First-line high-dose sequential chemotherapy with rG-CSF and repeated blood stem cell transplantation in untreated inflammatory breast cancer: toxicity and response (PEGASE 02 trial)

Despite the generalization of induction chemotherapy and a better outcome for chemosensitive diseases, the prognosis of inflammatory breast cancer (IBC) is still poor. In this work, we evaluate response and toxicity of high-dose sequential chemotherapy with repeated blood stem cell (BSC) transplantation administered as initial treatment in 100 women with non-metastatic IBC. Ninety-five patients (five patients were evaluated as non-eligible) of median age 46 years (range 26-56) received four cycles of chemotherapy associating: cyclophosphamide (C) 6 g m(-2) - doxorubicin (D) 75 mg m(-2) cycle 1, C: 3 g m(-2) - D: 75 mg m(-2) cycle 2, C: 3 g m(-2) - D: 75 mg m(-2) - 5 FU 2500 mg m(-2) cycle 3 and 4. BSC were collected after cycle 1 or 2 and reinfused after cycle 3 and 4. rG-CSF was administered after the four cycles. Mastectomy and radiotherapy were planned after chemotherapy completion. Pathological response was considered as the first end point of this trial. A total of 366 cycles of chemotherapy were administered. Eighty-seven patients completed the four cycles and relative dose intensity was respectively 0.97 (range 0.4-1.04) and 0.96 (range 0.25-1.05) for C and D. Main toxicity was haematological with febrile neutropenia ranging from 26% to 51% of cycles; one death occurred during aplasia. Clinical response rate was 90% +/- 6%. Eighty-six patients underwent mastectomy in a median of 3.5 months (range 3-9) after the first cycle of chemotherapy; pathological complete response rate in breast was 32% +/- 10%. All patients were eligible to receive additional radiotherapy. High-dose chemotherapy with repeated BSC transplantation is feasible with acceptable toxicity in IBC. Pathological response rate is encouraging but has to be confirmed by final outcome.

Cytotoxic effects of two gamma linoleic salts (lithium gammalinolenate or meglumine gammalinolenate) alone or associated with a nitrosourea: an experimental study on human glioblastoma cell lines

Gamma linoleic acid (GLA) salts may exert a direct antiproliferative activity on tumor cells. The cytotoxicity is linked to the generation of conjugated dienes, peroxyl radicals and superoxide radicals. Lithium gammalinolenate (LiGLA) and meglumine gammalinolenate (MeGLA) have been recently developed for enhancing the water solubility of these compounds. MeGLA or LiGLA (10(-5) to 10(-4) mol/l) and fotemustine (Fote) (2 x 10(-6) to 2 x 10(-4) mol/l) were applied, alone or in combination, for up to 9 days to two human glioblastoma cell lines A172 and U373MG. Fote was applied first followed by LiGLA and/or MeGLA. Cytotoxicity was evaluated by the MTT test, and the effects of drug combinations were analyzed by the isobolographic representation according to the Chou and Talalay method (combination indexes). For both GLA salts, cytotoxicity was manifested after 4 days of cell exposure and with very sharp dose-response curves. Comparison of IC50 values indicated that MeGLA was more active than LiGLA. There was a constant reduction in IC50 values following an increase in exposure time for A172 cells: between 4 and 9 days of cell exposure, IC50 changed from 73 to 46 microM for LiGLA and from 49 to 31 microM for MeGLA (p<0.05). With U373MG cells, there was no influence of exposure duration on IC50 values. Combination index values indicated that association between Fote and GLA salts globally resulted in slightly antagonistic effects. These results may be useful for further development of GLA salts at the clinical level.

Influence of electrical coupling on early afterdepolarizations in ventricular myocytes

Computer modeling is used to study the effect of electrical coupling between a myocardial zone where early afterdepolarizations (EAD's) can develop and the normal neighboring tissue. The effects of such coupling on EAD development and on the likelihood of EAD propagation as an ectopic beat are studied. The influence on EAD formation is investigated by approximating two partially coupled myocardial zones modeled as two active elements coupled by a junctional resistance R. For R values lower than 800 omega cm2, the action potentials are transmitted to the coupled element, and for R values higher than 850 omega cm2 they are blocked. In both ranges of R, when the electrical coupling increases, the EAD's appear at more negative takeoff potentials with higher amplitudes and upstrokes. The EAD's are not elicited if the electrical coupling is too high. In a separate model of two one-dimensional cardiac fiber segments partially coupled by a resistance R, critical R values exist, between 42 and 54 omega cm2, that facilitate EAD propagation. These results demonstrate that in myocardial zones favorable to the formation of EAD, the electrical coupling dramatically affects initiation of EAD and its spread to the neighboring tissue.

Subcutaneous interleukin-2, interferon alfa-2a, and continuous infusion of fluorouracil in metastatic renal cell carcinoma: a multicenter phase II trial. Groupe Français d'Immunothérapie

PURPOSE

A phase II trial was designed to determine the efficacy and the tolerance of interleukin-2 (IL-2), interferon alfa-2a (IFNalpha), and fluorouracil (5-FU) in patients with metastatic renal cell carcinoma.

PATIENTS AND METHODS

One hundred eleven patients were included. Patients received subcutaneous IL-2 9 x 10(6) IU daily for 6 days and IFNalpha 6 x 10(6) IU on days 1, 3, and 5 every other week for 8 weeks. 5-FU was administered through a continuous infusion at 600 mg/m2 for 5 consecutive days for 1 week every 4 weeks.

RESULTS

The response rate was 1.8% (95% confidence interval [CI], 0% to 4.3%) with only two partial responses (PRs). Toxicity was moderate with 3.6% grade 4 events and two deaths related to treatment.

CONCLUSION

This regimen of IL-2, IFNalpha, and 5-FU in patients with metastatic renal cell carcinoma was ineffective. The results raise the question of the dose and schedule of subcutaneous cytokines that must be used in metastatic renal carcinoma.

[Prognostic factors and therapeutic strategy of breast cancer]

The survival of patients with breast cancer depends on parameters known as prognostic factors. The first generation of prognostic factors are simple, have been validated, and have proved their usefulness. We know the importance of examining axillary lymph nodes. However, because there has been a constant increase in the percentage of patients with no invaded lymph nodes, tumor size has become an important parameter. The 10-year survival rate of patients with tumors less than 1 cm in diameter exceeds 90% suggesting that there might seem to be no need for adjuvant therapy. According to histological grade assessed by the Scarff-Bloom and Richardson method, grade I tumors have a better prognosis than grade II or III tumors. Knowledge of the concentration of estrogen and progesterone receptors in tumors provides not only prognostic information but also indicates whether hormone therapy is justified. All these first generation factors are intimately linked and, taken together, they are the main factors on which the oncologist bases his decision whether or not to prescribe adjuvant therapy. There is still no consensus regarding the assay methods and normal levels of second generation prognostic factors. Amongst these factors, the most promising are those, like S-phase determination by flow cytometry, that evaluate cell proliferation potential and those that investigate tumor invasiveness by assaying urokinase plasminogen activator or its inhibitor.

Cisplatin nephrotoxicity: a multivariate analysis of potential predisposing factors

STUDY OBJECTIVE

To evaluate the usefulness of biologic and pharmacologic parameters for early identification of cisplatin-induced renal dysfunction.

DESIGN

Prospective evaluation of 62 consecutively admitted patients with cancer.

SETTING

Cancer center.

PATIENTS

Sixty-two consecutive patients with cancer (52 men, 10 women; mean age 61.9 yrs).

INTERVENTIONS

Patients received cisplatin as a single short intravenous infusion every 3 weeks. One hundred twenty-one cycles were analyzed. The dosage in the first cycle ranged between 61 and 105 mg/m2 (mean 84 mg/m2). All patients received a standard hydration protocol.

MEASUREMENTS AND MAIN RESULTS

Renal function was evaluated for each cycle before treatment (day 0) and before next cycle (day 21) based on the estimated creatinine clearance (Clcr). For each cycle, the weighted relative decrease (WD) of Clcr was calculated (WDClcr = 100 x [Clcr (day 0) - Clcr (day 21)]/[Clcr (day 0)](2). Total and ultrafilterable (UF) platinum were measured as a single-sample assay taken 16 hours after the end of cisplatin administration. The mean WDClcr was 0.07 min/100 ml (range -1.0 to +1.7 min/100 ml). The intensity of renal dysfunction evaluated by WDClcr was independent of cisplatin dosage, age, sex, body surface area, initial Clcr, and cycle number. Of interest, total and UF platinum concentrations were significantly correlated to WDClcr: the higher the platinum concentration, the greater the intensity of renal dysfunction. In stepwise regression analysis, UF platinum concentration was the only selected factor. The best prediction of UF platinum was obtained by stepwise regression including cisplatin dosage, initial Clcr, and cycle number (r=0.58, p<0.0001).

CONCLUSION

We consider our results to be a first step toward a clinical strategy to identify patients at risk for renal dysfunction after cisplatin treatment.

[Prognostic value of early normalization of CA 125 during chemotherapy in stages III and IV ovarian tumors]

The value of early CA 125 assays and analysis of its diminution kinetics during chemotherapy have been the subject of numerous studies. In contrast, routine utilization of CA 125 assays in clinical practice remains controversial or at best difficult to apply because the definitions and prognostic values associated with CA 125 assays vary greatly from one study to the next. This study was designed to determine whether serial CA 125 assays during induction chemotherapy for ovarian carcinoma, using simple evaluation criteria directly applicable in routine clinical practice such as early normalization (level < 35 UI/ml) are predictive of response to treatment or improved survival. This retrospective longitudinal analysis concerned a historical population of 140 patients with ovarian carcinoma stages III and IV treated at the Antoine-Lacassagne Cancer Center between 1978 and 1993. All the patients were treated by chemotherapy based on platinum salts every 21 days. Serum CA 125 assays were performed both before and after surgery and during each chemotherapy cycle. Eighty-four patients had a pre-operative CA 125 assay. No difference is observed in survival as a function of their preoperative CA 125 concentration (p = 0.4). Sixty-seven patients had a CA 125 assay the 6th week after initiation of chemotherapy, 62 the 9th week and 47 the 18th week. Normalization of CA 125 the 6th week (p = 0.0001), the 9th week (p = 0.0008) and the 18th week (p = 0.03) after the initiation of the chemotherapy cycle are correlated with survival. The median survival in our study is 42 months if the CA 125 is below 35 UI/ml the 6th week versus 13 months if the level of CA 125 remains more than 35 UI/ml. In all, 66 of the 105 FIGO stage III patients underwent second-look surgery. Normalization of CA 125 levels is correlated with the absence of any gross residual tumor at the second-look procedure, the 6th week of chemotherapy (p = 0.0019), the 9th week of chemotherapy (p = 0.0003) and the 18th week of chemotherapy (p = 0.0015). This correlation is not confirmed when the presence of histologic residual tumor in biopsy specimens obtained during second-look surgery is taken into consideration. Overall, 88% of patients whose CA 125 levels failed to normalize during evaluation at the second cycle of chemotherapy have residual tumor at second-look surgery. Outside of clinical trials, repeated early CA 125 assays to determine the chemosensitivity and the prognosis of patients with ovarian carcinoma are of little interest compared to a single CA 125 assay at the 6th week after initiation of chemotherapy. This approach seems to be a good compromise between the information sought and its practical use. However the interest of early modification of chemotherapy regimen after 2 cycles, if the level of CA 125 remains more than 35 UI/ml, will have to be showed.

Non-specifically labelled cells that simulate bone marrow metastases in patients with non-metastatic breast cancer

AIMS

To determine whether the presence of disseminated bone marrow tumour cells at diagnosis is a prognostic factor for breast cancer patients at high risk of recurrence or bone metastasis, and to assess their presence as a criterion for evaluation of the potential benefits of adjuvant chemotherapy.

METHODS

Multiple bone marrow aspirates from 72 breast cancer patients free from metastasis were obtained during surgery at the time of diagnosis and were tested immunologically by alkaline phosphatase antialkaline phosphatase technique with a panel of three antiepithelial monoclonal antibodies (MoAb) KL1, EMA, and HMFG2.

RESULTS

In nine of 72 patients, with each MoAb tested, numerous strongly positive cells always isolated were observed. However, it was demonstrated that these cells were non-specifically labelled and could be found in normal controls.

CONCLUSIONS

There was no evidence of marrow tumour cells in 72 operable breast cancer patients. It is suggested that published results may be greatly overestimated and that non-specific labelling may be undetected. More specific MoAb should be found and a correlation with molecular biology should be performed if this criterion is to be considered as a prognostic factor.

[A comparative study of 4 sequential first-line chemotherapy protocols in locally advanced breast cancer]

Between 1977 and 1994, our center administered successively 4 different chemotherapy regimens to 242 evaluable patients with locally advanced breast cancer. Patients with inflammatory signs were excluded. Sixty-eight patients were treated by AVCF (A (adriamycine) + V (vincristine) + C (cytoxan) + F (5FU)), 47 by AECF (A + E (vindesine) + C + F), 81 by CAFP (C + A + F + P (prednisone)) and 46 by AN (A + N (vinorelbine)). The mean number of cycle was 3. One hundred and twenty-five patients (52.5%) responded to chemotherapy and we recorded 35 complete response (14.7%). The response rates at the different combinations were respectively: AVCF: 29.4%, AECF: 53.2%, CAFP: 64.9%, AN: 65.2%, and were independent of tumor size, grade and receptor status. The response rate at the AVCF regimen was significantly worse than the others (p = 0.0005). Breast conserving surgery was performed in 31 patients (14%) and 17 patients (8%) had a complete response. Among the 35 patients with complete response, 21 were treated by radiotherapy alone. Local recurrence occurred in 19 patients (7.9%) and 96 (40%) had advanced disease. The mean follow-up of AVCF regimen was 150 months, 115 months for AECF, 111 for CAFP and 42 months for AN. The disease-free survival and the overall survival were significantly better with AECF, CAFP and AN regimens (DFS p < 0.04, OS p < 0.02). Survival was better in those patients with an objective response (p = 0.002) or with non-affected axillary node at the time of surgery. Our study showed already that AVCF combination was significantly lower than AECF, CAFP, AN in terms of response rate, disease-free survival and overall survival. Waiting the results of randomized studies about the impact of neoadjuvant chemotherapy on survival, we look for chemotherapy regimen improving the rate of conservative surgery.

Simulation of action potentials from metabolically impaired cardiac myocytes. Role of ATP-sensitive K+ current

The role of the ATP-sensitive K+ current (IK-ATP) and its contribution to electrophysiological changes that occur during metabolic impairment in cardiac ventricular myocytes is still being discussed. The aim of this work was to quantitatively study this issue by using computer modeling. A model of IK-ATP is formulated and incorporated into the Luo-Rudy ionic model of the ventricular action potential. Action potentials under different degrees of activation of IK-ATP are simulated. Our results show that in normal ionic concentrations, only approximately 0.6% of the KATP channels, when open, should account for a 50% reduction in action potential duration. However, increased levels of intracellular Mg2+ counteract this shortening. Under conditions of high [K+]0, such as those found in early ischemia, the activation of only approximately 0.4% of the KATP channels could account for a 50% reduction in action potential duration. Thus, our results suggest that opening of IK-ATP channels should play a significant role in action potential shortening during hypoxic/ischemic episodes, with the fraction of open channels involved being very low ( < 1%). However, the results of the model suggest that activation of IK-ATP alone does not quantitatively account for the observed K+ efflux in metabolically impaired cardiac myocytes. Mechanisms other than KATP channel activation should be responsible for a significant part of the K+ efflux measured in hypoxic/ischemic situations.

Age-related difference in tamoxifen disposition

PURPOSE

To investigate the pharmacokinetic aspects of tamoxifen, such as the pharmacokinetic-pharmacodynamic (toxicity and clinical response) relationship and the influence of hepatic dysfunction, age, treatment duration, and associated chemotherapy on tamoxifen pharmacokinetics.

PATIENTS AND METHODS

Three hundred sixteen patients with breast cancer (247 postmenopausal women) were investigated. Mean age was 58 years (age range, 29 to 85 years). One hundred seventeen patients received tamoxifen as single therapy (adjuvant, 60; neoadjuvant, 17; metastatic, 40); 292 of 316 received 30 mg daily. We obtained 794 blood samples at steady state. Tamoxifen and metabolites, N-desmethyltamoxifen, N-desdimethyltamoxifen, primary alcohol, and 4-hydroxytamoxifen were measured by HPLC.

RESULTS

Serum concentrations of tamoxifen and metabolites showed a wide asymmetrical distribution. Median and extremes were 347 nmol/L (not detectable [ND] to 1677) for tamoxifen, 572 nmol/L (ND to 3132) for N-desmethyltamoxifen, 109 nmol/L (ND to 795) for N-desdimethyltamoxifen, and 59 nmol/L (ND to 390) for primary alcohol. 4-Hydroxytamoxifen was detectable in 9.5% of the samples (ND to 162 nmol/L). Neither the absolute nor the relative concentrations of each compound showed significant variations during treatment. Chemotherapy concomitant with tamoxifen slightly increased the tamoxifen blood concentration. Hepatic dysfunction had no obvious effect on drug concentrations, an exception being a slight reduction in the relative proportion of tamoxifen. The influence of age revealed that concentrations of tamoxifen and metabolites increased significantly with age: women younger than 40 years had a tamoxifen plus metabolite median concentration of 802 nmol/L compared with 2428 nmol/L for women older than 80 years. In the 28 patients in whom tamoxifen-related side effects developed, the proportion of demethylated metabolites was higher than that in patients in whom toxicity did not develop. There was no difference in drug concentrations between responding and nonresponding patients.

CONCLUSION

Despite the tremendous interpatient variability in drug concentrations, the present data show that tamoxifen and metabolite concentrations significantly increase with age.

[Is breast cancer prevention by tamoxifen possible?]

Breast cancer is a frequent disease especially in the Western world with an incidence that increases by 1% each year. Distressingly, even nowadays, 40% of patients with breast cancer will die of their disease. Postoperative adjuvant therapy and detection of non-palpable cancers by mass screening of women have improved patient survival but have not impinged upon the steady increase in incidence. Treatment before radiological detection could improve the chances of survival and even prevent the full-blown expression of the disease. The probability that a woman will develop breast cancer during her life-time is high but not evenly distributed. Knowledge of predisposing factors can help to identify those women subject to greater risk than the general population. The most important known risk factors are age, family history, factors related to ob-gyn antecedents, lifestyle, benign hyperplastic breast disease with or without atypia. These various risks, are often associated and cumulative. A woman who has already had breast cancer has a 3 to 5 times greater probability of developing cancer of the contralateral breast than the average woman. The second breast is therefore at risk in the same way as are the women with predisposing factors. Many clinical studies have demonstrated the benefits of postoperative adjuvant tamoxifen (TAM) in improving the disease-free interval and survival of patients. An analysis of the site of relapse has interestingly brought to light a marked decrease in the percentage of cancers of the contralateral breast. In order to establish whether TAM could prevent or delay the onset of high-risk women without detectable signs of illness into groups receiving either TAM or placebo. Is this ethically acceptable? The answer to this question rests heavily on an objective evaluation of the unwanted and beneficial side-effects of TAM in order to weigh up all pros and cons before initiating a trial.

[Treatment of ifosfamide induced encephalopathy with methylene-blue]

The authors report a case of encephalopathy after treatment with ifosfamide treated by a methylene blue infusion. This side-effect is rare but influenced by high doses and short infusions of this drug. Recently, a treatment of ifosfamide encephalopathy with methylene blue has been reported. This case report confirms the interest of such a treatment.

[Combination of mitoxantrone-vinorelbine as first-line chemotherapy for metastatic breast carcinoma]

A phase II trial was performed to assess the efficacy and toxicity of the combination mitoxantrone (MXN) and vinorelbine (VNR) as first-line chemotherapy for metastatic breast cancer. Forty-one patients with metastatic disease or local relapse recruited between March 1991 and April 1993 received a first-line chemotherapy treatment consisting in 12 mg/m2 intravenous (IV) bolus of MXN on day 1 followed by a 20-minute perfusion of 25 mg/m2 of VNR on days 1 and 8. Cycles were repeated every 21 days until evidence of disease progression or of severe toxicity. Thirty-seven patients were evaluable for response and all 41 for toxicity. An objective response was observed in 19 patients (51%; 95% confidence interval, 45 to 74%). The response was complete in a further 11 (30%). Median time to treatment failure was 9 months. Median survival was 14 months. There were no treatment-related deaths. Limiting toxicity was myelosuppression. Leukopenia occurred in 29 patients (71%) and was grade 3 or 4 in nine of these (15%). Grade 2 or 3 anemia was encountered in six patients (15%), grade 1 thrombocytopenia in one, neurotoxicity (constipation) in two, and grade 2 or 3 alopecia in 12 (29%). Nausea/vomiting requiring antiemetic treatment was experienced by only two patients (5%). There were two cases of septicemia treated by antibiotic therapy in hospital.