On heterogeneity of non-Hodgkin's lymphomas as regards sensitivity to cytostatic drugs. An in vitro study

Drug Sensitivity of Different Tumor Lesions from the Same Patient Evaluated by a Short-Term Assay

A short-term antimetabolic assay, which considers the interference with [3H]thymidine incorporation as an indicator of drug effect, has been used to comparatively assess the chemosensitivity of different tumor lesions from the same patient. The analysis was performed on primary tumors and their synchronous metastases from 67 patients with breast, ovarian, gastrointestinal and germ cell testicular tumors. A remarkable difference in sensitivity to cytostatic drugs was observed between the two lesions. In contrast, a strong association in chemosensitivity (81.7% agreement rate; p < 0.01) was observed between two synchronous metastases from 17 patients with breast, ovarian, germ cell testicular tumors or malignant melanoma. In addition, the predictive relevance of the antimetabolic assay on clinical response to chemotherapy was analyzed in relation to the type of tumor lesion tested in vitro in a retrospective correlative study on 57 patients with advanced ovarian and germ cell testicular tumors. The objective clinical response was significantly correlated to the in vitro sensitivity of metastases (83.7% agreement rate; p < 0.01), but not to that of the primary tumor.

Exploratory phase II trial in a multicenter setting to evaluate the clinical value of a chemosensitivity test in patients with gastric cancer (JACCRO-GC 04, Kubota memorial trial)

BACKGROUND

Although postoperative adjuvant chemotherapy with S-1, an oral fluoropyrimidine, has become a standard of care for gastric cancer in Japan, nonresponders may suffer from the cost and adverse reactions without clinical benefit. This multicenter exploratory phase II trial was conducted to see whether a chemosensitivity test, the collagen gel droplet embedded culture drug sensitivity test (CD-DST), can adequately select patients for chemotherapy.

METHODS

The CD-DST using four different concentrations of 5-fluorouracil was conducted with resected specimens from preregistered patients who underwent gastrectomy with D2 or more extensive lymphadenectomy. Patients who were histopathologically confirmed to have stage II or greater disease without distant metastasis were eligible for final enrollment. All patients underwent protocol-specified adjuvant chemotherapy with S-1. Three-year relapse-free survival was compared between patients determined as sensitive by the CD-DST (responders) and those deemed insensitive (nonresponders). Appropriate cutoff values for in vitro growth inhibition were defined when the hazard ratio for relapse in responders and the log-rank P values were at their minimum.

RESULTS

Of the 311 patients enrolled, 14 were ineligible and 27 failed to start the protocol treatment. The CD-DST failed in 64 other patients, and survival analyses were conducted with the remaining 206 patients (39 stage II disease, 155 stage III disease, and 12 stage IV disease). The outcome of patients who were determined to be responders was significantly superior to that of nonresponders regardless of the 5-fluorouracil concentrations, although no differences in clinicopathologic characteristics were observed between the two groups, except for age.

CONCLUSIONS

The CD-DST identified those who benefit from adjuvant chemotherapy. It deserves further evaluation in the setting of a prospective randomized trial. ClinicalTrials.gov identifier: NCT00287755.

Assay-based response evaluation in head and neck oncology: requirements for better decision making

This article gives an overview on different current strategies of assay-based response evaluation in head and neck squamous cell carcinomas (HNSCC) and critically summarizes their role and needs for future clinical evaluation. Due to a growing amount of data of phase III clinical trials of multimodality treatment options for HNSCC, treatment planning in regard to optimal outcome is becoming an interdisciplinary challenge. New concepts such as induction chemotherapy with bi- or ternary combinations of chemotherapeutics, integration of targeted therapies, concurrent and sequential chemoradiation concepts, and multimodality-based organ preservation strategies strongly compete with traditional definitive surgical procedures. Moreover, the outcome is difficult to predict due to heterogeneity of a tumor's response, impaired late functional outcome, and increased late toxicity if simultaneously applied to radiation. Retrospectively looking at non-responders with tumors classified as resectable, primary surgery is very likely to have achieved better results, since chemoradiation causes a high degree of early and late toxicities leading to extremely complicated terms and conditions in surgery following current multimodal therapeutic strategies. Unfortunately, predictive information on response characteristics of a given tumor before starting the therapy is not available in daily routine, although heterogeneity in response of a given tumor entity to treatments has been known for decades. Therefore, current therapy strategies for HNSCC still have to ignore this fact, creating an urgent need for the development of proper predictive assays. There are interesting clinical observations showing that response on induction chemotherapy may predict the outcome after radiotherapy. Some trials use this empiric phenomenon to pre-select non-responders for primary surgical treatment avoiding severe salvage complications after failure of complete chemoradiation treatment. Moving one step further, recent literature and our own investigations implicate that response evaluation of the individual patient's HNSCC in a suitable ex vivo assay just before starting the treatment is mature for clinical research. To this end, essential needs and hints are addressed and discussed.

Interaction between specific dietary factors and experimental chemotherapy of metastatic melanoma

The single and combined effects of (a) dietary restriction of phenylalanine and tyrosine, (b) levodopa methylester chemotherapy, and (c) megadose sodium ascorbate supplementation on experimental metastasis was determined in B16-BL6 melanoma. Dietary restriction and levodopa methylester therapy inhibited tumor outgrowth, whereas ascorbate alone was inactive. In combination, however, the effect of dietary restriction and levodopa methylester chemotherapy was augmented by sodium ascorbate. Tumor cells surviving this combination therapy (treated population) were isolated from the lungs of treated mice, and proved to be tumorigenic when inoculated SC into the back of naive mice. The resulting tumors grew more slowly than those produced by inoculation of similarly isolated control cells (control population), irrespective of whether the diet was adequate or deficient in phenylalanine and tyrosine. Failure of the treated tumor cell population to exhibit reduced sensitivity to the combination chemotherapy or, unlike the control population, to exhibit variation in pigmentation levels, suggests that the restriction of phenylalanine and tyrosine during drug therapy alters the tumor response to reduce heterogeneity and perhaps interferes with the emergence of drug resistance.

The human tumor stem cell assay revisited

The human tumor stem cell assay (HTSCA) is a bilayer soft agar system for growing fresh human tumor specimens in vitro to determine drug sensitivity and improve our understanding of tumor biology. Recent clinical correlations of 60% accuracy for predicting a positive clinical response and a 90% accuracy for predicting a lack of response to therapeutic agents suggest promising clinical usefulness. However, the clinician should be aware of the assay's inherent pitfalls, such as heterogeneity of the tumor specimen, inability to obtain pure single-cell suspensions, low cloning efficiency, unusual drug dose-dependent survival curves, uncertain validity of in vitro pharmacology, non-standardized criteria for in vitro sensitivity, and the variability of in vitro results. A brief summary of the concepts, potential, and limitations of this assay are discussed.

Some aspects of size-dependent differential drug response in primary and metastatic tumors

The response of cancer to various anticancer drugs is tumor-size dependent in many aspects. In general, problems stem partly from the fact that the entire tumor cell populations do not respond equally to a certain treatment. As a result of recent progress in cancer biology, it has become evident that cellular heterogeneity of the tumor underlies the difficulties of treating primary and metastatic tumors with chemotherapy. Moreover, as tumors grow, marked diversity develops on the tissue level as well. An uneven distribution with an increase of areas of lower growth fraction and of poorer drug delivery is more distinct in larger tumors. Heterogeneous distribution and low levels of tumor blood flow are considered to be causally related to the heterogeneous nature of tumor tissue. Considering the lack of evidence of a lymphatic system within the tumor, increased interstitial fluid pressure may be a natural result that further impedes blood flow in the tumor. The fact that the temporary and selective increase in tumor tissue blood flow by angiotensin-induced hypertension produces a remarkable chemotherapeutic effect should vividly indicate that delivery of the drug to the tumor is really the 'bottleneck' of cancer chemotherapy. Tumor-size-related change in the transvascular and extravascular transport of molecules and its relevance to chemotherapy are also discussed in this article.

Changes in growth pattern of human squamous-cell carcinomas of the head and neck during serial passages in nude mice

Six human squamous-cell carcinomas of the head and neck heterotransplanted to nude mice were studied with respect to changes in tumour volume doubling time (DT), cell cycle phase distribution and clonal composition during serial passages. The tumours exhibited a statistically significant decrease in DT between the first and third or fourth passages towards a constant value. The changes in DT are likely to depend on a reduction of cell loss factor. Five of the original tumours and serially passed heterotransplants were analyzed with flow cytometry. Two tumours were diploid and remained so after heterotransplantation. Three tumours had one diploid and one aneuploid cell population. At heterotransplantation there was a selection of clones and only the aneuploid cell populations could be recovered from the heterotransplants in the first as well as in later passages.

The selective nature of metastasis

The issue of whether metastases result from the random survival of cells released from a primary tumor or from the selective growth of specialized tumor subpopulations endowed with metastatic properties is important to our understanding of the metastatic process and to the development of therapeutic modalities against metastatic disease. We have found that the tumor cells populating spontaneous metastases are more metastatic than the cells populating the parent neoplasm, clearly indicating that metastasis is selective and not random. The selective nature of metastasis is a consistent observation, however, only when tumor cells are obtained from spontaneous metastases from mice bearing heterogenous, poorly metastatic tumors. Tumor cells from spontaneous metastases from mice bearing tumors that have been selected for metastatic potential or that are homogeneous (cloned) do not differ significantly in metastatic potential from tumor cells populating the parent tumor. Thus, under some conditions the process of metastasis can appear random. Although tumor cells from different individual metastases may be homogeneous with regard to a metastatic phenotype, they may be heterogeneous with regard to their sensitivity to chemotherapeutic agents. Thus, although metastasis selects for metastatic variants, resulting in the population of metastatic foci with tumor cells endowed with metastatic properties, it does not appear to select for phenotypes irrelevant to the process of metastasis such as sensitivity to therapeutic agents.

Tumor metastasis is not due to adaptation of cells to a new organ environment

Murine B16 melanoma cells were adapted for lung survival and growth by allowing them to attach to Bio-Carrier beads and injecting the beads intravenously into normal mice. The beads lodged mechanically in the microcirculation of the lung. When the melanoma cells had grown into visible tumors from the arrested beads, the tumors were removed and the cells were dispersed, cultured to remove normal cells, and reattached to new beads. The process was repeated nine times. Previously another B16 subline was injected intravenously as a suspension of separate tumor cells. Those cells that survived and colonized the lungs were harvested, cultured, and injected again. This selection process was also repeated nine times. Only the subline that was injected in suspension was more metastatic than the parental line, indicating that metastasis involves selection of preexistent metastatic cells and is not an adaptive process by which all cells gradually acquire the ability to grow at particular organ sites.