Combination chemotherapy with mitomycin and vindesine in advanced non-small cell lung cancer: a pilot study by the Lung Cancer Working Party (Belgium)

The combination of mitomycin plus vindesine in advanced non-small cell lung cancer induced an objective response rate of 23% in 43 evaluable patients: 33% in nonpretreated patients (nine responses among 27 patients) and 6% in pretreated patients (one response among 16 patients). Toxicity was tolerable. We conclude that the regimen was a moderately active and easy to administer treatment for advanced non-small cell lung cancer.

[Polychemotherapy of undifferentiated small cell bronchial cancer. Long-term results]

Long-term results of 2 studies combining etoposide and adriamycin with cisplatin (CAV) or cyclophosphamide (AVE) in small cell lung cancer indicate a 2-year survival rate of 22% and 18% respectively. The complete response rate 2 years after the onset of chemotherapy was 8% (8/98) : 11% (4/36) with CAV and 5% (4/62) with AVE. Among these 8 patients, 2 had a late relapse and one died of an unrelated cause. The actual long-term survival rate was 6% with CAV and 5% with AVE.

Intravenous infusion of high doses of liposomes containing NSC 251635, a water-insoluble cytostatic agent. A pilot study with pharmacokinetic data

In patients with resistant malignant tumors, we performed a pilot trial of intravenous infusion of a water-insoluble cytostatic agent, NSC 251635, entrapped in large volumes of liposomes made of egg yolk lecithin, cholesterol, and stearylamine (4:3:1). Forty liposome infusions were given to 14 patients in 38 courses. The volume of liposomes (20 mg of lipids/mL) varied from 205 to 1,000 mL or 124 to 617 mL/m2 of body surface, and amounts of NSC 251635 varied from 82 to 456 mg/m2. Three patients received repeated single courses. Liposomal therapy was very well tolerated. Side effects observed during some infusions were mild sedation, fever, chills, lumbar pain, urticarial rash, and bronchospasm. In all patients investigated, an important activation of the complement system was observed. No objective regression of the tumors was observed. The limiting factor in the phase I study was not toxicity but the volume of liposomes that could be prepared at once because of the long time required for its preparation. Pharmacokinetic data showed that maximal serum phospholipid and NSC 251635 concentrations were obtained at the end of the liposome infusion. The drug's peak was followed by a decreasing phase leading to a kind of plateau and a prolonged presence of the drug in the blood until 120 hours after its administration. Comparison of the pharmacokinetics of phospholipids and NSC 251635 suggests a rather rapid dissociation of the drug from the liposome.

Nonsurgical combined modality therapies in non-small cell lung cancer

Nonsurgical combined approaches of non-small cell lung cancer represent a concept that has only been investigated so far with chemotherapy and radiation therapy. Thoracic irradiation of locoregional disease is associated with a high rate of local control and a 5-10% long-term (5-year) survival; however, distant metastases remain the main cause of failure. This observation suggests that the tumor is often microscopically disseminated at the time of diagnosis. Systemic therapy therefore must be associated to radiation therapy to try to control both the undetectable metastases and the local disease. However, the results reported so far have been disappointing, probably because of the modest activity of the available chemotherapy. Further progress with the combined approach requires new developments in the chemotherapy of non-small cell lung cancer, particularly the introduction of new active drugs.

Superior vena caval obstruction syndrome in small cell lung cancer

In a series of 643 patients with small cell lung cancer (SCLC), 55 patients (8.6%) had signs or symptoms of superior vena caval obstruction syndrome (SVCO). Relatively long intervals from the onset of the first symptoms of SVCO to the start of therapy were observed, and invasive diagnostic procedures were safely performed in most patients. The pretreatment characteristics of patients with SVCO were not significantly different from those of patients without signs of the syndrome, and survival was similar in both groups. Patients with SVCO were usually treated first with induction chemotherapy, and prompt resolution of signs and symptoms occurred in the majority. Radiation was effective in controlling SVCO at relapse or after failure of initial chemotherapy. It was concluded that SVCO in patients with SCLC should be treated initially with systemic chemotherapy, as for other presentations of this disease. The current data do not support the commonly held view that SVCO in SCLC should be approached as an oncologic emergency.

Chemotherapy of non-small-cell lung cancer

Cisplatin (Platinol)-containing regimens, especially in combination with etoposide (VP-16) (VePesid), vindesine, and/or mitomycin-C, have proven beneficial to patients with non-small-cell lung cancer. A reproducible response rate of 30% to 40% has been achieved. Because current therapies are greatly in need of improvement, patients with non-small-cell lung cancer--especially those who have a good performance status and thus are more likely to respond--should be considered for participation in clinical studies in which the control regimens are associated with moderate response rates. Although chemotherapy affords some benefit to nonresponding patients, they might participate in phase I or phase II trials rather than continue treatment more likely to be toxic than beneficial.

Carcinoembryonic antigen: a useful prognostic marker in small-cell lung cancer

Plasma carcinoembryonic antigen (CEA) was determined in 180 patients with small-cell lung cancer (SCLC) before treatment. An abnormal level (greater than or equal to 6 ng/mL) was found in 34% of patients tested. Patients with extensive disease (39/83) had a significantly higher frequency of abnormal CEA (P = .001) than those with limited disease (22/97). There was a strong correlation between obtaining an objective response--particularly a complete response (P = .00003)--and the absence of an elevated CEA. Patients with an abnormal CEA also had a shorter survival time (P = .0007) and the difference remained statistically significant after logrank adjustment for extent of disease and ECOG (Eastern Cooperative Oncology Group) performance status. There was also a negative correlation between survival time and the quantitative level of CEA. In this series, only the group of patients with normal initial CEA levels included all survivors beyond 2.5 years. We conclude that CEA is a useful prognostic factor in SCLC.

Superior vena cava obstruction syndrome: recommendations for management

The main cause of superior vena cava syndrome (SVCS) is malignant disease. However, multiple other diseases must be considered in the differential diagnosis and a new entity, SVCS due to central venous catheters, represents an etiology of increasing importance. SVCS due to malignancy should not be considered as a radiotherapeutic emergency. Careful management including invasive procedures such as mediastinoscopy to make a definite diagnosis should be performed when necessary by skilled practitioners, as specific therapy depends on a histologic diagnosis. Irradiation remains the standard treatment for many solid tumours, particularly non-small cell lung cancer. For chemosensitive tumours such as small cell bronchogenic carcinoma or lymphoma, chemotherapy can be recommended as initial treatment, and it is associated with high regression rates of the SVCS. In the case of a recent thrombosis of the superior vena cava, fibrinolytics may be applied as suggested by the experience obtained with central venous catheters.

Combination chemotherapy with adriamycin, etoposide, and cyclophosphamide for small cell carcinoma of the lung. A study by the EORTC Lung Cancer Working Party (Belgium)

The current study reports the results of Adriamycin (doxorubicin), etoposide, and cyclophosphamide (AVE) in small cell bronchogenic carcinoma. The overall rate of response was 82% in patients with limited disease and 66% in patients with extensive disease; complete remissions have been achieved in 20% of the patients with limited disease and in 7% of those with extensive disease. The median duration of survival was 14 months in patients with limited disease and 8.3 months in those with extensive disease. The results, and the analysis of literature, suggest that survival rather than response should be used to compare studies of chemotherapy in small cell bronchogenic carcinoma.

Late intensification in small-cell lung cancer: a phase I study of high doses of cyclophosphamide and etoposide with autologous bone marrow transplantation

We conducted a late dose intensification pilot study of small-cell lung cancer (SCLC) treated with high doses of cyclophosphamide (200 mg/kg) and etoposide (1.0 to 3.5 g/m2), administered during a period of 48 hours, as well as autologous bone marrow infusion. We have been able to administer safely 3 g/m2 of etoposide with the autologous bone marrow infusion and 1.5 g/m2 without it. Limiting extrahematopoietic toxicity appeared to take the form of irreversible cardiac failure. Complete responses have been obtained with our regimen for late dose intensification, but the duration of the responses and the survival rates of the patients were poor. This suggests that late dose intensification in incomplete responders is not superior to the usually reported results obtained with standard regimens for the treatment of SCLC.

Progress in chemotherapy of non-small cell lung cancer

We reviewed the results in the literature on chemotherapy with cisplatin and/or other new agents such as etoposide and vindesine in the treatment of non-small cell lung cancer. Associations of cisplatin with vindesine or etoposide have been overall superior to combinations of older cytostatic agents. These combinations result in an average of 30-40% objective response rate with 5% complete responses. High doses of cisplatin seem to be associated with optimal results. Vinblastine, vincristine, bleomycin, methyl-GAG and dihydrogalactitol appear to be promising in combination with cisplatin.

Significance of serum bactericidal activity in gram-negative bacillary bacteremia in patients with and without granulocytopenia

Serum bactericidal activity was determined routinely in 89 patients with gram-negative bacillary bacteremia, 79 of whom were analyzed because they had granulocyte counts either below 100/mm3 or above 1,000/mm3. A peak (one hour after the administration of the antibiotics) serum bactericidal titer of 1:8 or more in non-granulocytopenic patients or 1:16 or more in severely granulocytopenic patients could be correlated with a favorable clinical response, in 98 percent (44 of 45) (p less than 0.0001) and 87 percent (20 of 23), (p less than 0.001) respectively. Granulocytopenic patients required a statistically significantly higher serum bactericidal activity for a favorable response. Serum bactericidal activity appears to be a useful and simple method to monitor antibiotic treatment in gram-negative bacillary bacteremia, especially when combination therapy is used.

Causes of death in febrile granulocytopenic cancer patients receiving empiric antibiotic therapy

We reviewed the causes of death of 55 granulocytopenic patients who received empiric antibiotic treatment for fever according to an EORTC cooperative protocol; 53 presented cancer and 2 aplastic anemia. Among the 55 patients, 19 (35%) deaths were attributed to infection: 16 to bacterial and 3 to fungal infections. Among the patients with bacterial infections, 12 died from septic shock, 3 from pneumonia and 1 from Pseudomonas aeruginosa meningitis. The most frequent non-infectious causes of death were the cancer progression (18%) and hemorrhagic complications (27%), most often cerebromeningeal in relationship to thrombocytopenia. A large number of the patients who died from infection (78%) and hemorrhage (74%) had advanced cancer with poor chances to respond to anticancer therapy.

Iv administration of a water-insoluble antimitotic compound entrapped in liposomes. Preliminary report on infusion of large volumes of liposomes to man

Five patients with advanced multiresistant neoplasms were infused with NSC-251635 (a water-insoluble antimitotic agent) entrapped in egg yolk lecithin, cholesterol, and stearylamine liposomes. The maximum volume injected was 400 ml containing 8 g of lipids, ie, a dose of 135 mg/kg of body weight. Overall tolerance of the treatment was excellent. This study indicates that liposomes may be used safely as carriers for the iv administration of water-insoluble drugs to humans.