The effect of five different administration intervals on the pharmacokinetics (pk) of paclitaxel (PTX) and pegylated liposomal doxorubicin (PLD) association regimen

13012

Background: The PTX-PLD association is a promising schedule for recurrent head/neck cancer. Their pk behavior could be dependent not only on PTX excipient (polyethoxylated castor oil) interference, but even on different i.v. administration intervals between the two drugs. This study evaluated any possible administration interval-dependent pk interaction, when PLD infusion started 0, 1, 3, 12 or 24 h after PTX infusion end. Methods: 25 patients, affected by recurrent cisplatin pre-treated squamous cell head/neck cancer, were randomized to receive PTX 80 mg/m2 q1w and PLD 12.5 mg/m2 q2w at administration intervals of 0, 1, 3, 12 or 24 h. Pk parameters were evaluated during the first course by non-compartmental analysis, while statistical analysis was performed by non-parametric Kruskal Wallis test. Results: Median PK parameters are reported in the table . PTX pk profile is strongly affected by PLD administration. PTX total exposure is highly reduced, with a consequent increase in Cltot; this alteration is totally due to Kel modifications. On the other side, no statistically significant interactions affected PLD pk parameters. Some in vitro experiments indicate that PLD is able to partially absorb PTX, driving to PTX plasmatic concentration reduction, when PLD is administered at 0–1 h intervals. Conclusions: PLD liposomal components seem to be able to entrap PTX, therefore reducing PTX plasmatic concentrations; so, it is very important to choose the ideal administration interval. In order to avoid pk interaction, the i.v. administration interval between PTX and PLD had to be 3 h at least. For shorter intervals, patients could be underexposed to PTX, with lesser clinical efficacy.

[Table: see text]

No significant financial relationships to disclose.

Effects of reduced glutathione (GSH) on oxaliplatin pharmacokinetics (OXA pk) and on Pt-DNA adducts formation in advanced colorectal cancer patients treated by FOLFOX4 regimen

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Background: Neurotoxicity is a common OXA toxicity in FOLFOX4 regimen for patients with advanced colorectal cancer. Recently, Cascinu et al. (JCO 2002; 20: 3478–3483) provided evidence that GSH reduces the OXA-induced neurotoxicity, but GSH influence on the formation of Pt-DNA adducts still remains unknown. This study evaluated the effect of GSH addition on OXA pk and on Pt-DNA adducts formation Table of Contents Methods: 28 patients were given twelve FOLFOX4 courses and randomized to receive either GSH 1,500 mg/m2 or normal saline solution (placebo) before OXA iv infusion. OXA pk and Pt-DNA adducts formation were evaluated at courses 5, 9 and 12. Total and ultrafiltered platinum were analyzed by atomic adsorption, Pt-DNA adducts in leukocytes (as model for tumour tissue) by adsorptive stripping voltammetry. Pk analysis were done by non-compartmental analysis, statistical analysis by non-parametric Mann-Whitney test. Results: Median total and ultrafiltered platinum median Cmax and AUCtot values were comparable to previously reported ones, being higher in the placebo arm, due to a moderate reduction of platinum clearance. The formation of Pt-DNA adducts was more pronounced in GSH arm (median value 20.3 Pt atoms/106 nucleotides vs. 5.7 Pt atoms/106 nucleotides), even not statistically significant. Conclusions: The addition of GSH to FOLFOX4 regimen is able to reduce the OXA-induced neurotoxicity, without affecting either the OXA pk behaviour or the formation of Pt-DNA adducts, without modifying FOLFOX4 clinical efficacy.

[Table: see text]

No significant financial relationships to disclose.

Paclitaxel and pegylated liposomal doxorubicin in recurrent head/neck cancer: An unexpected administration interval-dependent pharmacokinetic interaction

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Background: Combination of paclitaxel (PTX) with pegylated liposomal doxorubicin (PLD) is an interesting opportunity for recurrent head/neck cancer treatment. Their pharmacokinetic (PK) behavior could be dependent not only on PTX excipient (polyethoxylated castor oil) interference, but also on different iv administration interval between the two drugs. The study endpoint was to evaluate any possible administration interval-dependent PK interaction, when PLD infusion start is delayed from 0 to 24 h after PTX infusion end. Methods: 24 patients affected by recurrent cisplatin pre-treated squamous cellhead/neck cancer were enrolled, receiving PTX 80 mg/m2 q 1w and PLD 12.5 mg/m2 q 2w for 6w/2w rest. Administration interval was 0 h at d1 (PTX-PLD 0) and 24 h at d15 (PTX-PLD 24). Blood sampling was performed at d1–15, PTX and PLD blood levels were analyzed by high performance liquid chromatography techniques, while PK parameters by non-compartmental analysis. Results: PTX PK parameters had large statistically significant differences (median/IQR, PTX-PLD 0 vs. PTX-PLD 24, Mann-Whitney test): Cmax 261/219–531 vs. 407/250–1473 ng/ml p=0.142, AUC 869/688–1331 vs. 3361/969–7853 ng*h/ml p=0.013, Kel 0.39/0.26–0.57 vs. 0.11/0.02–0.26 h⁁−1 p=0.001, Cl 153/89–198 vs. 41/17–138 l/h p=0.013. Similarly, PLD Cmax and AUC were higher in PTX-PLD 24 (Cmax 5.1/3.3–8.1 vs. 6.8/5.3–7.8 mg/l p=0.043, AUC 341/104–1472 vs. 603/106–1006 mg*h/l p=1.000). The overall response rate was 37.5%, including 1 CR (4%); median response duration was 5.5 months (range, 2–16), median overall survival 10 months (range, 2–25+). Conclusions: This exploratory study, having a favourable palliative role in heavily pre-treated patients, showed that PTX PK profile is unexpectedly affected by a different administration interval. In PTX-PLD 0, PTX AUC is fourfold reduced, with a similar increase in Cl, totally due to Kel alteration: therefore, patients could be underexposed to PTX. PLD PK behavior confirmed previous studies results, in which PTX modified PLD disposition, prolonging the duration of its elimination phase and increasing total body exposure to PLD.

No significant financial relationships to disclose.

Bisphosphonates (BP)-related osteonecrosis of the jaw (ONJ): Clinical experience of the “Rete Oncologica di Piemonte e Valle d’Aosta” network

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Background: ONJ have been recently reported in patients (pts) treated with BP, especially Pamidronate (P) and Zoledronic Acid (Z). Measures of screening, treatment, and prevention have been planned in our regional oncology network. Methods: We evaluated dental history of pts previously treated with BP and/or under treatment in 2005, finding 60 cases of ONJ, but a large number of suspected cases are under investigation/observation. Full details of oncologic and dental history have been collected so far of 43 pts. Results: Pts characteristics: sex: 14/29 M/F; median age 66 years (range 45–81); tumour: 24 breast cancer, 7 prostate cancer; 12 myeloma. BP treatment: 5 P, 14 P changed to Z, 24 Z; median number of infusions: 22 of P (range 12–52), 18 of Z (range 7–43). Site of ONJ: 33 (77%) in mandible, 9 (21%) in maxilla, 1 (2%) in both. Presenting findings included exposed bone or infections (95%), pain, mobile teeth, soft-tissue swelling, nonhealing fistulas . Dental comorbidities were present in all pts and 92 % had precipitating events, as teeth extraction, periodontal surgery, dental implants, or traumatic use of dentures. Conclusions: Our oncology network planned: a) review of all pts treated with BP since 2000, to obtain real estimates of frequency and of possible risk factors; b) screening of all pts under treatment with BP, with panoramic X-rays and maxillofacial surgeon visit (w/o CT or MR scan in selected cases); c) careful evaluation of pts candidate to be treated with BP (as above), with pretherapy dental care if necessary; d) prospective evaluation of incidence in future, after pretherapy dental care policy and avoiding (as possible) surgical dental procedures during BP treatment; e) prospective trials of evaluation of palliative treatment of ONJ and related complications in affected pts (chlorohexidine mouthwashes, antibiotics, metronidazole, hyperbaric oxygen, etc.).

No significant financial relationships to disclose.

Hepatic intra-arterial infusion (HAI) for liver metastases in pretreated metastatic breast cancer patients

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Background: Breast cancer patients (pts) with liver metastases have a poor prognosis. HAI has been frequently used for liver metastases from colorectal cancer, with better response and possibly survival than with intravenous administration. We evaluated the activity of HAI in pretreated breast cancer patients with liver metastases only. Methods: From December 2001 to October 2005 thirty patients previously treated with anthracyclines, taxanes and vinorelbine were enrolled. Median age 58 years (44–68) and median PS 1 (0–2). Eight patients (27%) had 5 or more liver nodes, seventeen (57%) had 5 to 10 metastases and five (16%) more than 10 nodes. Eighteen patients received 2 previous lines of chemotherapy (67 %), eleven 3 lines (30%) and one (3%) three lines and one cicle of high dose chemotherapy followed by ABMT. Seventeen pts received prior hormonotherapy. Two patients had been submitted to liver metastasectomy. Patients underwent percutaneous implantation of an arterial hepatic port-a-cath. HAI regimen administered on days 1–3 every 4 weeks, consisted of cisplatin 10 mg/sqm bid, mitomycin-C 1 mg/sqm bid, 5-fluorouracil 1000 mg/sqm 72 hours continuous infusion. Results: On an intent-to-treat analysis, four pts had CR (13%) with a duration of responses of 12, 18, 24 and 36 months. Fourteen pts (47%) had PR with a median duration of 7 months. Six patients had stable disease (20%) with a median duration of 3 months. Six patients (20%) had PD. Responses were more frequent in patients with PS 0 (10/13, 77%) and in patients treated with 2 previous lines of chemotherapy (13/18, 72%) than 3 or more (5/12, 42%). Median survival for the whole population was 11.8 months (5–44; 95% CI, 10.0 to 13.9). For pts with CR or PR and those who had SD, median survival was 16 months (10–44) and 10 months (8–18), respectively. No treatment-related death occurred. Grade 3–4 neutropenia in 7 % of pts. Grade 4 thrombocytopenia and grade 3 anemia 3 % of patients. Most frequent G3 non-haematologic toxicities were nausea and vomiting (3%) and alopecia (3%). We observed 2 dislodgements of catheter (7%), 3 cases (10%) of gastroduodenal ulcers, neither cases of thrombosis, nor sclerosing cholangitis. Conclusions: This intra-arterial regimen seems active in this patient population, with a very good safety profile.

No significant financial relationships to disclose.

Current role of chemotherapy in exclusive and integrated treatment of malignant tumours of salivary glands

In the management of salivary glands carcinomas, surgery is the treatment of choice. Post-operative radiotherapy is indicated in cases with high risk of loco-regional relapse. Radiotherapy is also standard treatment in cases that are inoperable at onset. Chemotherapy plays a palliative role. Today, the integration between radiotherapy and chemotherapy, which provides increased local control, represents a significant step forward. This integration is important since 5-year survival in tumours with high grade histology is approximately 50%. Overall incidence of metastases is approximately 25%. Primary locations of metastases are lungs, liver, bone, central nervous system and other organs. In cases of metastatic disease, chemotherapy plays only a palliative role.

Ifosfamide in the treatment of head and neck cancer

Ifosfamide (IFO) has demonstrated activity in recurrent/metastatic squamous cell head and neck carcinoma with an overall response rate of 24-26%. Better results are reported for chemotherapy-naive patients; in heavily pretreated cases results are poor and toxicity unacceptable. Cisplatin-IFO combination in stage III-IV is probably more active than IFO alone (ORR = 60-72 vs. 50%) but is indicated in patients who desire aggressive treatment and are physically able to tolerate the drugs. The carboplatin-IFO scheme is better tolerated than the cisplatin-IFO regimen with superimposable clinical results (ORR = 69%; CR = 15%). Carboplatin-taxol-IFO is one of the most active regimens in recurrent (ORR = 59%; CR = 17%) and in locally advanced (ORR = 81%; CR = 31%) head and neck cancer. Its role in the multidisciplinary treatment of advanced head and neck cancer is under investigation. In recurrent/metastatic undifferentiated nasopharygeal carcinoma, IFO combinations have proven to be effective as first- and second-line treatment.

Oropharyngeal carcinoma during pregnancy: clinical and psycho-oncological aspects

Cancer is uncommon in pregnancy, occurring in approximately one out of 1000 pregnancies, although it has been noted that one out of 118 women diagnosed with cancer is pregnant at the time of diagnosis. In the last 10 years, two oropharyngeal carcinomas, (1 squamous cell carcinoma and 1 adenoid cystic carcinoma) which developed during pregnancy, have been diagnosed and treated in our Department. No cases of oropharyngeal cancer, during pregnancy, have so far been reported in the literature with the exception of one case of oral cancer. This report focuses not only on the clinical history but also the management of oropharyngeal carcinoma during pregnancy, in terms of choice and timing of treatment. A scrupulous psycho-oncological analysis was also carried out in order to throw further light on psychological repercussions of head and neck cancer in the pregnant woman.

Update and perspectives on non-surgical treatment of salivary gland malignancies

Surgery is the treatment of choice for major and minor salivary gland malignancies. Herein, the role of radiation and medical treatment in the multidisciplinary management of salivary gland tumours is discussed. Neutron irradiation and hyperfractionated external beam mega voltage irradiation improve local control. Combination of three dimensional conformal radiotherapy and intensive-modulated radiation therapy provide better local tumour delineation, better field design to encompass the tumour allowing dose escalation to target while sparing the surrounding normal tissue. Cisplatin-based chemotherapy provides a response rate > or = 45%, in a palliative setting. Concomitant chemo-radiotherapy could improve local control. Recent studies evaluated the expression of molecular targets in salivary gland carcinomas (c-kit = 53-90%, EGFR = 25-85%, c-erb-B2 = 11-58%, p53 = 11-67%, H ras = 18%); these targets are very important since new targeted drugs are now available. Anti-androgen therapy might have a role in the management of patients with ductal carcinoma. These new targeted drugs could be integrated with chemotherapy and radiotherapy in the treatment of locally advanced/metastatic salivary gland malignancies.

HIV/HCV co-infection: natural history

HIV and HCV share common transmission pathways, but HCV is more efficiently transmitted through blood than with sexual exposure. Thus HCV coinfection is frequent in HIV seropositives, mainly in those with history of injection drug use and/or transfusion. HIV coinfection increases HCV replication rate, the rate of HCV vertical transmission and accelerates the course of hepatitis C towards cirrhosis and hepatocellular carcinoma. The evidence of an effect of HCV on HIV disease progression is less convincing. The results of several studies suggest that HCV coinfection does not hasten the progression of HIV infection towards AIDS. However two recent studies showed that HCV coinfection is independently associated with a lower restoration of CD4 counts during combination antiretroviral treatment. However this finding should be confirmed by additional studies.

HIV-1 multi-dideoxynucleoside resistance mutation (Q151M): prevalence, associated resistance mutations and response to antiretroviral salvage treatment

The prevalence and clinical implications of the Q151M multidrug-resistance mutation gene (mut) to antiretroviral drugs in the HIV reverse transcriptase (RT) gene have not yet been fully explained. In the present study three out of 350 (0.85%) of HIV-infected patients who underwent a drug-resistance genotyping assay because of therapeutic failure showed the Q151M mut. All these patients had been previously treated with zidovudine in association with didanosine. One such patient failed to respond to all salvage regimens tried and was shown to harbour some of the characteristic mut associated with Q151M (77L and 116Y). Another two patients partially responded to salvage regimens, both virologically and immunologically, and harboured the M184V mut in the RT gene. The prevalence of Q151M mut in our group was less (0.85%) than in other studies, which ranged from 2 to 19%. The M184V mut seemed to confer some viro-immunological benefit when associated with the Q151M mutation, compared with the latter alone.

Clinical and pharmacokinetic data of a docetaxel-epirubicin combination in metastatic breast cancer

In order to explore activity and pharmacokinetic data of a docetaxel-epirubicin combination we analyzed a population of 60 metastatic breast cancer patients. All the patients had an ECOG performance status < 3; 41 patients (68%) had visceral metastases as dominant site of disease, including 33% with liver metastases. Three or more involved organs were present in 43% of patients; 35% had received prior hormonotherapy; 10% for metastatic disease. Twenty-five patients (42%) had received prior adjuvant chemotherapy; 15% a CAF regimen. Twenty per cent of patients had less than 12 months disease-free interval. Docetaxel and epirubicin were both given at a dose of 75 mg/m2 i.v. d. 1 every 3 weeks. After a median of six cycles we had 5 CR (8.3%), 40 PR (66.6%), 7 NC (11.6%), and 8 PD (13.3%). Response rates in patients with visceral and liver metastases were 78% and 55% respectively. Premenopausal status, < 1 year disease free survival and > 3 metastatic sites were associated with a lower response rate. After a median follow-up of 19 months (12-36), median disease-free survival is 11 months and median overall survival has not been reached. Grade 4 neutropenia was observed in 75% of courses but with febrile neutropenia in 6.2% of courses only. Non-hematologic toxicity wasn't clinically important. A NYHA class III reversible cardiac failure was observed in one patient (1.6%). The pharmacokinetic evaluation in 16 patients has shown that docetaxel transiently interfered with epirubicin plasma level when docetaxel was administered 1 h after epirubicin.

A sequence-dependent combination of docetaxel and vinorelbine: pharmacokinetic interactions

We studied possible pharmacokinetic interactions between docetaxel (DTX) and vinorelbine (VNR) in patients affected by different types of cancer. Patients with metastatic breast cancer or recurrent head and neck cancer received the following schedules: Protocol A: 11 patients were i.v. infused for 1 h with DTX (80 mg/m2) at once, followed by VNR (25 mg/m2) as slow i.v. bolus; Protocol B: VNR (25 mg/m2) as a slow 10 min i.v. bolus was administered to 12 patients, immediately followed by 1 h i.v. infusion of DTX (80 mg/m2). In both schedules, VNR and DTX plasma concentrations versus time were analysed by HPLC obtaining the corresponding non-compartmental pharmacokinetic parameters. VNR appeared pharmacokinetically affected by the sequential administration of DTX, since with protocol B, Cmax and AUC were significantly higher and clearance lower than in protocol A. Moreover, a significant increase in the VNR plasma level was observed in correspondence with the peak plasma level of DTX. By contrast, Cmax, AUC and clearance of DTX did not vary in the two protocols. Also the number of neutrophils at nadir on day 8 of treatment varied significantly in the two schedules. In conclusion we observed altered pharmacokinetic parameters between protocol A (DTX, VNR) and protocol B (VNR/DTX). In particular, patients following protocol B seemed to be exposed to higher VNR plasma concentration and to higher haematological toxicity.

A preliminary pharmacokinetic study of docetaxel, carboplatin and concurrent radiotherapy for regionally advanced squamous cell carcinoma of the head and neck

This work investigates the pharmacokinetics and toxicity resulting from the concomitant use of low dose carboplatin (CBCA)/docetaxel (DTX) plus concurrent radiotherapy in patients with head and neck cancer. The study comprised 11 patients with stage III-IV head and neck cancer. All patients received 2 Gy radiotherapy daily, 5 fractions per week, up to a planned total of 70 Gy over 7 weeks. CBCA (AUC 0.4 mg/ml, min/day) was also administrated as 20 min i.v. infusion, starting 1 day before the first radiotherapy fraction. CBCA was administered for 5 consecutive days every 2 weeks (weeks 1, 3, 5 and 7). DTX 30 mg/m2 (1 h i.v. infusion) was given as a single dose on days 10, 24 and 38. CBCA on day 1 and DTX on day 10 were analysed to determine the concentration-time curves during the first 24 h. CBCA Cmax and Cmin in 2-5 days and on day 15 and 29, as well as total plasma platinum on days 2, 3, 4, 5, 29 and 43 were also assayed. By calculating the non-compartmental pharmacokinetic parameters of the two drugs from the available plasma concentrations we found in the first week values similar to those reported in the literature as single agents. In contrast, during subsequent weeks (weeks 3 and 5), a significant and progressive increase of platinum levels was observed. So, it could be assumed that after 2 weeks of CBCA and DTX treatment a bias in dose calculation occurred because the linear relationship between creatinine clearance (used to calculate the expected AUC through the Calvert formula) and CBCA clearance was no longer observed.