A high rate of venous thromboembolism in a multi-institutional phase II trial of weekly intravenous gemcitabine with continuous infusion fluorouracil and daily thalidomide in patients with metastatic renal cell carcinoma

Chemotherapy Induced Cardiotoxicity: A State of the Art Review on General Mechanisms, Prevention, Treatment and Recent Advances in Novel Therapeutics

As medicine advances to employ sophisticated anticancer agents to treat a vast array of oncological conditions, it is worth considering side effects associated with several chemotherapeutics. One adverse effect observed with several classes of chemotherapy agents is cardiotoxicity which leads to reduced ejection fraction (EF), cardiac arrhythmias, hypertension and Ischemia/myocardial infarction that can significantly impact the quality of life and patient outcomes. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review comprehensively describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring possible mechanisms for cardiotoxicity observed with anticancer agents could provide valuable insight into susceptibility for developing symptoms and management guidelines. Chemotherapeutics are associated with several side effects. Several classes of chemotherapy agents cause cardiotoxicity leading to a reduced ejection fraction (EF), cardiac arrhythmias, hypertension, and Ischemia/myocardial infarction. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload, and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring mechanisms for cardiotoxicity observed with anticancer agents could provide insight that will guide management.

An overview of thrombotic complications of old and new anticancer drugs

Thrombosis is a common complication of cancer with a mean prevalence of 15%. Most commonly, this presents as venous thromboembolism; however, other manifestations such as arterial thrombosis or thrombotic microangiopathy may occur. Cancer itself is not only associated with risk factors for thrombotic complications, including intrinsic biological effect of malignant cells, accompanying operations, or the presence of indwellingvascular catheters, but there is also an additional risk caused by anticancer agents including chemotherapy and immunotherapy. In most cases the underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example by vascular endothelial growth factor inhibition). In addition, individual anticancer agents may have specific prothrombotic effects. As in recent years more intense anticancer drugs are administered, such as in myeloablative conditioning regimens preceding stem cell transplantation, thrombosis and in particular thrombotic microangiopathy are a more frequent complication in anticancer treatment.

Pathophysiology of Coagulopathy in Hematological Malignancies and in COVID-19

Many severe illnesses with a systemic impact may cause activation of coagulation. While systemic activation of coagulation leads to a coagulopathy that follows many common activation pathways and failure of endogenous regulatory anticoagulant systems, underlying conditions may utilize distinctive pathogenetic routes and may vary in clinical manifestations of the coagulopathy. The coagulation derangement associated with hematological malignancies and the coagulopathy of coronavirus disease 2019 (COVID-19) clearly demonstrate such differences. Malignancies are associated with venous thromboembolism due to the biological effect of malignant cells, frequent medical interventions, or the presence of indwelling vascular catheters. The underlying pathogenesis of cancer-associated coagulopathy relies on tissue factor-mediated activation of coagulation, cytokine-controlled defective anticoagulant pathways, fibrinolytic changes, and dysfunctional endothelium. There is an additional risk caused by anti-cancer agents including chemotherapy and immunotherapy. The underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example, by vascular endothelial growth factor inhibition). In addition, individual anti-cancer agents may have specific prothrombotic effects. One of the remarkable features of severe COVID-19 infections is a coagulopathy that mimics but is not identical to the disseminated intravascular coagulation and thrombotic microangiopathy and has been identified as a strong marker for an adverse outcome. Severe COVID-19 infections cause inflammation-induced changes in coagulation in combination with severe endothelial cell injury. This coagulopathy likely contributes to pulmonary microvascular thrombosis, bronchoalveolar fibrin deposition (which is a hallmark of acute respiratory distress syndrome) and venous thromboembolic complications.

Special Circumstances and Populations

Venous thromboembolism is a condition that includes both deep venous thrombosis and pulmonary embolism. Venous thromboembolism disease can result because of a combination of risk factors, including patient-related, treatment-related, and, more specifically, cancer-related factors. It is not disease-specific or a population-specific disorder, but it is more prevalent in certain specialty populations. This article will cover those specialty populations including cancer, pregnancy, and athletes.

A guide to clinically relevant drug interactions in oncology

This paper presents an overview of new information on clinically relevant drug-drug interactions, particular focuses on negative drug interactions in oncology. We have generated a concise table of drug-drug interactions that provides a synopsis of the clinical outcome of the interaction along with a recommendation for management. We have also generated other tables that describe specific interactions with methotrexate and dosing guidelines for cytotoxic drugs in the presence of renal or hepatic dysfunction. Since warfarin is one of the non-anticancer drugs that is commonly used in cancer patients for the treatment and prevention of venous thromboembolism, its interactions with other anticancer drugs that have been reported in literatures were also reviewed in this paper. In general, drug interactions observed in cancer patients may be categorized into pharmacokinetic, pharmacodynamic and pharmaceutic interactions. Pharmacokinetic interactions involve one drug altering the absorption, distribution, metabolism, or excretion of another drug. Interpatient variability in the pharmacokinetic profile of many anticancer agents often complicates the predictability of the antitumor response and toxicities. Among four pharmacokinetic characteristics, drug interactions involving hepatic metabolism is probably the most common and important mechanism responsible for oncologic drug interactions. For example, several anticancer drugs including taxanes, vinca alkaloids, and irinotecan are known to be metabolized by cytochrome CYP3A4. Enzyme-inducing anticonvulsants have been shown to significantly decrease the plasma levels of these anticancer drugs, thereby compromising the anti-tumor effects. N ephrotoxicity or changes in hepatic function caused by some anticancer drugs (e.g., cisplatin, asparaginase) may also have an impact on the pharmacokinetics of the interacting agents. Pharmacodynamic interactions may occur when two or more drugs acting at a common receptor-binding site impact on the pharmacologic action of the object drug, without influencing the pharmacokinetics of each interacting agent. In clinical setting, a decrease of antitumor efficacy was observed in breast cell lines when gemcitabine or vinorelbine were used in combination with paclitaxel. On the other hand, a decreased incidence of thrombocytopenia was seen in patients receiving combination of carboplatin and palcitaxel compared to those receiving carboplatin alone. The third type of drug-drug interaction is known as pharmaceutic interaction. When one drug may alter the physical or chemical compatibility of another drug that utlimately leads to a change in appearance of the solution or a decrease of effectiveness of the drug due to drug inactivation or degradation.

Mechanisms of Cardiotoxicity of Cancer Chemotherapeutic Agents: Cardiomyopathy and Beyond

Tremendous strides have been made in the treatment of various oncological diseases such that patients are surviving longer and are having better quality of life. However, the success has been tainted by the iatrogenic cardiac toxicities. This is especially concerning in the younger population who are facing cardiac disease such as heart failure in their 30s and 40s as the consequence of the anthracycline's side effects (used for childhood leukemia and lymphoma). This resulted in the awareness of cardiotoxic effects of anticancer drugs and emergence of a new discipline: oncocardiology. Since then, numerous anticancer drugs have been correlated to cardiomyopathy. Additionally, other cardiovascular effects have been identified, which includes but is not limited to myocardial infarction, thrombosis, hypertension, arrhythmias, and pulmonary hypertension. In this review we examine some of the anticancer agents that mitigate cardiotoxicity and present current knowledge of molecular mechanism(s). The aim of the review is to ignite awareness of emerging cardiotoxic effects as new generations of anticancer agents are being tested in clinical trials and introduced as part of the therapeutic armamentarium to our oncological patients.

Cytotoxic chemotherapy in the treatment of advanced renal cell carcinoma in the era of targeted therapy

BACKGROUND

Renal cell carcinoma (RCC) is a heterogeneous disease with regards to histology, progression, and response to treatment. Cytotoxic chemotherapy has been extensively studied in metastatic RCC (mRCC). Responses in most studies are modest and the mechanisms of resistance remain poorly understood. Targeted therapies have significantly improved outcomes in mRCC; however, most patients eventually relapse and die of their disease. Early clinical data suggest that combinations of chemotherapy and targeted agents are clinically active and are well tolerated.

METHODS

We reviewed the available literature for published clinical trials incorporating traditional chemotherapeutic agents in the treatment of mRCC. These papers were identified through a Medline search and were included if they employed at least one chemotherapeutic agent in the treatment of mRCC. The literature was also reviewed for information regarding mechanisms of chemotherapy resistance.

RESULTS

The data regarding the use of cytotoxic chemotherapy in mRCC consist of small, non-randomized phase I and II studies. The major response proportions with single agent chemotherapies are low but combination regimens either with other cytotoxic agents, cytokines, or targeted agents have demonstrated moderate activity. Disparate trial designs and lack of head to head clinical trials make it difficult to compare the efficacy of chemotherapy with that of immunotherapy or targeted agents. Chemotherapy is particularly useful in patients with collecting duct histology and predominantly sarcomatoid differentiation. Chemotherapy resistance may be mediated by overexpression of p-glycoprotein efflux pumps and the dysregulation of the microtubule-hypoxia inducible factor signaling axis.

CONCLUSIONS

The role of cytotoxic chemotherapy in the treatment for clear cell RCC remains poorly defined. Cytotoxic chemotherapy is considered a standard of care in patients with mRCC with predominantly sarcomatoid differentiation and collecting duct RCC variants (Motzer et al., 2014). Early trials combining chemotherapy with targeted therapies are generally well tolerated and show clinical activity. A better understanding of the biology of aggressive subsets of RCC and mechanisms of resistance will help elucidate the role of cytotoxic agents in the current treatment paradigm of RCC.

Direct Oral Anticoagulants and Their Use in Treatment and Secondary Prevention of Acute Symptomatic Venous Thromboembolism

Direct oral anticoagulants (DOACs) have been compared with standard therapy in large phase III studies to assess their safety and efficacy in the treatment of deep vein thrombosis and/or pulmonary embolism and in the secondary prevention of recurrent venous thromboembolism. Although the mean population age and the gross inclusion and exclusion criteria were similar across these studies, they differed in other aspects such as overall study design and acute treatment strategies. The 4 DOACs examined in phase III trials (apixaban, edoxaban, rivaroxaban, and dabigatran) showed noninferiority compared with standard therapy for the treatment of deep vein thrombosis and/or pulmonary embolism and for the prevention of recurrent venous thromboembolism. Furthermore, these DOACs exhibited a similar safety profile to standard therapy, with the risk of major bleeding significantly reduced in some of these studies. Rivaroxaban and apixaban were tested as a single-drug approach, whereas in the dabigatran and edoxaban studies, initial bridging with parenteral agents was employed. The purpose of this review is to compare the phase III studies of DOACs in this indication, to highlight the differences, and to discuss a series of clinically relevant issues, including the management of key patient subgroups (eg, fragile patients, those with cancer or renal impairment), extended treatment, use of comedications, heparin pretreatment versus a single-drug approach, and the bleeding profiles of the DOACs.

Cancer-related coagulopathies

The association between cancer and thrombosis is known for years. Besides the well-recognized connection between venous thromboembolism and malignancies, there are, however, also other manifestations of cancer-related activation of coagulation and (micro)vascular dysfunction. In fact, coagulation derangements and vascular disturbances in patients with cancer cover a wide spectrum of diseases and various clinical manifestations. In this review we will highlight the mechanisms that play a role in the systemic activation of coagulation in cancer patients, in its most severe form manifested as disseminated intravascular coagulation. Clinically, disseminated intravascular coagulation (DIC) in cancer has in general a less fulminant presentation than the types of DIC complicating sepsis and trauma. A more gradual, but also more chronic, systemic activation of coagulation can proceed subclinically. The relationship between venous thromboembolism and cancer as a consequence of the hypercoagulability will be discussed as well. Furthermore, the role of perturbed endothelium in the pathogenesis of microvascular dysfunction and microangiopathy in particular in the setting of cancer and chemo- or radiotherapy will be reviewed.

Risk of site-specific cancer in incident venous thromboembolism: a population-based study

BACKGROUND

The risk of venous thromboembolism (VTE) by cancer site is uncertain.

OBJECTIVE

To estimate VTE risk by tumor site.

METHODS

We enumerated observed active cancers by cancer site for Olmsted County, MN residents with incident VTE over the 13-year period, 1988-2000 (n = 345 of 1417). We used 1988-2000 Iowa State Surveillance, Epidemiology, and End Results (SEER) data to estimate the expected age-specific prevalence of cancer by cancer site for all VTE cases; standardized Morbidity Ratios (SMR) for each cancer site were estimated by dividing the observed number of cancers in the VTE incident cohort by the expected number. Relative risk regression was used to model the observed number of cancers of each site, adjusting for the expected value based on SEER prevalence data, using generalized linear regression with a Poisson error and the natural log of the age- and sex-group expected count as an offset.

RESULTS

For men and women with VTE, all cancer sites had an increased SMR, ranging from 4.1 for head neck cancer to 47.3 for brain cancer. Among women, the SMR for breast, ovarian and other gynecologic cancers were 8.4, 13.0 and 8.4, respectively; for men, prostate cancer SMR was 7.9. Adjusting for age and sex, the relative risk (RR) of cancer in VTE cases was associated with cancer site in a multivariable model (p < 0.001). Adjusting for age and sex, pancreatic, brain, other digestive cancers, and lymphoma had significantly higher RRs than the grouped comparison cancers.

CONCLUSIONS

Incident VTE risk can be stratified by cancer site.

Risk of venous and arterial thromboembolic events in cancer patients treated with gemcitabine: a systematic review and meta-analysis

AIMS

Gemcitabine has been associated with an increased risk of arterial and venous thromboembolic events (ATEs and VTEs), although the overall risk remains unclear. As indications for its use in oncology are expanding, a comprehensive characterization of these complications becomes imperative.

METHODS

Pubmed was searched for articles published from 1 January 1990 to 31 December 2012. Eligible studies included prospective randomized controlled phase II and III trials evaluating gemcitabine based vs. non-gemcitabine based chemotherapy in patients with solid tumours. Data on VTEs and ATEs were extracted. Overall incidence rates, odds ratio (OR), and 95% confidence intervals (CIs) were calculated employing fixed or random effects models depending on the heterogeneity of included trials.

RESULTS

A total of 4845 patients from 19 trials were included. Among patients treated with gemcitabine based chemotherapy, the overall incidence of VTEs (13 studies comprising 3823 patients) and ATEs (eight studies consisting of 2431 patients) was 2.1% (95% CI 1.2%, 3.8%) and 2.2% (95% CI 1.4%, 3.2%). The associated ORs of VTEs and ATEs were 1.56 (95% CI 0.86, 2.83, P = 0.15) and 1.82 (95% CI 0.89, 3.75, P = 0.10) compared with non-gemcitabine based therapy. A tendency to increase the risk of ATE and VTEs was also detected in any prespecified subgroup.

CONCLUSION

The use of gemcitabine does not significantly increase the risk of VTEs and ATEs in patients with solid tumours when compared with non-gemcitabine based chemotherapy.

Immunologics and chemotherapeutics for renal cell carcinoma

Treatment of metastatic renal cell carcinoma remains a challenge for clinicians. Traditional chemotherapy is ineffective and immunotherapy with interleukin-2 is only occasionally beneficial. The development of numerous agents targeting vascular endothelial growth factor and mammalian target of rapamycin signaling pathways that have been studied in phase III trials have resulted in significant improvement in survival for patients with clear cell renal cell carcinoma. Currently available U.S. Food and Drug Administration-approved first line targeted agents include sunitinib, pazopanib, temsirolimus, and bevacizumab (with interferon), while axitinib, everolimus, and sorafenib are most extensively used following progression as second- or third line therapy. Attempts to augment the activity of these agents by combining them together or with chemotherapy or immunotherapy have not yet proven to improve outcomes. As a result, the sequential use of single agents remains the current standard of care.

Antineoplastic therapy-induced pulmonary toxicity

Pulmonary complications of antineoplastic therapy are common and are an important cause of respiratory morbidity. The pulmonary toxicity should be taken into account in every patient with respiratory problems who is or has been treated with antineoplastic agents. The diagnosis of drug-induced pulmonary toxicity is complex and should be based on the medical history, clinical, radiological and pathological findings. None of them are specific but they can guide the diagnostic process. The treatment of pulmonary abnormalities caused by chemotherapy is mostly supportive and based on cessation of the causative agent. However, the therapeutic options in oncology setting are usually limited thus the decision about changing the treatment should be taken with caution.

Therapeutic effects of thalidomide in hematologic disorders: a review

The extensive autoimmune, anti-inflammatory, and anticancer applications of thalidomide have inspired a growing number of studies and clinical trials. As an inexpensive agent with relatively low toxicity, thalidomide is regarded as a promising therapeutic candidate, especially for malignant diseases. We review its therapeutic effects in hematology, including those on multiple myeloma, Waldenstroem macroglobulinemia, lymphoma, mantle-cell lymphoma, myelodysplastic syndrome, hereditary hemorrhagic telangiectasia, and graftversus-host disease. Most studies have shown satisfactory results, although several have reported the opposite. Aside from optimal outcomes, the toxicities and adverse effects of thalidomide should also be examined. The current work includes a discussion of the mechanisms through which the novel biological effects of thalidomide occur, although more studies should be devoted to this aspect. With appropriate safeguards, thalidomide may benefit patients suffering from a broad variety of disorders, particularly refractory and resistant diseases.

Design and biological characterization of hybrid compounds of curcumin and thalidomide for multiple myeloma

In our efforts to develop effective treatment agents for human multiple myeloma (MM), a series of hybrid molecules based on the structures of thalidomide (1) and curcumin (2) were designed, synthesized, and biologically characterized in human multiple myeloma MM1S, RPMI8226, U266 cells, and human lung cancer A549 cells. The biological results showed that two hybrid compounds, 5 and 7, exhibited significantly improved lethal effects towards all three human MM cell models compared to 1 or 2 alone, as well as the combination of 1 and 2. Furthermore, mechanistic studies in U266 cells demonstrated that 5 and 7 can induce the production of reactive oxygen species (ROS) and cause G1/S arrest, thus leading to apoptosis and cell death. Additionally, they exhibited inhibitory effects on NFκB activation in A549 cells. Collectively, the results obtained from these hybrid compounds strongly encourage their further optimization as new leads to develop effective treatment agents for human MM.

Management of treatment-associated toxicites of anti-angiogenic therapy in patients with brain tumors

Anti-angiogenic therapies, including bevacizumab, are being used with increasing frequency in the management of malignant glioma. Common clinically significant toxicities include hypertension and proteinuria, poor wound healing, and the potential for thromboembolic events. Literature related to the use of bevacizumab in malignant glioma, reported toxicities in this patient population, and management of these toxicities was reviewed. Recommendations for assessment and management are provided. Anti-angiogenic therapies will continue to have a role in the treatment of malignant glioma. Further studies of the prevention, assessment, and management of these toxicities are warranted.

A tale of two citizens: a State Attorney General and a hematologist facilitate translation of research into US Food and Drug Administration actions--a SONAR report

PURPOSE

Pharmaceutical safety is a public health issue. In 2005, the Connecticut Attorney General (AG) raised concerns over adverse drug reactions in off-label settings, noting that thalidomide was approved to treat a rare illness, but more than 90% of its use was off label. A hematologist had reported thalidomide with doxorubicin or dexamethasone was associated with venous thromboembolism (VTE) rates of 25%. We review US Food and Drug Administration (FDA) and manufacturer responses to a citizen petition filed to address these thalidomide safety issues.

METHODS

Case study.

RESULTS

The AG petitioned the FDA requesting thalidomide-related safety actions. Coincidentally, the manufacturer submitted a supplemental New Drug Approval (sNDA), requesting approval to treat multiple myeloma with thalidomide-dexamethasone. FDA safety officers reviewed the petition and the literature and noted that VTE risks with thalidomide were not appropriately addressed in the existing package insert. In the sNDA application, the manufacturer reported thalidomide-associated toxicities for multiple myeloma were primarily somnolence and neurotoxicity, and a proposed package insert did not focus on VTE risks. In October, the FDA informed the Oncology Drug Division that VTE risks with thalidomide were poorly addressed in the existing label. After reviewing this memorandum, an Oncology Drug Division reviewer informed the manufacturer that approval of the sNDA would be delayed until several thalidomide-associated VTE safety actions, including revisions of the package insert, were implemented. The manufacturer and FDA agreed on these actions, and the sNDA was approved.

CONCLUSION

New approaches addressing off-label safety are needed. The conditions that facilitated the successful response to this citizen petition are uncommon.

Preventing venous thromboembolism in hospitalized patients with cancer: improving compliance with clinical practice guidelines

PURPOSE

The use of anticoagulants for the prevention of venous thromboembolism (VTE) in hospitalized medical and surgical oncology patients is discussed.

SUMMARY

Hospitalized patients are often at risk for developing VTE, and risk is increased in patients who have cancer. Moreover, the incidence of VTE appears to be rising in hospitalized cancer patients, who have a 2.2-fold increased risk of mortality with a VTE compared with similar patients without VTE. The literature indicates that these patients are often inadequately anticoagulated, despite strong recommendations for prophylaxis. Although there are few studies that specifically address VTE prophylaxis in cancer patients, there are several large trials that have examined data in cancer subgroups. The trials have directly compared low-molecular-weight heparin (LMWH) with placebo, unfractionated heparin with LMWH, factor Xa inhibitor (fondaparinux) with placebo, and fondaparinux with LMWH. Three important guidelines provide current recommendations for VTE prophylaxis; the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American College of Chest Physicians (ACCP) recommend unfractionated heparin, LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications. Pharmacists can play an essential role in ensuring that VTE prophylaxis is appropriate for individual patients. Interventions to improve compliance with guidelines are particularly important now due to financial incentives from quality-focused organizations whose mandate is to decrease preventable mortality events in hospitals.

CONCLUSION

Hospitalized patients with cancer often do not receive appropriate thromboprophylaxis. Guidelines from ASCO, ACCP, and NCCN recommend unfractionated heparin, an LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications to such therapy.

Dynamic contrast-enhanced magnetic resonance imaging of sunitinib-induced vascular changes to schedule chemotherapy in renal cell carcinoma xenograft tumors

In an attempt to develop better therapeutic approaches for metastatic renal cell carcinoma (RCC), the combination of the antiangiogenic drug sunitinib with gemcitabine was studied. Using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), we have previously determined that a sunitinib dosage of 20 mg/kg per day increased kidney tumor perfusion and decreased vascular permeability in a preclinical murine RCC model. This sunitinib dosage causing regularization of tumor vessels was selected to improve delivery of gemcitabine to the tumor. DCE-MRI was used to monitor regularization of vasculature with sunitinib in kidney tumors to schedule gemcitabine. We established an effective and nontoxic schedule of sunitinib combined with gemcitabine consisting of pretreatment with sunitinib for 3 days followed by four treatments of gemcitabine at 20 mg/kg given 3 days apart while continuing daily sunitinib treatment. This treatment caused significant tumor growth inhibition resulting in small residual tumor nodules exhibiting giant tumor cells with degenerative changes, which were observed both in kidney tumors and in spontaneous lung metastases, suggesting a systemic antitumor response. The combined therapy caused a significant increase in mouse survival. DCE-MRI monitoring of vascular changes induced by sunitinib, gemcitabine, and both combined showed increased tumor perfusion and decreased vascular permeability in kidney tumors. These findings, confirmed histologically by thinning of tumor blood vessels, suggest that both sunitinib and gemcitabine exert antiangiogenic effects in addition to cytotoxic antitumor activity. These studies show that DCE-MRI can be used to select the dose and schedule of antiangiogenic drugs to schedule chemotherapy and improve its efficacy.

Long-term survival of patients with sarcomatoid renal cell cancer treated with chemotherapy

Sarcomatoid renal cell cancer is associated with a very poor prognosis, characterized by rapid progression of advanced disease. We previously reported the outcome of 18 patients with advanced sarcomatoid renal cell cancer treated with a regimen consisting of doxorubicin, 50 mg/m2 and gemcitabine, 1,500-2,000 mg/m2, administered every two weeks with growth factor support (A/G). Among the 18 patients, there were two complete and 5 partial responses and two patients with stable disease of more than 6 months of duration. We now report long-term survival of 4 patients with stage IV sarcomatoid renal cell carcinoma treated with this regimen at the 1,500 mg/m2 dose of gemcitabine, and achieving complete response (2 patients), or rendered complete responders following surgery after maximum response (2 patients). The two complete responders are alive, disease free at 6+ and 8+ years after starting A/G, and the 2 patients rendered CR by surgery survived 3½ and 6 years, respectively. Both died of progressive disease, one with clear cell recurrence, one with sarcomatoid recurrence. In summary, this regimen is associated with a high response rate, overall improvement in progression free survival and occasional meaningful long-term survival in a disease expected to be fatal within one year.

Pharmacokinetic properties and antitumor efficacy of the 5-fluorouracil loaded PEG-hydrogel

Background

We have studied the in vitro and in vivo utility of polyethylene glycol (PEG)-hydrogels for the development of an anticancer drug 5-fluorouracil (5-FU) delivery system.

Methods

A 5-FU-loaded PEG-hydrogel was implanted subcutaneously to evaluate the drug retention time and the anticancer effect. For the pharmacokinetic study, two groups of male rats were administered either an aqueous solution of 5-FU (control group)/or a 5-FU-loaded PEG-hydrogel (treated group) at a dose of 100 mg/kg. For the pharmacodynamic study, a human non-small-cell lung adenocarcinoma (NSCLC) cell line, A549 was inoculated to male nude mice with a cell density of 3 × 10⁶. Once tumors start growing, the mice were injected with 5-FU/or 5-FU-loaded PEG-hydrogel once a week for 4 weeks. The growth of the tumors was monitored by measuring the tumor volume and calculating the tumor inhibition rate (IR) over the duration of the study.

Results

In the pharmacokinetic study, the 5-FU-loaded PEG-hydrogel gave a mean residence time (MRT) of 8.0 h and the elimination half-life of 0.9 h; these values were 14- and 6-fold, respectively, longer than those for the free solution of 5-FU (p < 0.05). In the pharmacodynamic study, A549 tumor growth was significantly inhibited in the 5-FU-loaded PEG-hydrogel group in comparison to the untreated group beginning on Day 14 (p < 0.05-0.01). Moreover, the 5-FU-loaded PEG-hydrogel group had a significantly enhanced tumor IR (p < 0.05) compared to the free 5-FU drug treatment group.

Conclusion

We suggest that 5-FU-loaded PEG-hydrogels could provide a useful tool for the development of an anticancer drug delivery system.

Venous thrombosis in an outpatient oncologic center: distribution, type, and comorbidities

PURPOSE

To examine outpatient oncologic patients with venous thrombosis (VT) and correlate ultrasound findings with clinical characteristics and outcome.

MATERIALS AND METHODS

A retrospective study of 76 patients who had upper- and lower-extremity ultrasound examinations positive for VT formed the population, drawn from a total of 509 patients who presented over a 24-month period for non-invasive imaging. Clinical indication, demographics, sonographic findings, comorbidities, and development of pulmonary embolism in these patients were recorded. The Fisher-Freeman-Halton exact test was used to determine if test characteristics varied according to the location of VT (upper or lower extremity), the level of lower-extremity thrombosis (above the knee, below the knee, or both), the presence of active disease or remission, the chronicity or acuteness of thrombosis, and the presence of a central venous catheter (CVC).

RESULTS

In the study group, 64 patients had deep VT, and 12 had superficial VT. The most prevalent tumors in our study population were lymphoma and breast and lung cancers. The most common symptoms were swelling, pain, and erythema. Whereas 61 patients had active disease, 18 patients were in remission at the time of examination. Among 30 patients with upper-extremity VT, 18 had CVCs. Venous thrombosis involved the vessel containing the central venous line in 66% of studies. Pulmonary embolism developed in 8 patients who had lower-extremity VT despite an initiation of anticoagulation therapy. Patients with thrombus in the lower extremity had higher chance to develop pulmonary embolism, but there was no significant statistical difference in the level of lower-extremity thrombosis (above the knee, below the knee, or both), disease activity, and chronicity of thrombosis.

CONCLUSIONS

Venous thrombosis is most commonly acute and involves the lower extremity and the deep venous system above the knee. When VT involves the upper extremity, it is usually associated with a CVC. Pulmonary embolism is almost exclusively associated with lower-extremity VT and can occur despite anticoagulation therapy.

Thrombotic events in patients with cancer receiving antiangiogenesis agents

Tumor-associated neoangiogenesis has recently become a suitable target for antineoplastic drug development. In this overview, we discuss specific drug-associated hemostatic complications, the already known pathogenetic mechanisms involved, and the effect of varying antithrombotic strategies. Multiple agents with angiogenic inhibitory capacity (thalidomide, lenalidomide, bevacizumab, sunitinib, sorafenib, and sirolimus) have obtained US Food and Drug Administration approval, and many others have entered clinical trials. Arterial and venous thromboembolism and hemorrhage have emerged as significant toxicities associated with the use of angiogenesis inhibitors. We present a detailed analysis of the literature on thrombotic complication of antiangiogenic drugs. Close attention to hemostatic complications during antiangiogenic treatment is warranted. Further studies are required to better understand the pathophysiologic mechanisms involved and to define a safe prophylactic strategy.

Thrombosis associated with angiogenesis inhibitors

Recent advances in the understanding of the pathogenesis of cancer have led to the introduction of a variety of biological agents with novel mechanisms of action into clinical trials and even into clinical practice. In particular, tumour-associated neoangiogenesis has become a major target for this new class of antineoplastic agents. Five anti-angiogenic agents (thalidomide, lenalidomide, bevacizumab, sunitinib, sorafenib) have already obtained US Food and Drug Administration approval for clinical use, and many others have entered clinical trials. Many new biological agents with anti-angiogenic properties appear to be associated with an increased risk for thrombosis and, paradoxically, bleeding. Although the mechanisms underlying the increased thromboembolic risk remain ill defined, the main hypothesis is that perturbation of tumour-associated endothelial cells can switch the endothelium from a naturally anticoagulant surface to a prothrombotic surface, thus mediating the activation of systemic coagulation in cancer patients, who are already more susceptible to thromboembolism due to their underlying disease. The toxicity profile differs between the anti-angiogenic agents. Thalidomide, lenalidomide, semaxibin (SU5416) and prinomastat have produced more venous thromboembolic complications, whereas bevacizumab, sunitinib, sorafenib and ZD6126 have been associated with a higher risk of arterial thromboembolism and, in particular, myocardial ischaemia. The observation of these vascular toxicities suggests the need to establish, in randomized clinical trials, the usefulness of thrombosis prophylaxis when anti-angiogenic agents are used in cancer patients, especially when associated with chemotherapy. In addition, careful reporting of haemostatic complications during treatment with new anti-angiogenic drugs is warranted.

Arterial thrombosis in four patients treated with thalidomide

Thalidomide has been associated with venous thrombotic events, as reported in the post-marketing surveillance reports by Celgene Corporation; as well as case reports in the literature. Seven arterial thrombotic events have been reported in patients receiving thalidomide with 3 cases occurring in patients with other predisposing conditions. We report 4 additional cases of arterial thromboses in 1 lymphoma and 3 myeloma patients treated with thalidomide. The mechanism for these events is unclear; however, it is significant that 2 patients were receiving concomitant anticoagulation with aspirin and warfarin.

Hemostatic complications of angiogenesis inhibitors in cancer patients

Tumor vasculature and tumor-associated neo-angiogenesis have recently become major targets for rational drug design of antineoplastic agents. Five such agents with angiogenesis inhibiting activity (thalidomide, lenalidomide, bevacizumab, sunitinib, sorafenib) have already obtained US Food and Drug Administration approval for clinical use and many others have entered clinical trials. Vascular complications, including venous or arterial thromboembolism and hemorrhage, have emerged as relevant toxicities in several clinical trials with angiogenesis inhibitors. Given the well-known interplay between the blood clotting system, angiogenesis, and tumor growth, a better understanding of the impact of these new drugs on overall hemostatic balance is required. In this brief overview, we discuss the incidence of hemostatic complications, the likely pathogenetic mechanisms involved, and the critical need to establish in randomized clinical trials the usefulness of thrombosis prophylaxis to prevent these complications. Careful documentation of hemostatic complications during treatment with each of the new antiangiogenic drugs is warranted. Further studies are urgently required to better define the causal association of these new agents with hemostatic complications and to establish the best prophylactic strategy.

Genetic associations with thalidomide mediated venous thrombotic events in myeloma identified using targeted genotyping

A venous thromboembolism (VTE) with the subsequent risk of pulmonary embolism is a major concern in the treatment of patients with multiple myeloma with thalidomide. The susceptibility to developing a VTE in response to thalidomide therapy is likely to be influenced by both genetic and environmental factors. To test genetic variation associated with treatment related VTE in patient peripheral blood DNA, we used a custom-built molecular inversion probe (MIP)-based single nucleotide polymorphism (SNP) chip containing 3404 SNPs. SNPs on the chip were selected in "functional regions" within 964 genes spanning 67 molecular pathways thought to be involved in the pathogenesis, treatment response, and side effects associated with myeloma therapy. Patients and controls were taken from 3 large clinical trials: Medical Research Council (MRC) Myeloma IX, Hovon-50, and Eastern Cooperative Oncology Group (ECOG) EA100, which compared conventional treatments with thalidomide in patients with myeloma. Our analysis showed that the set of SNPs associated with thalidomide-related VTE were enriched in genes and pathways important in drug transport/metabolism, DNA repair, and cytokine balance. The effects of the SNPs associated with thalidomide-related VTE may be functional at the level of the tumor cell, the tumor-related microenvironment, and the endothelium. The clinical trials described in this paper have been registered as follows: MRC Myeloma IX: ISRCTN68454111; Hovon-50: NCT00028886; and ECOG EA100: NCT00033332.

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

Evaluation of interferon alpha-2B and thalidomide in patients with disseminated malignant melanoma, phase 2, SWOG 0026

BACKGROUND

Southwest Oncology Group protocol 0026 evaluated interferon alpha-2b plus thalidomide in patients with disseminated melanoma. Endpoints were 6-month progression-free survival rate, response rate, and toxicity.

METHODS

Twenty-six patients with Stage IV melanoma, measurable or nonmeasurable disease, performance status of 0-2, and adequate renal and hepatic functions were registered. One prior systemic therapy for Stage IV disease was required. Interferon was administered subcutaneously (1 million U) twice daily; thalidomide was orally administered (200-400 mg) each evening in a dose-escalating manner. Response evaluations using Response Evaluation Criteria in Solid Tumors were performed every 8 weeks.

RESULTS

After 2 sudden deaths and 1 grade 4 treatment-related pulmonary embolism, this study was temporarily closed. One patient with deep-vein thrombosis and 2 with grade 3 cardiac arrhythmias were reported. The relationship of these events to the treatment was worrisome but not definitive. Grade 3 treatment-related adverse events occurred in 14 of 26 patients. Because of concern for patient safety the study was permanently closed. No treatment responses were seen in the 22 evaluable patients. Estimated 6-month progression-free survival rate was 15% (95% confidence interval [CI], 2%-29%), estimated 6-month overall survival was 58% (95% CI, 39%-77%), and estimated response probability was 0 of 22 (95% CI, 0%-15%).

CONCLUSIONS

This regimen demonstrated a lack of response and was associated with multiple severe toxicities. Further investigation of interferon alpha-2b and thalidomide in this dose and schedule is not warranted.

Role of Chemotherapy With Gemcitabine Plus 5-fluorouracil and Chemoimmunotherapy in Metastatic Renal Cell Cancer (mRCC)

Several phase II trials have shown that gemcitabine and fluoropyrimidines have marginal but definite activity in patients with metastatic renal cell cancer (mRCC). We retrospectively analyzed the 193 mRCC patients consecutively seen in our institutions during the last 11 years, of whom 39 were treated with chemotherapy (CT): 16 were treated with CT alone (gemcitabine and 5-fluorouracil) and 23 with the same regimen plus low dose of interleukin-2 and interferon-alpha. The main end point of the analysis was to estimate response rate and time to progression (TTP); the secondary end point was to evaluate overall survival (OS) and toxicity. Overall TTP was 3.2 months (95% confidence interval: 2.22-4.18). Three patients (7.7%) achieved a partial response and 10 (25.6%) stable disease. Median OS was 9.23 months (95% confidence interval: 7.16-11.31) and the 1-year survival rate was 40.6%. Although not statistically significant, the response and disease control rates were better in the pretreated patients (8% vs. 7% and 44% vs. 14%), with a favorable trend for TTP and OS (4.9 vs. 3.2 mo and 12.9 vs. 4.2 mo). Grade 3 to 4 toxicities included hematologic toxicity and depressed mood. OS was strongly influenced by performance status, the presence of brain metastasis, and response after 3 cycles of therapy. In these mRCC patients, both CT and chemoimmunotherapy showed modest but definite activity and a regimen CT-based should be offered to patients with progressive mRCC. The association of these treatments with antiangiogenetic agents should be tested in future trials.

Venous gangrene and cancer: a cool look at a burning issue

Venous gangrene (VG) is defined as a clinical triad of skin necrosis and discolouration, documented evidence of venous thromboembolism (VTE) and presence of palpable or doppler-identifiable arterial pulsation. Venous gangrene is rare condition which is associated with poor prognosis in cancer patients. The pathogenesis of VG is multifactorial and could paradoxically be due to warfarin treatment. Heparin Induced Thrombocytopenia (HIT) associated venous gangrene develops when heparin therapy is discontinued and warfarin therapy initiated or continued. It has been reported that the presence of anticardiolipin antibodies appears to double the risk of thrombo-embolic events in cancer patients in comparison with those who are anticardiolipin antibody negative. The presence of anticardiolipin antibodies is therefore a warning sign for venous gangrene in cancer patients. Hypercoagulable state associated with malignancy, cancer treatment, prolonged immobilisation, surgical operations and metabolic syndrome are all associated with increased risk of VTE and VG. The current evidence suggests that cancer patients are at increased risk from recurrent venous thrombosis and venous gangrene, and LMWH provides potential promise as a safe and effective measure in the management of such patients.

Dietary supplements in patients with cancer: risks and key concepts, part 1

PURPOSE

The risks and key concepts regarding the use of dietary supplements in patients with cancer are described.

SUMMARY

There are six common characteristics of dietary supplements that must be addressed when used by patients with cancer. Clinicians must establish if the supplement is an antioxidant, is an anticoagulant or procoagulant, has immunosuppressive or immunomodulating properties, has hormonal properties, has known safety issues, and has known or theoretical drug interactions. These six characteristics of the dietary supplements commonly used by patients with cancer are reviewed to aid in the analysis of the scientific data and communication of the results with the patient or family members. A framework upon which clinicians can adequately help patients make informed decisions regarding the use of complimentary and alternative medicine and dietary supplements is also described. When evaluating the appropriateness of a supplement for use by a patient with cancer, clinicians must conduct a safety review (evaluate the six characteristics). If the supplement is considered safe, an efficacy review must be conducted, after which the clinicians can recommend the supplement's use, accept the patient's decision to use the supplement if no or inconclusive evidence exists, or discourage use if there is conclusive evidence supporting inefficacy. Available resources for locating information regarding dietary supplements are also discussed.

CONCLUSION

Counseling patients with cancer about dietary supplements requires a systematic thought process that considers the available theories and data, as well as the patients' views about the agents.

Venous Thromboembolism in Patients With Cancer Part I: Survey of Oncology Nurses' Attitudes and Treatment Practices for Ambulatory Settings

Patients with cancer have a higher incidence of venous thromboembolism (VTE). Little information currently exists on VTE and the understanding and beliefs of oncology nurses. Therefore, the attitudes and treatment practices of ambulatory oncology nurses were surveyed to determine the current knowledge base of VTE in patients with cancer. Survey results are presented along with a thorough literature review of thromboembolism and the unique risk factors for this frequent complication in patients with cancer. The causes of VTE in this patient population often are multifactorial and include hypercoagulability, stasis, and vascular endothelial damage from procedures or the neoplastic process itself. In particular, chemotherapy administration can increase the risk of thrombosis considerably. New therapies, including thalidomide, require oncology nurses caring for these patients to have heightened awareness of the potential for thrombogenic complications. This is the first of two articles that address the problem of thromboembolism in patients with cancer, including the survey results. (See part II on page 465.) Oncology nurses are essential in the care of VTE in patients with cancer and can help with patient identification, treatment, and compliance for improved patient outcomes.

Cardiac and cardiovascular toxicity of nonanthracycline anticancer drugs

Anthracyclines are a well-known cause of cardiotoxicity, but a number of other drugs used to treat cancer can also result in cardiac and cardiovascular adverse effects. Cardiotoxicity can result in the alteration of cardiac rhythm, changes in blood pressure and ischemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to catastrophic life-threatening, and sometimes fatal, sequelae. These events may occur acutely or may only become apparent months or years following completion of oncological treatment. Ischemia and rhythm abnormalities are treated symptomatically in most cases. Knowledge of these toxicities can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient.

A phase II study of gemcitabine and capecitabine in metastatic renal cancer: a report of Cancer and Leukemia Group B protocol 90008

BACKGROUND

The objective of this study was to verify previous reports of activity with gemcitabine plus a fluoropyrimidine in patients with metastatic renal cell cancer in a multiinstitutional setting.

METHODS

Eligibility included a Zubrod performance status from 0 to 2, no prior gemcitabine or fluoropyrimidine therapy, and normal organ function. Patients received gemcitabine at a dose of 1000 mg/m2 on Days 1, 8, and 15 and capecitabine at a dose of 830 mg/m2 twice daily on Days 1 through 21 on a 28-day cycle with specified dose reductions for baseline renal insufficiency. The primary endpoint was the response rate, which was assessed every 8 weeks. The statistical plan tested the hypothesis that the response rate was 5% versus an alternative of 15%.

RESULTS

Sixty patients were enrolled, and 4 of those patients never started treatment. Of the 56 evaluable patients, 79% of patients underwent prior nephrectomy, 75% of patients received prior systemic therapy, and 75% of patients had clear cell histology. Risk stratification revealed that 34%, 43%, and 16% of patients were in Risk Groups 1, 2, and 3, respectively. Toxicity (graded according to the National Cancer Institute's Common Toxicity Criteria [version 2.0]) included Grade 3 or 4 neutropenia in 45% of patients, Grade 2 or greater fatigue in 32% of patients, Grade 2 or greater nausea in 29% of patients, Grade 2 or greater hand-foot reaction in 39% of patients, and Grade 2 or greater diarrhea in 22% of patients. Six patients responded (11%; 95% confidence interval, 4-22%), and the overall median survival was 14.5 months.

CONCLUSIONS

Gemcitabine plus capecitabine had modest activity in patients with metastatic renal cancer, although the degree of activity and its associated toxicity would not support further evaluation in a Phase III trial of unselected patients. More focused investigations to identify patients most likely to benefit or to enhance activity with additional agents would be reasonable.

Low-molecular-weight heparins in the treatment of cancer-associated thrombosis: a new standard of care?

Cancer patients are twice as likely to develop postoperative venous thromboembolism (VTE) than non-cancer patients undergoing the same surgical procedure. Causes of cancer-associated thrombosis include: the capacity of tumor cells and their products to interact with platelets, clotting, and fibrinolytic proteins. Aggressive antitumor therapy with agents such as platinum compounds, high-dose fluorouracil, mitomycin-C, tamoxifen, and growth factors increase the risk of cancer-associated thrombosis. Despite the high risk of VTE in patients with cancer, thromboprophylaxis in surgical and medical oncology patients is low. Initial therapy of VTE in patients with cancer is low-molecular-weight heparin (LMWH) or unfractionated heparin. Long-term secondary prophylaxis of VTE is generally accomplished with oral anticoagulants, primarily warfarin. Evidence supports the use of LMWH for prevention and treatment of cancer-associated thrombosis because it is more easily administered, does not require laboratory monitoring, has a lower risk of adverse events, and is more cost effective than unfractionated heparin. In addition, the antineoplastic effects of LMWH have been demonstrated, including direct antitumor, antiangiogenic, and immune system modulatory action. Each LMWH is a unique biological entity having product-specific molecular and structural attributes; therefore, different LMWHs cannot be given interchangeably. Continued investigation of LMWH therapy in patients with cancer is warranted.