Multi-day fractionated administration schedule for paclitaxel

PURPOSE

To establish the feasibility of fractionating paclitaxel administration by utilizing daily one-hour infusions for three, four or five days with dose escalating to determine the patterns of hematologic and non hematologic toxicities. PATTERNS AND METHODS: Forty patients received 87 courses of daily fractionated paclitaxel for three, four or five days; cycles were repeated every 21 days. Six patients received concomitant daily cisplatin. The median number of cycles delivered per patient was two with a range of one to six.

RESULTS

Cumulative doses per cycle ranged from 120 mg/m2 to 250 mg/m2 with 25% of the cycles delivering 200 mg/m2 or more. Ten cycles (11.5%) were associated with dose limiting neutropenia (grade 3 [7 cycles]; grade 4 [3 cycles]). No hypersensitivity reactions were observed and no patient required cytokine support. No patient required hospitalization.

CONCLUSIONS

Administering paclitaxel on a daily fractioned schedule in an ambulatory setting is logistically feasible; does not require premedication; is associated with a toxicity pattern similar to single day schedules (e.g. 24-hour or three-hour infusion); is capable of delivering a higher dose per cycle than published 96- or 120-hour infusion schedules; and could possibly be escalated to doses higher than 250 mg/m2 in carefully selected patients. The optimal dose rate for five-day multifractionated administration of paclitaxel is 40 to 50 mg/m2/d or a cumulative cycle dose of 200 to 250 mg/m2 and does not require cytokine usage. Adding cisplatin on a fractionated daily schedule may accentuate the neurotoxicity associated with both agents. A prospective comparison of four-day fractionated vs. four-day continuous infusional paclitaxel has been proposed as a randomized study to determine clinical differences in response, dose intensity and toxicity.

Is the European standard series suitable for patch testing in Riyadh, Saudi Arabia?

Due to the lack of a regional patch test series in our geographical area, the suitability of the European standard series was evaluated by patch testing dermatitis patients in Riyadh, Saudi Arabia. Of 240 consecutive patients with various forms of dermatitis, 136 (57%) showed 1 or more positive patch tests, women, 74 (54%), slightly outnumbering men, 62 (46%). Positive reactions were found to 21 of the 22 items in the test series. Sensitization was most common to nickel sulfate (51 = 37.5%), potassium dichromate (48 = 35%) and cobalt chloride (43 = 32%) The frequency of sensitization to nickel was higher in women (41 = 30%) while that to dichromate was higher in men (39 = 29%). Less reactions were found to fragrance mix (21 = 15%), formaldehyde (15 = 11%) and neomycin sulfate (15 = 11%). Sensitization to other allergens ranged between 10 and 1%. Less than 1% of patients (0.7%) reacted to benzocaine and none to primin. The frequency of occurrence of multiple sensitivities is also presented. We conclude that the European standard series is suitable for patch testing dermatitis patients in our region, with the exception of benzocaine and primin. The addition of 3 allergens that could be of local relevance is discussed.

The activity of paclitaxel in gastrointestinal tumors

Gastrointestinal malignancies, which are common around the world, are relatively refractory to available cancer chemotherapeutic agents, necessitating a search for new agents able to improve palliation and survival of patients with advanced disease. Currently, metastatic or local-regional unresectable carcinoma of the esophagus or gastroesophageal junction carries a dismal prognosis. Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ), a new mitotic spindle inhibitor, has been studied in patients with advanced gastrointestinal carcinoma. In this phase II National Cancer Institute-sponsored study, previously untreated patients with unresectable local-regional or metastatic carcinoma of the esophagus or gastroesophageal junction (either squamous cell carcinoma or adenocarcinoma) received a starting dose of paclitaxel of 250 mg/m2 administered by a 24-hour intravenous infusion (with premedication) repeated every 21 days; all patients received subcutaneous granulocyte colony-stimulating factor 5 micrograms/kg daily 24 hours after the completion of the paclitaxel infusion. Fifty-one of 53 patients were assessable for response and response duration. Thirty-three patients had adenocarcinoma and 18 had squamous cell carcinoma. Sixteen (31%) patients achieved a response (one complete and 15 partial) and 11 (22%) achieved a minor response. Among 33 patients with adenocarcinoma, 12 (36%; 95% confidence interval, 14% to 58%) achieved either a complete (one patient) or partial (11 patients) response and six patients (18%) had a minor response. Four (22%; 95% confidence interval, 3% to 41%) of 18 patients with squamous cell carcinoma had a partial response and four (22%) had a minor response. At a median follow-up of 12+ months, 28 patients remain alive with an actuarial median survival duration of 10.2 months (range, 2 to 20+ months). These data suggest that paclitaxel is active against adenocarcinoma as well as squamous cell carcinoma of the esophagus. In a subsequent study, the combination of paclitaxel (175 mg/m2 over 3 hours on day 1), cisplatin (20 mg/m2 on days 1 to 5), and 5-fluorouracil (1,000 mg/m2/d in the first 10 patients but then reduced to 750 mg/m2/d, given as a continuous infusion on days 1 to 5) repeated every 28 days was given to patients with advanced adenocarcinoma or squamous cell carcinoma of the esophagus. Of 46 patients accrued (target accrual, 60), 35 are men and 11 are women, 30 have adenocarcinoma and 16 have squamous cell carcinoma. Among 39 patients evaluated for response so far, one has had a complete response and 16 have had partial responses (overall response rate, 44%; 95% confidence interval 28% to 59%). Five patients have had a minor response. The median granulocyte nadir was 1,200/microL.(ABSTRACT TRUNCATED AT 400 WORDS)

Phase II trial of weekly i.v. vinorelbine as a single agent in first-line advanced breast cancer chemotherapy. The Latin-American experience

This study investigated the therapeutic effect of single-agent i.v. weekly Navelbine (vinorelbine), a semisynthetic vinca alkaloid, in women who had received no prior treatment for locally advanced or metastatic breast cancer. Of 68 patients entered into the study, 63 were adequate inclusions, assessable for toxicity and response by WHO criteria; the 5 patients who were not evaluated were excluded from analysis because they were found not to meet the eligibility criteria of the study. Navelbine was given as a weekly 30 mg/m2 short i.v. (20 minutes) infusion; treatment was continued until disease progression. The overall response rate was 44% (complete response 8%, partial response 36%). The response rate according to target was lymph nodes, 62.9%; liver, 50.0%; lung, 50.0%; skin, 37.5%; and primary tumor, 30.8%. The median duration of response was 17.9 weeks (range: 7-52 weeks). The median time to treatment failure was 12.9 weeks, and the median survival was 50.3 weeks. The 63 eligible patients received 501 cycles. The mean dose intensity was 76%. At least one episode of WHO grade 3/4 granulocytopenia was seen in 46% of the patients (13.6% of cycles). Significant nausea/vomiting was seen in only 5% of patients corresponding to 1% of cycles. Only 5% of patients developed WHO grade 3-4 constipation and grade 3 peripheral neuropathy was observed in 1.6% of patients. Alopecia was rare (6.3% of patients), and other side effects were uncommon. This study confirms that Navelbine has major single-agent antitumor activity as frontline therapy in advanced breast cancer. Given its excellent tolerance profile and low morbidity, it should be recommended for inclusion in first-line combination chemotherapy regimens.

Chemotherapy for AIDS-related and endemic African Kaposi's sarcoma in southern Africa

BACKGROUND

Kaposi's sarcoma (KS), either in its endemic (African) form or its AIDS-related variant, is a common neoplastic disorder seen in Southern Africa. Chemotherapy has been proven to be very effective in advanced or relapsed African Kaposi's sarcoma, but much less so in AIDS-related, endemic KS.

PATIENTS AND METHODS

The study consists of a retrospective analysis of the results of chemotherapy alone in 17 patients with African KS (AKS) and in 32 patients with epidemic AIDS-related KS (EKS), treated at the Johannesburg General Hospital between 1982 and 1992. Single agents included vinblastine, actinomycin D, bleomycin, and vincristine; combined regimens were largely doxorubicin/vincristine/bleomycin or etoposide/methotrexate. Outcome classifications were: complete remission (CR), partial remission (PR), and treatment failure (TF).

RESULTS

Four of the 17 patients with AKS had CR, 10 a PR, and three were TF and died rapidly from their disease. The combined chemotherapeutic regimens produced marked symptomatic relief and even long-term remission in AKS. In patients with EKS, the response rate to chemotherapy was very low and of brief duration. No patient had a CR and debilitating side effects were common.

CONCLUSIONS

The African type of AKS is a chemo-sensitive tumor, whereas the endemic type EKS, like its Western counterpart, has a dismal prognosis.

Phase II studies of docetaxel in the treatment of various solid tumours. EORTC Early Clinical Trials Group and the EORTC Soft Tissue and Bone Sarcoma Group

Docetaxel has been evaluated in six tumour types in a total of 189 patients entered into phase II studies. Treatment consisted of a 1 h intravenous infusion of docetaxel 100 mg/m2 repeated every 3 weeks. No premedication was administered for possible hypersensitivity reactions. Docetaxel was found to be effective as first-line chemotherapy for head and neck cancer (response rate 44%) gastric cancer (23%) and melanoma (14%) and as second-line chemotherapy for soft tissue sarcomas (21%; 95% confidence interval: 7.5%-43.7%). The results in colorectal and renal cancer were disappointing, with response rates of less than 10%. The most frequent adverse effects were alopecia (81%), grade III-IV leukocytopenia of short duration (66%) and skin reactions (52%). Hypersensitivity reactions were mild and occurred in 26% of patients. Docetaxel is an important new drug in the treatment of solid tumours.

Phase II trial of paclitaxel by 3-hour infusion as initial and salvage chemotherapy for metastatic breast cancer

PURPOSE

To evaluate the efficacy and safety of paclitaxel administered by 3-hour infusion as initial and salvage chemotherapy for metastatic breast cancer.

PATIENTS AND METHODS

Forty-nine patients with metastatic breast cancer received paclitaxel via 3-hour intravenous infusion after standard premedication. Prophylactic granulocyte colony-stimulating factor (G-CSF) was not used, and chemotherapy was cycled every 3 weeks. For 25 patients who received paclitaxel as initial therapy (group I), the starting dose was 250 mg/m2. Twenty-four patients who had received two or more prior regimens, including an anthracycline (group II), started at 175 mg/m2. Paclitaxel pharmacokinetics were evaluated in 23 patients in group I.

RESULTS

Grade 3 and 4 toxicities included (groups I/II) neutropenia (36%/33%), thrombocytopenia (0%/8%), anemia (0%/13%), neuropathy (8%/0%), arthralgia/myalgia (16%/4%), and mucositis (4%/4%). No significant hypersensitivity-type reactions or cardiac arrhythmias were seen. Six patients who received paclitaxel at > or = 250 mg/m2 experienced transient photopsia, without apparent chronic neuro-ophthalmologic sequelae. The mean peak plasma paclitaxel concentration was 5.87 mumol/L (range, 1.99 to 7.89) for these patients, and 6.08 mumol/L (range, 0.81 to 13.81) for 17 of 19 patients who did not experience visual symptoms. In 25 assessable patients in group I at a median follow-up time of 12 months, one complete response (CR) and seven partial responses (PRs) have been observed, for a total response rate of 32% (95% confidence interval [CI], 15% to 53%). In group II, five PRs were noted in 24 assessable patients (20.8%; 95% CI, 7% to 42%). Median response durations were 7 months for group I and 4 months for group II.

CONCLUSION

Paclitaxel via 3-hour infusion, without prophylactic G-CSF, is active and safe as initial and subsequent therapy for metastatic breast cancer. The transient visual symptoms noted at higher doses seem unrelated to peak plasma paclitaxel concentration. Further studies that compare 3- and 24 hour (or other) infusion schedules are necessary to determine the optimal administration of paclitaxel in metastatic breast cancer.

Cutaneous manifestations of Taxol therapy

Taxol is a novel chemotherapeutic agent that has produced substantial responses in early clinical studies [1]. Taxol has excellent activity in a number of malignancies based on recently completed clinical trials, including a 30% response rate in platinum-refractory ovarian cancer patients [2-5]. We are currently conducting trials of dose-intense taxol with granulocyte colony stimulating factor (G-CSF) support in relapsed or refractory ovarian cancer patients. Such dose intensification produces a major response rate in 50% of patients with this disease [6]. Taxol was supplied in 5 ml ampules (6 mg/ml) in polyethoxylated castor oil (Cremophor EL) 50% and dehydrated alcohol and the dose was diluted in either 0.9% sodium chloride or 5% dextrose at concentrations of 0.6 to 1.2 mg/ml. We have noted 3 patients with previously unreported cutaneous manifestations which we believe are taxol related and also report our overall complication rate with the administration of taxol by peripheral intravenous lines.

Phase II trial of taxol in patients with adenocarcinoma of the upper gastrointestinal tract (UGIT). The Eastern Cooperative Oncology group (ECOG) results

Taxol was administered as a 24-hour continuous infusion at 250 mg/m2 in this Phase II trial in patients with adenocarcinomas of the upper gastrointestinal tract (UGIT). Twenty-five patients were entered between July 1991 and June 1992, twenty-three were eligible and were evaluated for toxicity and twenty-two were assessable for response. There was one partial response (4.5%) in a patient with liver metastases, with a duration of 6 months. Toxicity was primarily neutropenia. Taxol as a single agent appears to have little activity in adenocarcinoma of the UGIT.

Paclitaxel in metastatic breast cancer: a trial of two doses by a 3-hour infusion in patients with disease recurrence after prior therapy with anthracyclines

BACKGROUND

To date, anthracyclines are the most active drugs against breast tumors, and the taxane paclitaxel (Taxol) looks very promising. Both classes of drugs are affected by cellular multidrug-resistance mechanisms, and therefore their sequential use raises the possibility of clinical cross-resistance. It is therefore important to assess the activity of paclitaxel in patients with clinical resistance to anthracyclines.

PURPOSE

We assessed the safety and efficacy of paclitaxel administered by the logistically convenient 3-hour infusion to breast cancer patients who had disease progression within 12 months since prior therapy with anthracyclines.

METHODS

Fifty-one patients with metastatic breast cancer who had all relapsed or whose disease had progressed within 12 months from completion of an anthracycline-containing chemotherapy protocol (six receiving adjuvant therapy, 19 receiving neoadjuvant therapy, and 26 receiving treatment for metastatic disease) were enrolled in this phase II trial from June 1992 to May 1994. After medication to prevent type I acute hypersensitivity reactions, paclitaxel was given intravenously over 3 hours at 175 mg/m2 to the first 15 patients and at 225 mg/m2 to the next 36 patients. The median age was 50 years (range, 31-62 years), and the median Eastern Cooperative Oncology Group performance status was 0 (range, 0-2).

RESULTS

Patients received a median of five cycles (range, one to 11 cycles). After initial doses of 175 and 225 mg/m2, paclitaxel could be increased by 25 mg/m2 in 73% and 58% of cycles, respectively. Among 50 assessable patients, seven achieved a complete response and 12 achieved a partial response (response rate, 38% [95% confidence interval = 25%-53%]). The median duration of response was 7 months (range, 4-16 months), and the median time to disease progression for all patients was 5 months. Grade 4 neutropenia occurred in 3% of the cycles and in 12% of the patients and was never associated with fever and infection. Common toxic effects were myalgia and arthralgia (94% of the patients; 4% grade 3), peripheral neuropathy (92% of the patients; 8% grade 3), and alopecia (all patients). Pruritus and neuropathy were significantly more frequent and severe, respectively, with the higher dose (P < .01 by chi 2 test). Frequency and severity of other toxic effects were similar at either starting dose. Ten patients had symptoms of neuro-optic toxicity. Only one patient had a grade 2 hypersensitivity reaction.

CONCLUSIONS

Paclitaxel at starting doses of 175 and 225 mg/m2 given as a 3-hour infusion can safely be administered to, and is active in women whose disease has progressed after prior treatment with anthracyclines. There was evidence of increased toxicity at the higher dose but no suggestion of better efficacy.

IMPLICATION

Paclitaxel by a 3-hour infusion in combination with doxorubicin should be investigated in patients with metastatic breast cancer. Unless randomized trials demonstrate greater efficacy of the more toxic higher dose, it is suggested that a dose of 175-200 mg/m2 be administered with the 3-hour infusion schedule.

Australasian multicentre phase II study of paclitaxel (Taxol) in relapsed ovarian cancer

BACKGROUND

Until recently there has been no effective therapy for patients with relapsed ovarian carcinoma following standard platinum based chemotherapy. Paclitaxel has recently been approved for clinical use in this malignancy.

AIMS

To evaluate the objective response rate and toxicity of paclitaxel in patients with relapsed ovarian cancer.

METHODS

Paclitaxel was given on an outpatient basis as a three hour infusion every 21 days for a maximum of ten cycles to 72 patients with advanced ovarian cancer previously treated with at least one platinum containing regimen. The starting dose was either 175 mg/m2 (patients with one or two prior chemotherapy regimens) or 135 mg/m2 (three previous regimens). Premedication was given because of the documented risk of hypersensitivity reactions to paclitaxel.

RESULTS

The overall response rate was 22% (95% confidence interval [CI] 13% to 34%) in the 72 patients enrolled in the study: four patients had a complete response. Three patients (4%) ceased treatment due to hypersensitivity reactions. Other significant (WHO grade 3 or 4) toxicities included neutropenia (51%), myalgia (14%), neurological (3%), alopecia (93%) and nausea and vomiting (3%). The estimated median survival of all patients was 9.8 months (95% CI: 9.1-13.0 months) with 44% alive at one year (standard error [SE] 7%).

CONCLUSIONS

This study confirms that paclitaxel given as a three hour infusion has significant activity and acceptable toxicity in advanced ovarian carcinoma previously treated with platinum regimens.

Docetaxel: meeting the challenge of non-small cell lung cancer management

The combined results of four phase II studies of docetaxel in non-small-cell lung cancer (NSCLC) are presented. All patients had either locally advanced (stage IIIb) or metastatic (stage IV) disease. Results are given for the 248 patients included in the trials who received docetaxel at a dose of 100 mg/m2 given by intravenous infusion every 21 days on an outpatient basis. Among 200 patients evaluable for response, the overall response rate was 31.3% in 128 previously untreated patients and 19.4% in 72 previously treated patients. A subgroup of 30 previously treated patients who were platinum-refractory achieved a response rate of 13.5%. In previously untreated and previously treated patients, median duration of response was 24.6 weeks and 28.7 weeks, respectively, with median times to progression of 14.4 weeks and 13.6 weeks and median survival durations of 9.0 months and 8.1 months. Similar response rates were achieved in patients with stage IIIb and stage IV disease (32% and 25%, respectively) and in patients with visceral metastases (28%) although patients with single-organ involvement did better than those with two or more organs involved. Response rates were comparable to or better than those seen with previous single-agent chemotherapeutic regimens for advanced NSCLC and even with some combination treatments, with a tolerable adverse event profile.

Docetaxel: an interesting new drug for the treatment of head and neck cancers and soft tissue sarcomas

Results are summarized for two phase II studies of docetaxel as first-line therapy for advanced squamous cell carcinoma of the head and neck (SCCHN) and one study of docetaxel as second-line therapy for advanced soft tissue sarcomas. In all three studies, docetaxel was administered at a dose of 100 mg/m2 by intravenous infusion over 1 h every 3 weeks. A total of 62 patients were enrolled in the SCCHN trials, of whom 57 were evaluable for response. The combined overall response rate in the SCCHN patients was 35%. Median duration of overall response was 6.5 months in the EORTC-ECTG study. In the DFCI study, median durations of complete and partial remission were 6.75 months and 4.45 months, respectively. These results are at least comparable to those achieved with other single-agent therapies in this setting. In the soft tissue sarcoma study, 29 of the 31 patients enrolled were evaluable for response. Five patients (17%) achieved a partial response to docetaxel as second-line therapy and a further nine (31%) had stable disease. Median duration of response in these patients with soft tissue sarcomas was 5 months. Again, these results are similar to those seen with the three most active single agents in soft tissue sarcomas when used as second-line therapy. Docetaxel may therefore represent a useful drug in both advanced SCCHN and soft tissue sarcomas.

Docetaxel: a new defence in the management of breast cancer

The results of nine phase II trials of docetaxel in the first- and second-line treatment of patients with advanced breast cancer are summarized. All 316 patients included in this report received docetaxel at a dose of 100 mg/m2 administered over 1 h every 3 weeks on an outpatient basis. One hundred and fifty-four patients received docetaxel as first-line therapy for advanced disease, half of whom had received prior adjuvant chemotherapy (finished at least 1 year previously). An overall response rate of 59% (95% CI: 51-67) was achieved in these patients, with a median duration of response of 8.3 months and a median time to progression of 4.9 months. Similar results were seen in a subgroup of 68 patients with liver metastases. Among the 162 patients given docetaxel as second-line therapy, 134 had strictly defined anthracycline-resistant disease; 73 had liver metastases. The combined overall response rate for anthracycline-resistant patients in two US studies was 48% (95% CI: 37-59) while that in a multicenter French study was 29% (95% CI: 18-44). The median duration of response in each case was 6.3 and 5.5 months, respectively, with an overall median survival duration of 11 and 10 months, respectively. Among patients with liver metastases, second-line treatment with docetaxel achieved an overall response rate of 32%, a median duration of response of 7.8 months and a median survival duration of 9 months. These results for docetaxel as both first- and second-line therapy are comparable with those achieved with doxorubicin and are particularly promising in patients with liver metastases and anthracycline-resistant disease.

Docetaxel delivers new management opportunities for gastrointestinal carcinomas

The results of four phase II studies of docetaxel in cancers of the gastrointestinal tract are summarized. No prior chemotherapy was permitted except for adjuvant chemotherapy completed at least 1 year before entering the present study. In all studies, docetaxel was administered at a dose of 100 mg/m2 given by intravenous infusion over 1 h once every 3 weeks, adjusted according to toxicity. Routine premedication for hypersensitivity reactions was given to most patients in the US study in colorectal cancer but not to patients in the three European studies in gastric, pancreatic and colorectal cancers. In a European Organization for Research on Treatment of Cancer--Early Clinical Trials Group (EORTC-ECTG) study in gastric cancer, 8 (24%) of 33 evaluable patients achieved partial remissions lasting for a median of 7.5 months. Responses occurred in a variety of metastatic sites. Forty-two patients were evaluable in a French study of docetaxel in pancreatic cancer. Partial responses were achieved in 6 (20%) of 30 patients with metastatic disease and 3 of 12 patients with loco-regional disease showed some improvement. Two studies in colorectal cancer--one European and one US--found that docetaxel had little or no activity in these patients. Three (9%) of 33 evaluable patients in the European study achieved responses (one complete and two partial) and none of 19 patients in the US study. Hematological toxicity was the dose-limiting adverse effect. Acute hypersensitivity reactions and fluid retention also occurred in some patients. In conclusion, docetaxel appears to be as effective as standard single-agent therapies for gastric and pancreatic cancers but to have minimal effect in colorectal carcinoma. Toxicities were generally manageable; premedication with corticosteroids may reduce the incidence and severity of acute hypersensitivity reactions and delay the onset of fluid retention.

Role of intralesional vinblastine administration in treatment of intraoral Kaposi's sarcoma in AIDS

The purpose of this clinical study was to determine the effect of intralesional vinblastine administration on intraoral Kaposi's sarcoma (KS) in AIDS patients. One hundred and forty-four KS lesions in 50 HIV-positive homosexual males (mean CD4 count 64/mm3) were treated periodically with intralesional vinblastine injection (0.1 mg/cm2) until lesion resolution or no further reduction in lesional area. The most common lesion sites were: palate 56% (hard palate 42%, soft palate 14%); gingiva 22% (maxillary 15%, mandibular 7%); and maxillary tuberosity 6%. The mean lesion area was 4.6 cm2 (range = 0.1-35 cm2). Complete resolution occurred in 74%. The mean reduction in lesional area was 93% for all lesions. Lesions with only a partial response (26%) to vinblastine had a mean reduction in the lesional area of 69%. The mean number of treatments was 2.4 (range = 1-6). The recurrence rate was 26% with a mean disease-free period of 12.9 weeks. Recurrence rates were highest for nodular (40%) and purple macular lesions with focal nodularity (36%). The most frequent complications were transient pain (72%), superficial mucosal ulceration (22%) and transient paresthesia (12%). Intralesional vinblastine administration produced complete resolution in a substantial number of intraoral KS lesions and represents a well-tolerated treatment regimen for localised control of intraoral KS lesions. Owing to a 25% recurrence rate, re-evaluation is necessary for treatment of recurrent and new Kaposi's sarcoma lesions.

Docetaxel (Taxotere) associated scleroderma-like changes of the lower extremities. A report of three cases

BACKGROUND

Docetaxel (Taxotere) is a microtubule-stabilizing agent that is potentially important in chemotherapy for a variety of malignancies.

METHODS

A clinical study of the cutaneous reactions experienced by a group of patients receiving docetaxel chemotherapy was undertaken. Patients were examined before initiation of therapy, before and after each cycle of therapy, and were followed subsequent to the completion of docetaxel chemotherapy.

RESULTS

Three patients developed diffuse lower extremity edema (3-18 kg) and subsequent scleroderma-like changes after receiving multiple cycles of docetaxel therapy. These patients had different underlying malignancies and dissimilar prior therapy. Rheumatoid factor, antinuclear antibodies, anticentromere, and topoisomerase antibodies were not present in any patient. The diffuse lower extremity edema did not resolve with diuretic therapy. Cutaneous biopsies in two patients revealed diffuse sclerosis. One patient had a normal lymphangiogram during the edematous phase. Discontinuation of docetaxel correlated with resolution of edema and softening of the skin.

CONCLUSION

The etiology of the scleroderma-like skin changes is unclear but appears to be either a toxic effect of docetaxel or an effect of polysorbate 80 (Tween 80), the vehicle for docetaxel.

[Study on the mechanisms of diarrhea induced by a new anticancer camptothecin derivative, irinotecan hydrochloride (CPT-11), in rats]

We investigated the mechanisms of CPT-11-induced diarrhea. 1) CPT-11 (80 mg/kg, i.v.) induced watery diarrhea within 1 hr after dosing in saline-loaded (10 ml/kg, p.o.) rats. This was partially inhibited by subcutaneous injection of atropine (1 mg/kg) or ondansetron (1 mg/kg) and almost completely inhibited by a combination of atropine and ondansetron or by clonidine (0.3 mg/kg) or morphine (10 mg/kg) alone. 2) CPT-11 at the same dose reduced intestinal fluid absorption, which was blocked by the anti-diarrheal agents mentioned above. Intraluminal injection of CPT-11 (20 mg/2 ml) inhibited fluid absorption and induced fluid secretion. 3) CPT-11, 60 mg/kg, by single intravenous injection induced fewer enzymological and histological changes in the small intestine than 5-FU at 270 mg/kg, while 4 consecutive dosings of CPT-11 induced delayed diarrhea (days 5-7) associated with disruption of intestinal integrity. Co-administration with anti-diarrheal agents, except for ondansetron, protected against watery diarrhea appearing within 1 hr after CPT-11 on days 3 and 4, but worsened delayed diarrhea. These results suggest that single injection of higher doses of CPT-11 causes watery diarrhea at an acute phase at least partly by reducing fluid absorption or increasing secretion, and that while conventional anti-diarrheal agents protect against watery diarrhea, their co-administration in repeated CPT-11 administration has no ameliorative effect on CPT-11-induced delayed diarrhea.

Docetaxel (Taxotere), a review of preclinical and clinical experience. Part II: Clinical experience

Docetaxel, a promising inhibitor of microtubule depolymerization has shown significant anti-cancer activity during phase I and early phase II trials. The recommended dosage for phase II trials is 100 mg/m2 every 3 weeks which provides optimal activity with tolerable adverse effects. Docetaxel has shown high single agent activity including use as first- or second-line therapy and in anthracycline refractory breast cancer patients. Results have been comparable to that of established treatments for breast cancer. In addition, docetaxel has shown significant activity in non-small cell lung cancer and a range of other tumors, but no activity in renal or colo-rectal tumors. At present it is undergoing further evaluation in combination therapy. The safety profile of docetaxel is well defined. Major adverse effects include hypersensitivity reactions, fluid retention and neutropenia. Peripheral neuropathy is not a significant adverse effect. The aims of phase II trials with regard to counteracting side-effects are therefore 2-fold: firstly, to evaluate the use of premedication with corticosteroids and antihistamines as a means of counteracting hypersensitivity reactions and fluid retention; secondly, to determine whether granulocyte colony stimulating factor may be useful for attenuating neutropenia.

[Pilot study of irinotecan in refractory small cell lung cancer]

Sixteen patients with refractory small cell lung cancer (SCLC) were treated with an irinotecan starting dose of 100 mg/m2 given as a 90-minute iv infusion every week with subsequent doses based on toxicity. Mean age was 64 years; 14 male and 2 female; 4 with limited disease and 12 with extensive disease; all patients pretreated with combination chemotherapy containing etoposide. The overall response rate was 50% (95% CI 25-75%) with no CR and 8 PR. The median duration of response was 46 days. Major toxicities were leukopenia, diarrhea and pulmonary toxicity. Irinotecan was thus an effective agent in refractory SCLC.

Clinical pharmacokinetics and pharmacodynamics of paclitaxel: a 3-hour infusion versus a 24-hour infusion

The present study was conducted to compare the pharmacokinetics and pharmacodynamics (PD) of paclitaxel between Phase I trials of 3- and 24-h infusions and to determine the most informative pharmacokinetic parameter to describe the PD. Twenty-seven patients were treated in a Phase I study of paclitaxel by a 3-h infusion at one of six doses: 105, 135, 180, 210, 240, and 270 mg/m2. Pharmacokinetic data were obtained from all patients. Paclitaxel concentrations were measured in the plasma and urine using HPLC. The pharmacokinetics and PD were compared with those of a Phase I trial of paclitaxel by a 24-h schedule previously performed. The maximum tolerated dose of paclitaxel by a 3-h infusion was determined to be 240 mg/m2. The major toxicities were granulocytopenia, neuromuscular toxicities, and hypotension. Apparent differences in pharmacodynamic relationships for the change in granulocytes with dose, peak concentration, and areas under the concentration versus time curve were observed between the 3- and 24-h schedules. However, the relationship between the duration of plasma concentration above 0.05 microM and the change in granulocytes could be fitted to the same sigmoid maximum effect model in either schedule (P < 0.01). There were no clear relationships between peripheral neuropathy or hypotension and any pharmacokinetic parameters. The pharmacokinetics and PD of paclitaxel were schedule dependent. The duration of plasma concentration above 0.05 microM could be a common pharmacokinetic parameter predicting granulocytopenia for both schedules.

Vinorelbine tartrate (Navelbine): drug profile and nursing implications of a new vinca alkaloid

PURPOSE/OBJECTIVES

To review the drug profile and nursing implications of a new vinca alkaloid, vinorelbine tartrate (Navelbine, Burroughs Wellcome Co., Research Triangle Park, NC).

DATA SOURCES

Published articles, abstracts, professional communications, drug manufacturer, and personal experience with vinorelbine clinical studies.

DATA SYNTHESIS

The U.S. Food and Drug Administration approved vinorelbine for the treatment of advanced non-small cell lung cancer (NSCLC) in December 1994. Vinorelbine has shown significant activity in a variety of malignancies, including NSCLC and breast cancer. Studies of vinorelbine used as a single agent in treating patients with NSCLC have achieved results comparable to combination therapies but with less toxicity. Like other vinca alkaloids, vinorelbine is a microtuble-inhibiting agent. The recommended dose for a single-agent IV dose is 30 mg/m2 administered weekly. Vinorelbine is a moderate vesicant and venous irritant. The most common side effects are leukopenia and granulocytopenia; others include fatigue, injection site pain or irritation, nausea, vomiting, constipation, paresthesias, and diminished reflexes.

CONCLUSIONS

Vinorelbine is a well-tolerated treatment with mostly mild to moderate side effects that are reversible following treatment discontinuation.

IMPLICATIONS FOR NURSING PRACTICE

Nurses in diverse settings will focus on teaching and identifying and managing side effects of vinorelbine. Patient care concerns include risk for infection, potential for impaired skin integrity at injection site, altered comfort, constipation, and sensory/perceptual alterations.

Preclinical evaluation of docetaxel (Taxotere)

Progress in cancer chemotherapy has been made owing to the discovery and development of drugs that have new structures, new mechanisms of action, and high levels of experimental antitumor activity. Docetaxel (Taxotere; Rhône-Poulenc Rorer, Antony, France) is prepared by semisynthesis from 10-deacetyl baccatin III, an inactive taxoid precursor extracted from the needles of the European yew Taxus baccata. Docetaxel has been found to promote tubulin assembly in microtubules and to inhibit their depolymerization. As predicted by its unique biochemical mechanism of action, docetaxel acts as a mitotic spindle poison and induces a mitotic block in proliferating cells. In vitro, the docetaxel concentrations required to reduce murine and human cell survival by 50% range from 4 to 35 ng/mL, and the cytotoxic effects are greater on proliferating cells than on nonproliferating cells. Docetaxel also is cytotoxic at clinically relevant concentrations against fresh human tumor biopsy specimens (breast, lung, ovarian, colorectal cancer, melanoma) in a soft agar cloning system. Docetaxel has significant in vivo antitumor activity in the different models generally used for the preclinical evaluation of drugs. Eleven of 12 murine transplantable tumors in syngeneic mice have been found to be sensitive to intravenous docetaxel with complete regressions of advanced-stage tumors. Activity also has been observed with human tumor xenografts in nude mice at an advanced stage. In combination studies, synergism has been observed in vivo with 5-fluorouracil, cyclophosphamide, etoposide, vinorelbine, and methotrexate. Preclinical toxicity in mice and dogs has been evaluated by using one and five daily intravenous doses, respectively. The dog was found to be the more sensitive species. The dose-limiting toxicities are hematologic and gastrointestinal in both species. Neurotoxicity also has been observed at high dosages in mice.

Paclitaxel (Taxol) and docetaxel (Taxotere): active chemotherapeutic agents in lung cancer

Paclitaxel (Taxol), the prototype of a new class of plant-derived antineoplastic compounds, is a natural product isolated from the Pacific yew. Docetaxel (Taxotere) is a hemisynthetic product derived from the European yew. These agents share a unique mechanism of cytotoxic action by promoting assembly of microtubules and rendering the microtubules resistant to depolymerization. In vitro studies suggest a possible role for radiation sensitization. In Phase I trials, the dose-limiting toxicity was neutropenia for both agents. Other toxicities include infusion-related hypersensitivity reactions, alopecia, neurotoxicity, mucositis, diarrhoea and myalgias. To prevent infusion-related reactions, routine premedication is recommended. Noncumulative cardiac toxicity has been observed with paclitaxel. Fluid retention and rash have been reported with docetaxel. In Phase II studies of paclitaxel in advanced non-small cell lung cancer, response rates of 21% and 24% were observed. In Phase II studies of docetaxel in similar patients, response rates ranging from 28-38% were reported, including patients previously treated with cisplatin. The most common toxicity in these studies was neutropenia. Combination studies with cisplatin and other agents are in progress. Paclitaxel and docetaxel are among the most active chemotherapeutic agents for non-small cell lung cancer patients. Their testing will dominate trials of new therapies in this disease for years to come.

Relationship between the pharmacokinetics of irinotecan and diarrhea during combination chemotherapy with cisplatin

Two phase I trials of irinotecan (CPT-11) in combination with cisplatin were conducted. In both cases, the dose-limiting toxicities were leukopenia and/or diarrhea. During these trials the pharmacokinetics of CPT-11 and its active metabolite, 7-ethyl-10-hydroxycamptothecin (SN-38), were investigated to evaluate the relationship between pharmacokinetic parameters and diarrhea, since this is an unpredictable and severe toxicity of combination chemotherapy using CPT-11 and cisplatin. Twenty-three previously untreated patients with advanced lung cancer were evaluated in the pharmacokinetic study. Ten patients received CPT-11 at 80 or 90 mg/m2 plus cisplatin at 60 mg/m2. The other 13 patients received CPT-11 at 80 or 90 mg/m2 plus cisplatin at 80 mg/m2 with the granulocyte colony-stimulating factor support (2 micrograms/kg x 16 days). CPT-11 was given as a 90-min intravenous infusion on days 1, 8, and 15. Cisplatin was given on day 1. The pharmacokinetics of CPT-11 and SN-38 were analyzed on day 8 during the first course of treatment. The maximum tolerated dose of CPT-11 was 90 mg/m2 in both phase I trials. The severity of diarrhea was best correlated with the peak plasma concentration of SN-38 among the pharmacokinetic parameters tested. In addition, patients with a plasma SN-38 level > 12.4 ng/ml at 1.75 h after the start of CPT-11 infusion had a higher incidence of Eastern Cooperative Oncology Group grade 3-4 diarrhea than those with a lower SN-38 level (P = 0.0003). Stepwise logistic regression analysis identified the SN-38 concentration as a significant contributor to the development of diarrhea (P = 0.0021). We conclude that there is a clear relationship between the SN-38 concentration and diarrhea during chemotherapy with CPT-11 plus cisplatin.

Review of docetaxel (Taxotere), a highly active new agent for the treatment of metastatic breast cancer

Phase II studies have demonstrated that docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) is one of the most active single agents in the treatment of metastatic breast cancer. The overall response rate as front-line therapy for metastatic disease was 59% (95% confidence interval, 51% to 67%) in five phase II trials (four of which were multicenter) when 100 mg/m2 docetaxel was infused over 1 hour every 3 weeks. In the three phase II trials reported to date of patients with metastatic cancer who had failed previous frontline therapy, 100 mg/m2 docetaxel infused over 1 hour every 3 weeks produced an objective response rate of 49% (95% confidence interval, 40% to 58%). Two of these trials specifically included patients who had progressed while receiving either an anthracycline or an anthracenedione; the overall response rate in this subset of 83 patients was 48%. The most significant acute toxicity noted in these trials was neutropenia. Grade 4 neutropenia occurred in the majority of patients but rarely resulted in treatment delays. Hypersensitivity reactions also were common in nonpremedicated patients, but were rare after the institution of premedication with antihistamines and/or glucocorticoids. A novel toxicity observed in many patients was fluid retention syndrome, with onset at a median of four to five cycles. The fluid retention was of noncardiac or renal origin, was slowly progressive with additional cycles of therapy, was reversible after cessation of the drug, and could be largely ameliorated by oral diuretics and glucocorticoid premedication. Phase III studies to further define docetaxel's role in the treatment of breast cancer are now under way.

Phase II study of docetaxel for advanced or metastatic platinum-refractory non-small-cell lung cancer

PURPOSE

We conducted a phase II study to determine the response to and toxicity of docetaxel (Taxotere; Rhône-Poulenc Rorer Pharmaceuticals, Inc, Collegeville, PA) in patients with advanced non-small-cell lung cancer refractory to prior platinum-containing chemotherapy (PCC) regimens.

PATIENTS AND METHODS

Forty-four patients with stage IIIb or IV platinum-refractory non-small-cell lung cancer were treated with 100 mg/m2 of docetaxel intravenously over 1 hour every 3 weeks. The responses of 42 of 44 patients were assessable. Most patients had a Zubrod performance status of 1; the predominant histologic type was adenocarcinoma (61%), and 91% of patients had stage IV disease.

RESULTS

Nine of 42 assessable patients (21%) achieved a partial response to treatment. The median response duration (from response to progression) was 17 weeks, and the projected median survival duration of all patients is 42 weeks (51 weeks for adenocarcinoma and 22 weeks for nonadenocarcinoma). Grade 3/4 neutropenia occurred in 85% of patients and was associated with fever that required intravenous antibiotics in 16% of patients (3% of cycles). Other acute side effects included easily treated hypersensitivity reactions and dermatitis. Cumulative side effects included fluid retention and neuropathy.

CONCLUSION

Docetaxel administered at 100 mg/m2 intravenously every 3 weeks has notable activity against platinum-refractory non-small-cell lung cancer, with a 21% major response rate. Primary side effects were neutropenia, hypersensitivity, and fluid retention.

Phase II trial of a 75-mg/m2 dose of docetaxel with prednisone premedication for patients with advanced non-small cell lung cancer

BACKGROUND

A prior Phase II study of a 100-mg/m2 dose of docetaxel conducted at the Memorial Sloan-Kettering Cancer Center (New York, NY) demonstrated a 38% response rate with grade 3 or 4 neutropenia in 76% of the patients and a grade 2 or greater rash or infusion-related reaction in 41% and 34% of the patients, respectively. The current Phase II study sought to determine the activity of a 75-mg/m2 dose of docetaxel to establish whether this lower dose, combined with prednisone, ameliorates toxicity.

METHODS

Twenty untreated patients with advanced non-small cell lung cancer (NSCLC) received a 1-hour 75-mg/m2 dose of docetaxel every 21 days. Fifty milligrams of prednisone were administered twice the day before chemotherapy and once each of the next 3 days. Patients' disease-related symptoms were assessed prospectively using the Lung Cancer Symptom Scale (LCSS).

RESULTS

All patients were assessable for response and toxicity. Five patients had a major objective response (25%; 95% confidence interval, 11-50%). The median duration of response was 9.1 months. The projected 1-year survival was 71%. Grade 3 or 4 neutropenia occurred in 70% of the patients. Grade 2 or greater rash and infusion-related reactions decreased to 25% each. Analysis of the LCSS measurements found that six of nine component symptoms improved on Day 22, and all improved when baseline measurements were compared with the best value for each patient during the study.

CONCLUSIONS

Docetaxel administered at a dose of 75 mg/m2 every 21 days shows significant antitumor activity in untreated patients with NSCLC: Neutropenia is comparable with that observed at a 100-mg/m2 dose. The number of infusional reactions and rash decreased when docetaxel at this dose was administered with prednisone. Based on response rates observed in trials using a 100-mg/m2 dose with similar degrees of neutropenia, a 100-mg/m2 dose with steroid pretreatment is recommended future trials.

Docetaxel is a major cytotoxic drug for the treatment of advanced breast cancer: a phase II trial of the Clinical Screening Cooperative Group of the European Organization for Research and Treatment of Cancer

PURPOSE

This trial investigated the toxicity and efficacy of docetaxel as first-line chemotherapy in women with heavily pretreated advanced breast cancer.

PATIENTS AND METHODS

From April 1992 to August 1992, 35 patients with advanced breast cancer from 29 to 65 years of age with a performance status of 0 to 2 were entered onto the study. Docetaxel 100 mg/m2 was administered every 3 weeks as a 1-hour infusion on day 1 without routine premedication for hypersensitivity reactions. Thirty-one patients were assessable for response. Previous adjuvant chemotherapy had been given to 11 patients.

RESULTS

Five complete responses (CRs) and 16 partial responses (PRs) were observed, for an overall response rate of 67.7% (95% confidence interval, 49% to 83%). A CR occurred at 13 of 45 assessable sites (four liver, two lung, three breast, three lymph node, and one skin). The median duration of response was 44+ weeks, the median time to disease progression 37+ weeks, and the median overall survival time 16+ months. Among 34 patients assessable for toxicity (177 cycles; median, five cycles per patient), the following side effects were reported: nadir neutropenia grade 3 (three patients); grade 4 (31 patients); no grade 3 to 4 infection, acute hypersensitivity-like reaction (10 patients); grade 2 to 3 alopecia (all patients); and grade 2 to 3 nausea and vomiting (six patients). Fluid retention occurred in 26 patients and consisted of weight gain, edema alone (15 patients), or edema associated with serous effusion (11 patients). This side effect led to treatment discontinuation in 16 of 21 responding patients after a median of five cycles and a median cumulative dose of docetaxel of 574 mg/m2.

CONCLUSION

Our data suggest that docetaxel has major antitumor activity when used as a single cytotoxic agent as first-line chemotherapy in advanced breast cancer.

Phase II trial of CPT-11 in patients with advanced pancreatic cancer, an EORTC early clinical trials group study

BACKGROUND

CPT-11 (irinotecan) is a semi-synthetic derivative of camptothecin and exerts its activity by inhibiting DNA topoisomerase I. A phase II study of this drug was performed in patients with pancreatic cancer.

PATIENTS AND METHODS

Eligibility criteria included advanced non-chemotherapy-pretreated pancreatic cancer. CPT-11 was administered as a 30-minute i.v. infusion at a dose of 350 mg/m2 diluted in 250 ml normal saline every 3 weeks.

RESULTS

Thirty-four eligible patients were enrolled in the study, thirty-two of them were evaluated, and three achieved partial responses (9%; 95% C.I. = 3%-25%). The duration of response was 7.2, 7.5 and 7.8 months, respectively. Thirteen patients had no change, fourteen patients had progressive disease and two had early progressive disease. The median duration of survival for all patients treated was 5.2 months. The main toxicities (CTC grade > or = 3) were diarrhea, leukocytopenia, asthenia, nausea and vomiting in, respectively, 7%, 16%, 8%, 6%, 4% of the courses. These toxicities were reversible and manageable with anti-emetics and prophylactic or curative antidiarrheal agents.

CONCLUSION

CPT-11 is an interesting moderately effective drug in pancreatic cancer.

Phase II study of docetaxel (taxotere) in patients with previously untreated extensive small cell lung cancer

The objective of this multicenter phase II study was to evaluate the activity of docetaxel in previously untreated small cell lung cancer. Fourteen patients were treated at a dose of 75 mg/m2 intravenously every three weeks. Of the 12 patients evaluable for response, one had a partial response for a duration of 12 weeks for a response rate of 8.3%. Toxicity was mild. We conclude that docetaxel has, at the dose given in this study, little activity in previously untreated small cell lung cancer.

Current status of Taxotere (docetaxel) as a new treatment in breast cancer

Therapy for advanced breast cancer has not improved significantly in recent years, remaining strictly palliative in nature and intent. One approach to increase the effectiveness of the treatment is the introduction of active new drugs. Taxotere (docetaxel) is a taxoid derivative isolated from the needles of the European yew, Taxus baccata. Taxotere promotes the assembly of microtubules and inhibits their depolymerization. One EORTC Clinical Screening Group (CSG) phase II trial using Taxotere at 100 mg/m2, 1 hour infusion without routine premedication for hypersensitivity reactions, in first line chemotherapy, indicates a high anti-tumor activity: 5 complete and 18 partial responses in 32 patients assessable for response (overall response rate 72%, 95% CI 53%-86%). Other studies confirm this activity in first line and second line chemotherapy for advanced disease and in patients who are refractory to anthracycline containing regimens. Grades III and IV neutropenia without major infection, and grades I and II skin toxicity, were frequently observed adverse events. A fluid retention syndrome (chronic cumulative and non life-threatening toxicity) has been noted in patients treated with Taxotere. Methods for controlling fluid retention--dose reduction to 75 mg/m2 (which has little effect) or routine premedication from the start of treatment--are currently being studied.

Phase II study of a new vinca alkaloid derivative, S12363, in advanced breast cancer

Vinca alkaloids are widely used in the medical treatment of breast cancer. Our study aimed to evaluate the therapeutic activity of a new vinca alkaloid derivative, S12363 (vinfosiltine), which is 36 and 72 times more cytotoxic in vitro than vincristine and vinblastine, respectively. Because phase I studies did not allow a choice of the best treatment schedule, a randomization was performed between two schedules with the same dose intensity, that is, 0.3 mg/m2 given weekly or 0.6 mg/m2 given every 2 weeks. A total of 16 patients with advanced breast cancer who had failed a first-line treatment without any vinca alkaloid were entered in the study. Additionally, 6 women received the bimonthly regimen as first-line treatment of advanced breast cancer. Altogether, 17 patients received, prior to vinfosiltine, an anthracycline-based regimen given either as adjuvant (n = 4) or as first-line palliative treatment (n = 13). All 22 patients were evaluable for both toxicity and response. Neutropenia was the main toxic event (maximal toxicity per patient) with grade 3 (WHO) toxicity developing in 7/22 patients and grade 4, in 8/22. Other severe toxicities included leukopenia (n = 9), anemia (n = 1), diarrhea (n = 1), constipation (n = 1), and fatigue (n = 1). No patient achieved a complete or partial response. Vinfosiltine does not appear to have significant single-agent activity in advanced breast cancer at the doses and the schedules used in our study.

Effects of vinorelbine on epidermal growth factor-receptor binding of human breast cancer cell lines in vitro

Epidermal Growth Factor (EGF) is a mitogenic peptide that binds to surface membrane receptors (EGFR) of breast cancer cells. After binding, secondary transmitter molecules are activated by tyrosine phosphorylation of the intracellular receptor domaine. The activity of the EGF/EGFR system can be modulated by a variety of chemically unrelated compounds including cytostatic agents. The purpose of our present study was to determine the effects of vinorelbine, a novel semisynthetic vinca alkaloid on EGF receptor binding on human breast cancer cells. We have found that MDA-231 and MDA-468 cells bind substantially more [125I]-EGF after preincubation with vinorelbine. This effect was concentration- and time-dependent reaching a maximum at 100 ng/ml and 24 h incubation. Subsequent experiments showed an increase in the rate of EGF binding as well as maximal binding capacity. Scatchard analysis of binding experiments under equilibrium conditions indicated that this was mainly due to an increase in the number of apparent EGF binding sites. Modulation of EGF receptor binding by vinorelbine was not detectable when isolated membranes were used indicating that intact cytoplasmatic mechanisms are required for the upregulation of EGF receptors.

[Late phase II trial of RP56976 (Docetaxel) in patients with non-small-cell lung cancer]

A late phase II trial on RP 56976 (Docetaxel) was carried out against stage IIIB or IV non-resectable non-small cell lung cancer as a multicenter cooperative trial. Of 78 enrolled patients, seventy five patients were eligible and 71 were evaluable for the response. The overall response rate was 19.7% (14/71): 27.9% (12/48) of patients with adenocarcinoma and 10.0% (2/20) of patients with squamous cell carcinoma responded to docetaxel. The response rate was 15.0% (3/20) in patients with stage III B disease and 21.6% (11/51) in patients with stage IV disease. Leukopenia (neutropenia) occurred frequently, but most tended to recover in a short period of time. Other adverse reactions included nausea/vomiting, anorexia, general malaise, alopecia, all of which were not severe. Severe hypersensitivity reactions occurred in 2 patients (2.7%). The results seemed to show usefulness of docetaxel for the treatment of patients with non-small cell lung cancer.

A phase II trial of paclitaxel (Taxol) as first line treatment in advanced breast cancer

Paclitaxel (Taxol) is a natural product with a broad spectrum of activity against various solid tumors. This report includes nineteen patients with advanced breast cancer who have not previously received chemotherapy for metastatic disease. Fifteen patients had received adjuvant chemotherapy, eight of which were doxorubicin based. Patients were treated with 135 mg/m2 over 24 hours by continuous infusion given every 21 days. There were 2 complete and 4 partial responses for an objective response rate of 32% (95% C.I.: 14%, 57%) and eight patients or 42% with stable disease. Three of eight patients (38%) who had received adjuvant doxorubicin did respond to paclitaxel. Responses occurred in lung, liver, and soft tissue. The primary toxicity was hematologic with 13 hospitalizations for febrile neutropenia in 180 cycles (7%). Paclitaxel has moderate activity in a small number of patients with metastatic breast cancer at the dose of 135 mg/m2 over 24 hours in this study.

Phase I and pharmacologic studies of the camptothecin analog irinotecan administered every 3 weeks in cancer patients

PURPOSE

A phase I study was undertaken to determine the maximum-tolerated dose (MTD), principal toxicities, and pharmacokinetics of the novel topoisomerase I inhibitor irinotecan (CPT-11).

PATIENTS AND METHODS

Sixty-four patients meeting standard phase I eligibility criteria were included (24 women, 40 men; median age, 51 years; primary sites: colon, head and neck, lung, pleura; 60 of 64 had been previously treated). Pharmacokinetics was determined by high-performance liquid chromatography (HPLC).

RESULTS

One hundred ninety CPT-11 courses were administered as a 30-minute intravenous (IV) infusion every 3 weeks (100 to 750 mg/m2). Grade 3 to 4 nonhematologic toxicities included diarrhea (16%; three hospitalizations), nausea and vomiting (9%), asthenia (14%), alopecia (53%), elevation of hepatic transaminases (8%), and one case of skin toxicity. An acute cholinergic syndrome was observed during CPT-11 administration. Diarrhea appeared dose-limiting at 350 mg/m2, but this was circumvented by using a high-dose loperamide protocol that allowed dose escalation. Dose-dependent, reversible, noncumulative granulocytopenia was the dose-limiting toxicity (nadir, days 6 to 9; median recovery time, 5 days). Grade 3 to 4 anemia was observed in 9% of patients. One patient died during the study, 8 days after CPT-11 treatment. Two complete responses (cervix, 450 mg/m2; head and neck, 750 mg/m2) and six partial responses in fluorouracil (5-FU)-refractory colon cancer were observed (260 to 600 mg/m2). Pharmacokinetics of CPT-11 and active metabolite SN-38 were performed in 60 patients (94 courses). CPT-11 plasma disposition was bi- or triphasic, with a mean terminal half-life of 14.2 +/- 0.9 hours (mean +/- SEM). The mean volume of distribution (Vdss) was 157 +/- 8 L/m2, and total-body clearance was 15 +/- 1 L/m2/h. The CPT-11 area under the plasma concentration versus time curves (AUC) and SN-38 AUC increased linearly with dose. SN-38 plasma decay had an apparent half-life of 13.8 +/- 1.4 hours. Both CPT-11 and SN-38 AUCs correlated with nadir leukopenia and granulocytopenia, with grade 2 diarrhea, and with nausea and vomiting.

CONCLUSION

The MTD of CPT-11 administered as a 30-minute IV infusion every 3 weeks is 600 mg/m2, with granulocytopenia being dose-limiting. At 350 mg/m2, diarrhea appeared dose-limiting, but high-dose loperamide reduced this toxicity and allowed dose escalation. For safety reasons, the recommended dose is presently 350 mg/m2 every 3 weeks; more experience must be gained to establish the feasibility of a higher dose in large multicentric phase II studies. However, when careful monitoring of gastrointestinal toxicities is possible, a higher dose of 500 mg/m2 could be recommended in good-risk patients. The activity of this agent in 5-FU-refractory colorectal carcinoma makes it unique and mandates expedited phase II testing.

[Late phase II clinical study of RP56976 (docetaxel) in patients with non-small cell lung cancer]

A late phase II clinical study of RP56976 (Docetaxel) was conducted in patients with non-small cell lung cancer. Patients with non-small cell lung cancer in Stage IIIB and Stage IV not previously treated were enrolled. Docetaxel was administered at a dose of 60 mg/m2 based on the results of a phase I and an early phase II clinical study, and the efficacy and safety were examined. Of the 77 patients enrolled, 72 patients were evaluated to have completed the scheduled course of treatment by the Evaluation Committee. A partial response (PR) was seen in 18 patients, and the overall response rate was 25.0%. The response rate classified by clinical stage was 28.0% (7/25) in patients with Stage IIIB and 23.4% (11/47) in patients with Stage IV. Hematological adverse reactions included leukopenia of Grade III or more in 53.3% (40/75) and neutropenia of Grade III or more in 86.7% (65/75) as specified in the Adverse Event Reporting Form proposed by the Japan Society for Cancer Therapy. Other major adverse reactions included alopecia, asthenia, and fever, all of which were tolerable. From these results, the efficacy of docetaxel for the treatment of non-small cell lung cancer was confirmed.

Phase II trial of docetaxel in patients with platinum-refractory advanced ovarian cancer

PURPOSE

This phase II study was conducted to evaluate the efficacy and toxicity of docetaxel in the treatment of patients with platinum-refractory ovarian cancer.

PATIENTS AND METHODS

Twenty-five patients with platinum-refractory advanced ovarian cancer were treated. Twenty of the patients had failed to respond to platinum-based front-line chemotherapy and five had failed to respond to platinum-based therapy repeated at relapse. One patient had received prior pelvic radiation therapy. Patients were required to have bidimensionally measurable disease. Docetaxel was administered at a dose of 100 mg/m2 intravenously (i.v.) over 1 hour every 21 days. Twenty patients received no corticosteroid premedication and five received premedication with corticosteroids and antihistamines.

RESULTS

Eight of 23 assessable patients (35%) had a partial response (PR; 95% confidence interval, 16% to 57%). The median response duration was 5 months. Hospitalization for toxicity, predominantly neutropenic fever, occurred in 12 patients (48%) and 16% of courses. Anemia was common in the study population. Nonhematologic toxicities included alopecia, rash, fluid retention, diarrhea, peripheral neuropathy, and hypersensitivity reactions.

CONCLUSION

Docetaxel demonstrates significant activity in patients with platinum-refractory advanced ovarian cancer. Routine premedication is recommended. Further investigations of this agent in ovarian cancer, including combinations with other active agents, appear indicated.

[Early phase II clinical study of RP56976 (docetaxel) in patients with primary pulmonary cancer. Docetaxel Cooperative Study Group for Lung Cancer]

An early phase II clinical study of RP56976 (Docetaxel), a new anticancer agent of plant origin, was conducted in patients with primary pulmonary cancer as a multicentered study involving 28 Japanese institutions. Docetaxel was administered at an intravenous dose of 60 mg/m2 based on the results of a phase I clinical study, and efficacy and safety were examined. Of the 65 patients enrolled, 57 patients were evaluated to have completed the scheduled course of treatment by the Evaluation Committee. The antitumor effect in patients with non-small cell lung cancer was 21.4% (9/42). In patients not previously treated, the antitumor effect was 30.0% (6/20), in patients previously treated the antitumor effect was 13.6% (3/22), and in 13.3% (2/15) of patients with small cell lung cancer. This shows that docetaxel had an efficacy for non-small cell lung cancer. Hematological adverse reactions included leukopenia and neutropenia of Grade III or more as specified in the Adverse Event Reporting Form proposed by the Japan Society for Cancer Therapy in 53.3% (32/60) and 78.3% (47/60) patients, respectively. Other major adverse reactions included alopecia and anorexia. Neurological symptoms developed at a low frequency and were mild in severity.

[Late phase II clinical study of RP56976 (docetaxel) in patients with advanced/recurrent breast cancer]

A late phase II clinical study of RP56976 (Docetaxel), a new semisynthetic anticancer agent, was conducted in patients with advanced/recurrent breast cancer. RP56976 (Docetaxel) was in general administered at an intravenous dose of 60 mg/m2 with dose-free intervals of 3-4 weeks. Of the 74 patients enrolled, 64 patients completed the scheduled course of treatment. Three patients showed complete response (CR), 32 patients partial response (PR), 3 patients minor response (MR), 18 patients no change (NC), and 8 patients had progressive disease (PD). The overall response rate was 54.7%. The response rate in patients who previously had received chemotherapy was 55.7%, and the response rate in patients who had resistance to anthracycline agents or who did not respond to previous treatment was 58.7%. Adverse reactions included nausea/vomiting in 38 patients (57.6%), fatigue in 46 patients (69.7%), anorexia in 46 patients (69.7%), fever in 26 patients (39.4%), and alopecia in 60 patients (90.9%), all of which were tolerable. Abnormal laboratory findings included leukopenia (Grade III or more) in 57 patients (86.4%) and neutropenia (Grade III or more) in 56 patients (86.2%). The results show that RP56976 (Docetaxel) is an excellent agent with high antitumor effect for the treatment of advanced/recurrent breast cancer.

Treatment of adult T-cell leukaemia-lymphoma with irinotecan hydrochloride (CPT-11). CPT-11 Study Group on Hematological Malignancy

A late phase II study of a new camptothecin analogue, irinotecan hydrochloride (CPT-11), was conducted to evaluate the anti-tumour effect and toxicity in patients with refractory leukaemia and lymphoma including adult T-cell leukaemia (ATL)-lymphoma, in a multi-institutional cooperative study. All the patients with ATL had been previously treated with various conventional combination chemotherapies and were refractory to these therapies or had relapsed. CPT-11 was administered at a dose of 40 mg m-2 day-1 for three consecutive days repeated weekly until evidence of disease progression. One complete remission and four partial remissions were achieved in 13 assessable patients with ATL. The median total dose to achieve remission was 240 mg m-2 and the median duration of response was 31 days. The major toxicities were leucopenia (83%), diarrhoea (62%) and nausea/vomiting (69%). These were relatively severe, but they were generally tolerable and reversible. However, one patient died probably as a result of this therapy. No effective chemotherapy for adult T-cell leukaemia-lymphoma has yet been established, and the prognosis for patients with this disease is very poor. Our results suggest that CPT-11 may be a promising agent for this disease. Further combination therapy with CPT-11 is needed to improve the therapy for ATL.

[An early phase II clinical study of RP56976 (docetaxel) in patients with breast cancer]

An early phase II clinical study of RP56976 (docetaxel), a new anticancer agent of plant origin, was conducted in patients with breast cancer at 20 Japanese collaborative institutions. Docetaxel was administered at two or more doses of 60 mg/m2 by intravenous infusion with dose-free intervals of 3-4 weeks, and the efficacy and safety was evaluated. Of the 51 patients enrolled, 50 patients completed the scheduled course of treatment. Two patients showed a complete response (CR) and 19 showed a partial response (PR) with a response rate of 42.0%. The response rates based on the efficacy for metastatic lesions in soft tissue, liver and lung, were 46.2% (18/39), 37.5% (3/8), and 38.5% (5/13), respectively. Of the 50 patients who completed the study, 48 patients had previously been treated for the present malignancy. Forty-seven patients had previously been treated with chemotherapy and showed a response rate of 40.4% (19/47). The response rate in those who had received chemotherapy composed of anthracyclines and other agents was 44.1% (15/34). Grade 3 or more severe leukopenia and neutropenia developed in 43 patients (84.3%) and 48 patients (94.1%), respectively. Other adverse reactions which occurred in a Grade 3 or more severe form included nausea/vomiting (1 patient), anorexia (5 patients), diarrhea (4 patients), fatigue (2 patients), and alopecia (20 patients). Except for alopecia, most adverse reactions were generally transient and reversible without any specific treatment.