Topotecan chemotherapy in patients with breast cancer and brain metastases: results of a pilot study

BACKGROUND

Symptomatic brain metastases occur in approximately 10-15% of patients suffering from breast cancer and are linked to a clear deterioration of the patient's condition. Although radiotherapy is recommended as a primary therapy, the optimal management remains controversial. To evaluate the role of topotecan as a primary chemotherapy for brain metastases, we performed a pilot study in patients with metastatic breast cancer.

PATIENTS AND METHODS

24 patients with newly diagnosed, bidimensionally measurable brain metastases received topotecan, 1.5 mg/m(2) day, 30-min infusion for 5 days every 3 weeks. A total of 93 courses of therapy were administered (range 1-11, median 3 courses per patient). Prior radiotherapy was excluded. Most of the patients had received prior adjuvant or palliative chemotherapy.

RESULTS

3/24 patients were withdrawn from the study for various reasons, 16/24 patients could be evaluated in terms of their response to therapy; 1 and 5 patients showed complete and partial response to therapy, respectively, and 5 patients had a stable condition. The median time of survival was 6.25 months. Hematologic toxicity was the major side effect, nonhematologic side effects occurred rarely and were tolerable.

CONCLUSIONS

Our results demonstrate that primary chemotherapy with topotecan is an effective and well-tolerated treatment for patients with breast cancer and CNS metastases. Based on this pilot study, future clinical protocols should be developed including multimodal treatment strategies (i.e. radiotherapy).

The role of docetaxel (Taxotere) in neoadjuvant chemotherapy of breast cancer

Neoadjuvant chemotherapy has become standard therapy in the management of breast cancer patients with locally advanced disease with inoperable tumors and inflammatory breast cancer. Patients with earlier stage breast cancer and operable tumors may also benefit from treatment with neoadjuvant chemotherapy. Docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) is thought to be one of the most potent agents in the treatment of metastatic breast cancer and is therefore being investigated for its likely benefit in preoperative, neoadjuvant regimens. Several large phase II and randomized phase III trials are evaluating docetaxel as a single agent, in combination, and/or sequentially in the preoperative setting. Preliminary findings demonstrate high complete and partial response rates and a tolerable toxicity profile. These results are consistent with the view that incorporation of docetaxel in neoadjuvant chemotherapy regimens will contribute to improved patient outcome. Ongoing studies will provide important information regarding the most appropriate regimens and schedules of docetaxel to use in the preoperative, neoadjuvant setting.

Adjuvant randomized trials of doxorubicin/cyclophosphamide versus doxorubicin/cyclophosphamide/tamoxifen and CMF chemotherapy versus tamoxifen in women with node-positive breast cancer

PURPOSE

We report two randomized trials of adjuvant systemic therapy in 747 patients < or = 65 years of age with histologically proven node-positive breast cancer.

PATIENTS AND METHODS

Patients were selected for the two trials on the basis of lymph node and hormone receptor status. The only stratification was based on the treating institution. In patients with a lower probability of recurrence (n = 276), a comparison between endocrine therapy (tamoxifen [Tam] 30 mg/d for 2 years) and chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [CMF] intravenously [IV], six cycles every 4 weeks) was performed. In patients with a higher risk of recurrence (n = 471), a comparison between chemotherapy alone (doxorubicin plus cyclophosphamide [AC] i.v., eight cycles every 3 weeks) and the same chemotherapy plus Tam was made.

RESULTS

Overall, we found that CMF and Tam are equally effective in a subgroup of patients with a relatively good prognosis (low-risk patients). However, in the subset of women < or = 49 years old, a significantly greater disease-free survival (DFS) rate (P = .01) and overall survival (OS) rate (P = .002) was observed following therapy with CMF compared with Tam. In patients > or = 50 years old, the opposite was found, and Tam appeared to be superior to CMF (DFS, P = .003; OSm P = .5). These results must be interpreted cautiously, since a post-hoc stratification of patients by age (< or = 49, > or = 50) was performed, and significantly more younger, low-risk patients were randomized to receive chemotherapy alone and more older patients to receive Tam alone. Among patients with a relatively poor prognosis (high-risk patients), a combination of AC plus Tam was equivalent to AC and, when women were analyzed by age, this was found to be true of patients < or = 49 years as well. However, the addition of Tam to AC in women age > or 50 years resulted in a statistically significantly higher DFS (P = .01) and a trend toward better OS compared with women who received AC alone.

CONCLUSION

Further trials are required to analyze the role of combined simultaneous or sequential chemoendocrine adjuvant treatment or each single therapy alone in defined risk-adapted subsets of node-negative and node-positive patients.

Secretory differentiation and cell type identification of a human fetal bronchial epithelial cell line (HFBE)

A human fetal bronchial epithelial cell line (HFBE) grew in an undifferentiated pattern under conventional culture conditions. Despite a somewhat fibroblastic shape the cells maintained immunoreactivity to cytokeratin, carcinoembryonic antigen and epithelial membrane antigen. When grown on a collagen gel in a growth-hormone-supplemented medium, their spindle shape became more conspicuous. With an additional supplement of vitamin A (6 micrograms/ml), most of the cells underwent differentiation by producing many bright inclusion bodies which proved to be strongly positive with periodic acid-Schiff and weakly positive with alcian blue staining. Electron microscopy revealed a well-developed rough endoplasmic reticulum, an enlarged Golgi apparatus and many highly electron-dense secretory granules resembling those of Clara cells. Biochemical analysis demonstrated that HFBE cells cultured on collagen gel with vitamin A secreted hyaluronic acid and neutral glycoproteins containing mainly N-linked glycoproteins whose glycans were of a complex type. A monoclonal antibody (SEC-41) generated against the neutral glycoproteins detected a glycoprotein of approximately 52 kDa in the spent culture medium of differentiated HFBE cells. This antibody also reacted with the intracytoplasmic secretory granules in these cells. When tested on frozen sections of lung tissue, the immunohistochemical reactivity of the SEC-41 antibody was confined to Clara cells, some type II pneumocytes in the adult lung, and respiratory epithelial cells in the fetal lung. Moreover, this antibody could detect secretory glycoprotein in broncho-alveolar lavages from two patients. This paper clearly demonstrates that cells derived from human fetal bronchial epithelium can be cultivated in an undifferentiated precursor state and, under appropriate culture conditions, can be stimulated to undergo differentiation into a Clara cell type.

[Continuous ambulatory intravenous morphine infusion for pain therapy in advanced ovarian cancer]

We report on a female outpatient with cancer of the ovary, who received continuous intravenous morphine infusion for terminal pain control. The patient was treated over a period of 48 days with a morphine dosage ranging from 10 to 60 mg/h, which kept her free of pain. With treatment, she was alert, communicative with her relatives and moved freely. At a later stage, we complemented the treatment with Diazepam and Haloperidol. No side-effects were observed over the whole period of morphine infusion.

Secretory differentiation of human fetal bronchial epithelial cells in culture. A study by histochemistry and electron microscopy

Human fetal bronchial epithelial (HFBE) cells at 6-8 passages were cultivated on a collagen gel for 10 days. A basal differentiative medium (BDM), consisting of RPMI 1640 supplemented with hormones and growth factors, was employed. Histochemistry, scanning electron microscopy and transmission electron microscopy revealed that HFBE cells developed secretory granules when cultivated on collagen gel in BDM. They were electron-dense and stained positive for PAS but negative for alcian blue. On additional treatment with 8 micrograms/ml vitamin A (VA), the number of secretory granules was increased. Moreover, the HFBE cells lost their surface microvilli, and dilation of rough endoplasmic reticulum was more marked than in culture without VA.

Goserelin, a depot gonadotrophin-releasing hormone agonist in the treatment of premenopausal patients with metastatic breast cancer. German Zoladex Trial Group

One hundred thirty-four pre- and perimenopausal patients presenting with metastatic breast cancer (median age, 42 years; range, 25 to 55) were treated with goserelin (Zoladex [ICI 118 630]; ICI Pharma, Plankstadt, Germany) a long-acting gonadotrophin-releasing hormone (GnRH)-analogue depot formulation, injected subcutaneously every 4 weeks, as a first-line therapy. One hundred eighteen patients were evaluable for response. Serum concentrations of estradiol, luteinizing hormones (LH), and follicle-stimulating hormones were significantly suppressed by Zoladex. Mean serum estradiol values fell into the range of castrated or postmenopausal women within 2 to 3 weeks of therapy. This suppression was maintained for the duration of therapy. Overall objective response was: 12 (10.2%) complete remission; 41 (34.7%) partial remission; 33 (28.0%) no change; and 32 (27.1%) progression. In responders, the median time to response was 4 months (range, 2 to 11 months), median duration of response was 8 + months (range 2 to 24 months), and median time to progression was 11 + months (range, 5 to 30 months). Objective responses were seen for different sites of metastases: loco-regional (62.5%), bone (46.7%), visceral (45.0%), and multiple (35.1%). Tumor remission was more common in patients in which the primary tumor was estrogen receptor (ER)-positive (49.3%) or ER-unknown (44.0%), but appreciable response rates were also observed in ER-poor patients (33.3%). Zoladex depot was well tolerated both locally and systemically. It produced effective castration and the objective response rates and duration of remission are at least comparable to those seen following oophorectomy; however, the side effects are less. The use of depot Zoladex avoids the psychological trauma and operative morbidity of the irreversible operative castration.

[The prognostic value of lymphangiosis carcinomatosa and malignancy grading in T1/T2-N0 cancers of the breast using 10 or fewer examined axillary lymph nodes]

In 270 cases of T1 and T2 carcinomas of the breast with ten or less axillary lymph nodes having been examined, the prognostic relevance of the histopathological statement of nodal negativity was assessed in a retrospective study. In this collective study, the mean number of lymph nodes examined was 4.1 +/- 1.9 for the 153 N0 carcinomas and 4.4 +/- 2.2 for the 117 cases with axillary lymph node metastases, respectively. The patients with N0 carcinomas were grouped according to the number of lymph nodes examined, thus resulting three subgroups, those with 1-2, 3-6, and 7-9 lymph nodes having been sampled and subjected to histopathologic evaluation. There was an approximately equal distribution in these three groups with respect to tumor size and tumor types; a correlation between the patients' age and the number of lymph nodes examined could not be found. A comparison of the three groups revealed conspicuous differences among the N0 carcinomas regarding both the disease-free survival time (DFS) and the overall survival time (OS), whereas a higher representativity of the determination of the nodal state, correlating with the number of lymph nodes examined, could not be confirmed. The disease-free survival time, the rate of disease recurrence as well as the median survival time and the 5-year survival rate, however, could be shown to be significantly dependent on tumor-related conditions, especially the grade of malignancy in connection with the presence or absence of peritumoral lymphatic or blood vessel invasion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of raster mammography and real time sonography with histology in carcinoma of the breast]

In a retrospective study, the results of real-time sonography and grid mammography in 161 patients with histologically confirmed breast cancer were analyzed and compared with the histopathologic characteristics of the tumours to assess the diagnostic accuracy of these preoperative image-producing methods. The results showed the determination of the tumour size as obtained by the image-producing methods to correlate closely with the histopathologic findings. Furthermore, both real-time sonography and mammography yielded certain indications allowing prognostically valuable conclusions in respect of malignancy and invasiveness of the carcinomas. Taking into account the different but complementing diagnostic results of both methods, the combination of grid mammography and real-time sonography must be considered as the presently most reliable preoperative diagnostic procedure.

[Chemotherapy of advanced ovarian cancer. Göttingen-Hannover studies]

Patients with ovarian carcinoma stages III and IV were treated with cis-platin (P), adriamycin (A) and cyclophosphamide (C). The total rate of remission in group PC (n = 58) was 86% (CR = 55%), in group PA (n = 48) 65% (CR = 48%) and in group PAC (n = 43) 63% (CR 47%). The number of cycles administered were 8 in PA and PAC, and 5 in PC. Half of the patients survived 18 months (PA), 19 months (PAC) and 21 months (PC) without signs of progression with a survival time of 25 months (PA), 27 months (PAC) and 29 months (PC). In patients who had received primary PA therapy, secondary treatment with combined CPC was carried out. Rate of remission 56%. Treosulphan after PC resulted in 14% remissions, etoposid after CP (n = 38) 11 (29%) remissions.

Growth inhibition and transformation of a human fetal tracheal epithelial cell line by long-term exposure to diethylnitrosamine

In order to obtain more information on the in vitro transformation of human cells, a human fetal tracheal epithelial cell line (FHET16/5) was exposed for a long time to diethylnitrosamine (DEN). In 20 passages, this cell line (diploid, male) maintained strong immunohistochemical reactivity for carcino-embryonic antigen and wool merokeratin; it was negative for vimentin. The cells contained PAS-positive mucous substances and ultrastructurally were found to have desmosome-like attachments. Treatment of the cells was with 0.3% dimethyl sulphoxide (DMSO), or DMSO with 150, 450, 1000 or 2000 micrograms/ml of DEN. It was started at the ninth passage and continued for six passages over 9 weeks for the control (DMSO) and the three lowest control doses of DEN, and for three passages over 9 weeks for the 2000 micrograms/ml DEN group. Cells grown for 13 days after the end of treatment were plated in soft agar and injected subcutaneously in nude mice. The frequency of anchorage-independent colonies grown in soft agar was directly related to DEN dose. Colony-forming efficiency, as an expression of toxic effect, was also dose dependent. Autoradiographically detected unscheduled DNA synthesis indicated an association between anchorage-independent transformation and DNA alterations induced by DEN. Cells injected into nude mice did not produce tumours during a 6-month period, but invasiveness was observed when cells from the 2000 micrograms/ml DEN group were transplanted on the dermis of cultured chick embryo skin. The results indicate that DEN causes anchorage-independent transformation accompanied by unscheduled DNA synthesis in a fetal human tracheal epithelial cell line.

[The structure of decidual mucosa in the accessory horn of an uterus bicornis (author's transl)]

The loosely attached decidual mucosa in the accessory horn of an uterus bicornis does not principally differ from the mucosa in the horn containing the fetus. Structural studies show that the regression of decidual endometrium to a endothelium-like lining is a hormone-dependent process such as stromagland dissociation. Mechanical factors due to expansion of the fetus certainly play no major role. Degenerative phenomena, such as focal necrosis, sclerosing edema, thrombosis, and inflammatory infiltrates probably appear more frequently in the accessory horn. They may be explained by more pronounced regional disturbances concerning perfusion and the inferior sealing of the uterine cavity.

Effects of N-nitrosodiethanolamine and 1,1-diethanolhydrazine in Syrian golden hamsters

N-Nitrosodiethanolamine (NDEA) and 1,1-diethanolhydrazine (DEH) were synthesized and injected subcutaneously weekly in male and female Syrian golden hamsters. The total NDEA dose per hamster was approx. 15 g/kg body wt. applied in either 7 or 27 subdoses. DEH was administered in 78 applications to two groups yielding total doses of 1.1 g and 273 mg/kg body wt. Under these conditions, DEH did not show a specific demonstrable carcinogenic effect. However, within 78 weeks after the first application, 39 out of 56 hamsters treated with NDEA developed tumors. Primarily, neoplasms of the nasal cavity and tracheal tumors were observed, as well as a few hepatocellular adenomas and sarcomas at the injection site. These findings and those of the earlier study on carcinogenicity of NDEA in rats raise concern as to the safety for human consumption or industrial use of products with the potential for forming NDEA.

Tumors of the heart and stomach induced in European hamsters by intravenous administration of N-methyl-N-nitrosourea

One hundred twenty captured European hamsters (Cricetus cricetus L.) were inoculated iv with 1/5, 1/10, or 1/20 the median lethal dose of N-methyl-N-nitrosourea (MNU) once weekly for 18 weeks. MNU induced mainly sarcomas in the heart and squamous cell carcinomas and sarcomas in the stomach. The highest incidence of such tumors was demonstrated by the lowest-dosage group. They were more frequent in males than in females. The effect of MNU was also localized at the site of administration and resulted in squamous cell carcinomas of the oral cavity. The possible fibroblastic or neurogenic origin of the sarcomas was explored.

A study of tobacco carcinogenesis. XV. Effects of N'-nitrosonornicotine and N'-nitrosoanabasine in Syrian golden hamsters

N'-Nitrosonornicotine (NNN) and N'-nitrosoanabasine (NAB) were synthesized and injected subcutaneously three times weekly in male and female Syrian golden hamsters for 25 weeks (total dose 375 mg). N-Nitrosopiperidine (NPD) served as positive control (total dose 150 mg). Within 83 weeks 12 out of 19 hamsters given NNN had developed tracheal tumors, 1 had a carcinoma of the nasal cavity. During the same time none of the hamsters given NAB developed tumors, whereas all 20 hamsters given NPD developed tracheal tumors and about 50% had additional neoplasms in the nasal cavity. Under the described conditions and in comparison to NPD, NNN appears to be a moderately active tumorigenic agent in the upper respiratory tract of Syrian hamsters, whereas NAB is inactive.

The modification of the renal carcinogenicity of dimethylnitrosamine by actinomycin D and a protein deficient diet

The effect of a single treatment with 30 mg dimethylnitrosamine (DMN) and 6 mug actinomycin D (ACT), given at different time intervals (ACT application to DMN, 2 h before, simultaneously, 5, 9 or 48 h later), was tested in female Sprague-Dawley rats in relation to renal carcinogenesis; additionally, the animals were fed either a normal or a protein deficient diet. The ACT treatment did not significantly modify either the kidney tumour incidence or the survival time in the different groups fed a normal diet. Nevertheless, there are indications that additional ACT application may shorten the latency period for DMN induced renal neoplasms or, when administered 5 h later than DMN, a slightly decreased and delayed tumour induction can be assumed. In groups fed a protein deficient diet, a significantly higher percentage of kidney tumour bearing animals as well as a shortened latency period were found when compared with the DMN group on normal diet, but these differences were independent of the additional ACT treatment 9 h later than DMN and were due to the protein deprivation. Morphologically, the tumours were of epithelial and mesenchymal type with a clear preponderance of the former type. Biochemical and morphological aspects are discussed.

Comparative morphological studies on the carcinogenic effect of 7,12-dimethylbenz(A)anthracene (DMBA) in normal or intrasplenic ovarian tissue of C3H mice

A single intravenous injection of 100 mg/kg body weight (b.w.) of 7, 12 dimethylbenz(a)anthracene (DMBA) induces a high percentage of ovarian granulosa cell tumours in C3H mice. After implantation of ovarian tissue into the spleen of gonadectomized female C3H mice similar tumours were found, resulting from an over-stimulation by pituitary gonadotrophins. In the present study the tumour development in intrasplenic ovarian tissue was observed after an additional single intravenous application of 100 mg/kg b.w. DMBA. It was found that the induction of granulosa cell tumours did not seem to be affected by the carcinogen injection whether 12 weeks before or 12 weeks after ovarian tissue was implanted into the spleen. The morphology of these neoplasms corresponds to the DMBA induced granulosa cell tumours in orthotopic ovaries. A direct carcinogenic effect of DMBA on ovarian cells in mice could not be demonstrated but there are indications that the additional DMBA application accelerated the destruction of the oocytes, which might result in a more rapid intrasplenic tumour induction.