Treatment of metastatic islet cell carcinoma with a somatostatin analogue (SMS 201-995)

We used an octapeptide analogue of somatostatin, SMS 201-995, in dosages ranging from 150 to 450 micrograms/d administered subcutaneously in three daily doses for 1 to 16 months, to treat 22 patients with advanced malignant islet cell carcinomas. Of the 22 patients, there were 9 with gastrinomas; 3 with glucagonomas; 4 with insulinomas; 1 with ectopic production of parathyroid hormone; and 3 with mixed syndromes. The only biochemical marker in 1 patient was pancreatic polypeptide, and 1 patient had no demonstrable peptide production from the tumor. In 14 patients, dramatic decreases in the levels of circulating peptides (insulin, vasoactive intestinal polypeptide, gastrin, and glucagon) have been accompanied by major alleviations of symptoms. Steatorrhea appears to be the most significant toxicity. This analogue of somatostatin may be appropriate for use as early therapy in patients who have symptoms from syndromes related to islet cell carcinomas but in whom there is no immediate threat from tumor progression.

Intraoperative and external beam irradiation +/- 5-FU for locally advanced pancreatic cancer

Because of the poor local control rates obtained with external beam irradiation +/- chemotherapy for locally advanced pancreatic cancer, our institution has used intraoperative radiation therapy (IORT) with electrons to deliver a single "boost" dose of radiation in 52 patients with biopsy-proven adenocarcinoma (primary, unresectable-49; primary, residual-2; and recurrent, unresectable-1). Patients received 4500-5000 rad of fractionated external beam irradiation and an IORT dose of 1750 rad (2 patients) or 2000 rad (50 patients). Acute and chronic tolerance have been acceptable. Documented local progression within either the external beam or IORT fields has been infrequent (3 of 42 evaluable patients or 7%), but there has been little, if any, change in median or long-term survival from that seen in external beam series. This is probably because of a high incidence of liver and peritoneal metastases with pancreatic cancer. A phase II pilot trial, which combines upper or total abdominal irradiation and infusion 5-FU with tumor nodal irradiation plus IORT, is in progress in our institution to evaluate tolerance and the relative incidence of abdominal failures.

Metastatic carcinoid tumors and the carcinoid syndrome. A selective review of chemotherapy and hormonal therapy

Malignant carcinoid tumors are remarkably varied in their biologic behavior. The disease may be indolent for years with minimal or no symptoms. On the other hand, an acute carcinoid crisis with severe diarrhea, dehydration, and hypotension may develop in the patient. Patients with flushing and/or diarrhea, not responsive to standard symptomatic measures, may benefit from chemotherapy or hormonal therapy. Chemotherapy with single agents or combination chemotherapy may be associated with response rates ranging from 20 to 40 percent. Hepatic de-arterialization by ligation or occlusion is an effective means of inducing rapid tumor shrinkage for patients who have carcinoid tumors and hepatic dominant metastases. The addition of chemotherapy after induction of a partial remission with hepatic de-arterialization may prolong the duration of response, but this remains to be proven in prospective clinical trials. Hormonal therapy with the antiestrogen tamoxifen has been unsuccessful, but treatment of the carcinoid syndrome with a long-acting analogue of somatostatin has been strikingly effective.

Phase I trial of parenteral 6-thioguanine given on 5 consecutive days

For almost 30 years, 6-thioguanine (6-TG) has been administered p.o. for treatment of various human cancers, especially leukemias, even though the systemic availability of the drug given p.o. is known to be low and highly variable. Parenterally administered 6-TG has been studied in detail in humans only on a single-day intermittent schedule, although multiple-day intermittent schedules are known to produce maximal cytotoxic effects in several animal species. To develop a multiple-day regimen for parenteral 6-TG therapy, we carried out a dose-seeking and pharmacokinetic study of the drug given i.v. daily for 5 days in patients with various refractory advanced solid tumors. Dose-limiting myelosuppression without other significant toxicity occurred at 55-65 mg/m2 daily for 5 days. After i.v. administration at 65 mg/m2, the mean peak plasma concentration of 6-TG ranged from 6-10 microM. These concentrations are 8-300 times greater than peak plasma concentrations of 6-TG in plasma reported to occur after p.o. administration at 100 mg/m2. We suggest that the antitumor activity of 6-TG be reassessed against human cancers in regimens of i.v. administration on multiple-day intermittent schedules.

Treatment of the malignant carcinoid syndrome. Evaluation of a long-acting somatostatin analogue

We studied the effects of a long-acting analogue of somatostatin (SMS 201-995, Sandoz) in 25 patients with histologically proved metastatic carcinoid tumors and the carcinoid syndrome. This drug was self-administered by subcutaneous injection at a dose of 150 micrograms three times daily. Flushing and diarrhea associated with the syndrome were promptly relieved in 22 patients. All 25 patients had an elevated 24-hour urinary excretion of 5-hydroxyindoleacetic acid (5-HIAA) (mean, 265 mg per 24 hours; range, 14 to 1079), which served as an objective indicator of disease activity. Eighteen of the 25 patients (72 percent) had a decrease of 50 percent or more in their urinary 5-HIAA levels, as compared with the pretreatment values. The median duration of this biochemical response was more than 12 months (range, 1 to greater than 18). Since no serious toxicity was observed, we conclude that SMS 201-995 may be appropriate for use as early therapy in patients with symptoms due to the carcinoid syndrome who have not responded to simpler measures.

Clinical trial of cisplatin and intensive course 5-fluorouracil for the treatment of advanced colorectal cancer

A clinical trial of 5-day Cisplatin combined with loading course 5-fluorouracil (5-FU) was conducted in 37 patients with advanced colorectal carcinoma. Objective tumor responses were seen in 10 of 34 patients (29%) who had not received prior chemotherapy. The estimated median survival for previously untreated patients is 26 weeks measured from the onset of therapy. Toxicity consisted primarily of leukopenia, vomiting, and reversible renal insufficiency. This combination of cisplatin and intensive course 5-FU has demonstrated Phase II activity in patients with advanced colorectal cancer. A controlled trial is now in progress to prospectively compare this regimen with full dose single agent 5-FU.

Local control and survival in locally advanced gastrointestinal cancer

When conventional modalities (external beam irradiation and chemotherapy +/- resection) are used in the treatment of locally advanced gastrointestinal malignancies, although useful palliation can be achieved in many patients, local control and long-term survival are infrequent. In recent trials, investigators have used fractionated external beam doses of 4500-5000 rad in 180 rad fractions in combination with irradiation boost techniques of intraoperative electrons, or intraoperative or transcatheter brachytherapy (+/- chemotherapy and resection). With colorectal and biliary cancer, both local control and long-term survival appear to be improved, compared to results achieved with conventional treatment. With pancreatic cancer, an apparent improvement has been noted with local control and median survival, but long-term survival has not been altered. For partially resected gastric cancer, the use of intraoperative irradiation has yielded five year survival rates of approximately 20%. With unresectable or residual gastric cancer, accelerated fractionation alone or in combination with chemotherapy has yielded excellent local control, but patients have died as a result of abdominal failure or lung metastases. Prevention of abdominal failures will be necessary to improve long-term survival with pancreatic and gastric cancer. Randomized trials by site are needed to determine if the observed differences seen in prospective nonrandomized trials are real or due to differences in case selection.

Disposition of tricyclic nucleoside-5'-monophosphate in blood and plasma of patients during phase I and II clinical trials

Tricyclic nucleoside-5'-monophosphate (TCN-P) and its dephosphorylated metabolite tricyclic nucleoside (TCN) have been measured in the blood and plasma of patients receiving TCN-P by rapid iv infusion in a phase I trial at daily doses of 24-55 mg/m2 for 5 days and in patients receiving TCN-P in a phase II trial at a single dose of 250 mg/m2. TCN-P was rapidly accumulated by rbcs and had an initial half-life in blood of 6.1 hours and a terminal half-life of 89.2 hours. Total-body blood clearance of TCN-P was 2.6 ml/minute/m2. The concentration of TCN-P in blood was not related to the dose of TCN-P and did not increase over 5 days' administration in the phase I patients. Plasma contained little detectable TCN-P even 5 minutes after administration. Plasma contained low concentrations of TCN, up to 0.4 microgram/ml, which were maintained over several days. TCN did not accumulate in the plasma with repeated administration of TCN-P in the phase I patients. No other metabolites of TCN-P, apart from TCN, were detected in blood or plasma. No relationship was detected between pharmacokinetics and toxic response of TCN-P in the phase II patients.

Lymphocele after retroperitoneal node dissection for testis tumor

A patient is presented in whom a lymphocele developed after a retroperitoneal lymph node dissection for Stage II embryonal carcinoma of the testicle. The benign nature of this lymphocele has been confirmed not only by the diagnostic procedures outlined, but by its stability over a 42-month follow-up period with no further antitumor therapy. We conclude from reviewing the literature that while aggressive measures are necessary to confirm the diagnosis of a lymphocele, its management should be expectant. If significant obstruction of neighboring structures occurs, an attempt at percutaneous drainage (and possibly sclerosis) seems appropriate despite potential risks of interventional treatment such as hemorrhage and introduction of infection. Open procedures for marsupialization and drainage should be reserved for cases in which more conservative measures fail.

Testicular neoplasms: 29 tumors studied by high-resolution US

High-resolution (10-MHz) ultrasonography produces extremely detailed anatomic images of the testis. The sonographic features most helpful in detecting tumors are mass, bright echogenic foci, and diffuse parenchymal texture change. Of 29 patients with testicular neoplasms, 21 (72%) had one or more masses, 19 (66%) had one or more echogenic foci, and nine (31%) had a diffuse parenchymal texture change. Bright echogenic foci were present in six (86%) of seven testes that had a regressed germ-cell tumor. In an attempt to define the histologic features of bright echogenic foci, we performed needle localization under real-time guidance on four operative specimens. We observed immature bone and cartilage, calcification, tubular atrophy and fibrosis, and focal noncalcific scarring. Discovery of occult testicular neoplasms was common (9/29); four patients were thought to have had "extragonadal" germ-cell tumors before abnormalities were found on the sonograms.

A pilot study to determine clinical tolerability of intensive combined modality therapy for locally unresectable gastric cancer

Eighteen patients with unresectable carcinoma of the stomach whose known malignant disease was confined to structures immediately adjacent to the primary tumor and could be encompassed within a radiotherapy field were treated with an intensive sequential combined modality regimen. The regimen consisted of 5-FU plus adriamycin chemotherapy, followed by high dose megavoltage radiation therapy with 5-FU given as a radiation sensitizer, followed by maintenance chemotherapy with 5-FU plus adriamycin plus methyl CCNU (FAMe). Our primary objective was to determine patient tolerability. Severe and prolonged anorexia, nausea, and decreased performance status occurred during and after high dose radiotherapy given twice daily in 150-170 cGy (rad) fractions when given with 5-FU. Lengthening intervals between treatment segments, and the use of one daily dose of radiation therapy combined with 5-FU or two fractions daily without 5-FU seemed to decrease nutritional complications. Control of tumor at the primary site appeared to be achieved in most patients. Distant metastases represented the predominant mode of treatment failure with only two patients currently without progression of malignant disease. Our treatment regimen as initially conceived was too toxic for general use. Improved therapeutic results in locally unresectable gastric cancer will require the development of more effective therapy for occult distant metastases.

Randomized clinical trial of doxorubicin alone or combined with mitolactol in women with advanced breast cancer and prior chemotherapy exposure

One hundred fifty-one women with advanced breast cancer who had failed prior chemotherapy were randomized to monthly courses of doxorubicin (60 mg/m2 I.V. day 1, observation after 500 mg/m2) or doxorubicin (40 mg/m2 I.V. day 1; maximum 500 mg/m2) and mitolactol (135 mg/m2 orally, days 1-10; 180 mg/m2 after maximum doxorubicin). Median survival times were 232 days for doxorubicin and 225 days for doxorubicin + mitolactol, and median times to progression were 112 days and 97 days, respectively. Results are inconsistent with a 25% improvement in survival or time to progression for doxorubicin + mitolactol (p = 0.04 and 0.02, respectively, adjusted for stratification factors but not multiple testing). Regression rates for all patients, both measurable and evaluable, were 30% for doxorubicin alone and 26% for doxorubicin + mitolactol. Regression rates were significantly higher in patients with measurable indicator lesions. Cardiac toxicity was seen in four patients, all of whom were receiving doxorubicin alone. It appears that the combination of doxorubicin + mitolactol is not substantially more effective than doxorubicin alone in women with advanced breast cancer and prior chemotherapy exposure.

Residual, recurrent, or unresectable gastrointestinal cancer. Role of radiation in single or combined modality treatment

When conventional modalities of external beam irradiation and chemotherapy +/- resection are used in the treatment of locally advanced gastrointestinal malignancies, although useful palliation can be achieved in many patients, cure and long-term survival is infrequent. Aggressive combined modality approaches have recently encorporated irradiation boost techniques with intraoperative electrons or intraoperative or transcatheter brachytherapy. Both local control and long-term survival appear to be improved when compared with results achieved with conventional treatment. Randomized trials are needed to determine if the observed differences are real or due to differences in case selection.

Clinical trial of sequential N-phosphonacetyl-L-aspartate, thymidine, and 5-fluorouracil in advanced colorectal carcinoma

Preclinical studies have demonstrated enhanced cytotoxic effects of 5-fluorouracil (5-FU) when given in conjunction with N-phosphonacetyl-L-aspartate (PALA) or thymidine in several murine systems. Early clinical studies have demonstrated significant delayed depletion of pyrimidine nucleotides in tumor biopsy specimens following systemic PALA administration and prolonged serum levels of 5-FU after thymidine administration. Each of these biochemical effects would be anticipated to augment the cytotoxic activity of 5-FU. A phase II trial of a timed sequential administration schedule of PALA, thymidine, and 5-FU was conducted in 37 patients with advanced measurable colorectal cancer. Ten of 37 patients (27%) experienced objective tumor responses with a median response duration of 22 weeks, and 18 patients (49%) had stable disease for a median duration of 20 weeks. Six of 13 patients (46%) with anaplastic histology and/or rapidly progressive tumors experienced high-quality tumor responses. Leukopenia and neurologic side effects were the primary toxicities, including one death caused by sepsis. This regimen has demonstrated striking alteration in the 5-FU dose-effect relationship and definite antitumor activity in patients with advanced colorectal cancer. Further trials in patients with anaplastic carcinomas of the colon or other anatomic sites should be considered.

Intraoperative and external beam irradiation with or without resection: Mayo pilot experience

At our institution, intraoperative radiation therapy (IORT) with an electron beam has been administered as a single boost dose of 1,000 to 2,000 cGy (rad) in combination with 4,500 to 5,000 cGy (rad) of fractionated external beam irradiation. From April 1981 to July 1983, 50 patients received such treatment, and results are analyzed in detail in this article. All patients had locally advanced disease (initially unresectable for cure, residual after resection, or recurrent), and the main disease sites were gastrointestinal (pancreatic, colorectal, and biliary tumors) and soft tissue (sarcomas). Disease-free survival to date has been excellent in our colorectal and biliary subsets of patients. Although local progression has not been a major problem in patients with unresectable pancreatic lesions, failures in the liver and peritoneal cavity have been excessive, and treatment strategies have been altered in an attempt to decrease the frequency of such failures. Although both short-term and long-term morbidity are acceptable, pilot trials with use of radiation-dose modifiers are planned to determine whether the therapeutic ratio of local control to associated complications can be improved even further.