Dose-intensive weekly chemotherapy for treatment of relapsed small-cell lung cancer

PURPOSE

This study was undertaken to determine the activity and toxicity of dose-intensive weekly chemotherapy (cisplatin, vincristine, doxorubicin, and etoposide [CODE] regimen) for previous treated, recurrent small-cell lung cancer (SCLC).

PATIENTS AND METHODS

The 17 patients with relapsed SCLC entered onto the study were to receive intensive weekly chemotherapy with the CODE regimen. All 17 patients had been heavily pretreated with some form of cisplatin-based combination chemotherapy. Six patients had received previous chemotherapy with CODE and one patient with cisplatin and etoposide (PE) as induction therapy. Nine patients had been treated with concurrent or sequential PE plus thoracic irradiation (TRT). The median time off chemotherapy was 6.7 months (range, 3.3 to 72). Patients were treated with 9 weeks of the CODE regimen. Response, survival, and toxicity data were noted.

RESULTS

All 17 patients were assessable for response, survival, and toxicity. Fifteen of 17 patients (88.2%) had an objective response, with five complete responses (CRs; 29%) and 10 partial responses (PRs; 58.8%). The median durations of response and survival were 156 days and 245 days, respectively. Myelosuppression was significant, with 76% of patients developing grade 4 leukopenia. No treatment-related death was observed.

CONCLUSION

The CODE regimen is highly active in the treatment of relapsed SCLC with an encouraging survival outcome.

Overview of clinical studies of childhood acute lymphoblastic leukemia for more than ten years by the Japanese Children's Cancer and Leukemia Study Group

Since 1981, the Children's Cancer and Leukemia Study Group (CCLSG) has developed a series of protocols for treatment of acute lymphoblastic leukemia (ALL) in childhood. In the first randomized controlled study of the 811 protocol (1981-1983) a comparison of conventional daily 6-mercaptopurine and methotrexate with a pulsed regimen of the two drugs was performed. The superiority of the pulsed regimen was shown. In the next 841 protocol (1984-1987) a comparison of two drugs and three drugs during induction therapy was conducted. The three-drug regimen resulted in a significantly higher event-free survival (EFS) rate. In the 874 protocol (1987-1990) two regimens with or without cranial irradiation were randomly compared, and there was no significant difference between the two regimens for the standard-risk group. To further improve the EFS rate a risk group-directed protocol 911 was conducted starting in January 1991. Life-table analysis of serial CCLSG protocols revealed that the outcome of overall ALL has gradually improved with an increase of the EFS rate; 41.4% +/- 3.6% at 14 years for the 811 protocol, 51.3% +/- 3.5% at 11 years for the 841 protocol, 56.7% +/- 3.1% at 8 years for the 874 protocol, and 78.2% +/- 3.1% at 4 years for the more recent 911 protocol.

Phase II study of high-dose dexamethasone-based association in acute and delayed high-dose cisplatin-induced emesis--JCOG study 9413

Thirty-three patients with lung cancer receiving 80 mg m(-2) cisplatin were treated with high-dose dexamethasone (32 mg m(-2) on days 1-3, 16 mg m(-2) on day 4 and 8 mg m(-2) on day 5) combined with granisetron on day 1 and metoclopramide on days 2-5. Twenty-eight (85%) patients had no nausea or vomiting on day 1, and 16 (48%) achieved total control on days 1-5 with acceptable toxicity. High-dose dexamethasone for cisplatin-induced delayed emesis should be further evaluated in a phase III trial.

Expression of the Ets-1 proto-oncogene in human gastric carcinoma: correlation with tumor invasion

The proto-oncogene Ets-1 is a transcription factor known to control the expression of a number of genes involved in extracellular matrix remodeling and has been postulated to play a role in cell migration and tumor invasion. To elucidate the involvement of Ets-1 in human gastric carcinomas, we examined 11 cases of gastric adenoma and 110 cases of gastric carcinoma by immunohistochemistry and compared the degree of Ets-1 expression with the depth of carcinoma invasion. Ets-1 was not expressed either in the normal gastric epithelium or in gastric adenomas. Among the 110 cases with gastric adenocarcinoma, 70 (63.6%) showed positive staining for the Ets-1 protein. In mucosal carcinomas, only 3 of 26 cases (11.5%) showed positive immunostaining for Ets-1. In contrast, 67 of 84 cases (79.8%) with submucosal or more invasive carcinomas showed immunopositivity and intense staining for Ets-1 in the tumor cells. The pattern of Ets-1 immunostaining in mucosal carcinomas was weak and differed from that of other local invasive carcinomas (P < 0.001). Histologically, signet-ring cell and mucinous carcinomas expressed relatively weak positivity for Ets-1. Ets-1 expression correlated significantly with the presence of lymph node metastasis (P < 0.001). In situ hybridization, using an Ets-1 oligonucleotide probe, also confirmed the presence of Ets-1 mRNA in gastric carcinomas. Expression of Ets-1 mRNA was also detected in four different kinds of cultured human gastric carcinoma cell lines by the reverse transcription polymerase chain reaction method. These findings suggest that Ets-1 is overexpressed in gastric mucosal cells that have undergone malignant conversion and that Ets-1 is one of the factors involved in the penetration of gastric carcinoma beyond the muscularis mucosa.

Impairment of antioxidants in colonic epithelial cells isolated from trinitrobenzene sulphonic acid-induced colitis rats. Protective effect of rebamipide

BACKGROUND

The functional status of glutathione, its related enzymes, and Cu,Zn-superoxide dismutase in colonocytes isolated from rats with trinitrobenzene sulphonic acid-induced colitis, and the effect of rebamipide (a scavenger) on these antioxidants and on colitis, were studied.

METHODS

The rats were treated with rebamipide, killed on day 14, and compared with controls. Glutathione and enzymatic activities were spectrophotometrically estimated. The effect of rebamipide on colitis was also assessed histologically and by myeloperoxidase activity.

RESULTS

In controls the concentration of glutathione and the activities of glutathione S-transferase and Cu,Zn-superoxide dismutase were decreased, but that of glutathione peroxidase was increased. Rebamipide prevented the impairment of these enzymes, restored the concentration of glutathione, and attenuated (low damage scores and myeloperoxidase activity) the severity of the colitis.

CONCLUSIONS

These features suggest that the impairment of antioxidants is closely related to the development of the inflammatory lesions, and rebamipide has a beneficial effect on experimental colitis.

Expression of parathyroid hormone (PTH)-related peptide (PTHrP) and PTH/PTHrP receptor in giant cell tumour of tendon sheath

The giant cell tumour of tendon sheath (GCTTS) is mainly composed of mononucleated stromal cells (SC) and multinucleated giant cells (GC), so-called osteoclast-like GC. It is thought that GC are derived from SC, but their precise relationship is not fully understood. Parathyroid hormone (PTH)-related peptide (PTHrP) is now considered to be a cytokine for cell differentiation, which may stimulate osteoclast-like cell formation in haematopoietic cells. Five cases of GCTTS were evaluated immunohistochemically, using a variety of antibodies against PTHrP, PTH/PTHrP receptor, KP-1 as a histiocytic phenotypic antigen, fibronectin as a fibroblastic phenotypic antigen, and proliferating cell nuclear antigen (PCNA). In situ hybridization and immunohistochemistry revealed that in all cases both SC and GC expressed PTHrP. PTH/PTHrP receptor was observed only in histiocytic SC and GC, but not in fibroblastic SC. Almost all GC showed histiocytic features. PCNA immunoreactivity was detected only in the nuclei of SC, and not in GC. Moreover, SC with PTH/PTHrP receptor immunoreactivity were negative for PCNA. These results suggest that GC are derived from histiocytic SC expressing PTH/PTHrP receptor and losing proliferative activity in the process of transition from mononuclear to multinucleated. PTHrP produced by SC and GC may be involved in the formation of osteoclast-like cells in GCTTS by acting in an autocrine/paracrine fashion.

Incidence of intracranial meningiomas in Nagasaki atomic-bomb survivors

Among the Nagasaki atomic-bomb survivors registered at the Scientific Data Center for Atomic-Bomb Disaster, Nagasaki University School of Medicine, 45 cases of surgically treated intracranial meningioma were collected from 6 hospitals with departments of neurosurgery in or near Nagasaki City during the period from 1973 to 1992. All 45 patients were over 40 years of age at the time of diagnosis. Subsequently, the 45 cases were statistically analyzed in relationship to the estimated distance from the hypocenter by age, gender, intracranial location, histology and latent period. The analysis showed a high correlation between incidence of meningiomas and distance from the hypocenter. The incidence among Nagasaki atomic-bomb survivors over 40 years of age, especially in those proximally exposed, appears to be increasing, in inverse proportion to the exposure distance, since 1981, 36 years after the explosion of the atomic bomb.

Late recurrence of small-cell lung cancer: treatment and outcome

The 2-year survival of patients with small-cell lung cancer (SCLC) with limited disease is about 25% and the survival curve continues to decline after 2 years. We reviewed 34 cases of survivors of SCLC who had been free of disease for 2 years and who constituted 12.2% of the 278 patients with SCLC newly diagnosed at our institution from 1977 to 1991. The cancer had recurred in 13 patients, 10 of whom were treated with chemotherapy and/or radiotherapy, and 1 complete and 1 partial response were obtained. Three patients received only supportive care because of poor performance status. The median survival after recurrence in the 13 patients was 7.4 months (range 0-39 months). A second primary cancer was noted in 5 patients, but 3 of them died from recurrence of SCLC. The prognosis of patients with late recurrence of SCLC was relatively good, and it seems that adequate treatment in such cases may lead to long-term survival.

Phase II study of 3-hour infusion of paclitaxel in previously untreated non-small cell lung cancer

Paclitaxel has clinical activity in non-small cell lung cancer, with response rates of 21 and 24% in a 24-h infusion. Recent clinical studies have shown that a 3-h infusion of the drug with premedication did not result in hypersensitivity reactions, and that neutropenia was milder in the 3-h than in the 24-h schedule. In this Phase II study, we tried to evaluate the efficacy and toxicity of paclitaxel given over 3 h in patients with previously untreated, unresectable stage III or IV non-small cell lung cancer. In addition, we attempted to investigate the pharmacokinetics and pharmacodynamics of the drug. Paclitaxel was administered i.v. over 3 h at a dose of 210 mg/m2 every 3 weeks with premedication of dexamethasone, ranitidine, and diphenhydramine. Heparinized blood samples were obtained from 12 patients for pharmacokinetic studies. Twenty-three (38%) of 60 assessable patients achieved a partial response, with a median duration of 3.2 (range, 2.3-11.1) months. The median survival for all patients was 11.2 months, and the 1-year survival rate was 48%. Thirty (50%) patients developed grade 4 neutropenia. Nonhematological toxicities were mild, except for pulmonary toxicity in one (1.7%) patient who required mechanical ventilatory support for 4 days. The duration of the paclitaxel concentration above 0.1 microM correlated well with the percentage of decrease in the absolute neutrophil count. In conclusion, a 3-h infusion of paclitaxel was safe and probably not less effective than a 24-h infusion.

A randomized cross-over trial of granisetron and dexamethasone versus granisetron alone: the role of dexamethasone on day 1 in the control of cisplatin-induced delayed emesis

We studied the role of dexamethasone (DEX) administered on day 1 in controlling cisplatin-induced delayed emesis. Forty patients were randomly allocated to receive either granisetron (GRN) and DEX on day 1, or the same dose of GRN alone. On days 2-5, all the patients received metoclopramide and DEX. They were crossed over to the other antiemetic regimen with their second course of chemotherapy. Thirty-one patients were evaluable for efficacy. The mean visual analogue scale scores for nausea on days 1 and 2 were 9.1 and 18.8 mm for GRN and DEX, and 16.3 and 28.5 mm for GRN alone, respectively (P<0.05 on day 2). The mean numbers of emetic episodes on days 1-3 were 0.036, 0.46 and 0.36 for GRN and DEX, and 0.39, 0.89 and 0.57 for GRN alone, respectively (P<0.01 on day 1). Hiccups and restlessness were noted in 38% and 33% of cycles, respectively. Addition of DEX to GRN on day 1 thus enhanced the control of delayed emesis.

Efficacy of interferon in treating chronic hepatitis C in children with a history of acute leukemia

Interferon (IFN) is effective in treating adults as well as children with chronic hepatitis C. We investigated the efficacy of IFN therapy in 13 children with underlying acute leukemia who had chronic hepatitis C (age range, 5 to 17 years; mean age, 9.9 years). Natural IFN- alpha was administered at a dose of 0.1 mega unit (MU)/kg (maximum dose, 6.0 MU) daily for 2 weeks and then three times per week for an additional 22 weeks (total dose, 8 MU/kg). IFN treatment was initiated at least 2 years after the completion of treatment for acute leukemia. A complete response was obtained in 5 children (38%). The serum level of anti-hepatitis C virus core antibody was closely related to the response to IFN. IFN therapy was well tolerated by all but 1 of the children, who developed mild transient heart failure 4 months after the initiation of therapy. IFN therapy for children with chronic hepatitis C who had underlying acute leukemia was beneficial. However, further trials are required to confirm the safety and improve the dosage schedule of IFN therapy.

Roentgenographically occult small-cell lung cancer: case report and review of the literature

This report describes a rare case of roentgenographically occult small-cell lung cancer in a 73-year-old man with hemoptysis. Fiberoptic bronchoscopy disclosed a 5-mm dome-shaped lesion; a biopsy established the diagnosis of small-cell lung cancer. The patient received a combination of chemotherapy and radiotherapy. More than 10 years later, he is still alive without recurrent disease. A review of the literature of roentgenographically occult small-cell lung cancer revealed the following: (1) a history of heavy smoking was common; (2) double primary bronchogenic carcinoma was noted; (3) hemoptysis or bloody sputum was an initial common symptom; (4) the sensitivity of sputum cytologic analysis was relatively low; (5) the tumor, which was shiny, smooth, and covered with bronchial epithelium, was often located at the bifurcation; and (6) lymph node metastatic involvement occurred.

Three cases of hereditary nonspherocytic hemolytic anemia associated with red blood cell glutathione deficiency

Three unrelated Japanese patients with chronic nonspherocytic hemolytic anemia wer found to have marked deficiency of red blood cell (RBC) reduced glutathoine (GSH) (4.4%, 13.1%, and 6.9% of normal, respectively). A panel of RBC enzyme assays showed that one patient had decreased glutathione synthetase activity and the other two were moderately deficient in gamma-glutamylcystine synthetase. Some family members of each patient showed mild deficiency of the respective enzymes. RBCs of these patients also showed a decreased level of glutathione-S-transferase as in previously described GSH-deficient cases. Hemolytic anemia was their only manifestation, and neither 5-oxoprolinemia nor 5-oxoprolinuria, which are usually associated with to generalized type of glutathione synthetase deficiency, was noted in our patients.

Recurrent breast cancer treated successfully with mitomycin-C and vinblastine after failure of both doxorubicin-containing regimen and paclitaxel--a case report

Cross-resistance is one of the chief obstacles in salvage therapy for refractory breast cancer. Although paclitaxel is one of the most promising drugs, it shows a response rate of 30% at most for patients with breast cancer resistant to doxorubicin, and no effective treatments for tumors refractory to both agents have been reported. We describe a 38-year-old woman with recurrent breast cancer, who was treated successfully with mitomycin-C and vinblastine after doxorubicin-based chemotherapy and paclitaxel failed. The combinations of mitomycin-C and microtubule inhibitors including vinca alkaloids and taxanes may have a potential application to refractory breast cancer.

Autopsy case of colocalized tumors of hepatocellular carcinoma and malignant lymphoma

We present a rare case of colocalized tumors of hepatocellular carcinoma (HCC) and malignant lymphoma in the liver and bone marrow. A 64-year-old man with hepatitis B virus (HBV)-induced cirrhosis was admitted after detection of elevated serum alpha-fetoprotein level. He was diagnosed as having HCC and treated with chemotherapy and radiotherapy, but the size of the tumors did not diminish. After 11 months' hospitalization, he died due to rupture of esophageal varices. Autopsy revealed two heterogenic malignant tumors, HCC and malignant lymphoma (B cell type), in the liver. These tumors showed colocalization in the liver and bone marrow. The carcinogenetic process of colocalized tumors of HCC and lymphoma was not clarified, but the possibility that persistent HBV infection play a role in promoting hepatocarcinogenic and hematopoietic tumor growths in the reticuloendothelial organs could not be excluded.

Carcinoma in gastric hyperplastic polyps. A phenotypic study

One-hundred twelve hyperplastic polyps were analyzed. The aim was to study their malignant transformation. Among them, four hyperplastic polyps harbored adenocarcinoma; two were from our own institution (1.8%). The majority were pedunculated and located in the antrum with an average of 14.5 mm in diameter. The four polyps bore well-differentiated adenocarcinoma. Dysplasia and intestinal metaplasia were detected in two and three polyps, respectively. The cancer and dysplastic foci shared the same type of neutral and acid mucosubstances. p53 oncoprotein was positive in three cancer foci and in the dysplastic areas, and nucleolar organizer region counts were higher in the cancer foci. In conclusion, hyperplastic polyps have malignant potential. Such possibility increases in polyps larger than 14.5 mm. In our cases, the carcinoma foci may have arisen from dysplastic areas. Once the neoplastic changes occur, the cancer cells proliferate and behave as other adenocarcinomas of the stomach.

Histopathological characteristics of childhood thyroid cancer in Gomel, Belarus

We reviewed histopathologically 19 cases of childhood thyroid cancer occurring between 1991 and 1994 among 14,396 screening subjects in Gomel, Republic of Belarus, the region most severely radio-contaminated by the Chernobyl nuclear power plant accident in 1986. The patients were 13 girls and 6 boys with a mean age of 10.6 years. The mean age at the time of the accident was 3.2 years. Mean tumor diameter was 16 mm, and all cases were papillary carcinoma with various amounts of solid component. Psammoma bodies and stromal fibrosis were encountered to some extent in almost all cases. The tumors were highly prone to local invasion and regional lymph-node metastasis. No morphological evidence for radiation-induced cancer was obtained in these cases. 137Cs levels were relatively high in the patients' bodies and in the soil at the places of domicile. However, there was no dose-response relationship between cancer prevalence and radioactivity. These facts suggest that the incidence of aggressive pediatric thyroid cancer is extremely high in Gomel, where most of the children were exposed to a low level of radioactivity over a long time after the accident. At present, however, no definite conclusion can be drawn on the relationship between cancer occurrence and radioactive contamination.

Clinical evaluation of the efficacy of EDTA solution as an endodontic irrigant

The effect of eliminating the smear layer by means of 15% EDTA solution as a root canal irrigant was studied in 189 single-rooted infected teeth. Each tooth was treated at two appointments, and the root canal bacteriological examination was studied on the first (pretreatment, and after enlargement and irrigation) and second (pretreatment) visits. The root canals were irrigated with 15% EDTA solution with ultrasonics agitation. No antibacterial intracanal medications were used between the appointment. When 15% EDTA solution was used, no bacteria could be recovered from 93 of 129 root canals at the sampling stage on second visit. No bacteria were found in 21 of 60 root canals when saline solution was used as an irrigant. These results suggest that 15% EDTA solution is more effective than saline solution as a root canal irrigant.

Childhood thyroid diseases around Chernobyl evaluated by ultrasound examination and fine needle aspiration cytology

Screening by ultrasound examination and fine-needle aspiration cytological biopsy (FNA) was conducted in five regions in Belarus, Ukraine, and Russia to investigate the prevalence of childhood thyroid diseases around Chernobyl. Gomel, Zhitomir, Kiev, and the western area of Bryansk are the administrative regions where severe radioactive contamination occurred. The subjects from Mogilev, where contamination was relatively low, served as controls. Among 55,054 subjects (26,406 boys and 28,648 girls), the prevalence of ultrasonographic thyroid abnormalities such as nodule, cyst, and abnormal echogenity was significantly higher in the regions with severe contamination than in Mogilev. Of the 1,396 children showing echographic thyroid abnormalities 197 were selected for FNA, and a sample was successfully obtained for diagnosis from 171 (51 boys and 120 girls) of the 197 subjects. The aspirate was insufficient for diagnosis in the remaining 26 subjects. Thyroid cancer was encountered in four children (2.3%) from the contaminated regions, two children being from Gomel. The other thyroid diseases were follicular neoplasm, 6.4%; adenomatous goiter, 18.7%; chronic thyroiditis, 31.0%; and cyst, 24.0%, suggesting that a major cause of thyroid nodularity is nonneoplastic changes, mainly chronic thyroiditis and cysts. These results will serve as an important data base for further analyses and suggest that childhood thyroid diseases, including both neoplasms and immunological disorders, are consequences of radioactive fallout.

Efficacy of flashlamp-pumped pulsed dye laser therapy for port wine stains: clinical assessment and histopathological characteristics

Clinicopathological evaluation of flashlamp-pumped dye laser therapy for port wine stains was conducted on 474 subjects (135 male and 339 female) ranging in age from less than a year to 85 years (median = 17; lower quartile = 7 and upper quartile = 28). There was a significant variation in the rate of favourable response among lesion sites but the variation in relation to sex, age and radiation dose was not significant. Histological investigations of skin biopsy specimens from 23 subjects indicated that the mean depth of vessels is the main prognostic factor. The critical value (standard error) of the mean depth for a favourable response was estimated as 930(50) microns. Applications of this estimate to clinical prognosis are discussed.

Inhibition of epidermal growth factor binding system by ionizing radiation in A431 human squamous carcinoma cells

To elucidate the effect of ionizing radiation on the membrane anchored signal transduction, the binding of 125I epidermal growth factor (EGF) to its receptor (EGF-R) and the EGF-dependent EGF-R tyrosine phosphorylation were examined in a human squamous cell carcinoma cell line, A431. The significant suppression of 125I EGF binding to A431 cells was observed from 3-5 h after 10 Gy irradiation, whereas this inhibition was not observed both in non-irradiated and in 5 Gy-irradiated cells. This phenomenon was mediated by the protein kinase C pathway, because the inhibition was not observed in cells which had been pretreated with phorbol ester and treated with an inhibitor of the enzyme, H7. Scatchard analysis showed that the receptor affinity was decreased. In contrast, the level of EGF-dependent EGF-R-tyrosine phosphorylation was not decreased, compared with non-irradiated cells. These results suggest that ionizing radiation may modulate the function of EGF/EGF-R interaction through the direct activation of protein kinase C.

A limited sampling model for estimating pharmacokinetics of CPT-11 and its metabolite SN-38

The objective of this study was to develop a limited sampling model (LSM) to estimate the area under the curve (AUC) of 7-ethyl-10-[4-(1-piperidino)-1-piperidino]carbonyloxycamptothecin (CPT-11) and that of 7-ethyl-10-hydroxycamptothecin (SN-38) as predictive pharmacokinetic variables for leukopenia and episodes of diarrhea induced by CPT-11 administration. The model was developed with a training set consisting of pharmacokinetic studies in 36 patients who received a 90-min i.v. infusion of CPT-11 at a dose of 100 mg/m2. A multiple regression analysis of CPT-11 or SN-38 concentrations observed at each time point in the training set was used to predict the AUC of CPT-11 or SN-38. The final sampling models using only two time points were: AUCCPT-11 = 3.7891*C2.5 + 14.0479*C13.5 + 1.5463 AUCSN-38 = 0.5319*C2.5 + 19.1468*C13.5 + 72.7349 where C2.5 and C13.5 are the plasma concentration of CPT-11 (micrograms/ml) or SN-38 (ng/ml) at 2.5 and 13.5 h after the initiation of CPT-11 infusion, respectively. The models were validated prospectively on a separate test data set of 12 patients receiving the same dose of CPT-11 investigated in a previous study. Validation of the final LSM on the test data set gave values of root mean square error (RMSE) of 12.72% and 5.97% for the AUC of CPT-11 and that of SN-38, respectively. The model can be used to monitor the AUCs of both CPT-11 and SN-38 for the early prediction of toxicities and to establish a pharmacokinetically based dose modification strategy for safe administration of CPT-11.

Bone marrow transplantation for erythroleukemia: a case report

A 2 year old girl was diagnosed as having erythroleukemia (EL; M6 according to the French-American-British classification). After one course of low-dose cytosine arabinoside (Ara-C), complete remission was obtained. After three courses of low-dose Ara-C for consolidation, allogeneic bone marrow transplantation was performed from HLA-identical sibling. The course of post-transplantation was uneventful. Two years after transplantation, she continues to have durable engraftment and remission. In children with EL, conventional chemotherapy appears to be inadequate for producing durable long-term disease-free survival. Bone marrow transplantation should be considered in children with EL, in cases where suitable donors are available.