High-dose, brief duration, multiagent chemotherapy for metastatic breast cancer

BACKGROUND

The authors evaluated a high-intensity inpatient regimen using augmented but subtransplantation doses of multiple agents in patients with metastatic breast cancer. Two high-dose courses were given in an attempt to improve the efficacy of high-dose regimens using a single course.

METHODS

Forty women received treatment between October 1988 and October 1991. The median age was 38 years (range, 24-56 years). Twenty-five patients were receiving their first chemotherapy for metastatic disease; 15 patients had received one or more prior regimens. The patients received two courses of chemotherapy, which consisted of the following: cyclophosphamide 1500 mg/m2 intravenously (i.v.) on days 1 and 2; doxorubicin 45 mg/m2 i.v. on days 1 and 2; cisplatin 20 mg/m2 i.v. on days 1, 2, 3, 8, 9, and 10; 5-fluorouracil 1000 mg/m2 on days 8, 9, and 10 (continuous infusion); methotrexate 100 mg/m2 i.v. on days 15 and 22; leucovorin 15 mg/m2 i.v. or by mouth for four doses beginning 24 hours after methotrexate. Etoposide 400 mg/m2 i.v. on days 1, 2, and 3 was substituted for doxorubicin in 14 patients who had received prior doxorubicin.

RESULTS

Twenty-nine of 40 patients (73%) had objective response to therapy, with 10 (25%) complete responses. Four patients who obtained a complete response remain disease-free at 14, 21, 28, and 32 months, respectively; all of these patients received this regimen as first-line therapy for metastatic disease. Myelosuppression was severe, with median durations of leukocytes less than 1000/microliters and platelets less than 50,000/microliters of 15 days (range, 7-48 days) and 13 days (range, 3-49 days), respectively. Moderate or severe mucositis occurred in 56 of 68 courses. Four patients (10%) had treatment-related deaths.

CONCLUSIONS

This regimen produced high overall response and complete response rates compared with standard regimens. However, only 15% of patients who received this therapy as first-line treatment for metastatic breast cancer remain disease-free, and median response duration was shorter than that reported using high-dose therapy with bone marrow support. Toxicity with this regimen was greater than anticipated, although myelosuppression and stomatitis would be reduced by the use of cytokines. This regimen does not improve results achieved with standard therapy sufficiently to justify its toxicity and expense.

Challenges of preoperative chemotherapy in non-small cell lung cancer

Surgical extirpation of a non-small cell lung cancer (NSCLC) represents an individual's best opportunity for cure. Unfortunately, only a small percentage of patients present with surgically resectable disease. Many patients are diagnosed with tumor confined to the thorax but which is technically unresectable. In the setting of locally advanced disease, combination chemotherapy is capable of effecting tumor shrinkage in a majority of cases. When this occurs, it is tempting to subject the patient to thoracotomy in an attempt to resect the previously unresectable lesion. Use of chemotherapy in this manner is generally referred to as neoadjuvant or preoperative chemotherapy. Recently, several groups have demonstrated that such an approach is feasible but the impact on patient survival remains ill defined. Further studies designed to ascertain the feasibility of neoadjuvant chemotherapy are no longer warranted. It is time for a prospective, randomized trial designed to determine the true potential of neoadjuvant chemotherapy. The optimal design of such a trial is a matter of debate but several options are reasonable. This article will review the available data on preoperative chemotherapy in locally advanced non-small cell lung cancer and will review areas of controversy.

Combined modality treatment for locally advanced non-small cell lung cancer--which control arm?

Up to one-third of newly diagnosed patients with non-small cell lung cancer (NSCLC) present with locally advanced, unresectable disease. Traditionally, these patients have been treated with thoracic radiotherapy alone. Unfortunately, the vast majority eventually die as a result of the development of distant, extrathoracic metastases. While chemotherapy is not particularly effective against clinically obvious metastatic disease, there are good theoretical reasons why the use of this modality in earlier stage disease may be beneficial. Several recently completed pilot studies of combined modality therapy have yielded promising results suggesting improved survival. Indeed, the combination of chemotherapy and thoracic radiotherapy has been shown to be marginally superior to radiotherapy alone in a few recently completed randomized trials. However, this has not been a uniform observation. Thus, further study is needed to firmly establish the role of combined modality treatment in Stage III, unresectable non-small cell lung cancer. In these future trials, the best control arm is a matter of some controversy.

The effect of long-term medical therapy on the outcome of filtration surgery

Long-term medical therapy and laser trabeculoplasty have been implicated as risk factors in the outcome of glaucoma filtration surgery. A retrospective analysis was performed of patients undergoing primary trabeculectomy during three key periods: before use of beta-blockers and laser trabeculoplasty (1975 and 1976), after introduction of beta-blocker therapy but before use of the laser (1980), and after common use of beta-blockers and laser (1985 and 1986). A total of 150 patients were included in the analysis. Eyes treated with laser trabeculoplasty at some time before filtration surgery had a decreased probability of successful filtration surgery (intraocular pressure less than 21 mm Hg, 75% vs 91% at one year, P = .05; 50% vs 86% at five years, P = .01). It is unknown whether laser was detrimental to subsequent filtration surgery or merely acted as a selection factor in identifying patients who would have less successful surgical outcomes. Preoperative use of topical medication did not influence the outcome of surgery. Patients having bilateral filtration surgery had similar outcomes between fellow eyes despite the longer use of therapy in the second eye (mean of 1.8 years between operations). In the subgroup of eyes with low preoperative intraocular pressures (less than 21 mm Hg), surgery was successful in reducing pressure to a lower level in 70% of eyes at one year (preoperative pressure, 17.8 mm; one-year postoperative pressure, 13.3 mm, P = .007).

Effect of thoracic radiotherapy on mortality in limited small cell lung cancer. A meta-analysis of 13 randomized trials among 2,140 patients

This meta-analysis was designed to evaluate the hypothesis that thoracic radiotherapy contributes to a moderate increase in overall survival in limited small-cell lung cancer. We collected individual data on all patients enrolled before December 1988 in randomized trials comparing chemotherapy alone with chemotherapy combined with thoracic radiotherapy. The study included 13 trials and 2140 patients with limited disease. A total of 433 patient with extensive disease were excluded. Overall, 1862 of 2103 patients who could be evaluated died; the median follow-up period for the surviving patients was 43 months. The relative risk of death in the combined therapy group as compared with the chemotherapy group was 0.86 (95 percent confidence interval, 0.78 to 0.94; P = 0.001), corresponding to a 14 percent reduction in the mortality rate. The benefit in terms of overall survival at three years (+/- SD) was 5.4 +/- 1.4 percent. Indirect comparison of early with late radiotherapy and of sequential with non-sequential radiotherapy did not reveal any optimal time for treatment. There was a trend toward a larger reduction in mortality among younger patients. In conclusion, thoracic radiotherapy moderately improves overall survival in patients with limited small-cell lung cancer who are treated with combination chemotherapy.

A nonstationary Poisson point process describes the sequence of action potentials over long time scales in lateral-superior-olive auditory neurons

The behavior of lateral-superior-olive (LSO) auditory neurons over large time scales was investigated. Of particular interest was the determination as to whether LSO neurons exhibit the same type of fractal behavior as that observed in primary VIII-nerve auditory neurons. It has been suggested that this fractal behavior, apparent on long time scales, may play a role in optimally coding natural sounds. We found that a nonfractal model, the nonstationary dead-time-modified Poisson point process (DTMP), describes the LSO firing patterns well for time scales greater than a few tens of milliseconds, a region where the specific details of refractoriness are unimportant. The rate is given by the sum of two decaying exponential functions. The process is completely specified by the initial values and time constants of the two exponentials and by the dead-time relation. Specific measures of the firing patterns investigated were the interspike-interval (ISI) histogram, the Fano-factor time curve (FFC), and the serial count correlation coefficient (SCC) with the number of action potentials in successive counting times serving as the random variable. For all the data sets we examined, the latter portion of the recording was well approximated by a single exponential rate function since the initial exponential portion rapidly decreases to a negligible value. Analytical expressions available for the statistics of a DTMP with a single exponential rate function can therefore be used for this portion of the data. Good agreement was obtained among the analytical results, the computer simulation, and the experimental data on time scales where the details of refractoriness are insignificant.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase II trial of oral etoposide plus cisplatin in extensive stage small cell carcinoma of the lung: an Eastern Cooperative Oncology Group study

Based upon the schedule specificity of etoposide and the in vitro and clinical synergy observed with cisplatin, the Eastern Cooperative Oncology Group conducted a phase II trial of oral etoposide and cisplatin in newly diagnosed, untreated patients with extensive stage small cell carcinoma of the lung. 35 patients received 100 mg/m2 of cisplatin intravenously on day 1 and 50 mg/m2 of etoposide orally for 21 consecutive days. Cycles were repeated every 28 days. The most common toxicity observed was myelosuppression. Sixty-seven per cent of patients had grade 3 or 4 leukopenia and 34% had grade 3 or 4 thrombocytopenia during cycle one. Of 26 evaluable patients, 4 had a complete response (15%) and 17 had a partial response (65%). The median survival for the group as a whole was 8.5 months. We conclude that this regimen was associated with significant myelosuppression, and offered no therapeutic advantage to other commonly administered chemotherapeutic regimens for small cell carcinoma of the lung.

Microscale analysis of the glycosaminoglycans of human trabecular meshwork: a study in perfusion cultured eyes

Glycosaminoglycans (GAGs) and proteoglycans of the trabecular meshwork may be involved in the pathogenesis of primary open angle glaucoma and of corticosteroid-induced glaucoma. Although numerous studies of GAGs have been performed on trabecular cells in monolayer culture and in animals, few studies have examined intact human meshwork. Using a new analytic method for quantitative determination of GAGs from individual meshworks, we studied the GAGs of human trabecular meshwork in normal eyes and intact meshwork from perfusion-cultured eyes. Eyes in the culture system were treated with dexamethasone for 21 days in an attempt to create a model of steroid glaucoma. The effect of ascorbate, also known to influence GAG levels, was examined in a preliminary study. Cultured trabecular meshwork had a significant decrease in total GAG levels when compared with meshwork from normal, noncultured eyes (1.16 +/- 0.54 ng/mug vs. 3.51 +/- 0.57 ng/mug; p < 0.01). Ascorbate tended to cause a decrease (28%) in the total level of GAGs, although the difference was not significant. No significant difference in mean GAG levels was found between the dexamethasone-treated and fellow control eyes. Dexamethasone was associated with a large biologic variability in total GAG level (coefficient of variation 89%). In an attempt to identify individual steroid responders mixed in with a group of nonresponders, analysis of individual eyes revealed three of nine eyes to have total GAGs 250% than fellow control eyes, although this variability could also be due to other causes. No consistent change in group mean intraocular pressures was found in the dexamethasone-treated eyes. Intraocular pressures were positively correlated with total GAG levels (r = 0.59; p < 0.01).

Function-based modeling of binaural processing: level and time cues

From theoretical considerations, function-based modeling predicts the input-output characteristics of a neural system intended to perform a signal processing task within a sensory system. The sensory task under study here is the time- and level-based localization of a high-frequency, possibly amplitude-modulated, sound source in the horizontal plane. The stimulus is assumed to be represented by each ear's primary-like discharge pattern. An optimal system that extracts azimuthal angle from these discharge patterns, which represent acoustic time and level localization cues, has been derived. This system can be described as the maximization of a sum of three subsystems' outputs. The stimulus cues employed by these systems are interaural level difference for the level-based subsystem, the interaural onset-time difference for the time-based subsystem, and the interaural envelope-phase difference for the phase-based subsystem. The system encompassing all these cues is shown to trade-off the level, time, and envelope-phase cues depending upon the time since stimulus onset, the observation time, and the incident signal's level. How this system might correspond to known structures in the lower auditory pathway is described.

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus

OBJECTIVE

This study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus.

SUMMARY BACKGROUND DATA

Long-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently.

METHODS

Fifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection.

RESULTS

There were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827).

CONCLUSIONS

Multimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.

Postarthroscopy analgesia with intraarticular bupivacaine/morphine. A randomized clinical trial

BACKGROUND

Postarthroscopy analgesia has been provided with intraarticular bupivacaine, but the duration of analgesia may be only a few hours. More recently, longer-lasting analgesia has been achieved using intraarticular morphine, although the onset of analgesia may be delayed. The combination of intraarticular morphine and bupivacaine has been suggested as an ideal analgesic after knee arthroscopy.

METHODS

One hundred and twenty ASA Physical Status 1-2 outpatients, age 18-60 yr, having knee arthroscopy, were randomized into one of four treatment groups. Exclusion criteria included relevant drug allergy, extensive debridement or synovectomy, arthrotomy, postoperative intraarticular drainage, tracheal intubation, and patient refusal. All patients received general anesthesia with intravenous fentanyl, propofol, N2O, O2, and isoflurane. At the end of surgery, before tourniquet release, the following were injected intraarticularly through the arthroscope: group 1, 0.25% bupivacaine; group 2, 1 mg morphine in saline; group 3, 2 mg morphine in saline; and group 4, 1 mg morphine in 0.25% bupivacaine. The volume injected was 30 ml, and all solutions contained 1:200,000 epinephrine. Postoperative analgesia was provided with intravenous fentanyl and/or oral acetaminophen/codeine, and was recorded for 24 h. Visual analog pain scale (VAPS) scores and the McGill Pain Questionnaire (MPQ) were performed hourly from 1-6 h, and at 24 h postoperatively.

RESULTS

Visual analog pain scale and MPQ scores were lowest in groups 1 and 4 at 1-6 h, but at 24 h, VAPS scores were lowest in groups 2, 3, and 4. Analgesic requirements were lower for the first 12 h in groups 1 and 4, but no difference was seen between groups over the 24-h study period. No adverse effects were noted.

CONCLUSIONS

Morphine, 1 mg intraarticular, in 30 ml 0.25% bupivacaine, with 1:200,000 epinephrine, may provide superior postoperative analgesia for up to 24 h versus bupivacaine or morphine alone.

Excitation effects on LSO unit sustained responses: point process characterization

LSO units recover from a spike discharge in a characteristic way, modeled by an intrinsic recovery function that is stimulus invariant up to a scaling factor and a shifting constant. Data analysis shows that the effect of increasing excitatory stimulus level can be described by amplifying the intrinsic recovery function and by shifting it toward shorter intervals. The shifting process secondarily interacts with the absolute deadtime to produce the response characteristics of the three LSO unit types. Decreased excitation is clearly distinguished from inhibition, which affects the scaling, but not the time origin, of the recovery. We conclude that both excitatory and inhibitory stimulus levels are encoded in the timing of LSO unit discharges.

Preliminary results with neoadjuvant therapy and resection for esophageal carcinoma

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Combination chemotherapy with or without thoracic radiotherapy in limited-stage small-cell lung cancer: a randomized trial of the Southeastern Cancer Study Group

PURPOSE

The primary objective of this randomized prospective study was to compare the survival of limited-stage small-cell lung cancer (SCLC) patients treated with chemotherapy alone or chemotherapy plus thoracic radiotherapy (TRT). A secondary objective was to determine the effect of consolidation chemotherapy on survival.

PATIENTS AND METHODS

This multiinstitutional phase III study included 386 patients with limited-stage SCLC. All patients received cyclophosphamide 1,000 mg/m2, doxorubicin 40 mg/m2, and vincristine 1 mg/m2 (CAV) every 3 weeks for six cycles. Irradiated patients received 30 Gy in 10 fractions during weeks 1 and 2 of chemotherapy. Fifteen Gy in five fractions was administered during week 7 (total dose, 45 Gy). Following CAV, responding patients were randomized to receive two cycles of consolidation chemotherapy (cisplatin 20 mg/m2/d for 4 days plus etoposide 100 mg/m2/d for 4 days) or observation.

RESULTS

Complete (46% and 38%; P = .14) and overall response rates (67% and 64%; P = .58) were not statistically significantly different. Although not significantly different, median (14.4 v 12.8 months) and 2-year survival (33% v 23.5%) rates favored the irradiated patients. Grade 4 hematologic toxicity was greater in irradiated patients (60% and 39%; P < .001). Patients given consolidation chemotherapy experienced superior median (21.1 v 13.2 months; P = .028) and 2-year survival (44% v 26%; P = .028) rates.

CONCLUSION

The concurrent use of TRT and CAV chemotherapy as administered in this study failed to improve the survival of limited-stage SCLC patients compared with CAV alone. Life-threatening hematologic toxicities were more frequent with combined-modality therapy. The survival of limited-stage patients treated with CAV (with or without TRT) was improved with two cycles of cisplatin and etoposide consolidation therapy. Whether similar survival results could be achieved with cisplatin and etoposide alone requires additional study.

Analyzing and modeling fractal intensity point processes

Fractal intensity point processes--doubly stochastic point processes with a fractal waveform intensity process--are required to describe the discharge patterns recorded from the auditory and visual systems. The Fano factor--the ratio of the variance of the number of events in an interval to the mean of this number--captures the self-similar characteristics of the intensity via two quantities: fractal dimension and fractal time. The fractal dimension is the exponent of the asymptotic power law behavior of the Fano factor with interval duration. The fractal time delineates long-term fractal behavior from short-term characteristics of the data. The average rate and self-similarity parameter of the intensity process, absolute and relative refractory effects, and serial dependence all modify the fractal time. To generate fractal intensity point processes, stochastic fractal processes are derived by applying memoryless, nonlinear transformations to fractional Gaussian noise. The intensity's amplitude distribution in combination with the Fano factor form criteria to choose the transformation that best describes data.

Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections

Pneumonias caused by atypical organisms usually have extra-pulmonary features. Chlamydial pneumonia often starts with hoarseness and fever, and respiratory tract symptoms may not appear for days. Mycoplasmal pneumonia may manifest with ear pain and a nonproductive cough. Legionnaires' disease presents with high fevers and central nervous system and gastrointestinal abnormalities. Diagnosis of chlamydial infection is accomplished with serologic testing. Patients are unresponsive to erythromycin treatment and should be started on empirical doxycycline (Doryx, Vibramycin) therapy. The presence of cold agglutinins in the appropriate clinical setting permits a presumptive diagnosis of mycoplasmal infection. Clinical diagnosis of Legionella pneumonia may be made in patients with pneumonia who also have relative bradycardia with elevated serum transaminases or hypophosphatemia with gastrointestinal or central nervous system symptoms. Erythromycin is the mainstay of treatment of legionnaires' disease, but treatment failures have been reported. Doxycycline is less expensive, has a better safety profile, and is better tolerated than erythromycin.

Ethacrynic acid: outflow effects and toxicity in human trabecular meshwork in perfusion organ culture

The effect of ethacrynic acid, a potential outflow agent for the treatment of glaucoma, was studied in a series of 25 pairs of human eyes in perfusion organ culture. Concentrations varied from 0.01 mM to 2.4 mM and were used in single or repetitive doses. Intraocular pressure was continuously recorded for up to two weeks after exposure. Eyes were then fixed and the meshwork examined histologically. Ethacrynic acid in single doses of 0.05 mM, 0.3 mM, and 0.6 mM increased facility of outflow at least 40% when compared with fellow control eyes. The duration of effect was approximately 18 hours, during which time the intraocular pressure gradually returned to baseline. Histologic examination revealed dose related effects on the trabecular cells, ranging from clumping of nuclear chromatin in some eyes to cellular swelling, disruption of cytoplasmic membranes, and cell necrosis in other eyes at concentrations of 0.1 mM and higher. No recovery or reversal of these changes was noted with time, even two weeks after a single exposure to the drug. Although ethacrynic acid is effective in temporarily lowering intraocular pressure in the human eye, a low therapeutic index may limit its clinical usefulness.

A case study of a coordinated care program: development and implementation of Fort Sill's Catchment Area Management Project

One of the Department of Defense's initiatives to contain costs of the Civilian Health and Medical Program of the Uniformed Services is the Catchment Area Management (CAM) Demonstration Project. CAM's fundamental coordinated care concept is to contain the military's health care costs by granting the military treatment facility (MTF) commander full clinical and fiscal responsibility for the health care of all beneficiaries within the MTF's catchment area. This article describes the CAM Demonstration Project at Fort Sill during its developmental and implementation phase from June 1989 to April 1991. The six operational goals of the CAM Project are identified and discussed. Additionally, nine essential lessons learned are briefly reviewed.