Phase II trial of intrapleural paclitaxel injection for non-small-cell lung cancer patients with malignant pleural effusions

A phase II clinical trial of intrapleural paclitaxel injection for malignant effusions of non-small-cell lung cancer (NSCLC) was conducted in order to evaluate the efficacy and toxicity profile of paclitaxel pleurodesis in patients with malignant effusions. From February to May of 1996, 15 NSCLC patients with malignant pleural effusions were enrolled on study. After adequate drainage and assurance of lung re-expansion, paclitaxel 125 mg m-2 diluted in normal saline was infused through a preinserted pig-tail catheter which was removed 2 h later. Chest radiography and sonography were scheduled 4 days later; depending on whether there remained a significant amount of pleural effusion, further drainage by needle thoracentesis or by a pig-tail catheter was performed. All patients were assessable for toxicity. Ipsilateral chest and/or shoulder pain, fever, facial flushing and nausea were the most frequent side-effects. Grade 4 neutropenia, grade 3 anaemia, and grade 3 renal impairment occurred in one patient each. Fourteen patients were evaluable for response at the end of the fourth week. Overall response rate of pleural effusion in evaluable patients was 92.9%, with a complete response rate of 28.6%. There was one out of 14 evaluable patients whose measurable tumour lesion decreased by more than 50% (partial response). No disease progression was noted among evaluable patients at the end of the fourth week. It is concluded that paclitaxel is a useful agent for the treatment of malignant pleural effusions. Because of its relatively low systemic toxicity, intrapleural paclitaxel injection in combination with systemic chemotherapy or radiotherapy can be considered in treating NSCLC patients with malignant pleural effusions.

Paradoxical effect of GM-CSF gene transfer on the tumorigenicity and immunogenicity of murine tumors

The effect of granulocyte/macrophage colony-stimulating factor (GM-CSF) gene transfer on the tumorigenicity and immunogenicity of 2 different murine tumor lines was determined. Transduction of B16 melanoma cells with the GM-CSF gene rendered the cells more immunogenic. In contrast, transduction of NG4TL4 fibrosarcoma in FVB/N mice (NG) with the GM-CSF gene showed increased tumorigenicity in a high producer line (NG-MGh). The parent NG or NG-MG cells induced the same level of cytotoxic T-lymphocyte (CTL) response and the same magnitude of tumor transplantation immunity. However, the proliferation of the NG-MGh cells was increased 2- to 10-fold. There was no increase in apoptosis in the NG cells and there was no increase of NG-MGh cells in S-phase, hence the increase of the proliferative activity appeared to be indeed inherent to the cells. Mixing the splenocytes from the NG-MGh tumor bearers with the NG tumor cells did not increase tumorigenicity but totally inhibited the growth of the NG tumor, indicating that suppressor cells were not present. Mixing 10,000 rad X-irradiated NG-MGh cells with viable NG tumor cells resulted in 3- to 10-fold increased NG tumor growth rate. The in vitro proliferation of NG cells was increased by adding both GM-CSFs and macrophages and not by either one alone, suggesting that interaction between macrophages and GM-CSFs resulted in the production of tumor growth enhancing factor(s). Our findings suggest that transduction of NG tumor cells with the GM-CSF gene increases tumorigenicity, which is attributed both to an increased inherent proliferative ability of the tumor cells and to the in vivo production of a tumor growth enhancing factor(s) at the tumor site.

Cross regulation by IL-10 and IL-2/IL-12 of the helper T cells and the cytolytic activity of lymphocytes from malignant effusions of lung cancer patients

STUDY OBJECTIVE

Our previous report demonstrated that there was impairment of local cellular immunity with elevated interleukin-10 (IL-10) and undetectable IL-12 in neoplastic pleural effusion. These findings suggest that the local immune reactions favor the T-helper type 2 (Th2) pathway instead of Th1 pathway. The present study was designed to examine whether local cellular immunity could be manipulated by IL-2 and/or IL-12 treatment, and to determine their effect on the helper T-cell pathways and the cytolytic activity of the effusion-associated lymphocytes (EALs).

DESIGN

Using malignant pleural effusions obtained from four patients suffering from adenocarcinoma of lung, we separated the tumor cells from the EALs with Ficol-Hypaque centrifugation, followed by Percoll density centrifugation. To test whether the cytolytic function of lymphocytes could be enhanced by culturing with IL-2 and/or IL-12, lymphocytes were incubated with recombinant IL-2 with/without IL-12 for 6 days. Following this, the tumoricidal activity was assessed in an overnight 5'chromium-release assay. Autologous tumor cells for measuring specific antitumor activity, Daudi cells susceptible to lymphokine-activated killer cells, and NK-susceptible K562 cells were used as target cells.

MEASUREMENTS AND RESULTS

After treatment in vitro with IL-2, IL-12, or IL-2 plus IL-12, the Th pathway shifted from Th2 to Th1 type (increased gamma-interferon production). To further study the effect of cytokine treatment on the cytolytic activity of EALs, it was found that after 6-day culturing, the EALs failed to kill any of the three tumor targets, whereas the 6-day cultured peripheral blood lymphocytes (PBLs) gave low level of cytotoxicity against all three tumor targets. Stimulation with IL-2 alone partially restored the immunocompetence of EALs to kill the tumor targets. Stimulation with IL-12 alone showed no significant effect on their cytolytic activity. However, IL-12 synergized with IL-2 to increase the cytolytic activity of EALs and PBLs against autologous tumor targets. This synergistic effect was not found for Daudi cells and K562 cells.

CONCLUSIONS

These results suggest that EALs activated with IL-12 in the presence of a low concentration of IL-2, which converted the EALs from Th2 pathway to Th1 pathway, could be an alternative source of antitumor effectors for adoptive immunotherapy of cancer.

Primary pulmonary malignant hemangiopericytoma associated with coagulopathy

A 34-year-old woman with a massive pulmonary malignant hemangiopericytoma and coagulopathy as a paraneoplastic syndrome is reported. Although coagulopathy may appear as a paraneoplastic syndrome and cause treatment to be more complicated and difficult, it can also be a useful marker to monitor the results of operation and tumor recurrence. This unusual case shows that primary pulmonary malignant hemangiopericytoma deserves aggressive surgical intervention with complete resection even under the circumstances of coagulation abnormality.

Restoration of the immunocompetence by IL-2 activation and TCR-CD3 engagement of the in vivo anergized tumor-specific CTL from lung cancer patients

The present study investigates the nature of the immunosuppressed state of the lymphocytes obtained from the malignant pleural effusion (effusion associated lymphocytes, EAL) of lung cancer patients. The immunocompetence of EAL from 13 patients was assessed by determining their T-helper cell phenotype, proliferative response to alpha CD3-activation, and their cytolytic activity against three tumor targets: the autologous tumor, Daudi, and K562. Flow cytometry analysis showed that the lymphocytes in EAL were predominantly T cells with < 1% natural killer cells. The T-helper cell phenotype was found to be predominantly of Th2 type, but could be readily converted to Th1 type by culturing the EAL in vitro, and this conversion was augmented by interleukin-2 (IL-2) or IL-2 plus alpha CD3. To test the cytolytic activity of EAL, it was found that after 6-day culturing, the EAL remained in an immunosuppressed state so that they failed to kill any of the three tumor targets. Stimulation with IL-2 partially restored the immunocompetence of EAL. Further engagement of TCR-CD3 by alpha CD3 fully restored the cytolytic activity of the EAL to kill the autologous tumor target but not Daudi or K562 tumor cells, and thus seemed to be tumor specific. The specificity was further confirmed by testing the activated EAL and normal donor peripheral blood lymphocytes against a variety of tumor targets and control targets. Furthermore, the killing by EAL against the autologous tumor target seemed to be major histocompatibility complex-restricted and was inhibited by anti-human leukocyte antigen class I antibody. The EAL from lung cancer patients also showed much reduced responsiveness to the alpha CD3 stimulation to induce proliferation, and addition of IL-2 restored the responsiveness. These results suggest that, through close contact with tumor cells, anergy of cytotoxic T lymphocytes (CTLs) was induced in vivo at a localized site. IL-2 stimulation and TCR-CD3 engagement could reverse the anergic state and restored the full competence of CTLs in EAL to mediate the specific anti-tumor killing against the autologous tumor. Proper manipulation of EAL may prove useful as a source of anti-tumor effectors for cancer adoptive immunotherapy.

Microsatellite instability in sporadic-colon-cancer patients with and without liver metastases

Microsatellite instability (MSI) is intrinsic to most colorectal carcinomas (CRC) from patients with hereditary nonpolyposis colorectal cancer (HNPCC), reflecting germline mutations in the mismatch-repair (MMR) genes. Its occurrence and chronological sequence of development in sporadic CRC appears less well defined. To explore the time sequence in acquisition of MSI, and the role it plays during tumor progression in sporadic CRC, we compared the incidence of MSI in tissue samples from 40 Dukes'-B and 30 Dukes'-D CRC patients with liver metastases, at 4 different microsatellite loci, representing sites on the APC, DCC and p53 genes respectively as well as the D2S123 site. Among the 30 patients with hepatic metastases, MSI was found in 9 (30%) of the primary, and 13 (43.3%) of the metastatic tumors. In comparison, among the 40 Dukes'-B CRC, MSI was found in only 8 cases (20%). CRC with MSI were more frequently located in the right colon, less frequently on the left side, and seldom in the rectum. Tumor ploidy analysis shows that 46.2% of Dukes'-D primary tumors with MSI are diploid (chi2 = 4.46, p = 0.035). With a mean follow-up time of 4.2 years for the Dukes'-B CRC, there were no recurrences in the 8 patients with MSI, whilst 6 (18.8%) relapses occurred amongst the 32 patients without MSI, average time to recurrence being 15 months. In Dukes'-D CRC, mean survival time for patients with MSI was 37 months (95% CI, 24 to 51 months), for those without MSI 26 months (95% CI, 18 to 35 months), although this was not statistically significant. Our data suggest that tumor progression may involve increased genetic instability.

Experience with ifosfamide and etoposide combination chemotherapy in extensive-disease small-cell lung cancer

BACKGROUND

Ifosfamide, an isomeric analogue of cyclophosphamide, has significant activity against many human tumors including lung cancer, testicular cancer, lymphoma and sarcoma, and may be superior to its analogue. Herein, we report our preliminary experience using ifosfamide and etoposide (IE) combination chemotherapy in previously untreated patients with extensive-disease (ED) small-cell lung cancer (SCLC).

METHODS

Patients with histologically or cytologically confirmed SCLC, measurable or assessable ED, no previous chemotherapy or thoracic irradiation, younger than 70 years of age, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0-3, and adequate marrow, liver, and renal functions were eligible for treatment which consisted of ifosfamide 2.0 g/m2/d given intravenously (i.v.) for 3 days with mesna 400 mg/m2/dose i.v. administered 0, 4, and 8 hours after the daily administration of ifosfarnide, and etoposide 80 mg/m2/d i.v. given for 3 days in every 4 weeks for a maximum of 6 cycles.

RESULTS

Between January 1994 and February 1995, 10 patients were enrolled into the treatment. All were men with a mean age of 63 +/- 6 years. Five patients had an ECOG PS of 0 or 1, 4 patients of 2, and 1 patient of 3. A total of 45 cycles of IE were given. The mean number of cycles per patient was 4.5 +/- 2.1. Six patients completed 6 courses of therapy. Thirty-two of 45 cycles (71%) of IE were given at full doses, while the remaining 13 cycles (29%) were given at 75% of doses. Nine patients were assessable for response. Eight patients had a partial remission and one patient had stable disease. The overall response rate was 89%. The median survival was 8 months (range, 0 to 23 months) and the median failure-free survival duration was 5.5 months (range, 0 to 18 months). The 1- and 2-year survival rates were 30% and 0%, respectively. Myelotoxicity was the most important toxicity, particularly neutropenia, while thrombocytopenia and anemia were mild. Five of 10 patients (50%) experienced grade 4 neutropenia, which occurred in 2 patients during the first course of IE and resulted in one patient death from early sepsis. Other nonhematologic toxicities were mild.

CONCLUSIONS

Our preliminary experience demonstrates that ifosfamide is an active drug against SCLC and combination chemotherapy with IE results in similar response rate and median survival, but probably higher myelotoxicity than reported studies in patients with ED SCLC.

Activation of CDC 25 phosphatase and CDC 2 kinase involved in GL331-induced apoptosis

CDC 25 is a dual phosphatase responsible for dephosphorylation and, thus, activation of CDC 2 kinase in G2. Abnormal activation of cyclin B-associated CDC 2 kinase has been implicated in apoptosis induced by cancer chemotherapeutic agents such as paclitaxel (Taxol) and etoposide (VP-16). In this study, we found that the CDC 2 kinase could be transiently activated when nasopharyngeal carcinoma NPC-TW01 cells were treated for 3 h with a new anticancer agent, GL331. GL331 treatment also induced a concomitant increase in CDC 25A phosphatase activity and a reduced level of Tyr-15-phosphorylated CDC 2 in NPC-TW01 cells. Furthermore, subsequent apoptotic DNA fragmentation induced by GL331 could be interrupted by treatment of the cells with the cyclin B1-specific antisense oligonucleotides, suggesting that abnormal activation of cyclin B1-associated CDC 2 kinase and CDC 25A phosphatase was involved in GL331-induced apoptosis. Raf-1 has been shown to associate with CDC 25A and, thus, to stimulate its phosphatase activity. Our results revealed that GL331 could facilitate the association of CDC 25A with Raf-1, resulting in the cascade of CDC 25A phosphatase activation and CDC 2 kinase activation, as well as related signaling pathways, and ultimately causing apoptosis in cancer cells.

A phase I feasibility and pharmacokinetic study of intrapleural paclitaxel in patients with malignant pleural effusions

To evaluate the feasibility and pharmacology of intrapleural (IP(L)) administration of paclitaxel, 18 patients with malignant pleural effusions were entered onto a phase I clinical study, 13 were caused by lung cancer. Following an effusion drainage rate of less than 100 ml/24 h and full expansion of the lung, patients were treated with a single instillation of pacilitaxel administered IP(L) in 500 ml of normal saline and retained for a maximum of 96h when tolerated. No systemic chemotherapy or ipsilateral thoracic irradiation was given for 4 weeks before and after the IP(L) treatment. The starting dose was 82.5 mg/m2 with the dose escalation schedule of 125, 175, 225 and 300 mg/m2. There were minimal local or systemic toxicities, such as local chest pain or myelosuppression, even when the paclitaxel dose reached 225 mg/m2. The pharmacological advantages of the IP(L) administration of paclitaxel were demonstrated by the mean exposure of the pleural cavity (area under the concentration time curve) to paclitaxel after IP(L) delivery exceeding that of the plasma by approximately 370-fold (range 55-684) and by the extraordinarily slow IP(L) clearance of paclitaxel (mean +/- SE 0.49 +/- 0.07 l/m2/day; range 0.08-1.16 l/m2/day) with significant concentrations of paclitaxel persisting within the cavity for more than 48-96 h after a single IP(L) instillation. In patients with detectable plasma paclitaxel levels, the plasma levels achieved exceed the minimal concentrations that are required to induce cytotoxic effects in vitro. Four patients had progressive dyspnea during IP(L) retention of paclitaxel solution because of treatment failure and needed drainage of effusion. One of these patients who was at the dose level of 225 mg/m2 originally had severely chronic obstructive lung disease, developed acute respiratory failure, refused mechanical ventilation support and succumbed to respiratory failure. No further patients were included after this event. Antitumor effect was shown by four of the 15 evaluable patients having no recurrence of effusion on chest radiograph at 1 month. Most of these responders had a good performance status, normal pretreatment pleural pH and/or glucose compared with the non-responders. We conclude that paclitaxel at a dose level of 175 or 225 mg/m2 is feasible for use intrapleurally. It could be considered for incorporation into treatment programs for patients with less advanced thoracic tumors with carcinomatous pleuritis or with IP(L) tumors following surgical debulking.

Weekly CAF chemotherapy for advanced breast cancer patients

In a prospective phase II study, 102 women with advanced breast cancer were treated with low doses of cyclophosphamide, Adriamycin and 5-fluorouracil (CAF) at weekly intervals by intravenous injection. Seventy-five patients were evaluable for treatment response and the overall response rate was 52% (95% confidence interval, 41-63%). Of the evaluable patients, 15% had complete response and 37% had partial response. The median survival after therapy was 15.6 months, the median time to progression was 6.8 months and the median duration of response was 9.1 months. The main toxicities were mild vomiting and moderate myelosuppression. There was only 1 patient who experienced heart failure. Weekly CAF appears to have an efficacy with tolerable side effects comparable to standard CAF with an every-3-week schedule.

Frequent detection of aberrant RNA transcripts of the CDKN2 gene in human gastric adenocarcinoma

The tumor-suppressor gene CDKN2 (p16/INK4A/MTS1) is frequently altered in human gastric-cancer cell lines. However, mutation of the CDKN2 gene in primary human gastric-carcinoma tissues as seen through genomic DNA analysis has rarely been reported. In this study, a method combining reverse transcription and nested polymerase chain reaction was developed to detect different RNA transcripts of the CDKN2 gene in human gastric cancers. The results showed that, besides the wild-type CDKN2 transcript, 5 of 11 (45.5%) diffuse-type and 3 of 10 (30%) intestinal-type primary gastric adenocarcinoma had aberrant CDKN2 RNA transcripts. Among these 8 tumorous specimens with abnormal CDKN2 RNA transcripts, 6 had intragenic deletions of part of both CDKN2 exons 1 and 2, including 1 case which had an additional inserted sequence from part of CDKN2 intron 2. In addition, 1 case had a deletion of part of CDKN2 exon 1 and 1 case had its entire exon 2 deleted. In contrast, matched normal gastric mucosal tissues from the same patients did not have any aberrant CDKN2 RNA transcript. Furthermore, CDKN2 exon 1 or 2 genomic DNA from all the gastric-carcinoma tissues were PCR-amplified and sequenced and no genetic alteration was detected. Therefore, alteration and heterozygous expression of CDKN2 appears to be involved in the pathogenesis of human gastric cancers.

Gemcitabine versus the combination of cisplatin and etoposide in patients with inoperable non-small-cell lung cancer in a phase II randomized study

PURPOSE

A phase II randomized study was conducted to evaluate the efficacy and toxicity of gemcitabine (GEM) versus the combination of cisplatin and etoposide (EP) in Chinese patients with inoperable (stage III or IV) non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From March 1995 to February 1996, 53 patients were enrolled onto the study: 27 onto the GEM arm and 26 onto the EP arm. In the GEM arm, gemcitabine 1,250 mg/m2 was given as a 30-minute intravenous (i.v.) infusion on days 1, 8, and 15 of each 28-day cycle. In the EP arm, cisplatin 80 mg/m2 was given on day 1 and etoposide 80 mg/m2 was given on days 1, 2, and 3 of each 28-day cycle.

RESULTS

Twenty-six patients are assessable for treatment response on the GEM arm and 24 on the EP arm. Five patients (19.2%) on the GEM arm and five patients (20.8%) on the EP arm achieved a partial response (PR). No complete responses were attained on either treatment arm. All patients enrolled onto the study were eligible for toxicity assessment. The main toxicities were myelosuppression and vomiting, which included World Health Organization (WHO) grade 3 or 4 leukopenia (3.7%), thrombocytopenia (7.4%), anemia (7.4%), and nausea/vomiting (3.7%) on the GEM arm, and WHO grade 3 or 4 leukopenia (30.8%), thrombocytopenia (7.7%), anemia (15.4%), and nausea/vomiting (34.6%) on the EP arm. The median survival time was 37 weeks on the GEM arm and 48 weeks on the EP arm.

CONCLUSION

Gemcitabine is a well-tolerated chemotherapeutic agent for NSCLC. The antitumor activity was promising, with a 19.2% single-drug response rate, when compared with EP combination chemotherapy, which had a response rate of 20.8%. The safety profile is better than that of EP treatment.

A phase II study of carboplatin in nasopharyngeal carcinoma

This is a phase II study to evaluate the efficacy and toxicity of short-course carboplatin in advanced-stage nasopharyngeal carcinoma (NPC). Thirty-three previously untreated stage III-IV NPC patients were studied. Carboplatin was given as a rapid intravenous injection every 3 weeks. The dose of carboplatin was calculated according to the individual patient's creatinine clearance and desired platelet nadir of 75,000/microliter according to the Egorin formula. Response and toxicity were evaluated. Thirty-two patients were evaluated for response. The median age was 54 years, range 30-70 years. Twenty-four patients had local regional disease and 8 patients had metastatic disease. The median dose of carboplatin given was 415 mg/m2 (range 91-791 mg/m2). Fourteen (44%) patients had a partial response with a 95% confidence interval of 26-62%. Fifteen (47%) patients had stable disease and 3 (9%) progressive disease. The overall median survival rate was not reached at 43 months. Overall toxicity was tolerable. Grade III-IV myelosuppression occurred in 4 (12%) patients. There were no other major toxicity- or treatment-related deaths. We conclude that carboplatin has a significant anticancer effect in advanced NPC. Thus carboplatin combination chemotherapy for the treatment of NPC is worthy of future clinical investigations.

Identification of mutations at DNA topoisomerase I responsible for camptothecin resistance

A camptothecin-resistant cell line that exhibits more than 600-fold resistance to camptothecin, designated CPT(R)-2000, was established from mutagen-treated A2780 ovarian cancer cells. CPT(R)-2000 cells also exhibit 3-fold resistance to a DNA minor groove-binding ligand Ho33342, a different class of mammalian DNA topoisomerase I inhibitors. However, CPT(R)-2000 cells exhibit no cross-resistance toward drugs such as Adriamycin, amsacrine, vinblastine, and 4'-dimethyl-epipodophyllotoxin. The mRNA, protein levels, and enzyme-specific activity of DNA topoisomerase I are relatively the same in parental and CPT(R)-2000 cells. However, unlike the DNA topoisomerase I activity of parental cells, which can be inhibited by camptothecin, that of CPT(R)-2000 cells cannot. In addition, parental cells after camptothecin treatment results in a decrease in the level of DNA topoisomerase I, whereas CPT(R)-2000 cells are insensitive to camptothecin treatment. These results suggested that the mechanism of camptothecin resistance is most likely due to a DNA topoisomerase I structural mutation. This notion is supported by DNA sequencing results confirming that DNA topoisomerase I of CPT(R)-2000 is mutated at amino acid residues Gly717 to Val and Thr729 to Ile. We also used the yeast system to examine the mutation(s) responsible for camptothecin resistance. Our results show that each single amino acid change results in partial resistance, and the double mutation gives a synergetic effect on camptothecin resistance. Because both mutation sites are near the catalytic active center, this observation raises the possibility that camptothecin may act at the vicinity of the catalytic active site of the enzyme-camptothecin-DNA complex.

Phase II study of ifosfamide and etoposide chemotherapy for extensive-disease small-cell lung cancer

We conducted a phase II study of ifosfamide and etoposide chemotherapy in patients with untreated extensive-disease small-cell lung cancer to assess response and toxicity. Between January 1994 and December 1995, 16 patients were treated. Ifosfamide and etoposide doses were ifosfamide 2 g/m2, with mesna, i.v. infusion over 30 minutes on days 1-3 and etoposide 80 mg/m2 i.v. over 120 minutes on days 1-3 every 4 weeks for up to six cycles. All patients were evaluable for toxicity profile and treatment response. As expected, the major toxicity was myelosuppression. With one exception, grade 3 or 4 leukopenia occurred in all patients during treatment, and 48.7% of the total courses had grade 3 or 4 leukopenia. Nine of 16 patients (56.3%) experienced episodes of febrile neutropenia. One toxic death due to febrile neutropenia with sepsis was documented. Toxicities other than leukopenia were few and mild in severity. After two cycles of treatment, the overall response rate was 81.3% (95% confidence interval 62.2-100) in this study. The median duration of response was 8 months and median survival was 11 months. In conclusion, ifosfamide and etoposide is an active combination regimen with acceptable toxicity profile in Chinese patients with extensive-disease small-cell lung cancer.

Phase II study of megestrol acetate in the treatment of hepatocellular carcinoma

This is a report of a phase II study of megestrol acetate (160 mg/day, orally) in the treatment of hepatocellular carcinoma (HCC). Forty-six patients with advanced HCC were studied and tumour response, changes in appetite, bodyweight, a feeling of well-being, survival and toxicity were evaluated. Thirty-two patients were able to be evaluated for response; there were no complete responders or partial responders. Twelve patients (38%) had stable disease and seven of these patients had a minor response with a median size reduction in the tumour of 18%. Twenty patients (62%) had progressive disease. Five of 24 (21%) patients had a median reduction in alpha-fetoprotein levels of 59 ng/mL. The overall median survival was 4 months (range 1 week to 27 months). Twenty of 32 (62%) patients had an increased appetite and feeling of well-being. Fourteen of 22 (64%) patients had a median lean bodyweight gain of 5 kg (range 1-14 kg). Toxicities were minimal. Tests for glucocorticoid receptors were performed in 10 patients. Four of five patients who were positive for glucocorticoid receptors in the tumour had a stable disease and all five patients who were negative for glucocorticoid receptors had progressive disease. Megestrol acetate had no significant effect on the tumour in HCC patients. However, megestrol acetate is useful in the palliative management of HCC patients, with improvements in appetite, bodyweight and a feeling of well-being with minimal side effects. Some patients had stable disease, a minor reduction of tumour size and a prolonged survival after megestrol acetate treatment and this response may be related to the presence of glucocorticoid receptors in the HCC tumour.

Mitomycin-C induced hemolytic uremic syndrome: a case report and literature review

Hemolytic uremic syndrome spontaneously arises in a few patients with advanced cancer, but it is more commonly related to the use of certain chemotherapeutic agents. Mitomycin-C is, etiologically, the most common causative agent inducing hemolytic uremic syndrome, in a dose dependent manner. We report this syndrome, attributable to mitomycin-C at a cumulative dose of 40 mg/m2, in a gastric cancer patient. A 42-year-old female with stage III gastric cancer underwent radical gastrectomy and was given mitomycin-C at 10 mg/m2 intravenously every four weeks as adjuvant therapy. Hemolytic uremic syndrome was diagnosed three months after the last dose of mitomycin-C administration. The most prominent symptoms included pallor, hypertension and anasarca, with laboratory evidence of microangiopathic hemolytic anemia, azotemia and hyperkalemia. Her disease was progressive, but fortunately stabilized after staphylococcus column A dialysis. Her disease remained in remission for 24 months from the time of diagnosis, and then relapsed in the form of peritoneal carcinomatosis with partial intestinal obstruction.

Cross sectional study of use of alternative medicines in Chinese cancer patients

The aim of this study was to ascertain the prevalence of alternative medicine consumption in Chinese cancer patients on active conventional treatment. A cross sectional survey of 100 consecutive advanced cancer patients admitted to a cancer clinical trial referral unit were personally interviewed by their assigned oncology research nurse using a specially designed questionnaire. The results showed that 64% of our patients used indigenous Chinese medication. In all age groups except the over-70s (P = 0.043), > 50% took such medication, more female (76%) than male (57.6%) patients (P = 0.323). Patients of all educational levels (P = 0.062) and religious backgrounds (P = 0.08) consumed alternative medicines. Duration of alternative medication consumption was less than three months in 50% of patients, with costs between US$40 and 2000/month for 70% of patients. Reasons cited for alternative medication consumption was hope that it might be of some benefit to their well being or disease control, and maybe even result in a miracle cure. Sources of advice on medication were mostly from strangers (by word of mouth), family, friends, the media, and infrequently from qualified professional Chinese doctors. Reasons for discontinuing such treatment were mostly given as lack of positive effect. In conclusion, Chinese cancer patients, willingly, rampantly and non-selectively seek out and consume alternative medications, with almost total ignorance of the medication consumed, oblivious to any potential side effects, and with little subjective benefit.

Protein tyrosine phosphatase activities are involved in apoptotic cancer cell death induced by GL331, a new homolog of etoposide

GL331 is a semisynthetic topoisomerase II inhibitor derived from a plant toxin podophyllotoxin. In 72-h exposure assays, LD50 values of GL331 range from 0.5 to 2 microM, which are three- to ten-fold lower than those of its homologous compound etoposide (VP-16), depending on different cancer cell lines including nasopharyngeal, hepatocellular, gastric, cervical and colon cancer types. Apoptotic DNA ladders could be detected when cancer cells were treated with GL331 for 24 h even if the Bcl-2 and Bax protein levels were not altered during the period. Besides acting as topoisomerase II inhibitors, both GL331 and VP-16 decrease the cellular protein tyrosine kinase (PTK) activities in cancer cells. The activities of protein tyrosine phosphatase (PTP) are significantly increased after GL331 treatment but are not affected by VP-16. GL331-induced internucleosomal cleavage can be efficiently prevented by two inhibitors of PTP, sodium orthovanadate and zinc chloride, but not by okadaic acid, which inhibits serine/threonine phosphatase activity. These results indicate that GL331 may induce apoptotic cell death, and that activation of protein tyrosine phosphatases may be involved in this process.

Lack of NK cells and related cytokines in pleural effusion

BACKGROUND

Relatively low number and activity of natural-killer (NK) cells have been reported in malignant pleural effusions. However, there has been no report on NK cells related cytokines.

METHODS

Lymphocyte subpopulations were studied in 30 cases of pleural effusion with various etiologies, along with peripheral blood, by using flow cytometry. The related cytokine levels in peripheral blood and pleural fluid, including IL-1 alpha, IL-4 and IL-12, were also analyzed with ELISA assays.

RESULTS

The results showed significant increase of T-helper cell subpopulation in pleural effusion of various etiologies. No obvious change of B-lymphocyte subpopulation between peripheral blood and pleural effusion was found. IL-4 was undetectable in both peripheral blood and pleural fluid in most cases. IL-1 alpha was detectable in some cases and the level was highest in pleural fluid of empyema. Decreased NK cells were found in most cases of pleural effusion and accompanied by undetectable IL-12 both in pleural fluid and peripheral blood. The only one case with detectable IL-12 concentration in pleural fluid was the one with tuberculous pleurisy.

CONCLUSIONS

Increased T-helper cell subpopulation and decreased NK cell subpopulation were found in pleural effusion of various etiologies. In spite of the small series of our patients, the decrease of NK cell subpopulation and the undetectable IL-12 concentration in pleural effusion deserves further investigations.

A pharmacokinetic study with the high-dose anticancer agent menadione in rabbits

The aim of this investigation was to assess the pharmacokinetic properties of high-dose menadione (VK3), as an anticancer agent, in plasma and red blood cells (RBCs) in rabbits. An extremely high dose of 75 mg menadiol sodium diphosphate (Synkayvite) was intravenously injected. HPLC analysis was applied to measure the major metabolite, menadione, VK3. The kinetic properties of VK3 in both plasma and red blood cells showed a short elimination half-life, high clearance, and large volume of distribution in plasma and RBCs. The mean elimination t1/2 values of menadione in plasma and in RBCs were 27.17 +/- 10.49 min and 35.22 +/- 11.82 min, respectively. The plasma clearance (CL/F) of VK3 was 0.822 +/- 0.254 L min-1. The systemic clearance in RBCs was 0.407 +/- 0.152 L min-1. The apparent volume of distribution (Vd/F) in plasma was 30.833 +/- 12.835 L and that in RBCs 20.488 +/- 9.401 L. The plasma AUC was 32.453 +/- 9.785 micrograms min mL-1 and that of RBCs 67.219 +/- 24.449 micrograms min mL-1. Menadiol was rapidly biotransformed to menadione in blood. The formation rate constant (kf) of menadione in plasma was 0.589 +/- 0.246 min-1, and that of RBCs 1.520 +/- 1.345 min-1. Through this study the estimated menadione dosage needed to maintain a plasma level of 1 microgram mL-1 for anticancer purposes was 19.7 mg kg-1 every hour.

Elevation of interleukin-10 levels in malignant pleural effusion

STUDY OBJECTIVE

Human immunity has been found to have two major components, cellular and humoral immunity. T-helper type 1 (Th1) pathway favors cellular immunity and Th2 pathway favors humoral immunity. Early determination toward Th1 and Th2 cells in the immune response is dependent on the balance between interleukin-12 (IL-12), which favors Th1 responses, and IL-4, which favors Th2 responses. IL-2 and interferon-gamma (IFN-gamma) are produced in the Th1 pathway, and IL-4 and IL-10 are produced in the Th2 pathway. Lack of cellular immunity, IL-2, and IFN-gamma had been reported in malignant pleural effusions. However, to our knowledge, there are no previous reports on other cytokine components involving Th1 or Th2 pathway. The present study was designed to answer these questions.

DESIGN

Cytokine levels in peripheral blood and pleural fluid of 21 patients with malignant pleural effusion, including IL-4, IL-10, and IL-12, were analyzed with enzyme-linked immunosorbent assays. Lymphocyte subpopulations of peripheral blood and pleural effusion were also studied by using flow cytometry.

MEASUREMENTS AND RESULTS

The results showed a significant increase in IL-10 level as compared with blood samples. IL-4 and IL-12 were below minimal detectable concentrations both in the blood and the effusion. The ratio of pleural helper T cells was significantly higher than in the blood (p = 0.0002). The ratio of pleural natural killer (NK) cells was significantly lower than in the blood (p = 0.0001). The ratio of pleural suppressor T cells was lower than blood with borderline significance (p = 0.0522). No significant change in B-lymphocyte ratio between blood and pleural effusion was found (p = 0.2471). There was no correlation between difference in IL-10 level and lymphocyte subpopulation of pleural effusion and blood samples.

CONCLUSIONS

Helper T-cell subpopulations were increased while NK and suppressor T-cell subpopulations were decreased in malignant pleural effusions. The decrease in NK cell subpopulations with elevated IL-10 and minimal IL-12 concentration in neoplastic pleural effusion would suggest the usage of IL-12 or antibody of IL-10 to improve local cellular immunity. Further study is needed.