Effective therapy for poor-prognosis non-Hodgkin's lymphoma with 8 weeks of high-dose-intensity combination chemotherapy

PURPOSE

Despite substantial advances in the treatment of aggressive non-Hodgkin's lymphoma, therapeutic results with conventional regimens remain poor in some subsets of patients. In an attempt to improve the prognosis of such patients we used an 8-week, multidrug chemotherapy regimen of high dose-intensity.

PATIENTS AND METHODS

Between April 1986 and April 1991, 70 patients with advanced intermediate- or high-grade non-Hodgkin's lymphoma were treated. The median age was 41 years (range, 18 to 69). Fifty-one patients (73%) had stage IV disease; 37 (53%) were Shipp's category 3; 17 (24%) had small noncleaved-cell lymphoma; 35 (50%) had Eastern Cooperative Oncology Group (ECOG) performance status > or = 2; 24 (34%) had two or more extranodal sites involved; and 17 (24%) had bone marrow involvement. The 8-week regimen included cyclophosphamide, etoposide, doxorubicin, vincristine, bleomycin, methotrexate with leucovorin rescue, and prednisone.

RESULTS

Sixty-two of 70 patients completed the regimen as planned. Fifty-seven patients (81%) obtained a complete response (CR) and the actuarial 5-year failure-free survival rate is 52%. Thirty-seven patients remain alive and disease-free a median of 35 months (range, 7 to 68) after therapy. Adverse prognostic factors included age more than 50 years, bone marrow involvement, and serum lactic dehydrogenase (LDH) more than 500 IU/L (normal range, 125 to 250). Myelosuppression was responsible for most of the treatment-related toxicity. Severe leukopenia (< 1,000/microL) occurred in all patients and lasted a median of 9 days. Seven patients (10%) died of myelosuppression-related complications; five of these patients were older than 60 years.

CONCLUSION

This brief but intensive therapy was effective in treating poor-prognosis patients with non-Hodgkin's lymphoma. With this therapy, patients with small noncleaved-cell lymphoma or Shipp's category 3 disease had treatment outcome similar to the group as a whole. This therapy was not well tolerated by patients older than 60 years, and should not be given to this subgroup. Verification of these results in a randomized trial setting is indicated.

Bioavailability of low-dose oral etoposide

PURPOSE

To determine the bioavailability of oral etoposide capsules administered at doses of 100 mg and 400 mg.

PATIENTS AND METHODS

The bioavailability of oral etoposide was determined by measuring the area under the etoposide plasma concentration versus time curve (AUC) following intravenous (IV) etoposide administration and comparing that value to the AUC achieved following an oral dose administered 1 day later to the same patient. The bioavailability of a 100-mg oral dose of etoposide was measured on 16 occasions in 11 patients. The bioavailability of a 400-mg dose was determined on 12 occasions in six patients.

RESULTS

The mean (+/- SD) bioavailability following a 100-mg dose of oral etoposide was 76% +/- 22%, which was significantly greater (P < .01) than the mean bioavailability of 48% +/- 18% following a 400-mg oral dose. The coefficient of variation in oral etoposide bioavailability was significant: 29% with a 100-mg oral dose and 37% with a 400-mg dose.

CONCLUSION

Bioavailability of a 100-mg oral etoposide dose is greater than suggested in the package insert from Bristol Laboratories (Evansville, IN). Comparable oral etoposide doses are not uniformly twice that of an IV dose, as suggested by the package insert, but will depend on the final oral dose administered. Bioavailability is better at lower oral etoposide doses. This study confirms the wide interpatient and intrapatient variability in oral etoposide bioavailability.

Optimal therapy for small noncleaved cell lymphoma

Small noncleaved cell lymphoma is now well recognized as a specific subtype of non-Hodgkin's lymphoma with distinctive clinicopathologic characteristics. Initial treatment results in children with endemic Burkitt's lymphoma also indicated a unique sensitivity to cytotoxic chemotherapy; to this day, Burkitt's lymphoma remains one of the few human tumors potentially curable with single-agent chemotherapy. However, the development of effective therapy has proved more difficult in nonendemic SNCL, where presentation with advanced stage and large tumor bulk occurs in most patients. The combination chemotherapy regimens currently considered standard for treatment of large-cell lymphoma have usually produced only transient responses in patients (both children and adult) with SNCL. Recently, several regimens of increased dose intensity have yielded encouraging results both in children and adults. High complete response rates and long-term disease-free survival rates in the 60% range have been reported from several institutions using such regimens. At present, we feel that adults without severe coexisting problems should be treated with high dose-intensity regimens, such as those developed at MD Anderson and Vanderbilt. Routine treatment of these patients with standard lymphoma regimens should be avoided, since the cure rate with this approach has been low. Curative therapy for these patients can be of brief duration, and maintenance therapy is not necessary. Although guidelines are unclear, it seems reasonable at present to include meningeal prophylaxis in the treatment of Stage III and IV patients. Since dose intensity has emerged as an important factor in the curative therapy of SNCL, further exploration of this concept in future clinical trials is critical. The role of growth factors is undefined; if the frequently espoused possibility that growth factors can increase curability by allowing intensification of therapy is to be realized in any human tumor, SNCL leads the list of candidates. The role of early high-dose therapy with bone marrow transplantation is also largely unexplored in SNCL. At the other end of the spectrum, the possibility of administering lesser therapy while maintaining a high cure rate in patients with clinical Stage I SNCL needs further investigation. It is likely that continued clinical investigation will continue to improve therapeutic results in this uncommon but highly distinctive lymphoma.

Chronic administration of etoposide in the treatment of non-Hodgkin's lymphoma

The importance of schedule in the cytotoxic efficacy of etoposide is suggested by the mechanism of action and supported by clinical data in the treatment of small cell lung cancer. To further evaluate the effects of drug schedule, we studied the efficacy of oral etoposide 50 mg/m2 daily for 21 consecutive days, repeated every 28-35 days, in the treatment of refractory lymphoma. Twenty-five patients were treated; all had received previous chemotherapy and were considered incurable. Fifteen patients (60%) responded to treatment (14 partial responses, 1 complete response), including 5 of 9 patients who had received previous intravenous etoposide. Median response duration was 8 months in patients with low grade lymphoma and 3 months in those with intermediate or high grade lymphoma. The single complete responder remains disease-free 19 months after completion of therapy. Two patients responded to chronic oral etoposide immediately after progression on intravenous etoposide-containing regimens, demonstrating improved efficacy of the chronic schedule. Single agent etoposide, administered at this dose for 21 days, provides an effective and convenient treatment option for patients with indolent lymphoma. Incorporation of this etoposide schedule into combination regimens for aggressive lymphoma is currently under investigation, and preliminary results are reported. We are currently conducting a phase I study using low dose, continuous infusion etoposide (25 mg/m2/day). By avoiding high peak serum levels and maintaining a constant serum level of approximately 1 microgram/ml, we hope to retain efficacy and minimize or avoid myelotoxicity. Continuous infusion was continued for as long as tolerated. Blood counts were measured weekly, and therapy temporarily interrupted if WBC < 2000/microL developed.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of mitoxantrone, 5-fluorouracil and high-dose leucovorin in the treatment of advanced breast cancer

BACKGROUND

Metastatic breast cancer remains an incurable disease; therefore, both the efficacy and the toxicity of palliative chemotherapy are important considerations. Mitoxantrone and 5-fluorouracil (5-FU) with high dose leucovorin are active drugs in the treatment of breast cancer, and both can be given with relatively few side effects. We evaluated the efficacy and toxicity of these agents in a combination regimen for the treatment of metastatic breast cancer.

PATIENTS AND METHODS

In a phase II study, we treated 35 women with metastatic breast cancer with the following regimen: mitoxantrone 12 mg/m2 i.v. day 1; leucovorin 300 mg i.v. over 1 hour followed by 5-FU 350 mg/m2 i.v. push on days 1, 2 and 3; courses repeated every 21 days. Responding patients received a total of 6-8 courses. Most patients were receiving second-line chemotherapy for metastatic breast cancer, but some were receiving first-line therapy following failure of adjuvant chemotherapy.

RESULTS

Twenty of 31 assessable patients (65%) had objective responses; in addition, 2 of 4 patients with bone-only metastases had sustained symptomatic responses. Toxicity was mild and the regimen was well tolerated. The activity of this drug combination has been verified in several other phase II studies.

CONCLUSIONS

The combination of mitoxantrone, 5-FU and high-dose leucovorin provides an attractive option for second-line chemotherapy of metastatic breast cancer. The efficacy of this combination in first-line therapy is currently being compared to cyclophosphamide, methotrexate and 5-FU (CMF) in a randomized trial.

Combination chemotherapy with oral etoposide

Chronic administration of etoposide over multiple days has proved to be an effective schedule against a variety of neoplasms. The usual duration of etoposide administration is 3 to 5 days. However, recent studies have demonstrated this agent can be administered for up to 21 consecutive days with acceptable toxicity. Studies are currently under way to determine whether more protracted etoposide administration will prove to be more efficacious in the management of selected malignancies. Previous work at our institution has confirmed the activity of protracted administration of single-agent etoposide against small cell lung cancer and non-small cell lung cancer. More recently, we have combined either cisplatin or carboplatin with etoposide given orally for 21 consecutive days in phase II trials in patients with small cell lung cancer and non-small cell lung cancer. The results of these trials are reviewed.

Single-dose ondansetron for the prevention of cisplatin-induced emesis: efficacy results

Ondansetron 0.15 mg/kg, given intravenously (IV) every 4 hours for three doses, has replaced metoclopramide as standard antiemetic therapy for patients receiving cisplatin-based chemotherapy. Several clinical observations suggested that ondansetron may be effective when given in a single dose: (1) demonstration of efficacy over a wide dose range, (2) similar efficacy with dosing intervals of 2, 4, 6, and 8 hours, and (3) efficacy of single-dose regimens with high-dose metoclopramide and other 5-hydroxytryptamine3 antagonists. In this study, patients receiving cisplatin-based chemotherapy were randomized to receive one of three ondansetron dosing regimens: ondansetron 0.15 mg/kg IV every 4 hours x 3 (standard schedule), ondansetron 32 mg IV x 1, or ondansetron 8 mg IV x 1. All patients were chemotherapy naive, at least 18 years of age, Karnofsky performance status > or = 60%, and inpatients. The number of emetic episodes, nausea, and food intake were measured during the 24 hours following cisplatin administration. Six hundred eighteen evaluable patients were randomized to the three ondansetron treatment groups; 301 received moderate-dose cisplatin (50 to 70 mg/m2) and 317 received high-dose cisplatin (> or = 100 mg/m2). Patients in both cisplatin groups receiving ondansetron 32 mg had a higher complete response rate, lower failure rate, fewer total emetic episodes, less nausea, and more food intake than did patients receiving ondansetron 8 mg. In addition, the 32-mg schedule was superior to the standard three-dose schedule in that it had a lower failure rate and higher food intake and was equivalent to the standard regimen in all other comparisons. All three schedules were well tolerated. Ondansetron 32 mg given prior to cisplatin is superior to a single 8-mg dose and is at least as effective, if not superior to, the standard three-dose schedule (0.15 mg/kg every 4 hours). On the basis of these data, ondansetron 32 mg should be considered standard therapy in patients receiving cisplatin-based chemotherapy and should be the schedule with which new antiemetics and alternate dosing schedules are compared.

Etoposide/cisplatin-based chemotherapy for patients with metastatic poorly differentiated carcinoma of unknown primary site

Patients with poorly differentiated carcinoma (PDC) or poorly differentiated adenocarcinoma (PDA) of unknown primary site comprise a sizable minority (25% to 35%) of patients with carcinoma of unknown primary site. Some of these neoplasms are highly responsive to combination chemotherapy, and a minority of patients are curable. Between 1978 and 1982 we treated 67 patients with combination chemotherapy, most of whom received PVB (cisplatin/vinblastine/bleomycin) with or without doxorubicin. Thirty-eight patients (56%) responded to treatment, with 15 (22%) attaining complete responses (CRs). Nine patients (13%) are long-term disease-free survivors. Since that time, we have incorporated etoposide into our treatment program because of its synergism with cisplatin and its marked activity against several other neoplasms including germ cell tumors. Seventeen patients with PDC or PDA of unknown primary site received second-line therapy with etoposide/cisplatin after failing to respond to PVB. Ten of these patients had partial responses, with a median response duration of 5 months (range, 2 to 12). Eighty-five previously untreated patients with PDC or PDA received etoposide/cisplatin combinations as initial treatment; 57 of 78 evaluable patients (73%) responded to therapy, and 24 (31%) achieved CRs. Sixteen patients (19% of entire group) remain disease-free a median of 28 months (range, 9 to 66) after therapy. Etoposide is active against poorly differentiated carcinoma of unknown primary site. These results indicate that initial treatment with etoposide/cisplatin combinations is equivalent or superior to our previous results with PVB.

Chronic etoposide schedules in the treatment of non-Hodgkin's lymphoma

The importance of schedule in the cytotoxic efficacy of etoposide is supported by an increasing amount of clinical data. We studied the efficacy of oral etoposide (50 mg/m2/d x 21 repeated every 28 to 35 days) in the treatment of refractory lymphoma. Twenty-five patients were treated; all had received previous chemotherapy and were considered incurable. Fifteen patients (60%) had partial responses, including five of nine patients who had received previous intravenous etoposide. Median response duration was 8 months in patients with low-grade lymphoma and 3 months in those with intermediate- or high-grade lymphoma. Two patients responded to chronic oral etoposide immediately after disease progression with intravenous etoposide-containing regimens, demonstrating the improved efficacy of the chronic schedule. Single-agent oral etoposide, administered at 50 mg/m2/d for 21 days, provides an effective and convenient treatment option for patients with indolent lymphoma. Incorporation of this schedule into combination regimens for aggressive lymphoma is currently under investigation. In addition, we are exploring schedule modifications that may further decrease toxicity while maintaining efficacy.

Stratified, randomized, double-blind comparison of intravenous ondansetron administered as a multiple-dose regimen versus two single-dose regimens in the prevention of cisplatin-induced nausea and vomiting

PURPOSE

This study compares the efficacy and safety of two single-dose regimens with the approved three-dose regimen of ondansetron in the prevention of cisplatin-induced emesis.

PATIENTS AND METHODS

This multicenter study was a stratified, randomized, double-blind, and parallel group design. Chemotherapy-naive inpatients were randomized to receive intravenous (IV) ondansetron (Zofran; Glaxo Inc, Research Triangle Park, NC) 0.15 mg/kg times three doses, every 4 hours or a single 8-mg or 32-mg dose followed by two saline doses that began 30 minutes before cisplatin administration. Cisplatin (high-dose > or = 100 mg/m2 or medium-dose 50 to 70 mg/m2) was given as a single infusion (< or = 3 hours). Patients were monitored for emetic episodes, adverse events, and laboratory safety parameters for 24 hours after cisplatin administration.

RESULTS

A total of 699 patients (359 high-dose, 340 medium-dose) were enrolled. Of these, 618 were assessable for efficacy (15 ineligible, 66 protocol deviations). The 32-mg dose was superior to the 8-mg single dose with regard to total number of emetic episodes (high-dose, P = .015; medium-dose, P < .001), complete response (no emetic episodes: high-dose, 48% v 35%; P = .048; medium-dose, 73% v 50%; P = .001) and failure rate (> 5 emetic episodes, withdrawn or rescued: high-dose, 20% v 34%; P = .018; medium-dose, 9% v 23%; P = .005). The 32-mg single dose was also superior to the 0.15 mg/kg times three dose regimen with regard to total number of emetic episodes (medium-dose, P = .033) and failure rate (high-dose, 20% v 36%; P = .009; medium-dose, 9% v 22%; P = .011). Ondansetron was well tolerated. The most common adverse event was headache. An approximate 10-fold increase in the incidence of clinically significant transaminase elevations was observed in the high-dose versus medium-dose cisplatin strata (aspartate aminotransferase [AST], 6.5% v 0.7%; serum alanine aminotransferase [ALT], 5.0% v 0.3%).

CONCLUSION

A 32-mg single dose of ondansetron is more effective than a single 8-mg dose and is at least as effective as the standard regimen of 0.15 mg/kg times three doses in the prevention of cisplatin-induced acute emesis.

The use of ondansetron in patients receiving multiple-day cisplatin regimens

The control of nausea and vomiting in patients receiving multiple-day cisplatin chemotherapy has remained difficult, even with the use of combination antiemetic regimens containing metoclopramide. Although these patients receive a lower daily dose of cisplatin, the emetogenic potential remains high. In addition, many of the patients receiving multiple-day cisplatin regimens are young (eg, testicular cancer patients) and, therefore, have particular problems with the extrapyramidal side effects associated with metoclopramide. Studies show that ondansetron, used as a single antiemetic agent, is effective, safe, and well tolerated in the control of nausea and vomiting in patients receiving multiple-day cisplatin regimens.

Cisplatin-based combination chemotherapy in the treatment of poorly differentiated carcinoma and poorly differentiated adenocarcinoma of unknown primary site: results of a 12-year experience

PURPOSE

We previously reported excellent responses to cisplatin-based chemotherapy in a minority of patients with poorly differentiated carcinoma (PDC) or poorly differentiated adenocarcinoma (PDA) of unknown primary site. We have continued to study and to treat these patients, and now report clinical characteristics, treatment results, and prognostic factors in a large group of patients identified prospectively.

PATIENTS AND METHODS

Between February 1978 and December 1989, we treated 220 patients with PDC or PDA of unknown primary site. The median age was 39 years; 48% of patients had predominant tumor location in the mediastinum, retroperitoneum, or peripheral lymph nodes. Specialized pathologic studies resulted in the identification of specific tumor types in only a few cases. All patients received cisplatin-based chemotherapy; between 1978 and 1984, 116 patients received cisplatin, vinblastine, and bleomycin (PVeB) +/- doxorubicin, and 104 patients treated since January 1985 received cisplatin and etoposide +/- bleomycin.

RESULTS

One hundred thirty-eight patients (63%) had objective responses to therapy, and 58 (26%) had complete response. Thirty-six patients (16%) are currently disease-free at a median of 61 months following therapy (range, 11 to 142 months). Actuarial 10-year survival is 16%. Favorable prognostic factors identified by Cox regression analysis include: (1) predominant tumor location in the retroperitoneum or peripheral lymph nodes, (2) tumor limited to one or two metastatic sites, (3) no history of cigarette use, and (4) younger age.

CONCLUSION

Patients with PDC or PDA of unknown primary site represent another group of patients for whom potentially curative therapy is available. Patients with this syndrome should be distinguished from patients with well-differentiated adenocarcinoma of unknown primary site, and should receive a trial of cisplatin-based chemotherapy.

The role of cisplatin/bleomycin-based chemotherapy in the treatment of poorly differentiated carcinoma of unknown primary site

Between 1978 and 1990, 173 patients with poorly differentiated carcinoma or poorly differentiated adenocarcinoma of unknown primary site were treated with bleomycin-containing regimens at Vanderbilt University Medical Center. Patients were prospectively identified based on light microscopy findings. The median age of patients was 39 years; 78% were male and 76% had metastatic tumors in two or more sites. Dominant tumor location was the mediastinum, retroperitoneum, or peripheral lymph nodes in 82 patients (47%). Between 1978 and 1985, patients received cisplatin 20 mg/m2 intravenously (IV) days 1 through 5, vinblastine 0.15 mg/kg IV days 1 and 2, and bleomycin 30 U IV weekly. In 1986, etoposide 100 mg/m2 IV days 1 through 5 replaced vinblastine in the regimen. Responding patients received four courses of therapy at 3-week intervals. One hundred thirteen patients (65%) had a major response to therapy, including 47 (27%) complete responses. At present, 27 patients are disease free at a median of 78 months posttherapy (range, 11 to 142 months); an additional patient was lost to follow-up while in complete response. Median survival of the entire group was 11 months, with a 12-year actuarial disease-free survival of 16%. Combination chemotherapy with cisplatin/bleomycin and either vinblastine or etoposide is highly active in patients with poorly differentiated carcinoma of unknown primary site and is curative in a minority of these patients. A trial of this therapy should be considered in all such patients.

Tumors of unknown origin

The recognition of subsets of very treatable patients within the large heterogeneous population of carcinomas of unknown primary site represents an advance in the management of these patients. These patients with responsive tumors can be defined with appropriate clinical and pathologic evaluation. A summary of the subsets and an outline of the evaluation necessary for their identification is illustrated in Table 5. A therapeutic trial remains the only method to determine if patients have responsive tumors, and several patients who do not conform to a defined subset do respond to cisplatin-based chemotherapy. Unfortunately, there is still a large group of patients with relatively insensitive tumors. Improved therapy for these patients will probably await advances in the treatment of non-small cell lung cancer, pancreatic cancer, and the other gastrointestinal cancers, since the majority of insensitive carcinomas probably arise from these occult primary sites. We have a registry at Vanderbilt and are attempting to register patients of other physicians around the country. We request pathology material and clinical summaries and follow-up data on all these patients. An unstained slide bank has also been established so that special stains developed in the future may be rapidly evaluated. These data may eventually enable us to better determine the frequency and spectrum of these neoplasms and may allow for more specific diagnoses and therapy.

Carboplatin plus oral etoposide in the management of advanced, non-small cell lung cancer: preliminary results of a Vanderbilt trial

Twenty-eight patients with unresectable, metastatic non-small cell lung cancer (NSCLC) were treated with carboplatin/oral etoposide. Carboplatin was administered intravenously on day 1 at a dose of 300 mg/m2 (12 patients) or 350 mg/m2 (16 patients); oral etoposide was administered at a dose of 50 mg/m2/d for 21 consecutive days. Treatment was repeated every 28 days. Patient characteristics included male:female ratio of 23:5, median age of 60 years, median Eastern Cooperative Oncology Group performance status of 1, weight loss of 5% or more in seven patients; stage IIIB disease in two patients and stage IV in 26. Twenty-five patients were evaluable for response and seven (28%) achieved a partial response (95% confidence interval, 14% to 48%). Median duration of response was 3+ months (range, 2+ to 6+) and median survival was 4+ months (range, 1+ to 10+). Myelosuppression was the predominate toxicity; leukocyte and platelet nadirs occurred between days 22 and 29, with median counts of 2,900/microL and 172,000/microL, respectively. The median interval between the start of cycle 1 and the start of cycle 2 was 33 days (range, 26 to 42). Carboplatin/oral etoposide is a moderately active regimen against advanced NSCLC that can be administered in an outpatient setting with manageable toxicity. Its impact on survival remains to be determined.

Prolonged administration of oral etoposide in non-small-cell lung cancer: a phase II trial

PURPOSE

The trial was undertaken to investigate the activity and toxicity of a prolonged schedule of oral etoposide in the treatment of advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Between March 1989 and August 1990, 25 patients with advanced NSCLC were treated with oral etoposide 50 mg/m2/d for 21 consecutive days, repeated every 28 to 35 days. The median patient age was 60 years (range, 38 to 84 years); male:female ratio was 12:13. Eight patients had stage IIIB disease; 17 had stage IV. Seventy-six percent of patients had Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. No patient had received previous chemotherapy with standard agents; nine patients had received previous or concurrent radiation therapy. Plasma etoposide concentrations were measured to estimate etoposide bioavailability and kinetics.

RESULTS

Five of 22 patients (23%; 95% confidence interval [CI], 10% to 43%) had partial responses. Median response duration was 5 months (range, 2 to 6 months). Four of five responders were female. Besides alopecia, which occurred in all patients, myelosuppression was the most common toxicity, but was mild or moderate in most patients. Median leukocyte nadir during course 1 was 3,200/microL; only four of 69 courses produced a leukocyte nadir less than 1,000/microL. Severe thrombocythemia (less than 75,000/microL) did not occur. Gastrointestinal toxicity was uncommon. Median peak etoposide concentration was 3.4 micrograms/mL. A mean serum etoposide concentration greater than 1 microgram/L was maintained for more than 13 hours; the plasma concentration-time curve (AUC) was estimated to be 90% of that predicted after an identical dose of etoposide given intravenously.

CONCLUSIONS

Etoposide given by this dose and schedule has moderate activity as first-line systemic therapy for advanced NSCLC. In previously untreated patients, chronic oral etoposide is well tolerated, and incorporation into combination regimens should be feasible. Etoposide bioavailability may be increased at lower oral doses.

A phase II trial of cisplatin and prolonged administration of oral etoposide in extensive-stage small cell lung cancer

Etoposide is a schedule-dependent agent with greater activity against small cell lung cancer (SCLC) when a given dose is administered over several days compared with a 1-day administration of the same dose. In an attempt to capitalize on the schedule dependency of etoposide, 22 previously untreated extensive-stage SCLC patients were given cisplatin (100 mg/m2 on day 1) plus 21 days of low-dose, oral etoposide (50 mg/m2/d). Chemotherapy was repeated every 28 days for four cycles. Complete blood counts were monitored weekly, and etoposide was discontinued if either the leukocyte or platelet count dropped below 2000/microliters or 75,000/microliters, respectively. All 22 patients were evaluable for response; 18 had either a complete (9%) or partial response (73%), an overall response rate of 82% (95% confidence interval, 62% to 93%). The median response duration was 7 months, and the median survival was 9.9 months (range, 1 to 17+ months). Sixteen (73%) patients received all planned cycles of etoposide. In Cycle 1 of chemotherapy, the median leukocyte nadir was 2700/microliters (range, 100 to 6300/microliters), and median platelet nadir was 180,000/microliters (range, 51,000 to 397,000/microliters). Life-threatening leukopenia (less than 1000/microliters) was rare (3 of 74 cycles). There were three treatment-related deaths, only one of which was associated with neutropenia. One patient had mild renal insufficiency that resolved after discontinuation of therapy. Alopecia was observed in all patients, but other nonhematologic toxicities were uncommon. A randomized study is necessary to determine if this schedule of cisplatin and etoposide administration is superior to more standard methods. However, these data do not indicate a major survival benefit will be derived from increasing the duration of etoposide administration when used in combination with cisplatin given every 28 days.

Carboplatin plus oral etoposide in the management of unresectable non-small cell lung cancer. Preliminary results of a Vanderbilt trial

Forty-two patients with unresectable non-small cell lung cancer (NSCLC) were treated with carboplatin (300, 350 or 400 mg/m2) and 21 days of oral etoposide (50 mg/m2/day). Thirty-three patients were evaluable for response (too early to assess the remaining patients) and 9 patients (27%) achieved a partial remission. Median survival was 29 weeks (range, 4+ to 71+ weeks). The primary toxicity was myelosuppression. Leukocyte and platelet count nadirs occurred between days 22 and 29. In cycle 1, median leukocyte nadir was 2.8 x 10(9)/l and the platelet nadir was 142 x 10(9)/l. Nonhematologic toxicities were modest and included alopecia in all patients, mild nausea, mild to moderate diarrhea, and an occasional increase in serum creatinine. Carboplatin plus oral etoposide is a tolerable outpatient regimen with modest activity against unresectable NSCLC.

Prolonged administration of oral etoposide plus cisplatin in extensive stage small cell lung cancer

Etoposide is a highly schedule-dependent agent. We previously reported that a 21-day schedule of oral etoposide had good activity in small cell lung cancer (SCLC). The current phase II study was designed to test the combination of 21-day oral etoposide with cisplatin in hopes of capitalizing on etoposide's schedule dependency. Sixteen extensive stage SCLC patients were treated with cisplatin 100 mg/m2 day 1 plus 21 days of low-dose oral etoposide 50 mg/m2/day. Chemotherapy was repeated every 28 days for 4 cycles. Blood counts were monitored weekly, and etoposide was discontinued if the leukocyte or platelet count dropped below 2.0 x 10(9)/l or 75 x 10(9)/l, respectively. Fifteen of 16 patients were evaluable for response; 13 achieved either a complete (13%) or partial response (73%), for an overall response rate of 86% (95% confidence interval, 62-93%). Median response duration was approximately 7 months; median survival was not reached. Thirteen patients (81%) received all the planned cycles of chemotherapy. In cycle 1 of chemotherapy, the median leukocyte nadir was 2.8 x 10(9)/l (range, 0.1-6.3 x 10(9)/l; median platelet nadir was 180 x 10(9)/l (range, 51-397 x 10(9)/l). Life-threatening leukopenia (less than 1.0 x 10(9)/l) was unusual (2 of 58 cycles). There was 1 treatment-related death. One patient developed mild renal insufficiency that resolved after therapy. Nonhematologic toxicities were uncommon, but alopecia occurred in all patients. These data do not suggest that a major survival benefit will be derived for patients with extensive stage SCLC by increasing the duration of etoposide administration when used in combination with cisplatin. A randomized study is needed to determine if this long-term schedule of etoposide plus cisplatin is superior to the standard schedule of etoposide plus cisplatin.

Poorly differentiated carcinoma and germ cell tumors

Although many questions remain unanswered, recent clinical and pathologic studies have shed considerable light on the subject of carcinoma of unknown primary site. It is now clear that some patients in this group have extragonadal germ cell tumors. This is suggested by the superior treatment results in patients with clinical features of extragonadal germ cell tumor and is confirmed by the finding of the diagnostic chromosome abnormality in tumor cells of some patients. These patients have tumors that are unrecognizable using all available pathologic techniques other than molecular genetic analysis; most patients also do not have elevated serum tumor marker levels. Young men with poorly differentiated carcinoma located predominantly in the mediastinum or retroperitoneum should be strongly suspected of having germ cell tumors; chromosomal analysis should be obtained if possible, and these patients should be treated as for germ cell tumor. It is clear that some responsive patients with poorly differentiated carcinoma do not have extragonadal germ cell tumors. A few patients initially thought to have poorly differentiated carcinoma actually have non-Hodgkin's lymphoma. With the widespread availability of immunoperoxidase staining for LCA, this diagnostic error should be minimized. Other responsive patients have poorly differentiated neuroendocrine tumors. The nature and spectrum of neuroendocrine tumors is still being defined; however, our initial documentation of cisplatin responsiveness has been confirmed, even in poorly differentiated neuroendocrine tumors with a known primary site. It is likely that additional responsive subgroups also exist but have not yet been identified. With the availability of a diagnostic chromosomal marker, the answers to other questions regarding the relationship of poorly differentiated carcinoma and germ cell tumors will soon be forthcoming.(ABSTRACT TRUNCATED AT 250 WORDS)

Poorly differentiated carcinoma of unknown primary site: clinical usefulness of immunoperoxidase staining

To assess the clinical utility of immunoperoxidase tumor-cell staining in patients with poorly differentiated carcinoma of unknown primary site, we performed a battery of stains on tumors from 87 patients treated between August 1978 and April 1983. Poorly differentiated carcinoma or poorly differentiated adenocarcinoma was diagnosed on the basis of light microscopic examination, and all patients were treated before the technology of immunoperoxidase staining was routinely used. Therefore, results of immunoperoxidase staining can be correlated with clinical outcome in this group of similarly treated patients with a long median follow-up. Immunoperoxidase staining confirmed the diagnosis of poorly differentiated carcinoma in 49 patients (56%) and yielded other diagnoses in 14 patients (16%): melanoma, eight; lymphoma, four; prostatic carcinoma, one; and yolk sac carcinoma, one. In 24 patients (28%) the immunoperoxidase staining pattern was inconclusive; electron microscopy was usually helpful in clarifying the diagnosis in these patients. Seventy-five patients (86%) received combination chemotherapy with a cisplatin-based regimen, and 24 patients (28%) had a complete response. Nine of these patients were later given specific diagnoses by immunoperoxidase staining (lymphoma, four; melanoma, four; yolk sac tumor, one). All patients with an immunoperoxidase diagnosis of lymphoma also had clinical features compatible with lymphoma and are long-term survivors. Patients with immunoperoxidase features suggesting melanoma were surprisingly responsive to chemotherapy, with three of seven complete responses and two long-term survivors. Patients with melanoma diagnosed by immunoperoxidase staining should not be excluded from a trial of cisplatin-based therapy. Immunoperoxidase staining is useful in the routine evaluation of metastatic poorly differentiated carcinoma of unknown primary site, as it can occasionally suggest the lineage of the tumor and have specific therapeutic implications.

Mitoxantrone, fluorouracil, and high-dose leucovorin: an effective, well-tolerated regimen for metastatic breast cancer

Between September 1988 and August 1990, we treated 35 women with metastatic breast cancer with a novel regimen containing mitoxantrone, fluorouracil (5-FU), and high-dose leucovorin. This regimen was designed to take full advantage of the favorable toxicity profiles of these agents while maintaining a high level of activity. All patients had received previous chemotherapy (adjuvant only, 15 patients; at least one metastatic regimen, 20 patients). Seven patients had received previous doxorubicin, but none within 6 months of study entry. Of 31 assessable patients, 20 (65%) had objective responses (two complete, 18 partial), with a median response duration of 6 months (range, 3 to 16+ months). Four patients with bone metastases (abnormal bone scan only) and pain were not considered assessable by strict response criteria; two of these patients had sustained symptomatic relief for 6 and 8 months, respectively. Myelosuppression was the most frequent toxicity but was mild in most patients; only four hospitalizations for fever and neutropenia were required (2% of courses). No severe thrombocytopenia occurred and no RBC transfusions were required. Alopecia, mucositis, and nausea/vomiting were uncommon and were not severe in any patient. The combination of mitoxantrone, 5-FU, and high-dose leucovorin is well tolerated and active as a first- or second-line treatment for metastatic breast cancer. Comparison with other standard regimens for breast cancer is indicated.

Neoadjuvant cisplatin plus vinblastine chemotherapy in locally advanced non-small cell lung cancer

Twenty-eight patients with locally advanced, unresectable non-small cell lung cancer (NSCLC) received neoadjuvant chemotherapy with cisplatin (120 mg/m2 on days 1 and 29) and vinblastine (4 mg/m2 weekly for 6 weeks). At the completion of induction chemotherapy, all patients were assessed for resectability. Those patients judged to be resectable underwent thoracotomy. All remaining patients received thoracic radiation therapy (5500 cGy) followed by additional chemotherapy in those patients responding to neoadjuvant treatment. There were 15 partial responses to neoadjuvant chemotherapy for an overall response rate of 54% (95% confidence interval, 36% to 71%). Only five partially responding patients (18%) were thought to have had sufficient tumor regression to allow for a potentially curative resection. However, a complete resection was done in only two patients. Overall median survival was 12 months (range, 4 to 72 months) with 1-year, 2-year, and 3-year survival rates of 54%, 39%, and 11%, respectively. The primary toxicity associated with neoadjuvant chemotherapy was moderate to severe (Eastern Cooperative Oncology Group Grade 3 or 4) nausea and emesis in 25% of patients. Hematologic toxicity was relatively modest; only one patient had Grade 4 leukopenia (less than 1000/microliter). Fever and neutropenia were uncommon, and there were no documented septic episodes or treatment-related deaths. Compared with historic controls treated with radiation therapy alone, cisplatin-based neoadjuvant chemotherapy appeared to improve the median and long-term survival of Stage III NSCLC patients modestly.