PS-341 and gemcitabine in patients with metastatic pancreatic adenocarcinoma: a North Central Cancer Treatment Group (NCCTG) randomized phase II study

BACKGROUND

PS-341 is a proteasome inhibitor with preclinical activity in pancreatic cancer tumor models and synergistic activity with gemcitabine. This randomized phase II study determined the tumor response rate (RR) for PS-341 alone and the 6-month survival and RR for the combination of gemcitabine and PS-341 in patients with metastatic pancreatic adenocarcinoma.

PATIENTS AND METHODS

Patients were randomized to receive 3-week cycles of either arm A: PS-341 1.5 mg/m(2) i.v. bolus (over 3--5 s) on days 1, 4, 8 and 11 or arm B: PS-341 1.0 mg/m(2) (same as arm A otherwise) plus gemcitabine 1,000 mg/m(2) i.v. on days 1 and 8. Patients progressing on arm A were allowed to receive arm B treatment.

RESULTS

Arm A: 42 evaluable patients were enrolled with a confirmed RR of 0% (95% CI 0% to 8%), median survival of 2.5 months (95% CI 2.0-3.3), and median time to progression (TTP) of 1.2 months (95% CI 1.1--1.3). Twelve of 43 evaluable patients (28%) experienced at least one grade 4+ AE. Arm B: 39 evaluable patients yielded a 6-month survival rate of 41% (16/39, 95% CI 29.8% to 67.0%), median survival of 4.8 months (95% CI 2.4--7.4), median TTP of 2.4 months (95% CI 1.5--3.1), and confirmed RR of 10% (4 partial responses/0 complete responses, 95% CI 3% to 24%). Eleven of 43 evaluable patients (26%) experienced at least one grade 4+ AE. One patient had grade 5 hypotension.

CONCLUSION

The use of PS-341 alone or in combination with gemcitabine did not result in an overall survival and RR better than that expected for gemcitabine alone. Based on the lack of efficacy and the toxicity seen in our trial, there does not appear to be a role for PS-341 in pancreatic adenocarcinoma with either of the schedules used in this trial.

An EORTC phase I study of capecitabine (Xeloda) in combination with fixed doses of cyclophosphamide and epirubicin (cex) as primary treatment for large operable or locally advanced/inflammatory breast cancer

In breast cancer, chemotherapy regimens that include infusional 5-fluorouracil (5-FU) lead to high response rates, but require central venous access and pumps. To avoid these inconveniences, we substituted infusional 5-FU with capecitabine. The main objective of this study was to determine the maximum tolerated dose (MTD) of capecitabine when given in combination with fixed doses of epirubicin and cyclophosphamide (100 and 600 mg/m(2) day 1 every (q) 3 weeks) as primary treatment for large operable or locally advanced/inflammatory breast cancer without distant metastasis. Capecitabine was escalated from 750 mg/m(2) twice a day (bid) to 1250 mg/m(2) bid from day 1 to day 14 in four dose levels. Dose escalation was permitted if 0/3 or 1/6 patients experienced dose-limiting toxicity (DLT). A total of 23 patients were included and 117 courses were administered. At dose level 4, 2 of 2 patients presented DLTs defining the MTD. A high rate of capecitabine treatment modification was required with capecitabine 1050 mg/m(2) bid (dose level 3). 19 patients achieved an objective response (83%). In conclusion, we believe that capecitabine 900 mg/m(2) bid (dose level 2) is the recommended dose in combination with epirubicin 100 mg/m(2) and cyclophosphamide 600 mg/m(2). The acceptable toxicity profile and encouraging activity of this regimen warrant further evaluation.

An EORTC phase I study of epirubicin in combination with fixed doses of cyclophosphamide and infusional 5-fu (CEF-infu) as primary treatment of large operable or locally advanced/inflammatory breast cancer

PURPOSE

The association of continuous infusion 5-fluorouracil, epirubicin (50 mg/m2 q 3 weeks) and a platinum compound (cisplatin or carboplatin) was found to be very active in patients with either locally advanced/inflammatory (LA/I) [1, 2] or large operable (LO) breast cancer (BC) [3]. The same rate of activity in terms of response rate (RR) and response duration was observed in LA/I BC patients when cisplatin was replaced by cyclophosphamide [4]. The dose of epirubicin was either 50 mg/m2 [ 1, 2, 3] or 60 mg/m2/cycle [4]. The main objective of this study was to determine the maximum tolerated dose (MTD) of epirubicin when given in combination with fixed doses of cyclophosphamide and infusional 5-fluorouracil (CEF-infu) as neoadjuvant therapy in patients with LO or LA/I BC for a maximum of 6 cycles.

PATIENTS AND METHODS

Eligible patients had LO or LA/I BC, a performance status 0-1, adequate organ function and were <65 years old. Cyclophosphamide was administered at the dose of 400 mg/m2 day 1 and 8, q 4 weeks and infusional 5-fluorouracil 200 mg/m2/day was given day 1-28, q 4 weeks. Epirubicin was escalated from 30 to 45 and to 60 mg/m2 day 1 and 8; dose escalation was permitted if 0/3 or 1/6 patients experienced dose limiting toxicity (DLT) during the first 2 cycles of therapy. DLT for epirubicin was defined as febrile neutropenia, grade 4 neutropenia lasting for >7 days, grade 4 thrombocytopenia, or any non-haematological toxicity of CTC grade > or =3, excluding alopecia and plantar-palmar erythrodysesthesia (this toxicity was attributable to infusional 5-fluorouracil and was not considered a DLT of epirubicin).

RESULTS

A total of 21 patients, median age 44 years (range 29-63) have been treated. 107 courses have been delivered, with a median number of 5 cycles per patient (range 4-6). DLTs on cycles I and 2 on level 1, 2, 3: grade 3 (G3) mucositis occurred in 1/10 patients treated at the third dose level. An interim analysis showed that G3 PPE occurred in 5/16 pts treated with the 28-day infusional 5-FU schedule at the 3 dose levels. The protocol was subsequently amended to limit the duration of infusional 5-fluorouracil infusion from 4 to 3 weeks. No G3 PPE was detected in 5 patients treated with this new schedule.

CONCLUSIONS

This study establishes that epirubicin 60mg/m2 day 1 and 8, cyclophosphamide 400mg/m2 day 1 and 8 and infusional 5-fluorouracil 200 mg/m2/day day 1-21. q 4 weeks is the recommended dose level. Given the encouraging activity of this regimen (15/21 clinical responses) we have replaced infusional 5-fluorouracil by oral capecitabine in a recently activated study.

Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin

To confirm the safety and cutaneous tolerability of a new brand of baby wet wipes, we conducted the following clinical studies: (i) a double-blind in-use study in 102 infants over a period of 2 weeks, to compare skin tolerance of the wipes vs. water and a cleansing material (ii) a chamber scarification test on adults to assess the skin irritation potential of the baby wipe, and (iii) a 4-week clinical in-use study in 60 babies with atopic dermatitis, to confirm safety and skin tolerability in a sensitive skin subpopulation. In the clinical comparison with water and cleansing material, skin conditions were assessed visually for presence and severity of erythema and diaper dermatitis. The overall skin condition was not different in the group using wipes and in the group using only water and a cleansing material, indicating comparable skin mildness for both regimes. The chamber scarification test confirmed that the lotion contained in the wipe has a very low irritation potential, lower than that of a currently marketed baby wipe and comparable to that of water under occlusive patch test conditions. The good skin tolerance of the wipes was supported by the observations of a dermatologist in the clinical study in babies with atopic dermatitis. These data strongly support the suitability of the baby wipes tested in these studies for daily cleansing of the diapered area, even for infants with sensitive skin. These data also provide useful information regarding the comparative skin mildness of baby wipes and water.

Craniocerebral plasmacytoma: MR features

We report the MR imaging findings in two patients with solitary craniocerebral plasmacytoma, a benign plasma cell tumor that can arise from the skull, the dura, or, rarely, the brain. In both patients, the lesion was extraaxial and nearly isointense with gray matter on T2-weighted MR images, and diffusely enhanced after administration of contrast material, bearing some similarities to meningioma. A diagnosis of solitary craniocerebral plasmacytoma should be considered when a mass with these imaging features is seen, because total excision may not be necessary for this radiosensitive tumor.

An occupation based physical activity intervention program: improving fitness and decreasing obesity

The purpose of this quasi-experimental study was to determine the effectiveness of an occupation based health and fitness program. Subjects were 1,504 police trainees (85% male, 15% female) with an ethnic distribution of 82% white, 16% African American, and 2% other. Data were collected at 25 sites across the state of North Carolina. The sites were randomly assigned to either the experimental group (implemented the intervention) or the control group (continued usual training). As compared with controls, subjects at the experimental sites improved significantly in cardiovascular fitness (aerobic power), general muscular strength (number of sit ups per minute), and flexibility, and lowered their body fat. The intervention required minimal equipment and was taught primarily by peers who received a 1 week training program. This occupational approach to improving health could be particularly useful in occupations with many workers who seldom engage in leisure time physical activity.

Malignant islet cell tumor associated with hypercalcemia

BACKGROUND

Three cases of islet cell tumors of the pancreas with hypercalcemia were studied, and 16 similar cases have been found in a 25-year review of the English-language literature. The purpose of the study was to review the cause of the hypercalcemia and the clinical characteristics of the tumors.

METHODS

Tumor tissue retrieved from paraffin-embedded blocks was studied immunohistochemically for both parathyroid hormone (PTH) and PTH-related protein (PTHrP). PTH was measured in the serum in each patient and the serum PTHrP was measured by immunoassay in one patient.

RESULTS

One of our patients had a fatal serum calcium level of 26.4 mg/dl. PTHrP stains were positive in two of our tumors, and one patient had an elevated PTHrP serum level. Serum PTH levels were normal or low in each patient. All three tumors were malignant and extremely vascular. The total group of 19 patients have in common hypercalcemia associated with a normal or low serum PTH level. Although the cause of hypercalcemia has not been proved, the tumors apparently produce PTHrP, because seven of eight tumors stained positive for PTHrP and each of the four patients tested had an elevated PTHrP serum titer. The tumors are extremely vascular, are usually malignant (17 of 18), and become large, but they are compatible with a relatively long patient survival time.

CONCLUSIONS

These neuroendocrine tumors associated with hypercalcemia share several characteristics, but a claim that they represent another type of "functioning islet cell tumor" should await a clearer delineation of the cause of the hypercalcemia.

Evaluation of effects of altered gastric pH on absorption of dapsone in healthy volunteers

A prospective, randomized, crossover study was performed with seven healthy volunteers to address the effect of increased gastric pH on dapsone absorption. Subjects were randomized to receive a single 100-mg dose of dapsone or a single 100-mg dose of dapsone in addition to 30 ml of a high potency antacid 1 h before dapsone administration and hourly thereafter for a total of 10 doses. Dapsone concentrations in serum were measured periodically for 48 h. No statistical differences between the two regimens were noted when mean dapsone maximal initial concentrations, times to peak, and areas under the curve were compared. These data suggest that an increase in gastric pH has little or no effect on the absorption of dapsone in healthy subjects.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly

This study examined age differences in the timing of the decision to seek medical care. Two cohorts, one of middle-aged (40 to 55 years, n = 88) and one of older patients (65 and over, n = 80), who sought medical care when symptomatic were interviewed at the time of their visit. Age differences were examined with respect to total delay (the time from first noticing symptoms until calling for care), as well as its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more conserving of physical and psychic resources, and thus quicker in seeking care. The cohort effect was expected to be most visible for symptoms judged to be of uncertain seriousness. The delay results and ancillary findings on reasons given for delay are generally supportive of the hypotheses, with the caveat that the cohort difference also reflects higher levels of avoidance behavior by the middle-aged than by the older subjects.

[Breast screening in Geneva?]

Repeated screening-mammography is the best method for an earlier diagnosis of breast cancer in women aged 50 years and more. This diagnostic tool is closely related to the factor "time" and is responsible for the modification of the TNM-groups of the cancers to be treated. An actual project has to consider the local conditions as well as the results of the large randomized trials; special efforts have to be made to ascertain the quality of the screening and its control.

[Intra-epithelial neoplasia of the vulva and smoking]

VIN III etiology is multifactorial with a predominant role held by human papillomavirus infections, especially infections with HPV type 16. Other cofactors are also involved. We reviewed our patients presenting with VIN III, focusing our attention on smoking. Out of 37 patients 29 (78%) were smokers and among those who presented with a relapse after treatment (11 patients) all were smokers. We discuss mechanisms by which tobacco could act as a cofactor in VIN III.

Computerized tomography in the evaluation of myasthenia gravis

Thymomas occur in 10% to 15% of patients with myasthenia gravis. Since not all patients are referred for thymectomy, a test that could reliably predict the presence or absence of a thymoma would be of great assistance in the management of these patients. We studied all patients referred for thymectomy at Walter Reed Army Medical Center from 1983 to 1989. Complete records were available for 13 patients. Computerized tomography (CT) correctly predicted the presence of a thymoma in one patient and falsely predicted a thymoma in a patient with a thymic cyst; it accurately predicted the absence of a thymoma in the remaining 11 patients. The sensitivity of CT scanning was 100%, the specificity was 92%, and the accuracy was 92%, results that are in agreement with previously published data. Compared to conventional chest roentgenography, CT scanning provided a more precise anatomic localization, and accurately predicted local invasion. We recommend a CT scan of the mediastinum in all patients with myasthenia gravis to avoid delayed diagnosis of thymoma in patients who normally would not be referred for thymectomy.

Plasma vitamin D metabolite concentrations in chronic renal failure: effect of oral administration of 25-hydroxyvitamin D3

The circulating concentrations of 1,25-dihydroxyvitamin D and 24,25-dihydroxyvitamin D are abnormally low in patients with chronic renal failure (CRF). To determine the importance of substrate (25-hydroxyvitamin D) concentration in this phenomenon, five patients with end stage renal disease treated with hemodialysis were given 25-hydroxyvitamin D3 (25-OH-D3) orally for 4 weeks. The serum concentration of 25-OH-D3 increased from a mean (+/- SEM) of 26 +/- 5 ng/ml immediately before therapy to a maximum of 108 +/- 5 ng/ml 4 weeks after beginning administration of 25-OH-D3. The concentrations of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), 24,25-dihydroxyvitamin D3 (24,25(OH)2D3), and 25,26-dihydroxyvitamin D3 (25,26(OH)2D3) increased from 6.6 +/- 0.8 pg/ml, 0.29 +/- 0.10 ng/ml, and 0.36 +/- 0.06 ng/ml, respectively, immediately before 25-OH-D3 administration to 21.7 +/- 2.2 pg/ml, 0.48 +/- 0.09 ng/ml; and 0.78 +/- 0.12 ng/ml, respectively, after 4 weeks of administration of 25-OH-D3. These results suggest that substrate availability may be an important determinant of the circulating concentrations of these metabolites in patients with CRF. It seems possible that the therapeutic effects of 25-OH-D3 administration to the CRF patient may be mediated through the normal actions of 1,25-dihydroxyvitamin D3, 24,25-dihydroxyvitamin D3, and perhaps other metabolites rather than through analog effects of 25-OH-D3.

Quinolinic acid evokes [3H]acetylcholine release in striatal slices: mediation by NMDA-type excitatory amino acid receptors

Quinolinic acid evoked the release of [3H]acetylcholine from striatal slices with an EC50 of approximately 2 mM and an efficacy similar to that of N-methyl-D,L-aspartic acid. (+/-)-2-Amino-5-phosphonopentanoic acid and (-)-2-amino-7-phosphonoheptanoic acid antagonized quinolinic acid-evoked release, while glutamate diethylester and 2-amino-4-phosphonobutyric acid were ineffective as antagonists. Release of [3H]acetylcholine evoked by quinolinic acid was strongly attenuated by the presence of magnesium (1.2 mM) in the medium. The results are consistent with the interaction of quinolinic acid with NMDA-type excitatory amino acid receptors on the striatal cholinergic interneurons.