High-dose intensity systemic therapy of metastatic bladder cancer

A review for the impacts of circadian disturbance on urological cancers

Circadian rhythm is an internal timing system and harmonizes a variety of cellular, behavioral, and physiological processes to daily environment. Circadian disturbance caused by altered life style or disrupted sleep patterns inevitably contributes to various disorders. As the rapidly increased cancer occurrences and subsequent tremendous financial burdens, more researches focus on reducing the morbidity rather than treating it. Recently, many epidemiologic studies demonstrated that circadian disturbance was tightly related to the occurrence and development of cancers. For urinary system, numerous clinical researches observed the incidence and progress of prostate cancer were influenced by nightshift work, sleep duration, chronotypes, light exposure, and meal timing, this was also proved by many genetic and fundamental findings. Although the epidemiological studies regarding the relationship between circadian disturbance and kidney/bladder cancers were relative limited, some basic researches still claimed circadian disruption was closely correlated to these two cancers. The role of circadian chemotherapy on cancers of prostate, kidney, and bladder were also explored, however, it has not been regularly recommended considering the limited evidence and poor standard protocols. Finally, the researches for the impacts of circadian disturbance on cancers of adrenal gland, penis, testis were not found at present. In general, a better understanding the relationship between circadian disturbance and urological cancers might help to provide more scientific work schedules and rational lifestyles which finally saving health resource by reducing urological tumorigenesis, however, the underlying mechanisms are complex which need further exploration.

Circadian chemotherapy for gynecological and genitourinary cancers

The circadian timing of surgery, anticancer drugs, radiation therapy, and biologic agents can result in improved toxicity profiles, tumor control, and host survival. Optimally timed cancer chemotherapy with doxorubicin or pirarubicin (06:00h) and cisplatin (18:00h) enhanced the control of advanced ovarian cancer while minimizing side effects, and increased the response rate in metastatic endometrial cancer. Therapy of metastatic bladder cancer with doxorubicin-cisplatin was made more tolerable by this same circadian approach resulting in a 57% objective response rate. This optimally timed therapy is also effective in the adjuvant setting, decreasing the expected frequency of metastasis from locally advanced bladder cancer. Circadian fluorodeoxyuridine (FUDR) continuous infusion (70% of the daily dose given between 15:00h and 21:00h) has been shown effective for metastatic renal cell carcinoma resulting in 29% objective response and stable disease of more than 1 yr duration in the majority of patients. Toxicity is reduced markedly when FUDR infusion is modulated to circadian rhythms. In a multicenter trial in patients with metastatic renal cell cancer, patients were randomized to a flat or a circadian-modified FUDR infusion. This study confirmed a significant difference in toxicity and dose intensity, favoring the circadian-modified group. Hormone refractory metastatic prostate cancer has been treated with circadian-timed FUDR chemotherapy; however, without objective response. Biological agents such as interferon-alpha and IL-2 have shown low but effective disease control in metastatic renal cell cancer, however, with much toxicity. Each of these cytokines shows circadian stage dependent toxicity and efficacy in model systems. In summary, the timing of anthracycline, platinum, and fluoropyrimidine-based drug therapies during the 24h is relevant to the toxic therapeutic ratio of these agents in the treatment of gynecologic and genitourinary cancers.

Renal tolerance to cisplatin in patients 70 years and older

The purpose of this study was to evaluate cisplatin nephrotoxicity in patients 70 years and older and to identify factors influencing nephrotoxicity occurrence. Forty-nine (N = 49) patients older than 70 years were studied retrospectively. All patients received treatment with cisplatin. Variables under study were as follows: prechemotherapy serum creatinine levels (Crb), maximum serum creatinine level during treatment (Crmax), steady serum creatinine level 3 months after treatment completion (Crstb), as well as their corresponding creatinine clearance values (CrbC, CrmaxC, CrstbC) as calculated by the Cockroft and Gault formula. Maximum creatinine increment (Imax = Crmax - Crb), stable creatinine increment (Istb = Crstb - Crb) and the corresponding clearance decrements (Dmax and Dstb) were calculated as well. The potential relationship of the above variables to cisplatin dose intensity and accumulated dose as well as to different prognostic factors were also considered. Assessment of associated conditions was carried out by means of Charlson comorbidity index. The patients' mean age was 73 years (range: 70-79 years). There were 43 men (88%) and 6 women (12%). Mean cisplatin dose intensity was 27 mg/m2/wk. A total of 157 chemotherapy courses were administered with a mean of 3.2 per patient. Mean Crb was 1.02 mg/dl (95% CI = 1.02-1.12), mean Crmax was 1.45 (95% CI = 1.34-1.46), and mean Crstb was 1.24 (95% CI = 1.16-1.32). Imax was equal to 0 in 13 patients (26%) and more than 0.4 mg/dl in 21 patients (43%). Istb was equal to 0 or negative in 22 (45%) and more than 0.4 in only 9 patients (18.3%). No significant relationship of serum creatinine levels, creatinine clearance levels, or of their increments or decrements to cisplatin dose intensity or accumulated dose were found. These levels also did not correlate with age, sex, comorbidity or Eastern Cooperative Oncology Group score. In 85% of patients, Crmax was reached between chemotherapy initiation and the third chemotherapy course, and thereafter renal function began to recover despite continued administration of cisplatin. Cisplatin is well tolerated by patients 70 years and older and dose intensity does not seem to influence renal function deterioration. Therefore, we failed to find reasons to encourage modification or limitation of cisplatin treatment in the elderly population.

Circadian variation of cell proliferation and cell cycle protein expression in man: clinical implications

Most physiological, biochemical and behavioural processes have been shown to vary in a regular and predictable periodic manner with respect to time. This review focuses on the circadian rhythm in cell proliferation in bone marrow and gut and how this is associated with a circadian expression of cell cycle proteins in human oral mucosa. The control of circadian rhythms by the suprachiasmatic nuclei and the evolving understanding of the genetic and molecular biology of the circadian clock is outlined. Finally, the potential clinical impact of chronobiology in cancer medicine is discussed.

Activity of standard and investigational cytotoxic drugs in primary cultures of tumor cells from patients with kidney and urinary bladder carcinomas

PURPOSE

In vitro tumor models could support the process of development of new cytotoxic drugs and selection of suitable drugs for the individual patient. We investigated whether the testing of tumor cells from patients with kidney or urinary bladder carcinoma by fluorometric microculture cytotoxicity assay (FMCA) could provide clinically relevant data for these tumor types.

MATERIALS AND METHODS

A total of 45 tumor samples from patients with kidney or urinary bladder carcinoma were compared with 247 samples of other tumor types with respect to sensitivity to 8 standard and 6 investigational cytotoxic drugs in the FMCA, a 72 hour assay based on the concept of total cell kill. In bladder carcinomas, sensitivity to standard drugs was correlated to various tumor characteristics.

RESULTS

The technical success rate for kidney and bladder carcinomas was high; approximately 90% of the samples could be analyzed successfully. Kidney carcinomas were highly resistant to standard drugs and bladder carcinomas essentially as sensitive as carcinomas of the breast and ovary but with a steeper dose-response relationship. In bladder carcinoma there was no clear relationship between tumor stage, grade, ploidy, mitoses or p53 expression and drug sensitivity. Except for suramin, kidney carcinomas were poorly sensitive to the investigational drugs CdA, gemcitabine, paclitaxel, vinorelbine and topotecan. In bladder carcinomas paclitaxel, gemcitabine and suramin showed promising activity.

CONCLUSIONS

The FMCA seems suitable for cytotoxic drug sensitivity testing of urinary tract carcinomas. This technique may have a role in new drug development in these tumor types.

Chronobiology. Implications for cancer chemotherapy

Experimental studies have documented that both the toxicity and the antitumor activity of many cancer drugs are time dependent. Early clinical trials have confirmed this observation for several drugs. The basic concepts of chronobiology and its application to pharmacology are reviewed. As an example, clinical trials of circadian fluoropyrimidine delivery are reviewed. Other clinical results are presented in table form. The mechanisms pertinent to the circadian time dependence of fluoropyrimidines are discussed.

Systemic chemotherapy in the management of bladder cancer

The treatment of bladder cancer is in a state of evolution. With the advent of effective chemotherapy, multimodal treatment planning is needed to ensure the best results. This requires the participation of the urologist, medical oncologist, radiologist, and radiation therapist in order to determine the optimal treatment strategy for each patient. Currently, radical cystectomy should be considered standard therapy. Neoadjuvant or true adjuvant chemotherapy are still investigational. Randomized trials should be designed to define those patients who will benefit from combined modality therapy, the sequence in which it should proceed, and its impact on disease-free and total survival. Certain principles in patient management require emphasis. 1. The patient must be carefully staged prior to treatment and later restaged thoroughly; whenever possible pathologic confirmation is recommended. Following chemotherapy, all sites of measurable and evaluable disease should be reassessed. Patients with residual masses may have only fibrosis, or microscopic tumor, and complete resection may result in prolonged disease-free survival. 2. Cystectomy after chemotherapy appears to be indicated when this is the only site of disease. If a patient responds systemically with a CR, but has residual disease in the bladder, salvage cystectomy may translate into a prolonged survival. Similarly, a patient who relapses in the bladder following chemotherapy should have surgery. It is unclear if patients with initially unresectable disease who are downstaged (PR) to a resectable lesion should undergo surgery or be consolidated with radiation therapy. 3. Adequate renal function is needed to give optimal doses of chemotherapy. Patients with ureteral obstruction often benefit from a nephrostomy tube. The creatinine clearance may improve following urinary diversion to allow full-dose chemotherapy.

Daily variation in non-protein sulfhydryl levels of human bone marrow

There is increasing evidence that the dosing of certain antineoplastic agents based on a circadian type of schedule may have a beneficial effect on the outcome of patient therapy. Such regimens allow for a more intensive course of drugs to be administered due to a reduction in the toxicities associated with these agents. Since many of the antineoplastics in use today either form reactive intermediates or generate toxic free radical species within the cell, cellular thiols such as glutathione may play a role in their detoxification. Our studies were designed to investigate whether there exists a consistent daily fluctuation in the thiol content in human bone marrow samples. Five normal male volunteers, ages 26-32 years, underwent repeat bone marrow aspirations at approx. 8 a.m. and 8 p.m. Mean peak non-protein sulfhydryl (NPSH) levels of 47.7 nmole/mg protein occurred in morning bone marrow aspirates while evening aspirates showed markedly reduced mean levels of 7.9 nmole/mg protein. Reduced glutathione was used as a standard in these assays which measured sulfhydryls spectrophotometrically using Ellman's reagent. Our findings may help to explain the observed reduction in myelotoxicity in chemotherapy designed to take advantage of human circadian rhythms. These results support the proposition that the administration of certain cytotoxic drugs to match peak levels of thiols in the marrow may facilitate more intensive and active chemotherapy regimens.