Primary / localized osteosarcoma Primary osteosarcoma is seen only in the bone where the osteosarcoma originates, while localized osteosarcoma is found in adjacent bone tissue, such as muscle, tendon, or fat. It is believed that approximately 80% of osteosarcomas are localized at initial examination. In fact, most patients already have micrometastases at diagnosis, highlighting the importance of chemotherapy as a treatment for most osteosarcomas.

[0239] The doctors further divided the localized osteosarcoma into two groups: (i) resectable tumors and (ii) unresectable / inoperable tumors. Resectable tumors are those in which all visible tissue can be surgically removed. Unresectable / inoperable cancers are tumors that cannot be completely removed surgically.

[0240] Metastatic osteosarcoma Metastatic osteosarcoma spreads from primary osteosarcoma to other organs or tissues in the body. Osteosarcoma most commonly metastasizes to the lungs, but it can also metastasize to other bones, the brain, or other organs. Approximately 20% of osteosarcoma patients have metastases at diagnosis. Patients with metastatic osteosarcoma are more difficult to treat, but some can be cured if the metastases can be surgically removed. The cure rate for these patients is improved when chemotherapy is combined with surgery.

[0241] Osteosarcoma grading Several grading systems exist for osteosarcoma. The Musculoskeletal Tumor Society (MTS) osteosarcoma staging system is based on tumor grade (I = low; II = high), tumor extent (A = intra-regional; B = extra-regional), and whether distant metastasis has occurred (III). For example, in the MTS staging system, locally advanced high-grade osteosarcoma is classified as stage IIA or IIB, while metastatic disease (regardless of the extent of the primary lesion) is classified as stage III. Another grading system, the American Joint Cancer Society (AJCC) staging system, is similar to the MTS staging system, with a few notable differences. The AJCC staging system classifies stage III as any tumor with cutaneous metastases. Cutaneous metastases are tumor nodules that grow beyond the reactive rim but within the same bone or adjacent joints, representing regional intra-bone metastases or cross-joint metastases, respectively. Additionally, AJCC stages I and II are subdivided into categories A and B based on tumor size (greater or less than 8 cm in any dimension) rather than on tumor extent. This system also uses an additional IV stage, which is divided into IVA or M1 (describing lung metastases) and IVB or M1b (describing other metastases). The European and American Osteosarcoma Study Group uses the Enneking system to stage osteosarcoma. This system is based on the tumor grade (G), the local extent of the primary tumor (T), and the extent of metastasis to regional lymph nodes or other organs (M). Tumors are classified as low grade (G1) or high grade (G2), and the extent of the primary tumor is classified as local intra-regional (T1) or extended extra-regional (T2). Tumors that have not metastasized to lymph nodes or other organs are classified as M0, while those with metastases are classified as M1. In addition to these clinical grading systems, Meister et al. characterized osteosarcoma as a range of + to +++ based on a semi-quantitative evaluation of histological characteristics using cellular atypia and mitotic activity (see Dai et al., Med Sci Moni, 2011; 17(8): RA177-190).

[0242] Treatment of osteosarcoma Prior to the 1970s, when amputation was the primary treatment for osteosarcoma, the 5-year survival rate was 10–20% (see Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii 320–325). The combination of surgery and modern multi-drug dose-intensive chemotherapy has improved 5-year survival to approximately 60–70%. Current osteosarcoma treatment regimens typically consist of neoadjuvant (preoperative) therapy followed by adjuvant (postoperative) therapy if needed. The most commonly used chemotherapeutic agents include cisplatin, doxorubicin, ifosfamide, and high-dose methotrexate, with leucovorin rescue. The therapeutic potential of bisphosphonates such as zoledronic acid, minodronate, risedronate, and alendronate has been widely recognized in recent years due to their inhibitory effects on the growth of human osteosarcoma cells (see Dai et al., Med Sci Moni, 2011; 17(8): RA 177–190).

[0243] Operation Surgery remains an essential part of osteosarcoma treatment. The goal of surgery is to remove the entire tumor while preserving as much function as possible. As defined by Enneking's criteria for surgical procedure, surgical margins must be maintained, which means complete removal of the tumor surrounded by normal (i.e., tumor-free) tissue (Enneking, WF et al., Clin. Orthop. Relat. Res. 1980, 153, 106-120; Bielack, S. et al., Annals of Oncology, 20(Supplement 4): iv137-iv139(2009); Ando, ​​K. et al., Cancer 2013, 5, 591-616).

[0244] Tumors in the arm or leg can be treated with limb-sparing surgery or amputation. Limb-sparing surgery removes the tumor without amputation, while amputation involves removing the tumor and all or part of the arm or leg.

[0245] If osteosarcoma has spread (i.e. metastasized) to other parts of the body, these tumors will be surgically removed (if possible).

[0246] Chemotherapy for osteosarcoma Since the introduction of chemotherapy drugs in the mid-1970s, systemic chemotherapy has been the most common treatment for osteosarcoma patients (Allison, DC et al., Sarcoma 2012, 2012, ID 704872; Ando, ​​K. et al., Cancers 2013, 5, 591-616). Most osteosarcomas are treated with systemic chemotherapy (neoadjuvant therapy) for about 10 weeks before surgery and followed by systemic chemotherapy (adjuvant chemotherapy) for up to one year after surgery. The current standard regimen consists of cisplatin or cisplatin in combination with doxorubicin, methotrexate (with leucovorin rescue), with or without ifosfamide (Bielack, S. et al., Annals of Oncology, 20 (Supplement 4): iv137-iv 139 (2009)). Other drugs used to treat osteosarcoma include carboplatin, etoposide, cyclophosphamide, epirubicin, gemcitabine, and topotecan. These regimens last 6–12 months and have an overall survival rate of over 60% in patients with primary / localized osteosarcoma (Bielack, S. et al., Annals of Oncology, 20(Supplement4): iv137–iv139 (2009); Chou, AJ and Gorlick, R., Expert Rev. Anticancer Ther. 2006, 6, 1075–1085). However, chemotherapy is currently associated with both acute and long-term toxicities. For example, cisplatin-induced hearing loss, neuropathy, kidney damage, nausea, vomiting, and hypomagnesemia; anthracycline-induced cardiomyopathy associated with doxorubicin; leukoencephalopathy, liver damage, and kidney damage caused by methotrexate; and post-pubertal infertility associated with ifosfamide (Meyers, PA and Gorlick, R., Pediatr. Clin. NorthAm., 1997; 44:973-989; Baum, ES et al., Cancer Treat. Rep. 1981; 65:815-822; Brock, PR et al., Med. Pediatr. Oncol, 1991; 19:295-300; Hayes FA et al., Cancer Treat. Rep. 1979; 63:547-548; Von Hoff DD et al., Ann. Intern. Med., 1979; 91:710-717; Meistrich, M. et al., Cancer, 1989; 63: 2115-2123).

[0247] For example, immunomodulation via interferon-alpha could be another form of osteosarcoma treatment. In fact, it has been reported that adding the immunomodulatory agent liposomal muramyl tripeptide phosphatidylethanolamine (MTP) to postoperative chemotherapy was statistically significantly associated with overall survival (see Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii320-325.).

[0248] Radiotherapy for osteosarcoma External beam radiation therapy is the most common type of radiation therapy used to treat osteosarcoma. Newer irradiation techniques such as intensity-modulated radiation therapy (IMRT) and conformal proton beam therapy allow doctors to target the tumor more precisely while reducing the radiation dose to adjacent normal tissues.

[0249] Radiopharmaceuticals (radiotherapy drugs) Bone-adhering radioactive drugs such as samarium-153 are sometimes used to treat people with advanced osteosarcoma. These drugs are injected into a vein and accumulate in the bone. Once there, the drugs kill cancer cells and relieve pain caused by bone metastases.

[0250] stem cell therapy Several studies have been conducted to analyze the efficacy of combining autologous stem cells with high-dose chemotherapy for the treatment of recurrent osteosarcoma. However, these studies have failed to demonstrate a survival benefit (see Dai et al., Med Sci Moni, 2011; 17(8): RA177-190).

[0251] Treatment based on the extent of osteosarcoma Treatment for osteosarcoma depends on several factors, including the extent, location, and grade of the tumor, as well as the individual's overall health condition.

[0252] Local resectable osteosarcoma Treatment for locally resectable osteosarcoma consists of surgery and chemotherapy (Bielack, S. et al., Annals of Oncology, 20 (Supplement 4): iv 137-iv 139 (2009)). Most osteosarcomas are advanced, meaning they can grow and spread rapidly if left untreated. The usual treatment sequence for these cancers includes biopsy (to confirm the diagnosis), chemotherapy (usually about 10 weeks), surgery, and further chemotherapy (up to one year). This multimodal treatment improves disease-free survival to over 60% (Bielack, S. et al., Annals of Oncology, 20 (Supplement 4): iv137-iv 139 (2009)). Conversely, the disease-free survival rate for patients with advanced osteosarcoma treated with surgery or chemotherapy alone is 10–20% (Coventry, MB et al., J. Bone Joint Surg. Am. 1957, 39, 741–757; Bielack, S. et al., Annals of Oncology, 20(Supplement 4): iv 137–iv 139(2009); Jaffe, N. et al., Cancer 2002, 95, 2202–2210).

[0253] A small number of osteosarcomas are low-grade, meaning they are likely to grow slowly. Patients with low-grade resectable osteosarcomas can usually be cured with surgery alone (i.e., without chemotherapy).

[0254] Localized unresectable osteosarcoma Localized, unresectable osteosarcomas that haven't spread to other parts of the body, but which cannot be completely removed surgically, are caused by factors such as excessive gravity or proximity to vital structures. Chemotherapy is usually the first-line treatment for these patients. If the tumor shrinks sufficiently after chemotherapy to become resectable, it is surgically removed. Chemotherapy may continue for up to a year after surgery.

[0255] If the tumor remains unresectable after chemotherapy, radiotherapy is typically used to keep the tumor under control and alleviate symptoms. Chemotherapy is then more commonly used afterward.

[0256] Metastatic osteosarcoma The most common site of osteosarcoma metastasis is the lung, but metastases can occur in bone and other tissues. Patients diagnosed with metastatic osteosarcoma have a poor prognosis. The overall survival rate for patients with metastatic osteosarcoma is 10–50%, depending on the location and number of metastatic lesions (Meyers, PA et al., J. Clin. Oncol. 1993, 11, 449–453; Ferguson, WS et al., J. Pediatr. Hematol. Oncol. 2001, 23, 340–348; Harris, MB et al., J. Clin. Oncol. 1998, 16, 3641–3648; Goorin, AM et al., J. Clin. Oncol. 2002, 20, 426–433). Despite a poor prognosis, treatment for metastatic osteosarcoma is similar to or even the same as that for primary / localized disease, with the addition of surgical resection of all known metastatic lesions, usually by exploratory thoracotomy (including palpation of the entire lung) (Bielack, S. et al., Annals of Oncology, 20 (Supplement 4):iv 137-iv 139 (2009); Ritter and Bielack, Annals of Oncology, 2010; Supplement 7:vii320-325).

[0257] In addition to chemotherapy, resection of lung metastases (i.e., surgery) has been shown to improve or prolong the survival of patients with metastatic disease (Bacci, G. et al., Cancer 1997, 79, 245-254; Briccoli, A. et al., Cancer 2005, 104, 1721-1725; Marcove, RC et al., J. Bone Joint Surg. Am. 1973, 55, 1516-1520). The 5-year survival rate for patients who have undergone complete resection of lung metastases is 12-23%, while the 5-year survival rate for patients who do not undergo aggressive surgical resection is 2.6% (Harting MT et al., Semin. Pediatr. Surg. 2006, 15, 25-29; Ward, WG et al., J. Clin. Oncol. 1994, 12, 1849-1858). Similar to the treatment of primary / localized osteosarcoma, acute and long-term toxicities have been observed (Meyers, PA and Gorlick, R., Pediatr. Clin. North Am., 1997; 44:973-989; Baum, ES et al., Cancer Treat. Rep. 1981; 65:815-822; Brock, PR et al., Med. Pediatr. Oncol, 1991; 19:295-300; Hayes FA et al., Cancer Treat. Rep. 1979; 63:547-548; Von Hoff DD et al., Ann. Intern. Med., 1979; 91:710-717; Meistrich, M. et al., Cancer, 1989; 63:2115-2123).

[0258] Recurrent / relapsed osteosarcoma Osteosarcoma recurrence can occur locally, but is most common in the lungs (Ando, ​​K. et al., Cancers 2013, 5, 591-616; Merimsky, O. et al., IMAJ, 2004; 6:34-38). Treatment for recurrent osteosarcoma is primarily surgical (Bielack, S. et al., Annals of Oncology, 20(Supplement 4): iv 137-iv 139(2009)). Complete surgical resection of the recurrent disease is crucial, as it is almost always fatal (Bielack, S. et al., Annals of Oncology, 20(Supplement 4): iv 137-iv 139(2009); Merimsky, O. et al., IMAJ, 2004; 6:34-38).

[0259] The role of second-line chemotherapy in recurrent osteosarcoma is far from clear. Currently, there is no standard chemotherapy regimen for osteosarcoma that has relapsed following multimodal treatment with surgery and systemic chemotherapy. Chemotherapy options may be considered based on disease progression-free status and resectable disease, often including cisplatin or cisplatin in combination with cyclophosphamide or etoposide (Bielack, S. et al., Annals of Oncology, 20 (Supplement 4): iv 137-iv 139 (2009)). The prognosis for these patients is poor, with long-term survival after relapse being less than 20% (Ferrari, S. et al., J. Clin. Oncol, 2003; 21:710-715; Kempf-Bialek, B. et al., J. Clin. Oncol, 2005; 23:559-568).

[0260] Bacci et al. studied the treatment and outcomes of patients with recurrent osteosarcoma. They observed that the first recurrence was a solitary lung metastasis in over 80% of patients, a solitary distant bone metastasis in 8.6% of patients, and a solitary metastasis to other sites (kidney, heart), more than one site, or a local recurrence associated with lung metastasis in the remaining 7.6% of patients (Bacci et al., Acta Oncologica, 2005; 44:748-755). Bacci et al. noted that the mean interval from treatment initiation to the first recurrence was longer in patients with recurrent solitary metastases (29.4 months) than in patients with solitary local recurrence (24 months) (Bacci et al., Acta Oncologica, 2005; 44:748-755). In patients with solitary lung metastases, the remission rate was significantly correlated with the number of metastatic nodules. For example, the response rate was 89.2% for patients with only one or two nodules, while it was 46.9% for patients with more than two nodules (Bacci et al., Acta Oncologica, 2005; 44:748-755). For patients treated with surgery alone or surgery in combination with second-line chemotherapy, the response rates were 95.3% and 81.4%, respectively (Bacci et al., Acta Oncologica, 2005; 44:748-755).

[0261] Bacci et al. also investigated second, third, fourth, and fifth recurrences of lung metastases. Second recurrence of solitary lung metastases occurred in 66.6% of patients, while solitary metastases in other bones occurred in 15.8%. Metastases in more than one site occurred in 8.3% of patients, and solitary local recurrences occurred in 5%. When patients experienced third, fourth, and fifth recurrences, the most common site of recurrence was the lung (Bacci et al., Acta Oncologica, 2005; 44:748-755).

[0262] Bielack et al. conducted a similar study on the second and subsequent recurrences of osteosarcoma (Bielack et al., Journal of Clinical Oncology 27: 557-565). They observed survival after recurrence, with a median survival of 1.02 years after the second recurrence, 1.02 years after the third, 0.98 years after the fourth, and 0.94 years after the fifth. A longer interval between the current and previous recurrences than the median was generally associated with a better prognosis, as were patients with longer first recurrence-free intervals. Patients with isolated lesions had better outcomes than those with multiple lesions, and patients with unilateral lung metastases also had better outcomes (Bielack et al., Journal of Clinical Oncology 27: 557-565). Overall, the estimated 5-year survival rate for patients achieving surgical remission after recurrence was only about 25% (Bielack et al., Journal of Clinical Oncology 27: 557-565).

[0263] Despite the poor prognosis, there are no satisfactory alternatives to recurrent osteosarcoma, including metastatic resection and systemic chemotherapy. Therefore, there is a need to develop alternative treatments to improve the quality of life and prolong the survival of these patients.

[0264] Cisplatin Cisplatin (cis-diamine dichloroplatin(II)) is one of the oldest and most effective agents used for systemic treatment of cancer. Since its first clinical trial for cancer treatment in 1971, cisplatin has been used not only to treat osteosarcoma, but also to treat cancers such as bladder cancer, cervical cancer, malignant mesothelioma, non-small cell lung cancer, ovarian cancer, squamous cell carcinoma of the head and neck, and testicular cancer (http: / / cancer.gov / cancertopics / druginfo).

[0265] Cisplatin is believed to exert its anticancer effects by interacting with DNA and subsequently inducing programmed cell death (i.e., apoptosis). Cisplatin enters tumor cells via diffusion across the cell membrane or via active transport via Cu-transporters (Gately, DP and Howell, S., Br. J. Cancer, 1993, 67: 1171-1176; Ishida, S. et al., PNAS, 2002; 99: 14298-14302). Once inside tumor cells, cisplatin reacts with one of the DNA bases (usually guanine) to form a monofunctional DNA complex (Alderden, RA et al., JCE, 2006; 83(5): 728-734). Subsequent bifunctional complexes (e.g., guanine-guanine and / or adenine-guanine) can be present, resulting in significant DNA alterations that can be recognized by one or more DNA-binding proteins (Jamieson, ER and Lippard, SJ, Cehm. Rev. 1999; 99:2467-2498; Hambley, TW, Dalton Trans., 2001; 2711-2718; Cohen, GL et al., J. Am. Chem. Soc, 1980; 102:2487-2488). DNA-binding proteins initiate signals for DNA damage repair or apoptosis (Jamieson, ER and Lippard, SJ, Cehm. Rev. 1999; 99:2467-2498; Hambley, TW, Dalton Trans., 2001; 2711-2718; Kelland, LR, Drugs, 2000; 59 Supp L, 1-8; Fuertes, MA et al., Curr. Med. Chem. Anti-Cancer Agents, 2002; 2:539-551).

[0266] After being injected into the bloodstream, cisplatin is susceptible to attack by proteins present in the plasma, especially those containing thiol groups (Alderden, RA et al., JCE, 2006; 83(5):728-734). Studies have shown that 65-98% of the platinum in plasma is protein-bound one day after cisplatin injection (Ivanov, AI et al., J. Biol. Chem. 1998; 273:14721-14730; DeConti, RC et al., Cancer Res. 1973; 33:1310-1315). This protein binding is the cause of drug inactivation and some serious side effects associated with cisplatin treatment (Ivanov, AI et al., J. Biol. Chem. 1998; 273: 14721-14730; Barnham, KJ et al., J. Inorg. Chem. 1996, 35, 1065-1072; Lempers, ELM and Reedijk, J., Adv. Inorg. Chem. 1991; 37: 175-217; Andrews, PA et al., Anal. Biochem. 1984; 143: 46-56; Dolman, RC et al., J. Inorg. Biochem, 2002; 88: 260-267; Borch, RF and Pleasants, ME PNAS, 1979; 76: 6611-6614).

[0267] Like other chemotherapy drugs, systemic administration of cisplatin is associated with both acute and long-term toxicities. Side effects include hearing loss, neuropathy, kidney damage, nausea, vomiting, and hypomagnesemia (Baum, ES, et al., Cancer Treat. Rep. 1981; 65:815-822; Brock, PR, et al., Med. Pediatr. Oncol, 1991; 19:295-300; Hayes F. A., et al., Cancer Treat. Rep. 1979; 63:547-548).

[0268] Attempts to minimize cisplatin inactivation and toxicity include encapsulation in liposomes. Steerenberg et al. reported that cisplatin encapsulated in liposomes exhibited higher stability and lower toxicity compared to free (i.e., non-liposomal) cisplatin while retaining its potency (Steerenberg et al., International Journal of Pharmaceutics, 1087;40:51-62; Steerenberg et al., Cancer Chemother. Pharmacol., 1988; 21:299-307). Additionally, Chou et al. treated 19 patients with recurrent osteosarcoma in the lungs only with inhaled lipid cisplatin (ILC) and demonstrated that ILC was well-tolerated (i.e., few side effects) and showed lower systemic exposure compared to intravenous cisplatin doses (Chou et al., Pediatr Blood Cancer, 2012; DOI 10.1002 / pbc). Although efficacy was not the primary objective, Chou et al. suggested that patients who derive sustained benefit from ILC are limited to those with lesions ≤2 cm and those who have undergone complete surgical resection of the tumor (Chou et al., Pediatr Blood Cancer, 2012; DOI 10.1002 / pbc). Whether ILC has a role in cases of minimal residual disease or as adjuvant therapy is unknown (Chou et al., Pediatr Blood Cancer, 2012; DOI 10.1002 / pbc).

[0269] Although surgical reconstruction techniques have improved significantly compared to the past few decades, allowing limb salvage in most patients, chemotherapy still relies on the same drugs used in the early 1980s (Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii 320-325). As a result, survival has not improved (Ritter and Bielack, Annals of Oncology, 2010; Supplement 7: vii 320-325). Therefore, alternative treatments are needed to treat and cure patients with lung metastases from recurrent osteosarcoma. Invention Summary Methods and compounds that can be used to treat lung cancer have been publicly disclosed.

[0270] According to one aspect, the described invention provides a method for treating lung cancer in a subject in need, comprising: (1) surgically removing a lung cancer lesion until no grossly visible tumor residue remains; and (2) administering an inhaled dose of an inhaled cisplatin lipid complex (ILC) of 18 mg / m². 2 -36mg / m2 The ILC is dispersed throughout the aqueous phase of the dispersion.

[0271] According to another aspect, the described invention provides a method for treating pulmonary micrometastases in subjects with primary osteosarcoma without grossly visible pulmonary metastases, comprising: (1) having undergone combined systemic chemotherapy and surgical resection of primary osteosarcoma with no residual tumor; and (2) an inhaled dose of inhaled cisplatin lipid complex (ILC) of 18 mg / m². 2 -36mg / m 2 The ILC is dispersed throughout the aqueous phase of the dispersion.

[0272] According to one embodiment, lung cancer is a lung metastasis of osteosarcoma. According to another embodiment, a lung metastasis of osteosarcoma is recurrent osteosarcoma. According to another embodiment, lung cancer is non-small cell lung cancer (NSCLC). According to another embodiment, NSCLC is bronchioloalveolar carcinoma.

[0273] According to one embodiment, the ILC further comprises liposomes. According to another embodiment, the liposomes comprise sterols and phosphatidylcholine. According to another embodiment, the sterol is cholesterol. According to another embodiment, the phosphatidylcholine is dipalmitoylphosphatidylcholine (DPPC).

[0274] According to one embodiment, inhalation administration is performed using a nebulizer. According to another embodiment, inhalation administration is at a dose of 36 mg / m³. 2 The dosage. According to another embodiment, the minimum dose administered by inhalation is 24 mg / m³. 2 According to another embodiment, the minimum dose administered by inhalation is 18 mg / m³. 2 According to another embodiment, the drug is administered by inhalation at a rate of 0.3 mL / min for 20 minutes. According to another embodiment, the drug is administered by inhalation 1-4 times daily for 14 consecutive days.

[0275] According to one embodiment, the dispersion is composed of particles with a size ≤1 μm.

[0276] According to one embodiment, the subject has undergone combined systemic chemotherapy and surgical resection of primary osteosarcoma. According to another embodiment, the subject has undergone surgical resection of grossly visible lung metastases. According to another embodiment, the grossly visible lung metastases represent the first lung recurrence. According to another embodiment, the grossly visible lung metastases refer to lung recurrence of lung cancer. According to another embodiment, the lung recurrence is a second or subsequent lung recurrence.

[0277] According to one embodiment, the method further detects recurrent osteosarcoma by measuring biomarkers and comparing them with disease-free controls. According to another embodiment, the biomarkers are biomarkers found in systemic circulation. According to yet another embodiment, the systemic biomarkers are selected from microRNA-21 (miRNA-21), microRNA-199a-3p (miRNA-199a-3p), microRNA-143 (miRNA-143), differentiation cluster molecule 117 (CD117), Stro-1, bone-specific alkaline phosphatase (BALP), lactate dehydrogenase (LDH), and chondroitin sulfate epitope WF6 (WF6).

[0278] One or more embodiments of this application provide a method for treating lung cancer in a desired subject, comprising: (1) Surgical resection of the lung cancer lesion until no visible tumor residue remains; and (2) Inhalation administration of inhaled cisplatin lipid complex (ILC) at a dose of 18 mg / m³. 2 -36mg / m 2 The ILC is dispersed throughout the aqueous phase of the dispersion.

[0279] In one or more embodiments, the lung cancer is a pulmonary metastatic disease of osteosarcoma.

[0280] In one or more embodiments, the lung metastasis of the osteosarcoma is recurrent osteosarcoma.

[0281] In one or more embodiments, the ILC further comprises liposomes.

[0282] In one or more embodiments, the liposomes comprise sterols and phosphatidylcholine.

[0283] In one or more embodiments, the sterol is cholesterol.

[0284] In one or more embodiments, the phosphatidylcholine is dipalmitoylphosphatidylcholine (DPPC).

[0285] In one or more embodiments, the administration by inhalation is performed using a nebulizer.

[0286] In one or more embodiments, the dose administered by inhalation is 36 mg / m³. 2 .

[0287] In one or more embodiments, the minimum dose administered by inhalation is 24 mg / m³. 2 .

[0288] In one or more embodiments, the minimum dose administered by inhalation is 18 mg / m³. 2 .

[0289] In one or more embodiments, the dispersion is a particle with a size ≤1 μm.

[0290] In one or more embodiments, the administration by inhalation is carried out at a rate of 0.3 mL / min for 20 minutes.

[0291] In one or more embodiments, the inhalation administration is performed 1-4 times daily for 14 consecutive days.

[0292] In one or more embodiments, the subject has undergone combined systemic chemotherapy and surgical resection of primary osteosarcoma.

[0293] In one or more embodiments, the subject has undergone surgical resection of visible lung metastases.

[0294] In one or more embodiments, the visible lung metastases are the first lung recurrence.

[0295] In one or more embodiments, the visible lung metastases refer to lung recurrence of lung cancer.

[0296] In one or more embodiments, the lung recurrence is a second or subsequent lung recurrence.

[0297] In one or more embodiments, biomarkers are measured and compared with disease-free populations to further detect recurrent osteosarcoma.

[0298] In one or more embodiments, the biomarker is a biomarker found in systemic circulation.

[0299] In one or more embodiments, the systemic biomarker is selected from microRNA-21 (miRNA-21), microRNA-199a-3p (miRNA-199a-3p), microRNA-143 (miRNA-143), differentiation cluster molecule 117 (CD117), Stro-1, bone-specific alkaline phosphatase (BALP), lactate dehydrogenase (LDH), and chondroitin sulfate epitope WF6 (WF6).

[0300] In one or more embodiments, the lung cancer is non-small cell lung cancer (NSCLC).

[0301] In one or more embodiments, the NSCLC is bronchioloalveolar carcinoma (BAC).

[0302] One or more embodiments of this application provide a method for treating pulmonary micrometastases in a subject with primary osteosarcoma without visible pulmonary metastases, comprising: (1) Surgical resection of primary osteosarcoma with or without systemic chemotherapy, resulting in no grossly visible residual lesions in the subjects; and (2) Inhaled cisplatin lipid complex (ILC) was administered via inhalation at a dose of 18 mg / m². 2 -36mg / m 2 The ILC is dispersed throughout the aqueous phase of the dispersion.

[0303] In one or more embodiments, the ILC further comprises liposomes.

[0304] In one or more embodiments, the liposomes comprise sterols and phosphatidylcholine.

[0305] In one or more embodiments, the sterol is cholesterol.

[0306] In one or more embodiments, the phosphatidylcholine is dipalmitoylphosphatidylcholine (DPPC).

[0307] In one or more embodiments, the administration by inhalation is performed using a nebulizer.

[0308] In one or more embodiments, the dose administered by inhalation is 36 mg / m³. 2 .

[0309] In one or more embodiments, the minimum dose administered by inhalation is 24 mg / m³. 2 .

[0310] In one or more embodiments, the minimum dose administered by inhalation is 18 mg / m³. 2 .

[0311] In one or more embodiments, the dispersion is a particle with a size ≤1 μm.

[0312] In one or more embodiments, the administration by inhalation is carried out at a rate of 0.3 mL / min for 20 minutes.

[0313] In one or more embodiments, the inhalation administration is performed 1-4 times daily for 14 consecutive days.

[0314] One or more embodiments of this application provide the use of inhaled cisplatin lipid complex (ILC) in treating lung cancer in a subject, including: (1) Surgical resection of the lung cancer lesion until no visible tumor residue remains; and (2) Inhalation administration of inhaled cisplatin lipid complex (ILC) at a dose of 18 mg / m³. 2 -36mg / m 2 , The ILC is dispersed throughout the aqueous phase of the dispersion.

[0315] In one or more embodiments, the lung cancer is a pulmonary metastatic disease of osteosarcoma.

[0316] In one or more embodiments, the lung metastasis of the osteosarcoma is recurrent osteosarcoma.

[0317] In one or more embodiments, the ILC further comprises liposomes.

[0318] In one or more embodiments, the liposomes comprise sterols and phosphatidylcholine.

[0319] In one or more embodiments, the sterol is cholesterol.

[0320] In one or more embodiments, the phosphatidylcholine is dipalmitoylphosphatidylcholine (DPPC).

[0321] In one or more embodiments, the administration by inhalation is performed using a nebulizer.

[0322] In one or more embodiments, the dose administered by inhalation is 36 mg / m³. 2 .

[0323] In one or more embodiments, the minimum dose administered by inhalation is 24 mg / m³. 2 .

[0324] In one or more embodiments, the minimum dose administered by inhalation is 18 mg / m³. 2 .

[0325] In one or more embodiments, the dispersion is a particle with a size ≤1 μm.

[0326] In one or more embodiments, the administration by inhalation is carried out at a rate of 0.3 mL / min for 20 minutes.

[0327] In one or more embodiments, the inhalation administration is performed 1-4 times daily for 14 consecutive days.

[0328] In one or more embodiments, the subject has undergone combined systemic chemotherapy and surgical resection of primary osteosarcoma.

[0329] In one or more embodiments, the subject has undergone surgical resection of visible lung metastases.

[0330] In one or more embodiments, the visible lung metastases are the first lung recurrence.

[0331] In one or more embodiments, the visible lung metastases refer to lung recurrence of lung cancer.

[0332] In one or more embodiments, the lung recurrence is a second or subsequent lung recurrence.

[0333] In one or more embodiments, recurrent osteosarcoma is further detected by measuring biomarkers and comparing them with disease-free populations.

[0334] In one or more embodiments, the biomarker is a biomarker found in systemic circulation.

[0335] In one or more embodiments, the systemic biomarker is selected from microRNA-21 (miRNA-21), microRNA-199a-3p (miRNA-199a-3p), microRNA-143 (miRNA-143), differentiation cluster molecule 117 (CD117), Stro-1, bone-specific alkaline phosphatase (BALP), lactate dehydrogenase (LDH), and chondroitin sulfate epitope WF6 (WF6).

[0336] In one or more embodiments, the lung cancer is non-small cell lung cancer (NSCLC).

[0337] In one or more embodiments, the NSCLC is bronchioloalveolar carcinoma (BAC).

[0338] One or more embodiments of this application provide the use of a therapeutic dose of inhaled cisplatin lipid complex (ILC) for the treatment of pulmonary micrometastases in subjects with primary osteosarcoma without visible pulmonary metastases, including: (1) Surgical resection of primary osteosarcoma with or without systemic chemotherapy, resulting in no grossly visible residual lesions in the subjects; and (2) Inhaled cisplatin lipid complex (ILC) was administered via inhalation at a dose of 18 mg / m². 2 -36mg / m 2 , The ILC is dispersed throughout the aqueous phase of the dispersion.

[0339] In one or more embodiments, the ILC further comprises liposomes.

[0340] In one or more embodiments, the liposomes comprise sterols and phosphatidylcholine.

[0341] In one or more embodiments, the sterol is cholesterol.

[0342] In one or more embodiments, the phosphatidylcholine is dipalmitoylphosphatidylcholine (DPPC).

[0343] In one or more embodiments, the administration by inhalation is performed using a nebulizer.

[0344] In one or more embodiments, the dose administered by inhalation is 36 mg / m³. 2 .

[0345] In one or more embodiments, the minimum dose administered by inhalation is 24 mg / m³. 2 .

[0346] In one or more embodiments, the minimum dose administered by inhalation is at least 18 mg / m³. 2 .

[0347] In one or more embodiments, the dispersion is a particle with a size ≤1 μm.

[0348] In one or more embodiments, the administration by inhalation is carried out at a rate of 0.3 mL / min for 20 minutes.

[0349] In one or more embodiments, the inhalation administration is performed 1-4 times daily for 14 consecutive days.

[0350] Detailed description of the invention The described invention can be better understood from the following description of exemplary embodiments. It will be apparent to those skilled in the art that the embodiments described herein are exemplary and illustrative only, and not restrictive.

[0351] definition: All terms used throughout this specification have the definitions given herein.

[0352] As used herein, the terms “administration,” “dosage,” or “giving” mean the administration or supply of a drug, including in vivo administration and direct administration to living tissues or cells in vitro. Generally, a compound can be administered systemically via oral, oral, parenteral, topical, inhalation, or insufflation (i.e., through the mouth or nose) or rectal administration in a unit-dose formulation containing the desired conventional, non-toxic, pharmaceutically acceptable carrier, excipient, and medium, or via, for example, but not limited to, injection, implantation, transplantation, topical application, or parenteral administration.

[0353] As used herein, the term “adverse event” or “AE” refers to any undesirable change from a patient’s baseline condition related to the use of the medical product. An undesirable change is any adverse or unintentional symptom, including but not limited to abnormal laboratory findings, symptoms or illnesses occurring during the study (whether or not considered related to the investigational drug). As used herein, the term “treatment-related AE” refers to any AE that is temporally related to the use of the investigational drug, whether or not considered related to the investigational drug.

[0354] As used in this article, the term "aerosol" refers to substances that are suspended in a gas or that consist of fine solid or liquid particles dispensed from a pressurized container.

[0355] The terms “pharmaceutical” and “therapeutic agent” are used interchangeably herein to refer to a drug, molecule, complex, or other substance that provides a therapeutic effect. The term “active agent” as used herein refers to a component, part, or portion of the described complex of the invention responsible for the intended therapeutic effect.

[0356] The term "albumin" used in this article refers to a protein produced by the liver. Serum albumin testing can determine whether a patient has liver disease, kidney disease, or whether the body is not absorbing enough protein. For example, the normal range for blood albumin is 3.4-5.4 g / dL; serum albumin levels below normal may be an indication of liver disease, kidney disease, Crohn's disease, Whipple's disease, etc.

[0357] As used in this article, "alkaline phosphatase" refers to a hydrolytic enzyme responsible for removing phosphate groups from many types of molecules, including nucleotides, proteins, and alkaloids. An increase in blood alkaline phosphatase can be an indicator of liver disease or bone disorders such as osteosarcoma, rickets, Paget's disease, and so on.

[0358] The term "apoptosis" or "programmed cell death" refers to a highly regulated and active process that results in biological equilibrium, consisting of a series of biochemical events that cause various morphological changes (including bubbling, changes in the cell membrane such as asymmetry and loss of adhesion, cell shrinkage, nuclear fragmentation, chromatin condensation, and chromosomal DNA breaks) without harming the organism.

[0359] Apoptosis is induced by many different factors and involves multiple signaling pathways, some dependent on caspases (a class of cysteine ​​proteases) and others independent of caspases. It can be triggered by many different cellular stimuli, including cell surface receptors, stress-responsive mitochondrial responses, and cytotoxic T cells, leading to the activation of apoptosis signaling pathways.

[0360] Caspases involved in apoptosis transmit apoptotic signals in a proteolytic cascade, causing caspases to cleave and activate other caspases (which subsequently degrade other cellular targets leading to cell death). Caspases at the upper end of the cascade include caspase-8 and caspase-9. Caspase-8 is the initiating caspase involved in the response to receptors with death domain (DD)-like Fas.

[0361] Receptors in the TNF receptor family are involved in the induction of apoptosis and inflammatory signaling. The Fas receptor (CD95) mediates apoptosis signaling via Fas-ligands expressed on the surface of other cells. Fas-FasL interactions play a crucial role in the immune system, and the absence of this system leads to autoimmunity, indicating that Fas-mediated apoptosis removes self-reactive leukocytes. Fas signaling is also involved in immune surveillance to eliminate transformed and virus-infected cells. The binding of Fas to oligomeric FasL on another cell activates apoptosis signaling through a cytoplasmic domain called the death domain (DD). The death domain (DD) interacts with signal transducers (including FAF, FADD, and DAX) to activate the caspase proteolytic cascade. Caspase-8 and caspase-10 are first activated to subsequently cleave and activate downstream caspases and various cellular substances leading to cell death.

[0362] Mitochondria participate in apoptosis signaling pathways by releasing mitochondrial proteins into the cytoplasm. Cytochrome c, a key electron transport protein, is released from mitochondria in response to apoptosis signals and activates Apaf-1 (a mitochondrial-released protease). Activated Apaf-1 activates caspase-9 and the remainder of the caspase pathway. Smac / DIABLO is released from mitochondria and inhibits IAP proteins, which normally interact with caspase-9 to inhibit apoptosis. Apoptosis regulation by Bcl-2 family proteins occurs as family members form complexes that enter the mitochondrial membrane, thereby regulating the release of cytochrome c and other proteins. Apoptotic TNF family receptors directly activate the caspase cascade but can also activate Bid (a Bcl-2 family member), which activates mitochondrial-mediated apoptosis. Bax, another Bcl-2 family member, is activated through this pathway to localize to the mitochondrial membrane and increase its permeability, thereby releasing cytochrome c and other mitochondrial proteins. Bcl-2 and Bcl-xL prevent pore formation, thus blocking apoptosis. Like cytochrome c, apoptosis-inducing factor (AIF) is a protein found in mitochondria that is released from mitochondria upon apoptosis stimulation. Although cytochrome c is associated with caspase-dependent apoptosis signaling, AIF release stimulates non-caspase-dependent apoptosis, and AIF migrates to the nucleus (where it binds DNA). AIF DNA binding stimulates chromatin condensation and DNA fragmentation, likely through the recruitment of nucleases.

[0363] The mitochondrial stress pathway begins with the release of cytochrome c from the mitochondria, which then reacts with Apaf-1, thereby triggering the autocleavage and activation of caspase-9. Caspases-3, -6, and -7 are downstream caspases activated by upstream proteases and themselves play a role in cleaving cellular targets.

[0364] Granulase B and perforin released by cytotoxic T cells induce apoptosis in target cells, thereby forming transmembrane pores and triggering apoptosis, perhaps through cleavage by caspase, although a caspase-free mechanism for granase B-mediated apoptosis has been proposed.

[0365] The cleavage of multiple nucleases activated by the nuclear genome through apoptosis signaling pathway to produce the nucleosomal ladder is a cellular response specific to apoptosis. One nuclease involved in apoptosis is DNA cleavage factor (DFF), a caspase-activated DNAse (CAD). DFF / CAD is activated during apoptosis by caspase cleaving its associated inhibitor, ICAD. DFF / CAD interacts with chromatin components such as topoisomerase II and histone H1 to condense chromatin structure and may recruit CAD to chromatin. Another apoptosis-activated protease is endonuclease G (EndoG). EndoG is encoded in the nuclear genome but is located in mitochondria in normal cells. EndoG plays a role in mitochondrial genome replication and in apoptosis. Apoptosis signaling causes the release of EndoG from mitochondria. The EndoG and DFF / CAD pathways are independent because the EndoG pathway still exists in cells lacking DFF.

[0366] Hypoxia and subsequent re-oxidation can trigger cytochrome c release and apoptosis. Glycogen synthase kinase-3 (GSK-3), a serine-threonine kinase widely expressed in most cell types, mediates or enhances apoptosis induced by many stimuli that activate mitochondrial cell death pathways (Loberg, RD et al., J. Biol. Chem. 277(44): 41 667-673 (2002)). It has been shown to induce caspase 3 activation and activation of the pro-apoptotic tumor suppressor gene p53. GSK-3 has also been shown to promote the activation and translocation of the pro-apoptotic Bcl-2 family member Bax, which induces cytochrome c release during aggregation and mitochondrial localization. Akt is a key regulator of GSK-3, and phosphorylation and inactivation of GSK-3 can mediate some of Akt's anti-apoptotic effects.

[0367] The term “connected” as used in this article means fastened, fixed, combined, joined, bonded, adhered, or assembled with.

[0368] As used in this article, the term "bicarbonate" refers to a chemical that regulates the pH of the blood. Bicarbonate (HCO3) prevents the blood pH from becoming too acidic or too alkaline. Tests can be performed to measure blood bicarbonate levels to detect conditions that affect blood bicarbonate levels, including many kidney, lung, and metabolic disorders.

[0369] As used in this article, the term "bilirubin" refers to the slightly brownish-yellow substance found in bile. Bilirubin is produced when the liver breaks down aging red blood cells. Abnormal levels of bilirubin in the blood can indicate conditions such as liver disease, gallstones, pancreatic cancer, or hemolytic anemia.

[0370] As used herein, the term "biomarker" (or "bioimprint") refers to a peptide, protein, nucleic acid, antibody, gene, metabolite, or any other substance used as an indicator of a biological state. It is a characteristic objectively measured and evaluated as a cellular or molecular indicator of a normal biological process, a pathogenic process, or a pharmacological response to a therapeutic intervention. As used herein, the term "tumor biomarker" (or "cancer bioimprint") refers to a peptide, protein, nucleic acid, antibody, gene, metabolite, or any other substance used to detect susceptibility to or presence of primary or metastatic tumors in a subject. For example, biomarkers that can be used for osteosarcoma detection include, but are not limited to, microRNA-21 (miRNA-21), microRNA-199a-3p (miRNA-199a-3p), microRNA-143 (miRNA-143), differentiation cluster molecule 117 (CD117), Stro-1, bone-specific alkaline phosphatase (BALP), lactate dehydrogenase (LDH), chondroitin sulfate epitope WF6 (WF6), etc.

[0371] As used in this article, the term "calcium" refers to a mineral essential for bones, teeth, heart, nerves, and the blood clotting system. Testing blood calcium levels can indicate problems with the parathyroid glands, kidneys, or bones, pancreatitis, or cancer (e.g., osteosarcoma).

[0372] The term "capacity" as used in this article refers to the amount of oxygen absorbed by pulmonary capillary blood per unit of the average oxygen gradient between alveolar air and pulmonary capillary blood per minute. The term "vital capacity" or "VC" as used in this article refers to the maximum volume of air that can be exhaled from the lungs after a maximal inspiration. The term "forced vital capacity" or "FVC" as used in this article refers to the vital capacity measured when a subject exhales as quickly as possible.

[0373] As used in this article, the term "carbon monoxide diffusion capacity" or "DLco" refers to the lungs' ability to absorb inhaled, non-reactive test gases such as carbon monoxide (CO) that are bound to hemoglobin. DLco is the rate of CO absorption per driving pressure in the alveoli and can be expressed as: DLco = Vco / PAco, where Vco = CO absorption (mL / min); and PAco = mean alveolar pressure of CO (mL in mercury). For example, obstructive airway diseases, interstitial lung disease, and pulmonary vascular disease can cause a decrease in DLco.

[0374] As used herein, the term "carrier" or "pharmaceutically acceptable carrier" refers to a pharmaceutically acceptable inert agent or medium, often referred to as an "excipient," for the delivery of one or more active agents to a subject. The carrier must possess sufficiently high purity and sufficiently low toxicity to be suitable for administration to a therapeutically treated subject. The carrier should also maintain the stability and bioavailability of the active agent. The carrier may be liquid or solid and is selected according to the intended mode of administration to provide the required volume, consistency, etc., when combined with the active agent and other components of a given complex.

[0375] As used in this article, the term "cell" refers to the structural and functional unit of a living organism and is the smallest unit classified as a living organism.

[0376] As used in this article, "cholesterol" refers to the waxy, lipid-like substance found in all cells of the body. Cholesterol is the main sterol synthesized by animals and is an essential structural component of animal cell membranes, as well as a precursor in the biosynthesis of steroid hormones, bile acids, and vitamin D.

[0377] The term “cisplatin” or “cis-diamine dichloroplatin(II)” as used in this article refers to platinum-based anticancer chemotherapy drugs that act as alkylating agents.

[0378] As used in this article, the term "compatible" means that the components of a complex can be combined with each other in a manner that does not significantly reduce the effectiveness of the complex under normal use conditions.

[0379] The term "complete blood count" or "CBC" as used in this article refers to a laboratory test that provides detailed information about the quantity and quality of various blood cell types. It typically includes measurements of various blood cells in the three main blood cell types (red blood cells, white blood cells, and platelets), as well as measurements of hemoglobin and hematocrit. "Hemoglobin" (HGB) refers to the number of grams of hemoglobin (g / dL) in deciliters of blood. Normal hemoglobin levels in healthy adult subjects are approximately 14-18 g / dL for men and approximately 12-16 g / dL for women. As a rough guideline, hemoglobin should generally be about one-third of hematocrit. "Red blood cell count" (RBC) refers to the total number of red blood cells in a given blood volume. The normal range in human subjects is approximately 4.5 million cells / mm³ for men. 3 - Approximately 6.0 million cells / mm 3 For women, it is approximately 4.0 million cells / mm². 3 - Approximately 5.5 million cells / mm 3 White blood cell count (WBC) refers to the total number of white blood cells or white blood cells in a given blood volume. The normal range in human subjects is approximately 4.3 x 10⁻⁶. 3 cells / mm 3- Approximately 10.8 x 10 3 cells / mm 3 Hematocrit (HCT) refers to the percentage of red blood cells in the total blood volume. Normal hematocrit in human subjects is approximately 40%–55% for men and approximately 35%–45% for women.

[0380] The term "component" as used in this article refers to a component, element, or ingredient.

[0381] The terms “complex” or “formulation” are used interchangeably herein to refer to the product of the present invention comprising all active and inert ingredients. The term “active” refers to the ingredient, composition, or component in the complex of the present invention described that is responsible for the intended therapeutic effect. As used herein, the terms “pharmaceutical formulation” or “pharmaceutical complex” refer to a formulation or complex used to prevent, reduce, cure, or otherwise treat a target condition or disease.

[0382] The term “symptom” as used in this article refers to various health conditions and is intended to include disorders or diseases caused by injury or any underlying mechanism or disorder.

[0383] As used herein, the term "contact" and its various grammatical forms refer to a state or condition of touching or direct or partial proximity. Contact between a complex and a target can occur through any route of administration known to those skilled in the art.

[0384] As used in this article, the term "creatinine" refers to a waste product generated from the normal breakdown of muscle tissue. Blood tests that check creatinine levels are used to determine kidney function.

[0385] As used in this article, the terms “delay,” “slowdown,” “delayed,” or “to be delayed” mean to stop, prevent, or hinder for a period of time so that it occurs more slowly or gradually than it would normally.

[0386] As used herein, the term "derivative" refers to a compound that can be produced from another compound with a similar structure in one or more steps. One or more "derivatives" of a compound retain at least some degree of the desired function of the compound. Therefore, an alternative term for "derivative" could be "functional derivative." Derivatives can include chemical modifications such as alkylation, acylation, carbamylation, iodination, or any modification that derivatizes a peptide. Such derived molecules include, for example, those in which the free amino group has been derivatized to form an amine hydrochloride, p-toluenesulfonyl, benzyloxycarbonyl, tert-butoxycarbonyl, chloroacetyl, or formaldehyde group. The free carboxyl group can be derivatized to form a salt, ester, amide, or hydrazide. The free hydroxyl group can be derivatized to form an O-acyl or O-alkyl derivative.

[0387] The term "detectable marker" includes selectable markers and analytical markers. The term "selectable marker" refers to a variety of gene products that can be selected or screened by cells transformed with expression constructs, including drug resistance markers, antigenic markers that can be used for fluorescently activated cell sorting, adhesion markers such as receptors for ligand adhesion to allow selective adhesion, and so on.

[0388] The term "detectable reaction" refers to any signal or reaction that can be detected in an assay (which may be performed with or without a detection reagent). Detectable reactions include, but are not limited to, radioactive decay and energy emission (e.g., fluorescence, ultraviolet, infrared, visible light), absorption, polarization, fluorescence, phosphorescence, transmission, reflection, or resonance transfer. Detectable reactions also include chromatographic mobility, turbidity, electrophoretic mobility, mass spectrometry, ultraviolet spectroscopy, infrared spectroscopy, nuclear magnetic resonance spectroscopy, and X-ray diffraction. Alternatively, a detectable reaction can be the result of an assay that measures one or more properties of a biological material, such as melting point, density, conductivity, surface acoustic wave, catalytic activity, or elemental composition. A "detection reagent" is any molecule that generates a detectable reaction indicating the presence or absence of a target substance. Detection reagents include any of a variety of molecules, such as antibodies, nucleic acid sequences, and enzymes. To aid in detection, detection reagents may include biomarkers.

[0389] The term “dipalmitoylphosphatidylcholine” or “DPPC” used in this article refers to a phospholipid composed of two palmitic acids and is a major component of pulmonary surfactant.

[0390] As used in this article, the terms "disease" or "disorder" refer to a condition of impaired health or functional abnormality.

[0391] As used herein, the term "dispersion" refers to a two-phase system in which one phase is distributed as small droplets within a second, or continuous, phase. In these systems, the dispersed phase is typically referred to as the discontinuous or internal phase, and the continuous phase is called the external phase and contains the continuous processing medium. For example, in coarse dispersions, the particle size is 0.5 μm. In colloidal dispersions, the dispersed particle size ranges from approximately 1 nm to 0.5 μm. Molecular dispersions are dispersions in which the dispersed phase consists of individual molecules; if the molecules are smaller than the colloidal size, the result is a true solution.

[0392] The term “event-free survival” or “EFS” as used in this article refers to the time from the diagnosis of a previous lung relapse to the diagnosis of any subsequent relapse or death.

[0393] The term “forced expiratory volume” or “FEV” as used in this article refers to the maximum amount of air that can be expelled in a given number of seconds during a forced vital capacity (VC) measurement. Although sometimes given as a percentage of forced vital capacity (FVC), it is usually given as FEV, followed by a subscript indicating the number of seconds the measurement was performed.

[0394] The terms “functionally equivalent” or “functionally equivalent” are used interchangeably in this document to refer to substances, molecules, polynucleotides, proteins, peptides or polypeptides that have similar or identical effects or uses.

[0395] The term “improvement” (or “enhancement”) used in this article refers to producing a more desirable or better condition.

[0396] As used in this article, the terms “inhalation,” “absorption,” or “inhaled” refer to the activity of drawing a substance (e.g., a drug) into the lungs.

[0397] As used in this article, the term “damage” refers to any impairment or harm to the structure or function of a body caused by an external agent or force (which may be physical or chemical).

[0398] The term “separation” as used in this article, and its various grammatical forms, refers to the placement, separation, or acquisition of proteins, molecules, substances, nucleic acids, peptides, cells, or particles from their natural environment in a form substantially free of contaminants or other substances usually associated with them.

[0399] The term "Kaplan Meier curve" or "Kaplan Meier survival curve" as used in this article refers to a curve representing the probability of a patient in a clinical study surviving a given length of time while considering numerous small intervals. The Kaplan Meier curve assumes that: (i) patients removed (i.e., lost) at any time have the same expected survival as those who continue follow-up; (ii) the survival probability is the same for patients recruited early and late in the study; and (iii) the event (e.g., death) occurs at a specified time. The probability of an event occurring at a given time point is calculated by multiplying the successive probabilities by any earlier calculated probability to arrive at a final estimate. The survival probability at any given time is calculated by dividing the number of surviving patients by the number of patients at risk. Patients who have died, withdrawn, or been removed from the study are not considered at risk.

[0400] The term "lactate dehydrogenase" used in this article refers to an enzyme that helps produce energy in almost all body tissues. Blood levels of lactate dehydrogenase (LDH) can help diagnose lung diseases, lymphoma, anemia, and liver disease, and can also help assess the effectiveness of chemotherapy, especially during lymphoma treatment.

[0401] As used herein, the term "lipid" refers to fatty or waxy organic compounds that are readily soluble in nonpolar solvents. Examples of lipids include, but are not limited to, waxes, oils, sterols, cholesterol, fat-soluble vitamins, monoglycerides, diglycerides, triglycerides (fat), phospholipids, fatty acids, isoprene-like compounds, hormones, carotenoids, and arachidic acids. As used herein, the term "anionic lipid" refers to lipids with a net negative charge. Examples of anionic lipids include, but are not limited to, phosphatidylglycerol, phosphatidylinositol, cardiolipin, phosphatidylserine, etc. As used herein, the term "cationic lipid" refers to lipids with a net positive charge. Exemplary cationic lipids include, but are not limited to, N-[1-(2,3-diolenyloxy)propyl]-N,N,N-trimethylammonium chloride (DOTMA), [1,2-bis(oleoyloxy)-3-(trimethylammonium)propane] (DOTAP), 3β[N-(N',N'-dimethylaminoethane)carbamoyl]-cholesterol (DC-Chol), and bis(octadecyl)acylaminoglycine spermine (DOGS). The term "neutral lipid" as used herein refers to a lipid that has no net charge. Examples of neutral lipids include, but are not limited to, phosphatidylethanolamine, sphingomyelin, glycolipids, cerebrosides, gangliosides, dipalmitoylphosphatidylcholine (DPPC), cholesterol, and the like.

[0402] As used in this article, the terms "lipid complex" or "lipid-complexed" refer to reagents that associate, bind, or coordinate with lipid moieties.

[0403] As used herein, the terms “liposomes,” “liposome delivery system,” or “liposome drug delivery system” refer to vesicles consisting of one or more concentric phospholipid bilayers used to deliver microscopic substances (e.g., drugs) to cells.

[0404] As used in this article, the terms “metastasis” or “metastatic” refer to tumor growth or deposition in areas of the body distant from the primary tumor, spread via the lymphatic system or bloodstream. The term “grossly visible lung metastasis” as used in this article refers to osteosarcoma metastases deposited in the lungs that are large enough to be visually perceived.

[0405] As used in this article, "metastatic osteosarcoma" refers to osteosarcoma that has spread from its primary site to one or more other sites in the body via the bloodstream or lymphatic system. "Metastatic resection" as used in this article refers to surgical removal of one or more metastatic lesions.

[0406] The term “adjustment” as used in this article means to regulate, change, adapt, or adjust to a specific measurement or proportion.

[0407] As used in this article, the terms “spray” or “atomization” refer to the conversion of a liquid into an aerosol or spray for use, for example, in drug treatment.

[0408] As used in this article, the term "nebulizer" refers to a device for producing a fine spray of liquid for use, for example, inhaling therapeutic drugs.

[0409] As used herein, the term “nucleic acid” refers to deoxyribonucleotides or ribonucleotide polymers in single-stranded or double-stranded form, and unless otherwise specified, includes known analogs (e.g., peptide nucleic acids) that have the important property of natural nucleotides (i.e., hybridization with single-stranded nucleic acids in a manner similar to that of naturally occurring nucleotides).

[0410] As used herein, the term "nucleotide" refers to a compound consisting of a heterocyclic base, a sugar, and one or more phosphate groups. In the most common nucleotides, the base is a derivative of a purine or pyrimidine, and the sugar is a pentose-deoxyribose or ribose. A nucleotide is a monomer of a nucleic acid, in which three or more are bonded together to form a nucleic acid. Nucleotides are the structural units of RNA, DNA, and several cofactors, including, but not limited to, CoA, FAD, DMN, NAD, and NADP. Purines include adenine (A) and guanine (G); pyrimidines include cytosine (C), thymine (T), and uracil (U).

[0411] The term “overall survival” or “OS” as used in this article refers to the time from the diagnosis of a previous lung relapse to death from any cause.

[0412] As used herein, the term "particle" refers to a very small component (e.g., nanoparticles or microparticles) that may contain all or part of a therapeutic agent. The particle may contain the therapeutic agent within a coated core. The therapeutic agent may also be dispersed throughout the particle. The therapeutic agent may also be adsorbed into the particle. The particle may have release kinetics of any order, including zero-order release, first-order release, second-order release, delayed release, sustained release, immediate release, and any combination thereof. In addition to therapeutic agents, the particle may include any of those materials conventionally used in the pharmaceutical and medical fields, including but not limited to etchable, non-etchable, biodegradable, or non-biodegradable materials or combinations thereof. The particle may be a microcapsule containing a therapeutic agent in a solution or semi-solid state. The particle can be virtually any shape.

[0413] As used herein, the term "phosphatidylcholine" refers to phospholipids that are major components of cell membranes and function in lipoprotein transport within tissues. Examples of phosphatidylcholine include, but are not limited to, dipalmitoylphosphatidylcholine (DPPC).

[0414] As used in this article, the term "part" refers to a portion of a whole, independent form, or a part that is incorporated into it.

[0415] The terms “prevention,” “avoidance,” “preventive,” or “will stop” used in this article refer to the effective cessation of action or progress.

[0416] The terms “primary osteosarcoma” or “localized osteosarcoma” used in this article refer to osteosarcoma located at its site of origin (i.e., bone).

[0417] The terms “extend,” “extend,” “extended,” or “will be extended” as used in this article refer to an extension in time, degree, scope, or magnitude.

[0418] As used in this article, the term “reproduction” means the replication, multiplication, or increase in number, quantity, or magnitude through any process.

[0419] The term “purification” as used in this article refers to the process of separating or removing external or undesirable factors.

[0420] The terms “recurrence” or “re-occurrence” are used interchangeably in this article to refer to the recurrence of a tumor after treatment and after a period of time when the tumor is undetectable. The terms “lung recurrence,” “lung relapse,” “lung recurrent osteosarcoma,” “lung metastases of recurrent osteosarcoma,” or “lung recurrent osteosarcoma” as used in this article refer to the re-emergence of osteosarcoma cancer cells into lung tissue after treatment and after a period of time when the osteosarcoma is undetectable.

[0421] As used in this article, the terms “reduce,” “lower,” “reduced,” or “will decrease” refer to a reduction, decrease, weakening, or elimination of degree, intensity, range, size, quantity, density, or number.

[0422] As used in this article, the term "recurrence-free interval" or "RFI" refers to the time between the diagnosis of a previous pulmonary recurrence and the diagnosis of any subsequent recurrence. In the cases of pulmonary RFI (pRFI) and extrapulmonary RFI (eRFI), the subsequent recurrence must be either pulmonary or extrapulmonary, respectively.

[0423] The term "relative" as used in this paper refers to something being significantly associated with or related to something else. The term "relative frequency" as used in this paper refers to the occurrence rate of something being significantly associated with or related to the occurrence rate of something else. For example, two cell types, X and Y, occupy a given location. There are 5 X cells and 5 Y cells at that location. The relative frequency of cell type X at that location is 5 / 10; the relative frequency of cell type Y at that location is 5 / 10. After treatment, there are 5 X cells but only one Y cell at that location. The relative frequency of cell type X after treatment at that location is 5 / 6, and the relative frequency of cell type Y after treatment is 1 / 6.

[0424] As a noun, the term "repair" as used herein refers to any correction, enhancement, reconditioning, remedy, compensation, improvement, renewal, repair, patching, etc., that restores function. When used as a verb, it means to correct, enhance, recondition, remedy, compensate, improve, renew, repair, patch, or otherwise restore function. In some implementations, "repair" includes both complete and partial repair.

[0425] The term "risk factor" as used in this article refers to anything that increases an individual's chance of developing a disease.

[0426] The term "serum aspartate aminotransferase" as used in this article refers to an enzyme normally present in liver and heart cells. Serum aspartate aminotransferase (SGOT) is released into the bloodstream when the liver or heart is damaged. Therefore, elevated SGOT levels in the blood are an indicator of liver or heart disease or damage.

[0427] The term "serum alanine aminotransferase" used in this article refers to an enzyme normally present in liver and heart cells. Serum alanine aminotransferase (SGPT) is released into the bloodstream when the liver or heart is damaged. Therefore, elevated SGPT levels in the blood are an indicator of liver or heart disease or damage.

[0428] The term "side effect" as used in this article refers to unintended drug effects.

[0429] The term "Simon two-stage optimal design" used in this article refers to the design proposed by Richard Simon for phase II clinical trials. Simon proposed two criteria (maximum and optimal) for selecting sample size and critical values. The maximum sample size and the expected sample size under the null hypothesis (H0) are minimized in the maximum and optimal designs, respectively. The expected sample size is minimized if the protocol has low activity constrained by the magnitude of type 1 and type 2 errors (Simon, R., Controlled Clinical Trials, 1989; 10:1-10).

[0430] As used in this article, the term "sterol" refers to any of the major unsaturated solid alcohols in the steroid group found in the adipose tissue of plants and animals, such as cholesterol, ergosterol, etc.

[0431] As used in this article, the term "stimulus" means activation, arousal, or stimulation. The term "stimulant" as used in this article refers to a substance that exerts a force or effect.

[0432] The terms “subject” and “patient” are used interchangeably herein to refer to an animal species of mammalian origin that may benefit from administration or method of administration of the described pharmaceutical complex of the invention. Examples of subjects include humans and other animals such as horses, pigs, cattle, dogs, cats, rabbits, mice, rats, and aquatic mammals.

[0433] As used herein, the phrase “required subject” means a subject suffering from a disease, disorder, symptom, or injury characterized by damaged or cancerous differentiated cells who (i) will be administered the pharmaceutical complex of the described invention; (ii) is receiving the pharmaceutical complex of the described invention; or (iii) has received the pharmaceutical complex of the described invention to treat a symptom, unless the context and use of the phrase indicate otherwise.

[0434] The term "syndrome" as used in this article refers to a pattern of symptoms that serves as an indication of certain diseases or conditions.

[0435] As used in this paper, the terms "technetium-99m," "Tc-99m," or "99mTc" refer to the radioactive isotope of technetium that decays via isoenergetic transition, emitting monoenergetic gamma rays of approximately 142 keV with a half-life of 6.01 h. The term "technetium bone scan" as used in this paper refers to the scanning of technetium-99m (Tc-99m or...) using the radioactive isotope of technetium. 99m Tc is used as an imaging tracer to scan for bone damage or disease (e.g., cancer).

[0436] The terms “therapeutic dose,” “therapeutic effective dose,” and “effective dose” are used interchangeably herein to refer to the amount of one or more active agents sufficient to provide the intended therapeutic benefit. Dosage levels are based on a variety of factors, including the type of lesion, the patient’s age, sex, weight, medical condition, severity of the condition, route of administration, and the specific active agent used. Dosing regimens can vary widely but can be routinely determined by a physician using standard methods.

[0437] The term "therapeutic effect" as used in this article refers to the outcome of treatment, which is judged to be desired and beneficial. Therapeutic effect can directly or indirectly include the control, relief, or cure of disease manifestations. Therapeutic effect can also directly or indirectly include the control, relief, or cure of disease progression.

[0438] As used herein, the terms “treatment,” “management,” or “will be treated” mean accomplishing one or more of the following: (a) reducing the severity of the disorder; (b) limiting the development of symptoms characteristic of the disorder being treated; (c) limiting the worsening of symptoms characteristic of the disorder being treated; (d) limiting the recurrence of the disorder in patients who previously had the disorder; and (e) limiting the recurrence of symptoms in patients who were previously asymptomatic for the disorder. The terms “treatment,” “management,” or “will be treated” include canceling, substantially inhibiting, slowing, or reversing the progression of a disease, symptom, or disorder; substantially improving the clinical or aesthetic symptoms of a symptom; substantially preventing the occurrence of the clinical or aesthetic symptoms of a disease, symptom, or disorder; and providing protection against harmful or bothersome symptoms.

[0439] This disclosure provides methods and complexes that can be used to treat lung metastases of recurrent osteosarcoma.

[0440] According to some embodiments, the described invention provides a method for treating recurrent osteosarcoma of the lung in a subject in need, comprising administering a therapeutic amount of a sterile pharmaceutical complex containing a chemotherapeutic agent to the subject via inhalation. According to some embodiments, the chemotherapeutic agent is cisplatin. According to some embodiments, cisplatin may be conjugated with a lipid portion. According to some embodiments, the lipid-conjugated cisplatin is bound to liposomes. According to some embodiments, the lipid-conjugated cisplatin is encapsulated by liposomes. Cisplatin is available from commercial suppliers of pharmaceutical materials (e.g., Johnson Matthey, West Deptford, NJ).

[0441] The described inventive complexes can be used in the form of droplets or sprays (e.g., nasal sprays, aerosol sprays, or pump sprays) or other media for inhalation or intranasal administration (intranasal delivery). Aerosol spray formulations can be contained in a pressurized container with a suitable propellant such as a hydrocarbon propellant. Pump spray dispensers can dispense metered doses or doses having a specific particle or droplet size. Any dispensing device can be configured to dispense only a single dose or multiple doses. More generally, the inventive complexes formulated for inhalation or intranasal administration can also be provided as solutions, suspensions, or viscous complexes.

[0442] The compound of the described invention can be in the form of a dispersible dry powder for delivery by inhalation or blowing (through the mouth or nose). The dry powder compound can be prepared by methods known in the art, such as lyophilization and spray milling, as disclosed in International Patent Publication No. WO 91 / 16038 and U.S. Patent No. 6,921,527, the disclosures of which are incorporated herein by reference. The compound of the described invention is placed in a suitable dosing container in an amount sufficient to provide a unit dose of treatment to a subject. The dosing container is a container fitted within a suitable inhalation device to allow the formation of an aerosol by dispersing the dry powder compound into an airflow and subsequently capturing the aerosol thus generated in a chamber having a connected nozzle (which is used for subsequent inhalation by the subject as needed). Such a dosing container includes any container packaging a compound known in the art, such as a gelatin capsule or a plastic capsule, having a removable portion that allows a flow of gas (e.g., air) to be directed into the container to dispense the dry powder compound. Such containers are exemplified by those shown in U.S. Patent Nos. 4,227,522, 4,192,309, and 4,105,027. Suitable containers also include those used in conjunction with Glaxo's Ventolin® Rotohaler powder inhaler or Fison's Spinhaler® powder inhaler. Another suitable unit-dose container providing an excellent moisture barrier is formed from an aluminum foil-plastic laminate. The drug-based powder is filled by weight or volume into recesses in a formable foil and sealed with a covering foil-plastic laminate. Such a container for powder inhalation devices is described in U.S. Patent No. 4,778,054 and is used with Glaxo's Diskhaler® (U.S. Patent Nos. 4,627,432, 4,811,731, and 5,035,237). All of these references are incorporated herein by reference.

[0443] According to some embodiments, the compound of the described invention can be delivered by other tools. Examples include, but are not limited to, nebulizers (e.g., LC Star Reusable Nebulizer, part number 022F51, Pari USA, Midlothian, VA), blowers, inhalers, or smoke generators.

[0444] According to some embodiments, the described inventive complex can be formulated with excipients or carriers selected from solvents, suspending agents, binders, fillers, lubricants, disintegrants, and wetting agents / surfactants / cosolvents. The terms "excipient" or "carrier" refer to substances that do not react harmfully with glucagon-depleting compounds. Carriers must have sufficiently high purity and sufficiently low toxicity to be suitable for administration to therapeutic subjects. Carriers can be inert, or they can have pharmaceutical benefits.

[0445] The carrier can be liquid or solid and is selected according to the planned administration method to provide the required volume, consistency, etc. when combined with the active ingredient or other ingredients of a given composition. Typical pharmaceutical carriers include, but are not limited to, binders (including, but not limited to, pregelatinized corn starch, polyvinylpyrrolidone, or hydroxypropyl methylcellulose), fillers (including, but not limited to, lactose and other sugars, microcrystalline cellulose, pectin, gelatin, calcium sulfate, ethyl cellulose, polyacrylate, or dicalcium phosphate), lubricants (including, but not limited to, magnesium stearate, talc, silica, colloidal silica, stearic acid, metal stearates, hydrogenated vegetable oils, corn starch, polyethylene glycol, sodium benzoate, sodium acetate), disintegrants (including, but not limited to, starch, sodium glycolate), and humectants (including, but not limited to, sodium lauryl sulfate). Other suitable carriers for the described invention include, but are not limited to, water, salt solutions, alcohols, vegetable oils, polyethylene glycol, gelatin, lactose, amylose, magnesium stearate, talc, silica, viscous paraffin, aromatic oils, monoglycerides and diglycerides of fatty acids, petroleum fatty acid esters, hydroxymethyl cellulose, polyvinylpyrrolidone, etc. Pharmaceutical formulations can be sterilized and, if desired, mixed with excipients (e.g., lubricants, preservatives, stabilizers, humectants, emulsifiers, salts for influencing osmotic pressure, buffers, colorants, flavorings, and / or aromatic substances, etc.) that will not adversely react with the active agent.

[0446] As used herein, the term "pharmaceuticalally acceptable carrier" refers to any substantially nontoxic carrier that can be routinely used for drug administration, wherein the active agent remains stable and bioavailable. According to some embodiments, pharmaceutically acceptable carriers of the described inventive complexes include release agents such as sustained-release or delayed-release carriers. According to some embodiments, the carrier can be any material capable of maintaining or delaying the release of the active agent of the described inventive to provide more effective administration, thereby achieving lower frequency and reduced dosage of the active ingredient, ease of handling, and prolonged or delayed effects. Non-limiting examples of such carriers include lipids, liposomes, microsponges, microspheres, or microcapsules of natural and synthetic polymers, etc. According to some embodiments, the described inventive complexes further comprise liposomes. It should be understood that liposomes comprise at least one lipid. The lipid may be the same as or different from the lipid in the lipid complex cisplatin. According to some embodiments, liposomes may be formed from various phospholipids such as cholesterol, stearamine, or phosphatidylcholine.

[0447] The lipids used in the described invention can be synthetic, semi-synthetic, or naturally occurring lipids, including phospholipids, tocopherols, sterols, fatty acids, glycolipids, negatively charged lipids, cationic lipids, or neutral lipids. Exemplary phospholipids include, but are not limited to, methionine phosphatidylcholine (EPC), methionine phosphatidylglycerol (EPG), methionine inositol (EPI), methionine phosphatidylserine (EPS), phosphatidylethanolamine (EPE), and phosphatidic acid (EPA); soybean counterparts, soybean phosphatidylcholine (SPC), SPG, SPS, SPI, SPE, and SPA; hydrogenated egg and soybean counterparts (e.g., HEPC, HSPC), stearically modified phosphatidylethanolamine, and cholesterol derivatives. Carotenoids and other phospholipids consisting of fatty acids comprising chains containing 12-16 carbon atoms at the 2 and 3 positions of glycerol and ester bonds of different head groups (including choline, glycerol, inositol, serine, ethanolamine, and corresponding phosphatidic acids) at the 1 position of glycerol. The chains on these fatty acids can be saturated or unsaturated, and the phospholipids can be composed of fatty acids with different chain lengths and degrees of saturation. According to some embodiments, the complexes of the invention described herein may include dipalmitoylphosphatidylcholine (DPPC), a major component of naturally occurring lung surfactants. Other examples include dimyristoylphosphatidylcholine (DMPC), dimyristoylphosphatidylglycerol (DMPG), dipalmitoylphosphatidylglycerol (DPPG), distearate phosphatidylcholine (DSPC), distearate phosphatidylglycerol (DSPG), dioleylaminophosphatidylethanolamine (DOPE), and mixed phospholipids such as, for example, palmitoylstearoylphosphatidylcholine (PSPC), palmitoylstearoylphosphatidylglycerol (PSPG), triacylglycerols, diacylglycerols, seranide, sphinosine, sphingomyelin, and monoacylated phospholipids, such as mono-oleoyl-phosphatidylethanolamine (MOPE).

[0448] The complexes of the invention described herein can also be readily prepared using techniques known in the art, such as those described in Remington's Pharmaceutical Sciences, 18th or 19th edition, published by Mack Publishing Company of Easton, Pennsylvania, which are incorporated herein by reference.

[0449] According to some embodiments, the complexes of the invention described herein may further comprise one or more compatible active ingredients in addition to cisplatin, intended to provide a complex having a pharmaceutical effect other than that provided by cisplatin. As used herein, "compatible" means that the active ingredients of such a complex can bind to each other in a manner that does not significantly reduce the efficacy of the individual active ingredients or the complex under normal conditions of use. Examples of other therapeutic agents include, but are not limited to, chemotherapeutic agents, radiopharmaceuticals, immunomodulators, and stem cells. Examples of chemotherapeutic agents include, but are not limited to, methotrexate, doxorubicin, carboplatin, etoposide, ifosfamide, cyclophosphamide, epirubicin, gemcitabine, and topotecan. Examples of radiopharmaceuticals include, but are not limited to, samarium-153 and strontium-89. Examples of immunomodulators include, but are not limited to, alpha-interferon and muramyl tripeptide phosphatidylethanolamine (MTP). Examples of stem cells include, but are not limited to, embryonic stem cells, somatic stem cells, adult stem cells, and induced pluripotent stem cells (IPSCs). Stem cell sources include, for example, autologous, allogeneic, and syngeneic stem cells.

[0450] The described complexes of the invention, alone or in combination with other active ingredients, can be administered to subjects in a single dose or in multiple doses over a period of time. The terms “therapeutic amount,” “therapeutic effective amount,” and “pharmaceutical effective amount” as used herein are used interchangeably to refer to the amount of the complexes of the invention that, when administered to a subject, produce a therapeutic or beneficial effect.

[0451] The concentration of the active substance is chosen to exert its therapeutic effect, but the concentration is low enough to avoid unacceptable side effects within the range and reasonable judgment of a person skilled in the art. The effective amount of the complex can vary depending on the age and physical condition of the biological subject being treated, the severity of the disease, the duration of treatment, the nature of concurrent treatments, the specific compound used, the complex or other active ingredient, the specific carrier used, and similar factors. Those skilled in the art can readily evaluate these factors and, based on this information, determine the particularly effective concentration of the complex of the described invention for its intended purpose.

[0452] A person skilled in the art can determine the pharmaceutically effective amount of the compound of the present invention by determining the unit dose. As used herein, “unit dose” refers to the amount required to produce a 50% maximal effect from the described compound (i.e., ED50). The unit dose can be assessed by extrapolation from dose-response curves from in vitro or animal model testing systems. The amount of compound in the described inventive compound that effectively treats a specific disorder or condition depends on the nature of the disorder or disease and can be determined by standard clinical techniques (see, for example, Goodman and Gilman's *The Pharmaceutical Basis of Therapeutics*, Joel G. Harman, Lee E. Limbird, Eds.; McGraw Hill, New York, 2001; *The Physiological's Desk Reference*, Medical Economics Company, Inc., Oradell, NJ, 1995; and *Drug Facts and Comparisons*, Facts and Comparisons, INC., St. Louis, Mo., 1993). The precise dosage used in formulations also depends on the route of administration and the severity of the disease or disorder, and should be determined according to the judgment of the administrator and the individual patient's condition. Various routes of administration are clear to those skilled in the art.

[0453] The dosage range of the compound of the described invention is wide enough to produce the desired therapeutic effect. The therapeutically effective amount of the compound of the described invention is administered regularly once or more daily.

[0454] According to some embodiments, the described inventive compound can be combined with other therapeutic techniques. These techniques include, but are not limited to, surgery and radiotherapy. Radiotherapy includes, for example, external beam radiotherapy, intensity-modulated radiotherapy (IMRT), conformal proton beam radiotherapy, and so on.

[0455] In one embodiment, the required subject has a history of osteosarcoma that has metastasized to the lungs. In another embodiment, the required subject has experienced first and second lung recurrences that have been surgically removed. In another embodiment, the required subject has previously received second-line chemotherapy. In another embodiment, the required subject has no grossly visible tumor residue after resection of a single-lesion lung metastasis. In another embodiment, the required subject has no grossly visible tumor residue after resection of multiple-lesion lung metastases.

[0456] In one implementation, the study participants were patients who had experienced first and second lung recurrences but had no grossly visible tumor residue after resection of lung metastases. In another implementation, the study participants were patients who had not experienced a first lung recurrence after surgical resection of a primary extrapulmonary tumor. In yet another implementation, the study participants were patients with non-small cell lung cancer (NSCLC).

[0457] Where a range of values ​​is provided, it should be understood that all interpolated values ​​between the upper and lower limits of the range (to one-tenth of the lower limit unit, unless the context clearly indicates otherwise) and any other specified values ​​or interpolated values ​​within that specified range are included in this invention. The upper and lower limits of these smaller ranges, which may be independently included within a smaller range, are also included in this invention, unless any limit values ​​are specifically excluded within that specified range. Where a specified range includes one or two limit values, the range excluding two of these included limit values ​​is also included in this invention.

[0458] Unless otherwise specified, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. While similar or equivalent methods and materials to those described herein may also be used to practice or test the described invention, preferred methods and materials are described hereafter. All publications mentioned herein are incorporated by reference to disclose and describe methods and materials relating to the cited publications.

[0459] It should be noted that, as used herein and in the appended claims, the singular “a,” “an,” and “the” include plural references unless the context clearly indicates otherwise. All technical and scientific terms used herein have the same meaning.

[0460] The publications discussed herein are provided only for their disclosures prior to the filing date of this application, and each is incorporated herein by reference in its entirety. Nothing herein is to be construed as an admission that the described invention has precedence over such disclosures by way of prior invention. Furthermore, the dates of the publications provided may differ from the actual publication dates and may require independent verification.

[0461] Example The following embodiments are provided to offer a complete disclosure and illustration of how to make and use the described invention to those skilled in the art, and are not intended to limit the scope of the invention as the inventors believe, nor to represent that the following experiments are all or only the experiments performed. Efforts have been made to ensure the accuracy of the numerical values ​​used (e.g., quantities, temperatures, etc.), but some experimental errors and deviations should be taken into account. Unless otherwise specified, parts are by weight, molecular weights are weight-average molecular weights, temperatures are in Celsius, and pressures are at or near atmospheric pressure.

[0462] Example 1: Selection of eligible subjects The study population consisted of (1) osteosarcoma patients who had previously been treated with systemic chemotherapy and surgical resection of the primary bone lesion; and (2) recurrent osteosarcoma patients who had previously been treated with combined systemic chemotherapy and surgical resection of the primary bone lesion and had recently undergone successful surgical resection of all gross lung metastases of their first or subsequent lung recurrence.

[0463] Inclusion criteria 1) History of osteosarcoma metastasizing to the lungs. (First or second lung recurrence via surgical resection, with prior second-line systemic chemotherapy permitted).

[0464] 2) The patient has no grossly visible tumor residue after resection of single or multiple lung metastases. Complete surgical remission is achieved (no grossly visible tumor residue). Pleural destruction and / or positive microscopic resection margins are permissible.

[0465] 3) Age ≥ 13 years old.

[0466] 4) The patient’s previous acute adverse reactions (excluding hair loss) have recovered.

[0467] 5) Patient's Eastern Cooperative Oncology Group (ECOG) functional status score of 0-2 (Lansky score of 50-100, if age <16 years).

[0468] 6) The patient has fully recovered from surgery and has adequate airflow and pulmonary reserve. This assessment should be determined by the investigator taking into account preoperative lung function. (As a guideline: adequate airflow is determined by measuring forced expiratory volume (FEV1) of at least 50% of the predicted value and adequate pulmonary reserve is an FEV1 / FVC ratio of 65% or greater.)

[0469] 7) The patient has sufficient renal reserve, such as serum creatinine ≤1.5mg / dl.

[0470] 8) The patient has sufficient liver function reserve, such as total erythrocyte sedimentation rate ≤1.5 mg / dL and alanine aminotransferase (ALT) or aspartate aminotransferase (AST) <2.5 times the established upper limit of normal.

[0471] 9) The patient has adequate bone marrow function, such as an absolute neutrophil count (ANC) ≥ 1,000 / mm³. 3 and platelet count ≥100,000 / mm 3 .

[0472] 10) Obtain informed consent, including (where applicable) the consent of the patient’s legal guardian.

[0473] Table 1: ECOG Functional Status Scale

[0474] Oken, MM et al., Toxicity and Response Criteria of the EasternCooperative Oncology Group. Am. J. Clin. Oncol. 5: 649-655 (1982) Table 2: Lansky Functional Status Scale

[0475]

[0476] Lansky, SB et al., The Measurement of Performance in Childhood CancerPatients. Cancer 60(7): 1651-1656 (1987) Exclusion criteria 1) Current extrapulmonary diseases.

[0477] 2) Current gross tumor remnants.

[0478] 3) More than 2 lung relapses.

[0479] 4) More than 4 weeks after a thoracotomy that leaves no visible tumor residue on the patient's chest.

[0480] 5) Pregnant or breastfeeding women.

[0481] 6) Concomitant diseases or conditions that may interfere with the study or, according to the investigator, pose an unacceptable risk to patients in this study.

[0482] 7) Contraindications or unwillingness to undergo multiple computed tomography (CT) scans and chest X-ray examinations.

[0483] 8) Unwilling or unable to comply with the research agreement for any other reason.

[0484] 9) Participate in the study of the investigational drug or device or other anticancer treatments within 14 days of administration on the first day of this study.

[0485] Example 2: Treatment Plan Inhaled lipid cisplatin (ILC) is prepared by repeated cycles of cooling and heating as described in PCT / US2005 / 040489, disclosed in WO2006 / 055352, which is incorporated herein by reference. A method for preparing lipid-based platinum compound formulations may include mixing a platinum compound with a suitable hydrophobic matrix and subjecting the mixture to one or more cycles at two different temperatures. This process is believed to form associations with the active platinum compound. For example, in an aqueous solution, when the platinum compound is cisplatin, it can form large, insoluble aggregates with a diameter greater than a few micrometers. In the presence of an amphiphilic matrix system such as a lipid bilayer, cisplatin-lipid associations are formed. For example, associations can form in the internal aqueous space, the hydrocarbon core region of the lipid bilayer, or at the liposome interface or head group. During the heating cycles of this process, cisplatin is believed to return to solution in the aqueous region of the processed mixture at a faster rate than in the lipid matrix. As a result of applying more than one cold / hot cycle, cisplatin further accumulates in the lipid matrix. Beyond theoretical limitations, experiments have shown that cisplatin-lipid association results in a more hydrophobic and compact direct surrounding layer in the interfacial bilayer. This leads to a high level of encapsulation of the active platinum compound with repeated cooling and heating cycles.

[0486] Not limited to any particular theory, it is believed that cisplatin repeatedly dissolves and crystallizes during repeated cooling / heating processes. For example, as soluble cisplatin is cooled, a portion forms a lipid complex while the remainder precipitates. Upon subsequent heating, the unencapsulated crystallized cisplatin becomes soluble again and forms a lipid complex. The encapsulated cisplatin remains substantially within the lipid complex during cooling / heating cycles (i.e., no perceptible amount leaves the lipid complex during the heating phase).

[0487] Dosage calculation The dosage of ILC is based on body surface area (BSA) calculated from the patient's actual weight and height before each treatment cycle. For larger patients, the BSA should be 2.0 m². 2 The maximum value is the upper limit. The starting dose for all patients is 36 mg / m². 2 .

[0488] ILC application ILC is administered to outpatients unless hospitalization is required for another reason. The ILC dose is administered via inhalation through a nebulizer on day 1 of the start of a 14-day cycle. The ILC is administered every 13 days.

[0489] ILC is administered via inhalation. For one cycle, 36 mg / m². 2The dosage requires a maximum of four nebulizations. Nebulizations can be grouped to allow for rest periods after each group. Each nebulization session takes approximately 20 minutes and is repeated every 14 days. Monitor patients for toxicity. Patients can be given antiemetics according to established guidelines before administering ILC.

[0490] Treatment duration Treatment continues until: 1) New lung lesions are detected (patients with new lung lesions may remain in the study until the lesions are removed and histologically confirmed as osteosarcoma, at which point the patient should be removed from the study (the date of recurrence is the date of the first imaging examination confirming the new lesion)). If there is histological evidence of necrosis of the lesion (which is believed to be caused by ILC treatment), the investigator may decide whether to keep the patient in the study. If the new lesion is not osteosarcoma, the lesion is not considered a recurrence and the patient may continue to remain in the study, provided that no alternative chemotherapy is specified for the new lesion; 2) Extrapulmonary recurrence (determined by the investigator; patients experiencing extrapulmonary recurrence may continue treatment if ILC therapy is considered to be providing clinical benefit in the lungs and no other systemic chemotherapy is specified): 3) Unacceptable toxicity occurs; 4) The patient or doctor decides to terminate the procedure.

[0491] Example 3: Non-small cell lung cancer (NSCLC) patients ILC can be used as first-line treatment, neoadjuvant (i.e., before surgery), or adjuvant therapy (i.e., after surgical resection of the primary lung tumor) for patients with non-small cell lung cancer (NSCLC). Additionally, NSCLC patients can receive adjuvant systemic chemotherapy (e.g., IV cisplatin) to treat existing disease and prevent recurrence.

[0492] Similar to osteosarcoma, NSCLC patients undergo treatment after removal of all macroscopic lesions to prevent or delay lung recurrence.

[0493] A specific histological subtype of NSCLC (approximately 5%) is "bronchioloalveolar carcinoma" (BAC). BAC typically does not spread beyond the lungs. Patients with BAC and resectable tumors are treated with ILC as neoadjuvant and / or adjuvant therapy to improve surgical outcomes (i.e., prevent future local lung recurrence). Patients with BAC and unresectable tumors are treated with ILC alone or in combination with systemic cisplatin to slow or stop local lung progression.

[0494] Although the described invention has been illustrated with reference to specific embodiments thereof, those skilled in the art will understand that various changes and equivalent substitutions can be made without departing from the true spirit and scope of the invention. Furthermore, numerous modifications can be made to adapt specific conditions, materials, composition, processes, or one or more processing steps to the objective spirit and scope of the described invention. All such modifications are intended to be included within the scope of the appended claims.

Claims

1. Use of an inhalable cisplatin liposome complex (ILC) for the preparation of a medicament for preventing or delaying the recurrence of postoperative lung metastasis of osteosarcoma or postoperative recurrence of primary lung cancer.

2. The use as described in claim 1, wherein the dose of the inhaled lipid cisplatin complex (ILC) is 18 mg / m². 2 -36mg / m 2 The ILC is dispersed throughout the aqueous phase of the dispersion; preferably, the dose administered by inhalation is 36 mg / m³. 2 Preferably, the minimum dose for inhalation administration is 24 mg / m³. 2 Preferably, the minimum dose for inhalation administration is 18 mg / m³. 2 Preferably, the dispersion is a particle with a size ≤1μm; preferably, the administration by inhalation is performed using a nebulizer; preferably, the administration by inhalation is performed at a rate of 0.3mL / min for 20 minutes; preferably, the administration by inhalation is performed 1-4 times daily.

3. The use of claim 1, wherein the inhalable cisplatin liposome complex (ILC) is a liposome comprising cisplatin; preferably, the liposome comprises a sterol and a phosphatidylcholine; more preferably, the sterol is cholesterol; more preferably, the phosphatidylcholine is dipalmitoyl phosphatidylcholine (DPPC).

4. The use of claim 1 or 2, wherein the postoperative lung metastasis of osteosarcoma or postoperative lung cancer of primary lung cancer is a macroscopic lung tumor lesion that has been surgically removed, and there is no macroscopic lung tumor residue.

5. The use of claim 1, wherein the patient with recurrence of postoperative lung metastasis of osteosarcoma has been treated with systemic chemotherapy and / or surgical removal of primary osteosarcoma.

6. The use of claim 1, wherein the patient with recurrence of primary lung cancer has been treated with systemic chemotherapy and / or surgical removal of primary lung cancer.

7. The use of claim 1, wherein the postoperative lung metastasis of osteosarcoma is recurrent osteosarcoma.

8. The use of claim 1, wherein the macroscopic lung tumor lesion is the first recurrence of lung tumor.

9. The use of claim 1, wherein the recurrence is the second or later lung recurrence.

10. The use of claim 1, wherein the primary lung cancer is non-small cell lung cancer (NSCLC).

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