Phase 2 trial of liposomal doxorubicin (40 mg/m(2)) in platinum/paclitaxel-refractory ovarian and fallopian tube cancers and primary carcinoma of the peritoneum

BACKGROUND

Several studies have demonstrated liposomal doxorubicin (Doxil) to be an active antineoplastic agent in platinum-resistant ovarian cancer, with dose limiting toxicity of the standard dosing regimen (50 mg/m(2) q 4 weeks) being severe erythrodysesthesia ("hand-foot syndrome") and stomatitis. We wished to develop a more tolerable liposomal doxorubicin treatment regimen and document its level of activity in a well-defined patient population with platinum/paclitaxel-refractory disease.

METHODS AND MATERIALS

Patients with ovarian or fallopian tube cancers or primary peritoneal carcinoma with platinum/paclitaxel-refractory disease (stable or progressive disease following treatment with these agents or previous objective response <3 months in duration) were treated with liposomal doxorubicin at a dose of 40 mg/m(2) q 4 weeks.

RESULTS

A total of 49 patients (median age: 60; range 41-81) entered this phase 2 trial. The median number of prior regimens was 2 (range: 1-6). Six (12%) and 4 (8%) patients experienced grade 2 hand-foot syndrome and stomatitis, respectively (no episodes of grade 3). One patient developed grade 3 diarrhea requiring hospitalization for hydration. Six (12%) individuals required dose reductions. The median number of courses of liposomal doxorubicin administered on this protocol was 2 (range: 1-12). Four of 44 patients (9%) evaluable for response exhibited objective and subjective evidence of an antineoplastic effect of therapy.

CONCLUSION

This modified liposomal doxorubicin regimen results in less toxicity (stomatitis, hand-foot syndrome) than the standard FDA-approved dose schedule. Definite, although limited, antineoplastic activity is observed in patients with well-defined platinum- and paclitaxel-refractory ovarian cancer.

Inhibition of p53 function prevents renin-angiotensin system activation and stretch-mediated myocyte apoptosis

To determine whether stretch-induced activation of p53 is necessary for the up-regulation of the local renin-angiotensin system and angiotensin II (Ang II)-induced apoptosis, ventricular myocytes were infected with an adenoviral vector carrying mutated p53, Adp53m, before 12 hours of stretch. Noninfected myocytes and myocytes infected with AdLacZ served as controls. Stretching of Adp53m-infected myocytes prevented stimulation of p53 function that conditioned the expression of p53-dependent genes; quantity of angiotensinogen (Aogen), AT(1), and Bax decreased, whereas Bcl-2 increased. Ang II generation was not enhanced by stretch. Conversely, stretch produced opposite changes in noninfected and AdLacZ-infected myocytes: Aogen increased twofold, AT(1) increased 2. 1-fold, Bax increased 2.5-fold, and Ang II increased 2.4-fold. These responses were coupled with 4.5-fold up-regulation of wild-type p53. Stretch elicited comparable adaptations in p53-independent genes, in the presence or absence of mutated p53; renin increased threefold, angiotensin-converting enzyme increased ninefold, and AT(2) increased 1.7-fold. Infection with Adp53m inhibited myocyte apoptosis after stretch. Conversely, stretch increased apoptosis by 6.2-fold in myocytes with elevated endogenous wild-type p53. Thus, a competitor of p53 function interfered with both stretch-induced Ang II formation and apoptosis, indicating that p53 is a major modulator of myocyte renin-angiotensin system and cell survival after mechanical deformation.

Effects of inspiratory flow on diaphragmatic motor output in normal subjects

Increasing inspiratory flow (V) has been shown to shorten neural inspiratory time (TI(n)) in normal subjects breathing on a mechanical ventilator, but the effect of V on respiratory motor output before inspiratory termination has not previously been studied in humans. While breathing spontaneously on a mechanical ventilator, eight normal subjects were intermittently exposed to 200-ms-duration positive pressure pulses of different amplitudes at the onset of inspiration. Based on the increase in V above control breaths (DeltaV), trials were grouped into small, medium, and large groups (mean DeltaV: 0.51, 1.11, and 1.65 l/s, respectively). We measured TI(n), transdiaphragmatic pressure (Pdi), and electrical activity (electromyogram) of the diaphragm (EMGdi). Transient increases in V caused shortening of TI(n) from 1.34 to 1.10 (not significant), 1.55 to 1.11 (P < 0.005), and 1.58 to 1.17 s (P < 0. 005) in the small, medium, and large DeltaV groups, respectively. EMGdi measured at end TI(n) of the pulse breaths was 131 (P < 0.05), 142, and 155% (P < 0.05) of the EMGdi of the control breaths at an identical time point in the small, medium, and large trials, respectively. The latency of the excitation was 126 +/- 42 (SD) ms, consistent with a reflex effect. Increasing V had two countervailing effects on Pdi: 1) a depressant mechanical effect due primarily to the force-length (11.2 cmH(2)O/l) relation of the diaphragm, and 2) an increase in diaphragm activation. For the eight subjects, mean peak Pdi did not change significantly, but there was significant intersubject variability, reflecting variability in the strength of the excitation reflex. We conclude that increasing inspiratory V causes a graded facilitation of EMGdi, which serves to counteract the negative effect of the force-length relation on Pdi.

The antiemetic efficacy of oral ondansetron plus intravenous dexamethasone in patients with gynecologic malignancies receiving carboplatin-based chemotherapy

PURPOSE

The purpose of this study was to develop a cost-effective prophylactic antiemetic regimen for the prevention of carboplatin-induced emesis.

METHODS

Patients being treated in the Gynecologic Cancer Program of the Cleveland Clinic Taussig Cancer Center with a carboplatin-based chemotherapy regimen received a prophylactic antiemetic program consisting of a single dose of oral ondansetron (16 mg) plus intravenous dexamethasone (20 mg) approximately 30 min prior to chemotherapy. Evaluation of the effectiveness of this antiemetic regimen was performed during a single treatment course.

RESULTS

A total of 27 patients (median age, 62; range, 41-83) participated in this phase 2 trial. Three patients received single-agent carboplatin, and 24 were treated with either a carboplatin/paclitaxel or carboplatin/docetaxel regimen. The carboplatin AUC dosing level was 4, 5, or 6 in 6, 5, and 16 individuals, respectively. No patient developed vomiting; 2 (7%) individuals experienced nausea during the 24-h period following chemotherapy administration.

CONCLUSION

The combination of a single dose of oral ondansetron (16 mg) plus intravenous dexamethasone (20 mg) is an effective prophylactic antiemetic regimen for patients receiving carboplatin-based chemotherapy.

Declining CA-125 in an ovarian cancer patient with progression of measurable disease: a rational hypothesis for discordant results

OBJECTIVES

While a declining CA-125 has been demonstrated to be a useful indicator of response to chemotherapy in ovarian cancer, occasional patients will demonstrate discordant results between the level of this antigen and changes in the size of measurable tumor masses.

CASE

The patient was seen in the Gynecologic Oncology Program of the Cleveland Clinic Taussig Cancer Center.

RESULTS

This patient exhibited a "major response" by CA-125 criteria, significant shrinkage of multiple peritoneal and perirectal implants, but clear progression of a pelvic side wall mass. The discordant results in this case are likely an example of a "mixed response" to the chemotherapy regimen, with the declining CA-125 corresponding to shrinkage of the responding tumor cell population.

CONCLUSION

An evaluation of changes in both the serum CA-125 level and measurable masses may represent a more complete analysis of the status of disease in an individual with ovarian cancer.

Experience with prophylactic oral ciprofloxacin in gynecological cancer patients developing severe chemotherapy-induced neutropenia

The development of significant neutropenia is a relatively frequent complication of cytotoxic chemotherapy of malignant disease. In an effort to develop a cost-effective management strategy to prevent serious infectious events associated with severe chemotherapy-induced neutropenia, patients treated in the Gynecological Oncology Program of the Cleveland Clinic Taussig Cancer Center have been administered ciprofloxacin, a potent broad-spectrum antibiotic, 500 mg orally twice a day, beginning at the time of documentation of grade 4 neutropenia. The antibiotic is continued until granulocyte recovery. A total of 44 patients (57 treatment courses) have been treated in this manner. There have been no complications of therapy and no episodes of subsequent infections due to ciprofloxacin-resistant organisms. Two patients required hospital admission following the development of significant fever, despite the use of ciprofloxacin. While these results are encouraging and suggest that the use of prophylactic ciprofloxacin is a highly cost-effective management approach in this setting, randomized controlled trials are necessary to define the ultimate benefit of this clinical strategy.

Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations

There is wide variation in the management of patients with mechanical prosthetic valves who are taking anticoagulants and who require non-cardiac surgery. In this paper, we outline a pragmatic, practical approach to the adjustment of anticoagulation in relation to both the degrees of surgical trauma during oral and maxillofacial surgery and the risk of thromboembolism associated with the prosthetic valve. For minor surgery, no adjustment of anticoagulation is undertaken if the International Normalized Ratio is less than 4.0, if local haemostatic methods and tranexamic acid mouthwashes are used. For major surgery, warfarin is stopped preoperatively and low-molecular-weight heparin is used. For emergency surgery, partial reversal of anticoagulation with low-dose parenteral vitamin K is obtained.

The adherence to guidelines for facial radiography in an Accident & Emergency Department

OBJECTIVES

To evaluate the degree of adherence to guidelines for facial radiography.

METHODS

A retrospective review of 1538 facial radiographs from a consecutive series of 414 patients attending the Accident & Emergency Department of the North Staffordshire Hospital with suspected facial injuries over a 6 month period was undertaken. Information on age, sex and aetiology of injury was recorded along with the type of view and total number of films taken. The results were compared with guidelines from the Department of Oral & Maxillofacial Surgery.

RESULTS

Almost one-half of all injuries were due to assault. There was general adherence to the guidelines in terms of the number of films taken for mid-face and mandibular fractures.

CONCLUSIONS

There was a good adherence to the guidelines in terms of the number of films taken for midface and mandibular fractures. However, a small number of patients were still being exposed to a high radiation dose where combinations of skull and facial views were taken. Guidelines need to be subjected to regular audit.

The human papillomavirus (HPV) 16 E2 protein induces apoptosis in the absence of other HPV proteins and via a p53-dependent pathway

The human papillomavirus (HPV) E2 protein regulates viral gene expression and is also required for viral replication. HPV-transformed cells often contain chromosomally integrated copies of the HPV genome in which the viral E2 gene is disrupted. We have shown previously that re-expression of the HPV 16 E2 protein in HPV 16-transformed cells results in cell death via apoptosis. Here we show that the HPV 16 E2 protein can induce apoptosis in both HPV-transformed and non-HPV-transformed cell lines. E2-induced apoptosis is abrogated by a trans-dominant negative mutant of p53 or by overexpression of the HPV 16 E6 protein, but is increased by overexpression of wild-type p53. We show that mutations that block the DNA binding activity of E2 do not impair the ability of this protein to induce apoptosis. In contrast, removal of both N-terminal domains from the E2 dimer completely blocks E2-induced cell death. Heterodimers formed between wild-type E2 and N-terminally deleted E2 proteins also fail to induce cell death. Our data suggest that neither the DNA binding activity of E2 nor other HPV proteins are required for the induction of apoptosis by E2 and that E2-induced cell death occurs via a p53-dependent pathway.

Paclitaxel-associated hypersensitivity reactions: experience of the gynecologic oncology program of the Cleveland Clinic Cancer Center

PURPOSE

: This study expands the existing limited data as to whether patients developing clinically significant paclitaxel-induced hypersensitivity reactions can continue to be treated with this important antineoplastic agent and how such retreatment might be undertaken.

PATIENTS AND METHODS

More than 450 patients received paclitaxel, either as a single agent or in a combination regimen, for a female pelvic malignancy in the Gynecologic Oncology Program of the Cleveland Clinic Cancer Center from January 1995 through December 1998.

RESULTS

Of the more than 450 patients, 44 (approximately 9%) developed at least one episode of a clinically relevant hypersensitivity reaction to the cytotoxic drug. All 43 individuals (plus an additional four patients referred to our center after having previously experienced a severe paclitaxel-associated hypersensitivity reaction at another institution) who were retreated with paclitaxel were ultimately able to receive the agent. Five patients required treatment with a standardized desensitization regimen, developed by our group, to successfully receive paclitaxel.

DISCUSSION

On the basis of this large single-institution study of paclitaxel-associated hypersensitivity reactions, we conclude that with appropriate precautions essentially all individuals experiencing these reactions can be safely treated with this agent.

Serum CA-125 as a marker of disease activity in uterine papillary serous carcinoma

Papillary serous carcinoma of the endometrium exhibits many clinical features of ovarian cancer, including a high metastatic potential and response to platinum-based chemotherapy. We investigated the clinical utility of the serum CA-125 antigen level, an established marker of response or progression in ovarian cancer, to serve as a indicator of these events in patients with this highly malignant subtype of endometrial cancer. Of 21 individuals with this cancer treated in our program from 11/91 to 6/97, 16 had baseline CA-125 determinations prior to the administration of chemotherapy, of whom 13 were elevated above the normal range. Of these 13 patients, 8 (57%) experienced either a major reduction or normalization of CA-125 levels following therapy, consistent with their clinical course at that point in time. Similarly, of 11 patients who ultimately relapsed, 8 (73%) were found to have a rise in the CA-125 antigen level which closely corresponded to, or proceeded, clinical relapse. A single patient was demonstrated to have disease progression with a declining level of CA-125. We conclude the serum CA-125 antigen level is a useful indicator of disease response or progression in individuals with papillary serous carcinoma of the endometrium.

The role of operator experience in fine needle aspiration cytology of head and neck masses

Fine needle aspiration cytology (FNAC) was performed on 95 patients presenting with a mass in the head and neck region, where a subsequent surgical pathological diagnosis and adequate documentation were available. In this group, 70% of the samples were found to be of diagnostic yield. Of these, the number of true-positives was 27, and true-negatives 35. This gives a sensitivity and specificity of 90% and 97%, respectively. The accuracy was 100% when performed by a consultant and 91% when performed by junior staff. These sensitivity and specificity levels compare favourably with those reported in other studies using FNAC in head and neck lesions. Greater experience of the operator appears to improve the accuracy rate. FNAC is a useful diagnostic tool for head and neck tumours, as shown by the high specificity and sensitivity rates in this study.

Using cross-cultural input to adapt the Functional Assessment of Chronic Illness Therapy (FACIT) scales

Cross-cultural quality of life measurement and psychosocial assessment in oncology have become reality with the translation and international validation of quality of life questionnaires. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System, under development since 1987, produced its 4th version in November 1997. The FACIT system includes the Functional Assessment of Cancer Therapy (FACT), the Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) and the Functional Assessment of Multiple Sclerosis (FAMS). These questionnaires were developed in North America and, to date, many have been translated into almost 30 languages. One of the strengths of this ongoing translation project is its use of input from patients, linguists, psychologists and physicians internationally to assure that the wording of Version 4 is more cross-culturally relevant and more sensitive to measuring the psychosocial impact of illness in cultures outside the United States. Statistical analysis, aggregation of patient comments, and comments from linguists and users of the translated versions are used as needed to revise item wording to ensure clarity and consistency across languages. A 'decentering' approach is also used to adapt the source (English language) document in response to problems encountered during its translation.

Nefazadone-induced acute dystonic reaction

A 53-y-o patient presented approximately 2 h after taking her first dose of nefazadone. Chief complaint was lip smacking with hand and arm gesturing. The patient also took 25 mg meclizine which she had used before with no adverse effects. Diphenhydramine followed by benztropine led to resolution of symptoms within 1 h. Patient subsequently used meclizine with no untoward reactions. Nefazadone should be added to the list of agents that cause acute dystonic reactions.

Anchoring the detached temporalis muscle in craniofacial surgery

The temporalis muscle is often detached to enable craniofacial tumour and trauma access surgery. Failure to carefully handle and reattach the muscle often leads to a cosmetic and functional deformity. The authors discuss the principles of elevation of the whole temporal muscle within its surrounding fascia to reduce atrophy. The temporalis muscle is then reattached to its point of origin, using suspensory absorbable sutures attached to 3 mm titanium microscrews placed inferior to the limits of the muscle, to make them non-palpable. The aim is to reduce the postoperative temporal hollowing often seen when these principles are not observed. A series of cases using this technique are reported.

An effective and more convenient drug regimen for prophylaxis against paclitaxel-associated hypersensitivity reactions

"Standard" prophylaxis for paclitaxel-associated hypersensitivity reactions has included the systemic administration of H1 and H2 histamine antagonists, along with oral dexamethasone taken both the night prior to, and the morning of, each paclitaxel treatment. To improve patient convenience and compliance with steroid delivery, the Gynecologic Cancer Program of the Cleveland Clinic Foundation has treated patients with an all-intravenous prophylaxis regimen (diphenhydramine 50 mg, famotidine 20 mg, dexamethasone 20 mg) given 30 min prior to paclitaxel (without any earlier oral steroid dosing). To date, we have treated more than 200 patients who received all courses of paclitaxel with this simplified prophylactic regimen, of whom approximately 9% developed hypersensitivity reactions (major or minor). This incidence is comparable to our previously reported experience with hypersensitivity reactions in a similar number of patients receiving the standard prophylaxis (including oral dexamethasone) with their initial course of paclitaxel, and subsequent cycles employing this all-intravenous program. We conclude that this "modified" regimen for paclitaxel-associated hypersensitivity reactions (with all drugs administered approximately 30 min prior to the delivery of paclitaxel) is as effective as, and more convenient than, the standard regimen, and avoids delaying chemotherapy as a result of a patient failing to remember to take one or both oral steroid doses.

Response of ventilator-dependent patients to different levels of pressure support and proportional assist

The ventilator's response to the patient's effort is quite different in proportional assist ventilation (PAV) and pressure support ventilation (PSV). We wished to determine whether this results in different ventilatory and breathing pattern responses to alterations in level of support and, if so, whether there are any gas exchange consequences. Fourteen patients were studied. Average elastance (E) was 22.8 (range, 14 -36) cm H2O/L and average resistance (R) was 15. 7 (range, 9-21) cm H2O/L/s. The highest PSV support (PSVmax) was that associated with a tidal volume (VT) of 10 ml/kg (20.4 +/- 3.2 cm H2O), and the highest level of PAV assist (PAVmax) was 78 +/- 7% of E and 76 +/- 7% of R. Level of assist was decreased in steps to the lowest tolerable level (PSVmin, PAVmin). Minute ventilation, VT, ventilator rate (RRvent), and arterial gas tensions were measured at each level. We also determined the patient's respiratory rate (RRpat) by adding the number of ineffective efforts (DeltaRR) to RRvent. There was no difference between PSVmin and PAVmin in any of the variables. At PSVmax, VT was significantly higher (0.90 +/- 0.30 versus 0.51 +/- 0.16 L) and RRvent was significantly lower (13.2 +/- 3.9 versus 27.6 +/- 10.5 min-1) than at PAVmax. The difference in RRvent was largely related to a progressive increase in ineffective efforts on PSV as level increased (DeltaRR 12.1 +/- 10.1 vs 1.4 +/- 2.1 with PAVmax); there was no significant difference in RRpat. The differences in breathing pattern had no consequence on arterial blood gas tensions. We conclude that substantial differences in breathing pattern may occur between PSV and PAV and that these are largely artifactual and related to different patient-ventilator interactions.

Persistent chemosensitivity to platinum and/or paclitaxel in metastatic endometrial cancer

It has long been recognized that individuals with ovarian cancer who initially respond to a platinum-containing chemotherapeutic regimen may exhibt a second response to platinum (cisplatin or carboplatin) at the time of recurrence. In this report, we describe three individuals with metastatic endometrial cancer who demonstrated secondary responses to platinum/paclitaxel-based regimens. Endometrial cancer should be added to the list of malignancies for which platinum and/or paclitaxel are considered as second-line treatment options in patients previously responding to the agents.

Clinical features of hypersensitivity reactions to carboplatin

PURPOSE

To characterize the clinical features of carboplatin-associated hypersensitivity reactions.

PATIENTS

Patients with gynecologic malignancies treated at the Cleveland Clinic Foundation from June 1995 through July 1998 who experienced a carboplatin-associated hypersensitivity reaction were the subjects of this evaluation.

RESULTS

Of the 205 patients treated with carboplatin during this time period, 24 (12%) developed a carboplatin hypersensitivity reaction. The median number of platinum (carboplatin plus cisplatin) courses for the first episode was eight (range, six to 21). Only three patients (13%) developed this toxicity during their initial chemotherapy regimen, with the remainder experiencing a reaction during their second (n = 15) or third (n = 6) carboplatin treatment program for recurrent disease. Thirteen patients (54%) developed at least moderately severe symptoms (diffuse erythroderma, tachycardia, chest tightness, wheezing, facial swelling, dyspnea, hypertension, or hypotension). In approximately one half of patients, the reaction developed after more than 50% of the carboplatin had been infused. Only one of three patients was successfully treated with the agent upon rechallenge.

CONCLUSION

Carboplatin hypersensitivity reactions develop in patients who have been extensively pretreated with the agent. The clinical features are highly variable, but they are sufficiently different from those noted after the administration of paclitaxel that it should not be difficult to distinguish between reactions to the two agents. As carboplatin is increasingly used as initial and second-line chemotherapy of ovarian cancer and other malignancies, it can be anticipated that hypersensitivity reactions to the drug will become a more common and difficult clinical management issue.

Use of subcutaneous terbutaline to reverse peripheral ischemia

Four cases are presented, one involving extravasation of a dopamine and dobutamine solution in the arm and three involving accidental digital injection of epinephrine into the thumb. In three cases, local infiltration of terbutaline resulted in dramatic reversal of vasospasm and ischemia. In the remaining case the use of terbutaline resulted in minor clinical improvement. These are the first reported cases involving the successful treatment of peripheral ischemia with subcutaneous terbutaline. This experience suggests that terbutaline may be an effective alternative for treatment of peripheral ischemia when phentolamine is not available.

Use of low-dose oral prednisone to prevent paclitaxel-induced arthralgias and myalgias

OBJECTIVES

The aim of this study was to examine the clinical utility of low-dose oral prednisone in preventing severe paclitaxel-associated arthralgias and myalgias.

METHODS

Patients treated with paclitaxel in the gynecologic oncology program of the Cleveland Clinic Foundation who developed arthralgias/myalgias which were uncontrolled through the use of nonsteroidal anti-inflammatory medications received low-dose oral prednisone (10 mg B.I.D. starting 24 h after the completion of chemotherapy and continuing for a total of 5 days) with their next paclitaxel course.

RESULTS

Of 46 patients meeting the criteria for treatment with the oral prednisone regimen (i.e., subjective feeling of unacceptable discomfort despite the use of nonsteroidal anti-inflammatory agents), 39 (85%) experienced substantial relief of symptoms. All but one of the responding patients requested continuation of the oral prednisone regimen with subsequent paclitaxel treatment cycles. There were no significant toxicities noted in any patient receiving prednisone.

CONCLUSION

This low-dose oral prednisone regimen results in substantial improvement in the majority of patients experiencing significant paclitaxel-associated arthralgias/myalgias.