Quality of life during chemotherapy for small cell lung cancer. II. A longitudinal study of the EORTC Core Quality of Life Questionnaire and comparison with the Sickness Impact Profile

Sixty-two patients with small cell lung cancer, 36-80 years of age, who were receiving chemotherapy during a maximum of one year, were consecutively included in a study of quality of life during treatment. An interim version (C-36) of the EORTC Core Quality of Life Questionnaire (QLQ) was applied for quality of life assessment prior to treatment and every third month during the treatment period. The assessments were related to clinical variables (performance status and tumour response), and compared with results from assessment with the Sickness Impact Profile (SIP). The QLQ was sensitive to differences in clinical status and responded to clinical change over time. In general, the pattern of correlations with SIP lends support to the construct validity of the QLQ. However, some questions arose from the comparison with SIP: QLQ emotional functioning did not change in concordance with SIP, and assessment of social functioning was not optimal prior to treatment. The questionnaire was well accepted by the patients. The EORTC QLQ C-36 constitutes a promising step in the development of a feasible standard instrument for quality of life assessment in cancer clinical trials.

Phase II study of teniposide in patients with AIDS-related Kaposi's sarcoma

Antitumour activity of cytotoxic agents, evaluated in patients with AIDS-related Kaposi's sarcoma (KS), is about 30-80%. However, responses are mostly partial and short. Experience with etoposide is similar. Teniposide has a longer elimination half-life and superior antitumour activity compared with etoposide in some experimental models. Thus a phase II trial was done in 25 patients with AIDS-related KS. Teniposide was given by 60-min infusion at 360 mg/m2 every 3 weeks. 10 (40%) showed a partial response, median duration of 9 (6-20) weeks. The main side-effects were leukopenia, thrombocytopenia, nausea and vomiting, alopecia and mucositis.

[Plasma cell leukemia: our experience in 4 cases]

Clinical findings and response to treatment in four cases with plasma cell leukemia (PCL) out of 152 patients of multiple myeloma diagnosed at the Hospital La Paz from 1969 to 1988 are studied. Three of the four plasma cell leukemia cases presented a primary form, and one a secondary form. Our cases had a lower incidence of lymphadenopathy and splenomegaly than reported in previous series. The incidence of serum M band in PCL was similar to that found in multiple myeloma. The four patients received combination chemotherapy; one of them attained PR lasting for 2 months, and the remaining three failed to respond to similar therapy. The mean duration of survival was less than 8 months. Current treatments are reviewed.

Teniposide and etoposide in previously untreated small-cell lung cancer: a randomized study

A randomized study comparing teniposide (VM-26) and etoposide (VP-16) was performed to investigate whether there are any differences in the activity and toxicity of these two analogs in small-cell lung cancer (SCLC). Only previously untreated patients with SCLC were included; 46 and 48 patients receiving VP-16 and VM-26, respectively, are assessable for response. There were no differences between the two groups with respect to extent of disease, median age, and performance status (PS). The initial doses were for both compounds 70 mg/m2 intravenously (IV) daily for 5 days every 3 weeks. After inclusion of 25 patients in the study, the doses were increased to 80 mg/m2 for VM-26 and 90 mg/m2 for VP-16 because of differences in toxicity. VM-26 caused more hematologic toxicity than VP-16 throughout the study. The overall responses (complete response [CR] plus partial response [PR]) were 65% for VP-16 and 71% for VM-26, with CR occurring in 24% and 23%, respectively, for the two compounds. Median survival was 8.5 months for VP-16-treated patients versus 11.3 months for VM-26-treated patients (P = .58). It is concluded that both VP-16 and VM-26 are highly active single agents in SCLC.

Ewing's sarcoma: metastatic tumor to the jaw

Metastatic tumors to the jaw are a rare occurrence. The incidence of metastatic Ewing's sarcoma to the jaw has been reported to be less than 2% of all cases of Ewing's sarcoma. Early detection of such lesions is difficult because the signs and symptoms do not appear until the lesion has progressed considerably. The treatment options are therefore limited to palliative care of the patient rather than cure. This article reports a case of Ewing's sarcoma that had metastasized to the mandible and reviews the literature.

Familial hemophagocytic lymphohistiocytosis. Clinical review based on the findings in seven children

Clinical, laboratory, and histological findings in FHL of diagnostic importance were intermittent fever, hepatosplenomegaly, peripheral blood cytopenia, hypertriglyceridemia, hypofibrinogenemia, and a lymphohistiocytic accumulation with hemophagocytosis in the mononuclear phagocytic system. Fine-needle aspiration biopsy from the spleen appeared to be a useful method for revealing hemophagocytosis. The treatment of induction and relapses, as well as the maintenance therapy, included administration of teniposide, etoposide, and corticosteroids. The regimen had to be individualized for each child since the clinical course was highly variable. Half of the children given successful induction therapy (3/6) are still alive with over a 3-year survival after diagnosis.

Phase II study of teniposide in adenocarcinoma of the lung

A total of 26 evaluable patients with previously untreated, non-resectable adenocarcinoma of the lung were given 80 mg/m2 i.v. teniposide daily for 5 days every 3 weeks. Three partial responses (11%) were obtained that lasted for 12, 11 and 32 weeks, respectively. Leucopenia was the dose-limiting side effect, with WBC counts of less than 2 x 10(9)/l being observed in 42% of patients, resulting in one septic death. At the dose and schedule used in the present study, teniposide showed only limited activity in adenocarcinoma of the lung.

[Chemotherapy in malignant gliomas]

Considering the survival time of patients with malignant gliomas indication for chemotherapy in spite of side effects is recommended. One third of them are living 2 years, some even longer. Before starting such a treatment a critical evaluation is mandatory, a prolongation of dying must be avoided. In addition personal human care to the patient and his family has a great importance.

Sacrosine- and prolinedithiocarbamate pretreatment increases the therapeutic efficacy of doxorubicin, methotrexate, teniposide, mitoxantrone or cyclohexylchloroethylnitrosourea in leukemia L1210

The influence of different doses of the hydrophilic sarcosine- or prolinedithiocarbamate on the chemotherapeutic efficacy of doxorubicin, teniposide, methotrexate, mitoxantrone or cyclohexylchlorethylnitrosourea was evaluated in female B6D2F1 mice bearing leukemia L1210, implanted intraperitoneally. The simultaneous administration of these dithiocarbamates and the drugs used induced no increase of the therapeutic efficacy of the combinations compared to the corresponding dose of the drug and simultaneously applied saline. The results indicate that the subcutaneous pretreatment with sarcosine- or prolinedithiocarbamate increased the therapeutic efficacy of the drugs used compared to the corresponding monotherapy, in which saline was applied in the same interval as the dithiocarbamate and the antineoplastic agents. Sarcosine- or prolinedithiocarbamate applied alone did not influence leukemia L1210. The increase of the efficacy of the drugs used by sequential combination with sarcosine- or prolinedithiocarbamate seems to be influenced predominantly by diminishing the toxicity as well as by modulating the chemotherapeutic action.

[Chemotherapy of nonendemic Burkitt's lymphoma]

14 patients (12 men, 2 women, mean age 26.3 [15-47] years) with histologically confirmed Burkitt's lymphoma were subjected between 1984 and 1989 to chemotherapy originally developed for treating lymphomas in children. Treatment consisted of medium doses of methotrexate, cyclophosphamide, teniposide, cytarabine, adriamycin and prednisone, intrathecal administration of methotrexate and if necessary prophylactic or therapeutic irradiation of the cranium. Most of the patients (64%) were in advanced stages of the disease. The rate of complete remissions was 100%. Four patients (29%) had a recurrence. Side effects were leukopenia (WHO grade III and IV) in 71%, grade III anaemia in 43% and grade III-IV thrombopenia in 29% of the patients. Considerable mucositides in 5 of the 14 patients (36%), and in one case a tumour lysis syndrome with transient renal insufficiency were other therapy-induced side effects. These results suggest that this treatment course can be successful also in non-endemic Burkitt's lymphoma in adolescents and adults.

Teniposide in recurrent or advanced cervical carcinoma: a phase II trial in patients not previously treated with cytotoxic therapy

Thirty-two patients with advanced or recurrent cervical cancer were entered into this study of single-agent teniposide as first-line chemotherapy at a dose of 100 mg/m2 intravenously on Days 1-3 every 3 weeks. Of these patients, 7 (22%) had a partial response to therapy; no patient had a complete response. Median time to treatment failure was 13 weeks [95% confidence limits (CL): 10-21 weeks] and median survival was 28 weeks (95% CL: 14-43 weeks). Toxicity was moderate. Leukopenia and thrombocytopenia (WHO grade 3 or 4) was noted in 9 patients and 1 patient, respectively. Nausea and vomiting were mild. Seventy-five percent had alopecia requiring a wig. There were no treatment-related deaths. This study indicates that teniposide has some, although limited, activity in cervical cancer.

Teniposide (VM-26) in patients with non-squamous-cell carcinoma of the cervix. A phase II trial of the Gynecologic Oncology Group

Twenty-three evaluable patients with non-squamous-cell carcinoma of the cervix were treated with teniposide 100 mg/m2 per week administered as a 30-60 min infusion. Escalations of 20 mg/m2 per week to a maximum dose of 160 mg/m2 were performed in patients without toxicity. Thirteen of the 23 patients had no prior chemotherapy. One patient had a partial response (95% confidence intervals for response less than or equal to 19%). Toxicity was minimal. Seven patients had white blood cell counts of less than 2,000/mm3 but only one had less than 1,000/mm3. No patients had platelet counts less than 50,000/mm3, and no bleeding or septic episodes were noted. Two patients had mild nausea and seven had mild nausea and vomiting. Teniposide displays no major activity in patients with non-squamous-cell cervical cancer.

Teniposide (VM26) as second-line treatment for small cell lung cancer

Twenty-six out of 53 patients with small cell lung cancer (SCLC) who relapsed or progressed following a first treatment (induction plus maintenance), were treated by a second-line chemotherapy consisting of: Teniposide (VM26), 60 mg/m2 i.v., days 1-5, every 3 weeks until further progression. The response rate obtained in 24 evaluable patients was: 7 (29%) partial response, 4 (17%) minor response, 8 stable disease, 5 progressive disease and 2 patients with early death. In the whole group, median survival time from the start of VM26 treatment, was 4 months (range 1-11). These data were compared to the median survival (1.5 months, range 1-7) of the remaining 27 patients, the control group, who at the time of progression did not receive further treatment. The difference between survivals was statistically significant (Log-rank test: p less than 0.05). According to these data VM26 seemed to be active, but larger studies better focused on all clinical variables are needed before firm conclusions can be drawn.

Etoposide and teniposide in the treatment of acute leukemia

Etoposide and teniposide are semi-synthetic glucoside derivatives of podophyllotoxin with a documented anti-tumour activity in various types of malignant diseases. It was an early observation that these epiphodophyllotoxins were efficacious in hematological malignancies such as lymphomas and leukemias. In this report the clinical evidence supporting the activity of etoposide and teniposide in acute lymphoblastic (ALL) and non-lymphoblastic leukemia (ANLL) is reviewed. Unlike podophyllotoxin, etoposide and teniposide do not appear to affect microtubular function nor arrest cells in mitosis. These epiphodophyllotoxins, like other DNA intercalating agents, have topoisomerase II as their target. Most studies with etoposide have been performed in ANLL and with teniposide in ALL. This choice seems to be rather arbitrary and is better explained by traditional reasons than actual study results. The data in acute leukemias are partly flawed by the absence of certain prospective comparative trials. However, the current information on etoposide clearly shows that this agent has substantial activity in ANLL and may well be incorporated into front-line regimens and the same is true for teniposide in the treatment of ALL. Nevertheless, based on available literature, there are no convincing data to the author's mind to support that one of these agents is superior to the other in the treatment of acute leukemias.

Phase II study of teniposide (VM26) in cutaneous T-cell lymphomas

A Phase II study of teniposide (VM26) in cutaneous T-cell lymphoma (CTCL) was performed in 15 patients affected by stage III, IV according to TNM (mycosis fungoides or Sézary syndrome). All patients were pretreated, and VM26 was administered at a dose of 100 mg/m2 weekly for at least 3 weeks. Objective responses were observed in 40% of the patients, with two complete responses lasting 26 and 46 months. The drug was well tolerated in elderly patients and deserves further evaluation either for inclusion in first-line combination regimens or for palliative treatment in heavily pretreated or elderly patients.

VM-26 in colorectal carcinoma: a Southwest Oncology Group study

In this multi-institutional phase II study, VM-26 or Teniposide was administered to forty-two patients with advanced colorectal cancer. Patients were initially treated at 60 mg/M2 daily for 5 days with dose adjustments depending on toxicity. One complete response and one partial response were observed lasting six and four months respectively. Leukopenia was severe in 40% of patients. No drug related deaths were seen. In this Southwest Oncology Group (SWOG) study, VM-26 appeared to have minimal benefit in advanced colorectal cancer.

Phase II study of teniposide in advanced breast cancer

In a phase II study, 19 patients with previously treated, advanced breast cancer received 50 mg/m2 teniposide (VM-26) i.v. on days 1-5 every 3 weeks. One partial response (PR) (5%) was observed. Toxicity consisting of leukopenia and thrombocytopenia was frequent and severe. VM-26 has minimal therapeutic activity when given at this dose and on this schedule to patients with heavily pretreated metastatic breast cancer.

Antitumor activity of the two epipodophyllotoxin derivatives VP-16 and VM-26 in preclinical systems: a comparison of in vitro and in vivo drug evaluation

The epipodophyllotoxines VP-16 and VM-26 are chemically closely related. VM-26 has been found to be considerably more potent than VP-16 in vitro in a number of investigations. Although the drugs have been known for greater than 20 years, they have not been compared at clearly defined equitoxic doses on an optimal schedule in vivo and it has not been clarified as to whether a therapeutic difference exists between them. A prolonged schedule is optimal for both drugs; accordingly we determined the toxicity in mice using a 5-day schedule. The dose killing 10% of the mice (LD10) was 9.4 mg/kg daily (95% confidence limits, 7.4-11.8) for VP-16 and 3.4 (2.5-4.5) mg/kg daily for VM-26. In vitro, we found VM-26 to be 6-10 times more potent than VP-16 in a clonogenic assay on murine tumors P388 and L1210 leukemia and Ehrlich ascites. This pattern was also demonstrated in a multidrug-resistant subline of Ehrlich selected for resistance to daunorubicin (Ehrlich/DNR+), as it was 30 times less sensitive than Ehrlich cells to both VP-16 and VM-26. Using 90%, 45%, and 22% of the LD10 on the same murine tumors in vivo, we found that the effect of the two drugs was equal as evaluated by both the increase in life span and the number of cures. The drugs were also compared in nude mice inoculated with human small-cell lung cancer lines OC-TOL and CPH-SCCL-123; however, they were more toxic to the nude mice and only a limited therapeutic effect was observed. In conclusion, the complete cross-resistance between the two drugs suggests that they have an identical antineoplastic spectrum. VM-26 was more potent than VP-16 in vitro; however, this was not correlated to a therapeutic advantage for VM-26 over VP-16 in vivo.

[VM-26 and VP-16 salvage therapy for refractory germinal testicular cancers]

Thirteen evaluable patients with germinal testicular cancers failing to be cured with first-line therapy (refractory) were treated by salvage chemotherapy. Ten patients received salvage chemotherapy with VM-26 (50 mg/m2, twice a week X 6 weeks) and cisplatin (CDDP, 20 mg/m2 for 5 consecutive days every 3 weeks for 3-4 times) (P-VM), 3 patients were also treated by radiation therapy, and 3 patients received VP-16 (100 mg/m2) and CDDP (20 mg/m2) (P-VP), all given daily for 5 consecutive days every 3-4 weeks for 4-5 courses. Of 13 evaluable patients, 6 (46%) had complete response (CR) (three cases were also treated with radiation therapy), 4 (31%) achieved partial response (PR), and 3 (23%) had no response. Limited to 7 patients treated with only P-VM therapy, there were 3 (43%) CR and 4 (57%) PR. Nine patients (69%) remained alive and were continuously disease free 18 to 84 months (median 48 months). Hematologic toxicity was severe, but with no death related to sepsis. Salvage chemotherapy with VM-26 or VP-16 and cisplatin offers potentially curative treatment to patients with refractory testicular cancer. The addition of radiation therapy to salvage chemotherapy was also effective.

A phase II study with teniposide (VM26) in patients with progressed or relapsed small cell lung cancer (SCLC)

Sixteen patients with advanced small cell lung cancer who relapsed or progressed under first-line therapy, were treated with second-line chemotherapy consisting of: teniposide, 60 mg/m2, i.v. days 1-5, every 3 weeks until further progression. The response rate was: 3 minor responses, 6 stable disease, 5 progressive disease, 1 early death and 1 not evaluable. After the introduction of teniposide, median survival was 4.5 (range 1-11) months, compared to the median survival (2 months, range 1-11) observed in 40 contemporary patients of our series, who relapsed or progressed and subsequently received no treatment. The assessment of the difference was significant: chi-square = 4.05, P less than 0.05. In addition a particular comparison was performed with 15/40 patients who matched according to the major predictive parameters of disease. These patients experienced 2 months (range 1-7) of median survival which was significantly shorter than that of the teniposide treated group (chi-square = 4.48, P less than 0.05). On these bases, teniposide appeared to be effective, but the small size of the study suggests caution in evaluating the results.

Podophyllotoxins for brain metastases of small cell lung cancer

A patient with brain metastases of small cell lung cancer (SCLC) responded initially to cranial irradiation. Recurrences were subsequently successfully treated with high-dose intravenous etoposide (VP 16-213) and teniposide (VM 26). Epipodophyllotoxins are potentially useful for CNS metastases of SCLC.

Teniposide in the treatment of small-cell lung cancer: the influence of prior chemotherapy

Fifty patients with small-cell lung cancer (SCLC) were treated with teniposide (VM26) at 120 to 140 mg/m2 on days 1, 3, and 5, every 3 weeks. Twelve elderly patients were administered VM26 as first-line chemotherapy. Toxicity was manageable, myelosuppression being the major side effect. The response rate for 44 evaluable patients was 34% (36% for untreated patients); the median durations of response and survival were 230 and 208 days, respectively. Effectiveness of prior chemotherapy and time from last administration was found to influence patient response to VM26: 42% of responders to prior chemotherapy responded to VM26, while 0% of the nonresponders to prior chemotherapy responded to the new agent. Moreover, among patients pretreated with chemotherapy, 12% of those recently treated (earlier chemotherapy ending less than or equal to 2.6 months before administration of VM26) responded to VM26, while 53% of patients treated greater than 2.6 months earlier responded to VM26. Survival was influenced by common prognostic factors (performance status, weight loss, prior chemotherapy exposure). Selection of pretreated patients by type of exposure to prior chemotherapy may help in the testing of new drugs in this disease.

Phase II evaluation of teniposide (VM-26) in metastatic breast carcinoma. A Southeastern Cancer Study Group trial

The Southeastern Cancer Study Group performed a Phase II study of teniposide in previously treated patients with metastatic breast cancer. No responses were observed in 11 evaluable patients who received teniposide 60 mg/m2 by IV infusion for five consecutive days every three weeks. Toxicity was primarily gastrointestinal and hematologic and was frequently severe. This study demonstrated no therapeutic activity for teniposide when given in this dose and schedule to patients with heavily pretreated metastatic breast cancer.