Further evaluation of intensified and increased total dose of cyclophosphamide for the treatment of primary breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-25

PURPOSE

In 1989, the National Surgical Adjuvant Breast and Bowel Project initiated the B-22 trial to determine whether intensifying or intensifying and increasing the total dose of cyclophosphamide in a doxorubicin-cyclophosphamide combination would benefit women with primary breast cancer and positive axillary nodes. B-25 was initiated to determine whether further intensifying and increasing the cyclophosphamide dose would yield more favorable results.

PATIENTS AND METHODS

Patients (n = 2,548) were randomly assigned to three groups. The dose and intensity of doxorubicin were similar in all groups. Group 1 received four courses, ie, double the dose and intensity of cyclophosphamide given in the B-22 standard therapy group; group 2 received the same dose of cyclophosphamide as in group 1, administered in two courses (intensified); group 3 received double the dose of cyclophosphamide (intensified and increased) given in group 1. All patients received recombinant human granulocyte colony-stimulating factor. Life-table estimates were used to determine disease-free survival (DFS) and overall survival.

RESULTS

No significant difference was observed in DFS (P =.20), distant DFS (P =.31), or survival (P =.76) among the three groups. At 5 years, the DFS in groups 1 and 2 (61% v 64%, respectively; P =. 29) was similar to but slightly lower than that in group 3 (61% v 66%, respectively; P = 08). Survival in group 1 was concordant with that in groups 2 (78% v 77%, respectively; P =.71) and 3 (78% v 79%, respectively; P =.86). Grade 4 toxicity was 20%, 34%, and 49% in groups 1, 2, and 3, respectively. Severe infection and septic episodes increased in group 3. The decrease in the amount and intensity of cyclophosphamide and delays in therapy were greatest in courses 3 and 4 in group 3. The incidence of acute myeloid leukemia increased in all groups.

CONCLUSION

Because intensifying and increasing cyclophosphamide two or four times that given in standard clinical practice did not substantively improve outcome, such therapy should be reserved for the clinical trial setting.

A randomized trial of five and three drug chemotherapy and chemoimmunotherapy in women with operable node positive breast cancer

Women with breast carcinoma and four or more involved ipsilateral axillary lymph nodes were randomly assigned to receive an induction course and 2 yr of maintenance chemotherapy with cyclophosphamide, methotrexate and 5-fluorouracil (CMF, 150 patients), CMF plus vincristine and prednisone (CMFVP, 166 patients), or chemoimmunotherapy with CMF plus the methanol extraction residue of BCG (CMF-MER, 85 patients). After 5 yr of accrual and a median follow-up of 34 mo, CMFVP is superior to CMF (p less than 0.01) with disease-free survival estimates at 4 yr of 60% for CMFVP compared to 45% for CMF. The disease-free survival advantage of CMFVP over CMF was greater in postmenopausal (p = 0.02) than in premenopausal patients (p = 0.09). CMF-MER was similar to CMF alone. CMF related side effects were similar in each regimen (see text), except for a greater incidence of leukopenia during induction with CMF than with CMFVP (p less than 0.01).

Multiple myeloma resistant to melphalan: treatment with doxorubicin, cyclophosphamide, carmustine (BCNU), and prednisone

Sixty-five patients with multiple myeloma resistant to melphalan were randomized to receive cyclophosphamide, doxorubicin (Adriamycin), and prednisone (CAP) (30 patients) or carmustine (BCNU), doxorubicin, and prednisone (BAP) (35 patients). Objective responses occurred in two patients in the CAP group and in seven in the BAP group. Indirect responses were noted in seven additional patients in the CAP group and in six additional patients in the BAP group. Toxic effects consisted mainly of leukopenia and thrombocytopenia. Median survival did not differ between the two treatment groups (CAP, 8.4 months; BAP, 7.7). Objective responders had a longer survival than nonresponders (14.5 vs 7.7 months).

Leukemic iritis with hypopyon

A patient with acute lymphoblastic leukemia who had received CNS sanctuary treatment with cranial X-irradiation and intrathecal methotrexate displayed his first sign of relapse as iritis with malignant hypopyon. Treatment included topical and subconjunctival corticosteroids and local X-irradiation. Leukemic infiltration of the iris may be the first sign of leukemic relapse. Slit-lamp examination should be performed in all leukemic patients with ocular symptoms.

Platelet satellitism and phagocytosis by neutrophils: association with antiplatelet antibodies and lymphoma

Satellitism and phagocytosis of platelets by neutrophils in EDTA anticoagulated blood have been considered in vitro phenomena without clinical significance. We observed these in a patient with acute, severe thrombocytopenic purpura who subsequently proved to have malignant lymphoma. Wide oscillations in the platelet count were noted and recurrent, severe gastrointestinal bleeding occurred even when the platelet count was normal. Platelet function was abnormal as shown by decreased platelet adhesion to glass beads, absence of a secondary wave of aggregation in response to ADP and eqinephrine, and no aggregation with collagen. Suspension of control platelets in the patient's plasma induced similar aggregation defects in the control platelets. Combination chemotherapy resulted in regression of lymphadenopathy, but platelet abnormalities and bleeding persisted. Platelet satellitism and phagocytosis by neutrophils seen on peripheral blood films may be associated with true thrombocytopenia, abnormal platelet function and bleeding with an underlying systemic disease.

Studies of nondefective adenovirus 2-simian virus 40 hybrid viruses. VI. Characterization of the DNA from five nondefective hybrid viruses

Certain biophysical characteristics of the DNA from each of the five nondefective adenovirus 2 (Ad2)-simian virus 40 (SV40) hybrid viruses (Ad2(+)ND(1), Ad2(+)ND(2), Ad2(+)ND(3), Ad2(+)ND(4), Ad2(+)ND(5)) have been determined. The guanine plus cytosine content varied from 55 to 57% and was not significantly different from that of nonhybrid Ad2 (56%), and the hybrid DNA molecules had mean molecular lengths which were similar to that of the standard, Ad2. The Ad2 and SV40 components of each hybrid were linked by alkali-resistant, presumably covalent bonds. The percentage of SV40 DNA in each hybrid virus was determined by hybridization with SV40 complementary RNA in a calibrated system. The results indicate that each hybrid virus DNA contains a different percentage of SV40 nucleotide sequences. The estimated size of the SV40 DNA component varies from 48,000 daltons for Ad2(+)ND(3) to 840,000 daltons for Ad2(+)ND(4), the latter being equivalent to between one-fourth and one-third of the SV40 genome.

Studies of nondefective adenovirus 2-simian virus 40 hybrid viruses. V. Isolation of additional hybrids which differ in their simian virus 40-specific biological properties

Four new nondefective adenovirus 2 (Ad2)-simian virus 40 (SV40) hybrid viruses have been isolated. Although these viruses (designated Ad2(+)ND(2), Ad2(+)ND(3), Ad2(+)ND(4), and Ad2(+)ND(5)) were clonal derivatives of the same Ad2-SV40 hybrid population, they differ significantly from each other and from the previously isolated nondefective hybrid, Ad2(+)ND(1), in their biological properties or in the amount of SV40-specific RNA induced during lytic infection.Like Ad2(+)ND(1), Ad2(+)ND(2), and Ad2(+)ND(4) pass serially in both human embryonic kidney (HEK) and primary African green monkey kidney cells. In contrast, Ad2(+)ND(3) and Ad2(+)ND(5) pass serially only in HEK cells. Ad2(+)ND(2) is like Ad2(+)ND(1) in that it induces the SV40 U antigen, but not SV40 T antigen; however, in contrast to the perinuclear SV40 antigen induced by Ad2(+)ND(1), the SV40 antigen induced by Ad2(+)ND(2) is located peripherally in the cytoplasm as well as in the perinuclear region of infected cells. Ad2(+)ND(4) induces both the SV40 T and U antigens. Ad2(+)ND(3) and Ad2(+)ND(5) do not induce serologically detectable SV40 antigens and are distinguished from each other on the basis of the relative quantities of SV40-specific RNA which they induce. The induction of different SV40-specific functions suggests the incorporation of different segments of SV40 DNA within the genomes of the respective hybrid viruses.

Studies of nondefective adenovirus 2-simian virus 40 hybrid viruses. IV. Characterization of the simian virus 40 ribonucleic acid species induced by wild-type simian virus 40 and by the nondefective hybrid virus, Ad2 + ND 1

Ad2(+)ND(1), a nondefective adenovirus 2 (Ad2)-simian virus 40 (SV40) hybrid virus, has been previously shown to contain a small segment of the SV40 genome covalently linked to Ad2 deoxyribonucleic acid (DNA). The SV40 portion of this hybrid virus has been characterized by relating the SV40-specific ribonucleic acid (RNA) sequences transcribed from the Ad2(+)ND(1) DNA to those transcribed from the DNA of SV40 itself. RNA-DNA hybridization-competition studies indicate that the SV40 component of Ad2(+)ND(1) consists of some, but not all, of that part of the SV40 genome which is transcribed early, i.e., prior to viral DNA replication, in SV40 lytic infection.

Studies of nondefective adenovirus 2-simian virus 40 hybrid viruses. 3. Base composition, molecular weight, and conformation of the Ad2+ND genome

The nondefective adenovirus 2 (Ad2)-simian virus 40 (SV40) hybrid virus, Ad2(+)ND(1), differs from the defective Ad-SV40 hybrid populations previously described, in that this hybrid virus can replicate without the aid of nonhybrid adenovirus helper. Consequently, the deoxyribonucleic acid (DNA) from this virus, which can be obtained free of nonhybrid adenovirus DNA, is well suited for biophysical studies on Ad-SV40 hybrid DNA. Such studies have been performed and demonstrate Ad2(+)ND(1) DNA to have a buoyant density (1.715 g/cm(3)) and thermal denaturation profile (T(m) = 75.1 C) almost identical with nonhybrid Ad2 DNA. Furthermore, its molecular weight, as determined by analytical zone sedimentation and electron microscopy, was 22 x 10(6) to 25 x 10(6) daltons, which is also very similar to that determined for Ad2. Electron micrographs showed all of the hybrid molecules to be double-stranded and linear. By using this determination of the molecular weight of Ad2(+)ND(1) DNA and assuming that 1% of this molecule consists of covalently linked SV40 DNA (see companion paper), we calculate that the hybrid DNA molecule contains 220 x 10(3) to 250 x 10(3) daltons of SV40 DNA, or the equivalent of one-tenth of the SV40 genome.

Studies of nondefective adenovirus 2-simian virus 40 hybrid viruses. II. Relationship of adenovirus 2 deoxyribonucleic acid and simian virus 40 deoxyribonucleic acid in the Ad2+ND genome

A nondefective adenovirus 2 (Ad2)-simian virus 40 (SV40) hybrid virus, Ad2(+)ND(1), has been plaque-isolated from an Ad2-SV40 hybrid population. This virus, unlike the defective Ad-SV40 hybrid populations previously described, replicates without the aid of nonhybrid adenovirus helper. Consequently, the hybrid virus deoxyribonucleic acid (DNA) can be obtained free of nonhybrid adenovirus DNA. The DNA of the Ad2(+)ND(1) virus was shown by ribonucleic acid (RNA)-DNA hybridization to consist of nucleotide sequences complementary to Ad2- and SV40-specific RNA. Techniques of equilibrium density and rate zonal centrifugation were employed to demonstrate that these Ad2 and SV40 nucleotide sequences were linked together in the same DNA molecules by alkali-resistant bonds. Calibration curves were established relating the amount of tritium-labeled SV40-specific RNA (prepared in vitro or in vivo) bound to given amounts of SV40 DNA in a hybridization reaction, and these curves were employed to determine the equivalent amount of SV40 DNA in the Ad2(+)ND(1) molecule. From the results obtained, it was estimated that 1% of the Ad2(+)ND(1) DNA consists of SV40 nucleotide sequences.

Virus-specific deoxyribonucleic acid in simian virus 40-exposed hamster cells: correlation with S and T antigens

Several homologous hamster embryonic cell lines, transformed in association with simian virus (SV) 40 infection, were examined for the presence of deoxyribonucleic acid (DNA) complementary to SV40 ribonucleic acid (RNA) made in vitro. The methods employed permitted the detection of 10(-5) mug of viral DNA in 100 mug of cellular DNA, corresponding to one-fifth of an SV40 DNA molecule per cell. Those lines which contained both the SV40 surface (S) and tumor (T) antigens also contained DNA complementary to SV40 RNA synthesized in vitro. In contrast, neither of two lines which contained S, but not T, antigen contained detectable DNA complementary to SV40 RNA. These findings suggest that the production of S antigen does not depend upon the persistence of SV40 DNA in transformed cells.

In vitro transformation by the adenovirus-simian virus 40 hybrid viruses. V. Virus-specific ribonucleic acid in cell lines transformed by the adenovirus 2-simian virus 40 and adenovirus 12-simian virus 40 transcapsidant hybrid viruses

The ribonucleic acid-deoxyribonucleic acid hybridization technique was utilized to determine the presence of adenovirus (ad) and SV40 genetic information and to determine which ad genomes were present in clones of hamster cells transformed with the ad 2-SV40 and ad 12-SV40 transcapsidant hybrid virus populations. The results were correlated with the morphology of the transformed cells and colonies. It was found that cells transformed by either transcapsidant virus which had an SV40 morphology contained the ad 7 and SV40 genomes, whereas cells with a typical ad morphology contained only ad genetic information. Cells and colonies with morphological features of both ad- and SV40-transformed cells contained either the ad 2, or ad 12 genomes, depending on the transcapsidant used, together with the ad 7 and SV40 genomes. The results indicate the following: at least three different events occurred during transformation of hamster cells by the transcapsidant virus populations; the morphology of the resulting clones is determined by the viral genome(s) present; the linkage of the ad 7-SV40 genomes is confirmed since the ad 7- SV40 genomes were never found to be dissociated; the defective ad 7-SV40 genomes are capable of causing transformation; and the transcapsidant particle is probably composed of only ad 7 and SV40 genetic information.

A nondefective (competent) adenovirus-SV40 hybrid isolated from the AD.2-SV40 hybrid population

A new nondefective hybrid virus has been plaque-isolated from the Ad.2-SV40 hybrid population. This virus replicates efficiently with one-hit kinetics in both human embryonic kidney and African green monkey kidney cells, induces an SV40 specific antigen which is detectable by immunofluorescence and complement-fixation using sera from SV40 tumor-bearing hamsters, and produces SV40-specific RNA detectable by DNA-RNA hybridization. The SV40-specific antigen induced by this virus is heat-stable, sensitive to inhibitors of DNA synthesis, serologically different from SV40 T and viral antigens, and is an unrecognized SV40 antigen.

Virus-specific nucleic acids in SV40-exposed hamster embryo cell lines: correlation with S and T antigens

A number of homologous SV40-exposed hamster embryonic cell lines were examined for the presence of RNA complementary to SV40 DNA. Only those lines containing the SV40 T antigen were found to have such virus-specific RNA. In lines containing the SV40 S antigen, but not the SV40 T antigen, virus-specific RNA was not detected. These findings suggest that the S antigen is not coded for directly by the SV40 genome.

Characteristics of the RNA synthesized in vitro by the normal human small lymphocyte and the changes induced by phytohemagglutinin stimulation

These studies demonstrate that the circulating human small lymphocyte synthesizes ribonucleic acid (RNA) of high molecular weight which is not primarily a ribosomal precursor and which is, in part, complementary to human deoxyribonucleic acid (DNA). The stimulation of these lymphocytes by PHA brings a cell population in which few ribosomes are synthesized to a functional condition in which a large amount of these particles are produced. This increase in the synthesis of ribosomal RNA is one of the earliest and most relevant effects of PHA on the RNA metabolism of small lymphocytes.

Transformation of primary rat embryo cells by adenovirus type 2

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