Multicentric/multifocal breast cancer with a single histotype: is the biological characterization of all individual foci justified?

BACKGROUND

Invasive multiple breast cancers with a single histological feature (MBCSH) are routinely assessed for biological parameters to indicate adjuvant treatments only in the largest invasive carcinomas. However, the heterogeneity of individual foci in multiple carcinomas has not been widely studied. We analyzed whether such biological features are differently expressed in different MBCSH foci.

PATIENT AND METHODS

One hundred and thirteen invasive MBCSH were tested over a 5-year period. The expression of estrogen (ER) and progesterone (PgR) receptors, Ki-67 proliferative index, expression of HER2 and tumor grading were prospectively determined in each tumor focus, and mismatches among foci were recorded.

RESULTS

Mismatches in ER status were present in 5 (4.4%) cases and PgR in 18 (15.9%) cases. Mismatches in tumor grading were present in 21 cases (18.6%), proliferative index (Ki-67) in 17 (15%) cases and HER2 status in 11 (9.7%) cases.

CONCLUSIONS

In our experience, invasive MBCSH showed heterogeneity among foci. In our clinical practice, such assessment led to 14 (12.4%) patients receiving different adjuvant treatments compared with what would have been indicated if we had only taken into account the biologic status of the primary tumor.

Natural history of honeycombing: follow-up of patients with idiopathic pulmonary fibrosis treated with single-lung transplantation

PURPOSE

Although honeycombing is one of the key features for the diagnosis of idiopathic pulmonary fibrosis (IPF), its origin and evolution are still poorly understood. The aim of our study was to analyse the natural history of honeycombing in patients treated with single-lung transplantation.

MATERIALS AND METHODS

We considered seven patients who underwent single-lung transplantation; two of them (28.6%) were excluded from our analysis because they died in the posttransplantation period, whereas the remaining five (71.4%) were evaluated with computed tomography (CT) over 67.6±38.56 months. Each CT scan was assessed for disease extension and cyst size (visual score and size of target cysts); CT scans acquired after 2006 were also assessed for native lung volume.

RESULTS

All patients showed disease progression (with a concurrent reduction in lung volume in two, 40%) and a progression of honeycombing, with increased number and size of cysts in four (80%). We observed dimensional changes in all target cysts (enlargement or reduction); three patients (60%) also had radiological evidence of complications, such as spontaneous rupture with pneumothorax and development of mycetomas within the cysts.

CONCLUSIONS

Honeycombing is a dynamic process in which the overall trend is represented by a dimensional increase in cystic pattern; however, single cysts may have a different evolution (enlargement, reduction or complications). This behaviour could be explained by the variety of the pathogenetic processes underlying honeycombing, with cysts that may present abnormal communication with the airway, including the development of a check-valve mechanism.

P1-12-17: Fluorescent In Situ Hybridization Evaluation of HER2 Status in Tumors with Chromosome 17 Polysomy

Introduction: According to the American Society of Clinical Oncology-College of American Pathologists recommendations for HER2 testing, a positive fluorescent in situ hybridization (FISH) result is defined as >6 HER2 gene copies/nucleus (for test systems with no internal control probe [single-color]) or as HER2 gene/chromosome 17 centromere (CEP17) ratio > 2.2 (for systems with an internal control probe [dual-color]). Although an increase in CEP17 copy number (average ≥ 3.0 copies/nucleus) is commonly considered to represent polysomy of chromosome 17, it can also be a result of gains of 17q with centromere involvement, or amplification of the centromeric region. The classification of HER2−positive tumors according to the HER2/CEP17 ratio may therefore misclassify a fraction of truly amplified cases as polysomic. We prospectively evaluated tumors with chromosome 17 polysomy but no HER2 amplification to assess HER2 status using the above two FISH classifications and immunohistochemistry (IHC).

Materials and methods: Tumors were tested for gene amplification by FISH with probes to HER2/neu and CEP17 using the PathVysion HER-2 DNA Probe Kit (Vysis). Classification was based on the HER2/CEP17 ratio (amplified when > 2.2) and average HER2 gene copy number/nucleus (amplified when > 6 copies). Both polysomic and equivocal cases (HER2/CEP17 ratio 1.8 - 2.2) were further studied by IHC using the HercepTest (Dako) with 0–3 scoring system (overexpression when 3+).

Results: From March 2010 to May 2011 we evaluated 31 primary breast cancers showing chromosome 17 polysomy. Median HER2/CEP17 ratio was 1.3 (range 0.5−1.9), median HER2 copy number was 5.4 (range 2.6−13.8), and median CEP17 copy number was 4.2 (range 3.2−8.0). Thirteen (42%) had an average HER2 gene copy number > 6/nucleus (median 6.8, range 6.1−13.8) and would therefore be considered as amplified if classified according to the absolute HER2 gene copy number. Nine (75%) of these were 3+ at IHC and the remaining 4 were 2+, whereas among the 18 cases with an average HER2 gene copy number < 6/nucleus, one was 2+, ten were 1+, and 7 scored 0. Twenty-nine cases showed negative HER2/CEP17 ratios (< 1.8) and three cases equivocal HER2/CEP17 ratios (between 1.8 and 2.2). Using HER2/CEP17 ratio as first assessment and IHC only in equivocal cases, only one of the 31 “polysomic” cases would have been classified as HER2−positive. However, 8 polysomic cases with HER2/CEP17 ratio < 1.8 showed 3+ immunostaining (all with average HER2 gene copy number > 6/nucleus), while 3 other cases had an average HER2 gene copy number > 6/nucleus with 2+ immunostaining.

Conclusions: Our results show that both FISH evaluation criteria and IHC can modify the percentage of polysomic tumors classified as HER2−positive. However, the number of gene copies/nucleus appears more frequently associated with 3+ IHC than the HER2/CEP17 ratio. The predictive impact of the former method on response to anti-HER2 treatments warrants further investigation.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-12-17.

Abstract P6-05-02: Clinical-Pathological Features of All Nodules with the Same Histotype Affect Systemic Adjuvant Treatment Decision in Multifocal and Multicentric Breast Cancer

BACKGROUND

Decision criteria about systemic adjuvant treatment of patients affected by breast cancer include estrogen receptor (ER), progesterone receptor (PgR), HER2 status, histologic grading, and proliferative index. In case of multifocal or multicentric breast cancer, the College of American Pathologists (CAP) recommends to provide features for the largest invasive carcinoma. We evaluated the discordance of ER, PgR, HER2, grading, and proliferative index among all nodules with the same histotype of patients with multifocal or multicentric breast cancer and the impact on the choice of adjuvant treatment. METHODS

We retrospectively analyzed 113 consecutive patients operated for breast cancer between 2004 and 2009 in Forli (Italy). We performed histological examination of all nodules of each patient after surgery, at the same time. Immunohistochemical methods were used to detect ER/PgR status, and proliferative index (Ki67), whereas fluorescent in situ hybridization was used to determine HER2 status. ER/PgR < 10% was considered negative. Ki67 was considered high if ≥20%. Grading was determined according to Nottingham's score system. HER2 amplification was defined according to CAP guidelines or as the presence of a focal HER2 amplified clone ≥30% of tumor cells. We considered as “discordance” a difference in at least one nodule for any of the biologic features considered. In order to determine whether discordance among nodules affects systemic treatment approaches, we asked ten independent oncologists whether and how they would modify their prescribed adjuvant treatment. RESULTS

Discordance in ER or PgR status among different nodules was detected in 5 (4.4%) and 16 patients (14.1%), respectively. The majority of the oncologists (7 out of 10) decided to modify their prescribed systemic treatment in 3 patients (2.6%), in favor of a combined treatment (endocrine plus chemotherapy), instead of endocrine-or chemotherapy alone as if their decision was based on the receptor status only of the largest nodule. Discordance in HER2 status was detected in 10 (8.8%) patients. In 4 patients (3.5%), all clinicians found indication to an anti-HER2 treatment. Discordance in proliferative index occurred in 17 (15.0%) patients and discordance in grading was detected in 18 (17.8% over 101) patients. Five of ten oncologists decided to modify their prescribed systemic treatment by adding chemotherapy to endocrine-therapy alone in 5 patients (4.4%) based on Ki67 value, whereas there was no change based on grade. DISCUSSION

This study shows a discordance for all analyzed histological features among different nodules with the same histotype in multifocal and multicentric tumors. In a total of 8 patients (about 7%) this discordance affected the therapeutic decisions of oncologists, resulting in changes of the prescribed adjuvant systemic treatment, with respect to the prescriptions based on the clinicopathologic features only of the largest nodule. Therefore, we conclude that the analysis of all nodules in case of multifocality/multicentricity should be taken into consideration, in order to identify the best adjuvant treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-05-02.

Randomized phase III trial of adjuvant epicirubicin (E) followed by cyclophosphamide, methotrexate, and fluorouracil (CMF) or CMF followed by E in patients with N- or ≤ 3 N+ rapidly proliferating breast cancer (RPBC)

560

Background: Antimetabolites are active in proliferating cells, and the adjuvant schedule CMF is highly effective in RPBC, whereas the sequential administration of doxorubicin (D) and CMF is superior to CMF–>D, especially in indolent tumors. In a phase III study, we evaluated whether adjuvant E followed by CMF is superior to the inverse sequence in RPBC. Methods: Patients with N-, T > 1 cm or ≤ 3 N+ and any T RPBC (defined by thymidine labeling index or grade or S-phase or Ki67/MIB1) were randomized to receive E (100 mg/m2 i.v. d 1, q 21 days for 4 cycles) followed by CMF (600, 40, 600 mg/m2 i.v. d 1 and 8, q 28 days for 4 cycles) (arm A) or CMF followed by E (arm B) or CMF (600, 40, 600 mg/m2 i.v. d 1 and 8, q 28 days for 6 cycles) (arm C). Arm C was closed after the EBCTCG 2000 meta-analysis (data not shown). The main endpoint was overall survival (OS), and the study had 80% power to detect a 7% absolute increase in 5-year OS with 400 patients per arm. Results: From November 1997 to December 2004, 1066 patients were enrolled (arms A/B/C: 440/438/188): N- 53%, estrogen receptor positive 63%, grade 3, 77%. At a median follow up of 69 months, 5-year disease-free survival was 80% in both arms (A and B) (p = 0.93, logrank test), with adjusted hazard ratio (AHR) 0.99 (95% CI 0.73–1.33, Cox model), and OS was 91% in arm A and 93% in arm B (p = 0.66, logrank), with AHR 0.88 (95% CI 0.58–1.35, Cox model). Adverse events were similar, apart from a small increase in grade 4 neutropenia in arm B. Conclusions: No relevant differences in clinical outcome were observed with the 2 different sequences. Further subgroup analyses are ongoing to verify the efficacy of each sequence as a function of biomolecular and hormonal profiles.

No significant financial relationships to disclose.

The dynamics of tumour-vasculature interaction suggests low-dose, time-dense anti-angiogenic schedulings

OBJECTIVES

The administration schedule appears to be a particularly relevant factor in determining the effectiveness of an antiangiogenic drug. A better quantitative knowledge of the interactions between tumour growth and the development of its vasculature could help to design effective therapies.

MATERIAL AND METHODS

Biological and clinical inferences were derived from the analysis of a mathematical model proposed by Hahnfeldt et al. (1999), and some of its variants. In particular, we compared the effect of constant continuous infusion of an anti-angiogenic drug that induces vascular loss, to the effect of periodic, bolus-based therapy.

RESULTS AND CONCLUSIONS

The role of drug elimination rate and of dose fractionation was investigated, and we show that different schedulings, guaranteeing the same mean value of drug concentration, may exhibit very different long-term responses according to their concentration vs. time profile. For a large class of tumour growth laws, the profiles that approach the constant one are the most effective. This behaviour appears to depend on the 'cooperativity' of the tumour-vasculature interaction and on the functional form of the relationship between tumour growth and vasculature extent. Moreover, we suggest that a therapy approaching constant drug infusion might be advantageous also in the case of cytostatic anti-angiogenic drugs.

Antitumor activity and biological effects of primary endocrine therapy with GnRH analog and letrozole in premenopausal women with locally advanced operable ER and PgR positive breast cancer

21008

Background: Aromatase inhibitors (AIs) in combination with GnRH analog (A) were never systematically studied in premenopausal women with hormone receptor positive locally advanced operable breast cancer. Methods: We investigated in a two stage phase II trial, the activity of GnRH A plus letrozole (LT), added when E2 levels were in the postmenopausal range, in premenopausal women with T2-T4b N0-N2, endocrine responsive (ER and PgR ≥ 10% of the cells) breast cancer. We also investigated at baseline and at surgery the expression of ERβ, MAPkinases (MAPKs), ERa, EGFR, Her-2/neu, either normal or phosphorylated (p). Results: Thirty-nine patients (pts) were enrolled and 35 (ER >50%, 29 (90%) ; Ki 67 = 20%, 17 (53%); cT2/3, 24/5) are evaluable for response (3 of whom did not receive LT for refusal or failure of achievement of ovarian suppression). There were 16 objective responders (46%, 95% CI 29.5- 62.5), 1 of whom had pCR (3%). Nineteen pts (50%) were stable. Breast conserving surgery became possible for 42% of the patients. Side effects were mild. Endocrine therapy was correlated with grade 2 hot-flashes and arthralgia in 43% and 6% of the patients, respectively. Molecular analysis was performed in 27 pts (13 responders and 14 non responders). Treatment induced a significant decrease of pERa an upregulation of ER-β, which were independent of response. No overexpression of EGFR and HER-2 was registered at baseline and after treatment. Conclusions: The combination of LT and GnRH A is feasible and effective in premenopausal women with locally advanced endocrine responsive operable breast cancer. A biological response to estrogen suppression was observed. Tailored endocrine therapy of longer duration merits further investigations in the preoperative setting.

No significant financial relationships to disclose.

Preoperative concurrent chemo- and endocrine therapies for women with large operable breast cancer expressing steroid hormone receptors

21153

Background: Preoperative chemotherapy and endocrine therapy yielded low pathological complete remission (pCR) rates in patients with endocrine responsive breast cancer. Methods: Patients with large operable endocrine responsive (ER ≥ 10% of the cells) breast cancer (cT2-T3, N0–2, M0) were treated in 2 consecutive studies with preoperative chemotherapy (Study I: 6 courses of either fluorouracil, leucovorin, vinorelbine (FLN), or vinorelbine, cisplatin, and continuous infusion of fluorouracil (ViFuP), chosen at the discretion of the treating physician; Study II: an oral regimen with capecitabine and vinorelbine (CAVINO). In both studies concurrent endocrine therapies (letrozole, either alone or if premenopause, with triptorelin) were given. Results: Sixty-five (58 evaluable) and fifty-five (all evaluable) patients were enrolled to Studies I and II, (ER >50%, 51 and 50; Ki 67 = 20%, 42 and 39; cT2/3: 36 / 22 and 35 / 20; premenopausal 40 and 38) respectively. In Study I there were 43 objective responders (74%, 95% CI 63–85%), 4 of whom had pCR. In Study II 34 patients (62%, 95% CI 49–75%) had an objective response. Breast conserving surgery became possible for 64% and 62% of the patients in Study I and II, respectively. Conclusions: Intravenous, non anthracycline containing regimens together with tailored menopause status-adapted endocrine therapy, warrants further investigations in the preoperative setting.

No significant financial relationships to disclose.

Metronomic chemotherapy with capecitabine and oral cyclophosphamide in combination with bevacizumab in metastatic breast cancer (mbc): Evidence of activity of an antiangiogenic treatment

11501

Background: Metronomic chemotherapy has shown efficacy in patients (pts) with MBC. Laboratory and clinical studies suggest that the combination with a specific antiangiogenic drug may be particularly effective. Methods: We evaluated the activity and biological effects of low dose continuous oral Capecitabine (500 mg PO TID) and Cyclophosphamide (50 mg PO QD) plus Bevacizumab (10 mg/Kg Q 2 weeks) in a two stage phase II trial in MBC pts, who received =3 lines of chemotherapy for advanced disease. Planned sample size is 46 pts. Results: To date, 26 patients have been enrolled on the study and 23 are evaluable. Pts characteristics: 1/2/=3 sites of metastatic disease 6/9/11 pts; dominant sites of disease soft tissues/bone/viscera 1/11/22; previous treatment for MBC: endocrine/chemo/trastuzumab 13/21/1 pts (=2 lines 25). Results: there were 1 CRs (4.3%), 10 PRs (43.5%), 6 SD (26.1%), and 6 PD (26.1%), for an overall response rate of 48% (exact 95% CI 27–69%). Median progression free survival was 6 months (+). Grade 3 side effects: 6 hypertension , 1 leucopenia , 2 neutropenia , 2 transaminitis (both with liver metastases). No patient was withdrawn from the study due to side effects, and hypertension was manageable with adequate therapy. Data on median circulating endothelial cells (CECs) will be available. Conclusions: Metronomic chemotherapy with capecitabine and cyclophosphamide in combination with bevacizumab has clinical activity and low toxicity in advanced breast cancer.

No significant financial relationships to disclose.

Role of endocrine responsiveness and adjuvant therapy in very young women (below 35 years) with operable breast cancer and node negative disease

BACKGROUND

There is limited knowledge about prognosis, and treatment effects in young women with node-negative disease.

PATIENTS AND METHODS

We evaluated biological features, treatment recommendations and prognosis for 841 premenopausal patients with pT1-3, pN0 and M0, operated from 1997 to 2001.

RESULTS

Patients below 35 years (101, 12%) were more likely to have tumors > 2 cm (35.6% versus 24.2%, P = 0.002), grade 3 (48.5% versus 31.9%, P = 0.009) and with elevated Ki-67 expression (62.4% versus 50.7%, P = 0.002). At the multivariate analysis a statistically significant difference in disease-free survival (DFS, HR 4.44; 95% CI 2.53 to 7.78, P < 0.0001), risk of distant metastases (DDFS) (HR 3.23; 95% CI 1.32 to 7.94, P = 0.011) and overall survival (OS) (HR 2.89; 95% CI 1.06 to 7.87, P = 0.038) was observed for younger versus older patients and in the subgroup with endocrine responsive tumors (DFS, HR 5.17, 95% CI 2.72-9.83, P = < 0.0001; DDFS, 3.76, 95% CI 1.33-10.6, P = 0.013; OS, 4.71, 95% CI 1.09-20.4, P = 0.039 ).

CONCLUSIONS

Compared with less young, very young patients with endocrine responsive and node-negative breast cancer have a worse prognosis. Tailored treatments should be explored in this cohort of patients.

A phase II study of primary dose-dense sequential doxorubicin plus cyclophosphamide and docetaxel in cT4 breast cancer

BACKGROUND

Dose-dense chemotherapy with anthracyclines and taxanes has improved either disease free survival or overall survival in high risk patients with early breast cancer.

PATIENTS AND METHODS

The activity and safety of a dose-dense schedule (q14 days) of adriamycin 60 mg/sqm and cyclophosphamide 600 mg/sqm (AC) x 4 cycles followed by docetaxel 75 mg/sqm for 4 cycles with hematopoietic support in patients with stage IIIB breast cancer was explored. Patients with ER > or =10% tumors received concomitant endocrine therapy with 3-month triptorelin and letrozole.

RESULTS

Fifteen patients with histologically proven cT4b (three patients) and cT4d (twelve patients) M0 breast cancer were enrolled. Median age was 48 years (range 25-66). Eight clinical responses including one pathological complete remission (pCR), three stable disease (including minor responses) and four progression of disease, one during AC and three during taxotere, were observed. Four patients had grade 3-4 non hematological toxicities and all except one discontinued treatment.

CONCLUSION

Due to the high rate of progressive disease, this schedule should not represent a standard option in cT4 breast cancer.

Safety and efficacy of the combination carboplatin and paclitaxel in patients (pts) with recurrent head and neck squamous cell carcinoma (HNSCC)

15534

Background: Pts with recurrent HNSCC have a dismal prognosis; treatment options are poorly effective and burdened with toxicity. In this clinical setting, cisplatin and paclitaxel have demonstrated activity despite relevant side effects. The purpose of this phase II trial was to investigate whether a combination of carboplatin and paclitaxel could offer a better toxicity profile without affecting efficacy. Methods: Pts with bi-dimensionally measurable disease, previously treated with induction chemotherapy (Cisplatin and 5-FU) followed by concomitant chemo-radiotherapy, were studied. Treatment consisted of Carboplatin AUC 5 and Paclitaxel 175 mg/m2 intravenously every 3 weeks. G-CSF and darbepoetin alpha were allowed in case of neutropenia (N < 1000/mm3) or anemia (Hb < 11 g/dL). Pts were evaluated for toxicity and response. Results: So far, 15 pts were enrolled. Median age was 53 yrs; ECOG P.S. was 0–1. Site of disease at relapse was head and neck excluding lips and sinus; 12 out of 15 pts had stage IV disease. All pts were evaluated for response and toxicity. After three cycles of chemotherapy, we observed 1 complete response (6.6%) and 7 partial responses (46.6%), with a 53.2 % overall response rate (95% CI 26.6–78.7%). Stable disease was seen in 2 patients (13.3%) and progressive disease was observed in 5 pts (33.3%). Toxicity was mild: we recorded 1 case of G3 toxicity (neutropenia) and no G4 side effects. Three pts experienced G1–2 neuropathy and 4 pts G1–2 hematologic toxicity (neutropenia and thrombocytopenia). Conclusions: The current regimen was feasible and effective. The combination of Carboplatin and Paclitaxel was well tolerated and could be safely administered to pts with recurrent HNSCC as second line treatment. Enrollment and data collection are still ongoing.

No significant financial relationships to disclose.

Hepatic intra-arterial chemotherapy in patients with metastatic breast cancer

10581

Background: Hepatic intra-arterial chemotherapy has been reported to produce higher response rate than systemic in patients (pts) with metastatic colorectal cancer. In breast cancer the liver is involved in up to 60% of cases and often conditions the prognosis. Nevertheless, only rare hepatic arterial infusion studies were published. Therefore, based on our previous experience in hepatic metastatic colorectal malignancies, we evaluated efficacy and toxicity of hepatic intra-arterial chemotherapy in pts with metastatic breast cancer. Methods: A three-day continuous arterial infusion (CAI) of fluorouracil 1000 mg/m2 q 24 hrs, with cisplatin 10 mg/m2 twice daily, and mitomycin-c 1 mg/m2 twice daily, was performed through a percutaneous radiological temporary trans-subclavicular catheter. Pts with responsive disease received up to four cycles every six weeks. Pts still responding could carry on with cisplatin and fluorouracil, without mitomycin-c. Pts were hospitalized and the catheter was removed upon end of infusion. Results: From 9.2000 to 6.2005, 25 pts with progressive liver metastases from breast cancer were treated. Nine had more than 50% of liver involvement. Fifteen had also extra-hepatic metastases. All had received antracyclines and 22/25 taxanes. Pts had a median of five previous chemotherapy lines. Median time from diagnosis of liver metastases to first CAI was 33 months (range: 7–110). Sixty-four total courses were administered, with a median of 2 (range: 1–7) per pts. Epigastric pain was the main clinical toxicity (54%) and iatrogenic gastro-duodenal ulcer, the main complication (28%). No relevant catheter-related complications occurred. Fifteen partial responses (60%) and eight stable diseases (32%) were observed. Response duration was 5.4 months (range: 2 - 27), time to progression 5.1 months (range: 2.5–29+), and median overall survival 13 months (range: 3.5+–32+). Conclusions: Hepatic arterial infusion of chemotherapy in heavily pre-treated pts with metastatic breast cancer is feasible and effective. A specific evaluation of quality of life should be performed to verify a real clinical benefit. An earlier timing during course of liver disease, and a shift to radiological implanted arterial port (allowing out-patient treatment), will be investigated.

No significant financial relationships to disclose.

Vinorelbine-based chemotherapy in hormone-refractory prostate cancer

BACKGROUND

No consensus exists regarding further therapy for the management of hormone-refractory prostate cancer. In this phase II study, the combination of Vinorelbine with 5-Fluorouracil and folinic acid (FLN regimen) was evaluated in patients with progressive or resistant disease after hormone therapy.

PATIENTS AND METHODS

Thirty-four patients were treated with Vinorelbine at a dose of 20 mg/m2 intravenously (i.v.) on days 1 and 3, folinic acid (FA), 100 mg/m2 i.v. and 5-Fluorouracil (5-FU), 350 mg/m2 i.v. as a short infusion on days 1 to 3. The therapy was given in an out-patient setting, every 3 weeks.

RESULTS

All of the 34 eligible patients were evaluable for toxicity and 30 for activity. A total of 127 cycles was administered (91% at full dose). Among thelS5 patients with measurable disease, four had a partial response (26.6%; C.I. 95%, 28.3% to 65.7%) and four achieved stable disease. In 14 patients (47%) a clinical benefit was documented. Six out of 15 patients with bone-only involvement had stable disease (40%). The median duration of stabilization and partial response was 16 weeks (range 4-24 weeks). The most common toxicity was hematological: Grade 4 (NCI-CTC scale) in five patients at re-cycle. Other toxicities were of low incidence and easy to manage.

CONCLUSION

The encouraging results obtained with the FLN regimen in terms of clinical benefit and its predictable and manageable toxicity support the palliative role of this chemotherapeutic strategy in hormone-refractory prostate patients.

Oxaliplatin combined with 5-fluorouracil and methotrexate in advanced colorectal cancer

BACKGROUND

A promising regimen including 5-Fluorouracil, methotrexate and oxaliplatin is reported.

PATIENTS AND METHODS

Patients with untreated measurable metastatic disease received bolus 5-Fluorouracil (600 mg/m2) on days 2 and 16, modulated by methotrexate (200 mg/m2) 24 h earlier, alternated with 4 weeks of continuous infusion of 5-Fluorouracil (200 mg/m2/daily) plus oxaliplatin (130 mg/m2) on days 29 and 56, followed by 2 weeks of rest. Serum vascular endothelial growth factor (VEGF) was analyzed at baseline and before every cycle.

RESULTS

Fifty-eight patients were enrolled. Objective remissions were reported in 45.6% (95% CI=34.3%, 57.3%). The median progression-free survival was 7.8 months and the median overall survival was 19.4 months. No grade 4 toxicity was reported, except for one case of diarrhea. The serum VEGF evaluated in 23 patients showed a decreasing trend during therapy.

CONCLUSION

The regimen was active, well tolerated and may be a possible option in patients not suitable for radical surgery.

Metronomic low-dose oral cyclophosphamide and methotrexate plus or minus thalidomide in metastatic breast cancer: antitumor activity and biological effects

BACKGROUND

We previously demonstrated efficacy and impact on serum vascular endothelial growth factor (VEGF) for metronomic cyclophosphamide (C) and methotrexate (M) in patients with breast cancer. New metronomic schedules were investigated.

PATIENTS AND METHODS

Patients with advanced breast cancer were randomized to receive oral C (50 mg daily) and M (2.5 mg twice daily on days 1 and 4) (arm A) or the same regimen plus thalidomide (200 mg daily) (arm B).

RESULTS

The mean VEGF level decreased from 378.9 (+/-274.4) pg/ml at baseline to 305.9 (+/-203.6) pg/ml at 2 months (P<0.001), with similar change with respect to baseline in both arms. In 171 evaluable patients we observed three complete remissions (CR) in both arms A and B, 15 partial remission (PR) in arm A and seven in arm B, for an overall response of 20.9% [95% confidence interval (CI) 12.9% to 31%] in arm A and 11.8% (95% CI 5.8% to 20.6%) in arm B. The clinical benefit (CR+PR+SD>or=24 weeks) was 41.5% for both arms. Toxicity was generally mild. Higher neurological toxicity (2% versus 60%; P<0.0001) and constipation (8% versus 51%; P<0.0001) was observed in arm B.

CONCLUSIONS

Metronomic low-dose CM induced a drop in VEGF, and was effective and minimally toxic. The addition of thalidomide did not improve results.