Randomized clinical trial comparing mitoxantrone with doxorubicin in previously treated patients with metastatic breast cancer

Three hundred twenty-five women with metastatic adenocarcinoma of the breast who had failed one prior chemotherapeutic regimen for advanced disease were randomized to receive 14 mg/m2 of mitoxantrone or 75 mg/m2 of doxorubicin intravenously (IV) every 3 weeks. Enrollment was closed on October 31, 1984, after 165 patients were randomized to mitoxantrone and 160 patients to doxorubicin. Patients randomized to the two treatment groups were compared for response rate, duration of response, time to progression or death, time to treatment failure (TTF), and survival. The response rate to mitoxantrone was 20.6%, to doxorubicin 29.3% (P = .07). The median response duration was 151 days for the mitoxantrone group and 126 days for the doxorubicin group (P = .16). The median TTF was 70 days in the mitoxantrone group and 104 days in the doxorubicin group (P = .36). The median survival of patients initially randomized to receive mitoxantrone was 273 days; for doxorubicin 268 days (P = .40). There were three responses among 77 patients crossed over to mitoxantrone after initial treatment with doxorubicin. The major dose-limiting toxicity for both drugs was leukopenia. There was significantly less severe and less frequent toxicity with mitoxantrone administration. Severe nausea and vomiting occurred in 9.5% of mitoxantrone patients and 25.3% of doxorubicin patients (P less than .001). The incidence of severe stomatitis and mucositis was 0.6% in the mitoxantrone group and 8.4% in the doxorubicin group (P = .001). Severe alopecia occurred in 5.1% of mitoxantrone patients and 61.0% of doxorubicin patients (P less than .001). A life-table comparison of the cumulative dose to the development of a cardiac event showed that mitoxantrone had significantly less cardiotoxicity than doxorubicin (P = .0005). This study demonstrates that mitoxantrone is active as a single agent in the treatment of metastatic breast cancer. Compared with doxorubicin it appears to be marginally less active and significantly less toxic. We conclude that mitoxantrone can be used alone or with other standard drugs to palliate the symptoms of metastatic breast cancer, especially in settings where drug toxicity is an important consideration.

A randomized trial comparing mitoxantrone with doxorubicin in patients with stage IV breast cancer

Mitoxantrone (Novantrone; dihydroxyanthracenedione) is an anthraquinone previously shown to be active in human breast cancer. It appears to have less toxicity than doxorubicin. Results of this phase II-III randomized cross-over trial to determine the relative efficacy and toxicity of mitoxantrone in comparison to doxorubicin, are presented. Patients with measurable, recurrent breast cancer with limited prior chemotherapy with or without radiotherapy for metastatic disease, and who had not been exposed to prior doxorubicin, were randomized to receive either mitoxantrone or doxorubicin every three weeks with cross-over on progression. Response rates, duration of remission, time to treatment failure, and drug toxicity, including cardiac toxicity evaluated with serial radionuclide angiocardiography, were evaluated. Differences in the response rates for the two groups were not statistically significant. Neither time to treatment failure nor duration of response are significantly different (p greater than 0.05). With respect to toxicity, mitoxantrone treated patients consistently exhibited a lower incidence and less severe drug toxicity as compared to their doxorubicin-treated counterparts. Cardiac toxicity was carefully monitored and thus four patients on doxorubicin have had drug related congestive heart failure, as compared to none on mitoxantrone. In summary, mitoxantrone appears to be as active as doxorubicin in patients with stage IV breast cancer previously treated with chemotherapy; however, mitoxantrone causes significantly less nausea, vomiting, stomatitis and alopecia at doses which induce equal or greater myelosuppression than doxorubicin, and appears to be less cardiotoxic.

Totally implantable venous access system for cyclic administration of cytotoxic chemotherapy

Utilization of the totally implantable infusion system provides a convenient, cost-effective, and safe administration technique for oncology patients who require cyclic or continuous intravenous medication. In addition, it provides an excellent conduit for blood withdrawal access. The efficacy of this technique abrogates the necessity for periodic replacement of subclavian lines and their associated complications and possibly represents an advantage over percutaneous Broviac and Hickman catheters and the attendant catheter-related sepsis associated with their use. The initial low incidence of complications and absence of catheter thrombosis with this implantable system suggests its superiority over percutaneous silicone catheter devices for bolus drug injection and the continuous infusion of chemotherapeutic agents. Cyclic or continuous infusion of hypertonic dextrose and amino acid solutions (total parenteral nutrition) with this system is being evaluated but cannot yet be recommended as being more advantageous than infusion with an implanted Hickman or Broviac catheter.

An overview of thymidine

This review summarizes a body of information suggesting that proper metabolic modulation with certain metabolites can sensitize tumor cells to anti-metabolites, and others can de-sensitize (i.e. protect) normal cells from the toxicity of anti-metabolites. This new approach offers the possibility of increasing the selectivity of drug therapy, with the promise of a real advance in cancer chemotherapy. The metabolite thymidine (TdR), long used as a cell synchronizing agent, is known to exert this effect in vitro by metabolic modulation of a number of enzymes in the salvage pathway to DNA synthesis. Against this biochemical background, in vivo effects of TdR employed as an agent for cancer therapy are reviewed as follows: 1) TdR alone, and in combination with, 2) Methotrexate (MTX), or 3) 5-Fluorouracil (FU), or 4) Cytosine arabinoside (ara-C). TdR is shown in all instances either to protect against host toxicity (eg. MTX), or to potentiate the anti-tumor effect (eg. FU and ara-C). Findings are also presented that a sequential schedule of MTX prior to TdR prior to FU is important for the optimal therapeutic activity of these drugs. The biochemical basis for the MTX leads to FU augmentation is reportedly due to increased activation of FU by MTX (acting indirectely). On the basis of this biochemical insight, a completely different chemotherapeutic agent methyl-mercaptopurine raboside (MMPR) was substituted for MTX, resulting in a dramatic potentiation of anticancer activity. Metabolic modulation with still other metabolites (UR) and a hormone (testosterone) was demonstrated to protect from host toxicity due to certain anti-cancer agents without offsetting anti-tumor activity. The ability to prevent leukopenia by these means was particularly impressive. Clinical trials have been initiated with TdR alone, TdR + MTX, and TdR + FU; the available clinical data are summarized.

Phase I evaluation of piperazinedione in patients with advanced cancer

The effects of iv administered piperazinedione were studied in 28 evaluable adult and eight evaluable pediatric patients with advanced cancer. Piperazinedione produced predictable myelosuppression of moderate degree at dosages of 3--3.5 mg/m2/day X 5 days by iv injection. When given in this manner, nausea and vomiting did not occur. Single iv doses of 10--15 mg/m2 produced mild-to-moderate nausea and vomiting and mild myelosuppression. Thrombocytopenia was more severe than leukopenia in both schedules. The drug produced comparable dose-related effects in adults and children. Although no therapeutic response was observed in the adults, a partial remission of 6 months' duration was seen in one child with Hodgkin's disease.

Extraction and analytic procedures for cytosine arabinoside and 1-beta-D-arabinofuranosyluracil and their 5'-mono-, di-, and tri-phosphates

A qualitative and quantitative comparison of perchloric acid (PCA) and trichloroacetic acid (TCA) extraction procedures of biologic material containing cytosine arabinoside (Ara-C) and 1-beta-D-arabinofuranosyluracil (Ara-U) and their biologic 5'-phosphate derivatives revealed definite superiority of the PCA procedure over the TCA procedure. High-pressure liquid chromatography provides rapid and accurate quantitative and qualitative separation of both Ara-C and Ara-U and their 5'-mono-, di-, and tri-phosphates (mu Bondapak NH2 column), or their 5'-mono-, di-, and tri-phosphates without nucleosides (ABX Permaphase columns).

Separation of 5'-mono-, di- and triphosphates of 1-beta-D-arabinofuranosylcytosine and of 1-beta-D-arabinofuranosyluracil by thin-layer and high pressure liquid chromatography

The separation of all the 5'-mono-, di- and triphosphates of ara-C and ara-U by thin-layer (TLC) and high pressure liquid chromatography (HPLC) is described. Whereas for the TLC two different systems are necessary, HPLC allows a rapid separation of all the nucleotides with high resolution, reproducibility, and sensitivity within 15 minutes. An example of an HPLC separation of ara-C and ara-U nucleotides derived from a biological sample is presented.