Triple MEL100 therapy in multiple myeloma

BACKGROUND

Tandem high-dose melphalan therapy with autologous peripheral stem cell support has emerged as the standard of care for patients without prohibitive comorbidities. Mucositis and gastrointestinal side effects are the most common extrahematologic side effects. Two previously published studies presented a triple transplant with a conditioning regimen of melphalan 100 mg/m(2) (MEL100) with peripheral stem cell support every 2 to 5 months for patients with prohibitive comorbidities for high-dose tandem transplantation. We present a novel approach that investigates the triple melphalan 100/m(2) approach on a dose-dense, every-3-weeks schedule in a patient population without significant comorbidities.

PATIENTS AND METHODS

Thirteen standard or high-risk patients with stage III multiple myeloma were prospectively treated. This population contained eight patients with immunoglobin G clonality, three immunoglobin A, one nonsecretory, and one light chain isotype. The induction regimens of the 13 patients were heterogenous and included five VAD, three DCIE, two Thal/Dex, two CIE, and one pulse decadron. Patients underwent peripheral blood leukopheresis, and these cells were divided into three equal sets and frozen. The patients were scheduled to receive melphalan at 100 mg/m(2) on days 1, 20, and 41, and then the autologous infusions occurred at days 0, 21, and 42.

RESULTS

All patients were able to receive all three cycles of the MEL100 regimen. Seven patients (54%) received the treatments on the every-3-weeks schedule; three treatments (23%) during the second cycle and six treatments (46%) of the third cycle had to be delayed a median of 6 and 4 days, respectively. Three patients were managed completely in the outpatient setting, and the average total hospital stay for the three transplants was 18 days. Median progression-free survival was 854 days (range 73 to 1571), and the overall survival of this cohort has yet to be reached. No patient had worse than grade II mucositis, and no serious adverse events were recorded.

CONCLUSION

Our regimen of three consecutive autologous peripheral stem cell transplants with a reduced dose of melphalan at 100 mg/m(2) given every 3 weeks was very well tolerated. The progression-free survival and overall survival are similar and can be compared favorably with the standard tandem myeloma regimens. Our data is intriguing, and further studies with larger numbers need to be performed to confirm these results.

Is race a prognosticator for survival in metastatic non-small cell lung cancer?

6610

Background: Available cancer statistics for non-small cell lung cancer (NSCLC) in the US relate mainly to Caucasians and African Americans. NSCLC also represents a major health concern in other US American sub-populations. This study describes ethnic patterns of survival in metastatic NSCLC in eight different racial/ethnic groups. Methods: We analyzed the SEER (surveillance, epidemiology, and end results) program database for cancer specific survival rates in stage IV NSCLC patients who were diagnosed between 1991 and 2004 in the SEER catchment geographic areas. The primary exposure of interest was race. The eight different race groups were non-Hispanic whites, Hispanics, African Americans, American Indians/Alaskan natives, Filipinos, Japanese, Chinese, Hawaiians, and other. The later group consisted mainly of a mix of different Asian subpopulations. We performed uni- and multivariate non-parametrical and parametrical survival analysis and developed a final cox-proportional hazard model controlling for marital status, age at diagnosis, year of diagnosis, gender and histologic type and grade. We tested the proportional hazard assumptions with graphical and modeling methods Results: We identified 39,784 eligible patients. When compared to non-Hispanic whites the risk of death from lung cancer was highest amongst American Indians/Alaskan Natives hazard ratio 1.33(95% CI 1.09–1.62, p = 0.004). For patients with Chinese HR 0.84 (95% CI 0.77–0.91) and Filipino HR 0.80 (95% CI 0.73–0.88) ethnicity the risk of death from lung cancer was significantly lower when compared with non-Hispanic whites. Hispanics HR 1.00 (95% CI 0.94–1.07) and Blacks HR 1.00 (95% CI 0.97–1.04) had about equal hazards of death from stage IV NSCLC as whites. In patients of Japanese and Hawaiian origin a trend towards a lower hazard with HR 0.99(95% CI 0.90–1.08) and HR 0.97(95% CI 0.85–1.09) respectively was identified without reaching statistical significance. Conclusions: Significant racial disparities in the outcome in metastatic NSCLC can be observed in the US. The indigenous populations of the Western hemisphere have the worst outcome and the previously proposed worse outcome of African Americans with NSCLC when compared to non-Hispanic whites could not be confirmed in our study.

No significant financial relationships to disclose.

Marrow cell genetic phenotype change induced by human lung cancer cells

11108

Background: Murine lung-derived microvesicles are capable of inducing lung-specific mRNA in marrow cells, when co-cultured across from these cells, but separated from them by a cell-impermeable (0.4 micron) membrane. These converted murine marrow cells showed mRNA elevations, lung-specific protein production and enhanced capacity to convert to lung epithelial cells after in vivo transplantation into irradiated mice. We examine here whether fresh tissue from lung cancer patients would have the same capacity to genetically alter co-cultured human marrow cells. Methods: Lung cancer samples were collected from 5 patients undergoing surgery. Minced tumor tissue at 50–100 mg was co-cultured in a semi-permeable culture plate insert opposite 3.0 ×106 human marrow cells. The marrow cells were harvested after 2–7 days of co-culture. Marrow cell RNA was analyzed for lung specific mRNA using real time RT-PCR. Relative levels of gene expression was expressed a fold increase compared to level in controls. Results: Lung cancers studied were adenocarcinoma, endobronchial alveolar carcinoma, bronchioloalveolar carcinoma, non-small cell carcinoma and squamous cell carcinoma. mRNAs for aquaporin 1–5, specific for type I pneumocytes and surfactant A-D, specific for type II pneumocytes, were measured. Aquaporin I was elevated in marrow cells from co culture with all lung cancers; elevations ranging from 2.15 to 56.7 fold (mean 23 fold). Similarly surfactant B mRNA was induced in marrow cells by all lung cancers with fold elevations ranging from 7.9 to 2164 (mean fold elevation 668). More variable elevations were also seen with aquaporin 3, 4, and 5, surfactant A, surfactant C, and surfactant D. Ultracentrifugation (28,000 g) of conditioned media from these cancers revealed the presence of microvesicles with diameters of 100–180 nm. Conclusions: These observations indicate that the genetic phenotype of cells in the vicinity of lung cancer cells can be altered and that these alterations might be mediated by microvesicle transfer of genetic information.

No significant financial relationships to disclose.

Is survival improving in stage IV non-small cell lung cancer?

6577

Background: Non small cell lung cancer (NSCLC) represents the number one cause of cancer mortality in the United States. Over several decades clinical research has focused on the development of new, more active chemotherapeutic drugs to improve survival. Over the time period from 1994 to 2003 six drugs have been approved for the treatment of metastatic NSCLC. We are presenting a population based analysis of the survival in patients with metastatic NSCLC in the US from 1981–1990, 1991–1997 and 1998–2003. We also provide a pharmaco-economic view of this observation. Methods: We analyzed the SEER (Surveillance, Epidemiology, and End Results) program database for cancer specific survival rates in stage IV NSCLC patients who were diagnosed between 1980 and 2003 in the SEER catchment geographic areas. The primary exposure of interest was the year of diagnosis. Results: We identified 52,086 eligible patients in total. 8,950, 21,111 and 18,712 patients were diagnosed 1981 to1990, 1991 to 1997 and 1998 to 2003 respectively. The cox proportional hazard ratios were 0.97 (95% CI 0.94–0.99) and 0.85 (0.83–0.88) for the time periods 1991 to 1997 and 1998 to 2003, respectively, using the time period from 1981 to1990 as reference. This subtle increase in survival was strictly paralleled by increasing costs for the medical care of this patient population. Conclusions: The survival of stage IV NSCLC patients seems to be mildly improving, what is paralleled by increasing cost for the care of those patients.

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No significant financial relationships to disclose.

Is squamous cell histology an adverse prognosticator for survival of malignancies of the upper urinary tract?

6617

Background: Carcinomas of the renal pelvis and ureter are rare diseases, accounting for only about 1% of all urogenital malignancies. Previous reports suggest that squamous cell histology is associated with inferior survival. We present the largest population based analysis to date of survival in patients with upper urinary tract malignancies. Methods: We analyzed the Surveillance, Epidemiology and End Results database for cancer specific survival rates in patients with renal pelvis and ureteral malignancies who were diagnosed between 1973 and 2003 in the SEER catchment geographic areas. The primary exposure of interest was the underlying histology, squamous cell versus transitional cell differentiation. We performed descriptive statistics, non parametric survival analysis, and cox proportional hazard analysis. Results: We identified 13,213 eligible patients, 7,716 renal pelvis and 5,497 ureteral carcinomas. Among this cohort, 179 patients had squamous cell carcinoma (SCC), 12,395 had transitional cell carcinoma (TCC), including 121 papillary, and 619 had other histologies. Overall, patients with SCC histology fared worse. The median overall survival time was 10 months for SCC and 63 months for TCC. The cox analysis revealed a HR 0.42 (95% CI 0.36–0.47) for TCC when compared to SCC and corrected for decade of diagnosis, age, gender, prior treatment, and race. The difference between the two groups was entirely attributable to survival differences in patients with loco-regional disease. However, when stratified by lymph node involvement this difference disappeared for patients with locally involved lymph nodes (p = 0.84) and for patients with clear lymph nodes (p = 0.92). Conclusions: SCCs of the upper urinary tract present at a higher clinical stage and appear to represent more aggressive disease when compared to other histologies. However, when appropriately staged according to lymph node status, the survival of TCC and SCC of the upper urinary tract is identical when compared stage by stage.

No significant financial relationships to disclose.