A phase 1 trial of imatinib, bevacizumab, and metronomic cyclophosphamide in advanced colorectal cancer

Background:

This phase 1 clinical trial was conducted to determine the safety, maximum-tolerated dose (MTD), and pharmacokinetics of imatinib, bevacizumab, and metronomic cyclophosphamide in patients with advanced colorectal cancer (CRC).

Methods:

Patients with refractory stage IV CRC were treated with bevacizumab 5 mg kg⁻¹ i.v. every 2 weeks (fixed dose) plus oral cyclophosphamide q.d. and imatinib q.d. or b.i.d. in 28-day cycles with 3+3 dose escalation. Response was assessed every two cycles. Pharmacokinetics of imatinib and cyclophosphamide and circulating tumour, endothelial, and immune cell subsets were measured.

Results:

Thirty-five patients were enrolled. Maximum-tolerated doses were cyclophosphamide 50 mg q.d., imatinib 400 mg q.d., and bevacizumab 5 mg kg⁻¹ i.v. every 2 weeks. Dose-limiting toxicities (DLTs) included nausea/vomiting, neutropaenia, hyponatraemia, fistula, and haematuria. The DLT window required expansion to 42 days (1.5 cycles) to capture delayed toxicities. Imatinib exposure increased insignificantly after adding cyclophosphamide. Seven patients (20%) experienced stable disease for >6 months. Circulating tumour, endothelial, or immune cells were not associated with progression-free survival.

Conclusion:

The combination of metronomic cyclophosphamide, imatinib, and bevacizumab is safe and tolerable without significant drug interactions. A subset of patients experienced prolonged stable disease independent of dose level.

Temsirolimus combined with sorafenib in hepatocellular carcinoma: a phase I dose-finding trial with pharmacokinetic and biomarker correlates

BACKGROUND

Based upon preclinical evidence for improved antitumor activity in combination, this phase I study investigated the maximum-tolerated dose (MTD), safety, activity, pharmacokinetics (PK), and biomarkers of the mammalian target of rapamycin inhibitor, temsirolimus, combined with sorafenib in hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with incurable HCC and Child Pugh score ≤B7 were treated with sorafenib plus temsirolimus by 3 + 3 design. The dose-limiting toxicity (DLT) interval was 28 days. The response was assessed every two cycles. PK of temsirolimus was measured in a cohort at MTD.

RESULTS

Twenty-five patients were enrolled. The MTD was temsirolimus 10 mg weekly plus sorafenib 200 mg twice daily. Among 18 patients at MTD, DLT included grade 3 hand-foot skin reaction (HFSR) and grade 3 thrombocytopenia. Grade 3 or 4 related adverse events at MTD included hypophosphatemia (33%), infection (22%), thrombocytopenia (17%), HFSR (11%), and fatigue (11%). With sorafenib, temsirolimus clearance was more rapid (P < 0.05). Two patients (8%) had a confirmed partial response (PR); 15 (60%) had stable disease (SD). Alpha-fetoprotein (AFP) declined ≥50% in 60% assessable patients.

CONCLUSION

The MTD of sorafenib plus temsirolimus in HCC was lower than in other tumor types. HCC-specific phase I studies are necessary. The observed efficacy warrants further study.

Phase I trial of temsirolimus (TEM) plus sorafenib (SOR) in advanced hepatocellular carcinoma (HCC)

296

Background: SOR prolongs survival in patients (pts) with HCC. In preclinical studies, mammalian target of rapamycin (mTOR) inhibitors (I) impair HCC growth and angiogenesis. Adding mTOR-I to SOR augments antitumor effect. Phase I studies of mTOR-I plus SOR have shown tolerability but did not include cirrhotic pts. We developed a phase I trial of mTOR-I TEM plus SOR to determine safety, maximum tolerated dose (MTD), and recommended phase II dose (RP2D) in pts with HCC. The study was approved and funded by the National Comprehensive Cancer Network (NCCN).

Methods: Eligibility: Advanced HCC diagnosed histologically or clinically. No prior systemic therapy (Tx). Prior resection/local Tx permitted if ≥1 measurable site. ECOG score ≤2, Child-Pugh ≤7, bilirubin ≤2 mg/dL, platelets ≥75,000/mcL. Design: 3+3 escalation to MTD with dose-limiting toxicity (DLT) window 28 days; 6 pts at MTD for pharmacokinetics (PK). Endpoints: 1°: MTD, RP2D. 2°: Safety, toxicity, PK.

Results: 9 pts enrolled to date: 7 at DL1, 2 at DL-1. Toxicity: DL1: 1 DLT of Gr3 thrombocytopenia. 1 pt removed for hypertensive urgency, adjudicated not Tx-related. 1 pt not evaluable due to abscess. 1 pt removed for Gr3 hypersensitivity to TEM in cycle 2. All remaining pts required reduction and/or delay for adverse events (AE). Tx-related AE at DL1 include: fatigue 57%, Gr3 11%; weight loss 22%, all Gr1; anorexia 57%, all Gr1/2; diarrhea 71%, all Gr1/2; rash/hand-foot syndrome 71%, Gr3 11%; thrombocytopenia 57%, Gr3 11%; hypophosphatemia 77%, Gr3 57%, refractory 11%. Study de-escalated to DL-1 due to non-DLT cumulative AE. DL-1: 2 pts enrolled have not had DLT nor dose reduction to date. Response: 4 of 7 pts in DL1 were evaluable. 3 of 4 had stable disease as best response.

Conclusions: Tx-limiting, class-related AE occurred at DL1 of this double-biologic regimen. MTD in pts with Child-Pugh Class A cirrhosis appears lower than in pts without liver disease. Tolerability and dose delivery must be achieved to determine efficacy. A phase II study with correlative endpoints is planned at RP2D. Updated accrual and results will be presented.

[Table: see text]

[Table: see text]

First interim results of the global investigation of therapeutic decisions in hepatocellular carcinoma (HCC) and of its treatment with sorafenib (GIDEON) study: Use of sorafenib (Sor) by oncologists and nononcologists in the management of HCC

157

Background: GIDEON is an ongoing, global, prospective, non-interventional registry study of patients (pts) with unresectable HCC (uHCC) receiving Sor under real-life practice settings. From January 2009 to September 2010, over 2,200 pts have been enrolled from 32 countries. Per protocol, the first planned interim analysis was triggered when 500 enrolled pts were followed for at least 4 mos; the primary safety and efficacy results were reported in October 2010. A preplanned subset analysis of treatment patterns across MD specialities is reported here.

Methods: Demographics, medical, disease and treatment history are recorded at enrolment; Sor dose, concomitant treatments, performance status, liver function are noted at follow-up. Standard efficacy measures and adverse events (AEs) are captured. Preplanned subanalysis by MD specialty was conducted.

Results: Of the 141 treating MDs, 69 (49%) were hepatologists/gastroenterologists (Hep/GIs), 55 (39%) were medical oncologists (Oncs) and 17 (12%) were other specialties. Descriptive statistics of differences in pts' HCC stage, Sor treatment and AEs by the main specialties are shown for the 479 pts evaluable for safety (Table).

Conclusions: Interim data from the GIDEON study suggests differential use of Sor by MD specialties. It appears that Oncs tend to treat with lower doses of Sor and for a somewhat shorter duration than Hep/GIs. If these data persist, it will be important to explore the reasons for these differences in Sor usage between Oncs and Hep/GIs and potential impact on patient outcomes.

[Table: see text]

No significant financial relationships to disclose.

A phase II study of gemcitabine (GEM) given at fixed-dose rate (FDR) infusion, low-dose cisplatin (CDDP), and bevacizumab (BEV) for metastatic adenocarcinoma of the pancreas (PanCa): Update with completion of study accrual

4548

Background: The objectives of this study are to determine safety and efficacy in pts with metastatic PanCa treated with a novel combination consisting of FDR GEM, low-dose CDDP, and BEV. We present here updated results on the full 53-pt study cohort. Methods: Chemotherapy-naive pts with histologically confirmed PanCa and documented extrapancreatic metastases received GEM 1,000 mg/m2 at FDR infusion (10 mg/m2/min), CDDP 20 mg/m2, and BEV 10 mg/kg, all administered on dd 1 and 15 of a 28-dd cycle. Pts were monitored by CT scans every 2 cycles and monthly serum CA19–9 measurements. Results: 53 pts (24M,29F; median age 60 y.o. [range 39–85]; ECOG PS 0–1) were enrolled betw 6/2004 and 9/2006 (med f/u, 513 dd; range, 93–885). 16 pts remain alive, with 9 still undergoing study rx. Pts received a median of 4.75 cycles of rx (range, 0.5–20). 29 pts discontinued study rx 2o to progressive dz (med # of cycles, 5; range, 0.5–20); 9 pts 2o to rx-assoc toxicity; 4 pts 2o to plateau in response with cumulative asthenia (after 8–12 cycles); and 2 pts 2o to prolonged rx delay from bowel obstruction. Major events include 2 bowel perforations, one associated with placement of a duodenal stent; 4 major GI bleeds; 7 DVT/PE; 1 stroke-like sxs; and 3 cardiac events (MI x 1, arrhythmias x 2). 4 pts (7.5%) developed grade 3/4 HTN. Gr 3/4 hematologic toxicities inc. neutropenia in 4 pts (7.5%) and thrombocytopenia in 1 pt (2.9%). 16 pts (20%) required dose reduction in gemcitabine during study rx and 4 required holding of cisplatin. There were 3 deaths potentially assoc with rx. 12 pts (22.6%) have had an unconfirmed response (1 CR, 11 PR) and 26 pts (49.1%) have had stable dz for >2 cycles, for an overall dz control rate of 71.7%. 20 of 35 pts (57.1%) with elev baseline CA19–9 levels (>2X ULN) had >50% biomarker decline during rx. Median TTP is 6.2 months. Median overall survival is 8.0 months with an est. 1-yr survival rate of 40%. Conclusions: The addition of BEV to FDR GEM/low-dose CDDP shows promising efficacy, particularly in TTP and 1-yr survival rate, with manageable toxicity. Further efforts are ongoing to identify which pts are most likely to benefit from BEV-based rx.

[Table: see text]

Evaluation of patupilone as monotherapy in patients with advanced hepatocellular carcinoma (HCC)

15055

Background: Currently, there is no strong evidence that systemic therapies provide a survival benefit for patients (pts) with hCC. However, preclinical data have shown that the novel epothilone patupilone has potent anti-proliferative activity against 8 HCC cell lines with intrinsic multidrug resistance. This exploratory study tested whether patupilone monotherapy has antitumor activity in HCC patients with intact liver function. Methods: This open-label, single-arm, multicenter, 2-stage phase II study was to enroll 24 pts in the first stage and 41 pts in the second stage, if = 3 complete or partial responses were observed in the first stage. Patients with unresectable and/or metastatic HCC (histologically confirmed) with = 1 measurable lesion were eligible if they had well-preserved hepatic function (Child-Pugh Class A) and life expectancy = 3 months. Patupilone was administered as a single IV infusion at 10 mg/m2 over 20 minutes every 3 weeks. Primary endpoint was objective response. Results: Twenty-five patients were enrolled, 24 were evaluable, and 1 violated protocol. The most common adverse events (AEs) suspected to be study-drug related were NCI CTC grade 1/2 diarrhea, fatigue, and vomiting. Grade 4 serious AEs included hyponatremia (2 pts [8%]), cardiac arrest (1 pt [4%]), diarrhea (1 pt [4%]), and gastrointestinal hemorrhage (1 pt [4%]). Grade 3 serious AEs included diarrhea (3 pts [12%]), hyponatremia (2 pts [8%]), deep vein thrombosis (1 pt [4%]), abdominal pain (1 pt [4%]), and hyperkalemia (1 pt [4%]). Most pts had dose adjustments or delays; 3 discontinued treatment. During the first stage, 1 pt had a confirmed partial response through 4 cycles, and 11 pts (44%) had stable disease for = 2 cycles with a median of 4 cycles (range, 2 to 8 cycles). Median progression-free survival was 3 months (range, 1 to 6 months), and 10 pts (40%) progressed within the first 2 cycles. The study did not progress to stage 2. Conclusions: Patupilone demonstrated an acceptable safety profile. Serious AEs were observed in a minority of patients, and most did not require treatment discontinuation. Patupilone demonstrated only modest antitumor activity in pts with HCC in this study.

No significant financial relationships to disclose.

A phase II study of gemcitabine (GEM) given at fixed-dose rate (FDR) infusion, low-dose cisplatin (CDDP), and bevacizumab in metastatic pancreatic cancer (PanCa)

4041

Background: The objectives of this study are to determine safety and efficacy in pts with metastatic PanCa treated with a novel combination consisting of FDR GEM, low-dose CDDP, and BEV. We present here interim results of the first 35 pts. Methods: Chemotherapy-naive pts with histologically confirmed PanCa and documented extrapancreatic metastases received the following: GEM 1000 mg/m2 at FDR infusion (10 mg/m2/min), CDDP 20 mg/m2, and BEV 10 mg/kg, all administered on dd 1 and 15 of a 28-dd cycle. Pts were monitored by CT scans every 2 cycles and monthly serum CA19–9 measurements. Results: 35 pts (15M,20F; median age 60 y.o. [range 39–85]; ECOG PS 0–1) have been enrolled betw 6/2004 and 1/2006 (med f/u, 288 dd; range, 50–542). 18 pts remain alive, with 7 still undergoing study rx. Pts received a median of 4 cycles of rx (range, 0.5–12). Reasons for study discontinuation: 15 pts had progressive dz (med # of cycles, 6; range, 0.5–10); 2 pts completed max # of allowable rx cycles (twelve); 2 pts came off rx 2 o to cumulative asthenia after plateau in response with 8 and 10 cycles of rx. Other major events inc. 2 bowel perforations, one associated with placement of a duodenal stent; 3 major GI bleeds; 1 malignant HTN; and 1 stroke-like sx. 3 pts d/c’ed rx 2o to prolonged rx delays (two persistent bowel obstruction, one grade 3 renal/liver function abnls). Addn grade 3/4 toxicities inc. 7 pts with LFT abnls (20%), 4 with HTN (11.4%), and 3 with thromboembolic events (8.6%). Hematologic toxicities were rare (grade 3/4 neutropenia 5.7%, plts 2.9%). 7 pts (20%) required dose reduction of GEM and 2 required d/c of CDDP. No rx-associated deaths were observed. 7 of 33 evaluable pts (21.2%) have had an unconfirmed response (1 CR, 6 PR) and 15 pts (45.5%) have had stable dz for > 2 cycles, inc. 2 with minor response, for an overall dz control rate of 66.7%. 13 of 21 pts (61.9%) with elev. baseline CA19–9 levels (≥2X ULN) have had ≥50% biomarker decline during rx. Updated efficacy data will be presented at the meeting. Conclusions: The toxicity profile observed in this trial is similar to that previously reported with other BEV-containing regimens. Rates of disease control and CA 19–9 response are encouraging, suggesting this combination is deserving of further study.

[Table: see text]

A phase I/II study to assess the safety, tolerability and pharmacokinetics (PK) of intravenous (IV) infusion of MB07133 in subjects with unresectable hepatocellular carcinoma (HCC)

2054

Background: MB07133 is a novel cytarabine (araC) prodrug that uses the HepDirect technology to target production of the active form of araC, araC triphosphate (araCTP), to the liver. The study objectives were to determine the maximum tolerated dose, toxicity profile (NCI-CTC 2.0), PK & antitumor activity of MB07133 in patients (pts) with unresectable HCC. MB07133 was given as a continuous IV infusion at escalating doses during the first 7 days of a 28-day cycle until disease progression or unacceptable toxicity occurred. To date, 22 pts with Child-Pugh Class A liver function have been enrolled in 4 cohorts (300, 600, 1200, 1800 mg/m2/d, D1–7), with 3–6 pts/cohort. Enrolled pts had a median age of 57 yrs (range 20–67) & consisted of 21 males, 1 female, 19 Asians & 3 Caucasians. A total of 66 cycles have been administered (maximum 10 cycles in 1 pt) with no dose-limiting toxicities associated with therapy. Most drug-related toxicities (67%) were mild to moderate (gr 1–2 neutropenia, thrombocytopenia & increased ALT). There was 1 gr 3 ascites unrelated to study drug and no gr 4 toxicity. Six pts experienced 10 serious adverse events, all unrelated or unlikely related to study drug. The very low araC concentrations in the plasma (see table ) were consistent with previous animal studies, which demonstrated MB07133 to target araCTP production in the liver. 36% of pts who had ≥ 2 cycles of MB07133 had disease stabilization. Conclusions: MB07133 is well tolerated at doses up to 1800 mg/m2/d in pts with unresectable HCC. Enrollment of a 2400 mg/m2 cohort is ongoing. The disease stabilization observed in this study, although preliminary, warrants further investigation in Phase 2.

[Table: see text]

[Table: see text]

Serum CA19-9 response as a surrogate for clinical outcome in patients receiving fixed-dose rate gemcitabine for advanced pancreatic cancer

The use of serial serum measurements of the carbohydrate antigen 19-9 (CA19-9) to guide treatment decisions and serve as a surrogate end point in clinical trial design requires further validation. We investigated whether CA19-9 decline represents an accurate surrogate for survival and time to treatment failure (TTF) in a cohort of 76 patients with advanced pancreatic cancer receiving fixed-dose rate gemcitabine in three separate studies. Statistically significant correlations between percentage CA19-9 decline and both overall survival and TTF were found, with median survival ranging from 12.0 months for patients with the greatest degree of biomarker decline (>75%) compared with 4.3 months in those whose CA19-9 did not decline during therapy (P<0.001). Using specific thresholds, patients with ⩾25% decline in CA19-9 during treatment had significantly better outcomes than those who did not (median survival and TTF of 9.6 and 4.6 months vs 4.4 and 1.5 months; P<0.001). Similar results were seen using both 50 and 75% as cutoff points. We conclude that serial CA19-9 measurements correlate well with clinical outcomes in this patient population, and that decline in this biomarker should be entertained for possible use as a surrogate end point in clinical trials for the selection of new treatments in this disease.

A phase I and pharmacokinetic study of irinotecan in patients with hepatic or renal dysfunction or with prior pelvic radiation: CALGB 9863

BACKGROUND

To ascertain if hepatic or renal dysfunction or prior pelvic radiation (XRT) leads to increased toxicity at a given dose of irinotecan and to characterize the pharmacokinetics of irinotecan and its major metabolites in patients with hepatic or renal dysfunction.

PATIENTS AND METHODS

Adults with tumors appropriate for irinotecan therapy and who had abnormal liver or renal function tests or had prior radiation to the pelvis were eligible. Patients were assigned to one of four treatment cohorts: I, aspartate aminotransferase (AST) > or = 3x upper limit of normal and direct bilirubin <1.0 mg/dl; II, direct bilirubin 1.0-7.0 mg/dl; III, creatinine 1.6-5.0 mg/dl with normal liver function; IV, prior pelvic XRT with normal liver and renal function. Starting with reduced doses of either 145 or 225 mg/m(2), irinotecan was administered every 3 weeks to at least three patients within each cohort. Irinotecan and its metabolites in the blood were measured in all patients.

RESULTS

Thirty-five patients were evaluable for toxicity. No dose-limiting toxicity was seen in cohort I, although only three patients were treated and at a dose of 225 mg/m(2). Patients with elevations of direct bilirubin had dose-limiting toxicities, even though the starting dose was 145 mg/m(2). These same patients appeared to have comparable exposure to the active metabolite SN-38 as normal patients treated with full-dose irinotecan. Patients with elevations of creatinine or with prior pelvic radiotherapy did not appear to have increased risk of toxicity at the doses explored in this study.

CONCLUSIONS

Patients with elevated bilirubin treated with irinotecan have an increased risk of toxicity and a dose reduction is recommended. Patients with elevated AST, creatinine or prior pelvic radiation do not appear to have increased sensitivity to irinotecan, but the data are not adequate to support a specific dosing recommendation.

Therapeutic approaches to metastasis confined to the liver

Liver metastases nearly always represent disseminated cancer, and systemic therapies are usually indicated. However, in a minority of patients--some with colorectal cancer, others with selected tumors--management of the hepatic disease may be clinically important and even curative. This review identifies unique patient subgroups and novel treatment approaches that may be indicated in patients with liver metastases.

Hepatocellular carcinoma

Early detection of hepatocellular carcinoma (HCC) is feasible, particularly in patients known to be at risk from chronic hepatitis and chronic liver disease. The optimal surveillance strategy is unknown. HCC usually presents as an incurable disease even when detected on surveillance. Surgical resection is the treatment of choice, but the coexistence of chronic liver disease and the insidious nature of HCC make it unresectable in most patients. Orthotopic liver transplantation for selected patients or ablative techniques may offer an opportunity to render patients disease-free even if the tumor is unresectable. There are numerous therapies offered to patients with unresectable HCC, including chemotherapy, hormonal therapy, and regional intra-arterial treatments. While potentially palliative, none of these approaches has been demonstrated to prolong survival in these patients. If possible, the treatment of patients with HCC should be done on clinical trials.

Phase I and pharmacokinetic trial of gemcitabine in patients with hepatic or renal dysfunction: Cancer and Leukemia Group B 9565

PURPOSE

To ascertain if hepatic or renal dysfunction leads to increased toxicity at a given dose of gemcitabine and to characterize the pharmacokinetics of gemcitabine and its major metabolite in patients with such dysfunction.

PATIENTS AND METHODS

Adults with tumors appropriate for gemcitabine therapy and who had abnormal liver or renal function tests were eligible. Patients were assigned to one of three treatment cohorts: I-AST level less than or equal to two times normal and bilirubin level less than 1.6 mg/dL; II-bilirubin level 1.6 to 7.0 mg/dL; and III-creatinine level 1.6 to 5.0 mg/dL with normal liver function. Doses were explored in at least three patients within each cohort. Gemcitabine and its metabolite were to be measured in the blood in all patients.

RESULTS

Forty patients were assessable for toxicity. Transient transaminase elevations were observed in many patients but were not dose limiting. Patients with AST elevations tolerated gemcitabine without increased toxicity, but patients with elevated bilirubin levels had significant deterioration in liver function after gemcitabine therapy. Patients with elevated creatinine levels had significant toxicity even at reduced doses of gemcitabine, including two instances of severe skin toxicity. There were no apparent pharmacokinetic differences among the three groups or compared with historical controls.

CONCLUSION

If gemcitabine is used for patients with elevations in AST level, no dose reduction is necessary. Patients with elevated bilirubin levels have an increased risk of hepatic toxicity, and a dose reduction is recommended. Patients with elevated creatinine levels seem to have increased sensitivity to gemcitabine, but the data are not adequate to support a specific dosing recommendation.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a disease that is extremely difficult to manage and is increasing markedly in incidence. This presents both an opportunity and a challenge. At-risk patients can be identified and early detection of HCC is feasible. New surgical techniques and postoperative therapies, including hepatic intra-arterial radiation, may improve the outlook for some patients with resectable cancer. Unfortunately, the vast majority of patients with HCC will have unresectable cancers. Regional treatments may shrink or necrose tumors, but no clear benefit to such therapies has been demonstrated. Recent evidence suggests combination chemotherapy may help some patients, although this needs validation. Perhaps the best hope is that the further elucidation of the genetic and molecular features of HCC will lend us insight into innovative strategies to manage this difficult cancer.

Regional strategies for managing hepatocellular carcinoma

Hepatocellular carcinoma is a common, difficult-to-treat cancer that has a variable natural history depending on patient demographics and the etiology and extent of underlying liver disease. Resection is the preferred treatment option but is only possible in the rare patient who has adequate hepatic reserve and limited-stage cancer. Systemic chemotherapy is mostly inactive. Because most patients with hepatocellular cancer succumb to hepatic failure, this is a disease that appears to be amenable to regional treatments. For this reason, numerous intratumoral, ablative techniques are available. Other routinely used regional treatment modalities include intraarterial chemotherapy, chemoembolization, Lipiodol chemoembolization, and internal radiation. However, the benefits of these interventions have been difficult to ascertain given the variable clinical course of the disease. Regional delivery may prove to be most valuable as a route for administering newer agents.

Transcatheter embolization for the treatment of misperfusion after hepatic artery chemoinfusion pump implantation

BACKGROUND

The use of surgically implanted chemoinfusion pumps for the treatment of hepatic metastases from colorectal carcinoma can be complicated by intra- or extrahepatic misperfusion. This may result in suboptimal tumor exposure to the chemotherapeutic agent and injury to other gastrointestinal organs. Misperfusion can be managed by selective arterial transcatheter embolization.

METHODS

Between 1989 and 1996, 16 patients with liver metastases from colorectal carcinoma and with hepatic artery chemoinfusion pump misperfusion were treated using transcatheter coil embolization. Six female and 10 male patients (age range, 34-84 years; median, 51.5 years) were identified by retrospective review of the records of the Department of Interventional Radiology. After pump placement, abnormal liver perfusion scan or methylene blue endoscopy study results prompted angiography with coil embolization. After embolization, the imaging studies were repeated and patients were monitored in the Oncology Clinic.

RESULTS

Eight patients exhibited intrahepatic misperfusion (group 1) and eight extrahepatic misperfusion (group 2). Coil embolization was immediately successful in 100% of patients in group 1, with restoration of normal hepatic perfusion, and in 75% in group 2. There were no immediate procedure-related complications. Follow-up periods ranged from 1 to 23 months (median, 13.5 months). Embolization was unsuccessful for two patients (in group 2), who tolerated a modified chemotherapeutic regimen, with follow-up periods of 18.5 and 22 months.

CONCLUSIONS

Transcatheter coil embolization is the therapy of choice for the management of hepatic artery chemoinfusion pump misperfusion. It is rapid, effective, and well tolerated by patients and obviates the need for additional surgical intervention.

Octreotide acetate long-acting formulation versus open-label subcutaneous octreotide acetate in malignant carcinoid syndrome

PURPOSE

Subcutaneous (SC) octreotide acetate effectively relieves the diarrhea and flushing associated with carcinoid syndrome but requires long-term multiple injections daily. A microencapsulated long-acting formulation (LAR) of octreotide acetate has been developed for once-monthly intramuscular dosing.

PATIENTS AND METHODS

A randomized trial compared double-blinded octreotide LAR at 10, 20, and 30 mg every 4 weeks with open-label SC octreotide every 8 hours for the treatment of carcinoid syndrome. Seventy-nine patients controlled with treatment of SC octreotide 0.3 to 0.9 mg/d whose symptoms returned during a washout period and who returned for at least the week 20 evaluation constituted the efficacy-assessable population.

RESULTS

Complete or partial treatment success was comparable in each of the four arms of the study (SC, 58.3%; 10 mg, 66.7%; 20 mg, 71.4%; 30 mg, 61.9%; P> or =.72 for all pairwise comparisons). Control of stool frequency was similar in all treatment groups. Flushing episodes were best controlled in the 20-mg LAR and SC groups; the 10-mg LAR treatment was least effective in the control of flushing. Treatment was well tolerated by patients in all four groups.

CONCLUSION

Once octreotide steady-state concentrations are achieved, octreotide LAR controls the symptoms of carcinoid syndrome at least as well as SC octreotide. A starting dose of 20 mg of octreotide LAR is recommended. Supplemental SC octreotide is needed for approximately 2 weeks after initiation of octreotide LAR treatment. Occasional rescue SC injections may be required for possibly 2 to 3 months until steady-state octreotide levels from the LAR formulation are achieved.

Embolization and chemoembolization therapy for neuroendocrine tumors

Neuroendocrine tumors, particularly those of gastrointestinal tract origin, have a predisposition for metastasizing to the liver. In such patients, the clinical course is often dominated by the hepatic disease, either because of hormone secretion or because of tumor bulk. Because the liver has a dual vascular supply and hepatic metastases derive the majority of blood from the hepatic artery, the regional delivery of chemotherapy can offer pharmacokinetic advantages over systemic administration. The hepatic artery is also a nonsurgical avenue for inducing selective metastasis ischemia by the embolization of tumor vessels. The combination of these two therapies, or chemoembolization, may provide additive benefits. Such an approach has been demonstrated to reduce tumor bulk, reduce hormone levels, and palliate the symptoms of many patients with liver-dominant neuroendocrine metastases. Embolization or chemoembolization is an appropriate modality for some patients with neuroendocrine tumors.

Tamoxifen in liver disease: potential exacerbation of hepatic dysfunction

Tamoxifen, a non-steroidal anti-estrogen, has been used successfully for a decade as post-operative adjuvant therapy for breast cancer. Tamoxifen is generally well tolerated with few side effects, especially at the typical dose of 10 mg twice daily. However, hepatic effects have been reported after tamoxifen administration and are usually found to be cholestatic in nature. Although previous reports concentrate on tamoxifen as a probable cause of drug-induced hepatotoxicity, very little attention has been focused on the use of tamoxifen in patients with pre-existing liver dysfunction and the possible need for dose adjustment. We present the case of a 48-year-old woman with an acute exacerbation of her pre-existing liver dysfunction and subsequent elevations of tamoxifen blood levels after approximately one year of tamoxifen therapy for adjuvant treatment of breast cancer. Tamoxifen dosing was adjusted based on serum levels.

Phase I and pharmacokinetic trial of paclitaxel in patients with hepatic dysfunction: Cancer and Leukemia Group B 9264

PURPOSE

To characterize the maximum-tolerated dose, dose-limiting toxicities (DLTs), and pharmacokinetics of paclitaxel in patients with abnormal liver function.

PATIENTS AND METHODS

Adults with tumors appropriate for paclitaxel therapy who had abnormal liver function tests were eligible. Patients were assigned to one of three treatment cohorts: I, AST level twofold normal and bilirubin level less than 1.5 mg/dL; II, bilirubin level 1.6 to 3.0 mg/dL; and III, bilirubin level greater than 3.0 mg/dL. Doses were explored in at least three patients within each cohort. Although designed to assess a 24-hour infusion schedule, the trial was extended to also assess a 3-hour regimen. Pharmacokinetics were to be studied in all patients.

RESULTS

Eighty-one patients were assessable for toxicity. Patients with bilirubin levels greater than 1.5 mg/dL had substantial toxicity at all doses explored, whereas the toxicity for patients with elevated AST levels occurred at doses that ranged from 50 to 175 mg/m2 administered over 24 hours. In most patients, the DLT was myelosuppression. The pharmacokinetic data were insufficient to adequately evaluate the relationship between pharmacokinetics and toxicity in patients who received 24-hour infusions but provided evidence of a longer exposure to paclitaxel than anticipated for the doses used in this study in the 3-hour infusion group.

CONCLUSION

If paclitaxel is used for patients with elevated levels of AST or bilirubin, dose reductions are necessary, and an increase in toxicity can be anticipated. The increased myelosuppression observed is at least partially because of altered paclitaxel pharmacokinetics in such patients.

Update on hepatic intra-arterial chemotherapy

The use of hepatic intra-arterial (HIA) chemotherapy is based on the pharmacologic principle that the regional administration of certain drugs can lead to higher drug concentrations at the site of a tumor. This has been studied most extensively in patients with liver-only colorectal metastases. Four large randomized studies have failed to demonstrate a survival advantage of regional treatment over systemic chemotherapy, although two meta-analyses confirmed an improvement in response rate and suggest a trend toward improvement in survival. Two randomized studies have shown improved survival in patients treated with HIA chemotherapy, as compared with those given supportive care, and quality of life also appears to be superior in HIA chemotherapy recipients. The treatment employed in all of the randomized studies was hindered by substantial hepatobiliary toxicity and many surgical complications. Improved surgical techniques and newer chemotherapy combinations appear to have improved phase II results with HIA therapy, leading to a randomized trial now being conducted by the Cancer and Leukemia Group B (CALGB). The role of HIA chemotherapy in adjuvant settings and in other diseases has not been as well-studied, and such uses remain appropriate only for very selected patients. Ultimately, the regional advantage gained by the HIA route may prove to be most advantageous for the delivery of newer biologic agents.

Intra-abdominal desmoplastic small round-cell tumor: expansion of the pathologic profile

This report describes an intra-abdominal desmoplastic small round-cell tumor in a 29-year-old man that significantly differed from the classically described appearances of this unique tumor. It showed extensive papillary areas, no necrosis, and very little desmoplasia. The latter was limited, paucicellular, and present in areas separate from the papillary structures. Also, areas of back-to-back, single-cell infiltration, which mimicked lobular breast carcinoma, were present. These epithelial features suggested the diagnosis of adenocarcinoma or peculiar mesothelioma. But, the immunohistochemical features (tumor cells positive for keratin, desmin, and vimentin) were more consistent with an intra-abdominal desmoplastic small round-cell tumor. The diagnosis became clear after application of reverse transcriptase-polymerase chain reaction techniques to formalin-fixed, paraffin-embedded tissue, which showed the presence of a 100-base pair product containing the fusion junction of Ewing's sarcoma-1 exon 7 to Wilms' tumor-1 exon 8. This feature is considered unique to intra-abdominal desmoplastic small round-cell tumors. This case illustrates the less common histologic findings that can be found in intra-abdominal desmoplastic small round-cell tumor. This deviation from the classic histologic findings may be an expression of an uncommon morphologic variant and/or partially produced by the effects of prior chemotherapy. In either event, only by illustrating the various histologic appearances of intra-abdominal desmoplastic small round-cell tumor are the chances increased for the accurate diagnosis of this aggressive neoplasm with a poor prognosis.

Regional chemotherapy approaches for primary and metastatic liver tumors

There are pharmacologic principles that make regional chemotherapy to the liver a logical treatment strategy. Patients with colorectal liver metastases and hepatocellular carcinoma would appear to be the best candidates for such an approach. Although there are many objective responses to such treatment, survival benefit has not been demonstrated, but new regimens and refined techniques appear to be improving results. Ultimately, regional delivery may be best suited for innovative treatments such as biologicals and gene therapies.

Liver transplantation for hepatocellular carcinoma: results with preoperative chemoembolization

At the University of California, San Francisco, 17 patients who met the following criteria-hepatic tumor unresectable because of location or inadequate liver reserve, no metastases, HBsAg negative, no tumor larger than 5 cm in diameter, and no more than three tumors--were enrolled prospectively in a protocol employing preoperative chemoembolization to assess whether orthotopic liver transplantation (OLT) could cure a majority of highly selected patients with hepatocellular carcinoma (HCC). Thirteen patients had biopsy-proven HCC, 2 had the fibrolamellar variant, and 2 had radiological findings of HCC but no biopsy confirmation. Fourteen had underlying liver disease. All arteriographically apparent lesions were chemoembolized using a mixture including Gelfoam powder, doxorubicin, mitomycin-c, and cisplatin. Eight patients with poor hepatic reserve were chemoembolized when a donor organ became available, whereas 9 patients were chemoembolized and then placed on the waiting list. The only complication of chemoembolization was a gangrenous gallbladder in 1 patient. Thirteen patients underwent liver transplantation (2 patients without prior histological confirmation of carcinoma had no identifiable tumor at OLT); 3 patients developed metastases between the time of enrollment and donor organ availability and subsequently died; and 1 patient underwent a trisegmentectomy. Ten of the 11 patients with biopsy-proven HCC who underwent transplantation remain free of recurrent cancer at a median of 40 months; 1 patient died at 6 months of lymphoproliferative disease with no cancer found at autopsy. Although the role of chemoembolization is uncertain, these data show that the majority of carefully selected patients with HCC may achieve long-term survival with OLT.

Treatment of hepatocellular carcinoma: too many options?

PURPOSE

This study attempts to review the therapeutic interventions being used to treat patients with hepatocellular carcinoma (HCC).

DESIGN

An English language literature search, including abstracts and original articles, and a review of the bibliographies of such articles, was conducted.

RESULTS

Surgery is possible in few patients and curative in only a small percentage. Conventional chemotherapy is ineffective in HCC. Modifications of chemotherapy, including intraarterial infusion, chemoembolization, lipiodol, styrene-maleic acid-neocarzinostatin (SMANCS), and isolated hepatic perfusion, have led to improved tumor responses, but have not materially affected patient outcome. Radioimmunotherapy and conformal radiotherapy have had no more than a marginal impact on patient outcome. Surgical innovations such as cryosurgery and percutaneous alcohol injection have not yet been shown to offer any advantage, and liver transplantation, while curative in some patients, requires an enormous expenditure of resources to achieve cure in few patients.

CONCLUSION

Prevention is the ideal approach to HCC. Surgical cure is rarely possible, and while numerous therapies may palliate symptoms, patient selection and the lack of randomized studies make their impact on median survival difficult to assess. Patients being treated for HCC should be enrolled on treatment protocols testing multimodality or new strategies.

Gallium-avid thymic hyperplasia in an adult after chemotherapy for Hodgkin disease

This article presents the case of a 22-year-old patient with treated Hodgkin disease (HD) who had mediastinal widening on computed tomography scan after chemotherapy. This mass was gallium avid. These findings were explained by histologically documented benign thymic hyperplasia, the first such case reported in an adult with HD, to the knowledge of the authors. The literature on thymic hyperplasia after chemotherapy is reviewed.

A phase II study of constant-infusion floxuridine for the treatment of metastatic renal cell carcinoma

BACKGROUND

Twenty-nine patients with metastatic renal cell carcinoma (RCC) were treated with constant-infusion floxuridine (FUdR, Roche Laboratories, Nutley, NJ).

METHODS

The initial dosage was 0.075 mg/kg/day for 14 days every 28 days and was increased or decreased by 0.025-mg/kg/day increments at each subsequent cycle until the maximum tolerated dose (MTD) was achieved.

RESULTS

All patients were fully assessable. One (4%) patient had a complete response, 5 (17%) had a partial response, 13 (50%) had stabilized disease, and 10 (34%) had progressive disease. The treatment-limiting toxic effect was diarrhea, and the median tolerated dosage was 0.1 mg/kg/day for 14 days every 28 days (range, 0.05-0.275 mg/kg/day). Five of the six responses occurred at a dosage of 0.1 mg/kg/day or less, which was achievable in most patients. Patients who reached their MTD without achieving a complete or partial response were switched to circadian-infusion floxuridine to determine whether an increased dose intensity could be administered and whether this would translate into additional responses. A higher median tolerated dosage of 0.15 mg/kg/day was achieved with circadian administration; however, no additional responses were observed. The median survival time was 891 days after the diagnosis of metastatic RCC and 445 days after the institution of floxuridine therapy.

CONCLUSIONS

Constant-infusion floxuridine is active against metastatic RCC and produces a response rate that appears to be comparable to that of circadian administration of floxuridine.