L-folinic acid and 5-fluorouracil in the treatment of advanced breast cancer: a phase II study

BACKGROUND

The combination of 5-fluorouracil (5-FU) and folinic acid (FA) is an active combination for the treatment of advanced breast cancer (ABC). Theoretically, the biologically active isomer of FA, 1-FA, should be more effective than racemic FA in modulating 5-FU activity.

PATIENTS AND METHODS

Thirty-three patients (pts) with ABC, all previously treated with an anthracycline-based combination for advanced disease were treated with 1-FA: 100 mg/m2 i.v. and 5-FU: 370 mg/m2 i.v. for 5 consecutive days every 4 weeks.

RESULTS

Three complete remission (CR) and 11 partial remission (PR) were obtained for an overall response rate of 42% (95% CI = 25-59). Median duration of response was 10 months, median survival was 15 months for responders, 11 months for NC and 3 for PD. Eleven pts experienced a WHO grade III-IV oral mucositis (33%), 6 pts had grade III and one grade IV diarrhea, two pts had grade IV neutropenia resulting in one toxic death.

CONCLUSIONS

In this heavily pretreated population of pts with ABC, this regimen showed an interesting activity with substantial toxicity. Both the response rate and the pattern of side-effects seem similar to those experienced with the racemic mixture of d,1-FA. Modulated 5-FU warrants an increasing consideration in the treatment of breast cancer.

MICE: a new active combination for non-small cell lung cancer

We have treated 38 patients with stage III/IV non-small cell lung cancer with the following regimen: mitomycin-C = 6 mg/m2, ifosfamide = 3 g/m2, cisplatin = 75 mg/m2, vindesine = 3 mg/m2 (MICE), intravenously (i.v.) on day 1, every 3 weeks. Among 26 patients with stage IV disease, 15 obtained a partial remission (PR) (response rate = 57%, 95% confidence interval = 38-76), with a median time to disease progression and a median survival of 4.9 and 7.1 months, respectively. 6 out 7 patients with stage IIIA disease were documented as PR and 5 of them underwent radical surgery with two pathologically confirmed complete remissions. Overall toxicity was substantial but manageable: 3 patients had grade III/IV leucopenia (although 5 patients had neutropenic fever) whereas 13 patients experienced grade II/II anaemia. In conclusion we believe that MICE regimen is an interesting combination and warrants further evaluations both for palliation and in a neoadjuvant setting.

Steroid receptor enhancement by natural interferon-beta in advanced breast cancer

In the current study we investigated the effect of two different doses of natural interferon-beta (IFN-beta) on steroid hormone receptors in 45 patients with advanced breast cancer. IFN-beta seems to regulate the receptor mechanisms, inducing in cutaneous metastases an increase of oestrogen and progesterone receptors. Moreover, using IFN-beta and tamoxifen as a combined therapy in 23 receptor-positive patients, no negative interference of the two drugs was observed and no relevant side-effects due to the treatment were noticed. The modulation of steroid receptor content by IFN-beta in advanced breast cancer might represent an interesting way to ameliorate the clinical responsiveness to anti-oestrogens.

Fluorouracil, high-dose folinic acid, low-dose alpha-2b interferon and dipyridamole in the treatment of advanced colorectal cancer. A pilot study

Twenty-six patients with advanced colorectal cancer were treated with a combination based on multimodal biochemical modulation of 5-fluorouracil by means of high dose folinic acid, low-dose alpha-2b interferon and dipyridamole. The overall response rate was 42% (95% confidence intervals = 23%. 61%) with four complete remissions (15%). The median duration of response was 9 months and the median survival for responders was 15 months (all patients = 12 months). Toxic side effects included oral mucositis (grade III-IV = 38%) and a generally mild flu-like syndrome. This regimen seems active and safe enough to be compared with the combination of fluorouracil and high-dose folinic acid.

A phase II trial of ProMACE-CytaBOM in previously untreated non-Hodgkin's lymphoma of intermediate- or high-grade histology

Between November 1985 and June 1989 the aggressive combination chemotherapy programme ProMACE-CytaBOM was used at a community-based hospital as primary treatment for non-Hodgkin's lymphoma (NHL) of intermediate or high-grade histology in Ann-Arbor stages IB-IV. The 53 patients entering the study represented 90 per cent of all consecutive eligible patients with NHL diagnosed during the time period considered. Their median age was 54 years and median observation time was 36 months. Of 50 patients evaluable for response, 35 (70 per cent) achieved complete remission (CR), seven (14 per cent) partial remission, and five (10 per cent) were refractory. Treatment was given on an outpatient basis. Actually delivered drug doses ranged from 88 per cent to 97 per cent of the theoretical doses. Life-threatening toxicity was experienced by four patients. Treatment was stopped in three cases (6 per cent) because of toxicity and there was one treatment-related death. Actuarial 2-year disease-free survival of patients in CR was 73 per cent. Overall actuarial 3-year survival and disease-free survival were 67 per cent and 51 per cent respectively. High LDH level was a significant adverse prognostic factor both for achievement of CR (P less than 0.005) and for survival (P less than 0.0002). Age was of no prognostic importance. We conclude that ProMACE-CytaBOM is an effective, easy to administer and well-tolerated regimen for patients with aggressive NHL.

[Non-visual effects of light mediated via the optical route: review of the literature and implications for occupational medicine]

Artificial light which now plays an essential role in industrialized society differs from natural light both in intensity which is usually lower, and in spectrum, which is usually smaller. It is now a well-known fact that the human body is able to use luminous stimulation for aims other than sight; the pineal gland, though no longer directly sensitive to light as in lower animals, is nevertheless the fulcrum of a complex neuro-endocrine system which makes an interaction between light and the human body possible by means of the production of a number of substances of which melatonin is the most widely investigated. Melatonin is secreted at a circadian rhythm characterized by high nocturnal seric levels and low diurnal levels. This secretion appears to be correlated not only with the intensity of the light but also with its spectrum and time exposure. Even though the function of melatonin is still not fully understood, it seems possible to assign a mainly modulatory role to the pineal gland and melatonin. On the basis of studies performed on the pituitary-gonadal and/or hypothalamic axis and the reproductive system in animals, melatonin would appear to affect some endocrine functions (i.e., puberty) in man, too. Changes in melatonin secretion have been found in psychiatric illness, especially in cyclical affective disorders. Melatonin seems to be involved in stress-associated mechanisms, probably with an agonistic role, and also in carcinogenesis, where it seems to play a role in the growth of several tumors. Melatonin also affects both tumoral and cellular immune responses. Lastly, melatonin may be able to reduce the symptoms of the Jet Lag Syndrome. The consequences that prolonged and marked reduction in daylight exposure for occupational reasons could have on operators, especially young people, therefore constitute an interesting subject for occupational health; environmental photometry at the work-place, if adequately performed, could make a useful contribution to the development of this field of research.

Suramin: the discovery of an old anticancer drug

Suramin, an antitrypanosomal agent used since the early 1920s for the treatment of onchocerciasis and African sleeping sickness is now under active investigation as an antineoplastic drug characterized by an unusual and interesting mechanism of action and by a peculiar pattern of toxicity. Its capacity to interfere with the autocrine loop which promotes the growth of many human tumors as well as the suggested ability to modify the tumoral environment (chiefly by inhibiting the angiogenesis) holds out great promises for a major step forward in cancer therapy.

Mitomycin-C, vinblastine, and lonidamine as salvage treatment of advanced breast cancer. A pilot study

Thirty-two patients with advanced breast cancer were treated with mitomycin-C 10 mg/m2 IV and vinblastine 6 mg/m2 IV every 21 days in combination with lonidamine 450 mg/day P.O. and prednisone 15 mg/day P.O. given continuously. Among the 29 evaluable patients (all but three pretreated with an anthracycline-based regimen), one complete remission (CR) and six partial remissions (PR) (response rate, 24%) were seen. The median duration of response was 14 months (range, 4-30 months). Median survival for responders was 18 months (range, 4-30 months). Hematological toxicity was uncommon; the main lonidamine-related side effects were myalgia, abdominal cramps, and reversible deafness; these side effects were severe in two, one, and one patients, respectively. The regimen seems to have a reasonable degree of activity and toxicity in advanced, refractory breast cancer. The role of lonidamine in the treatment of this disease warrants further evaluation.

The emerging role of 5-fluorouracil and leucovorin in the treatment of advanced breast cancer. A review

Considerable interest has been generated by the clinical experience with 5-fluorouracil + leucovorin based regimens in colorectal cancer. Consequently, this combination was tested in other tumors in which 5-fluorouracil has some activity (gastric, pancreatic, head and neck and breast cancer). This review summarizes the interesting results reported so far in advanced breast cancer. Up to now, more than 300 patients have been treated with chemotherapeutic regimens based on this attempt at biochemical modulation of 5-fluorouracil's activity. Overall, a median response rate of 26% was achieved by nine studies performed in 245 mainly pretreated patients with an acceptable degree of toxicity. Moreover, two additional studies explored the clinical activity of this combination as first-line chemotherapy for advanced disease with impressive results. Current efforts to further improve the therapeutic index of this combination will also be briefly discussed.

Phase II trial of 5-fluorouracil and high-dose folinic acid in advanced renal cell cancer

Fourteen patients with metastatic renal cell carcinoma (RCC) were treated with high-dose folinic acid (HDFA): 200 mg/m2 i.v. and 5-fluorouracil (5-FU): 370 mg/m2 i.v. for 5 consecutive days every 28 days. Severe oral mucositis (WHO grade III-IV) was experienced by two patients, whereas hematological toxicity was mild. No complete or partial remission was observed. Short-lasting stable disease occurred in 8 patients (median = 5 months, range 2-11). This combination does not need further evaluation in patients with RCC.

5-Fluorouracil and dipyridamole in metastatic breast cancer: a pilot study

In an attempt to increase the clinical activity of 5-fluorouracil (5-FU) by blocking the thymidine salvage pathway, 15 patients with refractory metastatic breast cancer (MBC) were treated with oral dipyridamole (D): 75 mg p.o. q.i.d. and 5-FU: 400 mg/m2 i.v. by bolus for 5 consecutive days, every 28 days. All the patients were pretreated with 5-FU and an anthracycline-based regimen. Toxicity was minimal, with 8 patients experiencing a D-related moderate headache. Although no objective responses were seen, two patients with 5-FU refractory disease showed tumor shrinkage. A different D schedule and the addition of folinic acid (FA) to 5-FU might provide better results and deserves further evaluation.

Cyclophosphamide, epirubicin, high-dose folinic acid and 5-fluorouracil (super-FEC) as first-line chemotherapy for advanced breast cancer: preliminary results

Forty patients with metastatic breast cancer were treated with a new combination regimen consisting of cyclophosphamide, epirubicin, high-dose folinic acid and 5-fluorouracil (super-FEC). A major objective response was observed in 32 patients (80%). Among these, 11 patients (27%) experienced a complete remission. The median duration of response was 10+ and 12+ months for CR and PR, respectively. The most common side-effect was oral mucositis (Grade III = nine patients; grade IV = two patients), while haematological toxicity was virtually absent. Considering the high-risk characteristics of the vast majority of the enrolled patients (75% had dominant visceral disease), these preliminary results suggest that super-FEC has a powerful activity in poor-prognosis metastatic breast cancer with an acceptable degree of toxicity.

Complete estrogen blockade with buserelin and aminoglutethimide for advanced breast cancer: a phase I-II study with long-term hormonal correlations

We treated 21 patients with advanced breast cancer with buserelin, aminoglutethimide and cortisone acetate in an attempt to obtain a complete estrogen blockade both in premenopausal and postmenopausal patients. Ten patients (47%) obtained an objective response without any relevant side-effects. Dealing with hormonal data, it must be outlined that serum testosterone levels decreased significantly in postmenopausal patients, suggesting a possible explanation for the activity of luteinizing hormone-releasing hormone analogue in this group of patients.

[Update on paraneoplastic hypercalcemia. Our experience in the treatment of hypercalcemic states of patients with advanced breast carcinoma]

The treatment of hypercalcemia of malignancy is troublesome. Personal experience with breast cancer associated hypercalcemia is presented. Eight patients were hydrated with intravenous administration of saline solution containing high doses of salmon calcitonin and subsequently six were treated with antiblastic polychemotherapy. Calcium level fell to normal in all patients. Hypercalcemia, with or without evidence of metastatic bone disease, may be caused by the production of humoral substance by tumoral tissue. In our experience the first therapeutic stage is the infusion of saline solution containing high doses of calcitonin, while the elective treatment is antiblastic polychemotherapy which, acting on tumour growth, may inhibit the release of humoral mediators of hypercalcemia causing a slower but stable reduction in serum calcium level.

Premarin priming before prednimustine, high-dose folinic acid and 5-fluorouracil as salvage chemotherapy for advanced breast cancer

Thirty patients with advanced and mainly pretreated breast cancer were treated with a combination of premarin, prednimustine, high-dose folinic acid and 5-fluorouracil. Among the 30 evaluable patients, 9 (30%) achieved an objective response (median duration: 9 months). Oral mucositis was the limiting toxicity, while myelosuppression was quite mild. In spite of considerable activity as salvage regimen, these results do not seem better than those achieved in our Institute with high-dose folinic acid and 5-fluorouracil alone.

Peptichemio, teniposide and high-dose dexamethasone: a new active combination for relapsing and refractory multiple myeloma. A pilot study

Twelve patients with refractory (8 pts) and relapsing (4 pts) myeloma were treated with Peptichemio. Teniposide and high-dose dexamethasone. Eight patients experienced an objective response (5 out 8 with refractory and 3 out 4 with relapsing disease) with a median duration of 10+ months. Overall toxicity was mild to moderate and chiefly haematological. Our preliminary results seem very promising and justify a larger phase II study with this regimen.

Cisplatin, high dose folinic acid and 5-fluorouracil in squamous cell carcinoma of the esophagus. A pilot study

We treated 20 patients with squamous cell carcinoma of the esophagus with the following regimen: cisplatin = 100 mg/m2 i.v. day 1, HDFA = 200 mg/m2 i.v. day 1 to 5, 5-fluorouracil = 370 mg/m2 i.v. day 1 to 5 repeated every 28 days. Among the 17 evaluable patients, 4 (23%) had a partial remission, 6 had stable disease while 7 progressed. The median survival for all patients was 6+ months. Grade III or IV toxicity included 2 patients with grade III leukopenia, 1 with grade III thrombocytopenia, 1 patient with grade IV and 3 patients with grade III oral mucositis, 3 patients with grade III diarrhea. The regimen did not seem particularly active in the treatment of squamous cell carcinoma of the esophagus and had manageable but substantial toxicity.

Cyclophosphamide, epirubicin and cisplatin (CEP) in advanced breast cancer: preliminary results

Twenty-five patients with advanced breast cancer were treated every 28 days with Cisplatin, 30 mg/m2 iv on days 1,3,5; Epirubicin, 40 mg/m2 iv on day 1; Cyclophosphamide, 200mg/m2 iv on days 1,3,5. Partial remission was achieved by 7 patients (33%), all of whom had been untreated with chemotherapy. Overall toxicity was moderate but manageable. Severe haematological toxicity was experienced by 5 patients (20%) with grade III anemia; 2 patients had grade II oral mucositis; 4 had grade II diarrhoea Moderate nausea and vomiting were seen in all patients. Although they are only preliminary, our results suggest that this treatment had considerable activity as first line chemotherapy in advanced breast cancer and deserves further evaluation.

5-Fluorouracil and high-dose folinic acid as salvage treatment of advanced breast cancer: an update

We report an update of our results of a trial of high-dose folinic acid (HDFA) and 5-fluorouracil (5-FU) in advanced breast cancer. Thirty-eight patients with advanced and mainly refractory breast cancer were treated with the following regimen: HDFA (200 mg/m2/day) and 5-FU (340, 370, 400 mg/m2/day) given immediately afterwards, for 5 consecutive days every 4 weeks. Of 36 evaluable patients, 3 achieved complete remission (8%) and 13 partial remission (36%) for an overall response rate of 44%, while 11 patients (30%) had stable disease. Thirteen out of sixteen responders (85%) were pretreated with some 5-FU-containing regimens. The median duration of response was 9.6+ months, the median survival for responders and for patients with stable or progressive disease was 19.9+, 18.8+ and 9 months, respectively. The overall toxicity was acceptable: while hematological toxicity was very mild, oral mucositis, diarrhea and conjunctivitis were major side effects. These results seem very promising and deserve further evaluation.