172. Risk Factors for 30-Day Mortality in Patients with Staphylococcus aureus Bacteremia at a Community Hospital: A Prospective Case–Control Study

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Disclosures

Clinical and pharmacokinetic (PK) findings in a phase I study of 7-t-butyldimethylsilyl-10-hydroxycamptothecin (AR-67) in patients with refractory solid tumors

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Background: AR-67 is a 3rd generation camptothecin analog selected for development based on the high in vitro stability of its pharmacologically active lactone form and high potency in preclinical models. This report describes the initial phase I study of intravenous AR-67 in adults with refractory solid tumors. Methods: AR-67 was infused over 1 hour for 5 days of a 21-day cycle using an accelerated titration phase I trial design. PK was performed on the 1st and 4th day of cycle 1. AR-67 was assayed with a validated chromatography method. Toxicity and response were assessed using NCI CTC (v3) grading scale and RECIST. Results: In total, 26 patients were treated at 9 dose levels (mg/m2/day): 1.2 (n=2), 1.67 (n=3), 2.34 (n=3), 3.2 (n=3); 4.5 (n=1), 6.3 (n=1), 7.5 (n=7), 8.9 (n=4) and 12.4 (n=2). Median age 62 (range 31–79), 15M/11F, median prior therapies 3 (range 1 to 6). Tumor types included: colorectal (8), non-small cell lung (NSCLC) (4), small cell lung (3), soft tissue sarcoma, (3), head and neck (2), prostate (2), and other (4). 21 subjects completed 2 or more cycles of therapy, 5 subjects received 1 cycle of therapy and had rapid disease progression (1 received 2d of drug prior to PD), 1 subject is still under treatment after 9 cycles. DLTs were observed in 5 patients: 2 of 2 at 12.4 mg/m2/day (Gr 4 febrile neutropenia, Gr 3 fatigue); 2 of 4 at 8.9 mg/m2/day (Gr 4 thrombocytopenia), 1 of 7 at 7.5 mg/m2/day (Gr 4 thrombocytopenia). Common C1 worst-grade drug related toxicities (CTC I/II % vs III/IV %): Hg (27/8), WBC (11/19), ANC (19/8), platelets (19/12), fatigue (15/8) insomnia (8/0), flushing (15//0), constipation (8/0), nausea (23/0), ALT elevation (12/0), hiccups (8/0). Antitumor activity, assessed by development of PR and SD, was observed in NSCLC, SCLC, colon and bladder cancer. The lactone form was predominant in plasma (>85% of AUC) at all time points. Clearance was constant with increasing dose and exposure (AUC) correlated with toxicity. Conclusions: AR-67 has superior lactone stability compared to approved analogs, has a predictable toxicity profile that did not include diarrhea and has activity in NSCLC. The RP2D is 7.5 mg/m2/day for 5 days of a 21-day cycle. This work was supported by R21-CA-123867 and Arno Therapeutics.

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Pharmacokinetics (PK) of the highly lipophilic and blood stable camptothecin AR-67 (7-t-butyldimethylsilyl-10- hydroxycamptothecin) in adult patients with solid malignancies

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Background: Camptothecin analogs possess a labile lactone ring, which readily undergoes a pH dependent, albeit reversible, hydrolysis in plasma to yield a carboxylate moiety. The latter is considered inactive due to its electronegative charge that impedes transport into cells. Furthermore, the carboxylate is cleared rapidly and causes toxicity in eliminating organs due to lactonation. AR-67 is a highly lipophilic 3rd generation analog with superior stability of its lactone form in preclinical models. This report describes the PK of AR-67 in patients with refractory solid tumors enrolled in a phase I study. Methods: AR-67 was infused over 1 hr for 5 days every 21-days. PK was performed on the 1st and 4th day of cycle 1. Blood, plasma, and urine were collected (0–24 hrs) from 26 patients (see 09-AB-30336-ASCOAM) treated at 9 dose levels: 1.2–12.4 (mg/m2/day). AR-67 carboxylate and lactone were assayed with a validated chromatography method. Results: AR-67 was detectable at all dose levels. Blood concentrations mirrored those in plasma and were superimposable when adjusted by the hematocrit. AR-67 concentration peaked at the end of the 1-hr infusion and declined biexponentially with a terminal t1/2 of 1.4 hr (plasma lactone). A linear relationship was observed between dose and AUC. The lactone clearance on Day 1 was 16.6 (±5.5) vs. 19.6 (±6.3) L/hr/m2 on Day 5. The carboxylate clearance was ∼ 6-fold higher. Lactone was the major form in all samples and its area under the time vs. concentration curve (AUC) was 85.5% (range 74.0%-94.1%) of the total AUC. Urine (0–24 hr) contained 2.5% (0.3%-6.7%) of the dose on Day 1 vs. 2.7% (0.9–11.1%) on Day 4. Extensive metabolite peaks were not observed in plasma, blood, or urine samples. Plasma protein binding of the carboxylate was 90% (range 80%-96%) vs. 95% (range 90%-98%) for the lactone. Conclusions: AR-67 is a lipophilic camptothecin with a unique PK profile. Unlike other clinically approved analogs with lower lactone stability (35%-65%), over 85% of the AR-67 AUC is in the active lactone form. This high lactone-low carboxylate exposure coupled with the apparently limited metabolism of AR-67 may result in increased activity and decreased toxicity.

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Ring appearance of Tc-99m MIBI thoracic SPECTs and increased uptake on Tc-99m HMDP thoracic SPECTs in a pulmonary mass of small cell carcinoma

Tc-99m MIBI is taken up avidly by viable tumor tissue and does not accumulate in the necrotic carcinoma. We present a patient who underwent Tc-99m MIBI and Tc-99m HMDP thoracic SPECTs: a large area of increased MIBI uptake with central photopenia (ring appearance) in the right upper lung localizes bone imaging agent and does not localize multiple areas of intense uptake in the metastatic hilar mediastinum lymph nodes. Rapid growth of tumor cells in the lung leading to central necrosis/ischemia accounts for bone imaging agent localization in the tumor, as well as the ring-appearance of lung mass on Tc-99m MIBI imaging. These findings may reflect less viability of the lung tumor as compared with intense MIBI uptake in hilar/mediastinal lymph node uptake without bone agent localization.

Small cell carcinoma with two paraendocrine syndromes

Simultaneous elevated levels of ectopic arginine vasopressin (AVP) and ectopic adrenocorticotropin (ACTH) were found in a patient with small cell carcinoma (SCC). The finding of one of these paraendocrine syndromes at the time of diagnosis is common; however, the simultaneous presence of both syndromes has been reported in the literature only on four occasions in the past 25 years. This is the only report in which elevated plasma levels of both hormones are documented in a patient who simultaneously fulfills the criteria for the syndrome associated with each ectopically produced peptide. In the English-language literature, this is the first case that demonstrates by immunohistochemical staining the presence of both of these hormones in the patient's neoplasm. In addition to the use of radiographs, the presence of paraendocrine disorders can provide a method of monitoring the patient's response to therapy. The levels of ACTH and AVP were assayed during this patient's course and correlated with disease refractory to therapy, resulting in poor survival.

Randomized phase II evaluation of iproplatin (CHIP) and carboplatin (CBDCA) in lung cancer. A Southeastern Cancer Study Group trial

Cisplatin-containing regimens have shown activity in both small and non-small cell lung cancer. We therefore conducted a randomized Phase II trial of the new platinum congeners iproplatin and carboplatin in bronchogenic carcinoma. The overall response rate in chemotherapy-naive non-small cell patients with iproplatin was 3/48 (6%; 95% confidence interval 2-18%) and with carboplatin 6/50 (12%; 95% confidence interval 5-25%). The response rates in previously treated small cell patients were 0/16 and 1/18, respectively. Overall, neither agent has pronounced activity in bronchogenic carcinoma.

Treatment of unresectable pancreatic carcinoma using irradiation with concurrent intravenous 5-FU infusion therapy

Ten patients with unresectable carcinoma of the pancreas who had only bypass surgery to relieve biliary obstruction were treated with radiation therapy to the pancreas and liver with concurrent 5-fluorouracil (5-FU) intravenous infusion therapy. Treatment regimen was three cycles of chemoradiotherapy with a two week rest period between cycles. 5-FU (1,000 mg/m2 per day) was administered by continuous infusion for the first five days of each cycle. In the first cycle radiotherapy was given to the pancreas to 2,000 cGy/10 fractions using 6 to 10 mV x-rays. In the second cycle 2,400 cGy/160 rads/fraction radiation was delivered to the pancreas and whole liver. In the third cycle, 1,600 cGy/160 rads/fraction to a total dose of 6,000 rads, was administered to the pancreatic tumor. All ten patients completed the treatments without interruption. No major side effects were noticed during the course of treatment. Survival ranged from 9 to 16 months and median survival was 11 months. Symptomatic relief was obtained in all 10 patients. One patient who lived for 16 months developed duodenal stenosis and underwent gastrojejunostomy.

Treatment of liver metastases with a combination of chemotherapy and hyperfractionated external radiation therapy

Twelve patients with liver metastases from colorectal cancer were treated with 5-FUdR hepatic artery, or 5-FU i.v. infusion therapy and hyperfractionated whole liver irradiation (2,100 rad in 14 fractions, two fractions/day over a period of 9 days). All 12 patients tolerated treatments well and no unusual toxicity was noted from this therapy. Response was assessed on completion of treatment and on follow-up examinations by physical examination, repeat liver function tests (LFTS), and CT scans. Symptomatic relief was achieved in all patients. Decreased liver size and improved LFTS were noted in 10/12 (83%) of patients. CT scans showed decrease in size of metastases. Survivals ranged from 16 to 120 weeks. Infusion therapy was given either by implanted infusion pump or continuous i.v. infusion therapy, 5-FUdR 0.3 mg/kg of body weight/day or 5-FU 1,000 mg/m2/day. Hyperfractionated external radiotherapy with concomitant 5-FUdR hepatic artery of 5-FU i.v. infusion therapy for liver metastases was well-tolerated, and both subjective and objective response and quality of survival were noted. Hyperfractionated external beam irradiation with concurrent chemotherapy can be effective in palliating patients with liver metastases.

Phase II evaluation of diaziquone in gastric and pancreatic cancers. A Southeastern Cancer Study Group Trial

Seventeen patients with pancreatic carcinoma and 30 patients with gastric carcinoma were treated with diaziquone on days 1 and 8 of repeated 4-week courses. No objective responses were seen. Toxicity was primarily myelosuppression, nausea, and vomiting. Since only 10 chemotherapy-naive patients were treated in each disease category, we do not regard this as a definitive trial, but our experience suggests that this dose schedule is not likely to be useful in these types of cancer.

Subrenal capsule assay: feasibility of transporting tissues to a central facility for testing

Hepatic hemangioma patients with Kasabach-Merritt syndrome have reportedly been cured by liver transplantation. However, liver transplantation as a potential cure for a stable patient without Kasabach-Merritt syndrome remains debatable. We report the case of a 27-year-old female patient with a giant hepatic hemangioma. The hemangioma measured 50 × 40 × 25 cm in size and weighed 15 kg, which is the largest and heaviest hemangioma reported in the literature. The patient showed jaundice, ascites, anemia, and appetite loss; but no disseminated intravascular coagulation was observed through laboratory findings. We successfully operated using a right lobe graft without the middle hepatic vein from a 55-year-old donor. At the long-term follow-up, the patient experienced two acute rejections, which were confirmed by biopsy. However, the patient still survives with good graft function after 50 months.

A phase II study Nolvadex: tamoxifen citrate in the treatment of advanced prostatic adenocarcinoma

Prostatic Carcinoma is known to be a hormonally responsive neoplasm which contains both estrogen and androgen receptors. Sixty-three heavily pretreated patients with Stage D prostatic adenocarcinoma received tamoxifen (Nolvadex) at a dose of 20 mg twice a day. Patients were examined every 4 weeks at which time they also had a white count, hemoglobin and platelet count, acid phosphatase, SMA-12, and recording of the status of their measurable or evaluable disease. If the evaluable disease was metastatic to bone, the relevant x-rays were repeated every 8 weeks. The median age of the patients was 66. The Karnofsky status of the patients for whom this information was known was 40% (6), 45% (1), 50% (1), 60% (8), 70% (11), 80% (6), 90% (5), and 100% (2). Forty-one patients were eligible for response evaluation; the majority had evaluable bone disease. No serious toxicity was encountered; two patients withdrew from the protocol because of nausea and vomiting and one patient had hot flashes. One complete response was seen in measurable nodal disease which is continuing after 13+ months, 1 minor response was seen in evaluable bone disease, and 4 patients had long (more than 10 months) stability of bone disease with subjective improvement. We conclude that although the response rate was low, patient acceptability was excellent and that tamoxifen may warrant further trial in a less heavily pretreated patient population.

Faculty and house staff attitudes toward cancer status and comparison

This study describes a survey of attitudes toward cancer held by faculty and house staff physicians in a major teaching hospital. The instrument was designed to measure the two groups' (a) responses to declaratory statements about cancer and cancer patient management, (b) anticipated reactions to situations involving cancer, and (c) perceptions of each other relative to cancer-oriented issues. Data obtained from this project indicated significant differences between the perceptions of faculty and house staff members as to their counterpart's approach to cancer. In addition, the study has specific implications for increased attention toward attitudes and interpersonal communication as factors for improved cancer education in medical schools.

The role of thymectomy in red cell aplasia

Red cell aplasia is an unusual cause of anemia. Fifty percent of all patients with red cell aplasia will have a thymoma. Twenty-five to 30% of those who undergo thymectomy will be cured. Data are presented that suggest that any patient with red cell aplasia should have thymectomy through a median sternotomy. One of 3 such patients who underwent the operation has had complete remission for two years.

cis-Dichlorodiammineplatinum(II) and hexamethylmelamine in the treatment of non-oat cell lung cancer: a pilot study of the Southeastern Cancer Study Group

Fifty-one patients with metastatic non-oat cell carcinoma of the lung were treated with a combination of cis-dichlorodiammineplatinum(II) and hexamethylmelamine. The overall response rate (all cell types) was 16%. Four of 20 patients with adenocarcinoma had a partial response and an additional five patients classified as having stable disease had tumor regression less than 50%. The median survival of responders and of those with stable disease (all types) was 8 and 7 months respectively, significantly longer than the median survival of patients who progressed (median survival, 2 months [P less than 0.05]). The major dose-limiting toxicity was nausea and vomiting in over half of the patients; hematologic toxicity and peripheral neuropathy were the other adverse effects of the combination.

Use of radiolabeled antibodies to carcinoembryonic antigen for the detection and localization of diverse cancers by external photoscanning

To determine whether tumors containing carcinoembryonic antigen could be detected by administration of a radiolabeled, affinity-purified, goat lgG having 70 per cent immunoreactivity against carcinoembryonic antigen, 18 patients with a history of cancer of diverse histopathology received an average total dose of 1.0 mCi of 131l-labeled lgG. Total-body photoscans were performed with a gamma scintillation camera at various intervals after administration of the radioactive antibody. Ordinary photoscans proved difficult to interpret because of blood-pool background radioactivity, thus necessitating the computer subtraction of radioactive blood-pool agents from the antibody's 131l activity. Tumor location could be demonstrated at 48 hours after injection in almost all cases studied. The scans were negative in patients without demonstrable tumors or with tumors apparently devoid of carcinoembryonic antigen. Circulating antigen levels of up to 350 ng per milliliter did not prevent successful tumor imaging after injection of the radioantibody.

Combined chemotherapy (COP) in treatment of mycosis fungoides: report of four cases

Four consecutive patients with mycosis fungoides received cyclic chemotherapy using cyclophosphamide, vincristine, and prednisone (COP). In one case, there was complete remission of disease for 15 months. In another, there was 50% regression of tumors with healing of the ulcerated surfaces. The third patient showed complete clearing of scaling and redness of the skin. In the fourth patient, the lesions progressed.