Phase II study of marimastat (BB-2516) in malignant melanoma: a clinical and tumor biopsy study of the National Cancer Institute of Canada Clinical Trials Group

OBJECTIVES

To determine the tolerability and efficacy of daily oral marimastat (BB-2516 in patients with metastatic melanoma and to determine the matrix metalloproteinase (MMP) activity, tumour necrosis, peri- and intra-tumoral fibrosis and tumor inflammation in pre- and post-treatment tumor biopsies.

PATIENTS AND METHODS

Patients with measurable metastatic melanoma who had received no more than one prior chemotherapy regimen and lesions accessible for biopsy were eligible. The first 18 were treated with 100 mg p.o. twice daily and the next 11 received a reduced dose of 10 mg p.o. twice daily because of musculoskeletal toxicity. Response was assessed according to standard criteria.

RESULTS

Twenty-nine patients were entered and 28 were eligible. Five had early progression (< 4 weeks of therapy), 2 experienced a partial responses persisting for 3.2 months and 3.6 months, 5 had stable disease and 16 progressive disease. Eleven patients had both pre- and post-treatment biopsies. In 3, no tumor tissue was present in one or the other biopsy. Two patients showed a clear increase in peri-tumoral fibrosis and two others showed an increase in tumor necrosis, but no consistent pattern in histologic changes was seen. In one patient, who later developed a PR, apoptosis was increased.

CONCLUSION

Marimastat has only limited activity in patients with metastatic malignant melanoma. However, the observation of two partial responses was interesting given that this agent might have been expected to cause tumor stasis rather than regression. Additional studies will be required to determine if the development of peri-tumoral fibrosis or tumor necrosis antedates a clinical response to marimastat.

Epoetin alfa in patients not on chemotherapy - Canadian data

A prospective open-label study was designed to evaluate the safety, efficacy, and impact on quality of life of recombinant human erythropoietin (rHuEPO, epoetin alfa) therapy for cancer-related anemia. Of the 401 patients enrolled at 34 centers from across Canada, a cohort of 183 patients did not receive chemotherapy during the 16-week study period. All patients received epoetin alfa 150 IU/kg subcutaneously 3 times per week. The dose was increased to 300 IU/kg if the hemoglobin level did not increase by at least 1.0 g/dL after 4 weeks. Epoetin alfa therapy significantly increased hemoglobin levels and reduced transfusion requirements. Moreover, epoetin alfa provided statistically significant and clinically meaningful improvements in quality of life as measured by the Functional Assessment of Cancer Therapy-Anemia and Linear Analog Scale Assessment (also known as Cancer Linear Analog Scale). Increases in hemoglobin were correlated significantly with improvements in quality of life as well as Eastern Cooperative Oncology Group performance status. Treatment with epoetin alfa was well tolerated. These results demonstrate that epoetin alfa therapy is effective and safe in cancer patients with anemia, regardless of whether they are or are not receiving chemotherapy.

Epoetin alfa therapy increases hemoglobin levels and improves quality of life in patients with cancer-related anemia who are not receiving chemotherapy and patients with anemia who are receiving chemotherapy

PURPOSE

To evaluate efficacy, safety, and quality of life (QOL) changes with epoetin alfa therapy for anemia in patients with nonmyeloid malignancies.

PATIENTS AND METHODS

Anemic cancer patients were enrolled onto this prospective, open-label study from 34 centers across Canada. The trial had two cohorts: patients who were and were not receiving chemotherapy during the 16-week study. All patients initially received epoetin alfa 150 IU/kg subcutaneously three times per week. The dose was doubled after 4 weeks for patients who did not experience sufficient response.

RESULTS

Of the 183 patients enrolled in the nonchemotherapy cohort, statistically significant and clinically relevant improvements in QOL were observed with epoetin alfa therapy using both the FACT-An questionnaire and linear analog scale assessment. Hemoglobin levels increased significantly (P <.001; mean increase 2.5 g/dL from baseline to end of study) and these increases were positively correlated with improved QOL and change in Eastern Cooperative Oncology Group (ECOG) scores. There was a significant reduction in the percentage of patients who required blood transfusions. The 218 patients in the chemotherapy cohort also experienced significant improvements in QOL, decreased transfusion use, and increased hemoglobin levels that correlated with QOL improvements and change in ECOG scores. Epoetin alfa was well-tolerated in both cohorts.

CONCLUSION

Epoetin alfa administered to patients with cancer-related anemia for up to 16 weeks resulted in significantly improved QOL, increased hemoglobin levels, and decreased transfusion use. These benefits were observed in cancer patients who were not receiving chemotherapy as well as those who were.

Intratumoral sickling in a patient with cervix cancer and sickle trait: effect on blood flow and oxygenation

BACKGROUND

Sickle trait affects approximately 8% of the black population in the United States and up to 40% of individuals in some parts of tropical Africa, but rarely causes clinically significant illness. This report provides the first conclusive evidence that erythrocytes in patients with sickle trait may sickle in the microvasculature of solid tumors, leading to impaired perfusion and hypoxia.

CASE

A black woman who was sickle trait positive presented with stage IIIB squamous cell carcinoma of the cervix. A biopsy showed extensive intravascular sickling of erythrocytes. An aspirate of blood obtained directly from the tumor also showed numerous sickled cells. A peripheral blood smear was normal. Direct measurement of oxygen tension using the Eppendorf electrode revealed the tumor to be markedly hypoxic, with 93% of a total of 142 individual oxygen reading <5 mm Hg.

CONCLUSIONS

Erythrocytes in patients with sickle trait may sickle in the microvasculature of solid tumors and contribute to reduced blood flow and the development of hypoxia. Hypoxia is a strong independent prognostic factor in patients with cervix cancer, and further study is needed to evaluate the impact of intratumoral sickling on long-term outcome.

Epoetin alfa in cancer patients: evidence-based guidelines

Anemia is a common cause of cancer-related fatigue. A systematic review of the literature was performed to establish guidelines on the use of epoetin alfa for the treatment of anemia. The evidence in support of these guidelines was selected, reviewed, and summarized by the members of the Canadian Cancer and Anemia Guidelines Development Group. The effects of epoetin alfa on quality of life (QOL) in patients with cancer were examined in 5 randomized, placebo-controlled trials and 2 large, open-label, nonrandomized, community-based studies. The effects of epoetin alfa on red blood cell transfusion requirements were examined in 19 randomized controlled trials (RCTs) with 21 comparisons. All trials compared epoetin alfa to a suitable control group, examined specified outcome measures that could be analyzed, and studied patients with cancer who were receiving chemotherapy. Trials involving patients with hematologic malignancies originating in the bone marrow were excluded. Outcome measures included 1) quality of life (QOL) (as measured by scales including the Linear Analogue Self-Assessment [LASA] and the Functional Assessment of Cancer Therapy [FACT] subscales), and 2) transfusion requirements (as measured by the proportion of patients requiring transfusion and amount of transfusion). The analysis confirmed that epoetin alfa produced statistically significant and clinically relevant improvements in QOL in patients with cancer. The overall relative risk ratio for transfusion among patients receiving epoetin alfa was calculated to be 0.60 (95% Cl, 0.53-0.69; P < 0.00001), representing a 40% reduction in the proportion of patients requiring transfusion. These results support recommendations for the use of epoetin alfa in patients with cancer-related anemia.

Erythropoietin in the management of patients with nonhematologic cancer receiving chemotherapy. Systemic Treatment Program Committee

GUIDELINE QUESTIONS

1) Does erythropoietin (EPO) reduce the need for transfusion of red blood cells in patients receiving chemotherapy for a nonhematologic cancer? 2) Does the administration of EPO improve the quality of life of these cancer patients?

OBJECTIVE

To make recommendations regarding the use of EPO to reduce the need for transfusion of red blood cells in patients receiving chemotherapy for a nonhematologic cancer.

OUTCOMES

First transfusion requirement from the start of chemotherapy is the main outcome of interest. Quality of life and costs are also considered.

PERSPECTIVE (VALUES)

Evidence was selected and reviewed by 5 members of the Ontario Cancer Treatment Practice Guidelines Initiative (OCTPGI) and the Systemic Treatment Program Committee (STPC). Drafts of this document have been circulated to and reviewed by members of the STPC. The STPC comprises medical oncologists, pharmacists, supportive care personnel and administrators. No community representative participated in the development of this practice guideline.

QUALITY OF EVIDENCE

Eleven randomized controlled trials (RCTs), most placebo-controlled, were available for review. A meta-analysis was performed with 8 trials that shared a clinically relevant outcome measure. Only 1 trial assessed quality of life.

BENEFITS

The meta-analysis showed a relative risk for transfusion among EPO patients of 0.64 (95% confidence interval 0.53-0.78), which translates into a 36% relative reduction in the proportion of patients requiring transfusion (p = 0.00001). Reduction in transfusion requirements was similar across strata defined by methodological quality, EPO dose, hematologic status, tumour type at trial entry and chemotherapy regimen. In the 1 trial that assessed quality of life, EPO was associated with improved quality of life.

HARMS

Hypertension has been noted rarely in EPO-treated cancer patients. The RCTs did not report adverse effects in EPO-treated patients compared with control patients during the follow-up period. Long-term adverse effects are unknown. EPO is more costly than transfusion, but formal cost-effectiveness studies are unavailable.

PRACTICE GUIDELINE

For patients receiving chemotherapy for nonhematologic cancer in whom symptoms of anemia are expected and in whom transfusion of red blood cells is not considered an acceptable treatment option, EPO can be recommended as a safe, effective treatment alternative. The evidence in support of using EPO is stronger for patients receiving platinum-based chemotherapy regimens that for those receiving non-platinum-based regimens. CLINICAL PRACTICE GUIDELINE DATE: Apr. 4, 1997.

Treatment of Advanced Hodgkin's Disease With Chemotherapy—Comparison of MOPP/ABV Hybrid Regimen With Alternating Courses of MOPP and ABVD

The institution affiliation section on page 1638 of the April 1997 article entitled, "Treatment of Advanced Hodgkin's Disease With Chemotherapy—Comparison of MOPP/ABV Hybrid Regimen With Alternating Courses of MOPP and ABVD: A Report From the National Cancer Institute of Canada Clinical Trials Group" by Connors, et al (J Clin Oncol 15:1638–1645, 1997) was incomplete. The "London Regional Cancer Centre, London, Ontario, Canada" should have been included in the listing of author-affiliated institutions.

Cost-benefit analysis of prophylactic granulocyte colony-stimulating factor during CHOP antineoplastic therapy for non-Hodgkin's lymphoma

Several randomised comparative trials have shown that granulocyte colony-stimulating factor (G-CSF) reduces the duration of neutropenia, hospitalisation and intravenous antibacterial use in patients with cancer who are receiving high-dosage antineoplastic therapy. However, one area that has received less attention is the role of G-CSF in standard-dosage antineoplastic regimens. One such treatment that is considered to have a low potential for inducing fever and neutropenia is the CHOP regimen (cyclophosphamide, doxorubicin, vincristine and prednisone) for non-Hodgkin's lymphoma. We conducted a cost-benefit analysis from a societal perspective in order to estimate the net cost or benefit of prophylactic G-CSF in this patient population. This included direct costs for hospitalisation with antibacterial support, as well as indirect societal costs, such as time off work and antineoplastic therapy delays secondary to neutropenia. The findings were then tested by a comprehensive sensitivity analysis. The administration of G-CSF at a dosage of 5 micrograms/kg/day for 11 doses following CHOP resulted in an overall net cost of $Can1257. In the sensitivity analysis, lowering the G-CSF dosage to 2 micrograms/kg/day generated a net benefit of $Can6564, indicating a situation that was cost saving to society. The results of the current study suggest that the use of G-CSF in patients receiving CHOP antineoplastic therapy produces a situation that is close to achieving cost neutrality. However, low-dosage (2 micrograms/kg/day) G-CSF is an economically attractive treatment strategy because it may result in overall savings to society.

Treatment of advanced Hodgkin's disease with chemotherapy--comparison of MOPP/ABV hybrid regimen with alternating courses of MOPP and ABVD: a report from the National Cancer Institute of Canada clinical trials group

PURPOSE

This randomized, prospective trial compares outcomes for patients with advanced Hodgkin's disease treated with mechlorethamine, vincristine, procarbazine, and prednisone (MOPP)/doxorubicin, bleomycin, and vinblastine (ABV) hybrid regimen or alternating MOPP/doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD).

METHODS

Three hundred one patients with advanced Hodgkin's disease were randomized to receive MOPP/ ABV hybrid regimen or alternating MOPP/ABVD after stratification for prior treatment, B symptoms, and treatment center. Eligible patients were either previously untreated and found to have stage IIIB, IVA, or IVB disease or previously treated with wide-field irradiation. Responding patients received a minimum of eight cycles of chemotherapy. Those with residual disease in a localized region received irradiation between the sixth and seventh cycle of treatment.

RESULTS

Response rates to the two regimens were similar. Five-year overall survival rates were 81% and 83% for MOPP/ABV hybrid and alternating MOPP/ ABVD, respectively (P = .74; 95% confidence interval [CI] for the difference, -11% to 7%). Five-year failure-free survivals were 71% and 67% for MOPP/ABV hybrid and alternating MOPP/ABVD, respectively (P = .87; 95% CI for the difference, -9% to 17%). Significantly more episodes of febrile neutropenia and stomatitis were observed with the MOPP/ABV hybrid regimen; there was no significant difference in fatal toxicity. Patients with predefined, high-quality partial responses (PR-1s) had results similar to those with complete responses (CRs). Planned subset analysis showed no significant difference in outcome between the two arms of the trial for patients with newly diagnosed disease (5-year failure-free survival rates were 70% for MOPP/ABV hybrid and 59% for alternating MOPP/ABVD; P = .180), but superiority of alternating MOPP/ABVD for patients with prior irradiation (5-year failure-free survival 94% v 73%; P = .017).

CONCLUSION

MOPP/ABV hybrid and alternating MOPP/ABVD regimens are equally effective for patients with advanced Hodgkin's disease.

HIV-associated lymphoma of the gastrointestinal tract: the University of Toronto AIDS-Lymphoma Study Group experience

We present a retrospective analysis of 31 (30 male) patients with HIV-associated gastrointestinal lymphoma which was undertaken to determine the natural history and response to therapy. Only seven patients had stage I or II lymphoma and 22 had stage IV. Pathology included diffuse large cell (13), immunoblastic (10), and small cell non-cleaved (7). The median age at presentation was 39 years (range 24-59), and the median CD4 count before treatment was 100/microL (range 4-1150). Eighty-seven percent of patients received systemic chemotherapy and significant response was seen in 84% (CR 38%; PR 46%). Hematologic toxicity was high (febrile neutropenia in 44% and dose reductions were required in 81%) and perforation occurred in five patients. Median survival for all patients was 6 months and death was secondary to lymphoma in 61%, treatment toxicity in 10%, other AIDS-related illnesses in 25% and other causes in 4%. Survival was shorter for patients with bone marrow involvement and for those with poor performance status. HIV-associated GI lymphoma has a poor prognosis despite good initial response to chemotherapy and is associated with a higher perforation rate than in HIV negative patients.

Phase II trial of 10-EDAM in advanced soft tissue sarcoma. A study of the Canadian Sarcoma Group and the National Cancer Institute of Canada Clinical Trials Group

BACKGROUND

Inoperable locally recurrent soft tissue sarcomas (STS) are incurable with chemotherapy. Therefore the National Cancer Institute of Canada Clinical Trials Group are performing phase II studies in an attempt to find better drugs.

PATIENTS AND METHODS

Thirty-one evaluable patients with incurable soft tissue sarcoma were treated with the antifol 10-EDAM at a dose of 80 mg per m2/week.

RESULTS

Mucositis was the most common toxicity. Only 41% of patients received > or = 90% of the planned dose time because of dose modification mainly for grade 1 mucositis. Two patients died after neutropenic episodes. Toxicity otherwise was generally mild (< grade 2). One patient had a pathologically confirmed complete response but relapsed after four months. Another had a partial response lasting 16 weeks. Eleven other patients had stabilization of disease.

CONCLUSIONS

In this study, 10-EDAM was not found to be an effective agent to treat advanced soft tissue sarcoma.

Outcome and prognostic factors in soft tissue sarcoma in the adult

PURPOSE

To evaluate the outcome, patterns of failure and prognostic factors in this rare disease in adult patients treated at a single institution in the modern era.

METHODS AND MATERIALS

The records of all patients (389 cases) with soft tissue sarcoma in the extremities, torso (excluding retroperitoneum), and head and neck managed between 1980 and 1988 were reviewed. A curative (radical) approach was used in 321 patients of whom 10% were recurrent lesions. The local management consisted of surgery alone in 54 cases, surgery and radiotherapy in 250 and radiotherapy alone in 17. Adjuvant chemotherapy was used as a policy for high grade lesions in the initial five years of the study (98 cases), but was omitted subsequently.

RESULTS

Extremity lesions fared more favourably compared to head and neck and torso lesions (p = 0.02) with respect to survival. Extremity and torso lesions had significantly better local control (p < 0.0001) than in the head and neck where local failure was a common cause of death. A multiple Cox regression analysis revealed that resection margins, local extension of tumor, age at diagnosis, and grade correlated with local relapse and distant relapse was also associated with local extension, high grade and in addition, large lesions. Size appeared especially predictive for distant failure, the most common cause of death. Distant failure was not influenced by the use of adjuvant chemotherapy. Patients treated for recurrence in this series had significantly worse survival due to increased distant failure despite similar local control to primary cases.

CONCLUSION

This series highlights the overall problem of distant failure in this disease. It also reaffirms the importance of obtaining local control both in the head and neck, where uncontrolled local disease is the major cause of death, and in general since local relapse appears to increase the risk of distant failure. It appears that the current staging systems should be reviewed in the light of the apparent effect of different prognostic factors.

Adult paratesticular sarcomas: a review of 21 cases

We reviewed 21 patients more than 16 years old who were seen with a diagnosis of paratesticular sarcoma from 1958 to 1987. Of the patients 14 presented with primary disease and 7 with recurrent disease. The survival of the primarily treated patients was 58% at 5 years, calculated by the product limit method. Of the 14 patients with primary disease 13 had grade 3/4 or 4/4 sarcoma and 13 of 14 underwent initial radical orchiectomy. In addition, 6 of the 14 patients underwent an adjuvant operation or radiotherapy to the groin, or groin and scrotum, and none had local relapse. Some patients also had chemotherapy. Three patients underwent adjuvant retroperitoneal node dissection and 2 had microscopically positive nodes. All 3 patients remain without relapse. Six patients had relapse: 2 locally, 2 in the retroperitoneal nodes and 2 with distant metastases. Only 1 patient (with scrotal recurrence) was salvaged. Of the 7 patients referred with recurrent disease none was salvaged. In this series there is a 2 of 14 (14%) risk of local failure and a 4 of 14 (28%) risk of retroperitoneal relapse after radical orchiectomy. Since salvage has not proved successful, patients with rhabdomyosarcoma, intermediate or high grade malignant fibrous histiocytoma, or fibrosarcoma should be considered for adjuvant retroperitoneal node dissection. All patients should undergo adjuvant dissection or irradiation of the ipsilateral pelvic and groin nodes, and scrotum.

Combination chemotherapy with doxorubicin, dacarbazine, and ifosfamide in advanced adult soft tissue sarcoma. Canadian Sarcoma Group--National Cancer Institute of Canada Clinical Trials Group

Forty-three adult patients with locally advanced or metastatic soft tissue sarcoma entered a pilot study of combination chemotherapy comprising 50 mg of doxorubicin/m2 by intravenous bolus, 850 mg of dacarbazine/m2 by 1-hour infusion, and 5 g of ifosfamide/m2 by 24-hour infusion with mesna uroprotection. The overall response rate in 40 assessable patients was 25% with two complete remissions. Twenty-four episodes of infection occurred in 148 courses (16%). These infections were usually associated with neutropenia (granulocyte count less than 0.5 X 10(9)/L), which occurred in 70% of the courses. These results do not differ from those elicited by each agent alone, and may reflect inadequacies of dose intensity or scheduling, or evaluation in a study population with adverse prognostic factors.

Predictive value of staging investigations in patients with clinical stage I malignant melanoma

We reviewed the charts of 393 consecutive patients referred to the Toronto-Bayview Regional Cancer Centre and the Ontario Cancer Institute between January 1, 1978, and December 31, 1982, with clinical stage I malignant melanoma to determine the predictive value of routine staging investigations. The investigations reviewed included physical examination, liver function tests, radionuclide liver-spleen and bone scans, chest x-ray, whole-lung tomograms, CT chest scans, CT brain scans, and bipedal lymphangiograms. The clinical stage of nine patients was changed, eight as a result of physical examination and one as a result of lymphangiogram. No other investigations detected metastatic melanoma at referral. We recommend that staging investigations for patients referred with clinical stage I malignant melanoma be restricted to a complete physical examination and a baseline chest x-ray for all patients.

Is bone marrow examination in small-cell lung cancer really necessary?

Of 403 patients with small-cell lung cancer, we identified by aspiration, biopsy, or both 67 with bone marrow involvement and found the two procedures to be complementary in detecting marrow involvement. The mean surface area of the positive biopsy specimens was significantly greater than that of a randomly selected group of negative biopsy specimens, suggesting that the larger the specimen, the greater the chance of detecting tumour. Patients with marrow involvement had only a slightly worse prognosis compared with other patients who had extensive disease. Only 7 of the 403 patients (1.7%) had extensive disease based on marrow involvement alone. Because bone marrow examination rarely changes the stage of cancer in noninvasively assessed patients, and has no impact on the tolerance of chemotherapy and only a small effect on length of survival, we do not recommend this procedure in the routine staging of small-cell lung cancer.

Toxicity of oral N-methylformamide in three phase II trials: a report from the National Cancer Institute of Canada Clinical Trials Group

Three National Cancer Institute of Canada phase II studies of N-methylformamide (NMF), given in a three times/week oral schedule, closed early because of frequent and occasionally severe toxicity. Eighteen of 41 (44%) cycles of treatment were not completed because of problems with NMF-induced hepatic and gastrointestinal toxicity. Several other reactions occurred, including skin rashes, abdominal pain, and gastritis, which were drug induced. One death occurred on study and was thought to be due in part to NMF toxicity. Further work exploring alternative schedules is needed before phase II studies of oral NMF can be done.

Lomustine, vincristine, and procarbazine in the treatment of metastatic malignant melanoma

Sixty-five previously untreated patients with metastatic malignant melanoma were treated with lomustine, vincristine, and procarbazine. Sixty-four patients were evaluable for response, with a response rate of 13%. Only one complete response was observed, in a patient with nodal disease only. Three partial responses were observed in patients with disease confined to soft tissue, and four partial responses were observed in patients with pulmonary metastases. Median survival for all patients was 22 weeks. We conclude that this regimen offers no improvement compared to other drug combinations.

A phase II study of spirogermanium as second line therapy in patients with poor prognosis lymphoma. An NCI Canada Clinical Trials Group Study

The National Cancer Institute of Canada Clinical Trials Group conducted a phase II study of spirogermanium given daily for 5 days every 3 weeks to patients with poor prognosis non-Hodgkin's lymphomas. All patients had had a maximum of one prior treatment regimen. No responses were seen in 13 evaluable patients. Toxicity was primarily neurologic and mild or moderate in most patients. There is no evidence of activity of spirogermanium given in this schedule in this subset of lymphoma patients.

A phase II study of spirogermanium in patients with metastatic malignant melanoma. An NCI Canada Clinical Trials Group Study

The National Cancer Institute of Canada Clinical Trials Group conducted a phase II study of spirogermanium given daily for 5 days every 3 weeks to previously untreated patients with malignant melanoma. In 21 evaluable patients one complete response was seen (response rate 5%). Disease progression occurred in the other 20 patients. Toxicity was primarily neurologic and mild or moderate in most patients, though there was one treatment related death. In this schedule spirogermanium has extremely limited activity against malignant melanoma and will not contribute significantly to the systemic therapy of this disease.