Phase I trial of gemcitabine and carboplatin in metastatic non-small-cell lung cancer: a Groupe Français de Pneumo-Cancérologie Study

BACKGROUND

The purpose of this study was to determine the maximum-tolerated dose (MTD) and the dose-limiting toxicity (DLT) of the 21 days carboplatin plus gemcitabine regimen in previously untreated patients with stage IV non small-cell lung cancer (NSCLC).

METHODS

At least three patients were entered at each dose level. The starting dose was carboplatin AUC 4 mg/ml per min (Area Under the Curve; Calvert formula) on day 1 and gemcitabine 750 mg/m(2) on days 1 and 8. Carboplatin was increased to AUC 5 (level 3, 4) then to AUC 6 (level 5-7). Gemcitabine was increased to 875 (level 2, 3), 1000 (level 4, 5), 1250 (level 6) and finally 1500 mg/m(2) (level 7). Twenty-nine patients were entered into this phase I study.

RESULTS

At dose level 6, a DLT (grade 4 thrombocytopenia) was observed in one out of six patients. At dose level 7, no DLT was observed during the first course, so the MTD was not reached. During the second course, two out of four patients presented grade 4 thrombocytopenia. None of the five patients receiving two courses at level 6 presented a DLT, so this level was retained for further phase II studies. Of the 25 patients assessable for response, five achieved partial responses with a response rate of 20% (95% CI, 7 to 41%). The median survival time was 7 months and the 1-year survival rate was 24% (95% CI, 9 to 45%).

CONCLUSION

The combination of carboplatin given on day 1 and gemcitabine given on days 1 and 8 every 3 weeks seems to be an acceptable regimen. The DLT consists exclusively of severe thrombocytopenia. Despite the MTD was not reached with carboplatin AUC 6 mg/ml per min and gemcitabine 1500 mg/m(2), the recommended dose for further phase II studies is carboplatin AUC 6 mg/ml per min and gemcitabine 1250 mg/m(2).

Increased release of matrix metalloproteinase-9 in the plasma of acute severe asthmatic patients

BACKGROUND

Matrix metalloproteinases (MMPs) are likely to be relevant mediators of the extracellular matrix (ECM) degradation and airway remodelling.

OBJECTIVE

We have compared the levels of MMPs, eotaxin and soluble interleukin 2 receptor (IL-2R) in the plasma of healthy subjects, atopic patients and asthmatic patients.

METHODS

The asthmatic patients were separated into two groups, either well controlled on inhaled therapy or acute severe asthma. Patients with acute severe disease had all received systemic corticosteroids from 12 to 48 h before the blood was taken. Blood was recovered in EDTA tubes, incubated with either f MLP, PMA or vehicle for 10 min and centrifuged. MMP-9, TIMP-1, IL-2R and eotaxin levels were measured in the plasma by ELISA. Moreover, the activity of MMPs was also evaluated by zymography.

RESULTS

An increased basal level of MMP-9 and IL2-R was observed in acute severe asthma. Following stimulation with f MLP and PMA there was an enhanced production of MMP-9 in the plasma of all groups of patients. However, the MMP-9 level was significantly enhanced in acute severe asthma, compared with the others. No difference was found for the TIMP-1 level between the patients. The eotaxin level in plasma was found to be significantly lower in acute severe asthmatics compared with the others groups. Zymography technique showed a significant increased activity of MMP-9 (92 kDa) but not MMP-2 (66 kDa) in the plasma of patients with acute asthma.

CONCLUSION

The increased in MMP-9 production and activity observed in the present study suggests a process of extracellular matrix degradation in acute severe asthmatic patients and proposes MMP-9 as a non-invasive systemic marker of inflammation and airway remodelling in asthma.

Lung macrophages and dendritic cells express HLA-G molecules in pulmonary diseases

HLA-G is selectively expressed in extravillous trophoblast of human placenta, which does not express classical HLA-A and -B molecules. Several studies report the role of HLA-G as a molecule involved in immune tolerance. By interacting with NK and T cells inhibitory receptors, HLA-G may downregulate their cytotoxicity functions. To appreciate the biologic and clinical relevance of HLA-G expression in lung diseases, HLA class I and HLA-G expression were analyzed in a panel of 36 ex vivo neoplastic tissues and 8 non-neoplastic lung tissues. Immunohistochemical analysis was performed using a pan-HLA class I antibody (W6/32) and three different specific anti-HLA-G antibodies (87G, MEMG/9 and 4H84). These findings demonstrated that HLA-G products were not expressed in pulmonary structural cells. However, HLA-G molecules were detected in activated macrophages and dendritic cells infiltrating lung carcinomas (33%) and nontumoral pulmonary diseases (25%). HLA-G expression was not correlated with classical HLA alterations. No statistical correlation was found between HLA-G expression and clinical or biologic parameters except high tumor size. The expression of HLA-G in myelo-monocytic cells infiltrating lung pathologic tissues could alter antigenic presentation and contribute to decrease immune response efficiency, subsequently favoring the progression of tumoral or inflammatory processes.

Unusual cause of recurrent pneumothorax: excavated metastasis of osteosarcoma

We report the case of a recurrent right pneumothorax, revealing metastasis of an osteosarcoma, 40 months after complete remission. Seven years after surgical excision, the patient is still considered in complete remission. Pneumothorax is rarely the first manifestation of lung metastasis. Osteosarcoma is the most frequent primary tumor. Chest computed tomography detects excavated or subpleural lung metastasis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies.

[Prevention of infection transmitted by bronchial fibroscopes]

A growing number of infectious complications are reported after bronchial fibroscopy procedures. The risk of nosocomial patient-to-patient or environment-to-patient infection is real via contaminated fibroscopes. Cross transmission can be caused by several microorganisms, the most frequently identified being Pseudomonas aeruginosa, Mycobacterium tuberculosis and other atypical mycobacteria. Fibroscopes can be contaminated via different mechanisms, generally related to poorly adapted cleaning and decontamination protocols. Identified errors include an insufficient cleaning phase, an inappropriate disinfecting agent (iodine derivatives, chlorhexidine), defective cleaning or disinfection of accessory equipment, or use of tap water for rinsing. Finally several episodes of Pseudomonas and atypical mycobacteria infections have been found to result from the use of automatic cleaning machines. Particular attention must be paid to the use of these devices. Official guidelines for the disinfection of endoscopic equipment must be rigorously applied in all centers. The personnel should have adequate training. It is also important to take regular samples and make regular bacteriology controls of the water and fibroscopic equipment.

Phase II trial of paclitaxel and carboplatin in metastatic small-cell lung cancer: a Groupe Français de Pneumo-Cancérologie study

PURPOSE

To evaluate the efficacy and safety of paclitaxel and carboplatin in the treatment of previously untreated patients with metastatic small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Eligible patients were aged 18 to 75 years with an Eastern Cooperative Oncology Group (ECOG) score < or = 2 and life expectancy > or = 12 weeks. Paclitaxel (200 mg/m(2)) was infused over 3 hours, before carboplatin (area under the curve [AUC] 6; Calvert formula) infused over 1 hour, once every 3 weeks for six cycles maximum. Prednisolone, dexchlorpheniramine, and ranitidine were standard premedication. Response to treatment was assessed every two cycles, and nonresponding patients were withdrawn from the trial to receive standard chemotherapy.

RESULTS

Of the 50 patients entering the study, 48 and 46 patients were assessable for toxicity and response, respectively. The overall response rate was 65%, with complete responses in three patients. Five patients had stable disease (11%) and 11 patients experienced progressive disease (24%). Median survival was 38 weeks, and median duration of response was 20 weeks. One-year survival was 22.5%. For a total of 232 cycles, grade 3 and 4 toxicity was 33% for neutropenia, 3.5% for thrombocytopenia, and 4% for anemia. Four patients had neutropenic fever (one toxic death). Nonhematologic toxicity was mainly grade 1 and 2 paresthesia (21% of patients); grade 3 myalgia/arthralgia was observed in 6.5% of patients.

CONCLUSION

First-line chemotherapy with paclitaxel and carboplatin in metastatic SCLC achieved a response rate and survival similar to standard regimens. With 1-day administration and a tolerable toxicity profile, this combination merits further investigation.

Results of a phase III study of early versus delayed whole brain radiotherapy with concurrent cisplatin and vinorelbine combination in inoperable brain metastasis of non-small-cell lung cancer: Groupe Français de Pneumo-Cancérologie (GFPC) Protocol 95-1

PURPOSE

To determine if the timing of whole brain radiotherapy (WBRT) with respect to chemotherapy with cisplatin and vinorelbine would influence survival in patients with non-small-cell lung cancer (NSCLC) and concurrent brain metastasis.

PATIENTS AND METHODS

One hundred seventy-six patients with brain metastasis from NSCLC were included in the study between July 1995 and October 1997. All patients received chemotherapy with cisplatin 100 mg/m2 on day 1 and vinorelbine 30 mg/m2 on days 1, 8, 15, 22. Cycles were repeated every four weeks. Evaluation of response was performed after two, four or six cycles. After two cycles, chemotherapy was administered to the responders to a maximum of six cycles. Patients were randomised to receive WBRT 30 Gy/10 fx/12 days and delayed corticosteroids. (arm A) for the intracranial nonresponders, or early on day 1 to 12 during the first cycle of chemotherapy (arm B).

RESULTS

One hundred seventy-one patients were eligible: eighty-six in arm A and eighty-five in arm B; none had received prior chemotherapy; seventy-six and seventy-three, respectively, were assessable for response. There was a 21% overall objective response rate (OR) (with 1 complete response and 17 partial responses) after two cycles of chemotherapy alone (arm A) and a 20% OR (with 17 partial responses) to chemotherapy and early WBRT (arm B). The intracranial OR was 27% and 33%, respectively (P = 0.12). The six months survival rate (46% and 40%) and the median survival duration (24 and 21 weeks, respectively) were not significantly different between the two arms (P = 0.83, log-rank test). The major toxicity was severe or life-threatening neutropenia (grade 4), which occurred in 35% of arm A patients and 36% of arm B patients. There were thirteen treatment-related deaths (six in arm A and seven in arm B). There was no difference between the arms for haematological and neuro-toxicities.

CONCLUSIONS

These results confirm the efficacy of chemotherapy in brain metastases of NSCLC and suggest that the timing (early or delayed) of WBRT did not influence survival of NSCLC with brain metastasis treated with concurrent chemotherapy.

[A rare biphasic pulmonary tumor, carcinosarcoma. A separate entity or differentiation variant of spindle-cell carcinoma?]

We report a case of pulmonary carcinosarcoma. Surgery is required for this rare mixed type, biphasic tumor. It is generally considered to be a malignant formation issuing from a single cell line but with a two-way differentiation into epithelial and conjunctive components. There is a differentiation continuum between spindle-cell carcinomas (also called monophasic sarcomatoid carcinoma) and carcinosarcoma (or biphasic sarcomatoid carcinoma) leading to debate concerning the immunohistochemical and ultrastructural features.

[Bronchial dilatation and rheumatoid arthritis: a little known association]

Since Ellmann's description in 1948 numerous authors have studied the respiratory manifestations associated with rheumatoid arthritis. Amongst the numerous disorders described, dilatation of the bronchi, although one of the most frequent, remains largely under-estimated. The authors report a series of 21 patients presenting jointly with both rheumatoid arthritis and bronchiectasis which was documented using thoracic computed scanning. All the subjects were female. For 20 of these patients, the appearance of bronchial suppuration preceded that of the articular manifestations by several years. Bronchial dilatation in these cases can, only with difficulty, be considered as a complication of arthritis as has been previously suggested. Rather it appears as a possible pre-disposing factor in the occurrence of the rheumatoid disease. These hypotheses explain the pathophysiological mechanisms implicated in this association are discussed.

Treatment of human lung carcinoma xenografts with a combination of 131I-labelled monoclonal antibody Po66 and doxorubicin

Po66, a mouse monoclonal antibody, is directed against an intracytoplasmic antigen present in human lung squamous cell carcinoma cells. In previous work it was found that the co-administration of 125I-radiolabelled Po66 and doxorubicin strongly enhanced the uptake of radioactivity by the tumour. The present-work was designed to evaluate, in a tumour-bearing mouse model of lung carcinoma, the ability of 131I-labelled Po66 to retard tumour growth when injected alone, or in combination with doxorubicin (8 mg kg-1 at 1-week intervals). A single dose of 550 microCi 131I-Po66 alone had no effect on tumour growth, whereas three fractionated doses of 250 microCi 131I-Po66 decreased it over two doubling times from 14.5 +/- 1.5 days for untreated control mice to 24.8 +/- 2.7 days. Mice treated with doxorubicin alone had a double tumour doubling time of 22.6 +/- 4.9 days, compared to 35.2 +/- 2.9 days (1.55-fold increase) in mice treated with doxorubicin and a single dose of 550 microCi 131I-Po66. Doxorubicin combined with three fractionated doses of 250 microCi 131I-Po66 provoked a twofold decrease in tumour growth compared to mice treated with doxorubicin alone. The administration of fractionated doses of 131I-Po66 simultaneously with doxorubicin resulted in a highly delayed mortality, which was not observed when 131I-Po66 was administered after doxorubicin. Thus, in a non-small-cell lung tumour model, a 131I-radiolabelled monoclonal antibody, directed against an intracellular antigen, significantly potentiated the effect of chemotherapy. Such a therapeutic approach could be used as an adjuvant therapy and improve the effect of chemotherapy on distant small metastases.

Long-term nasal intermittent positive pressure ventilation (NIPPV) in sixteen consecutive patients with bronchiectasis: a retrospective study

Life expectancy and quality of life are poor in patients with chronic respiratory failure due to bronchiectasis. The indication for nocturnal nasal intermittent positive pressure ventilation (NIPPV) remains controversial in chronic obstructive lung disease. The purpose of the present study was to determine whether some of the objectives of home mechanical ventilation, i.e. improvement in blood gas values and reduced length of hospitalization, were fulfilled by NIPPV and oxygen plus medical treatment in patients with chronic respiratory failure due to bronchiectasis. Sixteen consecutive patients (12 females and four males; mean age 57 +/- 11 yrs) with chronic respiratory failure due to bronchiectasis, treated at home with nocturnal NIPPV in addition to oxygen therapy, were retrospectively studied in terms of blood gas values and duration of hospitalization before and after NIPPV. Details of the therapy received by each patient were recorded. Nine patients agreed to complete a questionnaire to determine their perception of the benefits of the treatment. NIPPV was performed using a volumetric respirator and was applied with a customized nasal mask modelled with silicone paste. NIPPV was used for a mean of 26 months (range 0.5-60 months). Eleven patients were alive 12 months after use of NIPPV. No significant improvement in blood gas values was noted on room air during NIPPV, but arterial carbon dioxide tension (Pa,CO2) stabilized after the period of worsening observed before initiation of NIPPV. Duration of hospitalization, the year before and the year after NIPPV, was 19 (3-40) and 16 (8-37) days, respectively (NS). For the 11 patients who were alive 2 yrs after the start of NIPPV, duration of hospitalization the year before NIPPV and between 12 and 24 months after NIPPV were 17 (4-40) and 7 (2-27) days, respectively (p < 0.05). Nine patients who had received NIPPV for at least 12 months at the time of the study reported an improvement in their quality of life. The results suggest that home ventilatory support by nasal intermittent positive pressure ventilation offers an acceptable alternative to tracheotomy, with less discomfort, in the management of severe respiratory failure due to bronchiectasis, in order to allow the patient to return home. These results should be confirmed by controlled studies.

Azygos vein aneurysm: contribution of transesophageal echography

We report a case of idiopathic aneurysm of the azygos vein associated with lung cancer. This abnormality is exceptional because we could find only 8 previous published cases. Computed tomographic scan and especially transesophageal echography were of major importance in identifying the vascular nature of the radiographic abnormality and thus excluding extension of lung cancer.

Exogenous lipoid pneumonia complicated by Mycobacterium fortuitum and Aspergillus fumigatus infections

We report the case of a nonimmunocompromised female patient, who developed exogenous lipoid pneumonia with Mycobacterium fortuitum infection at diagnosis, later followed by Aspergillus fumigatus infection. The association of exogenous lipoid pneumonia with atypical mycobacterial infection is uncommon but well-recognized, but, to our knowledge, association with A. fumigatus infection has not previously been reported.

Monoclonal antibody Po66 uptake by human lung tumours implanted in nude mice: effect of co-administration with doxorubicin

The efficacy of radioimmunotherapy of tumours with radiolabelled monoclonal antibodies (MAbs) depends on the amount of antibody taken up by the tumour and on its intratumoral distribution. In the case of MAbs directed against intracellular antigens, increasing the permeability of the cytoplasmic membrane may augment the bioavailability of the antigen for the antibody. This raises the question whether the induction of tumour necrosis by chemotherapy can enhance the tumour uptake of radiolabelled monoclonal antibodies. In this work, the effect of doxorubicin on the biodistribution of Po66, an MAb directed against an intracellular antigen, was studied in nude mice grafted with the human non-small-cell lung carcinoma cell line SK-MES-1. After injection on day 0 of 125I-labelled Po66, tumour radioactivity increased up to days 3-5, and then remained unchanged to day 14. The combined administration of 125I-labelled Po66 with 8 mg kg-1 doxorubicin, in two doses separated by 7 days, doubled the radioactivity retained by the tumour. Histological and historadiographic analysis showed, however, that the drug induced cellular damage. In the absence of doxorubicin, the accumulation of Po66 was restricted to some necrotic areas, whereas with doxorubicin the necrosis was more extensive and the antibody more evenly distributed. These results suggest that chemotherapy and immunoradiotherapy combined would enhance tumour uptake of radioisotope and promote more homogenous distribution of the radiolabelled MAb. This would promote eradication of the remaining drug-resistant cells in tumours.