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Metronomic Chemotherapy Based on Topotecan or Topotecan and Cyclophosphamide Combination (CyTo) in Advanced, Pretreated Ovarian Cancer. Cancers (Basel) 2023; 15:cancers15041067. [PMID: 36831410 PMCID: PMC9954570 DOI: 10.3390/cancers15041067] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Patients with advanced ovarian cancer (OC) have a detrimental prognosis. The options for systemic treatment of advanced OC in later lines of treatment are limited by the availability of active therapies and their applicability to often fragile, exhausted patients with poor performance status. Metronomic chemotherapy (MC) is a concept of a continuous administration of cytotoxic drugs, which is characterized by multidirectional activity (anti-proliferative, anti-angiogenic, and anti-immunosuppressive) and low toxicity. We have performed a retrospective analysis of consecutive, advanced, chemo-refractory OC patients treated with MC based on single-agent topotecan (1 mg p.o. q2d) or on a topotecan (1 mg q2d) and cyclophosphamide (50 mg p.o. qd) combination (CyTo). Metronomic chemotherapy demonstrated promising activity, with 72% and 86% of patients achieving biochemical or objective disease control and 18% and 27% of patients achieving a biochemical or objective response, respectively. The median PFS in the whole population was 3.65 months, but the median PFS in patients with a biochemical response to MC (18.2% of patients) reached 10.7 months. The study also suggested that overweight or obese patients had significantly better outcomes on MC than patients with BMI <25 kg/m2. This article is the first report in the literature on metronomic chemotherapy based on a topotecan + cyclophosphamide combination (CyTo). The CyTo regimen demonstrated safety, clinical activity, and potential broad clinical applicability in advanced OC patients and will be evaluated in a forthcoming clinical trial.
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Cazzaniga ME, Cordani N, Capici S, Cogliati V, Riva F, Cerrito MG. Metronomic Chemotherapy. Cancers (Basel) 2021; 13:cancers13092236. [PMID: 34066606 PMCID: PMC8125766 DOI: 10.3390/cancers13092236] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary The present article reviews the state of the art of metronomic chemotherapy use to treat the principal types of cancers, namely breast, non-small cell lung cancer and colorectal ones, and of the most recent progresses in understanding the underlying mechanisms of action. Areas of novelty, in terms of new regimens, new types of cancer suitable for Metronomic chemotherapy (mCHT) and the overview of current ongoing trials, along with a critical review of them, are also provided. Abstract Metronomic chemotherapy treatment (mCHT) refers to the chronic administration of low doses chemotherapy that can sustain prolonged, and active plasma levels of drugs, producing favorable tolerability and it is a new promising therapeutic approach in solid and in hematologic tumors. mCHT has not only a direct effect on tumor cells, but also an action on cell microenvironment, by inhibiting tumor angiogenesis, or promoting immune response and for these reasons can be considered a multi-target therapy itself. Here we review the state of the art of mCHT use in some classical tumour types, such as breast and no small cell lung cancer (NSCLC), see what is new regarding most recent data in different cancer types, such as glioblastoma (GBL) and acute myeloid leukemia (AML), and new drugs with potential metronomic administration. Finally, a look at the strategic use of mCHT in the context of health emergencies, or in low –and middle-income countries (LMICs), where access to adequate healthcare is often not easy, is mandatory, as we always need to bear in in mind that equity in care must be a compulsory part of our medical work and research.
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Affiliation(s)
- Marina Elena Cazzaniga
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza (MB), Italy;
- Phase 1 Research Centre, ASST-Monza (MB), 20900 Monza, Italy; (S.C.); (V.C.)
- Correspondence: (M.E.C.); (M.G.C.); Tel.: +39-0392-339-037 (M.E.C.)
| | - Nicoletta Cordani
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza (MB), Italy;
| | - Serena Capici
- Phase 1 Research Centre, ASST-Monza (MB), 20900 Monza, Italy; (S.C.); (V.C.)
| | - Viola Cogliati
- Phase 1 Research Centre, ASST-Monza (MB), 20900 Monza, Italy; (S.C.); (V.C.)
| | - Francesca Riva
- Unit of Clinic Oncology, ASST-Monza (MB), 20900 Monza, Italy;
| | - Maria Grazia Cerrito
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza (MB), Italy;
- Correspondence: (M.E.C.); (M.G.C.); Tel.: +39-0392-339-037 (M.E.C.)
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3
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Pramanik R, Bakhshi S. Metronomic therapy in pediatric oncology: A snapshot. Pediatr Blood Cancer 2019; 66:e27811. [PMID: 31207063 DOI: 10.1002/pbc.27811] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Abstract
Metronomic chemotherapy transitioned from the bench to bedside in the early 2000s and since then has carved a niche for itself in pediatric oncology. It has been used solely or in combination with other modalities such as radiotherapy, maximum tolerated dose chemotherapy, and targeted agents in adjuvant, palliative, as well as maintenance settings. No wonder, the resulting medical literature is extremely heterogeneous. In this review, the authors review and synthesize the published literature in pediatric metronomics giving a glimpse of its history, varied applications, and evolution of this genre of chemotherapy in pediatric cancers. Limitations, future prospects, and grey areas are also highlighted.
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Affiliation(s)
- Raja Pramanik
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B. R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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Lee HM, Clark EP, Kuijer MB, Cushman M, Pommier Y, Philpot BD. Characterization and structure-activity relationships of indenoisoquinoline-derived topoisomerase I inhibitors in unsilencing the dormant Ube3a gene associated with Angelman syndrome. Mol Autism 2018; 9:45. [PMID: 30140420 PMCID: PMC6098585 DOI: 10.1186/s13229-018-0228-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/06/2018] [Indexed: 01/26/2023] Open
Abstract
Background Angelman syndrome (AS) is a severe neurodevelopmental disorder lacking effective therapies. AS is caused by mutations in ubiquitin protein ligase E3A (UBE3A), which is genomically imprinted such that only the maternally inherited copy is expressed in neurons. We previously demonstrated that topoisomerase I (Top1) inhibitors could successfully reactivate the dormant paternal allele of Ube3a in neurons of a mouse model of AS. We also previously showed that one such Top1 inhibitor, topotecan, could unsilence paternal UBE3A in induced pluripotent stem cell-derived neurons from individuals with AS. Although topotecan has been well-studied and is FDA-approved for cancer therapy, its limited CNS bioavailability will likely restrict the therapeutic use of topotecan in AS. The goal of this study was to identify additional Top1 inhibitors with similar efficacy as topotecan, with the expectation that these could be tested in the future for safety and CNS bioavailability to assess their potential as AS therapeutics. Methods We tested 13 indenoisoquinoline-derived Top1 inhibitors to identify compounds that unsilence the paternal allele of Ube3a in mouse neurons. Primary cortical neurons were isolated from embryonic day 14.5 (E14.5) mice with a Ube3a-YFP fluorescent tag on the paternal allele (Ube3am+/pYFP mice) or mice that lack the maternal Ube3a allele and hence model AS (Ube3am-/p+ mice). Neurons were cultured for 7 days, treated with drug for 72 h, and examined for paternal UBE3A protein expression by Western blot or fluorescence immunostaining. Dose responses of the compounds were determined across a log range of drug treatments, and cytotoxicity was tested using a luciferase-based assay. Results All 13 indenoisoquinoline-derived Top1 inhibitors unsilenced paternal Ube3a. Several compounds exhibited favorable paternal Ube3a unsilencing properties, similar to topotecan, and of these, indotecan (LMP400) was the most effective based on estimated Emax (maximum response of unsilencing paternal Ube3a) and EC50 (half maximal effective concentration). Conclusions We provide pharmacological profiles of indenoisoquinoline-derived Top1 inhibitors as paternal Ube3a unsilencers. All 13 tested compounds were effective at unsilencing paternal Ube3a, although with variable efficacy and potency. Indotecan (LMP400) demonstrated a better pharmacological profile of Ube3a unsilencing compared to our previous lead compound, topotecan. Taken together, indotecan and its structural analogues are potential AS therapeutics whose translational potential in AS treatment should be further assessed.
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Affiliation(s)
- Hyeong-Min Lee
- 1Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Neuroscience Research Building, Room 5119 115 Mason Farm Rd., Campus Box 7545, Chapel Hill, NC 27599-7545 USA
| | - Ellen P Clark
- 1Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Neuroscience Research Building, Room 5119 115 Mason Farm Rd., Campus Box 7545, Chapel Hill, NC 27599-7545 USA
| | - M Bram Kuijer
- 1Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Neuroscience Research Building, Room 5119 115 Mason Farm Rd., Campus Box 7545, Chapel Hill, NC 27599-7545 USA
| | - Mark Cushman
- 2Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University School of Pharmacy and the Purdue Center for Cancer Research, West Lafayette, IN USA
| | - Yves Pommier
- 3Developmental Therapeutics Branch and Laboratory of Molecular Pharmacology, Center for Cancer Research, National Cancer Institute, Bethesda, MD USA
| | - Benjamin D Philpot
- 1Department of Cell Biology and Physiology, University of North Carolina School of Medicine, Neuroscience Research Building, Room 5119 115 Mason Farm Rd., Campus Box 7545, Chapel Hill, NC 27599-7545 USA.,4UNC Neuroscience Center, Carolina Institute for Developmental Disabilities, University of North Carolina School of Medicine, Chapel Hill, NC USA
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Pramanik R, Agarwala S, Gupta YK, Thulkar S, Vishnubhatla S, Batra A, Dhawan D, Bakhshi S. Metronomic Chemotherapy vs Best Supportive Care in Progressive Pediatric Solid Malignant Tumors: A Randomized Clinical Trial. JAMA Oncol 2017; 3:1222-1227. [PMID: 28384657 DOI: 10.1001/jamaoncol.2017.0324] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although oral metronomic chemotherapy is often used in progressive pediatric solid malignant tumors, a literature review reveals that only small single-arm retrospective or phase 1 and 2 studies have been performed. Skepticism abounds because of the lack of level 1 evidence. Objectives To compare the effect of metronomic chemotherapy on progression-free survival (PFS) with that of placebo in pediatric patients with primary extracranial, nonhematopoietic solid malignant tumors that progress after at least 2 lines of chemotherapy. Design, Setting, and Participants A double-blinded, placebo-controlled randomized clinical trial was conducted from October 1, 2013, through December 31, 2015, at the cancer center at All India Institute of Medical Sciences in children aged 5 to 18 years with primary extracranial, nonhematopoietic solid malignant tumors that progressed after at least 2 lines of chemotherapy and had no further curative options. Interventions One arm received a 4-drug oral metronomic regimen of daily celecoxib and thalidomide with alternating periods of etoposide and cyclophosphamide, whereas the other arm received placebo. Disease status was assessed at baseline, 9 weeks, 18 weeks, and 27 weeks or at clinical progression. Main Outcomes and Measures The primary end point was PFS as defined by the proportion of patients without disease progression at 6 months, and PFS duration and overall survival (OS) were secondary end points. Results A total of 108 of the 123 patients screened were enrolled, with 52 randomized to the placebo group (median age, 15 years; 40 male [76.9%]) and 56 to the metronomic chemotherapy group (median age, 13 years; 42 male [75.0%]). At a median follow-up of 2.9 months, 100% of the patients had disease progression by 6 months in the placebo group vs 96.4% in the metronomic chemotherapy group (P = .24). Median PFS and OS in the 2 groups was similar (hazard ratio [HR], 0.69; 95% CI, 0.47-1.03 [P = .07] for PFS; and HR, 0.74; 95% CI, 0.50-1.09 [P = .13] for OS). In post hoc subgroup analysis, cohorts receiving more than 3 cycles (HR for PFS, 0.46; 95% CI, 0.23-0.93; P = .03) and those without a bone sarcoma (ie, neither primitive neuroectodermal tumor nor osteosarcoma) (HR for PFS, 0.39; 95% CI, 0.18-0.81; P = .01) appeared to benefit from metronomic chemotherapy. Conclusions and Relevance Metronomic chemotherapy does not improve 6-month PFS, compared with placebo, among pediatric patients with extracranial progressive solid malignant tumors . However, patients without bone sarcoma and those able to tolerate therapy for more than 3 cycles (9 weeks) benefit. Trial Registration clinicaltrials.gov Identifier: NCT01858571.
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Affiliation(s)
- Raja Pramanik
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Yogendra Kumar Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | | | - Atul Batra
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepa Dhawan
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
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Zhang L, Wu B, Baruchel S. Oral Metronomic Topotecan Sensitizes Crizotinib Antitumor Activity in ALK F1174L Drug-Resistant Neuroblastoma Preclinical Models. Transl Oncol 2017; 10:604-611. [PMID: 28666189 PMCID: PMC5491461 DOI: 10.1016/j.tranon.2017.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 04/24/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND: Anaplastic lymphoma kinase (ALK) inhibitor crizotinib has proven to be effective in the treatment of ALK-mutated neuroblastoma, but crizotinib resistance was commonly observed in patients. We aimed to overcome crizotinib resistance by combining with the MEK inhibitor trametinib or low-dose metronomic (LDM) topotecan in preclinical neuroblastoma models. METHODS: We selected a panel of neuroblastoma cell lines carrying various ALK genetic aberrations to assess the therapeutic efficacy on cell proliferation in vitro. Downstream signals of ALK activation, including phosphorylation of ERK1/2, Akt as well as HIF-1α expression were evaluated under normoxic and hypoxic conditions. Tumor growth inhibition was further assessed in NOD/SCID xenograft mouse models. RESULTS: All NBL cell lines responded to crizotinib treatment but at variable ED50 levels, ranging from 0.25 to 5.58 μM. ALK-mutated cell lines SH-SY5Y, KELLY, LAN-5, and CHLA-20 are more sensitive than ALK wild-type cell lines. In addition, we demonstrated that under hypoxic conditions, all NBL cell lines showed marked decrease of ED50s when compared to normoxia except for KELLY cells. Taking into consideration the hypoxia sensitivity to crizotinib, combined treatment with crizotinib and LDM topotecan demonstrated a synergistic effect in ALKF1174L-mutated SH-SY5Y cells. In vivo, single-agent crizotinib showed limited antitumor activity in ALKF1174L-mutated SH-SY5Y and KELLY xenograft models; however, when combined with topotecan, significantly delayed tumor development was achieved in both SH-SY5Y and KELLY tumor models. CONCLUSIONS: Oral metronomic topotecan reversed crizotinib drug resistance in the ALKF1174L-mutated neuroblastoma preclinical model.
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Affiliation(s)
- Libo Zhang
- New Agent and Innovative Therapy Program, The Hospital for Sick Children, Toronto, Canada; Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Bing Wu
- New Agent and Innovative Therapy Program, The Hospital for Sick Children, Toronto, Canada; Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Sylvain Baruchel
- New Agent and Innovative Therapy Program, The Hospital for Sick Children, Toronto, Canada; Division of Hematology and Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Institute of Medical Sciences, University of Toronto, Toronto, Canada.
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Tsui PC, Lee YF, Liu ZWY, Ip LRH, Piao W, Chiang AKS, Lui VWY. An update on genomic-guided therapies for pediatric solid tumors. Future Oncol 2017; 13:1345-1358. [PMID: 28589766 DOI: 10.2217/fon-2017-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Currently, out of the 82 US FDA-approved targeted therapies for adult cancer treatments, only three are approved for use in children irrespective of their genomic status. Apart from leukemia, only a handful of genomic-based trials involving children with solid tumors are ongoing. Emerging genomic data for pediatric solid tumors may facilitate the development of precision medicine in pediatric patients. Here, we provide an up-to-date review of all reported genomic aberrations in the eight most common pediatric solid tumors with whole-exome sequencing or whole-genome sequencing data (from cBioPortal database, Pediatric Cancer Genome Project, Therapeutically Applicable Research to Generate Effective Treatments) and additional non-whole-exome sequencing studies. Potential druggable events are highlighted and discussed so as to facilitate preclinical and clinical research in this area.
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Affiliation(s)
- Pui Chi Tsui
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yin-Fai Lee
- School of Pharmacy & Medical Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Zoey Wing Yee Liu
- Department of Anatomical & Cellular Pathology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Laura Ren Huey Ip
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wenying Piao
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alan Kwok Shing Chiang
- Department of Pediatrics & Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Vivian Wai Yan Lui
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Senerchia AA, Macedo CR, Ferman S, Scopinaro M, Cacciavillano W, Boldrini E, Lins de Moraes VL, Rey G, de Oliveira CT, Castillo L, Almeida MT, Borsato ML, Lima E, Lustosa D, Barreto JH, El-Jaick T, Aguiar S, Brunetto A, Greggiani L, Cogo-Moreira H, Atallah A, Petrilli AS. Results of a randomized, prospective clinical trial evaluating metronomic chemotherapy in nonmetastatic patients with high-grade, operable osteosarcomas of the extremities: A report from the Latin American Group of Osteosarcoma Treatment. Cancer 2016; 123:1003-1010. [PMID: 28263383 DOI: 10.1002/cncr.30411] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Metronomic chemotherapy (MC) consists of the administration of a low dose of chemotherapy on a daily or weekly basis without a long break to achieve an antitumoral effect through an antiangiogenic effect or stimulation of the immune system. The potential effect of MC with continuous oral cyclophosphamide and methotrexate in patients with high-grade operable osteosarcomas (OSTs) of the extremities was investigated. METHODS Patients with high-grade OSTs who were 30 years old or younger were eligible for registration at diagnosis. Eligibility for randomization included 1) nonmetastatic disease and 2) complete resection of the primary tumor. The study design included a backbone of 10 weeks of preoperative therapy with methotrexate, adriamycin, and platinum (MAP). After surgery, patients were randomized between 2 arms to complete 31 weeks of MAP or receive 73 weeks of MC after MAP. The primary endpoint was event-free survival (EFS) from randomization. RESULTS There were 422 nonmetastatic patients registered (May 2006 to July 2013) from 27 sites in 3 countries (Brazil, Argentina and Uruguay), and 296 were randomized to MAP plus MC (n = 139) or MAP alone (n = 157). At 5 years, the EFS cumulative proportions surviving in the MAP-MC group and the MAP-alone group were 61% (standard error [SE], 0.5%) and 64% (SE, 0.5%), respectively, and they were not statistically different (Wilcoxon [Gehan] statistic = 0.724; P =.395). The multivariate analysis showed that necrosis grades 1 and 2, tumor size, and amputation were associated with shorter EFS. CONCLUSIONS According to the current follow-up, EFS with MAP plus MC is not statistically superior to EFS with MAP alone in patients with high-grade, resectable OSTs of the extremities. Cancer 2017;123:1003-10. © 2016 American Cancer Society.
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Affiliation(s)
- Andreza A Senerchia
- Institute of Pediatric Oncology/Support Group for Adolescents and Children With Cancer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carla Renata Macedo
- Institute of Pediatric Oncology/Support Group for Adolescents and Children With Cancer, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Sima Ferman
- National Cancer Institute, Rio de Janeiro, Brazil
| | - Marcelo Scopinaro
- Hospital de Pediatria SAMIC-Professor Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Walter Cacciavillano
- Hospital de Pediatria SAMIC-Professor Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | | | | | - Guadalupe Rey
- R. Gutierrez Children's Hospital, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Antonio Sergio Petrilli
- Institute of Pediatric Oncology/Support Group for Adolescents and Children With Cancer, Federal University of Sao Paulo, Sao Paulo, Brazil
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Rosé A, André N, Rozados VR, Mainetti LE, Menacho Márquez M, Rico MJ, Schaiquevich P, Villarroel M, Gregianin L, Graupera JM, García WG, Epelman S, Alasino C, Alonso D, Chantada G, Scharovsky OG. Highlights from the 1st Latin American meeting on metronomic chemotherapy and drug repositioning in oncology, 27-28 May, 2016, Rosario, Argentina. Ecancermedicalscience 2016; 10:672. [PMID: 27610198 PMCID: PMC5014555 DOI: 10.3332/ecancer.2016.672] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Indexed: 12/22/2022] Open
Abstract
Following previous metronomic meetings in Marseille (2011), Milano (2014), and Mumbai (2016), the first Latin American metronomic meeting was held in the School of Medical Sciences, National University of Rosario, Rosario, Argentina on 27 and 28 of May, 2016. For the first time, clinicians and researchers with experience in the field of metronomics, coming from different countries in Latin America, had the opportunity of presenting and discussing their work. The talks were organised in three main sessions related to experience in the pre-clinical, and clinical (paediatric and adult) areas. The different presentations demonstrated that the fields of metronomic chemotherapy and repurposing drugs in oncology, known as metronomics, constitute a branch of cancer therapy in permanent evolution, which have strong groups working in Latin America, both in the preclinical and the clinical settings including large, adequately designed randomised studies. It was shown that metronomics offers treatments, which, whether they are combined or not with the standard therapeutic approaches, are not only effective but also minimally toxic, with the consequent improvement of the patient’s quality of life, and inexpensive, a feature very important in low resource clinical settings. The potential use of metronomic chemotherapy was proposed as a cost/effective treatment in low-/middle-income countries, for adjuvant therapy in selected tumours. The fundamental role of the governmental agencies and non-governmental alliances, as the Metronomic Global Health Initiative, in supporting this research with public interest was underlined.
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Affiliation(s)
- Adriana Rosé
- Hospital de Pediatría 'JP Garrahan', Combate de los Pozos 1800, C 1245 AAM, CABA Argentina
| | - Nicolas André
- Inserm UMR_S 911, Centre de Recherche en Oncologie Biologique et Oncopharmacologie, 27 Boulevard Jean Moulin, Faculté de Pharmacie, Aix-Marseille Université; Service d'Hématologie & Oncologie Pédiatrique, AP‑HM, 13005 Marseille, France
| | - Viviana R Rozados
- Instituto de Genética Experimental, Facultad de Ciencias Médicas, Santa 3100, 2000 Rosario, Argentina
| | - Leandro E Mainetti
- Instituto de Genética Experimental, Facultad de Ciencias Médicas, Santa 3100, 2000 Rosario, Argentina
| | - Mauricio Menacho Márquez
- Instituto de Genética Experimental, Facultad de Ciencias Médicas, Santa 3100, 2000 Rosario, Argentina
| | - María José Rico
- Instituto de Genética Experimental, Facultad de Ciencias Médicas, Santa 3100, 2000 Rosario, Argentina
| | - Paula Schaiquevich
- Unidad de Farmacocinética Clínica, Hospital de Pediatría 'JP Garrahan', Combate de los Pozos 1800, C 1245 AAM, CABA Argentina
| | - Milena Villarroel
- Av Antonio Varas 360, Santiago, Providencia, Región Metropolitana, Chile
| | - Lauro Gregianin
- Hospital de Clínicas de Porto Alegre, Serviço de Oncologia Pediátrica, Rua Ramiro Barcelos, 2350, Petrópolis, Porto Alegre, RS 90670150, Brazil
| | - Jaume Mora Graupera
- Department of Paediatric Haemato-Oncology, Hospital Sant Joan de Déu, Passeig de Sant Joan de Déu, 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Wendy Gómez García
- Hospital Infantil Dr Robert Reid Cabral, Servicio de Hem-Oncología HIRRC, Ave Abraham Lincoln 2, Casi Esq Ave, Independencia, Santo Domingo, Dominican Republic
| | - Sidnei Epelman
- Paediatric Oncology Department, Santa Marcelina Hospital, R Rio Negro, 48, Itaquaquecetuba, São Paulo, SP 08599-280, Brazil
| | - Carlos Alasino
- Instituto de Oncología de Rosario, Córdoba 2457, S2000KZE Rosario, Argentina
| | - Daniel Alonso
- Laboratorio de Oncología Molecular, Universidad Nacional de Quilmes, Roque Sáenz Peña 352, B1876BXD Bernal, Buenos Aires, Argentina
| | - Guillermo Chantada
- Instituto de Investigaciones, Hospital de Pediatría 'JP Garrahan', Combate de los Pozos 1800, C 1245 AAM, CABA Argentina
| | - O Graciela Scharovsky
- Instituto de Genética Experimental, Facultad de Ciencias Médicas, Santa 3100, 2000 Rosario, Argentina
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Porkholm M, Toiviainen-Salo S, Seuri R, Lönnqvist T, Vepsäläinen K, Saarinen-Pihkala UM, Pentikäinen V, Kivivuori SM. Metronomic therapy can increase quality of life during paediatric palliative cancer care, but careful patient selection is essential. Acta Paediatr 2016; 105:946-51. [PMID: 26801815 DOI: 10.1111/apa.13338] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/20/2015] [Accepted: 01/18/2016] [Indexed: 12/16/2022]
Abstract
AIM Children with refractory or high-risk malignancies frequently suffer from poor quality of life during palliative care. This study explored the effect of metronomic drug administration on survival and quality of life in paediatric patients with various refractory or high-risk tumours. METHODS We treated 17 patients with a maintenance therapy that consisted of metronomic thalidomide, etoposide and celecoxib. The endpoints of the study were overall and progression-free survival, changes in the Karnofsky-Lansky scores from baseline to the end of the study therapy and radiological responses. RESULTS The median overall survival after the start of the study therapy was 6.2 months (range 2.0-57.7), and the six-, 12- and 24-month survival rates were 59%, 18% and 18%, respectively. The median progression-free survival was 3.2 months (range 0.3-17.8). The Karnofsky-Lansky scores increased significantly during the study therapy (p = 0.02), with 35% of the patients having a transient improvement in their clinical status. Radiologically, one partial response and two disease stabilisations were encountered. Grade III-V adverse events occurred in 76% of the patients. CONCLUSION Metronomic therapy may increase the quality of life during palliative care for childhood cancer, but requires careful patient selection to minimise the risk of serious adverse events.
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Affiliation(s)
- Mikaela Porkholm
- Division of Hematology-Oncology and Stem Cell Transplantation; Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Sanna Toiviainen-Salo
- Department of Pediatric Radiology; Helsinki Medical Imaging Center; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Raija Seuri
- Department of Pediatric Radiology; Helsinki Medical Imaging Center; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Tuula Lönnqvist
- Division of Child Neurology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Kaisa Vepsäläinen
- Department of Pediatrics; Kuopio University Hospital; Kuopio Finland
| | - Ulla M. Saarinen-Pihkala
- Division of Hematology-Oncology and Stem Cell Transplantation; Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Virve Pentikäinen
- Division of Hematology-Oncology and Stem Cell Transplantation; Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Sanna-Maria Kivivuori
- Division of Hematology-Oncology and Stem Cell Transplantation; Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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11
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Ali AM, El-Sayed MI. Metronomic chemotherapy and radiotherapy as salvage treatment in refractory or relapsed pediatric solid tumours. ACTA ACUST UNITED AC 2016; 23:e253-9. [PMID: 27330362 DOI: 10.3747/co.23.2873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Metronomic chemotherapy (mctx) combined with radiation therapy (rt) is an emerging anticancer strategy. The aim of the present study was to assess the efficacy of mctx combined with rt as salvage treatment in children with refractory or relapsed solid malignancies. METHODS This prospective study enrolled patients with refractory or relapsed pediatric solid tumours from January 2013 to January 2015. Treatment consisted of 3-12 courses of mctx in all patients, followed by rt in patients who experienced local recurrence, distant metastases, or both. Each course of mctx consisted of oral celecoxib 100-400 mg twice daily (days 1-42), intravenous vinblastine 3 mg/m(2) weekly (weeks 1-6), oral cyclophosphamide 2.5 mg/m(2) daily (days 1-21), and oral methotrexate 15 mg/m(2) twice weekly (days 21-42). Statistical methods used were the log-rank test and binary logistic regression. RESULTS A favourable disease response (partial response or stable disease) was seen in 49 of 64 patients (76.6%), with mild acute toxicity occurring in 41 (64%). After a median follow-up of 14 months, 1-year overall survival was 62%. Pattern of disease relapse (p < 0.0001), time from initial treatment to relapse (p = 0.0002), and response to treatment (p < 0.0001) significantly affected survival. Age was the only factor that significantly correlated with treatment toxicity (p = 0.002; hazard ratio: 3.37; 95% confidence interval: 1.53 to 7.35). CONCLUSIONS Combining mctx with rt resulted in a favourable response rate, minimal toxicity, and 62% 1-year overall survival in patients with heavily pretreated recurrent disease. Patients with localized late recurrence or disease progression are the most likely to benefit from this regimen.
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Affiliation(s)
- A M Ali
- Department of Pediatric Oncology, South Egypt Cancer Institute, Assiut University, Egypt
| | - M I El-Sayed
- Department of Radiotherapy, South Egypt Cancer Institute, Assiut University, Egypt
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12
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Bocci G, Kerbel RS. Pharmacokinetics of metronomic chemotherapy: a neglected but crucial aspect. Nat Rev Clin Oncol 2016; 13:659-673. [DOI: 10.1038/nrclinonc.2016.64] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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13
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Roberts JK, Birg AV, Lin T, Daryani VM, Panetta JC, Broniscer A, Robinson GW, Gajjar AJ, Stewart CF. Population Pharmacokinetics of Oral Topotecan in Infants and Very Young Children with Brain Tumors Demonstrates a Role of ABCG2 rs4148157 on the Absorption Rate Constant. ACTA ACUST UNITED AC 2016; 44:1116-22. [PMID: 27052877 DOI: 10.1124/dmd.115.068676] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/05/2016] [Indexed: 01/21/2023]
Abstract
For infants and very young children with brain tumors, chemotherapy after surgical resection is the main treatment due to neurologic and neuroendocrine adverse effects from whole brain irradiation. Topotecan, an anticancer drug with antitumor activity against pediatric brain tumors, can be given intravenous or orally. However, high interpatient variability in oral drug bioavailability is common in children less than 3 years old. Therefore, this study aimed to determine the population pharmacokinetics of oral topotecan in infants and very young children, specifically evaluating the effects of age and ABCG2 and ABCB1 on the absorption rate constant (Ka), as well as other covariate effects on all pharmacokinetic parameters. A nonlinear mixed effects model was implemented in Monolix 4.3.2 (Lixoft, Orsay, France). A one-compartment model with first-order input and first-order elimination was found to adequately characterize topotecan lactone concentrations with population estimates as [mean (S.E.)]; Ka = 0.61 (0.11) h(-1), apparent volume of distribution (V/F) = 40.2 (7.0) l, and apparent clearance (CL/F) = 40.0 (2.9) l/h. After including the body surface area in the V/F and CL/F as a power model centered on the population median, the ABCG2 rs4148157 allele was found to play a significant role in the value of Ka Patients homozygous or heterozygous for G>A demonstrated a Ka value 2-fold higher than their GG counterparts, complemented with a 2-fold higher maximal concentration as well. These results demonstrate a possible role for the ABCG2 rs4148157 allele in the pharmacokinetics of oral topotecan in infants and very young children, and warrants further investigation.
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Affiliation(s)
- Jessica K Roberts
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Anna V Birg
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Tong Lin
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Vinay M Daryani
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - John C Panetta
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Giles W Robinson
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar J Gajjar
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Clinton F Stewart
- Department of Pharmaceutical Sciences (J.K.R., A.V.B., V.M.D., J.C.P., C.F.S.), Department of Biostatistics (T.L.), and Department of Oncology (A.B., G.W.R., A.J.G.), St. Jude Children's Research Hospital, Memphis, Tennessee
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14
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Zhang L, Marrano P, Wu B, Kumar S, Thorner P, Baruchel S. Combined Antitumor Therapy with Metronomic Topotecan and Hypoxia-Activated Prodrug, Evofosfamide, in Neuroblastoma and Rhabdomyosarcoma Preclinical Models. Clin Cancer Res 2015; 22:2697-708. [DOI: 10.1158/1078-0432.ccr-15-1853] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/17/2015] [Indexed: 11/16/2022]
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15
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Di Desidero T, Xu P, Man S, Bocci G, Kerbel RS. Potent efficacy of metronomic topotecan and pazopanib combination therapy in preclinical models of primary or late stage metastatic triple-negative breast cancer. Oncotarget 2015; 6:42396-410. [PMID: 26623560 PMCID: PMC4767441 DOI: 10.18632/oncotarget.6377] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/16/2015] [Indexed: 12/21/2022] Open
Abstract
Metronomic chemotherapy has shown promising activity in numerous preclinical studies and also some phase II clinical studies involving various tumor types, and is currently undergoing phase III trial evaluation. Triple-negative breast cancer (TNBC) is an aggressive histological subtype with limited treatment options and very poor prognosis following progression after standard chemotherapeutic regimens. Herein, we evaluated the potential therapeutic impact and molecular mechanisms of topotecan administered in a continuous low-dose metronomic (LDM) manner, alone or in concurrent combination with pazopanib, an antiangiogenic tyrosine kinase inhibitor (TKI), in a triple-negative, primary and metastatic breast cancer orthotopic model; potential molecular mechanisms of efficacy were also studied, especially the impact of hypoxic conditions. The combination of metronomic topotecan and pazopanib significantly enhanced antitumor activity compared to monotherapy with either drug and prolonged survival, even in the advanced metastatic survival setting, with a marked decrease in tumor vascularity, proliferative index, and the induction of apoptosis. Significant changes in tumor angiogenesis, cancer cell proliferation, apoptosis, HIF1α levels, HIF-1 target genes and ABCG2 were found both in vitro and in tumor tissue. Notably, the pazopanib and metronomic topotecan combination treatment inhibited expression of HIF1α and ABCG2 genes in cells grown under hypoxic conditions, and this was associated with an increased intracellular concentration of the active form of topotecan. Our results suggest a potential novel therapeutic option for the treatment of metastatic triple-negative breast cancer patients.
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Affiliation(s)
- Teresa Di Desidero
- Biologic Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
- Divisione di Farmacologia, Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
| | - Ping Xu
- Biologic Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Shan Man
- Biologic Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Guido Bocci
- Divisione di Farmacologia, Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
| | - Robert S. Kerbel
- Biologic Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
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An in vitro assessment of liposomal topotecan simulating metronomic chemotherapy in combination with radiation in tumor-endothelial spheroids. Sci Rep 2015; 5:15236. [PMID: 26468877 PMCID: PMC4606561 DOI: 10.1038/srep15236] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 09/02/2015] [Indexed: 12/31/2022] Open
Abstract
Low dose metronomic chemotherapy (LDMC) refers to prolonged administration of low dose chemotherapy designed to minimize toxicity and target the tumor endothelium, causing tumor growth inhibition. Topotecan (TPT) when administered at its maximum tolerated dose (MTD) is often associated with systemic hematological toxicities. Liposomal encapsulation of TPT enhances efficacy by shielding it from systemic clearance, allowing greater uptake and extended tissue exposure in tumors. Extended release of TPT from liposomal formulations also has the potential to mimic metronomic therapies with fewer treatments. Here we investigate potential toxicities of equivalent doses of free and actively loaded liposomal TPT (LTPT) and compare them to a fractionated low dose regimen of free TPT in tumor-endothelial spheroids (TES) with/without radiation exposure for a prolonged period of 10 days. Using confocal microscopy, TPT fluorescence was monitored to determine the accumulation of drug within TES. These studies showed TES, being more reflective of the in vivo tumor microenvironment, were more sensitive to LTPT in comparison to free TPT with radiation. More importantly, the response of TES to low-dose metronomic TPT with radiation was comparable to similar treatment with LTPT. This TES study suggests nanoparticle formulations designed for extended release of drug can simulate LDMC in vivo.
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Burzynski SR, Janicki TJ, Burzynski GS, Marszalek A. The response and survival of children with recurrent diffuse intrinsic pontine glioma based on phase II study of antineoplastons A10 and AS2-1 in patients with brainstem glioma. Childs Nerv Syst 2014; 30:2051-61. [PMID: 24718705 PMCID: PMC4223571 DOI: 10.1007/s00381-014-2401-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 03/06/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Brainstem gliomas (BSG) are relatively rare tumors of which recurrent pediatric diffuse intrinsic pontine gliomas (RPDIPG) comprise a distinct group. Numerous trials have been conducted on RPDIPG, none of which have resulted in identifying any proven pharmacological treatment benefit. This study included 40 patients diagnosed with different types of BSG, but it was decided to describe first the encouraging results in the most challenging group of RPDIPG. MATERIALS AND METHODS This single-arm phase II study evaluated the efficacy and safety of the combination of antineoplastons A10 and AS2-1 (ANP) in patients with RPDIPG. Seventeen patients (median age 8.8 years) were enrolled, and all were diagnosed with RPDIPG. ANP was administered intravenously daily. Efficacy analyses were conducted in this group of patients. RESULTS In this group, complete responses were observed in 6 % of patients, partial responses in 23.5 %, and stable disease in 11.8 %. Six-month progression-free survival was 35.3 %. One-year overall survival was 29.4 %, 2 years 11.8 %, and 5, 10, and 15 years 5.9 %. One patient with DIPG is alive over 15 years post-treatment. Grade 3 and higher toxicities including hypokalemia and fatigue occurred in 6 %, hypernatremia in 18 %, fatigue and urinary incontinence in 6 %, and somnolence in 12 %. In a single patient, grade 4 hypernatremia occurred when he was on mechanical ventilation. He was disconnected from the ventilator and died from brain tumor according to the attending physician. Responding patients experienced improved quality of life. CONCLUSION The results suggest that ANP shows efficacy and acceptable tolerability profile in patients with RPDIPG.
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Affiliation(s)
| | | | | | - Ania Marszalek
- Burzynski Clinic, 9432 Katy Freeway, Houston, TX 77055 USA
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Digklia A, Voutsadakis IA. Combinations of vascular endothelial growth factor pathway inhibitors with metronomic chemotherapy: Rational and current status. World J Exp Med 2014; 4:58-67. [PMID: 25414818 PMCID: PMC4237643 DOI: 10.5493/wjem.v4.i4.58] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/16/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
Chemotherapy given in a metronomic manner can be administered with less adverse effects which are common with conventional schedules such as myelotoxicity and gastrointestinal toxicity and thus may be appropriate for older patients and patients with decreased performance status. Efficacy has been observed in several settings. An opportunity to improve the efficacy of metronomic schedules without significantly increasing toxicity presents with the addition of anti-angiogenic targeted treatments. These combinations rational stems from the understanding of the importance of angiogenesis in the mechanism of action of metronomic chemotherapy which may be augmented by specific targeting of the vascular endothelial growth factor (VEGF) pathway by antibodies or small tyrosine kinase inhibitors. Combinations of metronomic chemotherapy schedules with VEGF pathway targeting drugs will be discussed in this paper.
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Abstract
Pediatric gliosarcoma (GS) is a rare variant of glioblastoma multiforme. The authors describe the case of an unusual pontine location of GS in a 9-year-old boy who was initially diagnosed with low-grade astrocytoma (LGA) that was successfully controlled for 4 years. Subsequently, his brain tumor transformed into a GS. Prior treatment of his LGA included subtotal tumor resection 3 times, standard radiation therapy, and Gamma Knife procedure twice. His LGA was also treated with a standard chemotherapy regimen of carboplatin and vincristine, and his GS with subtotal resection, high-dose cyclophosphamide, and thiotepa with stem cell rescue and temozolomide. Unfortunately, he developed disseminated disease with multiple lesions and leptomeningeal involvement including a tumor occupying 80% of the pons. Upon presentation at our clinic, he had rapidly progressing disease. He received treatment with antineoplastons (ANP) A10 and AS2-1 for 6 years and 10 months under special exception to our phase II protocol BT-22. During his treatment with ANP his tumor stabilized, then decreased, and, ultimately, did not show any metabolic activity. The patient's response was evaluated by magnetic resonance imaging and positron emission tomography scans. His pathology diagnosis was confirmed by external neuropathologists, and his response to the treatment was determined by central radiology review. He experienced the following treatment-related, reversible toxicities with ANP: fatigue, xerostomia and urinary frequency (grade 1), diarrhea, incontinence and urine color change (grade 2), and grade 4 hypernatremia. His condition continued to improve after treatment with ANP and, currently, he complains only of residual neurological deficit from his previous surgery. He achieved a complete response, and his overall and progression-free survival is in excess of 13 years. This report indicates that it is possible to obtain long-term survival of a child with a highly aggressive recurrent GS with diffuse pontine involvement with a currently available investigational treatment.
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Characterization of a novel anti-cancer compound for astrocytomas. PLoS One 2014; 9:e108166. [PMID: 25255031 PMCID: PMC4177861 DOI: 10.1371/journal.pone.0108166] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/19/2014] [Indexed: 11/19/2022] Open
Abstract
The standard chemotherapy for brain tumors is temozolomide (TMZ), however, as many as 50% of brain tumors are reportedly TMZ resistant leaving patients without a chemotherapeutic option. We performed serial screening of TMZ resistant astrocytoma cell lines, and identified compounds that are cytotoxic to these cells. The most cytotoxic compound was an analog of thiobarbituric acid that we refer to as CC-I. There is a dose-dependent cytotoxic effect of CC-I in TMZ resistant astrocytoma cells. Cell death appears to occur via apoptosis. Following CC-I exposure, there was an increase in astrocytoma cells in the S and G2/M phases. In in vivo athymic (nu/nu) nude mice subcutaneous and intracranial tumor models, CC-I completely inhibited tumor growth without liver or kidney toxicity. Molecular modeling and enzyme activity assays indicate that CC-I selectively inhibits topoisomerase IIα similar to other drugs in its class, but its cytotoxic effects on astrocytoma cells are stronger than these compounds. The cytotoxic effect of CC-I is stronger in cells expressing unmethylated O6-methylguanine methyltransferase (MGMT) but is still toxic to cells with methylated MGMT. CC-I can also enhance the toxic effect of TMZ on astrocytoma when the two compounds are combined. In conclusion, we have identified a compound that is effective against astrocytomas including TMZ resistant astrocytomas in both cell culture and in vivo brain tumor models. The enhanced cytotoxicity of CC-I and the safety profile of this family of drugs could provide an interesting tool for broader evaluation against brain tumors.
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Chu FM, Chang KT, Chen KM, Wei GT. Supercritical Fluid Extraction of Camptothecin from Nothapodytes Foetida. J CHIN CHEM SOC-TAIP 2014. [DOI: 10.1002/jccs.201300631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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André N, Carré M, Pasquier E. Metronomics: towards personalized chemotherapy? Nat Rev Clin Oncol 2014; 11:413-31. [PMID: 24913374 DOI: 10.1038/nrclinonc.2014.89] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Since its inception in 2000, metronomic chemotherapy has undergone major advances as an antiangiogenic therapy. The discovery of the pro-immune properties of chemotherapy and its direct effects on cancer cells has established the intrinsic multitargeted nature of this therapeutic approach. The past 10 years have seen a marked rise in clinical trials of metronomic chemotherapy, and it is increasingly combined in the clinic with conventional treatments, such as maximum-tolerated dose chemotherapy and radiotherapy, as well as with novel therapeutic strategies, such as drug repositioning, targeted agents and immunotherapy. We review the latest advances in understanding the complex mechanisms of action of metronomic chemotherapy, and the recently identified factors associated with disease resistance. We comprehensively discuss the latest clinical data obtained from studies performed in both adult and paediatric populations, and highlight ongoing clinical trials. In this Review, we foresee the future developments of metronomic chemotherapy and specifically its potential role in the era of personalized medicine.
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Affiliation(s)
- Nicolas André
- Service d'Hématologie & Oncologie Pédiatrique, AP-HM, 264 rue Saint Pierre, 13385 Marseille, France
| | - Manon Carré
- INSERM UMR 911, Centre de Recherche en Oncologie Biologique et Oncopharmacologie, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005 Marseille, France
| | - Eddy Pasquier
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW, PO Box 81, Randwick NSW 2031, Australia
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Sie M, den Dunnen WF, Hoving EW, de Bont ES. Anti-angiogenic therapy in pediatric brain tumors: An effective strategy? Crit Rev Oncol Hematol 2014; 89:418-32. [DOI: 10.1016/j.critrevonc.2013.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/10/2013] [Accepted: 09/27/2013] [Indexed: 12/15/2022] Open
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Ye L, Shi J, Wan S, Yang X, Wang Y, Zhang J, Zheng D, Liu Z. Development and validation of a liquid chromatography-tandem mass spectrometry method for topotecan determination in beagle dog plasma and its application in a bioequivalence study. Biomed Chromatogr 2013; 27:1532-9. [PMID: 23788247 DOI: 10.1002/bmc.2956] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 04/12/2013] [Accepted: 05/07/2013] [Indexed: 01/15/2023]
Abstract
Topotecan (TPT) is an important anti-cancer drug that inhibits topoisomerase I. A sensitive and robust liquid chromatography-tandem mass spectrometry (LC-MS/MS) method that potentially determines TPT in beagle dog plasma is needed for a bioequivalence study of TPT formulations. We developed and validated LC-MS/MS to evaluate TPT in beagle dog plasma in terms of specificity, linearity, precision, accuracy, stability, extraction recovery and matrix effect. Plasma samples were treated with an Ostro(TM) sorbent plate (a robust and effective tool) to eliminate phospholipids and proteins before analysis. TPT and camptothecin (internal standard) were separated on an Acquity UPLC BEH C18 column (1.7 µm, 2.1 × 50 mm) with 0.1% formic acid and methanol as the mobile phase at a flow rate of 0.25 mL/min. TPT was analyzed using positive ion electrospray ionization in multiple-reaction monitoring mode. The obtained lower limit of quantitation was 1 ng/mL (signal-to-noise ratio > 10). The standard calibration curve for TPT was linear (correlation coefficient > 0.99) at the concentration range of 1-400 ng/mL. The intra-day and inter-day precision, accuracy, stability, extraction recovery and matrix effect of TPT were within the acceptable limits. The validated method was successfully applied in a bioequivalence study of TPT in healthy beagle dogs.
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Affiliation(s)
- Ling Ye
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
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Wolf DS, Cohen KJ. Is low and slow the way to go? Metronomic therapy in the treatment of pediatric brain tumors. CNS Oncol 2013; 2:211-3. [DOI: 10.2217/cns.13.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- David S Wolf
- Department of Neurology, The Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg 11379, Baltimore, MD 21287, USA
| | - Kenneth J Cohen
- The Sidney Kidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg 11379, Baltimore, MD 21287, USA
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Mehta PS, Wiernikowski JT, Petrilli JAS, Barr RD. Essential medicines for pediatric oncology in developing countries. Pediatr Blood Cancer 2013; 60:889-91. [PMID: 23450774 DOI: 10.1002/pbc.24476] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 12/26/2012] [Indexed: 11/11/2022]
Abstract
The burden of cancer in children in low and middle income countries (LMICs) is substantial, comprising at least 80% of incident cases globally, and an even higher proportion of cancer-related deaths. With survival rates exceeding 80% in high income countries, it is imperative to transfer these successes to LMICs. A major challenge is the poor availability of safe, cost-effective chemotherapy. A list of 51 drugs-chemotherapeutics, infectious disease agents, and supportive care medications-is proposed as essential to improving the survival of children with cancer in LMICs with an additional 13 drugs identified as being of further value.
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Affiliation(s)
- Parth S Mehta
- Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77094, USA.
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Romiti A, Cox MC, Sarcina I, Di Rocco R, D'Antonio C, Barucca V, Marchetti P. Metronomic chemotherapy for cancer treatment: a decade of clinical studies. Cancer Chemother Pharmacol 2013; 72:13-33. [PMID: 23475105 DOI: 10.1007/s00280-013-2125-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 02/12/2013] [Indexed: 12/20/2022]
Abstract
PURPOSE Over the past few years, more and more new selective molecules directed against specific cellular targets have become available for cancer therapy, leading to impressive improvements. In this evolving scenario, a new way of delivering older cytotoxic drugs has also been developing. Many studies demonstrated that several cytotoxic drugs have antiangiogenic properties if administered frequently and at lower doses compared with standard schedules containing maximal tolerated doses (MTD). Such a new strategy, named metronomic chemotherapy, focuses on a different target: the slowly proliferating tumour endothelial cells. About 10 years ago, metronomic chemotherapy was firstly enunciated and hereafter many clinical experiences were published related to almost any cancer disease. This review analyses available studies dealing with metronomic chemotherapy and its combination with several targeted agents in solid tumours. METHODS A computerized literature search of MEDLINE was performed using the following search terms: metronomic OR "continuous low dose" AND chemotherapy AND cancer OR solid tumours. RESULTS Satisfactory results have been achieved in diverse tumour types, such as breast and prostate cancer or paediatric sarcomas. Moreover, many studies have reported that metronomic chemotherapy determined minimal toxicity compared to MTD chemotherapy. Overall, published series on metronomic schedules are very heterogeneous often reporting on retrospective data, while only very few studies were randomized trials. These limitations still prevent to draw definitive conclusions in diverse tumour types. CONCLUSIONS Large well-designed studies are eagerly awaited for confirming the promises of metronomic schedules and their combinations with targeted molecules.
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Affiliation(s)
- Adriana Romiti
- Department of Oncology, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
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von Gruenigen VE, Frasure HE, Smith DA, Fusco NL, Eaton SM, DeBernardo RL, Heugel AM, Waggoner SE. Toxicity of weekly oral topotecan in relation to dosage for gynecologic malignancies: a phase I study. Anticancer Drugs 2012; 23:724-30. [PMID: 22555194 DOI: 10.1097/cad.0b013e32835396d4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The aim of this study was to determine the dose of weekly oral topotecan that allows safe administration and to evaluate the pharmacokinetics of this dose in patients with recurrent gynecologic malignancies. The first cohort of patients received oral topotecan 6 mg/week administered orally on days 1, 8, and 15 of a 28-day regimen. A standard 3+3 dose-escalating phase design was used for dose levels II-V (8, 10, 12 and 14 mg/week). Toxicity was scored according to the Common Terminology Criteria for Adverse Events. Cumulative toxicity was summarized in the 6-12 mg/week combined cohort and 14 mg/week cohort separately. Pharmacokinetic samples were obtained for day 1, cycle 1 only in the expansion cohort (dose level V). Twenty-five patients received a total of 88 cycles of therapy. Hematologic toxicities of grade 3 (6-12 mg dose) were neutropenia (25%) and anemia (8.3%). Gastrointestinal toxicities of grade 3 were diarrhea (16.7%) and obstruction (8.3%, disease-related). Grade 3 or 4 (14 mg/week) hematologic toxicities consisted of neutropenia (38.5%), platelets (15.4%), anemia (15.4%), infection with neutropenia (7.7%), and thrombosis (7.7%). Gastrointestinal toxicities of grade 3 were diarrhea (7.7%), obstruction (7.7%), and vomiting (7.7%). One patient died secondary to neutropenic sepsis. One patient (4%; 95% confidence interval: 2.1, 22.3) showed a partial response and five patients (20%; 95% confidence interval: 7.6, 41.3) had stable disease. An oral topotecan dose of 14 mg/week for 3 consecutive weeks out of 4 is mostly associated with acceptable toxicities and may be considered for use in future single-agent phase II trials.
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Affiliation(s)
- Vivian E von Gruenigen
- Department of Obstetrics & Gynecology, Summa Akron City Hospital, Akron, Ohio 44309, USA.
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Metronomic chemotherapy in progressive pediatric malignancies: old drugs in new package. Indian J Pediatr 2012; 79:1617-22. [PMID: 22544675 DOI: 10.1007/s12098-012-0759-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 04/04/2012] [Indexed: 02/04/2023]
Abstract
Despite intensive research in the field of cancer, many pediatric cancers are still incurable with current treatment protocols. Repetitive administration of conventional chemotherapy at maximal tolerated dose imposes many side effects that further limits the dosing and therefore decreases the anticancer effects. Usually limited options remain when a malignancy progresses after one or two lines of standard chemotherapy protocol. The goal of an oncologist at this point of time remains mainly palliative with an effort to halt the progression of cancer and improve quality of life. Metronomic chemotherapy is defined as the chronic administration of chemotherapeutic agents at relatively low, minimally toxic doses, and with no prolonged drug-free breaks. It is thought this type of chemotherapy inhibits tumor growth primarily through anti-angiogenic mechanisms, promoting apoptosis and immune- surveillance.
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Sun T, Wan W, Wu Z, Zhang J, Zhang L. Clinical outcomes and natural history of pediatric brainstem tumors: with 33 cases follow-ups. Neurosurg Rev 2012; 36:311-9; discussion 319-20. [DOI: 10.1007/s10143-012-0428-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 06/19/2012] [Accepted: 07/15/2012] [Indexed: 10/27/2022]
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André N, Abed S, Orbach D, Alla CA, Padovani L, Pasquier E, Gentet JC, Verschuur A. Pilot study of a pediatric metronomic 4-drug regimen. Oncotarget 2012; 2:960-5. [PMID: 22156656 PMCID: PMC3282100 DOI: 10.18632/oncotarget.358] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Metronomic chemotherapy (MC) is defined as the frequent administration of chemotherapy at doses below the maximal tolerated dose and with no prolonged drug-free break. MC is gaining interest as an alternative strategy to fight resistant cancer. Objective to assess the safety of 4 drug MC regimen in pediatric patients with refractory or relapsing various tumors types. Setting From November 2008 to December 2010, in three academic pediatric oncology centers, 16 children (median age 12 years old; range 5.5-20) were included in this pilot study. This treatment was proposed to children with refractory disease for whom no further effective treatments were available. Most frequent diagnosis were medulloblastoma/cerebral PNET (5) osteosarcoma (5), and one case each of nephroblastoma, high grade glioma, Hodgkin lymphoma, rhabdomyosarcoma, neuroblastoma and kidney rhabdoid tumour. The MC regimen consisted in cycles of 56 days (8 weeks) with weekly vinblastine 3 mg/m2 (week 1-7), daily cyclophosphamide 30 mg/m2 (days 1-21), and twice weekly methotrexate 10 mg/m2; (days 21-42), and daily celecoxib 100 mg to 400 mg twice daily (days1-56) followed by a 2-weeks chemotherapy break. Adverse events were determined through laboratory analysis and investigator observations. Results One objective response was observed in a patient with Hodgkin lymphoma, and 4 patients experienced disease stabilization and continued their treatment for 3 cycles (24 weeks) or more. At last follow-up, 7 patients (43%) are alive including 1 still undergoing treatment. During the overall 36 cycles of treatments received by patients, 4 grade IV toxicities and 24 grade III toxicities were observed in 11 cycles in only 10 different patients. Conclusion The metronomic regimen we report here was well tolerated and associated with disease stabilization. This regimen is currently being evaluated in a national multicenter phase II study.
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Affiliation(s)
- Nicolas André
- Service d'Hématologie et Oncologie Pédiatrique, Hôpital pour Enfants de La Timone, Marseille, France.
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Current world literature. Curr Opin Pediatr 2012; 24:134-44. [PMID: 22245849 DOI: 10.1097/mop.0b013e328350498a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mross K, Steinbild S. Metronomic anti-cancer therapy – an ongoing treatment option for advanced cancer patients. ACTA ACUST UNITED AC 2012. [DOI: 10.7243/2049-7962-1-32] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Current world literature. Curr Opin Oncol 2011; 23:700-9. [PMID: 21993416 DOI: 10.1097/cco.0b013e32834d384a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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