Management of apparent single foci of epithelial ovarian cancer

Four patients with proven ovarian cancer were found to have single lesions in the liver parenchyma after completing chemotherapy. They otherwise appeared to be in complete clinical remission. Percutaneous needle biopsy was sometimes misleading and dangerous. Laparoscopy and laparotomy were required for optimum safe diagnosis, staging, and treatment. Definitive resection appeared to be beneficial but usually only as a palliative form of debulking. Subsequent adjuvant combination chemotherapy may sometimes improve the duration of useful remissions. Unusual sites of metastatic ovarian cancer appear to be increasing in frequency. Successful management of late recurrences in the liver is possible, provided the diagnosis is immediately suspected and one utilizes both definitive surgery and chemotherapy.

Infections associated with transhepatic biliary drainage devices

To determine the infectious complications associated with transhepatic biliary drainage devices, an analysis of the records of 38 patients who underwent placement of a pigtail catheter (n = 11), a Ring catheter/feeding tube (n = 13), or a Carey-Coons endoprosthesis (n = 15) was carried out. Nineteen infectious events occurred in 38 patients with 39 biliary devices. Infections consisted of bacteremia, cholangitis with and without documented bacteribilia, and intrahepatic abscesses and were frequently associated with obstruction (66.7 percent of infectious episodes). The most frequent organisms isolated from blood were Escherichia coli and Pseudomonas aeruginosa, and the most frequent organisms isolated from bile were P. aeruginosa, Klebsiella pneumoniae and Streptococcus faecalis. Trends for more frequent occurrence of neoplasms involving the gallbladder or biliary tract, recent surgical procedures and catheter manipulations in infected as compared with noninfected patients, and a delayed time to infection were noted in patients with an endoprosthesis.

Prognostic factors: cisplatin regimens for patients with ovarian cancer after failure of chemotherapy

For 129 ovarian cancer patients failing prior chemotherapy, overall clinical response rates were: 21% with cisplatin, 36% with cisplatin plus doxorubicin, 52% with cyclophosphamide added to the two drugs, and 44% with hexamethylmelamine added to the three drugs. Median survival was six or seven months in each trial. Twenty-five percent of the patients survived nine months with cisplatin and 14 to 16 months with each of the three combinations. Characteristics associated with best rate of response included: performance status 1 (completely ambulatory), age greater than or equal to 50, residual tumor less than or equal to 5 cm, and two or less prior cytotoxic drugs. In multivariate analyses, performance status dominated, although age and possibly treatment (cisplatin versus others) were significant. With performance status removed from the model, all of the remaining factors became significant. Factors associated with best survival included: performance status 1, tumor size less than or equal to 5 cm, and complete or partial response. In a multivariate analysis for survival, performance status entered the model. In a series of analyses with performance status removed, tumor size or response entered the model. These findings provide reasons to study both treatment with cisplatin before disease progression reduces the number of favorable characteristics and systematic second attempts at debulking surgery.

Toxicity associated with adjuvant postoperative therapy for adenocarcinoma of the rectum

The Gastrointestinal Tumor Study Group's (GITSG) adjuvant rectal carcinoma study compared four postoperative treatment regimens: (1) control (no adjuvant therapy); (2) chemotherapy alone consisting of pulses of 5-fluorouracil and methyl CCNU for 18 months; (3) pelvic and perineal radiotherapy using parallel opposed fields with 4000 rad in 4.5 to 5 weeks or 4800 rad in 5 to 5.5 weeks; and (4) a combination of both modalities. The results of this study are published elsewhere and show a significantly reduced recurrence rate and prolonged disease-free survival time for the combined modality arm compared with the no therapy arm. Severe toxicity in the combined therapy arm was significantly worse (P less than 0.001) than in either single modality arm. Most of the differences in toxicity experienced between the three regimens involved diarrhea, thrombocytopenia, and leukopenia. Analysis of all parameters of radiotherapy quality assurance data was not significantly associated with toxicity. Radiation enteritis was noted in 5 patients of 96 (5.2%) in the two arms containing irradiation. All five required laparotomy. The two enteritis fatalities occurred late at 605 and 1000 days after start of combined modality treatment, respectively. One other patient on the chemotherapy arm died of acute nonlymphocytic leukemia. The authors conclude that combined radiotherapy and chemotherapy, although significantly more effective in reducing recurrence than no therapy, is significantly more toxic than single-modality therapy in many parameters, although most of the toxicity is transient and therefore not limiting. Late complications, which are less reversible and therefore much more important than early reactions, and radiation enteritis in this study were relatively uncommon. This schedule of combined modality therapy is not only effective but appears to have tolerable toxicity, because of the relative lack of late effects.

A randomized comparison of cyclophosphamide, Adriamycin, and 5-fluorouracil with triethylenethiophosphoramide and methotrexate, both as sequential and as fixed rotational treatment in patients with advanced ovarian cancer

The combinations of triethylenethiophosphoramide and methotrexate (TM) and cyclophosphamide, Adriamycin (doxorubicin), and 5-fluorouracil (CAF) were compared, both as sequential and fixed rotational treatments for advanced ovarian cancer, with L-phenylalanine mustard (L-PAM). Treatment with CAF produced a higher response rate (25% complete responses plus 31% partial responses) than treatment with L-PAM (15% complete responses plus 18% partial responses). A fixed rotation of TM and CAF resulted in longer survival (median of 15 months and 75th percentile of 27 months) than sequential treatment with TM initially, followed by CAF upon failure (median of 12 months and 75th percentile of 22 months). The fixed rotation of TM and CAF also increased progression-free survival (median of 12 months and 75th percentile of 24 months) over that achieved by initial treatment with TM (median of 6 months and 75th percentile of 15 months) or L-PAM (median of 9 months and 75th percentile of 21 months). Most patients (96%) on the fixed rotation were treated with both TM and CAF. Fewer patients (62%) on the sequential schedule with TM actually received both combination regimens, and even fewer patients (37%) beginning on CAF ever crossed over to TM. Patient age of 50 years or younger was a favorable prognostic factor for response, survival, and time to first treatment failure (progression-free survival). Disease Stage IIIA or IIIB, surgery including a bilateral salpingo-oophorectomy plus hysterectomy, and treatment within 6 months of initial diagnosis were favorable predictors for both survival and time to first treatment failure. Ambulatory performance status and well-differentiated disease were favorable prognostic factors for survival. Patients with unevaluable disease failed later than those with evaluable disease who, in turn, failed later than patients with measurable disease.

Multidrug treatment of advanced and recurrent endometrial carcinoma: a Gynecologic Oncology Group study

Patients (358) with advanced (FIGO stages III and IV) or recurrent endometrial cancer were treated with one of two regimens: 1) melphalan and 5-fluorouracil daily for four days, repeated every four weeks with megace daily for eight weeks and 2) adriamycin, 5-fluorouracil, and cyclophosphamide, intravenous bolus every 21 days with megace daily for eight weeks. All patients were randomized except for 63 with known cardiac disease who were assigned to regimen 1 (to avoid adriamycin) and studied separately. Stratification was effected for performance status, history of previous progestational therapy, presence or absence of measurable disease, and stage of disease. The objective response rate in those with measurable disease was 36.8% in both groups; 36.8% of each group had stable disease, and only 26.4% progressed on treatment. Response was unaffected by site of recurrence, time to first recurrence, presence or absence of previous treatment by progestational or radiation therapy, or age. Grade of tumor and performance status did affect response, although 44 of 57 objective responders had undifferentiated tumors. The two combinations achieved response rapidly, required careful supervision, and were especially useful in treating patients with usually poor prognostic features.

MTX/5-FU trials in gastrointestinal and other cancers

Seventy-two patients with neoplastic disease in a variety of anatomic sites were treated with sequential methotrexate (MTX) and 5-fluorouracil (5-FU) followed by leucovorin (LV) rescue. Treatment consisted of MTX, 160 mg/m2 as a 10-min infusion; 5-FU, 600 mg/m2 as a bolus 90 min later; and LV, a minimum of 25 mg/m2 or 15 mg/m2 p.o. q.6h. X 4, repeated at 1- or 2-wk intervals. Responses of any type included 4 of 24 colon cancers, 3 of 12 stomach cancers, 0 of 6 pancreas cancers, 1 of 2 gallbladder cancers, 4 of 6 breast cancers, 1 of 1 uterus cancer, 2 of 2 selected lung cancers, 1 of 1 parotid cancer, 1 of 2 sarcomas, and 0 of 6 ovary cancers. Response appeared to increase survival. The best-quality responses were observed in patients with stomach, breast, and parotid tumors. Toxicities included anemia requiring transfusion (20%), anorexia during treatment with LV (16%), moderate thrombocytopenia (12%), grade 3 stomatitis (12%), moderate granulocytopenia (10%), severe conjunctivitis (6%), severe gastroenteritis (6%), vomiting (6%), anamnestic reactions (6%), possible renal failure (4%), and possible pulmonary failure (2%). One patient had life-threatening gastroenteritis and reappearance of a grade 1 to 2 skin reaction of the entire treatment field more than 5 yr after radiotherapy. Patients with prior cis-platin therapy had a 50% risk of life-threatening pancytopenia. The results encourage controlled primary trials testing intensification of the sequential combinations with parallel investigations of MTX alone with and without diminished doses of LV.

Improved therapy with cisplatin regimens for patients with ovarian carcinoma (FIGO Stages III and IV) as measured by surgical end-staging (second-look operation)

Between 1974 and 1982, 273 patients with epithelial cancer of the ovary (International Federation of Gynaecology and Obstetrics Stages III and IV) were randomized in four therapeutic trials. In Trial I Adriamycin plus cisplatin versus cisplatin alone versus thiotepa plus methotrexate was tested. The superiority of Adriamycin plus cisplatin in producing the best response rate led to its use as the reference arm in subsequent trials. All investigational arms included cisplatin plus other drugs (cyclophosphamide, Adriamycin, hexamethylmelamine, and thiotepa) in various combinations. Eligibility for second look required complete clinical remission and completion of at least 10 cycles of chemotherapy. To date, 73 second-look operations have been performed on randomized patients. An additional 43 nonrandomized patients underwent second-look procedures and are analyzed separately. Between 40% and 46% of patients treated with cisplatin regimens had no disease at second look. Cell differentiation and volume of postoperative disease did not influence response.

Cisplatin regimens and improved prognosis of patients with poorly differentiated ovarian cancer

Patients with advanced ovarian carcinoma, Stage III or IV (International Federation of Gynaecology and Obstetrics), were randomized to primary chemotherapy with doxorubicin (Adriamycin) and cisplatin plus or minus hexamethylmelamine, and cyclophosphamide (CHAP). The four-drug CHAP regimen produced a 57% complete clinical response rate and a 26% partial response rate for clinically evaluable patients. The median survival of CHAP patients is 25 months. The two-drug Adriamycin-cisplatin (AP) regimen produced a 43% complete response rate and a 35% partial response rate. The median survival is 18 months. The four-drug regimen produced a significantly longer median survival (28 versus 18 months) for patients with poorly differentiated tumors than for patients with well-differentiated tumors on either treatment. Examination of treatment failure or death by treatment, histology, and size of largest residual tumor and comparison to similar patients treated with AP in this and two preceding controlled trials also suggest that CHAP is superior to AP for patients with poorly differentiated tumors.

Phase II trial of combination chemotherapy of colonic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine

HexMF consists of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C (MMC) 10 mg/m2 D2 and 5-fluorouracil (5-FU) 30 mg/kg/day as a continuous infusion D1-5 in 4-5 week cycles. It was designed as an alternative to treating patients with standard single agents in sequence, thereby preventing the testing of new drugs as part of primary therapy. Median survival was 12+ months for patients with measurable and 18+ months for patients with nonmeasurable colorectal cancer. It was 9+ months from the onset of secondary chemotherapy. Toxicity included severe thrombocytopenia (50%), severe leukopenia (25%), and moderate stomatitis (50%). Only one instance of leukopenia was life-threatening. The MMC and 5-FU infusion skeleton provides an attractive strategy for testing new drugs as primary therapy. HexMF itself has a potentially broad antitumor spectrum and excellent acceptance by patients. It is suitable for additional phase II trials.

Phase II trial of combination chemotherapy for pancreatic cancer with 5-fluorouracil, mitomycin C, and hexamethylmelamine

A combination consisting of hexamethylmelamine 150 mg/m2 D2-15, mitomycin C 10 mg/m2 D2 and 5-fluorouracil 30 mg/kg/day as a continuous infusion for 5 days, in 4-5 week cycles, underwent phase II trial as primary therapy for 21 patients with regional and metastatic cancer of the pancreas. Median survival from the onset of therapy was 43 weeks. There were 2 complete responses, 4 minor responses and 6 stable diseases for more than 6 months. Nonambulatory patients were among the responders. There was only 1 life-threatening toxicity (thrombocytopenia) and only 33% of patients had clinically silent severe hematological toxicity. The regimen is well tolerated, active and associated with excellent survival. This regimen is suitable for further confirmatory trials.

Routine clinical chemistries as improved determinates of prognosis for patients with metastatic cancer of the stomach

Pretreatment total serum protein of less than 6 g%, serum glumatic oxaloacetic transaminase (SGOT) greater than 40 mU/ml or a total serum bilirubin greater than 0.6 mg% predicted a bad prognosis for patients with metastatic gastric cancer. If two of these objective laboratory tests predicted a good prognosis, partially nonambulatory patients lived an additional 20 weeks (median survival 27.9 vs 8.7, p less than 0.001) and patients with no clinically recognized liver metastases lived an additional 22 weeks (median survival 34.2 vs. 12.4, p less than 0.001). Patients with liver metastases lived an additional 11 weeks (median survival 20.9 vs. 9.6, p less than 0.001). These objective laboratory tests improve the assessment of patients in clinical trials. The model corrected a false assessment of a poor prognosis for 38% of all patients and 64% of patients with liver metastases.

Studies in prognostic factors relating to chemotherapy for advanced gastric cancer

The prognostic value of pretreatment information relating to prior treatment, demography, physical status, symptoms, disease involvement, pathologic, immunologic, and clinical chemistries were analyzed for a series of 322 patients with advanced gastric cancer. All patients received chemotherapy upon entry into Gastrointestinal Tumor Study Group protocols which were active between 1975 and 1978. Multivariate models were used to study relationships between prognostic factors and survival for all patients and objective tumor resonse for a subset of 137 patients with measurable disease. The initial performance status was a leading determinant of survival (P less than 0.0001). In addition, new summary measures relating to blood chemistries (P less than 0.01) and differential counts (P less than 0.001) were shown to influence patient survival. Blood chemistry parameters included SGOT, total serum protein, and total direct bilirubin while differential counts included absolute granulocytes, lymphocytes, and monocytes. Thus, the initial performance status, measurable disease status, blood chemistries, and differential counts are recommended as stratification factors in the design and analysis of trials involving patients with advanced gastric cancer. The initial performance status was examined in relation to other pretreatment data. The performance status at study entry correlated independently with the degree of weight loss (P less than 0.001), blood chemistries (P less than 0.01), differential counts (P less than 0.05), and peritoneal metastases (P less than 0.05). The measurable and nonmeasurable subgroups were compared with respect to baseline characteristics. Patients with measurable disease had more liver metastases (56 versus 35%) and less peritoneal metastases (76 versus 49%) than patients with nonmeasurable disease. Controlling for the imbalance in liver and peritoneal metastases, the presence of measurable disease was less favorable than nonmeasurable disease with respect to survival. Regarding the pathways of disease spread, there was a strong correlation (P less than 0.001) between primary tumor site within the stomach and location of metastases. Diffuse lesions were associated with the lowest frequency (25%) of liver metastases. Diffuse lesions (58%) and tumors of the pyloris (54%) were associated with the highest percentage of peritoneal metastases. Tumors of the cardia or fundus were more likely to metastasize to the liver while diffuse tumors were more likely to spread to the peritoneum. Pretreatment factors under study did not appear to be the dominant factors responsible for prolongation of survival in patients with an objective tumor response. Pretreatment factors predicted a three week advantage; however, a 22 week advantage was observed for responders over nonresponders.

Studies of Baker's antifol, methotrexate, and razoxane in advanced gastric cancer: A Gastrointestinal Tumor Study Group Report

In this multi-institutional study of advanced gastric cancer, 73 patients were evaluable for response or survival. Patients were treated with either triazinate (Baker's antifol), standard-dose methotrexate, or ICRF-159 (razoxane). Objective responses were seen in four patients receiving Baker's antifol, in three receiving methotrexate, and in none receiving razoxane. Baker's antifol produced a median survival of 18 weeks and methotrexate and razoxane produced a median survival of 8 and 9 weeks, respectively. Seventy of the 73 patients entered in this study had been previously treated, most frequently with combination chemotherapy regimens containing 5-FU or doxorubicin. This study appears to demonstrate that Baker's antifol is an active drug for patients with advanced gastric cancer, according to both response and survival criteria. Examination of the pretreatment prognostic characteristics of the patients further suggests that a possible survival advantage is due to treatment with Baker's antifol rather than the prognostic characteristics of the patients.

Absolute granulocyte, lymphocyte, and moncyte counts. Useful determinants of prognosis for patients with metastatic cancer of the stomach

Pretreatment absolute granulocyte (less than 6,000/cu mm), lymphocyte (greater than 1,500/cu mm), and monocyte (300 to 900/cu mm) counts are three independent indicators of good prognosis for patients with metastatic gastric cancer. There tests improve the prediction of survival significantly compared with estimates based on ambulatory status alone. If the patient is completely ambulatory, median survival (MS) is 27.6 weeks, and it improves further to 37.6 weeks if results of two hematology tests indicate a good prognosis. If the patient is partially ambulatory, MS is 16.2 weeks; however, if results of two blood tests indicate a good prognosis, MS is 25.7 weeks, and if two tests indicate a poor prognosis, MS is only 11.1 weeks. The model corrected a false assessment of a poor prognosis for 56% of all patients.

Improved chemotherapy for ovarian cancer with cis-diamminedichloroplatinum and adriamycin

In a prospective controlled randomized trial, patients with advanced ovarian carcinoma (FIGO Stage III or IV) were treated with cis-diamminedichloroplatinum (II), (DDP), alone, DDP and Adriamycin (ADM), or Triethylenethiophosphoramide (ThioTEPA) and methotrexate (MTX). DDP alone produces objective responses in 31% of evaluable patients, ThioTEPA and MTX in 36%. The combination of DDP and ADM produces the best response rate, 80% (.01 less than P less than 0.25). The risk of progression or death is substantially reduced for the two DDP regimens combined when compared with ThioTEPA-MTX (P = .03). Multivariate analysis further suggests the superiority of the two DDP regimens because poorly differentiated tumors and large, greater than 2 cm, residual tumors failed to produce their usual adverse effect on prognosis when patients were treated with the two DDP regimens. Patients with poorly differentiated tumors or tumors of unknown grade treated with platinum or DDP-ADM experienced better survival than similar patients treated with ThioTEPA (P = .01).