The role of chemotherapy in the treatment of non-small cell carcinoma of the lung

Within the past 10 years, the role of chemotherapy in the treatment of patients with non-small cell lung cancer has expanded greatly. Previously chemotherapy was used only for patients with disseminated disease and, despite advances in combination therapy with new agents, response rates remained low, response duration was short, and cures were rare. Performance status is an important prognostic indicator both from the standpoint of response and duration of survival. Patients with locally advanced disease who are otherwise candidates for operation have a significantly higher response rate to chemotherapy and tolerate the treatment reasonably well. Combination chemotherapy given preoperatively seems to be associated with improved survival, especially in those patients able to undergo complete resection. Radiation therapy and chemotherapy given preoperatively may be even more efficacious than either modality alone. The question as to whether surgical resection improves on what can be accomplished with radiation therapy and chemotherapy in patients with mediastinal lymph node involvement remains an open one and is currently being evaluated.

Phase II trial of all-trans retinoic acid in metastatic non-small cell lung cancer

The toxicity and marginal effectiveness of cytotoxic chemotherapy in metastatic non-small cell lung cancer (NSCLC) necessitates the search for new agents. Preliminary data in lung cancer and other malignant and premalignant disorders have identified retinoid compounds as potentially useful antitumor agents. Twenty-eight patients with metastatic NSCLC were treated with oral all-trans retinoic acid in a phase II trial. The study population consisted of patients with excellent performance status and minimal weight loss. Toxicities were generally mild and included cutaneous effects, headache, and myalgia. A significant number of patients developed elevations of hepatic transaminases or hyperlipidemia and 3 patients had treatment-related leukocytosis. Two patients (8%) achieved a partial response, and 1 had a mixed response. The duration of remission in the 2 responders was 7 and 13 months and the median survival of all patients 7 months. Therefore, all-trans retinoic acid has minimal activity as a single agent in NSCLC but warrants further study in combination with biological agents and chemotherapy.

Plasma thrombospondin levels in patients with gynecologic malignancies

BACKGROUND

Thrombospondin is a high molecular weight glycoprotein, originally described as a secretion product of platelets, that functions as an adhesive protein in cell-cell and cell-substratum interactions. It promotes metastases in the murine model. Plasma thrombospondin has been shown to be elevated in patients with disseminated breast, lung, and gastrointestinal malignancies.

METHODS

Blood samples were collected by venipuncture into cubes containing ethylenediamine tetraacetic acid as anticoagulant. They were placed on ice immediately and centrifuged under refrigerated conditions. Plasma was removed and frozen until thrombospondin was quantitated by a competitive enzyme-linked immunosorbent assay. Wilcoxon's two-sample rank-sum test was used to evaluate differences between the patient and control groups.

RESULTS

The median plasma thrombospondin level was significantly higher in the patient group compared with the control group, and it was directly correlated with stage of disease. There was no correlation between platelet count and thrombospondin level.

CONCLUSIONS

Tumor-synthesized thrombospondin could explain the elevated levels in the patent group and also the observation of the correlation between the thrombospondin level and tumor burden. Its function as an adhesive protein may allow it to act as the mediator of metastases. thrombospondin may promote or mediate the metastatic process through its function in cell adhesion.

Thrombospondin levels in patients with malignancy

Thrombospondin (TSP), a large glycoprotein present in platelets, and various normal and tumor tissues, has recently been shown to promote cell adhesion and platelet aggregation. Most importantly because TSP has been shown to promote metastasis of melanoma tumor cells to the lung in a murine model (1) and since thromboembolic events commonly occur in patients afflicted with metastatic tumors, we explored the role of TSP in human cancer by measuring TSP blood levels in patients with various malignant neoplasms. Blood TSP levels were measured by indirect enzyme-linked immunoadsorbent assay (ELISA) from 20 control subjects, 22 patients with gastrointestinal (GI) cancer, 18 patients with breast cancer, and 17 patients with lung cancer. Control subjects consisted both of healthy subjects and acutely ill patients with no malignancies. TSP levels of both healthy and acutely ill controls were found to range between 245-440 ng/ml with a mean of 365 ng/ml. In contrast, elevated levels of TSP greater than the mean value of 400 ng/ml for controls ranging between 590-3,650 ng/ml were found in 20/22 (91%) patients with GI malignancies, 13/18 (72%) patients with breast cancer, and 15/17 (88%) with lung cancer. Mean TSP levels of GI, breast, and lung cancer patients were 3, 2, and 3 fold greater than controls, respectively. Increased blood TSP levels in patients were not due to increased levels of platelets since both control and patient groups had platelet counts within the normal range. These results suggest that TSP may play a role in tumor cell metastasis in man and could serve as a blood marker for metastasis.

Continuous infusion 5-fluorouracil with bolus adriamycin and mitomycin and low-dose cisplatin (FAMP) in the treatment of metastatic gastric carcinoma: an evaluation of efficacy and toxicity

A pilot study was performed to evaluate the feasibility of administering prolonged continuous infusion 5-fluorouracil with multiple bolus chemotherapeutic agents. Twelve patients with advanced measurable gastric carcinoma were treated with a combination chemotherapy program of continuous infusion 5-fluorouracil, bolus Adriamycin, mitomycin C, and low-dose cisplatin (FAMP). Responses were observed in 5 patients (2 complete and 3 partial). Observed toxicities included leukopenia, thrombocytopenia, mucositis, and hand-foot syndrome. Although the FAMP regimen has activity in advanced gastric carcinoma, the number of patients evaluated was small and significant improvement over currently available regimens could not be demonstrated. Evaluation of toxicities indicates that bolus administration of multiple agents (specifically, Adriamycin, mitomycin C, and cisplatin) can be used in conjunction with continuously infused 5-fluorouracil without excessive toxicity.

Transfusion-induced graft-versus-host disease in patients with malignant lymphoma. A case report and review of the literature

A case of transfusion-induced graft-versus-host disease (GVHD) occurring in a 31-year-old female with Hodgkin's disease in complete remission is reported. Clinical features are similar to 19 other reported cases of transfusion-induced GVHD associated with malignant lymphoma. The lack of relationship with underlying histology or disease stage and the nearly uniformly fatal outcome underscores the importance of prophylactic irradiation of blood products given to patients with malignant lymphoma undergoing therapy.

Antitumor activity of liposome-encapsulated doxorubicin in advanced breast cancer: phase II study

Previous studies in animals have demonstrated liposome-encapsulated doxorubicin (LED) has substantially less cardiac toxicity than free doxorubicin but retains antitumor activity. In a phase I clinical study of LED, the maximum tolerated dose was 90 mg/m2 and dose-limiting toxicity was considered to have been reached when granulocytopenia was produced. We used LED to treat 20 patients with advanced, measurable breast cancer. LED was given at doses of 60-75 mg/m2 every 3 weeks as an intravenous infusion. Regression of disease was objectively measured in nine patients; in five of these patients, complete regression of the index lesion occurred. The mean duration of the responses was 7 months. Hematologic toxicity consisted of grade 1-2 leukopenia in some patients. Gastrointestinal toxicity and mucositis were generally mild and tolerable. Alopecia occurred in all patients and usually was complete. Twelve patients received cumulative doses of LED of greater than 400 mg/m2 and were evaluated with radionuclide ventriculograms. In eight patients, the cumulative dose was greater than 500 mg/m2, and five had endomyocardial biopsies. Four of these biopsy results were Billingham grade 0, while one (cumulative LED dose, 750 mg/m2) showed grade 1 changes with mild myofibrillar loss and dilatation of the sarcoplasmic reticulum involving less than 5% of cardiac myocytes. Two patients had decreases in left ventricular ejection fraction. One of these patients had received a total dose of LED of 630 mg/m2 and had a decline of 13% in left ventricular ejection fraction, but had no clinical evidence of congestive heart failure and had a Billingham grade 0 endomyocardial biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

New findings in treatment of colon cancer

Patients with colon cancer involving regional lymph nodes (stage C disease) have a 5-year survival rate of only 30% to 40%, and the majority die of recurrent disease. Recent trials have shown increased survival rates with postoperative use of fluorouracil plus levamisole. The authors discuss these findings and the implications on treatment recommendations for stage C colon cancer.

A phase I clinical trial and pharmacokinetic evaluation of liposome-encapsulated doxorubicin

We have treated 14 cancer patients with liposome-encapsulated doxorubicin (LED) at doses of 30, 45, 60, and 90 mg/m2. Nausea and vomiting, phlebitis, and stomatitis were minimal or absent at each dose, but dose-limiting granulocytopenia occurred at 90 mg/m2. Thrombocytopenia and/or anemia also occurred in all patients treated at 60 or 90 mg/m2. Complete alopecia was seen in one of three cases at 60 mg/m2 and all cases at 90 mg/m2. No hepatic, renal, or other major organ toxicities were encountered. Clinical cardiac toxicity did not occur in any patient, but the cumulative doxorubicin doses in 13 cases were less than 400 mg/m2. The plasma elimination of LED out to 24 hours was analyzed in terms of a two-compartment model. Depending upon the dose and the infusion time, maximum plasma concentrations ranged from 2.6 mumol/L to 36.89 mumol/L and the area under the plasma concentration x time curve (AUC) values ranged from 1.86 mumol/L x h/L to 49.57 mumol x h/L. These values are significantly higher than those expected for free doxorubicin. Urinary excretion of LED was approximately 10% after 24 hours. Doxorubicinol and doxorubicinone appeared at low levels in plasma 12 to 24 hours after injection. LED pharmacokinetics differ from those of free drug by the higher plasma levels and AUC of doxorubicin achieved, and by the low conversion of LED to metabolites. Overall, LED was well tolerated and produced only moderate nausea and vomiting and little stomatitis at myelosuppressive doses. The study also suggested that LED produces less venous sclerosis than free doxorubicin, but this requires further clinical verification.

Treatment of metastatic colorectal carcinoma. Recent advances in use of fluorouracil

Fluorouracil (Adrucil) has been used for more than 20 years to treat metastatic colorectal carcinoma and has provided significant palliation of symptoms to some patients. Investigators are attempting to exploit pharmacologic aspects of fluorouracil that will provide further benefits. Prolonged infusion of the drug appears to overcome the problems of its brief half-life and the small percentage of cancer cells that are susceptible to the drug at any one time. The addition of leucovorin increases fluorouracil's ability to inhibit thymidylate synthase and thus colon cancer cell replication. It is hoped that the increased response rates produced by these advances will produce increased survival rates as well.

Elliptinium: phase II study in advanced measurable breast cancer

Eighteen patients with advanced measurable breast cancer were treated with elliptinium acetate 100 mg/m2 x 3 days every 3 weeks. Fourteen of these patients had failed prior chemotherapy. Two patients had an objective tumor response of greater than 4 weeks. Myelosuppression, renal insufficiency and thrombophlebitis were rarely encountered and alopecia was not seen at all. This study demonstrates that elliptinium has minimal activity in recurrent breast cancer with a favorable toxicity profile.

Phase II trial of methotrexate-FAM (m-FAM) in adenocarcinoma of unknown primary

Nineteen patients with adenocarcinoma of unknown primary were treated with the m-FAM regimen, consisting of methotrexate 50 mg/m2 days 0, 28; 5-fluorouracil 600 mg/m2 days 1, 8, 29, 36; Adriamycin 30 mg/m2 days 1, 29; and mitomycin-C 10 mg/m2 day 1. All drugs were recycled every 56 days. No complete responses were seen. Seven patients (37%) achieved partial remission for a median duration of 11 months. An additional nine patients (47%) had stable disease for a median duration of 6 months. Median survival for responders was 16 months and was 10 months for those with stable disease. Toxicity was acceptable. This Phase II study attempted to evaluate the clinical impact of the pharmacological modulation of 5-fluorouracil with methotrexate, the goal being improvement of the results of FAM alone in adenocarcinoma of unknown primary. However, the addition of methotrexate, at least in the schedule employed in this study, did not appear superior to FAM.

Therapy of advanced gastric carcinoma. The Georgetown-Lombardi Cancer Center experience

Gastric carcinoma, despite a decreasing incidence in the United States over the past 40 years, is the seventh most common cause of cancer death in this country and remains a significant worldwide problem. The 5-fluorouracil, Adriamycin (doxorubicin), and mitomycin (FAM) chemotherapy regimen, which was initially reported by Georgetown in 1979, has become a standard for advanced gastric carcinoma with response rates in the 40% range. The FAM regimen as well as subsequent trials conducted at Georgetown and our current approach to management of this tumor are discussed. Despite a decade of intensive clinical research, we have not identified a modification or innovation that is superior to the original FAM.

Peripheral neuropathy and low dose cisplatin

Five of 55 patients with metastatic carcinomas or unresectable primary carcinomas developed a peripheral neuropathy with "low dose" cisplatin therapy, consisting of 20 mg/m2 weekly. The neuropathy was primarily sensory, consisting of painful parasthesias and numbness in a "stocking glove" distribution. The cumulative dose at which neuropathy developed varied from 100 to 640 mg/m2. The symptoms and signs of neurologic dysfunction were minimally reversible despite discontinuation of the drug. Despite lower dose delivery of cisplatin, significant debilitating neurologic toxicity may occur.

Radiotherapy in the management of pancreatic islet cell tumors

Malignant islet cell tumors are commonly treated with surgical resection. Chemotherapy is reserved for residual, unresectable, or metastatic disease. The role for radiotherapy has not been clearly defined. This article describes three cases of advanced islet cell tumors treated effectively with radiotherapy. This experience, in addition to that from other published reports, suggests that radiotherapy is a useful mode for treating advanced islet cell carcinoma.