Review article: colorectal cancer chemotherapy

Colorectal cancer is a leading cause of cancer death world-wide. There have been important advances in the chemotherapeutic management of colorectal cancer as a result of a deliberate collaborative process of well-designed clinical trials. From the earlier standard of 5-fluorouracil-based therapy alone, the recent availability of newer agents, including capecitabine, irinotecan and oxaliplatin, has significantly expanded the options available for the management of patients with advanced colorectal cancer, with consequent improvements in survival. For patients with resected, high-risk, localized disease, adjuvant systemic chemotherapy improves survival. The identification of new chemotherapy regimens, the use of predictive testing and the integration of novel targeted therapies with cytotoxic chemotherapies are areas of active clinical investigation. A review of the chemotherapeutic management of colorectal cancer is presented.

Combination effects of Ara-C and 5-fluorodeoxyuridine against leukemia cells in vitro and in mice

BACKGROUND

Ara-C (1-beta-D-arabinofuranosylcytosine) is widely used for treatment of human leukemia. However, due to emergence of resistance, new drug combinations need to be developed.

MATERIALS AND METHODS

We tested the combination of Ara-C with 5-FdUrd (5-fluorodeoxyuridine) in L1210 and P388D1 mouse leukemia cells in vitro and in vivo by growth inhibition and recovery assay in leukemia-bearing mice.

RESULTS

Simultaneous incubation of cells with Ara-C and 5-FdUrd yielded more than additive effects for most combinations in both cell lines; synergy was seen in P388D1 cells. P388D1 cells showed delayed growth after treatment with Ara-C or 5-FdUrd in a growth recovery assay. In animal studies, simultaneous subcutaneous administration of the compounds did not show any significant beneficial effects as compared with monotherapy. Intraperitoneal administration of both compounds, however, significantly prolonged the survival of P388D1 animals.

CONCLUSION

Depending on cell type and route of drug administration, the combination of Ara-C and 5-FdUrd might offer a promising additional treatment option for leukemia.

Phase I/II study of hepatic arterial therapy with floxuridine and dexamethasone in combination with intravenous irinotecan as adjuvant treatment after resection of hepatic metastases from colorectal cancer

PURPOSE

Patients who undergo resection of liver metastases from colorectal cancer have an average 2-year survival of 65%. With hepatic arterial infusion (HAI) plus systemic fluorouracil and leucovorin, 2-year survival increased to 86%. For further improvement in both local and systemic control, combinations of new systemic drugs with HAI are being explored. The purpose of this study was to determine the maximum-tolerated dose (MTD) of systemic irinotecan (CPT-11) and HAI floxuridine (FUDR) plus dexamethasone (DEX) as combination adjuvant therapy after liver resection.

PATIENTS AND METHODS

Ninety-six patients who underwent complete resection of liver metastases from colorectal cancer were treated with six monthly cycles of HAI FUDR plus DEX for 14 days of each 4-week cycle plus escalating doses of systemic CPT-11. The primary end points of the phase I/II study were the MTD and efficacy of this regimen.

RESULTS

The MTD for combined systemic CPT-11 and HAI FUDR was CPT-11 at 200 mg/m2 every other week and FUDR at 0.12 mg/kg x pump volume / pump flow rate. The dose-limiting toxicities were diarrhea and neutropenia. With a median follow-up time of 26 months, the 2-year survival rate is 89%. All of the 27 patients who were treated at the MTD are alive.

CONCLUSION

In patients who undergo resection of liver metastases from colorectal cancer, adding systemic CPT-11 to HAI therapy in an adjuvant regimen is feasible. This regimen seems to have comparable activity to fluorouracil and leucovorin, but further studies are needed to assess whether it improves local control or decreases extrahepatic recurrences.

[A case of multiple lung metastases of colon cancer with long-term survival following 5'-DFUR and cimetidine therapy]

A 77-year-old woman treated for diabetes mellitus was admitted to our hospital for further examination of abnormal findings on chest plain radiograph. Many nodular shadows in both lung fields were seen on chest X ray and chest CT scan. Colonoscopic examination revealed a type 2 tumor in the ascending colon. We diagnosed this case as ascending colon carcinoma with multiple lung metastases, and performed right hemicolectomy and D1 lymph node dissection. After surgery, the patient was administered 5'-DFUR 600 mg/body/day, cimetidine 800 mg/body/day orally. Though no remarkable reduction of tumors was recognized, the increase of tumor size was relatively slow. The patient remains alive 3 years after surgery.

Intraperitoneal therapy as consolidation for patients with ovarian cancer and negative reassessment after platinum-based chemotherapy

Although three large phase III trials have documented the benefit of IP chemotherapy, this therapy as consolidation has been studied in only a few pilot studies. These small studies have included patients with a variety of baseline prognostic characteristics, and only one series had a comparator group of surgically documented pathologic complete response to uniform systemic chemotherapy. No randomized trials have been done to assess the impact of IP consolidation on progression-free survival or survival in either positively or negatively reassessed patients. It is hoped that the current experience will trigger further consideration of future phase III trials to assess the value of IP consolidation after initial induction with chemotherapy (ie, chemical debulking).

Multidetector CT arteriography with volumetric three-dimensional rendering to evaluate patients with metastatic colorectal disease for placement of a floxuridine infusion pump

OBJECTIVE

We sought to evaluate the usefulness of multidetector CT (MDCT) arteriography with volumetric three-dimensional (3D) rendering to depict the hepatic vascular anatomy. Our study population was patients who had undergone arterial mapping in preparation for placement of a hepatic arterial floxuridine infusion pump for treatment of metastatic hepatic colorectal carcinoma.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 26 patients with hepatic colorectal metastases who had been scheduled for implantation of a hepatic artery pump. Before surgery, all patients underwent MDCT arteriography with volumetric 3D rendering of the hepatic vessels. The axial and 3D arteriograms were evaluated for their usefulness in depicting hepatic arterial anatomy. Subsequently, three patients also underwent catheter angiography. Twenty-two of the 26 patients imaged had a hepatic artery floxuridine infusion pump implanted. Results of the CT arteriography were correlated with findings at surgery or on catheter angiography if surgery was not performed.

RESULTS

MDCT arteriography correctly revealed hepatic arterial anatomy in all 25 patients with angiographic or surgical confirmation. One patient with aberrant hepatic arterial anatomy did not have angiographic or surgical confirmation. Classic hepatic arterial anatomy was identified in 16 (64%) of 25 patients. The following hepatic arterial variants were found in one patient each: the common hepatic artery arising directly from the aorta; a replaced left hepatic artery; an accessory right hepatic artery; a replaced left hepatic artery and accessory right hepatic artery; a replaced right hepatic artery; a right hepatic arterial branch arising early (before the origin of the gastroduodenal artery); and replaced right and left hepatic arteries. Three patients were not suitable candidates for placement of a hepatic artery floxuridine pump. The patient who had no angiographic or surgical confirmation was also not considered a good surgical candidate because of replaced right and left hepatic arteries. Two patients (8%) had an accessory left hepatic artery.

CONCLUSION

MDCT arteriography with volumetric 3D rendering is an accurate, noninvasive method of depicting hepatic arterial anatomy and, therefore, of selecting patients with colorectal metastatic disease who could benefit from hepatic artery pump implantation. Catheter angiography provides no additional information, and we have eliminated it as a routine preoperative imaging examination.

Pharmacokinetics of 5-Fluorouracil Following Hepatic Intra-arterial Infusion in a VX2 Hepatic Metastasis Model

BACKGROUND

Hepatic intra-arterial infusion chemotherapy of 5-fluorouracil (5-FU) or fluorodeoxyuridine (FUDR) has been a treatment option for liver metastasis from colorectal cancer. However, an optimal administration schedule of 5-FU is still controversial. This study was conducted to evaluate a suitable schedule from the viewpoint of 5-FU metabolites and related enzymes.

METHODS

5-FU was infused into the hepatic artery of rabbits having hepatic deposits of VX2 tumor cells in a daily dose of 1, 4, or 8 mg/kg using various schedules. 5-FU, Thymidylate synthase (TS), TS inhibition rate (TSIR), and the amount of fluoro-RNA (F-RNA) were measured.

RESULTS

A high concentration of 5-FU was detected in the tumors of the group that was administered a dose of 8 mg/kg. TSIR in the tumor was about two-fold higher in the rabbits that were administered a total dose of 8 mg/kg than in those that were administered doses of 4 mg/kg or less. F-RNA, ranging from 27 to 36 ng/mg RNA, was detected in the tumor of the rabbits that were administered a total dose of 8 mg/kg. No difference was observed between the short period and the continuous administration schedules of rabbits that were administered a dose of 8 mg/kg of 5-FU. However, DNA synthesis inhibition in normal hepatic tissue was more dependent on the administration schedule than on the total dose of 5-FU because TSIR was significantly higher with shorter periods of drug administration.

CONCLUSION

Intermittent bolus administration of large doses of 5-FU might cause more severe hepatic impairment than continuous administration. These results suggest that hepatic intra-arterial infusion of 5-FU should be administered continuously for liver metastasis, although further experiments including a longer administration period of 5-FU are required.

[Floxuridine-containing regime in the treatment of gestational trophoblastic tumor]

OBJECTIVE

To analyse the efficacy of the floxuridine (FUDR)-containing regime (single agent or in combination) in the treatment of gestational trophoblastic tumor.

METHODS

Seventy-four patients with gestational trophoblastic tumors (GTT), 47 invasive mole and 27 choriocarcinoma, were treated with FUDR-containing regime. The clinical staging of the disease were: 33 cases of stage I, 3 cases of stage II, 31 cases of stage IIIa, 6 cases of stage IIIb, and 1 case of stage IV.

RESULTS

The cure rate of FUDR-containing regime in the treatment of GTT was 91.9% (68 out of 74 cases). Twenty-one out of these 74 patients showed drug resistant to 5-FU-containing or MTX-containing regime and were cured after they changed to the FUDR-containing regime. All 7 patients of advanced stage (> or = III b) got cured. The major adverse event of FUDR-containing regime was myelodepression and gastrointestinal toxicity: III-IV degree granulopenia 26%, III-IV thrombopenia 6.2%, III degree vomiting 57.1%, and III degree diarrhea 4.3%.

CONCLUSION

FUDR-containing regime is efficient for the treatment of GTT, even for those with advanced stage or drug-resistant disease.

Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: the M.D. Anderson experience

BACKGROUND

Carcinoid tumors have a predilection for metastasizing to the liver. The presence of liver metastases is associated with poor prognosis and also results in significant deterioration of patient's quality of life. Several reports suggest that hepatic artery embolization or chemoembolization can be used for control of liver disease in these patients. We retrospectively reviewed our experience with the use of hepatic arterial embolization or chemoembolization in patients with liver-dominant metastatic carcinoid disease, evaluating the clinical and radiologic response rates, duration of response, and progression-free and overall survival rates of these patients.

MATERIALS AND METHODS

The medical records of all patients with carcinoid tumors metastatic to the liver who underwent hepatic artery embolization or chemoembolization between January 1992 and December 2000 were reviewed. For the purposes of this study, we compared the follow-up computed tomography or magnetic resonance imaging with the baseline imaging to determine each patient's objective tumor response. The interval between the dates of response and disease progression was considered the response duration. Progression-free survival duration was calculated from the date of initial treatment to the date disease progression was recorded or the date of death. Survival durations were calculated using the Kaplan-Meier method.

RESULTS

Eighty-one patients (48 men and 33 women; age range, 38-79 years) were included in this study. The mean duration of disease from the initial discovery of liver metastases until embolization was 24.5 months. Fifty patients were treated with bland hepatic artery embolization, and 31 underwent chemoembolization. Of the 69 patients in whom radiologic response could be evaluated, partial response was observed in 46 patients (67%), minimal response (MR) in six (8.7%), stable disease in 11 (16%), and progressive disease in six (8.7%). The median duration of response in the 42 patients with partial response was 17 months (range, 4-51 months). Sixty-three percent of patients had a reduction in their tumor-related symptoms. The median progression-free survival duration was 19 months (95% confidence interval, 17-21 months); the probability of progression-free survival was 75%, 35%, and 11% at 1, 2, and 3 years, respectively. The median overall survival time was 31 months (95% confidence interval, 23-38 months); the survival probability was 93% at 1 year, 62% at 2 years, and 24% at 5 years.

CONCLUSIONS

Hepatic arterial occlusive therapy using hepatic artery embolization or chemoembolization results in symptomatic and radiologic response in most patients with carcinoid metastases in the liver. The progression-free survival of 19 months achieved with embolization in our study is encouraging, given that most patients had extensive liver involvement and had shown disease progression while receiving systemic treatment.

Effectiveness of doxifluridine (5'-DFUR)/docetaxel against advanced/recurrent gastric cancer showing resistance to various anticancer drug regimens

A 58-year-old man was diagnosed as having type 3 gastric cancer (poorly differentiated adenocarcinoma). He underwent total gastrectomy with splenectomy, as well as D3 dissection, and received postoperative chemotherapy combining oral uracil and futrafur (UFT) with cisplatin (CDDP), but results showed recurrence of multiple abdominal lymph node metastases around the aorta. He therefore received various anticancer drug regimens (irinotecan [CPT-11]/CDDP; 1 M tegafur-0.4 M gimeracil-1 M oteracil potassium [TS-1], methotrexate (MTX)/5-fluorouracil); however, final results showed growth of lymph node metastasis and simultaneous worsening of his general condition. The patient then received combined administration of doxifluridine (5'-DFUR)/docetaxel (5'-DFUR, 1000 mg/body [666.7 mg/m(2)], given by consecutive daily administration, orally, for days 1-14; and docetaxel, 80 mg/body [60 mg/m(2)], on day 8, by venous drip, every 3 weeks). Three courses of this regimen resulted in approximately 90% reduction of the abdominal lymph node size, disappearance of the right cervical lymph node metastasis, reductions of the levels of two tumor markers (carcinoembryonic antigen [CEA] and carbohydrate antigen [CA]19-9), and improvement of his general condition. In total, seven courses of the regimen were carried out. The patient died on day 298 after starting this combined regimen and showed a response period of 126 days. The primary toxicity identified was neutropenia (grade 4), as well as other low-grade (grade 1, 2) hematological and nonhematological toxicities. In the field of gastric cancer treatment, especially for patients showing multiple resistance to anticancer drugs, an effective therapy is critically needed.

[Effect of preoperative oral 5'-DFUR on PyNPase level in gastrointestinal malignant tumor tissues]

BACKGROUND & OBJECTIVE

Pyrimidine nucleoside phosphorylase (PyNPase) exists mainly in tumor tissues.5'-deoxy-5-fluorouridine(5'-DFUR) can decrease its level in tumor tissues. However, the effect of preoperative oral 5'-DFUR on PyNPase level in the different time after administration has not been reported. This study was designed to investigate the suitable duration of preoperative chemotherapy through observing the changes of PyNPase levels in gastrointestinal malignant tumors after preoperative oral administration of 5'- DFUR in different duration.

METHODS

Seventy-three patients with gastrointestinal malignant tumors were divided into four groups by the duration of preoperative oral 5'-DFUR (600-1,200 mg x d(-1)): group A, three days, 27 cases; group B, one week, 22 cases; group C, two weeks, 15 cases; group D, two months, 9 cases. Meanwhile, group E, control group, had 24 inpatients with gastrointestinal malignant tumors at the same term. All the above-mentioned patients did not receive the other chemotherapy or radiotherapy. The changes of PyNPase levels in tumor tissues of different groups were tested using reverse transcription polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC), etc.

RESULTS

(1)Under electron microscope, there were many irrecoverable, lethal changes in tumor cells of group C. The outlines of the tumor cells were normal under light microscope, and more fibroconnective tissues were seen only in the stroma of group D. (2)The expressing levels of PyNPase mRNA and protein production in tumor tissues reduced obviously in group A (0.79+/-0.08, 19.26+/-1.65), and decreased most obviously in group C (0.43+/-0.07,5.91+/-1.45) comparing with group E (0.95+/-0.09, 29.34+/-1.82). However, there was no significant difference between group C and group D (0.42+/-0.04, 5.36+/-1.19) for the levels of PyNPase mRNA and protein production. The correlation coefficient between the levels of PyNPase mRNA and protein in tumor tissues of different group was r=0.92(P< 0.0001).

CONCLUSION

5'-DFUR by oral administration before operation might destroy gastrointestinal malignant tumor cells. As the duration prolonged, the content of PyNPase in tumor tissues decreased progressively, being lowest level in two weeks after chemotherapy. So two-week duration might be suitable for the treatment.

Adjuvant hepatic arterial chemotherapy following metastasectomy in patients with isolated liver metastases

OBJECTIVE

To examine survival and toxicity by querying a single-institutional experience with adjuvant hepatic arterial infusional (HAI) chemotherapy.

SUMMARY BACKGROUND DATA

Three randomized series in the literature have examined adjuvant HAI after complete resection of liver metastases. Only one of these trials showed an overall survival benefit at 2 years but not over the entire time period of the study. Previous studies in patients with unresectable disease were plagued by high rates of biliary toxicity.

METHODS

A retrospective review of a prospectively maintained database was performed. Hepatic arterial pumps were placed in the standard fashion. Patients received floxuridine at doses previously demonstrated as safe in the literature. Standard statistical methods were used.

RESULTS

Twenty-one of 92 patients underwent placement of hepatic arterial pumps at the time of liver resection. The HAI group was similar in all demographic measures to the non-HAI group, with the exception that the HAI patients were significantly younger. No differences were seen between the groups in either disease-free or overall survival, although a trend toward improved hepatic progression-free survival was noted. Significant biliary sclerosis developed in six patients in the HAI group, requiring chronic indwelling stents in four patients. One patient died of progressive liver failure associated with this toxicity.

CONCLUSIONS

Biliary toxicity is an important potential side effect of hepatic arterial chemotherapy. Although larger randomized studies and this one suggest significant improvements in hepatic recurrences, these have not reliably translated into overall survival benefit. This fact, in light of the potential toxicity, would argue for a larger confirmatory trial of HAI in the adjuvant setting, incorporating recent advances in systemic therapy and careful attention to hepatotoxicity.

[A case of liver metastasis of colon cancer demonstrating complete remission with combination chemotherapy of 5'-DFUR and MMC]

The patient was a 77-year-old man with advanced colon cancer and liver metastasis, who underwent right hemicolectomy and liver resection. After surgery, a new liver metastasis was found. Chemotherapy of 5'-deoxy-5-fluorouridine (5'-DFUR) and mitomycin C (MMC) was conducted for 6 months. 5'-DFUR was administered orally at 1,200 mg/day for 5 days/week in combination with intravenous administration of MMC at 10 mg/4-week. The treatment was effective and the lesion disappeared. The patient received a subsequent single administration of 5'-DFUR, and remained in remission for 3 years after surgery.

Induction of thymidine phosphorylase expression and enhancement of Furtulon sensitivity by Taxol in a human ovarian carcinoma cell line

OBJECTIVE

Thymidine phosphorylase (TP) is one of the enzymes involved in the salvage pathways of nucleotide synthesis. The enzyme converts thymidine to thymine and 2'-deoxyribose-1-phosphate and can also metabolize the prodrug 5'-deoxy-5-fluorouridine (Furtulon) to 5-fluorouracil and 5'-deoxy-D-ribose-1-phosphate. The aim of this study was to determine whether Paclitaxel (Taxol) induces TP expression and whether increased TP expression is further sensitized to Furtulon, using a human ovarian carcinoma cell line.

MATERIAL AND METHODS

KF 28, a single-cell clone of a human ovarian carcinoma cell line, was used. TP expression was assessed by RT-PCR and Western blot analysis. Cell growth was evaluated by MTT assay.

RESULTS

The concentration of Taxol that inhibited the growth of cells to the level of 50% of the control growth was 4.65 +/- 0.35 nM. TP gene expression was significantly increased at 72 hours 1 nM Taxol exposure compared to the control by RT-PCR (p = 0.020). Western blot analysis confirmed that the TP protein level was elevated compared to the control at 72 hours 1 nM Taxol exposure. Cell growth did not significantly differ between the control and 72 hours 1 nM Taxol exposure groups (p = 0.917). After 48 hours treatment with Furtulon followed by 72 hours 1 nM Taxol exposure, cell growth was dose-dependently inhibited in Taxol-treated cells (p = 0.022), but not in non-Taxol-treated cells (p = 0.082).

CONCLUSION

Our results show that a low concentration of Taxol is a candidate for increasing TP expression in a human ovarian carcinoma cell line, and that cells with an elevated level of TP expression can be further sensitized to Furtulon. This information might be valuable in the development of new therapeutic interventions for epithelial ovarian cancer.

[Oral combination chemotherapy of 5'-deoxy-5-fluorouridine (furtulon) and cyclophosphamide for advanced breast cancer]

OBJECTIVE

To evaluate the efficacy and safety of the oral combination chemotherapy of furtulon (FTL) and cyclophosphamide (CTX) for advanced breast cancer (ABC).

METHODS

From Jun 2000 to Jun 2002, eighty-three patients with ABC were treated with the two oral drugs as combined chemotherapy. The mean number of cycles was 5, median number of cycles was 6 (range 2-6).

RESULTS

The overall response rate was 45.8%, The median time to progression was 6 months. The treatment was well tolerated, with related Grade 3 clinical adverse effect being only nausea and vomiting in 2 patients (2.4%) and mild hematologic toxicities.

CONCLUSION

Oral combined chemotherapy of FTL and CTX, being convenient and safe, is effective for patients with advanced breast cancer.

[Evaluation of weekly paclitaxel and doxifluridine (5'-DFUR) combination therapy in patients with advanced or recurrent breast cancer]

To evaluate the feasibility and efficacy of weekly paclitaxel and 5'-DFUR combination therapy in advanced or recurrent breast cancer, 13 patients were enrolled in this pilot study. 5'-DFUR was administered orally at a dose of 800 mg/day for 14 consecutive days, and paclitaxel was administered by 1 hour infusion at a dose of 80 mg/m2 after short premedication on day 1 and 8. This was repeated every 3 weeks, until disease progression or severe side effects precluded further treatment. Antiemetic agents and G-CSF were also administered, as needed. Nine patients had not received prior therapy, and four patients had received prior anthracycline containing therapy, two of whom were concomitantly receiving docetaxel treatment. Median administration time was 14 weeks, and median time to progression was 16.6 weeks. The overall response rate was 46.2% with 7.7% complete response and 38.5% partial response, and the response rate was consistent regardless of metastatic sites. Two patients achieved stable disease for at least 6 months and the clinical benefit was 61.5%. Responses were observed in 25% of the patients with prior anthracycline therapy. Grade 3/4 side effects involved leukopenia in 15.4%, peripheral neuropathy in 7.7%, malaise in 23.1% and nausea in 7.7%. There were no complaints of severe diarrhea. Although one patient withdrew from this study because of a hypersensitive reaction, this regimen was generally well tolerated and QOL was high enough so that it was possible to continue the regimen. Weekly paclitaxel and 5'-DFUR combination therapy seems to be feasible and effective in patients with advanced or recurrent breast cancer.

Totally implantable arterial device (TIAD): a questionable complication

The authors report a complication of a totally implantable arterial device in a patient in which the device was inserted to prevent recurrence of hepatic metastasis. After intrahepatic chemotherapy, during the nursing of the totally implantable arterial device, the patient developed a mass close to the duodenal loop that disappeared seven months later. The spontaneous decrease of this mass suggests the hypothesis of a hematoma due to a rupture of a pseudoaneurysm of a small collateral artery.

Efficient intracellular delivery of 5-fluorodeoxyuridine into colon cancer cells by targeted immunoliposomes

Immunoliposomes, liposomes with monoclonal antibodies attached, are being developed for targeting the anti-cancer drug 5-fluoro-2'-deoxyuridine (FUdR) to colon cancer cells. A monoclonal antibody against the rat colon carcinoma CC531 was covalently coupled to liposomes containing a dipalmitoylated derivative of the anti-cancer drug FUdR (FUdR-dP) as a prodrug in their bilayers. We studied the association with the tumor cells of different types of immunoliposomes varying in the position and orientation of the antibody at the liposome surface. We also assessed the in vitro anti-tumor activity of these liposomes and the mechanism by which the active drug FUdR is delivered intracellularly. Specific binding of the immunoliposomes to the tumor cells was observed. Immunoliposomes containing FUdR-dP caused a much stronger inhibition of CC531 cell growth in vitro than FUdR-dP in non-targeted liposomes. After binding to the cell surface only limited amounts of the immunoliposomes were internalized. By contrast, already within 24 h immunoliposome-incorporated FUdR-dP was hydrolyzed virtually completely to the parent drug FUdR, intracellularly. The mechanism of intracellular delivery of the drug most likely involves a selective transfer of the lipophilic prodrug from the liposomes to the cell membrane and subsequent intracellular processing. In conclusion, we developed a targeted liposomal formulation, which is able to deliver FUdR to colon carcinoma cells intracellularly with high efficiency, without the need for the cells to internalize the liposomes as such. This approach may be attractive for other lipophilic anti-cancer (pro)drugs. In this sense our system also serves as a model for the development of new lipid-based drug delivery systems for anti-cancer therapy.

Complications of hepatic artery infusion: a review of 4580 reported cases

PURPOSE

The resurgence of hepatic artery infusion (HAI) for the treatment of colorectal liver metastases has been dampened by concern over its complications. We have reviewed the incidence and frequency of complications associated with HAI and discussed the factors associated with these complications.

METHODS

A PUBMED search was conducted from 1950-2001 using various combinations of these keywords: hepatic arterial infusion, colorectal carcinoma, complications, and trials. The main inclusion criterion was the reporting of HAI complications. The main exclusion criterion was duplicated patients. Extracted data included chemotherapeutic agents, catheter technique, drug toxicities, and catheter related complications. Relative risks and 95% confidence intervals were calculated.

RESULTS

We reviewed 437 articles/abstracts and included 101 studies. 4580 patients with 4582 toxicities and complications were reported. The mortality rate was 1%. The most common toxicities were: GI symptoms 22%, chemical hepatitis 19%, and bone marrow toxicity 8%. 5-fluorouracil (5-FU) HAI had statistically significant risk for GI symptoms and bone marrow toxicity. Floxuridine (FUDR) HAI had statistically significant risk for chemical hepatitis, sclerosing cholangitis, and biliary toxicity. The most common catheter complications were: hepatic artery occlusion 6%, catheter thrombosis 5%, and catheter displacement 7%.

CONCLUSIONS

This literature review of the complications of HAI confirms a low mortality associated with HAI. Sclerosing cholangitis and chemical hepatitis are associated with the use of FUDR, while the use of 5-FU is associated with bone marrow toxicity. Our observations support the development of hepatic cytoprotective agents and other effective anti-tumor agents to improve the results and morbidity of HAI for colorectal liver metastases.

Preparation and characterization of chitosan microspheres containing doxifluridine

Chitosan microspheres containing 5-fluorouracil (5-FU), tegafur (FT), and doxifluridine (DFUR) were prepared by the dry-in-oil method using silicone oil with no surfactant as a dispersion medium. For DFUR-containing chitosan microspheres (DFUR-M), reacetylation with acetic anhydride or coating using chitosan and glutaraldehyde was performed. DFUR-M, reacetylated DFUR-M, and chitosan-coated DFUR-M were investigated on in vitro drug release, and the former two microspheres were examined for in vivo degradation after subcutaneous (s.c.) implantation in mice, and in vivo plasma concentration-time profiles after s.c. implantation in rats. The present method gave fairly large microspheres purely composed of chitosan and drug because of no use of surfactant, which showed the mean particle diameters of 300-900 microm and the drug contents of 4-22% (w/w). Encapsulation efficiency of DFUR was higher than that of 5-FU and FT. DFUR-M and reacetylated DFUR-M exhibited spherical shape except chitosan-coated DFUR-M. DFUR-M showed high initial rapid release, which was suppressed to some extent by reacetylation or chitosan coating. DFUR-M and reacetylated DFUR-M subcutaneously implanted were gradually degraded, and approximately half or a little more of the microspheres disappeared from the implanted site at 3 weeks postimplantation. DFUR-M and reacetylated DFUR-M implanted subcutaneously gave similar plasma concentration-time profiles of DFUR, which did not indicate prolonged release in vivo. DFUR-containing chitosan microspheres with fairly large size and good drug content could be obtained by the present preparation but remained to be improved for drug release properties.

Massive mucinous carcinoma of the breast untreated for 6 years

We report a patient with a massive mucinous carcinoma of the breast that had been untreated for 6 years. A 47-year-old premenopausal woman presented with a large right-breast mass. Although she had noticed a lump in the right breast 6 years previously, she had not sought treatment. The tumor had enlarged gradually and become ulcerated. With a diagnosis of advanced breast cancer with skin invasion, she underwent right mastectomy with a free skin graft. No lymph node metastases or distant metastases were detected. The histologic diagnosis of the tumor was pure mucinous carcinoma of the breast with no component of ordinary invasive ductal cancer. She has been well without evidence of tumor recurrence for 7 years after the surgery. The prognosis for mucinous carcinoma of the breast has been recognized as relatively good. The results in our patient are consistent with the biological behavior of this carcinoma.

Randomized controlled trial comparing oral doxifluridine plus oral cyclophosphamide with doxifluridine alone in women with node-positive breast cancer after primary surgery

PURPOSE

We compared the therapeutic usefulness of doxifluridine (5'-DFUR) alone and a combination of 5'-DFUR plus cyclophosphamide (CPM), both of which are considered effective against advanced and recurrent breast cancer, to determine which treatment is more beneficial as postoperative adjuvant chemotherapy.

PATIENTS AND METHODS

A total of 1,131 women with node-positive primary breast cancer were randomly assigned after primary surgery to receive 5'-DFUR alone or 5'-DFUR plus CPM. All patients initially received 5'-DFUR in an oral dose of 1,200 mg/d for 4 weeks, starting 4 weeks after surgery. Chemotherapy was then not given for 2 weeks. Patients in the 5'-DFUR group subsequently received five 4-week cycles of treatment consisting of oral 5'-DFUR (1,200 mg/d) for the first 2 weeks and no chemotherapy for the next 2 weeks. Those assigned to the 5'-DFUR plus CPM group also received oral CPM 100 mg/d for the first 2 weeks and no chemotherapy for the next 2 weeks. Women 50 years or older concurrently received 20 mg/d of tamoxifen for 2 years in both groups.

RESULTS

Of the 1,088 eligible women, 546 were assigned to receive 5'-DFUR alone and 542 were assigned to receive 5'-DFUR plus CPM. Overall disease-free survival was significantly better in women who received 5'-DFUR plus CPM than in those who received 5'-DFUR alone (log-rank test, P =.021). Toxic effects occurred in 20.0% of patients (109 of 546) in the 5'-DFUR group and 32.3% of patients (175 of 542) in the 5'-DFUR plus CPM group (chi(2) test, P <.001).

CONCLUSION

Combination therapy with 5'-DFUR plus CPM is more effective in preventing recurrence than 5'-DFUR alone.