Systemic anticancer therapy in gynecological cancer patients with renal dysfunction

Systemic oncological therapy in breast cancer patients on dialysis

The advancement of renal replacement therapy has significantly enhanced the survival rates of patients with end-stage renal disease (ESRD) over time. However, this prolonged survival has also been associated with a higher likelihood of cancer diagnoses among these patients including breast cancer. Breast cancer treatment typically involves surgery, radiation, and systemic therapies, with approaches tailored to cancer type, stage, and patient preferences. However, renal replacement therapy complicates systemic therapy due to altered drug clearance and the necessity for dialysis sessions. This review emphasizes the need for optimized dosing and administration strategies for systemic breast cancer treatments in dialysis patients, aiming to ensure both efficacy and safety. Additionally, challenges in breast cancer screening and diagnosis in this population, including soft-tissue calcifications, are highlighted.

Genetic overlap for ten cardiovascular diseases: A comprehensive gene-centric pleiotropic association analysis and Mendelian randomization study

Recent studies suggest that pleiotropic effects may explain the genetic architecture of cardiovascular diseases (CVDs). We conducted a comprehensive gene-centric pleiotropic association analysis for ten CVDs using genome-wide association study (GWAS) summary statistics to identify pleiotropic genes and pathways that may underlie multiple CVDs. We found shared genetic mechanisms underlying the pathophysiology of CVDs, with over two-thirds of the diseases exhibiting common genes and single-nucleotide polymorphisms (SNPs). Significant positive genetic correlations were observed in more than half of paired CVDs. Additionally, we investigated the pleiotropic genes shared between different CVDs, as well as their functional pathways and distribution in different tissues. Moreover, six hub genes, including ALDH2, XPO1, HSPA1L, ESR2, WDR12, and RAB1A, as well as 26 targeted potential drugs, were identified. Our study provides further evidence for the pleiotropic effects of genetic variants on CVDs and highlights the importance of considering pleiotropy in genetic association studies.

Systemic Treatment for Gynecological Cancer Patients Undergoing Hemodialysis

Gynecological cancer poses a serious threat to women's health. Chemotherapy-based systemic therapy plays a crucial role in the treatment of gynecological cancers. Many systemic therapeutic drugs are metabolized in the kidneys. Therefore, normal renal function is a prerequisite for gynecological tumor patients to complete the full course of systematic treatment and provide a guarantee for achieving an ideal prognosis. Chronic kidney disease often places restrictions on systematic treatment to different extents, such as influencing drug pharmacokinetics, increasing drug toxicity, and the risk of adverse drug reactions. Unfortunately, women undergoing renal replacement have a higher risk of developing gynecological cancers. This article summarizes the current knowledge on systemic treatment drugs for patients with gynecological cancer undergoing dialysis. We discuss the optimal choice of the systematic therapeutic protocol, administration of form and dosage, and window of chemotherapy during hemodialysis sessions to ensure both effectiveness and safety in gynecological cancer patients.

Hodgkin Lymphoma on Hemodialysis: A Review of Treatment and Recommendations

Chemotherapy for classic Hodgkin lymphoma (cHL) patients on hemodialysis (HD) is an extremely challenging situation because pharmacokinetic and pharmacodynamic studies of most chemotherapeutics are lacking for the HD patient, and the small amount of evidence available comes mostly from case reports and small case series. In this review, we provide recommendations based on treatment experience of cHL patients on HD in the literature. HD patients undergoing chemotherapy are at risk of overdose and toxicities because many drugs are significantly eliminated by the kidneys, and at the same time, are at risk of undertreatment because many drugs are removed by HD. Therefore, dose modifications and timing of drug administration in relation to HD sessions must be carefully planned according to the distinct traits of each chemotherapeutic. We carried out an exhaustive literature review of reports of actual administrations of chemotherapeutics to cHL on HD, and also extrapolated data from reports of the same chemotherapeutics that were administered to HD patients with malignancies other than cHL. We summarized the information found in the literature, and provide practical and balanced recommendations concerning dose modifications and optimal timing of drug administration in relation to HD sessions for each chemotherapeutic. Chemotherapy regimens and individual chemotherapeutics studied in this review include ABVD (doxorubicin + bleomycin + vinblastine + dacarbazine), BEACOPP (bleomycin + etoposide + doxorubicin + cyclophosphamide + vincristine + procarbazine + prednisolone), MOPP (mechlorethamine + vincristine + procarbazine + prednisolone), gemcitabine, vinorelbine, brentuximab vedotin, and PD-1 inhibitors (nivolumab and pembrolizumab).

The effect of concomitant use of Colony-Stimulating factors on bleomycin pulmonary toxicity - A systematic review and meta-analysis

BACKGROUND

Changes in the incidence of bleomycin pulmonary toxicity (BPT) as a result of adding colony-stimulating factors (CSF) to bleomycin regimens has been investigated in numerous studies. We performed a systematic review and meta-analysis to assess the outcomes of these studies.

METHODS

A systematic search was performed using Pubmed, Scopus, Web of Science, and Embase on April 2021. Studies evaluating the incidence of BPT in patients receiving bleomycin with and without CSF were included. In addition, meta-analysis was performed by pooling odds ratios using R.

RESULTS

Out of 340 obtained records, our qualitative and quantitative analysis included 3234 and 1956 patients from 22 and 14 studies, respectively. The quantitative synthesis showed that addition of CSF significantly increased the risk of BPT incidence (OR = 1.82, 95 % CI: 1.37-2.40, p < 0.0001; I2 = 10.7 %). Subgroup analysis did not show any association between continent, bleomycin dose, cancer type, type of study, and pulmonary function test with BPT incidence.

CONCLUSION

This systematic review and meta-analysis showed that co-administration of CSF with bleomycin increases the incidence of BPT. The physicians need to consider this finding while deciding the best strategy for this cohort of patients.

Individualized treatment of breast cancer with chronic renal failure: A case report and review of literature

BACKGROUND

Studies have shown that patients with chronic renal failure (CRF) are more likely to suffer from breast cancer and other malignant tumors. To our knowledge, CRF can reduce drug excretion, thereby increase drug exposure and lead to increased toxicity, which will limit drug treatment and lead to tumor progression. Currently, there are few successful reports on the combination of docetaxel, trastuzumab, and pertuzumab (THP) as a neoadjuvant treatment regimen for breast cancer patients with CRF.

CASE SUMMARY

We report a breast cancer (cT2N2M0, Her-2+/HR-) patient with CRF. It was a clinical stage IIIA tumor on the left breast. The patient had suffered from uremia for 2 years, and her heart function was normal. Based on the pathological type, molecular type, and clinical stage of breast cancer, and the patient’s renal function, the clinician analyzed the pharmacological and pharmacokinetic characteristics of the antitumor drugs after consulting the relevant literature, and prescribed the neoadjuvant regimen of THP (docetaxel 80 mg/m², trastuzumab 8 mg/kg for the first dose, and 6 mg/kg for the maintenance dose with pertuzumab 840 mg for the first dose and 420 mg for the maintenance dose), once every 3 wk, for a total of 6 courses. The neoadjuvant treatment had a good effect, and the patient then underwent surgery which was uneventful.

CONCLUSION

CRF is not a contraindication for systemic treatment and surgery of breast cancer. The THP regimen without dose adjustment may be a safe and effective neoadjuvant treatment for HER-2 positive breast cancer patients with CRF.

Limitations of Systemic Oncological Therapy in Breast Cancer Patients with Chronic Kidney Disease

Breast cancer is the most common malignancy, affecting middle-age and older women frequently suffering from other chronic diseases, including chronic kidney disease. The risk of breast cancer development in women on renal replacement therapy (peritoneal dialysis and haemodialysis) is higher than in the general population. Chronic kidney disease does not limit surgical treatment or radiotherapy; however, it affects the pharmacokinetics of drugs used in the systematic treatment to a different extent, increasing their toxicity and the risk of adverse drug reactions. This article summarizes the current knowledge (published studies accessed through PUBMED) on drugs used in chemotherapy, hormone therapy, anti-HER2 drugs, CDK4/6 inhibitors, PARP inhibitors, and immune therapy in breast cancer patients undergoing dialysis. We discuss the data, the optimal choice of the chemotherapeutic protocol, and the administration of drugs in a specific time relation to the haemodialysis session to ensure the most effective and safe treatment to breast cancer patients.

Decreased Disposition of Anticancer Drugs Predominantly Eliminated via the Liver in Patients with Renal Failure

Background:

Evidence has revealed that renal impairment can affect the systemic exposure of drugs which are predominantly eliminated via the liver. The modulation of drug-metabolizing enzymes and transporters expressed in the liver and/or small intestine by diverse entities, including uremic toxins, in systemic circulation of patients with severe renal failure is considered as the cause of atypical pharmacokinetics, which sometimes induce undesirable adverse events that are especially critical for drugs with narrow therapeutic window such as anticancer drugs. A dosing strategy for anticancer drugs in these patients needs to be established.

Methods:

The effects of renal impairment on the systemic exposure and safety of anticancer drugs were summarized. The proposed mechanisms for the alterations in the pharmacokinetics of these anticancer drugs were also discussed.

Results:

Changes in pharmacokinetics and clinical response were reported in 9 out of 10 cytotoxic anticancer drugs investigated, although available information was limited and sometimes controversial. Systemic exposure of 3 out of 16 tyrosine kinase inhibitors was higher in patients with severe renal failure than that in patients with normal kidney function. An increase in systemic exposure of anticancer drugs in patients with renal impairment is likely to be observed for substrates of OATP1B1, despite the limited evidence.

Conclusion:

The molecular basis for the effect of uremia on non-renal drug elimination still needed to be clarified with further studies to generate generalizable concepts, which may provide insights into establishing better clinical usage of anticancer drugs, i.e. identifying patients at risk and dose adjustment.

Retrospective cohort study on the safety and efficacy of docetaxel in Japanese non-small cell lung cancer patients with nondialysis chronic kidney disease stage 3b or higher

Background

It has been reported that 20% of lung cancer patients have renal impairment caused by chronic kidney disease (CKD). Since docetaxel is predominantly excreted by the hepatobiliary system, it is administered to non‐small cell lung cancer (NSCLC) patients with renal impairment. However, few clinical data are available on the toxicity and efficacy of docetaxel for patients with nondialysis renal impairment. Furthermore, some cases of tubular nephrotoxicity caused by docetaxel in NSCLC patients have been reported. Therefore, a retrospective cohort study was conducted to assess the influence of nondialysis CKD on the toxicity and efficacy of docetaxel in NSCLC patients.

Methods

NSCLC patients who received docetaxel were assessed for renal function, occurrence of adverse events and treatment efficacy.

Results

A total of 34 NSCLC patients who received docetaxel were studied. Eight (23.5%) patients had nondialysis CKD stage 3b or higher, with an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m². Although the differences were not statistically significant, the starting dose of docetaxel (mg/m²) was lower (60 mg/m²; 37.5% vs. 69.2%) in patients with an eGFR <45 than that in patients with an eGFR ≥45. No significant association was observed between pretreatment eGFR and hematological and nonhematological toxicities. No significant difference was observed in the disease control rate (62.5% vs. 65.4%, P = 1.000) or in the median overall survival (10.7 vs. 11.7, P = 0.735) between patients with an eGFR <45 and those with an eGFR ≥45.

Conclusion

Docetaxel is a reasonable option for NSCLC patients with nondialysis CKD stage 3b or higher. Dose reduction of docetaxel is also a possibility for NSCLC patients with CKD stage 3b or higher.

Individualized Treatment Analysis Of Breast Cancer With Chronic Renal Failure

We report the case of a breast cancer patient with chronic renal failure (CRF). The clinical pharmacist adjusted the chemotherapy regimen and dosage according to the patient’s renal function after reviewing the literature and analyzing the pharmacological and pharmacokinetic characteristics of the patient’s antineoplastic drugs. To the best of our knowledge, this is the first report of successful multimodal treatment of breast cancer in a patient with CRF in China. The purpose of this case report is to optimize breast cancer therapy in patients with CRF and provide a reference for clinicians and clinical pharmacists to use antineoplastic drugs rationally.

Clinical Pharmacokinetics in Kidney Disease: Fundamental Principles

Kidney disease is an increasingly common comorbidity that alters the pharmacokinetics of many drugs. Prescribing to patients with kidney disease requires knowledge about the drug, the extent of the patient's altered physiology, and pharmacokinetic principles that influence the design of dosing regimens. There are multiple physiologic effects of impaired kidney function, and the extent to which they occur in an individual at any given time can be difficult to define. Although some guidelines are available for dosing in kidney disease, they may be on the basis of limited data or not widely applicable, and therefore, an understanding of pharmacokinetic principles and how to apply them is important to the practicing clinician. Whether kidney disease is acute or chronic, drug clearance decreases, and the volume of distribution may remain the same or increase. Although in CKD, these changes progress relatively slowly, they are dynamic in AKI, and recovery is possible depending on the etiology and treatments. This, and the use of kidney replacement therapies further complicate attempts to quantify drug clearance at the time of prescribing and dosing in AKI. The required change in the dosing regimen can be estimated or even quantitated in certain instances through the application of pharmacokinetic principles to guide rational drug dosing. This offers an opportunity to provide personalized medical care and minimizes adverse drug events from either under- or overdosing. We discuss the principles of pharmacokinetics that are fundamental for the design of an appropriate dosing regimen in this review.

Confounder factors masking a Leydig-cell ovarian tumor in a post-menopausal woman treated for androgen-positive receptor breast cancer

Post-menopause hyperandrogenism is a condition that needs careful evaluation. Aromatase inhibitors (AI), which are important in the management of positive estrogen breast cancer, and chronic kidney disease (CKD) can puzzle the evaluation of this condition. A postmenopause female with type-2 diabetes and advanced CKD was attended due to progressive virilization, which has started after the introduction of an AI for breast cancer 5 years earlier. Clinical and radiological investigation has confirmed a pure Leydig cell tumor as source of hyperandrogenism. Re-evaluation of the breast tumor immunohistochemistry has shown positive androgen receptor expression and negative expression for estrogen, progesterone and HER-2 receptors. Even though an ovarian tumor was the source of androgen excess, we discuss that AI could exert a slight contribution to patient's virilization by reducing estradiol counterbalance. Also, although the onset of hyperandrogenic symptoms was unclear, we could not exclude that the ovarian tumor had produced enough androgens to play a role in breast tumor progression. This case report supports the literature regarding the possible association between Leydig cell tumor and androgen-receptor-positive breast cancer development. Finally, progressive hyperandrogenic symptoms in postmenopause, even under AI therapy or the presence of advanced CKD, impose a more detailed investigation.

Anticancer Dose Adjustment for Patients with Renal and Hepatic Dysfunction: From Scientific Evidence to Clinical Application

Most anticancer agents exhibit a narrow therapeutic index, i.e., a small change in plasma concentrations can lead to a less efficacious treatment or an unacceptable degree of toxicity. This study aimed at providing health professionals with a feasible and time-saving tool to adapt the dose of anticancer agents for patients with renal or hepatic dysfunction. A guideline for anticancer agents was developed based on a literature search. An algorithm was generated to enhance the efficiency of the dose adaptation process. Finally, the dosing guideline was converted into an easy-to-use Excel^TM tool. The concept was applied to a total of 105 adult patients at the Centre for Integrated Oncology, Bonn, Germany. In total, 392 recommendations for dose adaptation were made and 320 (81.6%) recommendations were responded to by the oncologists. 98.4% of the recommendations were accepted. The algorithm simplifies the decision and screening process for high-risk patients. Moreover, it provides the possibility to quickly decide which laboratory tests are required and whether a dose adjustment for a particular anticancer drug is needed. The Excel^TM tool provides a recommended individual dose for patients with renal or hepatic dysfunction. The effectiveness of this strategy to reduce toxicity should be investigated in further studies before being adopted for routine use.

Drug interactions with aprepitant or fosaprepitant: Review of literature and implications for clinical practice

Purpose Aprepitant and its parenteral formulation fosaprepitant are widely used for the prevention of chemotherapy-induced nausea and vomiting. Aprepitant exerts modest inhibitory effect on CYP3A4 and modest inductive effect on CYP2C9 substrates such as some antineoplastics and multiple other medications. This article is aimed to provide pharmacists and other healthcare professionals with an updated summary of drug-drug interactions of aprepitant/fosaprepitant and implications for clinical practice. Method We reviewed publications reporting drug-drug interactions between aprepitant/fosaprepitant and other medications. Results Coadministration of aprepitant with antineoplastics or opiods may result in significant elevations in the serum levels of the agents metabolized via CYP3A4, with the best documentation for cyclophosphamide, ifosfamide, erlotinib and oxycodone. These alterations did not translate into adverse outcomes and/or necessitate dosing adjustments. The levels of warfarin were significantly decreased by aprepitant requiring prolonged monitoring after discontinuation of aprepitant. Among direct oral anticoagulants, a theoretical interaction between aprepitant and rivaroxaban or apixaban exists. Interactions between aprepitant and quetiapine or diltiazem or sirolimus required dose reductions to avoid adverse outcomes. The intravenous route had a weaker inhibitory effect on CYP3A4 than the oral pathway. Conclusion The evidence on drug interactions of aprepitant with other medications is limited, and the impact on therapeutic outcomes remains to be determined. The intravenous regimen may be a preferred option. As utilization of aprepitant is expanding, practitioners and patients need to be educated about the potential for drug interactions and a need for careful monitoring of patients concurrently receiving aprepitant and CYP2C9 or CYP3A4 substrates, especially those with a narrow therapeutic window.

Irinotecan and Carboplatin (IC) Regimen for Small-Cell Lung Cancer and Non-Small-Cell Lung Cancer

The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy, and the agents, both commercially available and investigational, used to treat malignant diseases. Questions or suggestions for topics should be addressed to Dominic A. Solimando, Jr, President, Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203, e-mail: OncRxSvc@comcast.net; or J. Aubrey Waddell, Professor, University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804, e-mail: waddfour@charter.net.

Management of anticancer treatment in patients under chronic dialysis: results of the multicentric CANDY (CANcer and DialYsis) study

BACKGROUND

One million people worldwide benefit from chronic dialysis, with an increased rate in Western countries of 5% yearly. Owing to increased incidence of cancer in dialyzed patients, the management of these patients is challenging for oncologists/nephrologists.

PATIENTS AND METHODS

The CANcer and DialYsis (CANDY) retrospective multicenter study included patients under chronic dialysis who subsequently had a cancer (T0). Patients were followed up for 2 years after T0. Prescriptions of anticancer drugs were studied with regard to their renal dosage adjustment/dialysability.

RESULTS

A total of 178 patients from 12 institutions were included. The mean time between initiation of dialysis and T0 was 30.8 months. Fifty patients had received anticancer drug treatment. Among them, 72% and 82% received at least one drug needing dosage and one drug to be administered after dialysis sessions, respectively. Chemotherapy was omitted or prematurely stopped in many cases where systemic treatment was indicated or was often not adequately prescribed.

CONCLUSIONS

Survival in dialysis patients with incident cancer was poor. It is crucial to consider anticancer drug treatment in these patients as for non-dialysis patients and to use current available specific drug management recommendations in order to (i) adjust the dose and (ii) avoid premature elimination of the drug during dialysis sessions.

Baseline blood work before initiation of chemotherapy: what is safe in the real world?

INTRODUCTION

This is an observational study of patterns of practice of the timing of baseline blood work (BBW) before chemotherapy initiation. The primary objective was to evaluate the incidence of significant changes in laboratory values within 6 weeks before therapy.

METHODS

All consecutive patients receiving chemotherapy within a 6-month period were analyzed retrospectively. Time interval between date of chemotherapy initiation and nearest blood work was calculated. Data from patients with one or more sets of values within 6 weeks were used to evaluate dosing changes. Changes in laboratory values collected closest to the date of chemotherapy and values collected before that but within 6 weeks were graded according to the National Cancer Institute's Common Toxicity Criteria. A change of ≥1 grade was considered clinically meaningful.

RESULTS

Five hundred ninety-two patients were included. Median interval between BBW and initiation of chemotherapy was 4 days. Three hundred thirty-five patients had two or more sets of laboratory tests within the 6-week period, 33% of patients had a meaningful change in one or more values. The majority of changes occurred in hemoglobin (22%), ALT (14%), WBC (11%) and AST(10%), yet only 66% of patients had liver function tests as part of the BBW.

CONCLUSIONS

Adherence to the institutional recommendation of BBW within 6 weeks was high. Baseline laboratory tests performed within 7 days of chemotherapy initiation would have detected nearly all significant changes; therefore, we suggest that this interval be tested in future randomized trials.

[Pharmacotherapy in patients suffering from chronic kidney disease]

The number of patients suffering from chronic kidney disease (CKD) is increasing worldwide and exceeds 15% of the entire population in industrialized countries. Half of the patients aged 70 + years suffer from CKD. The most prevalent underlying diseases leading to CKD are diabetes and hypertension. CKD per se increases the risk of cardiovascular events, cancer, and infections; hence, adequate and intensified pharmacotherapy is of utmost importance in this patient population. About 60% of all regularly used drugs are excreted by the kidney. For those, dose adjustment is of utter importance to avoid untoward effects and serious complications. The first important step for dose adjustment is the accurate estimation of renal function, i.e., glomerular filtration rate (GFR). Renal function cannot be assessed by serum creatinine alone as it only rises after a substantial (> 50%) loss of glomerular function and depends on many factors, e.g., age, gender, weight, and race. GFR can easily be estimated using formulas, e.g., the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.

[Management of chemotherapy in hemodialysis patients]

BACKGROUND

The increased incidence of cancer in dialysis patients has been discussed since the mid-70s. Consequently, oncologists, nephrologists and pharmacists are increasingly facing challenging situations of cytotoxic drug handling in dialysis patients. In dialysis patients, two main issues must be considered. First, renal function of hemodialysis (HD) patients is no longer functional. Therefore, these patients may necessitate drug dosage reduction, namely drug prescription, must be cautiously checked before administration with appropriate dosage adjustment whenever necessary to ensure efficacy while avoiding overdosage and related side effects. Secondly, drug clearance by dialysis must be taken into account for appropriate chemotherapy timing in order to avoid drug removal, which may result in a loss of efficacy.

METHODS

We reviewed the international literature on the pharmacokinetics, efficacy, tolerance and dosage adjustment of anticancer drugs used on hemodialysis cancer patients, using the key words: kidney, renal, dialysis, hemodialysis, end-stage renal disease and the name of each drug.

RESULTS

Only case reports and small series were found. 57.1% of the drugs need dosage adjustment and 64.3% should be administered after the dialysis session.

CONCLUSION

Cancer treatment in feasible in dialysis patients. Some drugs require dosage adaptation while others can be given as in patients with normal kidney function. These patients need coordinated care between oncologists, nephrologists and pharmacists to optimize drug delivery and logistics. Frailty scores, like in oncogeriatrics, should be built to optimally adapt cancer treatments in these dialysis patients.

Evaluation of current practice: management of chemotherapy-related toxicities

Adverse effects induced by cytotoxic chemotherapy (CT) have been mostly evaluated in clinical trials. The aim of this study was to assess in a nonselected patients group the incidence of CT-related toxicities and to identify risk factors in daily practice. Patients treated with CT (except cisplatin-based or carboplatin-based CT), for a solid tumour, were included in a prospective multicentre observational study. Clinical parameters, renal function and albumin level were assessed at baseline. Multivariate logistic regression was used to identify risk factors of CT-related toxicities. A total of 502 patients were recruited in different types of oncology departments. During CT, 62% of patients experienced grade 2-4 toxicities. Haematological toxicities affected 34% of patients and 20% of patients developed an infection requiring antibiotics. For 55% of patients, toxicities induced dose reduction (59% of cases), CT delay (25%) or discontinuation (16%) according to the management habits in the investigating centre. Performance status≥1, breast cancer, lymphopenia, hypoalbuminaemia and clearance creatinine<60 ml/min were risk factors for haematological toxicity. Performance status≥1, hypoalbuminaemia, proteinuria and clearance creatinine<90 ml/min were risk factors for change of CT schedule. A majority of patients receiving CT experienced significant toxicity leading to change of standard CT protocol. Albumin, creatinine clearance and lymphocyte should be routinely monitored at baseline to manage CT and to prevent their toxicities.

A Modified Shortened Administration Schedule for Neoadjuvant Chemotherapy With Irinotecan and Cisplatin in Locally Advanced Cervical Cancer

Introduction:

The commonly used administration schedule of irinotecan in combination therapy with cisplatin in cervical cancer was once weekly for 3 weeks. To some extent, this administration schedule may be inconvenient for patients who were far from hospital. The aim of the current study is to investigate the efficacy and toxicities of a modified shortened administration schedule for neoadjuvant chemotherapy with irinotecan and cisplatin in locally advanced cervical cancer.

Methods:

We retrospectively reviewed the clinical records of patients with cervical cancer who received neoadjuvant chemotherapy with irinotecan and cisplatin delivered by the modified administration schedule at Sun Yat-sen University Cancer Center from November 2005 to May 2010. Irinotecan was administrated by intravenous infusion for 1 hour at a dose of 80 mg/m2on days 1 and 8. Cisplatin was administrated intravenously at a total dose of 60 to 70 mg/m2, which was infused on day 1 or was divided into 2 or 3 doses and given on days 1 to 2 or 3. The treatment was repeated every 3 weeks.

Results:

The total response rate was 78.8% (42/52), including a complete response and partial response rate of 11.5% (6/52) and 67.3% (35/52), respectively. Pathologically confirmed complete response was noted in 7.7% (4/52) of patients. Stable disease was observed in 17.3% (9/52) of patients and progression disease in 3.8% (2/52) of patients. Diarrhea and hematological toxicity were the major dose-limiting toxicities. Diarrhea occurred in 23.1% of patients with grades 1, 2, and 3 in 11.5%, 7.7%, and 3.8% of patients, respectively. No grade 4 diarrhea was noted. Grade 3/4 neutropenia developed in 7.7% (4/52) of patients. Grade 3/4 anemia occurred in 19.2% (10/52) of patients.

Conclusions:

The modified shortened administration schedule of combined therapy with irinotecan and cisplatin may be active against cervical cancer as neoadjuvant chemotherapy. The adverse effects could be controllable.

Nephrotic syndrome and renal failure in a patient with metastatic breast cancer

This report presents a case of nephrotic syndrome and renal failure that developed in a 53-year-old female with metastatic breast carcinoma. She was diagnosed to have osteolytic bone metastases 5 years prior to admission, and had been administered pamidronate with a total dose of approximately 6800 mg. A renal biopsy revealed tubulointerstitial damage and marked wrinkling and retraction of the glomerular basement membrane with hypertrophy and hyperplasia of the epithelial cells, compatible with the collapsing form of focal segmental glomerulosclerosis (FSGS). Despite the discontinuation of pamidronate after admission, her renal function gradually decreased. She was finally managed with continuous palliative care for advanced malignancy through a shared effort, and died 96 days after undergoing the renal biopsy. Although the clinical impact of the pamidronate-associated kidney injury on the longitudinal changes in renal function remains to be delineated, it is therefore reasonable to consider that the collapsing FSGS associated with tubulointerstitial damage may have resulted in the irreversible renal injuries that were observed in the current case. Further studies and accumulated experience with renal biopsy are required to better determine the relationship between pathological alterations and prognostic characteristics among patients with pamidronate-associated renal impairments.

Drug therapy in patients with chronic renal failure

BACKGROUND

Roughly 20% of patients in hospital have impaired kidney function. This is frequently overlooked because of the creatinine-blind range in which early stages of renal failure are often hidden. Chronic kidney disease is divided into 5 stages (CKD 1 to 5).

METHODS

Selective literature search.

RESULTS

Methotrexate, enoxaparin and metformin are examples of drugs that should no longer be prescribed if the glomerular filtration rate (GFR) is 60 mL/min or less. With antidiabetic (e.g. glibenclamide), cardiovascular (e.g. atenolol) or anticonvulsive (e.g. gabapentin) drugs, the advice is to use alternative preparations such as gliquidone, metoprolol or carbamazepine which are independent of kidney function. Drug dose adjustment should be considered with antimicrobial (e.g. ampicillin, cefazolin), antiviral (e.g. aciclovir, oseltamivir) and, most recently, also for half of all chemotherapeutic and cytotoxic drugs in patients with impaired kidney function (with e.g. cisplatin, for instance, but not with paclitaxel).

CONCLUSION

Decisions concerning drug dose adjustment must be based on the pharmacokinetics but this is an adequate prerequisite only in conjunction with the pharmacodynamics. There are two different dose adjustment rules: proportional dose reduction according to Luzius Dettli, and the half dosage rule according to Calvin Kunin. The latter leads to higher trough concentrations but is probably more efficient for anti-infective therapy.

[Questionnaire surveying nephrologists on drug dose adjustment in patients with impaired kidney function]

OBJECTIVE

Our intention was to assess knowledge and requirements related to drug dose adjustment in patients with impaired kidney function.

METHOD

In 2005, we sent a questionnaire containing 22 questions to nephrologists in Germany and Austria. With 77 responses, the study was not representative. However, it was probably of importance for the target group of practising physicians and potential users of a future drug information system.

RESULTS

Only 28% of the responding colleagues use the package inserts; these are obviously not considered to be an obligatory guideline for dose adjustment. The most common dosing problems (p < 0.05) were associated with anti-infective (48%) and anti-cancer drugs (25%). The greatest problems with dosing were encountered within intensive care units (29%). The risk of excessive dosing is estimated significantly more serious than the risk of underdosing (51% vs. 23%, p = 0.02). There was support for the statement that for cephalosporin antibiotics the trough levels are more important than peak levels (58% vs. 27%, p < 0.01). However, only 8% knew that in patients with impaired kidney function, trough concentrations of aminoglycosides and vancomycin need to be higher than in patients with normal kidney function for adequate peak levels to be obtained. Forty-five percent of respondents erroneously presumed that ceftriaxone must be adjusted to the kidney function. Half of the respondents were incorrect in assuming that ceftriaxone or moxifloxacin would be removed by dialysis.

CONCLUSIONS

We see the need for more knowledge-based information on drug dosing in patients with kidney impairment and those in the intensive care unit. The risk to life posed by underdosage might be underestimated, especially for anti-infective drugs.

Uridine 5'-diphospho-glucuronosyltransferase genetic polymorphisms and response to cancer chemotherapy

Pharmacogenetics aims to elucidate how genetic variation affects the efficacy and side effects of drugs, with the ultimate goal of personalizing medicine. Clinical studies of the genetic variation in the uridine 5'-diphosphoglucuronosyltransferase gene have demonstrated how reduced-function allele variants can predict the risk of severe toxicity and help identify cancer patients who could benefit from reduced-dose schedules or alternative chemotherapy. Candidate polymorphisms have also been identified in vitro, although the functional consequences of these variants still need to be tested in the clinical setting. Future approaches in uridine 5'-diphosphoglucuronosyltransferase pharmacogenetics include genetic testing prior to drug treatment, genotype-directed dose-escalation studies, study of genetic variation at the haplotype level and genome-wide studies.

Proposal for dosage adjustment and timing of chemotherapy in hemodialyzed patients

BACKGROUND

The increased incidence of malignancies in patients with chronic renal failure has been discussed since the mid-70s. On the other hand, the high frequency of chronic renal insufficiency among cancer patients has been recently assessed in the Insuffisance Rénale et Médicaments Anticancéreux Study which demonstrated a prevalence as high as 50%-60% of the patients for all stages of kidney disease. Furthermore, the incidence of end-stage renal disease is growing worldwide and so is the number of patients on chronic dialysis, hemodialysis (HD) for the large majority of them. As a result, the question of cytotoxic drug handling in those patients in terms of dosage adjustment and time of administration regarding the dialysis sessions needs to be addressed to optimize cytotoxic drug therapy in those patients.

METHODS

We reviewed the international literature on the pharmacokinetics, efficacy, tolerance and dosage adjustment of cytotoxic drugs used to treat solid tumor patients and when available, specific literature on HD cancer patients.

RESULTS

From these data, dosing recommendations are given for the most prescribed cytotoxic drugs in clinical practice.

CONCLUSIONS

Dosage adjustments are often necessary in HD cancer patients. These adaptations have to be carefully carried out to optimize drug exposure, ensure efficacy and reduce the risk of side-effects.

Children's toxicology from bench to bed--Drug-induced renal injury (2): Nephrotoxicity induced by cisplatin and ifosfamide in children

Cisplatin and carboplatin cause dose-dependent renal dysfunction. Electrolyte abnormalities such as hypomagnesaemia and hypokalemia are commonly reported adverse effects, in addition to increased serum creatinine and uremia. Cumulative dose, dehydration, hypoalbuminemia, and concurrent use of nephrotoxic drugs have been suggested as risk factors for cisplatin nephrotoxicity. The adverse effects of ifosfamide include proximal tubular damage, and renal wasting of electrolytes, glucose and amino acids, Fanconi syndrome, rickets and osteomalacia have also been reported with ifosfamide treatment. Risk factors for ifosfamide nephrotoxicity include the cumulative dose, young age, previous or concurrent cisplatin treatment, and unilateral nephrectomy. Ifosfamide/Carboplatin/Etoposide (ICE) combination therapy induces hypouricemia, which frequently includes renal wasting of electrolytes, and persistent hypouricemia has been observed in recurrent or chemotherapy-resistant patients. We retrospectively examined the incidence of hypouricemia and clinical findings in pediatric patients treated with an ICE regimen. Twenty of 28 (71.4%) pediatric patients had hypouricemia. The duration of hypouricemia was longer in the non-remission subgroup of patients, which suggests that hypouricemia may be a predictive marker for prognosis of malignant disease and efficacy of drugs such as ifosfamide, carboplatin and cisplatin. Nephrotoxicity induced by these drugs may also be more common in pediatric patients than in adults, but it is unclear why a young age is a risk factor and further research is required regarding the mechanism of antineoplastic drug induced-nephrotoxicity in children.

Dose individualization can minimize nephrotoxicity due to carboplatin therapy in patients with ovarian cancer

Carboplatin (Carbo-Pt), an alkylating agent cleared from the plasma through glomerular filtration, is commonly used for the treatment of ovarian cancer. When administered at high dosage or to patients with reduced renal function, Carbo-Pt may be nephrotoxic. The dose of Carbo-Pt is calculated with Calvert formula, using the value of 24-hour creatinine clearance (24h Ccr) as an estimate of glomerular filtration rate (GFR). The aim of this study was to evaluate the possibility of individualizing the dose of Carbo-Pt using an alternative method to estimate GFR, based on body composition analysis, and then to assess the nephrotoxicity of Carbo-Pt therapy individualized with this new method. First, we evaluated the agreement between GFR (renal clearance of diethylene triamine pentaacetic acid (99mTc-DTPA)), 24h Ccr, and the new estimate of GFR (BCMGFR) calculated on the basis of individual values of body cell mass (BCM) and plasma creatinine. BCMGFR gave a better estimate of GFR than 24h Ccr. Then, we evaluated the nephrotoxicity of a combination chemotherapy based on Carbo-Pt (AUC(5-6)) in 23 patients affected by ovarian cancer. The dose of Carbo-Pt was adjusted to residual renal function of patients, evaluated as BCMGFR. No case of acute renal failure was observed with this treatment regimen. Urinary excretion of proteins (albumin, beta2-microglobulin, and retinol-binding protein) and tubular enzymes, measured as markers of tubular damage, increased significantly and transiently only in the first days after chemotherapy, whereas no evidence of chronic nephrotoxic effect was documented. Dose individualization, using the value of BCMGFR, may minimize nephrotoxicity due to Carbo-Pt therapy.

Renal function as a predictor of irinotecan-induced neutropenia

Although approximately half of the administered dose of irinotecan is recovered in urine, scarce data are available on the association of renal function with irinotecan pharmacokinetics and toxicity. Here, these relationships are investigated in 187 patients treated with irinotecan in a three-weekly schedule. No significant effects on irinotecan pharmacokinetics were found in these patients. However, in 131 patients treated with the registered dose, categorized renal function was related to hematological toxicity. The incidence of grade 3-4 neutropenia decreased as function of creatinine clearance, particularly in nonsmoking patients (P < 0.01). Patients with slower creatinine clearance (35-66 ml/min) had a four-times higher risk of grade 3-4 neutropenia (58% vs. 14%; P < 0.001). This study suggests that pretreatment renal function values are associated with irinotecan-induced neutropenia. A confirmatory analysis is warranted to determine whether measures of renal function should be incorporated in future attempts toward individualized treatment with irinotecan.

Continuous ambulatory peritoneal dialysis: pharmacokinetics and clinical outcome of paclitaxel and carboplatin treatment

Purpose

Administration of chemotherapy in patients with renal failure, treated with hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) is still a challenge and literature data is scarce. Here we present a case study of a patient on CAPD, treated with weekly and three-weekly paclitaxel/carboplatin for recurrent ovarian cancer.

Experimental

During the first, second and ninth cycle of treatment, blood, urine and CAPD samples were collected for pharmacokinetic analysis of paclitaxel and total and unbound carboplatin-derived platinum.

Results

Treatment was well tolerated by the patient. No excessive toxicity was observed and at the end of treatment she was in a complete remission. The plasma pharmacokinetics of paclitaxel were unaltered compared to historical data, with neglectable urinary and CAPD clearance. In contrast, the pharmacokinetics of carboplatin were altered, with doubled half-lives compared to patients with normal renal function. Of the administered carboplatin dose, up to 20% was cleared via the dialysate, while only up to 8% was cleared via the urine.

Conclusion

Paclitaxel and carboplatin can be safely administered to patients with chronic renal failure on CAPD. For paclitaxel the generally applied dose can be administered, and although for carboplatin dose-adjustment is required due to the diminished renal function, the dose can be calculated using Calvert’s formula.

Pegylated liposomal doxorubicin treatment in recurrent gynecologic cancer patients with renal dysfunction

OBJECTIVES

A paucity of data exists regarding the efficacy and toxicity of pegylated liposomal doxorubicin (PLD) in cancer patients with chronic kidney disease (CKD). We sought to investigate the toxicity and efficacy of PLD in gynecologic cancer patients with CKD.

METHODS

The clinical records of all patients with recurrent gynecological cancer and CKD at the University of Texas M.D. Anderson Cancer Center from 08/1999 to 08/2006 were reviewed retrospectively to identify patients who received PLD.

RESULTS

Twenty-eight patients were identified, which included 14 with epithelial ovarian cancer, 4 with peritoneal cancer, and 10 with other gynecologic cancers. CKD was defined as a creatinine clearance (CrCl) of <90 ml/min/1.73 m(2) and classified as mild (5 patients), moderate (16 patients), or severe (7 patients) (CrCl 60-89, 30-59, and <30 ml/min/1.73 m(2), respectively). The initial doses of PLD were classified into regular initial dose (40 mg/m(2)/4 weeks) and lower initial dose (30-35 mg/m(2)/4 weeks). The median cycle was 4.5 (range 1-17). The incidence of grade 3-4 palmar-plantar erythrodysesthesia, stomatitis, and hematologic toxicity was 11.1% (2/18), 5.6% (1/18), and 16.7% (3/18) among 18 patients with an initial dose of 40 mg/m(2)/4 weeks, which included 5, 10, and 3 patients with mild, moderate, and severe CKD, respectively. Dose reduction due to toxicities occurred in 33.3% (6/18) patients. In 18 patients with ovarian and peritoneal cancer (all platinum-resistant), the rates of complete response, partial response, stable disease, and progression were 0%, 11.1%, 44.4%, and 44.4%, respectively.

CONCLUSIONS

Patients with CKD who received PLD therapy at an initial dose of 40 mg/m(2)/4 weeks may require greater subsequent dose reduction mainly secondary to mucocutaneous and hematologic toxicities. Treatment response in this population with ovarian and peritoneal cancer was similar to that of patients with normal renal function.