Synthesis and structural comparison of a series of divalent Ln(Tp(R,R)')2 (Ln = Sm, Eu, Yb) and trivalent Sm(Tp(Me2))2X (X = F, Cl, I, BPh4) complexes

Reaction of LnI2 (Ln = Sm, Yb) with two equivalents of NaTp(Me2) or reduction of Eu(Tp(Me2))2OTf gives good yields of the highly insoluble homoleptic Ln(II) complexes, Ln(Tp(Me2))2 (Ln = Sm (1a), Yb (2a), Eu (3a)). Use of the additionally 4-ethyl substituted Tp(Me2,4Et) ligand produces the analogous, but soluble Ln(Tp(Me2,4Et))2 (1-3b) complexes. Soluble compounds are also obtained with the Tp(Ph) and Tp(Tn) ligands (Tn = thienyl), Ln(Tp(Ph))2 (Ln = Sm, 1c; Yb, 2c) and Ln(Tp(Tn))2 (Ln = Sm, 1d; Yb, 2d). To provide benchmark parameters for structural comparison the series of Sm(Tp(Me2))2X complexes (X = F, 1e; Cl, 1f; Br, 1g; I, 1h; BPh4, 1j) were prepared either via oxidation of the Sm(Tp(Me2))2 or salt metathesis from SmX3 (X = Cl, Br, I). The solid-state structures of 1-3a, 1b, 1-2c and 1e, 1f, 1h, and 1j were determined by single-crystal X-ray diffraction. The homoleptic bis-Tp complexes are all six-coordinate with trigonal antiprismatic geometries, planes of the kappa(3)-Tp ligands are parallel to one another. In the series of Sm(Tp(Me2))2X complexes the structure changes from seven-coordinate molecular compounds, with intact Sm-X bonds, for X = F, Cl, to six-coordinate ionic structures [Sm(Tp(Me2))2]X (X = I, BPh4), suitable crystals of the bromide compound could not be obtained. The dependence of the structures on the size of X is understandable in terms of the interplay between the size of the cleft that the [Sm(Tp(Me2))2](+) fragment can make available and the donor ability of the anionic group toward the hard Sm(III) center.

Solid-state structure and solution behavior of eight-coordinate Sm(III) poly(pyrazolyl)borate compounds

[Sm(Tp(Me2)(2)(kappa(2)-S(2)CNR(2))] compounds (R = Et (1), Me (2); Tp(Me2) = HB(3,5-Me2pz)(3)) have been isolated from reaction of (R(2)NC(S)S)(2) with 2 equiv of [Sm(Tp(Me2)(2)]. Reductive cleavage of 2,2'-dipyridyl disulfide or 2,2'-dipyridyl diselenide by [Sm(Tp(Me2)(2)] afforded good yields of [Sm(Tp(Me2)(2)(kappa(2)-Y)] compounds (Y = 2-SC(5)H(4)N (3), 2-SeC(5)H(4)N (4)). 4 is the first selenopyridine complex of an f-block element. Sm(Tp(Me2)(2)(2-OC(5)H(4)N) (5) has been synthesized by salt metathesis of [Sm(Tp(Me2)(2)Cl] with the sodium salt of the 2-hydroxypyridine. The solid-state structures of 1, 3, 4, and 5 were determined by single-crystal X-ray diffraction analysis and revealed that the compounds are all eight-coordinate with dodecahedral geometry. The samarium atoms are bound in tridentate fashion to two pyrazolylborate ligands and in bidentate fashion by the third ligand. The solution behavior of the compounds was studied by (1)H NMR techniques. (1)H-(1)H exchange spectroscopy experiments give evidence for two distinct dynamic regimes occurring in solution.

Sperm extraction at orchiectomy for testis cancer

OBJECTIVE

To evaluate the value of aspirating sperm from the vas and epididymis at orchiectomy in azoospermic patients.

DESIGN

Retrospective clinical study.

SETTING

Tertiary care academic hospital.

PATIENT(S)

Three patients with known azoospermia who presented with testicular masses suspected to be cancerous.

INTERVENTION(S)

At orchiectomy, immediately after ligation of the spermatic cord, the contents of the epididymis and vas deferens were extracted into preserving media.

MAIN OUTCOME MEASURE(S)

Fertility rate.

RESULT(S)

Sperm retrieval was successful in all three patients. The mean total sperm count was 2.3 x 10(6)/mL with 20% motility. Intracytoplasmic injection of sperm harvested by using this method was successful in two couples, one of which delivered a healthy infant.

CONCLUSION(S)

Sperm can be aspirated from the vas deferens and epididymis at orchiectomy for preservation. In azoospermic patients, this procedure may salvage enough sperm for successful use in micromanipulation techniques. It may be worthwhile to perform sperm aspiration during orchiectomy for testis cancer in any patient with known or suspected infertility.

Phase II EORTC trial with 5-fluorouracil, cisplatin and interferon-alpha as second-line treatment of advanced transitional cell cancer of the urothelial tract

BACKGROUND

Based on the favorable results of the combination 5-fluorouracil (5-FU), cisplatin and interferon-alpha as second-line treatment in advanced metastatic transitional-cell carcinoma of the urothelial tract a confirmatory study was executed in a multicenter setting.

PATIENTS AND METHODS

In this open label phase II study 43 patients failing adequate previous chemotherapy were treated with IFN-alpha2b 5 MU/m2 subcutaneously for 5 consecutive days starting on day 1 and 22 simultaneous with 5-FU 500 mg/m2 daily as a continuous infusion. In between the same dose of IFN-alpha2b was given 3 times weekly with CDDP 25 mg/m2 on days 1, 8, 15 and 22. This cycle was repeated every six weeks.

RESULTS

In 40 eligible patients 5 PR were seen (12.5%; 95% confidence interval (95% CI): 4.1%-26.8%). The major toxicity was hematological. Two toxic deaths were seen due to gastrointestinal hemorrhage.

CONCLUSIONS

In view of these results this combination can not be recommended as second line treatment for metastatic transitional-cell carcinoma of the urothelial tract.

Combination chemotherapy following adrenal suppression in androgen- independent prostate cancer

OBJECTIVES

Recent trials with modern chemotherapy have demonstrated activity in androgen-independent prostate cancer, but all focused on patients with progression following androgen suppression or antiandrogen withdrawal. Limited data are available on the activity of chemotherapy in androgen-independent, hormone-refractory (progressing following adrenal suppression) prostate cancer. We evaluated the activity of estramustine combined with vinblastine in this subset of androgen-independent prostate cancer.

METHODS

From January 1995 until April 1999, 19 patients with hormone-refractory prostate cancer received estramustine 140 mg p.o., three times daily along with weekly vinblastine 5 mg/m(2).

RESULTS

A decrease in prostate-specific antigen of 50% or more was noted in 12 patients (63.1%, 95% CI 38.3-83.7%). The median decrease in prostate-specific antigen was 71.2% (range 50.5-85.2%). None of the 7 patients with measurable soft-tissue disease showed an objective response. The median survival from onset of chemotherapy was 6 (range 1.4-27.7) months and from initiation of adrenal suppression 16.9 (range 3.8-40. 5) months.

CONCLUSIONS

The combination of estramustine and vinblastine is capable of inducing activity in androgen-independent prostate cancer progressing after adrenal suppression. In our small sample, the survival rate was low, and we obtained no response in soft-tissue sites. Future prospective trials are needed to determine the benefit of sequential versus simultaneous incorporation of adrenal suppression with chemotherapy in the management of androgen-independent prostate cancer.

Low PSA metastatic androgen- independent prostate cancer

OBJECTIVES

To describe the clinical parameters of low PSA, progressive metastatic androgen-independent prostate cancer.

METHODS

From April 1995 to May 1999, we selected 18 patients with clinically progressive androgen-independent prostate cancer and low PSA (</=10 ng/ml). Patients received cisplatin-based therapy. Specimens from the primary tumor were reviewed and neuroendocrine differentiation was determined with chromogranin-A and neuron-specific enolase immunocytochemical staining.

RESULTS

The median initial PSA level was 1.6 ng/ml (0-9.5). Each patient demonstrated elevation of at least one of the following markers: carcinoembryonic antigen, CA 19-9, CA15-3 and CA 125 CA. Metastases involved bone in 11 patients (61.1%) - 5 (27.7%) blastic, 2 (11.1%) lytic, and 4 (22.2%) combined - liver in 10 patients (55.5%), lymph nodes in 8 (44.4%), and lung in 6 (33.3%); solitary sites as orbit, skin and spleen were noted as well. A prostatic pelvic mass was detected in 13 patients (72.2%). Of the 12 patients who consented to chemotherapy, 8 (66.6%) achieved an objective response (95% CI, 34. 8-90%), including 1 patient with complete response. Hematoxylin and eosin evaluation revealed two major groups: neuroendocrine tumors, either pure small cell cancer in 6 patients (37.5%) or combined small cell cancer and adenocarcinoma in 8 (50%), and predominant poorly differentiated prostate cancer in 2 (12.5%). Neuroendocrine immunoreactivity was detected in all the specimens.

CONCLUSIONS

Progressive androgen-independent prostate cancer with low serum PSA is characterized by visceral metastases, high proportion of lytic bone disease, sensitivity to cisplatin-based chemotherapy, and histological features of small cell or poorly differentiated prostate cancer. In this subgroup of patients, selection of the therapeutic approach can be based on clinical parameters. The rise of the serum markers may aid in the diagnosis and follow-up of these patients.

Bladder neck involvement at radical prostatectomy: positive margins or advanced T4 disease?

OBJECTIVES

To assess the prognosis of patients with bladder neck (BN) involvement in radical prostatectomy specimens and compare it with patients with seminal vesicle invasion (SVI) presumed to have an inferior stage according to the TNM classification.

METHODS

Two hundred eighty-six case files of consecutive radical prostatectomies were reviewed. The records of patients with pathologic BN involvement (pT4a) or SVI (pT3c) were thoroughly analyzed and compared. The mean and median follow-up periods were 30.8 and 35.5 months (range 9 to 40), respectively, for the patients with Stage pT4a and 40.8 and 44.1 months (range 8 to 86), respectively, for the patients with Stage pT3c. Particular attention was paid to the preoperative clinical and pathologic evaluation, the pathologic analysis of the prostatectomy specimen, and the postoperative follow-up data. Progression was defined as a prostate-specific antigen level of 0.2 ng/mL and rising. Adjuvant therapy was not initiated unless prostate-specific antigen failure had occurred.

RESULTS

BN involvement was identified in 25 patients (8.7%) and SVI was found in 26 patients (9.1%). In 7 patients (2.4%), the BN was the only site of positive margins. Thirty-six percent of patients with BN involvement and 62% of patients with SVI demonstrated biochemical progression. Disease-free survival and metastasis-free survival rates were significantly better for the patients with Stage pT4a than for the patients with Stage pT3c at 24 and 36 months after surgery. Univariate analysis identified the prostate-specific antigen nadir to be the most significant predictor of prognosis.

CONCLUSIONS

In this study, BN involvement in the surgical specimen carried a lower risk of progression than SVI. On the basis of our preliminary results and those in other studies, a conceivable downstaging of BN involvement in the TNM staging system should be considered. Possibly, additional modification of the TNM staging system should be contemplated on the basis of the results of pathologic analysis and prognosis. The significance of BN involvement and the role of adjuvant therapy in this group of patients need further evaluation.

Lanthanide chalcogenolate complexes: synthesis and crystal structures of the isoleptic series [Sm(TpMe,Me)2ER] (E = O, S, Se, Te; TpMe,Me = tris-3,5-dimethylpyrazolylborate)

A series of lanthanide complexes containing a chalcogenolate ligand supported by two TpMe,Me (tris-3,5-dimethylpyrazolylborate) groups has been prepared and crystallized and provides direct comparisons of bonding to hard and soft ligands at lanthanide centers. Reaction of [Sm(TpMe,Me)2Cl] with NaOR (R = Ph, Ph-Bu(t)) gives [Sm(TpMe,Me)2OR] (1a and 1b, respectively) in good yields. Reductive cleavage of dichalcogenides by samarium(II) was used to prepare the heavier congeners. Complexes of the type [Sm(TpMe,Me)2ER] for E = S, R = Ph (2a), E = S, R = Ph-4-Me (2b), E = S, R = CH2Ph (2c), E = Se, R = Ph (3a), E = Se, R = Ph-4-Bu(t) (3b), E = Se, R = CH2Ph (3c), and E = Te, R = Ph (4) have been prepared together with the corresponding complexes with TpMe,Me,4-Et as ancillary. The X-ray crystal structures of 1b, 2b, 3a, 3b, and 4 have been determined. The crystal of 1b (C40H57B2N12OSm.C7H8) was monoclinic, P2(1)/c, a = 10.6845(6) A, b = 18.5573(11) A, c = 24.4075(14) A, beta = 91.616(2) degrees, Z = 4. The crystal of 2b (C37H51B2N12SSm) was monoclinic, P2(1)/n, a = 15.0154(9) A, b = 13.1853(8) A, c = 21.1254(13) A, beta = 108.628(2) degrees, Z = 4. The crystal of 3a (C36H49B2N12SeSm.C7H8) was triclinic, P1, a = 10.7819(6) A, b = 19.3011(10) A, c = 23.0235(12) A, alpha = 79.443(2) degrees, beta = 77.428(2) degrees, gamma = 89.827(2) degrees, Z = 4. The crystal of 3b (C40H57B2N12SeSm) was triclinic, P1, a = 10.1801(6) A, b = 10.2622(6) A, c = 23.4367(14) A, alpha = 88.313(2) degrees, beta = 86.268(2) degrees, gamma = 62.503(2) degrees, Z = 2. The crystal of 4 (C36H49B2N12TeSm.C7H8) was monoclinic, P2(1)/c, a = 18.7440(10) A, b = 10.3892(6) A, c = 23.8351(13) A, beta = 94.854(2) degrees, Z = 4. The compounds form an isoleptic series of seven-coordinate complexes with terminal chalcogenolate ligands. Examination of 1b and other crystallographically characterized lanthanide alkoxides suggests that there is little correlation between bond angle and bond length. The structures of 3a and 3b, however, contain molecules in which one of the pyrazolylborate ligands undergoes a major distortion arising from twisting around a B-N bond so as to give an effectively eight-coordinate complex with pi-stacking of the phenyl group with one pyrazolyl ring. These distortions shed light on the fluxionality of these systems.

[Alopecia due to Seroxat therapy]

There are 2 stages of alopecia, anagen and telogen effluvium, both of which may be associated with medication-related alopecia. We describe massive hair loss in a 51-year-old woman during treatment with Seroxat (paroxetine), which remitted after it was discontinued. Pathological mechanisms of drug-associated alopecia are complex and have yet to be fully elucidated.

[Psychogenic polydipsia leading to water intoxication]

Psychogenic polydipsia and its frequent complication, water intoxication, are well-known to psychologists. There are biochemical and psychiatric theories of psychogenic polydipsia which often correlate with each other. A 48-year-old man with chronic paranoid schizophrenia developed symptoms of psychogenic polydipsia. This provoked disturbances in electrolyte balance, resulting in a rapid decrease in serum sodium concentration and eventual death. There is a paucity of information and little awareness of this problem in the professional literature.

Complications of retroperitoneal lymph node dissection in testicular cancer: primary and post-chemotherapy

Retroperitoneal lymph node dissection (RPLND) is utilized in low-stage testis cancer as a primary diagnostic and therapeutic procedure. In the post-chemotherapy setting, it serves as an adjuvant procedure to resect residual tumor. Primary RPLND entails minimal resection of lymphatic tissue in the retroperitoneum; the complications are minor and insignificant. Wound infection is the main complication, affecting less than 5% of patients. Atelectasis and small bowel obstruction may occur in less than 2% of patients. In post-chemotherapy RPLND, the template and the surgical challenge are much larger. Extensive tumor size, difficult location, adherence to major vessels, and vital structures, together with inferior pre-operative status, are probably the main reasons for complications. The overall complication rate is 20% to 35% and mortality is 0.8% to 1%. Pulmonary insufficiency secondary to bleomycin-induced interstitial fibrosis is the cause of the most severe side effects and mortality in these operations. Chylous ascites may occur, especially where resection of the inferior vena cava is necessary. Other complications occur to a lesser extent. A summary of all complications is presented and measures to avoid or manage them are depicted.

[Information provided in writing for "informed consent" in clinical trials]

The Helsinki Declaration contains recommendations guiding physicians who conduct clinical trials. One is that the requirement for informed consent is essential for approval of a trial. An important component of the informed consent doctrine is that all data required for the participant's decision must be provided. We analyze data of a therapeutic trial, and define 12 data components outlined in, or directly derived from the Helsinki Declaration. 61 instances of informed consent for therapeutic clinical trials from various fields of medicine, from 1994 to 1997, were analyzed. In each the presence of the 12 components was evaluated. The data demonstrated that there were only 5 components cited in most cases of informed consent: trial objectives, methods, treatment plan, risks, and the option of withdrawing. Benefit to the participant was mentioned in half the cases, while only limited information was provided about other components such as life-threatening and unpredictable risks, and alternative treatment. Examples of informed consent from 1997 showed statistical improvement since 1994 in the data concerning trial objectives, methods, risks and alternative therapy. Informed consent documents of international multicenter trials compared with local trials showed statistical improvement in the data components of the trial objectives, methods, and risks, including those of potentially life-threatening and unpredictable risks, and alternative therapy. Analysis of informed consent showed that not all components required for a comprehensive decision regarding participation in a clinical trial are included. These data emphasize the need to design a structured informed consent protocol in which all the required data components are specifically outlined for potential participants.

[Combination chemotherapy with M-VAC protocol in metastatic urothelial cancer]

The treatment of metastatic urothelial cancer is based on the combination of cisplatin, methotrexate, vinblastine and adriamycin (M-VAC). From November 1994 to May 1997 we treated 25 patients (51 men, 3 women, aged 50-77) with M-VAC. The tumor originated from the urinary bladder in 14 (56%) and the upper urinary tract in 11 (44%). Disease sites included: primary--5 (25%), lymph nodes--17 (68%), lungs--10 (40%), bones--8 (32%), pelvic mass and liver each--4 (16%), with an overall median of 2 (1-5) sites per patient. 9 patients (38%) had complete responses and 8 (32%) had partial responses, for an overall response rate of 68% (95% CI 48.5%-85%). The median duration of response was 15.3 (1.6-29.6+) months. Median survival of responders was 19.1 (4.8-35.7+) months compared to 6.2 (0.7-11.2) for the non-responders (p < 0.05). 13 (52%) of patients are alive, of whom 8 (32%) are free of disease and 5 with a single metastatic site on presentation at follow-up. In the 118 treatment cycles we observed grade III-IV toxicity: myelosuppression 53 (45%), thrombocytopenia 4 (3%), stomatitis 8 (6.7%), diarrhea 3 (2.5%). There were 22 infectious episodes and 1 patient died of sepsis. We achieved a high response rate with the combination M-VAC. However, only a third had long-term disease-free states and treatment was associated with excessive toxicity. Therapeutic approaches with new agents are required to improve the response rate and toxicity.

Inhibition of adamalysin II and MMPs by phosphonate analogues of snake venom peptides

Phosphonate analogues of the peptidomimetic N-(Furan-2-yl)carbonyl-Leu-Trp-OH were prepared with the goal of evaluating the effect of phosphonate for carboxylate replacement on binding with snake venom metalloproteinases and MMPs. N-(Furan-2-yl)carbonyl-Leu-L-Trp(P)-(OH)2 showed a 75-fold increase of the inhibiting activity against adamalysin II, a snake venom metalloproteinase structurally related to MMPs and TACE. Both the phosphonate and carboxylate peptidomimetics fit into the active site adopting a retrobinding mode and provide the structural base for a new class of metalloproteinases inhibitors.

Antiandrogen withdrawal syndrome with cyproterone acetate

OBJECTIVES

To determine whether the antiandrogen withdrawal syndrome occurs with the steroidal antiandrogen cyproterone acetate.

METHODS

Cyproterone acetate was withheld in 12 patients with progressing androgen-independent metastatic prostate cancer. Eight patients had been receiving cyproterone acetate concomitant with androgen ablation, and in 4 patients it was prescribed after failure of androgen suppression. Time to response and to disease progression were defined by serum prostate-specific antigen (PSA) levels and imaging studies.

RESULTS

PSA levels decreased in 5 of the 1 2 patients; in 4 of them (33%), the decrease exceeded 50%. The decline lasted a median of 24 weeks (range 9 to 37.8). All 5 patients had received initial concomitant exposure to androgen ablation and cyproterone acetate.

CONCLUSIONS

We recommend that the steroidal antiandrogen cyproterone acetate be added to the list of agents capable of inducing antiandrogen withdrawal syndrome.

Combination chemotherapy for metastatic or locally advanced genitourinary squamous cell carcinoma: a phase II study of methotrexate, cisplatin and bleomycin

PURPOSE

The prognosis of patients with advanced squamous cell carcinoma of genitourinary origin is poor. While single agent chemotherapy results mainly in partial responses of short duration, data on the efficacy of combination chemotherapy are extremely limited. We determined the response rate and toxicity of a combination of 3 of the most active agents, methotrexate, cisplatin and bleomycin, in patients with advanced genitourinary squamous cell carcinoma.

MATERIALS AND METHODS

Patients with metastatic or locally advanced genitourinary squamous cell carcinoma were eligible for study. Treatment consisted of 200 mg./m.2 methotrexate on days 1, 15 and 22, and 20 mg./m.2 cisplatin and 10 mg./m.2 bleomycin on days 2 through 6 during a 28-day cycle.

RESULTS

Of the 30 patients who enrolled in the trial 29 were evaluable for response. Objective response was achieved in 16 patients (55%, 95% confidence interval 36 to 72), 4 of whom achieved a complete response (14%). Median objective response duration was 4.7 months (range 1.9 to 39.5). Median survival of the entire group was 11.5 months (range 1.5 to 87.0). Of the patients 9 achieved disease-free status, including 6 following consolidation surgery or radiation therapy. Median survival of these 9 patients (34.4 months, range 9.6 to 87.0) was significantly greater (p = 0.0003) than that of patients who did not become disease-free (7.0 months, range 1.5 to 38.6). Grade III or IV hematological toxicity in 116 courses included neutropenia (13%) and thrombocytopenia (6%). Among 30 patients evaluable for toxicity serious nonhematological toxic effects included stomatitis (3%) and renal toxicity (7%). There was 1 death from neutropenic sepsis.

CONCLUSIONS

Methotrexate, cisplatin and bleomycin combination chemotherapy for genitourinary squamous cell carcinoma results in a high but short lived overall response rate, and a low complete response rate with manageable toxicity. A multidisciplinary approach to achieve disease-free status may provide the best opportunity to effect survival and should be the focus of future trials.

Intravesical bacillus Calmette-Guérin treatment for Stage T1 grade 3 transitional cell carcinoma of the bladder

OBJECTIVES

To retrospectively analyze intravesical bacillus Calmette-Guerin (BCG) treatment for Stage T1 grade 3 (T1G3) transitional cell carcinoma (TCC) of the bladder.

METHODS

Between 1984 and 1995, 78 patients with Stage T1 grade 3 tumor were treated by transurethral resection of all visible tumors and adjuvant BCG intravesical instillations. Median follow-up was 56 months (range 12 to 141).

RESULTS

After an initial induction course, 52 patients (67%) were tumor-free. Twenty-two patients (28%) had recurrent tumor after a median of 7 months (range 5 to 62). Progression occurred in 6 patients (7.7%) after a median of 18 months (range 5 to 56).

CONCLUSIONS

Intravesical BCG appears to be an effective treatment for patients with Stage T1 grade 3 TCC. Patients whose tumors recur after an initial induction course may benefit from a second course of BCG. Intravesical BCG treatment may lower the tumor progression rate. Late recurrence, beyond 2 years, warrants long-term follow-up.

Phase II trial of 5-fluorouracil, interferon-alpha and continuous infusion interleukin-2 for patients with metastatic renal cell carcinoma

BACKGROUND

This study was designed to evaluate the efficacy and toxicity of the combination of 5-fluorouracil, interferon-alpha, and interleukin-2 for patients with metastatic renal cell carcinoma.

METHODS

Previously untreated patients with a Zubrod performance status of < or =2; adequate cardiac, pulmonary, and renal function; and absence of brain metastases were eligible. One course of therapy was 28 days. 5-fluorouracil was administered at a dose of 600 mg/m2/day as a continuous infusions on Days 1-5. Interleukin-2 also was administered as a continuous infusion on Days 1-5 at a dose of 2 million Roche U/m2/day. Interferon-alpha was given as a daily subcutaneous injection of 4 million U/m2/day.

RESULTS

Fifty-five patients were enrolled in the trial and 52 were evaluable for response. All patients experienced fever and flu-like symptoms. Grade 3 or 4 nonhematologic toxic effects included hypertension (48%), dermatitis (12%), stomatitis (11%), and altered mental status (9%). There was one toxic death. Four complete responses and 12 partial responses were observed for a total response rate of 31% (95% confidence interval, 18-46%). The survival of responding patients was significantly better than that of nonresponding patients. The improvement in survival was even more significant when comparing patients with at least stable disease with those who progressed through treatment.

CONCLUSIONS

The three-drug combination described in this study demonstrates activity. However, it appears to be more toxic than other regimens with similar response rates and cannot be recommended for standard practice. Changing the interleukin-2 route to subcutaneous administration may permit more continuous administration with less toxic effects.

Hyperplasia of axillary nodes in patients undergoing immunotherapy

OBJECTIVE

CT scans of the chest in 32 patients undergoing immunotherapy for metastatic renal cell carcinoma were evaluated to determine the incidence and significance of axillary lymph node enlargement during therapy.

CONCLUSION

Axillary node enlargement in cancer patients undergoing immunotherapy should not be assumed to be metastatic in origin but may result from the stimulation of the immune system during treatment.

Carpal tunnel syndrome associated with interleukin-2 therapy

BACKGROUND

Interleukin (IL-2) has been extensively used in our institution in the treatment of cancer and has protean neurologic side effects. Carpal tunnel syndrome developing in patients receiving IL-2 appears to have a good prognosis and may spare the patient unneeded investigation.

METHODS

A retrospective evaluation was undertaken for all patients using our institution's Patient Studies database. The patients were examined and their charts reviewed.

RESULTS

We found eight patients with renal cell carcinoma who developed carpal tunnel syndrome (CTS) during treatment with IL-2, fluorouracil (5-FU), and alpha-interferon (alpha-IFN). The symptoms were bilateral in five patients and all patients improved with cessation of therapy. Three patients had recurrent symptoms with subsequent courses of therapy. Symptoms occurred during or shortly after IL-2 infusion and resolved after therapy was completed with conservative management. The number of courses given did not seem to correlate with development of symptoms. Neurophysiologic studies demonstrated conduction velocity slowing without evidence of acute denervation.

CONCLUSIONS

IL-2 can produce focal entrapment of the median nerve at the wrist, which reverses with drug withdrawal. IL-2 mediates the inflammatory response and can cause interstitial edema that likely causes CTS to develop in predisposed patients undergoing treatment.

A phase I trial of intermittent high-dose alpha-interferon and dexamethasone in metastatic renal cell carcinoma

BACKGROUND

Evidence exists that the toxic of alpha-interferon can be ameliorated by co-administration of dexamethasone without compromise of therapeutic efficacy. We therefore conducted a phase I trial to determine the maximum tolerated dose of intermittent interferon when combined with oral dexamethasone.

PATIENTS AND METHODS

Thirty patients with metastatic renal cell carcinoma were enrolled. The starting dose of interferon was 20 million IU/m2/day given as a subcutaneous injection days 1 to 4 of each 14 day cycle. Dose levels were escalated at increments of 5 million IU/m2. Dexamethasone 4 mg was administered orally every 6 hours during administration of high-dose interferon. Low-dose maintenance interferon, 3 million IU/m2/day, was administered without dose escalation on days 5 to 14 of each cycle.

RESULTS

The maximum tolerated dose of intermittent high-dose interferon was 40 million IU/m2/day. The dose limiting toxicity was fatigue. EEG abnormalities developed in five patients and neuropsychiatric parameters deteriorated significantly in seventeen.

CONCLUSIONS

We conclude that co-administration of dexamethasone improves the tolerance of intermittent high-dose interferon. The results of this trial may be useful in designing high-dose interferon regimens for renal cell carcinoma and other interferon-sensitive diseases.