A phase I/II study of topotecan in combination with carboplatin in recurrent epithelial ovarian cancer

Topotecan as a molecular targeting agent which blocks the Akt and VEGF cascade in platinum-resistant ovarian cancers

OBJECTIVE

Topotecan, a novel topoisomerase-1 inhibitor, is a drug that appears to be effective against platinum-resistant ovarian cancers. However, the molecular mechanisms by which Topotecan treatment inhibits cancer cell proliferation are unclear. We investigated whether Topotecan increases the efficacy of Cisplatin in platinum-resistant ovarian cancer models in vitro and in vivo.

METHODS

We used Cisplatin-resistant Caov-3 cells and Cisplatin-sensitive A2780 cells. We examined the effect of Cisplatin and Topotecan on the cell viability of Caov-3 and A2780 cells by MTS assay. We examined the Akt kinase activity, VEGF and HIF-1α expression after Cisplatin and Topotecan by a Western blot analysis. Moreover, we also evaluated the effects of Cisplatin and Topotecan on the intraabdominal dissemination of ovarian cancer in vivo.

RESULTS

Topotecan significantly inhibited Cisplatin-induced Akt activation in Caov-3 cells, but not in A2780 cells. In the presence of Topotecan, Cisplatin-induced growth inhibition and apoptosis were significantly enhanced in Caov-3 cells. Topotecan inhibited not only Cisplatin-induced Akt activation but also VEGF and HIF-1α expression. Moreover, treatment with Topotecan increased the efficacy of Cisplatin-induced growth inhibition in the intraabdominal dissemination and production of ascites in athymic nude mice inoculated with Caov-3 cells.

CONCLUSION

We herein demonstrated that Topotecan inhibits Akt kinase activity and VEGF transcriptional activation after Cisplatin treatment in platinum-resistant ovarian cancers. We clarified how Topotecan enhanced the clinical activity in the platinum-resistant ovarian cancer. These results provide a rationale for using Topotecan in clinical regimens aimed at molecular targeting agents in platinum-resistant ovarian cancers.

Phase II study of belotecan, a camptothecin analogue, in combination with carboplatin for the treatment of recurrent ovarian cancer

BACKGROUND

Belotecan (CKD602; Camtobell, Chong Keun Dang Corp., Seoul, Korea) is a recently developed camptothecin derivative with antitumor properties. This phase II study was designed to evaluate the toxicity and efficacy of belotecan combined with carboplatin in patients with recurrent epithelial ovarian cancer (EOC).

METHODS

Thirty-eight patients with recurrent EOC were treated with belotecan 0.3 mg/m(2) /day (days 1-5) and carboplatin AUC 5 (day 5) every 3 weeks for 6 cycles. The primary objective was to determine the response rate as defined by Response Evaluation Criteria in Solid Tumors and CA-125 response. Other end points included toxicities and progression-free survival (PFS).

RESULTS

All 38 patients were assessed for toxicity, and 35 patients were assessed for response. The overall response rate was 57.1%; there were 7 complete responses (20.0%), 13 partial responses (37.1%), 6 patients with stable disease (17.1%), and 9 patients with progressive disease (25.7%). Grades 3 and 4 hematologic toxicities included neutropenia (28.8%), thrombocytopenia (19.8%), and anemia (14.4%), and there were 2 episodes of febrile neutropenia. Median PFS was 7 months, with a median follow-up of 12 months.

CONCLUSIONS

The newly developed topoisomerase I inhibitor belotecan (CKD-602) combined with carboplatin is a well-tolerated regimen with activity in recurrent EOC. Further testing of this regimen is warranted to further characterize efficacy and indications for use.

Emerging role of pemetrexed in ovarian cancer

The current treatment of choice of epithelial ovarian cancer involves aggressive tumor cytoreductive surgery followed by platinum- and taxane-based chemotherapy; however, despite the encouraging activity of these agents, most ovarian carcinomas relapse and many patients die from drug-resistant disease. After the failure of platinum- and taxane-based schedules, several cytotoxic agents have demonstrated activity in advanced ovarian cancer but none were able to induce significant and durable responses. Among the new cytotoxic agents, pemetrexed plays an emerging role in different tumors, demonstrating competitive activity and a promising safety profile. In ovarian cancer, pemetrexed has been investigated, with encouraging results, as a single agent and in association with platinum compounds; moreover, the drug has shown interesting activity both in platinum-sensitive and platinum-resistant ovarian cancer. According to these clinical results it appears reasonable to explore the combination of pemetrexed with other cytotoxic agents and also with targeted therapies in relapsed ovarian cancer patients.

Phase I/IIa study of combination chemotherapy with CKD-602 and cisplatin in patients with recurrent epithelial ovarian cancer

The aim of this study was to determine the maximum tolerated dose (MTD) and therapeutic efficacy of a newly developed CKD-602 topoisomerase I inhibitor and cisplatin in patients with recurrent epithelial ovarian cancer. CKD-602 (0.30 mg/m(2) daily for 5 days) and cisplatin (60 mg/m(2) on day 5) were administered to patients every 3 weeks with dose adjustment of CKD-602 by 0.05 mg/m(2) daily until the MTD was reached. Dose-limiting toxicity was defined as grade >or= 3 neutropenia or thrombocytopenia for more than 4 days or accompanied by fever >or= 38.5 degrees C, infection, hemorrhage, or transfusion; grade >or= 3 nonhematological toxicity except for alopecia, nausea, and vomiting. We enrolled 26 patients with recurrent epithelial ovarian cancer who had measurable disease (MD) estimated by computed tomography scan (n= 12) and nonmeasurable disease (NMD) evaluated by serum CA-125 levels (n= 14). All patients received 188 cycles of CKD-602 and cisplatin with a median number of six cycles per patient (range, 2 to 12). MTD of CKD-602 was 0.30 mg/m(2) daily. The overall response rate was 69.2% (18/26) with 58.3% (7/12) and 78.6% (11/14) in MD and NMD, respectively. Among the responsive patients, 14 were platinum sensitive (14/18, 77.7%) and four were platinum resistant (4/8, 50.0%). The most common toxicity was grade >or= 3 neutropenia developing in 17 patients (65.4%) and 72 cycles (38.3%). Grade 3 nausea and anorexia were the most common gastrointestinal toxicities, developing in 15 cycles (8.0%) of four patients (15.4%) and 10 cycles (5.3%) of five patients (19.3%), respectively. The median disease-free interval was 6 months (range 0-26 months). CKD-602 at a concentration of 0.3 mg/m(2) daily for 5 days and cisplatin at 60 mg/m(2) on day 5 every 3 weeks showed high efficacy, with acceptable toxicity, against platinum-sensitive/resistant recurrent epithelial ovarian cancer.

Review role of topotecan in gynaecological cancers: current indications and perspectives

BACKGROUND

Ovarian cancer is the fourth cause of death from gynaecological cancer and cervical cancer is the first in women <45 years old in developing countries. The aim of this article is to review the role of topotecan (Hycamtin), a semi-synthetic alkaloid derivative of camptothecin, in ovarian and cervical cancer in monotherapy and in combination.

METHODS

This article reviews the mechanism of action, pharmacokinetics, toxicity and efficacy of topotecan. The paper also reports the principal phases II and III studies of topotecan in advanced or recurrent ovarian and cervical cancer.

RESULTS

Topotecan (Hycamtin), currently indicated for the treatment of relapsed ovarian cancer, has demonstrated activity both in platinum-sensitive and in platinum-resistant disease. The combination cisplatin-topotecan for the treatment of advanced and recurrent cervical cancer has demonstrated a clinical benefit in terms of response rate, overall survival and progression free survival. Haematological toxicity of topotecan also is easy to manage and not cumulative, especially with the weekly scheduled recently introduced in clinical practice.

CONCLUSION

Topotecan (Hycamtin) will continue to play a role in the treatment of advanced ovarian and cervical cancer, in monotherapy or in combination with other cytotoxic agents.

Key role of topoisomerase I inhibitors in the treatment of recurrent and refractory epithelial ovarian carcinoma

Ovarian cancer remains one of the most difficult gynecologic cancers to treat, owing to its aggressive biology and high relapse rate, as well as the toxic side effects of available chemotherapeutic agents used to treat recurrent disease. Topoisomerase I inhibitors, including topotecan and irinotecan, are some of the most effective and tolerable treatment options for recurrent ovarian cancer. The ideal dosing, timing of administration, role in combination with other chemotherapies or biologics and potential role in up-front therapy remains an area of active research. This article reviews the mechanism of action of topoisomerase I inhibitors and the efficacy, dosing, schedule and toxicity for topotecan, irinotecan, 9-nitrocamptothecin, DX-8951 and 9-aminocamptothecin. Conclusions include a discussion of future avenues of research and ongoing projects.

Topotecan for ovarian cancer

BACKGROUND

Chemotherapeutic agents such as topotecan can be used to treat ovarian cancer. The effects of using topotecan as a therapeutic agent have not been previously been systematically reviewed.

OBJECTIVES

To systematically evaluate the effectiveness and safety of topotecan for the treatment of ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 4, 2006); Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register (Cochrane Library Issue 4, 2006); MEDLINE (January 1990 to 27 July 2006); EMBASE (January 1990 to 27 July 2006); The European Organization for the Research and Treatment of Cancer (EORTC) database (to 1 August 2006); CBM (Chinese Biomedical Database) (January 1990 to 27 July 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) which randomized patients with ovarian cancer to single or combined use of topotecan versus interventions without topotecan, or different remedies of topotecan.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and analysed data.

MAIN RESULTS

Six studies including 1323 participants were eligible for this review (Gordon 2004a; Gore 2001a; Gore 2002; Hoskins 1998; Huinink 2004; Placido 2004) All studies, as reported, were identified as being of poor methodological quality. Topotecan had comparable effectiveness to prolong progression-free survival (PFS) compared with pegylated liposomal doxorubicin (PLD), (16.1 weeks versus 17.0 weeks; p = 0.095). Overall survival (OS) time was similar in participants using PLD compared with topotecan (56.7 weeks versus 60 weeks; p = 0.341). Topotecan was more hematologically toxic compared with paclitaxel or PLD, relative risks (RRs) of hematological events: ranged from 1.03 to 14.46 and 1.73 to 27.12 respectively. A 21-day cycle of topotecan was more toxic than a 42-day cycle (RRs of hematological and non-hematological events ranged from 1.03 to 8). Intravenous and oral topotecan had comparable toxicity. Topotecan delayed progression more effectively compared with paclitaxel (23.1 weeks versus 14 weeks, p = 0.0021). Participants were more likely to respond to topotecan on a 21-day cycle as opposed to a 42-day cycle (RR 7.23, 95% CI 0.94 to 55.36). Small tumor diameter, sensitivity to platinum-based chemotherapy was associated with better prognosis. Small sample size, methodological flaws and poor reporting of the included trials made measurement bias of the trials difficult to assess.

AUTHORS' CONCLUSIONS

Topotecan appears to have a similar level of effectiveness as paclitaxel and PLD, though with different patterns of side effects. Larger, well-designed RCTs are required in order to define an optimal regime.

Topotecan and carboplatin in patients with platinum-sensitive recurrent ovarian cancer. Results of a multicenter NOGGO: phase I/II study

OBJECTIVE

Second-line treatment with paclitaxel and carboplatin enhances survival of women with platinum-sensitive recurrent ovarian cancer (ROC). However, because of its cumulative neurotoxicity, there is a strong demand for platinum-combinations with better therapeutic index. Because of its pharmacological properties, topotecan is a good adjunct to carboplatin in this setting, but its safety and efficacy remains to be defined.

METHODS

Patients with platinum-sensitive ROC were eligible in this multicenter phase I/II study, stratified according to treatment-free interval (TFI). Dose level 0 consisted of topotecan 1 mg/m(2)/d1-3/q21d plus carboplatin AUC5/d3/q21d. DLT was defined as grade > or =3 neutropenia or thrombocytopenia or grade > or =3 non-hematological toxicity excluding alopecia, nausea and vomiting, accompanied by a treatment delay >1 week.

RESULTS

From June 2004 to August 2005, 26 patients were enrolled, receiving a total of 145 cycles of chemotherapy. MTD was reached at topotecan 0.75 mg/m(2) and carboplatin AUC5. We observed a single grade 4 leucopenia. There were 3 (12%), 15 (58%) and 8 (31%) events of grade 3/4 hematological anaemia, leucopenia, and thrombocytopenia. Response rate was 67% (95% CI 43-85), median progression-free survival 9.5 months (95% CI 7.3-12.0), median overall survival 19.4 months (95% CI 12.3-26.9). None of the toxicity or efficacy endpoints were associated with TFI.

CONCLUSION

Topotecan and carboplatin is a well tolerated novel doublet option for women with platinum sensitive ROC. We encourage further studies on this approach, but to limit the doses of topotecan to 0.75 mg/m(2)/d1-3 and carboplatin AUC 5/d3.

Pegylated liposomal doxorubicin HCL (PLD; Caelyx/Doxil): experience with long-term maintenance in responding patients with recurrent epithelial ovarian cancer

BACKGROUND

We hypothesized that a response to pegylated liposomal doxorubicin (PLD, Caelyx/Doxil) followed by maintenance is beneficial and safe in recurrent ovarian cancer.

PATIENTS AND METHODS

Sixteen patients have received PLD for more than 1 year for recurrent ovarian (14) or fallopian tube (2) cancer. All had stable disease or better responses to PLD + carboplatin (5) or topotecan (9) doublets or to PLD alone (2). PLD maintenance therapy 30-40 mg/m(2) was given every 4-8 weeks. This analysis focuses on cardiac status, overall tolerance, and time to recurrence.

RESULTS

Termination of PLD was due to progression in all patients. Noteworthy was the lack of cumulative myelosuppression and, with one exception, clinical cardiac toxicity. This patient was hospitalized with cardiogenic shock and fever complicating grade 4 pancytopenia from topotecan ten months after discontinuation of PLD. Seven patients continue to receive PLD after a median of 1680 mg/m(2) (1180-2460 mg/m(2)). Four of these had documented relapses after 3-6 years on maintenance occurring in the setting of lengthening of the treatment interval. Maintenance PLD was reinstituted after 'reinduction' with a platinum.

CONCLUSIONS

PLD appears to be safe as long-term maintenance in ovarian cancer and may be important for a continued response.

Three sequential chemotherapy doublets for the treatment of newly diagnosed advanced müllerian malignancies: The modified triple doublet regimen

OBJECTIVE

Previously, we reported the use of three sequential doublets (Triple Doublets) in the treatment of women with newly diagnosed and advanced stage müllerian malignancies. The surgically defined negative second look operation (SLO) rate to Triple Doublets was 38%. Modifications were made to this treatment regimen that were predicted to reduce toxicity and possibly increase efficacy.

METHODS

Open label two-cohort study. Patients with a new diagnosis of Stages II-IV müllerian malignancy were eligible. After cytoreductive surgery, patients were treated with three sequential doublets including 3 cycles of carboplatin and gemcitabine, and 3 cycles of carboplatin and paclitaxel, and 3 cycles of doxorubicin and topotecan. After therapy, all women were clinically staged and evaluated at SLO if clinical staging was negative for residual disease. Primary endpoints were toxicity and negative SLO rate with rates of 60% and 40% defined a priori in optimally cytoreduced (cohort 1) and suboptimally cytoreduced or Stage IV (cohort 2), respectively.

RESULTS

Eighty-five eligible patients were enrolled with a median age of 52 years. Forty-seven and thirty-eight women were in cohorts 1 and 2, respectively. 723 cycles of chemotherapy were delivered with no toxic deaths. Grades 3 and 4 toxicities included neutropenia in 75% of patients and thrombocytopenia in 65% of patients during at least one cycle of therapy. Fever and neutropenia were seen in 3.5% of patients. All Grades 3 and 4 non-hematologic toxicities were seen at a frequency of <10%. Seventy women underwent SLO with a negative SLO rate of 53% with an additional 9% having microscopically positive procedures. Negative SLO rate was 74% in cohort 1 and 36% in cohort 2.

CONCLUSIONS

Treatment with the modified triple doublet regimen is tolerable with an encouraging pathologic CR rate.

Optimizing gemcitabine regimens in ovarian cancer

Ovarian cancer represents the leading cause of death from gynecologic neoplasms. The chance of response to secondary treatment is currently disappointing; few agents have shown notable activity in recurrent/progressive patients. Among these agents, gemcitabine represents one of the most interesting newer antineoplastic agents, showing significant activity, synergism with cisplatin, and a mild toxicity profile in both platinum-sensitive and platinum-resistant (and also taxane-pretreated) recurrent/progressive patients. Moreover, first-line combination chemotherapy including gemcitabine has shown promising response rates in phase I and II studies. The ongoing phase III, five-arm, randomized Gynecologic Oncology Group Protocol 182/International Collaborative Ovarian Neoplasm 5 study should clarify the clinical impact of the addition of a third drug to the standard paclitaxel plus carboplatin treatment regimen.

A phase II study of a paclitaxel and oxaliplatin combination in platinum-sensitive recurrent advanced ovarian cancer patients

PURPOSE

A multicentric, phase II study to evaluate the efficacy and safety of the combination paclitaxel and oxaliplatin in patients with platinum-sensitive recurrent ovarian cancer.

PATIENTS AND METHODS

Patients received 175 mg/m(2) paclitaxel (over 3 h) followed by 130 mg/m(2) oxaliplatin (over 2 h) every 21 days for up to nine cycles without hydration or primary granulocyte colony-stimulating factor prophylaxis. Patients had to have an Eastern Cooperative Oncology Group performance status of 0-2 and to have received no more than one prior cisplatin- and/or carboplatin-containing chemotherapy regimen with a platinum-progression-free interval > or =6 months.

RESULTS

Of the 105 patients enrolled and treated, 98 were eligible. An overall response rate of 81% (79 of 98 patients) (95% confidence interval 71% to 88%) was observed according to RECIST criteria (third party reviewed), and 88% (86 of 98) when this was complemented with CA-125 response. With a median follow up of 43.6 months (range 30.2-64.2) the median progression-free survival was 10.2 months (range 0.3-21.4) and the overall survival 32.4 months. Seven hundred and eight cycles were administered (median seven per patient; range one to nine). A total of 67% of patients experienced National Cancer Institute Common Toxicity Criteria grade 3-4 neutropenia, including 8% with concomitant febrile episode, without treatment-related deaths. Ninety-three per cent of patients experienced neuropathy of grade 1 or more, including 25% with cumulative reversible peripheral neuropathy of grade 3-4. Oxaliplatin doses were reduced in 30 patients due to neurotoxicity.

CONCLUSIONS

The oxaliplatin/paclitaxel combination can be administered in an outpatient setting every 3 weeks without specific measures. The high level of activity and its duration observed warrants further evaluation of this combination in pretreated platinum-sensitive advanced ovarian cancer patients.

Medical treatment of epithelial ovarian cancer

Epithelial ovarian carcinoma is still the most common cause of death from gynecologic cancer in the USA and Europe. Only 20-30% of patients are diagnosed at the initial stage where appropriate staging surgery can be curative. Patients with high-risk Stage I disease can benefit from adjuvant chemotherapy with platinum-based schedules. The treatment of patients with advanced disease consists of a staging surgery with maximum cytoreductive effort, followed by chemotherapy with a platinum-taxane combination. Unfortunately, the majority of patients with advanced disease will relapse and become candidates for additional chemotherapy. In those patients with recurrence over 6 months after initial therapy (platinum sensitive), combinations of paclitaxel plus carboplatin and carboplatin plus gemcitabine have shown a benefit over carboplatin alone. Patients with early relapse should be managed with supportive care and sequential monotherapy if chemotherapy is indicated.

Paclitaxel and Carboplatin as Second-Line Therapy in Women With Platinum-Sensitive Ovarian Carcinoma Treated With Platinum and Paclitaxel as First-Line Therapy

The study was performed to assess response rate, progression-free interval (PFI), and side effects of the combination paclitaxel and carboplatin as second-line therapy among women with platinum-sensitive epithelial ovarian carcinoma (EOC). Thirty women who achieved partial surgical response at second-look surgery (n = 8) or who had recurrence (n = 22) more than 6 months after treatment with platinum-based chemotherapy were treated with paclitaxel (135 mg/m2 for 3 hours) and carboplatin (area under the concentration-time curve 5) every 3 weeks. Response rate, PFI, and side effects of treatment were recorded. One hundred sixty-seven cycles of treatment (median = 6, range = 2-11) were administered. Among 22 patients with measurable or assessable disease, 14 had complete response and 3 had partial response. Five patients had progressive disease. The overall response rate was 77%. The median PFI was 10 months (range = 1-29). Among 22 patients in whom recurrence or progression developed after second-line therapy, the median interval was 9 months (range = 1-26). The incidence of grade III or IV neutropenia, leukopenia, and thrombocytopenia was 48%, 27%, and 3%, respectively. One patient discontinued treatment secondary to persistent thrombocytopenia. Eight patients died secondary to their disease. It was concluded that the combination paclitaxel and carboplatin has a high success rate, long duration of response, and is well tolerated as a second-line therapy among patients with platinum-sensitive EOC.

Is combination chemotherapy superior to single-agent chemotherapy in second-line treatment?

Treatment of relapsed ovarian carcinoma is still a matter of controversy. One important question to be solved is the potential superiority of combination chemotherapy over single-agent chemotherapy. This is a field in which a nonconclusive small number of randomized clinical trials have been conducted, and therefore, definitive conclusions are lacking. Patients with recurrent platinum-resistant disease are better treated with sequential single agent, because of higher toxicity without clear benefit usually associated with combination chemotherapy. In patients with platinum-sensitive disease, we can choose between three options: single-agent carboplatin, single-agent new drug or platinum combination-based therapy. In this paper, we will review these options and recently closed or ongoing randomized clinical trials in this setting.

Chemotherapeutic management of advanced ovarian cancer

OBJECTIVE

To review current treatment strategies for patients with advanced ovarian cancer. Factors for treatment selection are discussed.

DATA SOURCES

Research articles and textbooks.

CONCLUSION

Research efforts continue to identify novel agents and/or combination therapies that can effect a cure or prolong survival. Several agents offer similar efficacy outcomes but vary in safety aspects and administration requirements.

IMPLICATIONS FOR NURSING PRACTICE

Numerous clinical trials have defined the efficacy and safety of chemotherapy in patients with ovarian cancer. Oncology nurses can prepare patients to make treatment decisions; educate them about treatment-related side effects; and develop an ongoing relationship as patient advocates to ensure quality of life.

Topoisomerase I interactive agents

Increased insight into the mechanism of interaction of topoisomerase I interactive agents will maximize the therapeutic index and enhance the development of additional agents. Preclinical studies designed to elucidate mechanisms by which the topoisomerase I interactive agents induce cell death will be essential. The role of ABC transporters in resistance to topoisomerase I interactive agents has been recently appreciated and future studies should be directed at circumventing this resistance. The results of preclinical studies must be translated into the design of clinical trials so that these agents can be used rationally. In this regard results of preclinical studies have clearly pointed to the enhanced antitumor activity from protracted dosing of topoisomerase I interactive agents and results of clinical trials are now supporting these preclinical findings. Finally, investigators are trying to understand better the mechanism(s) of the dose-limiting toxicities observed with the currently available topoisomerase I interactive agents in an effort to enable the optimal dosing of these agents. Even though the first priority must be to determine the therapeutic potential of the currently available agents, it is reassuring to know that other topoisomerase I interactive agents are currently under development.

ZD0473 combined with other chemotherapeutic agents for the treatment of solid malignancies

Platinum-based combination chemotherapy regimens are the mainstay of current treatments for advanced solid malignancies. Preclinical in vitro studies have shown synergism with ZD0473 in combination with several agents, including vinorelbine and topotecan. This paper reviews the tolerability and activity observed with ZD0473 in combination with vinorelbine or topotecan, in two Phase I dose-escalating studies in patients with advanced, solid, refractory malignancies. Twenty-four patients were included in the ZD0473 plus vinorelbine trial and were treated with doses of ZD0473 60-150 mg/m2 and vinorelbine 15-25 mg/m2. In this trial, dose-limiting toxicity comprised non-haematological events and the most common grade 3/4 toxicities included neutropenia (54.2%), thrombocytopenia (29.2%) and anaemia (20.8%). Eleven patients were included in the ZD0473 plus topotecan trial and were treated with ZD0473 60-90 mg/m2 and topotecan 0.5 mg/m2/day for 3 or 5 days. In this trial, dose-limiting toxicity comprised haematological events and the most common grade 3/4 toxicities included thrombocytopenia (63.6%), neutropenia (36.4%) and anaemia (18.2%). No objective responses were observed in either trial, but disease stabilisation occurred in 29.2% and 27.3% of patients in the vinorelbine and topotecan trials, respectively.