Survival after combined modality therapy for pancreatic cancer

Twenty consecutive patients with unresectable, locally advanced pancreatic cancer were treated with split courses of radiotherapy (RT) and simultaneous multidrug chemotherapy consisting of 5 fluorouracil, continuous infusion, streptozotocin, and cisplatin. A separate, retrospective study identified a group of 28 contemporary patients with less advanced pancreatic cancers, all of which were successfully resected. The survival rate of the two groups were similar over the first 2 years, although it initially favored the unresectable group. This pattern of survival among patients treated with combined modality therapy provides a basis for new studies. At the two clinical extremes, these include treatment of unresectable tumors previously considered ineligible for this treatment and initial treatment before resection of stage I tumors.

Circulating pancreatic polypeptide in patients with adenocarcinoma of the bile duct

Using radioimmunoassay methods, the blood of patients with pancreatic tumors was screened for circulating polypeptide hormones. This screening discovered pancreatic polypeptide in abnormally high concentration in the serum of six of seven patients with adenocarcinomas of the bile duct. The assay appears to be very sensitive finding excessive residual pancreatic polypeptide production after palliative resections. Serum pancreatic polypeptide assays warrant evaluation as an aid in the diagnosis and management of patients with bile duct tumors.

Combined modality therapy increasing local control of pancreatic cancer

Twenty patients with inoperable locally advanced Stage II and III pancreatic cancer were treated with combined modality therapy. Radiotherapy consisted of split courses of 2000 cGy each and, as needed, an additional 1400 cGy, separated by 2-week intervals. Simultaneous multidrug regimen chemotherapy consisted of 5-fluorouracil, continuous infusion, 1 g/m2 days 1-5; streptozotocin, 300-500 mg/m2 days 1, 2, 3; and cisplatin, 100 mg/m2 day 3 of every 4-week radiotherapy course (RT-FSP). Primary tumors decreased more than 50% in volume in 11 of 20 patients. Computed tomography scans demonstrated apparent complete disappearance of the primary tumor in 7 patients. Only 3 patients had tumor regrowth within the radiotherapy field, all after the end of radiotherapy. Local control improved as measured by increased frequency of tumor shrinkage and decreased frequency of primary tumor growth, recognizing the limitations of a pilot study and comparisons to best historical results achieved with standard short 5-fluorouracil schedules and radiotherapy. Successful local control largely eliminates the most common cause of refractory pain and may decrease the need for some forms of early palliative surgical intervention. Tumor shrinkage sometimes downstages tumors, creating frequent investigational opportunities for either elective extirpative surgery or intraoperative radiotherapy. This pilot experience also supports testing of expanded eligibility staging criteria for combined modality treatment and testing of new drugs as part of 5-fluorouracil-radiotherapy-based regimens.

Treatment of a large high-grade neurofibrosarcoma with concomitant vinblastine, doxorubicin, and radiotherapy

A patient with neurofibromatosis developed a large inoperable malignant schwannoma on the posterior neck. The tumor underwent complete local regression following combined-modality treatment with radiotherapy, vinblastine, and doxorubicin. Vinblastine may be effective in combined-modality therapy.

Clostridium difficile diarrhea induced by cancer chemotherapy

Four patients had diarrhea due to Clostridium difficile after receiving chemotherapy for cancer. None of the patients had received antibiotics for at least 4 weeks before the onset of diarrhea. At the time of admission of any of these four patients no outbreak of diarrhea was noted on the ward. Each patient was admitted with the acute onset of diarrhea after receiving chemotherapy, at different times of the year. Diarrhea was clinically important and was associated with dehydration, toxemia, and blood in the stool in all cases. Diagnosis of C difficile was confirmed by endoscopic examination, positive biopsy specimen, and positive test for toxin in the stool. All patients recovered after undergoing specific treatment. Drugs not believed to carry serious risk to the bowel mucosa may facilitate proliferation of C difficile. Patients with severe diarrhea after receiving chemotherapy, particularly those with blood in the stool, should be promptly tested for C difficile even in the absence of a history of antibiotic administration. Early and specific treatment can prevent additional morbidity and reduce cost of care.

Folate biochemical modulation regimen for the treatment of gastric cancer

Twenty patients with metastatic gastric cancer were treated with methotrexate (MTX, M), 100 to 160 mg/m2 at 0 h, and, in sequence, 5-fluorouracil (FU, F), 600 to 1000 mg/m2 at 4 h; leucovorin (LV, L), 200 mg/m2 at 18 h, then 20 mg/m2 every 6 h x 12; 5-fluorouracil, 600 mg/m2 at 19 h; and high-dose cisplatin (DDP, P), 100 mg/m2 at 20 h. In addition, they were treated with a continuous 5-fluorouracil infusion, 1000 mg/m2/24 h from 18 h to 114. There were 8 complete and 6 partial responses among the 16 patients with measurable tumors. Five patients, each with one remaining clinical site of disease, received supplementary regional therapy: three received intraperitoneal therapy, two received hepatic arterial therapy. Intraperitoneal therapy and hepatic artery therapy each produced one complete response. Median survival was 16 months for all patients, and 25% survived 2 years. In comparison with matched patients, both response rates and survival improved twofold.

Hexamethylmelamine for the treatment of ovarian cancer--the Mount Sinai experience

Two regimens were tested, CHAP I and CHAP II, the latter, a hexamethylmelamine dosage-intensive regimen, first as second line (salvage) therapy and then as primary therapy. Both produced the most successful results achieved in the Mount Sinai series up to the time of their introduction, when compared to their predecessor regimens: CAP, AP and P. In an overall interim comparison, CHAP II was significantly superior to historical AP and CAP as primary therapy, as was CHAP I vs. AP in several important subgroups compared as part of a randomized trial. CHAP II overall progression-free survival was improved in spite of added new sensitive test methods. Salvage therapy also improved markedly with the addition of intensive hexamethylmelamine. Several biological and treatment characteristics strongly influenced outcome, especially young age and adding hexamethylmelamine. Other possible factors included: poor tumor grade, poor performance status, and extent of surgical debulking, even to intermediate residual, 2-6 cm size [CHAP II only]; extensive (optimum) surgery [CHAP I only]. The hexamethylmelamine-containing regimens interact favorably with some of these factors, better than did the preceding regimens. Five-year follow-up analyses weakened slightly for extensive surgery, intermediate size and poorly differentiated tumors. It confirmed and strengthened several findings favoring CHAP I & II, the hexamethylmelamine-containing regimens.

Effective chemotherapy for gastrointestinal tumors. 21st Symposium on Recent results in chemotherapy of malignant diseases (Chairmen: J. van de Loo, V. Diehl) of the Gesellschaft zur Bekämpfung der Krebskrankheiten Nordrhein-Westfalen (GBK), Düsseldorf, June 1989

Chemotherapy can achieve approximately 50% rates of response, survival advantage or both for every type of gastrointestinal tumor. Findings favor adjuvant therapy for all high-risk tumors. Test-worthy candidate regimens possibly increase safety and efficacy, and challenge traditional choices of treatment for patients with either unresectable or metastatic disease. They create many new options and an unprecedented order of complexity. Treatments remain to be compared and integrated. Efforts to assess the impact of patient characteristics, cost and safety are preliminary at best, and critical to rational usage. There are as yet no perfect regimens, only a series of options supported by incomplete but clearly more promising findings than heretofore. These include: biochemical modulation for gastric and colonic cancer; chemotherapy as a radiotherapy adjuvant for esophageal, rectal, anal, and pancreatic cancer; and immunotherapy for gastric and colorectal cancer. Selective application of endocrine therapy, circadian time schedules or regional therapy may augment safety and quality of life. While response rates have probably improved, their exact frequency, quality and effect on survival are incompletely characterized. Investigations, offer the best way to deal with the options and speed progress, in the context of building upon apparent best therapies.

Dose-dependent leucovorin efficacy with an intermittent high-dose 5-fluorouracil schedule

Sixteen patients with metastatic carcinoma of the colon were treated with a regimen of leucovorin 200 mg/m2, given as a 10-min infusion followed by a median dose of 833 mg/m2 (range 500-1000 mg/m2) 5-fluorouracil every two weeks. For the 16 patients with proven metastatic disease, two-year survival exceeds 50%. Responses were: 2 complete; 4 partial; 4 minor; 3 progression; and 3 not evaluable but without progression to date. Toxicities include: 8 (50%) leukopenia; 9 (56%), 1 severe thrombocytopenia; 9 (56%), 2 severe, diarrhea; 9 (56%), 3 severe, nausea/vomiting; 8 (50%), 1 severe, stomatitis; 7 (44%) conjunctivitis; 6 (38%) alopecia; and 13 (81%), 3 severe, neurotoxicity. Leucovorin appears to exert a dose-dependent beneficial effect on both the response and survival produced by the intermittent high-dose 5-fluorouracil schedule. This benefit first appears to increase substantially when the leucovorin dose is increased from 120 to 200 mg/m2. Findings identify a testable candidate regimen for selected good risk patients. Full selection criteria remain to be identified.

Complete remission of refractory small cell carcinoma of the pancreas with cisplatin and etoposide

A case of unusually large widespread metastatic small cell carcinoma of the pancreas is presented. The patient remains in complete remission 50 months after the diagnosis and initiation of combination chemotherapy using a schedule consisting of etoposide (150 mg/m2) intravenously (IV) on days 1 to 3 and cisplatin (100 mg) IV on day 2. Initial chemotherapy with streptozotocin, 5-fluorouracil, and methotrexate, doxorubicin, cyclophosphamide, and lomustine (MACC) had been unsuccessful.

Treatment of advanced refractory ovarian carcinoma with a gonadotropin-releasing hormone analogue

Leuprolide acetate, a gonadotropin-releasing hormone analogue, produced a variety of beneficial therapeutic responses in five patients with ovarian carcinoma. Four patients had failed intensive chemotherapy with alkylating agents, cisplatin, and Adriamycin. All had one or more clinical conditions that precluded treatment with cytotoxic agents and characteristics associated with resistance to hormone therapy. Our findings support evaluation of expanded eligibility criteria for new hormonal therapy in cases of refractory ovarian carcinoma.

The modulation of fluorouracil with leucovorin in metastatic colorectal carcinoma: a prospective randomized phase III trial. Gastrointestinal Tumor Study Group

A total of 343 patients with previously untreated metastatic measurable colorectal carcinoma were studied to evaluate the impact on toxicity, response, and survival of leucovorin-modulated fluorouracil (5-FU). A maximally tolerated intravenous bolus loading course regimen of 5-FU alone (500 mg/m2 x 5 days every 4 weeks with 25 mg/m2 escalation) was compared with a high-dose leucovorin regimen (600 mg/m2 of 5-FU with 500 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest) and with a similar low-dose leucovorin regimen (600 mg/m2 of 5-FU with 25 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest). The dose-limiting toxicity for the two 5-FU and leucovorin regimens was gastrointestinal, specifically diarrhea; severe diarrhea was seen frequently, and treatment-related toxicity was implicated in the demise of 11 of the patients (5%). Significant improvements in response rates were observed with a response rate of 33 of 109 (30.3%) on the high-dose leucovorin regimen (P less than .01 v control); 13 of 107 (12.1%) on the 5-FU control; and 21 of 112 (18.8%) on the low-dose leucovorin regimen. A trend toward longer survival in the 5-FU plus high-dose leucovorin regimen was observed. In this study, leucovorin was shown to significantly enhance the therapeutic effect of 5-FU in metastatic colorectal carcinoma.

Schedule and dosage modification of a cyclophosphamide, hexamethylmelamine, doxorubicin, cisplatin combination chemotherapy regimen for refractory ovarian cancer

A cyclophosphamide, hexamethylmelamine, doxorubicin and cisplatin (CHAP II) regimen produced median survival of 15 and 17 months. All patients had prior chemotherapy, 26 with cisplatin in the former group, and 27 without cisplatin in the latter group. Treatment employed both a novel sequential schedule of cisplatin (usually in the evening) 24 h before cyclophosphamide-doxorubicin and novel stepwise escalation, first of doxorubicin, then of hexamethylmelamine until either nadir white blood counts fell to 1000-1500/mm3 or platelets to 75,000-100,000/mm3. Compared to prior Mount Sinai experience: (i) survival was significantly improved; (ii) with and without prior cisplatin, response rates approached a significant improvement, 12% and 29% complete and 24% and 35% partial. Five of seven additional patients with progression during unmaintained remission also responded, two with pathologically complete remissions. Findings suggest: (i) the importance of maximum dose intensity in ovarian cancer treatment; (ii) the responsiveness of patients failing first line treatment to dose intensive treatment; (iii) the possible importance of schedule, and sequential or circadian timing of cisplatin, and other drugs; (iv) and testing revised clinical criteria of resistance to drugs.

Modulation and intensification of a cyclophosphamide, hexamethylmelamine, doxorubicin, and cisplatin ovarian cancer regimen

For 61 patients with stage III-IV carcinoma of the ovary, chemotherapy consisted first of cisplatin 50 mg/m2 on day 1, cyclophosphamide 500 mg/m2 on day 3, doxorubicin 50 mg/m2 on day 3, and hexamethylmelamine 100 mg/m2 on days 4-15 every 4 weeks. The dosages of doxorubicin and hexamethylmelamine were increased by 60 and 100%, respectively, until the nadir white blood cell counts fell to 1.0 x 10(9)/L. This regimen was less neurotoxic and nephrotoxic than other intensive treatments and produced better therapeutic effects than did the immediate preceding Mount Sinai regimens: 1) The overall median survival was 43 months and progression-free survival was 25 months; 2) the greatest benefit occurred among patients under 50 years of age; 3) regression of large tumors increased in frequency, with 33% of tumors 2-6 cm and 16% of tumors larger than 6 cm converted to either pathologically proved remission or microscopic disease; and 4) for the first time, partial surgical debulking producing residual tumors less than 6 cm in size improved early survival.

Primary treatment of regional and disseminated pancreatic cancer with hexamethylmelamine, mitomycin C and 5-fluorouracil infusion

Hexamethylmelamine, mitomycin C and 5-fluorouracil infusion (HexMF) achieved a median survival of 9 months for the 45 patients with either metastatic stage III or unresectable stage II carcinoma of the pancreas. Fifteen percent survived 2 years. Of 32 patients with measurable tumors, 7 had partial and 3 had minor responses (31%); an additional 44% has stable disease for 3 months or more. Response was associated with a 17-month median survival. These findings are indications for further evaluation of both dosage-intensive 5-fluorouracil infusions alone and HexMF as an alternative to streptozotocin- or adriamycin-containing regimens. Patients with nonmeasurable disease are candidates for survival-oriented phase III studies.

Leucovorin and 5-fluorouracil as a treatment for disseminated cancer of the pancreas and unknown primary tumors

Chemotherapy with leucovorin (100 to 200 mg) and 5-fluorouracil (30 mg/kg) every 2 wk produced four (three complete) objective responses among a group of eight patients with early metastatic pancreatic primary and unknown cancers. Complete remissions were associated with exceptionally long durations of survival, one in a patient failing prior combination chemotherapy. This treatment warrants testing because of its ease, scientific rationale, and the large population of patients with early metastatic pancreatic cancer for whom there is no accepted treatment. Early metastatic disease is defined as small metastatic lesions not immediately life threatening found in a physiologically intact patient. Controlled trials, demonstrating benefit associated with other 5-fluorouracil-containing regimens for patients with nonmetastatic stages of pancreatic cancer, provide a rationale for extending testing of leucovorin and 5-fluorouracil to other early stages of pancreatic cancer.

Extrahepatic obstructive jaundice due to colorectal cancer

A prospective registry of patients with obstructive jaundice referred for percutaneous bile duct drainage found six patients with extrahepatic obstruction due to colorectal cancer in a 21-month period. This cause of jaundice in patients with colorectal cancer is not uncommon, and deserves routine diagnostic consideration, even in the presence of intrahepatic metastases. Percutaneous biliary drainage was beneficial for four of the six patients.