Treatment of neuroendocrine carcinomas with combined etoposide and cisplatin. Evidence of major therapeutic activity in the anaplastic variants of these neoplasms

Forty-five patients with metastatic neuroendocrine tumors were treated with a regimen of etoposide 130 mg/m2/d for 3 days plus cisplatin 45 mg/m2/d on days 2 and 3. Both drugs were given by continuous intravenous infusion. Among 27 patients with well-differentiated carcinoid tumors or islet cell carcinomas, only two partial objective tumor regressions were observed (7%). Among 18 patients prospectively classified as having anaplastic neuroendocrine carcinomas, however, there were nine partial regressions and three complete regressions, an overall regression rate of 67%. For anaplastic disease, the median duration of regression was 8 months (range to 21 months). Tumor response was unrelated to primary site, endocrine hyperfunction, or prior therapy experience. The median survival of all patients with anaplastic tumors was 19 months; this seemed favorable when considering the small experiences with these rare tumors reported in the literature. Toxicity, which was severe for most patients, consisted primarily of vomiting, leukopenia, thrombocytopenia, anemia, alopecia, and neuropathy. The anaplastic neuroendocrine tumor is strongly responsive to therapy with combined etoposide and cisplatin. Patients with undifferentiated carcinomas, originating in typical neuroendocrine tumor sites (small and large bowel, pancreas, and stomach) or of unknown origin, who have consistent histologic findings by light microscopy should be evaluated for this possibility with appropriate immune staining or electron microscopy.

Treatment of neuroendocrine carcinomas with combined etoposide and cisplatin. Evidence of major therapeutic activity in the anaplastic variants of these neoplasms

Forty-five patients with metastatic neuroendocrine tumors were treated with a regimen of etoposide 130 mg/m2/d for 3 days plus cisplatin 45 mg/m2/d on days 2 and 3. Both drugs were given by continuous intravenous infusion. Among 27 patients with well-differentiated carcinoid tumors or islet cell carcinomas, only two partial objective tumor regressions were observed (7%). Among 18 patients prospectively classified as having anaplastic neuroendocrine carcinomas, however, there were nine partial regressions and three complete regressions, an overall regression rate of 67%. For anaplastic disease, the median duration of regression was 8 months (range to 21 months). Tumor response was unrelated to primary site, endocrine hyperfunction, or prior therapy experience. The median survival of all patients with anaplastic tumors was 19 months; this seemed favorable when considering the small experiences with these rare tumors reported in the literature. Toxicity, which was severe for most patients, consisted primarily of vomiting, leukopenia, thrombocytopenia, anemia, alopecia, and neuropathy. The anaplastic neuroendocrine tumor is strongly responsive to therapy with combined etoposide and cisplatin. Patients with undifferentiated carcinomas, originating in typical neuroendocrine tumor sites (small and large bowel, pancreas, and stomach) or of unknown origin, who have consistent histologic findings by light microscopy should be evaluated for this possibility with appropriate immune staining or electron microscopy.

An autopsy study of the peritoneal cavity from patients on continuous ambulatory peritoneal dialysis

Sixteen autopsies were performed on patients aged 56 +/- 15 (SD) years who were on continuous ambulatory peritoneal dialysis (CAPD) for 834 +/- 766 (SD) days. Lactate-buffered dialysate and povidone-iodine antiseptic were used in all cases. Multiple peritoneal sections were taken to evaluate peritoneal membrane thickening, inflammation, neovascularization, fibrosis, and adhesions. Peritoneal thickening, inflammation, or adhesions were not related to sex, race, or etiology of renal failure. Time on dialysis was also not a direct determinant of peritoneal adhesions or neovascularization. Peritonitis episodes correlated with chronic peritoneal serosal changes. This study supports the hypothesis that peritoneal alterations in patients on CAPD are related to episodes of peritonitis.

Lymphoma of the maxillary sinus in a patient infected with human immunodeficiency virus type 1

A 27-year-old woman with a history of intravenous drug abuse presented with a stage IE, diffuse, large cell lymphoma of the right maxillary sinus. A test for antibodies to the human immunodeficiency virus was positive. The patient was treated with systemic chemotherapy and local maxillary sinus irradiation which resulted in complete regression of the disease. Therapy was complicated by mucositis, neutropenia, and opportunistic infections. This is the first case report to discuss the presentation and treatment of acquired immunodeficiency syndrome (AIDS)-related lymphoma of the maxillary sinus.

A randomized trial of cyclophosphamide, doxorubicin, and prednisone versus cyclophosphamide, 5-fluorouracil, and prednisone in patients with metastatic breast cancer

Ninety-four patients were entered in a clinical trial assessing the clinical activity of cyclophosphamide, doxorubicin, and prednisone (CAP) versus a combination of cyclophosphamide. 5-Fluorouracil, and prednisone (CFP) in patients with advanced breast cancer. Objective response rates were comparable, 49% for CFP and 46% for CAP. There was no statistical difference between the duration of response of the two regimens or in time to progression. Most importantly, survival differences were not apparent. Both regimens were clinically tolerable and toxicities, for the most part, were comparable. Thus, no therapeutic advantage existed for either of these polychemotherapy regimens in patients with advanced breast cancer.

Tumor necrosis factor-alpha inhibits 1,25-dihydroxyvitamin D3-stimulated bone Gla protein synthesis in rat osteosarcoma cells (ROS 17/2.8) by a pretranslational mechanism

Tumor necrosis factor-alpha (TNF alpha), a 17,000 mol wt protein, mediates a variety of immunological and inflammatory events. TNF alpha is a potent inhibitor of bone collagen synthesis and stimulator of osteoclastic bone resorption, the net effect of which is to cause bone loss. We have previously reported that TNF alpha inhibits the synthesis of collagen by osteoblastic cells in culture out of proportion to effects on total protein synthesis, suggesting that inhibition of bone formation by TNF alpha may be due to selective inhibition of matrix protein synthesis. To further test this hypothesis and to evaluate the mechanism of TNF alpha action, we studied the effect of TNF alpha on synthesis of the osteoblast-specific bone Gla protein (BGP) by ROS 17/2.8 cells, which have the osteoblast phenotype. Cells were cultured with 10 nM 1,25-dihydroxyvitamin D3 to stimulate BGP secretion, followed by the addition of TNF alpha (1-100 ng/ml) in 1,25-dihydroxyvitamin D3-containing medium. TNF alpha (10 ng/ml) inhibited BGP secretion to 42 +/- 5%, 19 +/- 10%, and 15 +/- 3% of control values after 24, 48, and 72 h of treatment. After 48 h, inhibition of BGP secretion was observed with 2 ng/ml TNF alpha and was maximum with 100 ng/ml. To determine the effect of TNF alpha on total protein synthesis, cells were pulse labeled with [14C]leucine during the last 4 h of TNF alpha treatment, and incorporation of radioactivity into trichloroacetic acid-precipitable protein in cell layer and medium was determined. The TNF alpha inhibition of BGP secretion was independent of changes in [14C]leucine incorporation, suggesting that TNF alpha did not have a general inhibitory effect on total protein synthesis. Cell number was not affected by TNF alpha. Northern analysis of steady state BGP mRNA revealed a dose-dependent decrease in the BGP/cyclophilin mRNA hybridization signal intensity after 24 h of treatment. The maximum inhibitory effect was 41 +/- 5% of the control value with 100 ng/ml TNF alpha. The effect of TNF alpha on steady state BGP mRNA levels was not prevented by treatment of cells with cycloheximide, suggesting that TNF-induced new protein synthesis was not required for TNF alpha action. These results suggest that the mechanism of TNF alpha inhibition of BGP synthesis includes a pretranslational site and support the hypothesis that TNF alpha inhibits bone formation by a selective inhibition of matrix protein production.

Phase I-II study of pibenzimol hydrochloride (NSC 322921) in advanced pancreatic carcinoma

Pibenzimol is a fluorescent molecule known to bind to double stranded DNA. It also induces prolongation of the G2 phase of the cell cycle, inhibition of DNA replication and cessation of the growth of some cells in late S phase after DNA content has been doubled. It has been shown to increase the life span of mice bearing intraperitoneally implanted L1210 and P388 leukemia. These factors coupled with the affinity of pibenzimol for pancreatic tissue led us to conduct a phase I-II trial of pibenzimol hydrochloride in patients with advanced pancreatic cancer. Twenty-six patients were treated with a five day continuous infusion of pibenzimol at a dose ranging from 6-28 mg/m2/d. There were no treatment related deaths. Major toxicity was hyperglycemia which was self-limited. No objective responses were noted.

Continuous ambulatory peritoneal dialysis: ten years at one facility

A review of continuous ambulatory peritoneal dialysis (CAPD) performed at one facility over a period of 10 years showed that age and type II diabetes mellitus were associated with the worst technique survival. The median survival of patients entering CAPD was not significantly different when the etiology of renal failure was chronic glomerulonephritis (CGN; 27 months), chronic interstitial nephritis (CIN; 21 months), diabetes mellitus type I (21 months), or hypertension (16 months). Patients with diabetes mellitus type II had significantly (P less than 0.05) worse survival (11 months). A patient remaining on CAPD 6 months had a 55% to 60% chance of remaining on therapy at 2 years and a 47% chance at the end of 3 years, whereas a patient with diabetes mellitus type II had a 34% conditional probability of remaining on dialysis at 2 years and 18% at 3 years. Sex, race, and educational achievement were not important determinants of dialysis technique survival. Studies are indicated to identify predictors of a poor dialysis experience.

A study of cyproheptadine in the treatment of metastatic carcinoid tumor and the malignant carcinoid syndrome

Sixteen patients with metastatic neuroendocrine tumors and the malignant carcinoid syndrome were treated with cyproheptadine (Periactin, Merck, Sharp & Dohme, West Point, PA) at maximum tolerable doses that ranged from 12 to 48 mg daily. Usual side effects were mild sedation and dry mouth, but three patients found it impossible to sustain treatment due to nausea and vomiting. Most patients had significant relief of diarrhea, frequently associated with weight gain. Relief of flushing was uncommon. The therapeutic benefit produced by cyproheptadine would appear to be a peripheral effect because 5-hydroxyindoleacetic acid (5-HIAA) excretion in these patients was not reduced. Although there have been case reports of objective tumor regression with cyproheptadine therapy, this was not observed in any of these 16 patients. Cyproheptadine would appear to be a useful therapeutic tool for the management of diarrhea associated with the malignant carcinoid syndrome. An appropriate initial total daily dose is 0.4 mg/kg divided in three fractions with prompt modification to produce minimal and tolerable side effects.

Stomal recurrence after laryngectomy: interrelated risk factor study

This study was designed to identify pathogenic factors in recurrent carcinoma at the tracheal stoma. The charts of 444 patients with laryngeal cancer who were treated surgically between 1976 and 1988 revealed stomal recurrence in 15 (3.4%). Eighty percent of the patients with stomal recurrence had tumors in the subglottis. In comparison to patients with different sites involved this was significant (p less than 0.001). Other variables examined and analyzed included primary stage, previous treatment, neck pathologic status, neck treatment, age, sex, postoperative adjunctive therapy, and timing of tracheotomy. Tumor involvement of the subglottis is the single most important variable in stomal recurrence of carcinoma. Previous conservation laryngeal surgery and preoperative/emergency tracheotomy are not related to stomal recurrence of carcinoma. Mean length of survival for patients with stomal recurrence of carcinoma in our series was 8.9 months. Two patients were successfully treated with extensive surgical resection. The dismal prognosis of stomal recurrence of carcinoma suggests that management of this condition should focus on prevention. Treatment of patients with tumors of the subglottis should include attention to the paratracheal region and superior mediastinum, in conjunction with laryngectomy immediately after initial diagnosis.

Absorption of sulfamethoxazole and albumin from the peritoneal cavity

The rates of disappearance of sulfamethoxazole and albumin from the peritoneal cavity were measured in humans. Albumin was added to the peritoneal cavity in concentrations commonly found during peritonitis (250-500 mg/100 ml) to ascertain if protein binding within the peritoneal cavity inhibited absorption from the peritoneal cavity. There were no statistical differences between the removal rates; 64-70% of the administered dose was absorbed after 180 min of intraperitoneal residence. The addition of albumin to the peritoneal cavity did not alter absorption of sulfamethoxazole. The total protein removed in dialysate effluent in the absence of albumin was 1,653 +/- 906 mg. The protein losses when albumin was added to dialysate [( albumin + control losses] - losses in dialysate drainage) were 1,037 +/- 2,305 mg and 1,364 +/- 1,653 mg for the 6 and 12 g studies.

A clinical trial of biochemical modulation of 5-fluorouracil with N-phosphonoacetyl-L-aspartate and thymidine in advanced gastric and anaplastic colorectal cancer

A novel sequential administration schedule of PALA (N-phosphonoacetyl-L-aspartate) and thymidine to enhance the cytotoxic effect of 5-fluorouracil (5FU) was tested in 36 patients with advanced gastric cancer and 21 patients with advanced poorly differentiated (anaplastic) colorectal cancer. The potency of 5FU was dramatically increased as indicated by the observation of dose-limiting leukopenia at less than one tenth the maximum tolerated dose of 5FU when given as a single agent by intravenous bolus technique. Twenty-five percent of gastric cancer patients and 33% of colorectal cancer patients experienced an objective tumor response, including three patients with complete response. However, response duration was brief (median, 6 months), and there were four treatment-related fatalities due to severe and unpredictable leukopenia leading to sepsis. Survival was short with a median of 6 months for gastric cancer patients and 3 1/2 months for colorectal cancer patients. We conclude that therapeutic index of 5FU was not improved by the addition of PALA and thymidine in this patient population based on considerations of objective tumor response rate, patient survival, and toxicity.

Interferon-gamma inhibits 1,25-dihydroxyvitamin D3-stimulated synthesis of bone GLA protein in rat osteosarcoma cells by a pretranslational mechanism

Interferon-gamma (IFN) is produced by lymphocytes in areas of inflammation and connective tissue destruction. IFN inhibits collagen and DNA synthesis in cultured rat long bones and osteoblastic ROS 17/2.8 cells, suggesting that the periarticular loss of bone that occurs in inflammatory joint diseases may be due to IFN inhibition of bone formation. Since serum levels of bone gla protein (BGP) have been correlated with the bone formation rate, we studied the effect of IFN on production of this osteoblast-specific protein and steady state BGP messenger RNA (mRNA) levels in ROS 17/2.8 cells. RIA of BGP was done using an antibody raised against rat BGP peptide. BGP synthesis was stimulated with 10(-8) M 1,25-dihydroxyvitamin D3 24 h before and continuously after addition of recombinant rat IFN. IFN (100 U/ml) inhibited BGP secretion 52%, 78%, and 70% in the first, second, and third 24 h periods after IFN treatment, compared to control cells cultured with 1,25-dihydroxyvitamin D3 alone. The ED50 for IFN inhibition of BGP production was 3.3 U/ml (0.29 nM). Pulse labeling with [14C]leucine or [3H]proline during the last 4 h of culture revealed that IFN (3-100 U/ml) did not inhibit total protein secretion into the medium. The percent inhibition of BGP production by IFN was independent of media serum concentration or cell density. IFN (100 U/ml) decreased the steady state level of BGP mRNA as measured by Northern analysis using an oligomeric probe for rat BGP. The decrease in hybridization signal for BGP mRNA was detectable by 1 h after IFN exposure and continued to decline at 6 and 24 h. Treatment with cycloheximide (5 micrograms/ml) blocked the inhibitory effect of IFN on steady state levels of BGP mRNA. These results suggest that IFN may inhibit bone formation by selective inhibition of osteoblast matrix protein production. The mechanism of IFN inhibition of BGP production is, at least in part, pretranslational.

Human keratinocyte growth factor activity on proliferation and differentiation of human keratinocytes: differentiation response distinguishes KGF from EGF family

Human keratinocyte growth factor (KGF) is an epithelial cell specific mitogen which is secreted by normal stromal fibroblasts. In the present studies, we demonstrate that KGF is as potent as EGF in stimulating proliferation of primary or secondary human keratinocytes in tissue culture. Exposure of KGF- or EGF-stimulated keratinocytes to 1.0 mM calcium, an inducer of differentiation, led to cessation of cell growth. However, immunologic analysis of early and late markers of terminal differentiation, K1 and filaggrin, respectively, revealed striking differences in keratinocytes propagated in the presence of these growth factors. With KGF, the differentiation response was associated with expression of both markers whereas their appearance was retarded or blocked by EGF. TGF alpha, which also interacts with the EGF receptor, gave a similar response to that observed with EGF. These findings functionally distinguish KGF from the EGF family and support the role of KGF in the normal proliferation and differentiation of human epithelial cells.

Comparison of rehabilitation in patients undergoing home dialysis. Continuous ambulatory or cyclic peritoneal dialysis vs home hemodialysis

Rehabilitation was assessed in 70 patients undergoing continuous ambulatory (CAPD; n = 67) or cyclic (CCPD; n = 3) peritoneal dialysis and 76 patients undergoing home hemodialysis (HHD). In the CAPD/CCPD group, there were more blacks (83% vs 53%) and diabetics (24% vs 8%). If patients too infirm to work were excluded, no statistically significant differences were found between those working for gain and in school (19% for CAPD/CCPD vs 32% for HHD); homemakers (16% for CAPD/CCPD vs 28% for HHD); and those not working (66% for CAPD/CCPD vs 41% for HHD). Although the CAPD/CCPD group had less formal education (8.9 +/- 3.7 years vs 10.9 +/- 2.2 years for HHD), illiteracy rates were similar (CAPD/CCPD, 16%; HHD, 7%). If unemployable (elderly and debilitated) patients were excluded, full rehabilitation was excellent in both groups (57% for CAPD/CCPD vs 65% for HHD), despite the greater number of blacks and diabetics in the CAPD group.

A prospective randomized evaluation of chronic peritoneal catheters. Insertion site and intraperitoneal segment

The insertion site (midline or through the lateral rectus muscle) and type of chronic dialysis catheter (straight or spiral intraperitoneal segment) were evaluated in a prospective randomized trial. Dialysis catheter complications and catheter survival were the endpoints of evaluation. Eighty-five first catheters were evaluated. Neither race, gender, renal diagnosis, type of catheter, nor insertion site was a determinant of dialysis catheter survival. Overall median catheter survival was 308 days. There were 40 catheter complications (70%, n = 28) that occurred during the first 61 days following insertion. Median time to the first complication occurring within the first 61 days was 3 days. Late catheter removals were due to peritonitis episodes that failed to resolve. Complications are frequent with peritoneal dialysis catheters, and care of the peritoneal dialysis catheters requires constant vigilance.

Extramedullary plasmacytoma of the thyroid associated with a serum monoclonal gammopathy

Extramedullary plasmacytoma is a malignant plasma cell dyscrasia that is most commonly found in the head and neck. Progression to disseminated disease in the form of multiple myeloma occurs in 17% to 32% of cases. Herein, we describe a patient with extramedullary plasmacytoma of the thyroid gland in whom a serum monoclonal gammopathy resolved with surgery and irradiation of the primary. Although rare, this diagnosis should be considered in patients presenting with obstructive thyromegaly and autoimmune thyroiditis.

Complications of Tenckhoff catheters post removal

Complications due to Tenckhoff catheters can occur at prolonged intervals after their removal. From January 1979 to October 1989, 431 patients at our center began continuous ambulatory peritoneal dialysis (CAPD), 278 of whom subsequently transferred to another form of renal replacement therapy. We identified 12 patients (4.3% or 12/278) with post removal catheter complications. There were 14 post removal complications, two each in two patients, and one in each of 12 others. The mean time to complication was 541 +/- 143 days (27-2,040). In 71% (10/14) of the complications, an abscess was found at the site of the previously removed Tenckhoff catheter. In 29% (4/14) of the complications, foreign body material consistent with a retained cuff was recovered. Documentation at the time of Tenckhoff catheter removal should include a statement regarding the presence of the Tenckhoff catheter cuffs, and patients with retained cuffs should be monitored closely for the development of abscesses or other complications. Immunocompromised patients are at high risk for these complications.

Pharmacodynamics of enoximone during intravenous infusion

Twenty-one patients with heart failure (NYHA class II-IV) received a 24-hour infusion of enoximone, followed by a 12-hour washout period. Patients were randomly assigned to one of four treatment groups. Groups I-III received a 0.5 mg/kg bolus, followed by a maintenance infusion of 2.5, 5.0 or 10.0 micrograms/kg/minute. Group IV patients received a maintenance infusion of 5.0 micrograms/kg/minute without the bolus. Serial assessments of haemodynamics, plasma levels of enoximone and enoximone sulphoxide, and ventricular ectopy were performed. Enoximone produced a significant increase in cardiac index (28.1-46.7%) and a decrease in mean pulmonary artery wedge pressure (6.4-35.7%) and systemic vascular resistance (34.7-78.9%). Enoximone had minimal effect on heart rate and blood pressure. In patients who did not receive an initial bolus of 0.5 mg/kg, haemodynamic changes were delayed by approximately 1 hour. Significant haemodynamic improvement was noted at even the lowest infusion rate and did not increase in linear fashion at higher infusion rates. During infusion of enoximone at 10.0 micrograms/kg/minute, both enoximone and its sulphoxide accumulated non-linearly and did not achieve a steady state. No significant adverse effects were noted in these patients. Enoximone infusion at rates greater than 5.0 micrograms/kg/minute may confer minimal additional haemodynamic benefit, while resulting in significant accumulation of enoximone and enoximone sulphoxide. Ventricular ectopy did not increase significantly in most patients.

Phase I and clinical pharmacological evaluation of pirozantrone hydrochloride (oxantrazole)

Pirozantrone hydrochloride, an anthrapyrazole analogue, was selected for clinical evaluation based on broad antitumor activity against murine tumor systems and on potentially less cardiotoxicity when compared to anthracyclines. This anthrapyrazole analogue is currently under clinical evaluation, and we now report results on a Phase I clinical trial incorporating a pharmacologically guided dose-escalation scheme. Dose escalation was designed to proceed by factors of 2 until the patient drug exposure (concentration x time) was 40% of the murine exposure at the LD10 dose (90 mg/m2). Thereafter, more moderate dose escalations were employed. The target concentration x time value (59 micrograms-min/ml) derived from preclinical pharmacology data was exceeded in all three patients at a dose of 90 mg/m2. A dose of 160 mg/m2 was found to reproducibly result in appropriate myelosuppression. This dose is recommended for further testing in Phase II studies. Nonhematological toxicities encountered in this trial were mild, the most notable being phlebitis at the infusion site. Objective responses were observed in two patients, one with metastatic breast cancer and another with metastatic melanoma. Following a 60-min infusion, pirozantrone hydrochloride plasma elimination was monoexponential, with a half-life of approximately 30 min, mean total body clearance of 1.29 liters/min/m2, and mean steady state volume of distribution of 29 liters/m2.

Nutritional support during peritoneal dialysis-related peritonitis

Early intravenous (IV) hyperalimentation was used in seven patients who had peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD). Results were compared with those in a control group of seven nonperitonitis CAPD patients. Nitrogen balance was measured to determine whether this therapy was effective in nutritional maintenance during an episode of peritonitis. IV nutrition accounted for 70% to 80% of nitrogen intake. Caloric intake was similar in both groups (34 and 32 calories/d/kg). The control group received 22 g/d of nitrogen and the peritonitis group 17 g/d (P less than 0.05). Nitrogen losses in dialysate were 12.6 g/d in the control group and 13.6 g/d in the peritonitis group. The mean nitrogen balance (intake - output) was 9.5 g/d in controls and 3.7 g/d in the peritonitis group.

Digital clubbing due to secondary hyperparathyroidism

Five patients in our dialysis population had digital changes suggestive of clubbing in association with severe secondary hyperparathyroidism. All had parathyroidectomies between June 1986 and December 1987. They represented 0.6% of the patients in our dialysis population and 17.8% of our patients who required operative management of secondary hyperparathyroidism. The clubbing was occasionally painful, and the digits were tender in response to palpation. Parathyroidectomy yielded excessive amounts of hyperplastic parathyroid tissue in each case. Postoperatively, the symptoms were relieved, when present, and the digital changes were stabilized. We believe that these findings are associated with severe secondary hyperparathyroidism and should be looked for in dialysis patients with renal osteodystrophy.