Cisplatin neuropathy. Clinical, electrophysiologic, morphologic, and toxicologic studies

Long-term sequelae of treatment for testicular germ cell tumours

Seventy-four patients previously treated in our department for germ cell tumour of the testis underwent a series of tests to determine the frequency of long-term therapeutic complications. All had received cisplatin-based chemotherapy as part of their treatment. There was a significant deterioration in renal function throughout the group. Eighteen (24%) had supine blood pressure greater than systolic 140 mmHg or diastolic 90 mmHg after treatment but hypertension did not correlate with renal impairment. Raynaud's phenomenon was common after chemotherapy (26/74) as was persistent sensory neuropathy (23/74). Although 34% had testosterone levels below the normal range, only six patients had a low free testosterone index with one testis still in situ; 18 patients have fathered children after chemotherapy. Approximately half of the patients completed a psychosexual questionnaire and some 30% of them admitted to sexual problems which they attributed to their treatment. Long-term sequelae of cisplatin-based chemotherapy for testicular malignancy are frequent and persistent, and follow-up of these patients should include prospective measurement of changes in blood pressure.

Cisplatin-induced peripheral neuropathy. Frequent off-therapy deterioration, demyelinating syndromes, and muscle cramps

Forty-five patients with cisplatin-induced peripheral neuropathy (PN) were evaluated retrospectively after treatment with cumulative doses of cisplatin ranging from 201 to 1952 mg/m2. The patients were followed for up to 23 months (median, 4.5 months), and 32 of them were evaluated more than once. Severity of symptoms was related to higher cumulative doses of cisplatin but with marked individual variability. Off-therapy deterioration of the PN continued in 14 patients (31%) for 2.5 to 5.5 months after withdrawal of cisplatin, and only four patients showed some improvement during the follow-up period. Symptomatic deterioration often was heralded by new onset of muscle cramps (with normal Ca2+/Mg2+ levels) and/or by manifestations of probable spinal dorsal column and/or nerve root demyelinating syndromes presenting as either Lhermitte's sign and/or as an electric-shock sensation along the upper extremities when outstretched in 90 degrees shoulder abduction. Cramps and demyelinating syndromes were each noted in 31% of the patients. Muscle cramps tended to resolve several months after withdrawal of therapy, and demyelinating syndromes were always transient (1.5 to 6.0 months) and did not progress despite ongoing therapy in five patients. Our study indicates that, after withdrawal of therapy, patients with cisplatin-induced PN may continue to deteriorate for several months. Manifestations of muscle cramps and demyelinating syndromes signify a worsening course of the PN but should not automatically indicate interruption of therapy.

Low prevalence of cisplatin-induced neuropathy after 4-day continuous infusion in head and neck cancer

The toxicity of cisplatin on peripheral nerves was studied using electrophysiologic recordings in 52 patients with head and neck squamous cell carcinoma. Induction chemotherapy (cisplatin: 25 mg/m2/day, days 1-4; 5-fluorouracil: 1 g/m2/day, days 1-4) was administered by continuous infusion every 3 weeks. Electrophysiologic recordings were performed before and after the completion of three courses of chemotherapy (cisplatin total dose: 250-300 mg/m2). The comparison between the recordings showed 14% of the patients had an increase in the latency of the soleus muscle monosynaptic reflex as studied by the Hoffman reflex and 9% showed a decrease in the conduction velocity of the cutaneous sensory fibers of the median nerve. These results indicated a low prevalence of cisplatin-induced neuropathy. The respective roles played by the continuous infusion of the drug and by the potentiation of neurotoxic effects resulting from the association of cisplatin with other neurotoxins is discussed to explain this low toxicity.

Prospective study of nerve conduction parameters and serum magnesium following cisplatin therapy

This study evaluated the effects of cisplatin on 18 nerve conduction parameters of median, ulnar, peroneal, and sural nerves in relation to age, magnesium nadir, average magnesium, and magnesium replacement in gynecologic oncology patients. The 37 patients in this study received cisplatin (70 mg/m2) at 4-week intervals either as a single agent (17 patients) or in combination with doxorubicin and cyclophosphamide (20 patients) following inpatient hydration. The patients were placed randomly on either magnesium supplementation (intravenous plus oral) or placebo. For all patients, nerve conduction studies were performed before and after cisplatin therapy in the same EMG laboratory. Statistical analysis revealed that postcisplatin nerve conduction parameters were significantly predictable based upon pretherapy nerve conduction parameters, magnesium supplementation, total cisplatin, age, magnesium nadir, and average magnesium. Total cisplatin, age, and serum magnesium level were significant predictors in 8, 2, and 2 of the 18 nerve conduction parameters, respectively. Following cisplatin therapy, there was a significant decrease in sensory nerve action potential amplitude of median, ulnar, and sural nerves, whereas sensory latency of median and ulnar nerves was significantly increased. Cisplatin therapy had no effect on motor nerve conduction parameters of median, ulnar, and peroneal nerves. Factors responsible for the decrease in sural sensory action potential amplitude were not identified. Sensory nerve action potential amplitude and sensory latency of ulnar nerve are the two best objective parameters that can be utilized to monitor patients for adverse nerve conduction side effects of cisplatin.

Prevention of cisplatin neurotoxicity with an ACTH(4-9) analogue in patients with ovarian cancer

In a randomized, double-blind, placebo-controlled study, we assessed the efficacy of an ACTH(4-9) analogue, Org 2766, in the prevention of cisplatin neuropathy in 55 women with ovarian cancer. The analogue was given subcutaneously in a dose of 0.25 mg (low dose) or 1 mg (high dose) per square meter of body-surface area before and after treatment with cisplatin and cyclophosphamide (75 and 750 mg per square meter every three weeks). The threshold of vibration perception was used as the principal measure of neurotoxicity. After four cycles of chemotherapy, the mean (+/- SEM) threshold value for vibration perception in the placebo group increased from 0.67 +/- 0.12 to 1.61 +/- 0.43 microns of skin displacement (P less than 0.0001). In the high-dose treatment group, there was no increase in the threshold value after four cycles (from 0.54 +/- 0.12 to 0.50 +/- 0.06 micron). After six cycles of chemotherapy, the threshold value was 5.87 +/- 1.97 microns in the placebo group (more than an eight-fold increase from base line), as compared with 0.88 +/- 0.17 micron (less than a twofold increase) in the high-dose treatment group (P less than 0.005). In the high-dose group, fewer neurologic signs and symptoms were recorded than in the placebo group. With the lower dose of the analogue, these protective effects were less prominent. No side effects were seen after treatment with Org 2766. The rates of clinical response to chemotherapy were similar in all groups. These results suggest that Org 2766 can prevent or attenuate cisplatin neuropathy without adversely affecting the cytotoxic effect of the drug.

Changes of stapedius reflex and hearing threshold in patients receiving high-dose cisplatin treatment

The value of stapedius reflex (SR) measurement in the clinical management of the ototoxic side-effect of cisplatin was examined in 24 patients who had received a dose of 100-120 mg/m2. The main finding was a frequent but inconsistent deterioration of the SR threshold (SRT) at 3 and/or 4 kHz, usually with a moderate rise of the hearing threshold (HT) in the frequency range 3-8 kHz. A hearing loss exceeding 60 dB HL is detected with high probability as an SRT deterioration. None of the patients showed any influence on the SRT before the HT rise could be detected. The SR test cannot replace pure-tone audiometry for the identification of cisplatin ototoxicity. The pathological SR results observed in this study indicated a cochlear lesion. It was not possible to identify those patients most susceptible to ototoxic changes from the pretreatment results of the SR test.

Cisplatin rescue therapy: experience with sodium thiosulfate, WR2721, and diethyldithiocarbamate

Cisplatin has a steep dose response curve for both antitumor and adverse effects. Therapeutic strategies aimed at reducing toxicity and allowing dose escalation of intravenous cisplatin, such as administration in hypertonic saline and pharmacokinetically based dosing schedules, have been partially successful in reducing nephrotoxicity and bone marrow suppression. However, new dose-limiting toxicities consisting of peripheral neuropathy and ototoxicity have emerged, which continue to restrict potential use of high dose cisplatin therapy. Intraperitoneal administration of high dose cisplatin also offers the potential of markedly increased local drug exposure if systemic toxicity can be avoided. Proposed chemoprotective agents, including sodium thiosulfate, WR2721, and diethyldithiocarbamate (DDTC) are being extensively examined as "rescue agents" for either regional or systemic administration of cisplatin. Although each agent offers unique advantages to be considered in developing successful rescue therapy, many questions remain regarding molecular and pharmacokinetic interactions with cisplatin, appropriate dosing schedules, and effects on antineoplastic activity. We present a review of current investigations of chemoprotectors for prevention of cisplatin-related toxicities.

Ocular complications of systemic cancer chemotherapy

Cancer chemotherapy has changed rapidly in recent years. New agents are constantly being developed. Established agents are being used with increased frequency, in new combinations, at higher dosages, and via new routes of administration. Enhanced survival, as well as increased drug toxicity, has resulted. Ocular toxicity is not uncommon and can greatly impact on quality of life. Practitioners in all fields are increasingly caring for patients who are receiving cancer chemotherapy. The recognition of eye disease resulting from chemotherapy is essential to appropriate patient management. We provide a review of the rapidly growing body of literature on the ocular toxicity of systemic cancer chemotherapy with particular attention to context, clinical course, mechanism, prevention and treatment.

Vibration perception and thermoperception as quantitative measurements in the monitoring of cisplatin induced neurotoxicity

In 20 ovarian cancer patients treated by cisplatin-based chemotherapy quantitative investigations of the vibration and the thermoperception were performed. Following the administration of cisplatin of 300 mg/m2 and more the vibration perception threshold (VPT) was shown to be significantly elevated in all patients, despite the absence of clinical symptoms and signs in a number of patients. The VPT returned within 8 months to its original level in the 2 patients who were followed after cessation of therapy (cumulative dose of cisplatin 450-525 mg/m2). The changes seen in hands and in feet were comparable. There was no significant difference between the left and the right hand side. Thermoperception thresholds did not change during the treatment period. This study shows that quantitative measurement of vibration perception thresholds in patients treated with cisplatin is a relatively simple, accurate and reliable technique. Measurement is only required at the hand. It is concluded that this technique is a valuable tool in the assessment of cisplatin neurotoxicity and may be used in the monitoring of drugs that claim to be of benefit in the prevention and treatment of this affliction.

Cisplatin-induced neurotoxicity with seizures in frogs

Cis-diamminedichloroplatinum II (cisplatin) given by injection to adult frogs (Rana pipiens) resulted in tonic-clonic seizures 3 to 5 weeks later. The seizures could be induced multiple times; the animals appeared entirely normal between seizures. In the spinal cord there was vacuolation in the anterior grey horns. Ultrastructurally, the vacuoles consisted of swollen astrocytic processes in the neuropil and around neurons. Generalized edema with swelling of perivascular astrocyte foot processes was not seen. Systemic administration of cisplatin to frogs results in neurotoxicity with seizures and astrocytic swelling in the spinal cord.

Cellular distribution of cis-diamminedichloroplatinum(II)-DNA binding in rat dorsal root spinal ganglia: effect of the neuroprotecting peptide ORG.2766

The in situ binding of the anticancer drug cis-diamminedichloroplatinum(II) (cisDDP) to DNA was studied in the rat dorsal root spinal ganglion (DRG), using an antiserum against cisDDP-modified calf thymus DNA in a quantitative immunocytochemical assay. Rats received a dose of cisDDP (1 mg/kg), two times a week, up to a cumulative dose of 15 mg/kg (group I) or 34 mg/kg (group II). Rats of group III were given a single dose of 15 mg/kg. Rats were killed 48 hr (groups I and II) or 6 hr (group III) after the last injection. In groups I and II cisDDP-induced neurological damage was assessed by measuring both motor and sensory nerve conduction velocities (MNCV and SNCV). Whereas the MNCV was not influenced by the treatment with cisDDP, the SNCV decreased significantly. The level of cis-DDP-DNA binding in DRG satellite cells equalled that in liver cells, but binding could not be shown in DRG neuron nuclei. The level of cisDDP-DNA binding in spinal cord and brain was very low. The neuroprotecting peptide ORG.2766, an ACTH4-9 analog, was given sc (10 micrograms/rat) four times a week concomitantly with cisDDP to some rats of groups I and II. ORG.2766 prevented the decrease of the SNCV, but did not change the extent of cisDDP-DNA binding in satellite or liver cells. It is concluded that the amelioration of cisDDP toxicity by ORG.2766 is not directly related to the cisDDP-DNA binding in satellite cells.

Carboplatin and etoposide pharmacokinetics in patients with testicular teratoma

The pharmacokinetics of carboplatin and etoposide were studied in four testicular teratoma patients receiving four courses each of combination chemotherapy consisting of etoposide (120 mg/m2 daily x 3); bleomycin (30 mg weekly) and carboplatin. The carboplatin dose was calculated so as to achieve a constant area under the plasma concentration vs time curve (AUC) of 4.5 mg carboplatin/ml x min by using the formula: dose = 4.5 x (GFR + 25), where GFR is the absolute glomerular filtration rate measured by 51Cr-EDTA clearance. Carboplatin was given on either day 1 or day 2 of each course and pharmacokinetic studies were carried out in each patient on two courses. Etoposide pharmacokinetics were also studied on two separate courses in each patient on the day on which carboplatin was given and on a day when etoposide was given alone. The pharmacokinetics of carboplatin were the same on both the first and second courses, on which studies were carried out with overall mean +/- SD values (n = 8) of 4.8 +/- 0.6 mg/ml x min, 94 +/- 21 min, 129 +/- 21 min, 20.1 +/- 5.41, 155 +/- 33 ml/min and 102 +/- 24 ml/min for the AUC, beta-phase half-life (t 1/2 beta), mean residence time (MRT), volume of distribution (Vd) and total body (TCLR) and renal clearances (RCLR), respectively. The renal clearance of carboplatin was not significantly different from the GFR (132 +/- 32 ml/min). Etoposide pharmacokinetics were also the same on the two courses studied, with overall mean values +/- SD (n = 8) of: AUC = 5.1 +/- 0.9 mg/ml x min, t 1/2 alpha = 40 +/- 9 min, t 1/2 beta = 257 +/- 21 min, MRT = 292 +/- 25 min, Vd = 13.3 +/- 1.31, TCLR = 46 +/- 9 ml/min and RCLR = 17.6 +/- 6.3 ml/min when the drug was given alone and AUC = 5.3 +/- 0.6 mg/ml x min, t 1/2 alpha = 34 +/- 6 min, t 1/2 beta = 242 +/- 25 min, MRT = 292 +/- 25 min, Vd = 12.5 +/- 1.81, TCLR = 43 +/- 6 ml/min and RCLR = 13.4 +/- 3.5 ml/min when it was given in combination with carboplatin. Thus, the equation used to determine the carboplatin accurately predicted the AUC observed and the pharmacokinetics of etoposide were not altered by concurrent carboplatin administration. The therapeutic efficacy and toxicity of the carboplatin-etoposide-bleomycin combination will be compared to those of cisplatin, etoposide and bleomycin in a randomised trial.

Intra-arterial cisplatin for the treatment of malignant gliomas

Cisplatin (DDP) is a chemotherapeutic agent that has shown efficacy against primary CNS malignancies. Intra-arterial (IA) administration of DDP to patients with brain tumors should produce higher peak levels of drug than intravenous (IV) administration of an identical dose and reduce systemic toxicity. Twelve patients with malignant glioma were entered into the study. All had failed irradiation, 11 had failed IA BCNU. Each patient received IA DDP, 58-100 mg/m2, into the internal carotid artery at four to six week intervals. One of 12 patients had a partial response of 6 months. The remaining 11 patients had progressive disease or severe complications. Toxicity included seizures in four patients, weakness and/or aphasia in four patients, coma in two patients, and visual deterioration in two patients. IA DDP has very limited efficacy in patients with malignant gliomas after failure of nitrosoureas and is associated with an unacceptable level of toxicity. IA DDP may be more effective when used as initial chemotherapy of malignant gliomas.

Streamlining outpatient cisplatin therapy to meet the challenges of today

Increasing numbers of patients are receiving full courses of cisplatin therapy in such outpatient settings as clinics, offices, day hospitals, or home. Outpatient cisplatin therapy is administered safely and effectively in the ambulatory environment. Outpatient therapy is about one third the cost of inpatient therapy and offers the patient significant benefits in terms of work, illness perception, tolerance of side effects, and family strain. As more patients receive cisplatin on an outpatient basis, it is imperative that new strategies be developed to help streamline care to accommodate the growing number of outpatients. This article reviews methods used in a variety of settings to provide quality care to larger numbers of patients. A critical factor to consider when developing new care methods is how to maintain the fine balance between efficient, effective, economical, and quality care. Keeping that balance may necessitate a lot of trials and false starts. Developing a comfortable environment for cisplatin infusion is a matter of creativity. It is not necessary to spend large sums of money to create an acceptable setting. Flow sheets, standardized teaching protocols, patient information guides, patient diaries, and standardized hydration, anti-emetic, and therapy protocols are just a few of the approaches that have been used to streamline care. Becoming involved in oncology nurse groups, networks, or continuing education programs are excellent avenues to meeting people who are all working on methods to streamline and provide quality care. The three elements of a successful outpatient program for the administration of cisplatin include having a comfortable setting, a well-organized, experienced staff, and appropriate patient selection.(ABSTRACT TRUNCATED AT 250 WORDS)

Focal encephalopathy after cisplatin therapy

Focal encephalopathy after cisplatin therapy, although described previously, is a rare adverse effect. Recently, four patients who received cisplatin therapy at our institution developed focal encephalopathy which manifested itself as cortical blindness, aphasia with seizures, aphasia with hemianopia and a focal seizure, respectively, shortly after the administration of cisplatin. Each episode occurred while the patients were febrile with neutropenia although no evidence of central nervous system infection was found. The neurological symptoms occurred after at least two courses of cisplatin therapy (minimum total cisplatin dose, 300 mg/m2) and three of the four patients also were noted to have hypomagnesaemia. In each case, the neurological deficit resolved and two patients received further cisplatin therapy without a recurrence of the neurological symptoms. Our experience suggests that focal encephalopathy that is associated with cisplatin therapy may resolve completely with supportive measures alone and need not preclude further therapy with cisplatin.

Brachial plexopathy as a complication of intraarterial cisplatin chemotherapy

Intraarterial administration of chemotherapeutic agents provides greater local concentration at the tumor site without increased systemic toxicity. Although intravenous infusion of cisplatin is known to cause peripheral neuropathy and intraarterial administration has been reported to cause lumbosacral plexopathy, brachial plexopathy has not been described. We present a case in which infusion of cisplatin into the axillary artery resulted in permanent neurological damage to the posterior cord of the brachial plexus. Proper positioning of the infusion catheter is necessary to minimize potential neural damage.

Testicular cancer in young Norwegians

The clinical experience is reviewed in 597 Norwegian testicular cancer patients (age range: 15-45 years) treated from 1979 to 1986. During this period, computer tomography, determination of serum AFP/HCG, and cisplatin-based chemotherapy represented the modern diagnostic and therapeutic modalities. Before orchiectomy 67% of the patients had elevated AFP/HCG. An abnormal postorchiectomy serum tumour marker decrease and the presence of small vessel infiltration in the histological sections of the primary tumour significantly predicted microscopic retroperitoneal metastases in patients with clinical stage I (CSI) nonseminoma. One-third of these patients had a pathological stage II (PSII). After radiotherapy 99% of 90 seminoma patients (CSI/IIa) survived for 5 years. After cisplatin-based chemotherapy (+radiotherapy/surgery) the 5-year survival rate in 25 patients with advanced seminoma was 81%. The survival rate in 148 nonseminoma patients PSI/IIa was 100% and 87% in 94 patients with advanced nonseminoma (greater than or equal to CSIIb). Nausea, general exhaustion, myelosuppression, peripheral neuropathy, and Raynaud-like phenomena were the main acute treatment-related side effects. Slight gastrointestinal problems, slight peripheral neuropathy, Raynaud-like phenomena, and fertility disturbances were frequent late side effects. The sexual life in testicular cancer patients did not seem to be significantly impaired as compared to the normal population. Most of the patients reported no or only slight emotional problems during and after treatment. The need of thorough information at the time of diagnosis was stressed by most of them. Secondary cancer was diagnosed in 27 of 795 patients (1970-1982) (Testicular: 15; pulmonary: 4; sarcoma: 2; others: 6). Testicular cancer is today a curable malignancy. Future clinical research has to concentrate on the identification of high-risk and low-risk patients, the avoidance of overtreatment, and the reduction of toxicity (especially of long-term side effects).

Effects of cisplatin and thiosulfate upon auditory brainstem responses of guinea pigs

Two side effects which limit the use of cisplatin in cancer chemotherapy are severe nephrotoxicity and ototoxicity. The concurrent administration of sodium thiosulfate with cisplatin reportedly protects from cisplatin nephrotoxicity, however, protection from ototoxicity has not been documented. The purpose of this study was to examine the efficacy of using thiosulfate to ameliorate the ototoxic effects of cisplatin. Toward this end, the effects of cisplatin alone, cisplatin administered concurrently with sodium thiosulfate (CIS/THIO), and sodium thiosulfate alone on the auditory brainstem response (ABR) of guinea pigs were compared. ABR waveforms, comparing latencies, amplitudes and response thresholds, were monitored before, immediately after, and 30 days post treatment. Sodium thiosulfate administered with cisplatin (CIS/THIO) consistently protected animals from hearing loss and surprisingly yielded significant increases in amplitude when compared to baseline and saline controls. However, ABRs of CIS/THIO animals returned toward baseline values after 30 days.

Cisplatin neuropathy. Risk factors, prognosis, and protection by WR-2721

A prospective study of patients receiving cis-diaminedichloroplatin II (DDP) was carried out to determine if risk factors could be identified related to the patient's living habits or past medical history that would predict in which patients DDP neuropathy might develop. Sixty-nine patients receiving six different combinations of chemotherapeutic agents, including DDP were examined. Twenty-eight of these patients received DDP in combination with the radioprotective agent S-2-(3-aminopropylamino)-ethylphosporothioic acid (WR 2721). No risk factors were identified relating to personal habits or past medical history of the patients. However, patients receiving DDP (40 mg/m2) on 5 consecutive days had a significantly higher incidence of neuropathy. Patients receiving DDP in combination with WR 2721 had a significantly lower incidence of neuropathy, and the mean dose at onset was significantly higher than the mean dose at onset of neuropathy for all other groups. In addition, five of six patients who were available for long-term follow-up demonstrated nearly complete reversal of the signs and symptoms of neuropathy.

Cerebral herniation in patients receiving cisplatin

5 Patients with intracranial mass lesions are described who experienced cerebral herniation and coma following intravenous cisplatin therapy. Although the pathogenesis of the acute cerebral swelling is unknown, it is most likely multifactorial. Possible contributing factors include pre-existing cerebral edema, acute hypo-osmolality with fluid shifts into an already swollen brain, seizures and possible direct neurotoxicity of cisplatin.

Efficacy of the neuropeptide ORG.2766 in the prevention and treatment of cisplatin-induced neurotoxicity in rats

In rats chronic systemic treatment with cisplatin results in a sensory neuropathy as evidenced by a reduction in the sensory conduction velocity in the sciatic nerve. Concomitant administration of the neurotrophic ACTH4-9 analog, ORG.2766, prevents the occurrence of the neuropathy. In addition, treatment with ORG.2766 stops further deterioration and improves recovery of an already established cisplatin-induced neuropathy. Furthermore, concomitant administration of ORG.2766 during a first cisplatin treatment period results in a better resistance against neurotoxicity in a second exposure period. Finally, ORG.2766 was shown not to hamper the anti-tumor effect of cisplatin in mice, carrying implanted tumor cells from a FMa human tumor line. These data are discussed in view of the potential clinical use of ORG.2766 in prevention and treatment of cisplatin-induced neuropathy.

Neuropsychological evaluation of patients with inoperable non-small cell lung cancer treated with combination chemotherapy or radiotherapy

Neuropsychological tests were used to evaluate possible central nervous system dysfunction in patients treated with chemotherapy. Ninety-five patients with non-small cell lung cancer limited disease were randomized to either radiotherapy (2.8 Gy x 15) or combination chemotherapy with cisplatin and etoposide. In order to evaluate cognitive functions three neuropsychological tests were applied: Trail Making, Benton Visual Retention Test and Verbal Learning. Changes in the patients' test scores before and after treatment were compared. The chemotherapy patients showed reduced performance on some of the neuropsychological tests compared to the radiotherapy group. This indicates a treatment related effect on the central nervous system, possibly caused by the combination chemotherapy.

Cisplatin-induced gastric paresis

A 27 year old male with metastatic testicular carcinoma was treated with cisplatin, vinblastine, and bleomycin (PVB) chemotherapy. After receiving a cumulative dose of 500 mg/m2 of cisplatin, he developed severe nausea and vomiting and had clinical evidence of a cisplatin-induced peripheral neuropathy. His vomiting resolved five weeks after discontinuation of cisplatin. We believe this case represents the first report of gastric autonomic neuropathy induced by cisplatin.

High dose carboplatin in the treatment of lung cancer and mesothelioma: a phase I dose escalation study

Sixteen patients with lung cancer or mesothelioma have been treated with escalating doses of carboplatin. Five patients (10 courses) were given 800 mg/m2, four patients (five courses) 1200 mg/m2 and seven patients (eight courses) 1600 mg/m2. Myelosuppression was the major toxicity encountered. The median duration of grade 4 neutropenia ranged from 1 day (800 mg/m2) to 11 days (1600 mg/m2) and the median duration of grade 4 thrombocytopenia ranged from 1 day (800 mg/m2) to 7 days (1600 mg/m2). The median fall in haemoglobin (Hb) ranged from 2.2 g/l (800 mg/m2) to 3.6 g/l (1600 mg/m2). Nephrotoxicity was encountered at all dosages and was in part, though not entirely, dose related. 2/9 patients receiving 800 mg/m2 and 4/6 of the patients receiving 1600 mg/m2 had a fall in glomerular filtration rate (GFR) greater than 25% but less than 50%. 800 mg/m2 of carboplatin was well tolerated, the performance status in 9/10 (90%) courses being 0-1 (ECOG scale). At 1600 mg/m2 in 6/8 (75%) courses the performance status was 2-4. There was one treatment-related death from neutropenia at this dose level. The severity of nausea and vomiting was not dose related but other toxicities including diarrhoea, alopecia, mild neuropathy and ototoxicity and possible CNS toxicity occurred at doses of 1200 mg/m2 and over. 5/7 patients with small cell lung cancer achieved a complete or partial response to treatment.

Electrophysiological study of the peripheral and central neurotoxic effect of cis-platin

We describe clinical and electrophysiological findings in 8 patients with tumors of germ cell origin before and after treatment with high-dose cisplatin (800-1400 mg) combined with etoposide and bleomycin. All patients developed clinical or electrophysiological signs, or both, of a peripheral sensory neuropathy. One had in addition clinical and electrophysiological signs of CNS involvement, and 2 had a central conduction defect revealed by auditory stimulation.

Peripheral neuropathy and ototoxicity of dichlorodiamineplatinum: instrumental evaluation. Preliminary results

Clinical use of cis-platinum in the treatment of many human tumors is increasing. Since side effects could represent a limitation of its use, we evaluated neurotoxic effects of this compound in a group of 23 patients on antiblastic treatment for gynecological neoplasms. Evaluation was performed by clinical-neurological examination, neurophysiological data (electromyography, maximal motor conduction velocity, and sensory conduction velocity) and potentials. Seven patients reported subjective symptoms of neurological involvement. In 2 cases there was a change in the electromyographic pattern. The otolaryngological examination showed a change in the hearing threshold in 3 patients and in 1 case the fatigue test was positive. Neurotoxic effects and hearing damage was not related to the treatment schedule.

In vitro mechanism study of microtubule assembly inhibition by cis-dichlorodiammine-platinum(II)

The inhibitions of microtubule protein (MTP) and tubulin 6S polymerizations by cis-dichlorodiammine-platinum(II) (CDDP) have been investigated by turbidity measurements and electron microscopy. For 2.5 X 10(-4) M CDDP after 40 min contact time at 27 degrees, the inhibition was 60% for MTP (1.2 mg/ml) and nearly 90% for tubulin 6S (1.2 mg/ml). Microtubules were not present after a 1 hr contact time at 27 degrees with 2.5 X 10(-4) M CDDP. Free sulfhydryl group determinations with 5,5'-dithio-bis-(2-nitrobenzoate) (DTNB) showed that 20.10 (+/- 0.05) sulfhydryl groups were found per tubulin dimer. In the presence of excess CDDP, this number was reduced to 17.74 (+/- 0.05) after a 1 hr contact time at 27 degrees. By using CDDP-tubulin dialysis assays, the CDDP-tubulin complex formation was found to be an irreversible reaction through a covalent binding at the sulfhydryl group sites. By the DEAE filter paper method, CDDP was shown to slightly decrease vinca-alkaloid and colchicine bindings to tubulin likely by inducing a conformational change of the protein.

The effects of cisplatin on rat spinal ganglia: a study by light and electron microscopy and by morphometry

Cisplatin given in doses of 0.5-2 mg to Wistar and to Sprague-Dawley rats produced nucleolar segregation of the dense fibrillar from the granular component in spinal root ganglion cells. The nucleolar segregation, found to the same extent in large and small neurons, was confirmed by specific silver staining and by electron microscopy. After repeated doses of 1 mg or 0.5 mg, up to 40% of affected nucleoli were observed by light microscopy. Focal clearing of the nucleoplasm of nuclei also occurred. Disorganisation of ribosomes was found in more severely intoxicated animals, especially in large light cells with shrinkage of the Nissl substance and apparent increase in neurofilaments, the latter occasionally distending the initial segment of the axon, but never extending further. Hypertrophy of the satellite cells with increase in the perineuronal intercellular spaces, often associated with irregular, scalloped nuclear and cell outlines, suggested that neuron shrinkage had occurred. This was confirmed by morphometry and marked alterations were found in nucleolar-to-nuclear and nucleolar-to-cell diameter ratios, nuclear and cell diameters were also somewhat reduced without change in the nucleus-to-cell ratios. Peripheral sensory nerve degeneration was not seen, and the animals died from non-neural causes. The probable role of these events in the production of sensory neuropathy is discussed.

Metastatic epidural osteosarcoma initially diagnosed as cisplatin neuropathy

Unexpected early epidural spinal metastasis in a case of osteosarcoma occurred in a patient receiving treatment with cis-diamminedichloroplatinum-II (cisplatin). The initial neurologic symptomatology manifested as paresthesias in the feet which developed 2 months after initiation of treatment (cumulative dose of cisplatin 450 mg/M2) at which stage the primary tumor demonstrated a marked response. Concurrently two small pulmonary metastases appeared. Epidural metastasis in osteosarcoma is generally considered a late complication and is usually associated with disseminated disease. This communication draws attention to changes in the metastatic pattern which may occur with the administration of seemingly effective treatment and the potential for confusing the symptomatology of epidural spinal metastasis with cisplatin neuropathy.

Cisplatin neuropathy with Lhermitte's sign

Following chemotherapy with cis-diamminedichloroplatinum II (cisplatin) three patients developed Lhermitte's sign and peripheral neuropathy. The toxic side effects did not become apparent until after treatment had ceased. Because of increasing use of cisplatin to achieve lasting remission in patients with malignant disease proprioceptive and myelopathic side effects may become increasingly common.

High-dose intracavitary cisplatin with intravenous thiosulfate. Low incidence of serious neurotoxicity

Recent published reports have suggested that cisplatin administered in high doses or in certain combination chemotherapy can cause serious neurotoxicity in a large percentage of patients treated. In several high-dose cisplatin-based intracavitary chemotherapy trials with the simultaneous intravenous administration of sodium thiosulfate, the incidence of clinically relevant neurotoxicity has been extremely low. In addition, several patients with serious preexisting cisplatin-induced neurologic dysfunction were treated without worsening of their clinical condition. It is suggested that thiosulfate might have been responsible for the low incidence of neurotoxicity in this patient population. Further experimental and clinical investigation of the potential of this agent to protect against cisplatin-induced neuropathy appears warranted.