Clinical factors predictive of overall survival (OS) and the identification of prognostic groups in patients (pts) with unresectable stage III non-small cell lung cancer (NSCLC) treated with chemoradiotherapy on Cancer and Leukemia and Group B trial (CALGB) 39801

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Background: CALGB 39801 was designed to test whether treatment with induction chemotherapy and concurrent chemoradiotherapy (arm B) would improve OS in comparison to identical chemoradiotherapy alone (arm A), and demonstrated no significant benefit in OS for induction therapy. The objective of this analysis was to identify factors predictive of OS, and to use relevant factors to dichotomize pts into prognostic groups. Methods: Between July 1998 and May 2002, 331 pts were studied and included in a Cox proportional hazard regression analysis investigating previously identified prognostic factors: age (< 70 vs. ≥ 70 years), gender, race/ethnicity, hemoglobin (hgb) (< 13 vs. ≥13), performance status (PS) (0 vs.1), pretreatment weight loss (wt loss) (<5% vs. ≥ 5%), and treatment arm. Results: Cox regression analysis identified weight loss ≥ 5%, age ≥ 70, PS of 1, and hgb < 13 as predictive of worse survival (p<0.05), but not treatment arm (p=0.55). The median survival for pts with 0 (n=66), 1 (n=100), 2 (n=100), or ≥ 3 (n=65) risk factors were 24, 18, 10, and 8 months, respectively (p=0.0001). The pts were dichotomized into “poor prognosis” (PP) defined as ≥2 factors (n=165) and “good prognosis” (GP) defined as ≤ 1 factors (n=166). The hazard ratio (HR) for overall survival for the PP in comparison GP was 1.88 (95% CI, 1.49 to 2.37; p-value < 0.0001); the median survival times (MST) observed were 9 and 18 months, respectively (p<0.0001). The reasons for discontinuing treatment, and the rates of hematologic and non-hematologic adverse events were similar between the two groups. In the PP group the OS was similar between arms A (n=82) and B (n=83) (HR=0.97, 95% CI, 0.70 to 1.4; p=0.34); MST of 8.7 and 9.5 months, respectively. In the GP the OS was similar between arms A (n=79) and B (n=87) (HR=0.86, 95% CI, 0.63 to 1.1; p=0.87); MST of 19.3 and 17.6 months, respectively. Conclusions: Factors predictive of OS can be used to dichotomize pts into prognostic groups. Induction chemotherapy was not beneficial in either prognostic group.

No significant financial relationships to disclose.

Feasibility study of capecitabine (cap) and cisplatin (cis) with radiation therapy (RT) in the management of patients with locally advanced unresectable squamous cell carcinoma of the head and neck (HNSCC)

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Background: Concurrent chemoradiation has become the standard of care for locally advanced unresectable HNSCC. The most commonly used chemotherapy is cis and 5-fluorouracil (5-FU). We evaluated the feasibility of using cap and cis during RT in this population. Cap is an oral pro-drug of 5-FU that can be given daily with RT in order to enhance the activity of RT. Methods: Between Oct, 2003 and Sept, 2005, 12 male patients aged 46–83 were treated at the VA Medical Center. Patients received cis 100 mg/m2 on days 1 and 29 and cap 450 mg/m2 bid (2 hours prior to RT and 12 hours later) for 5 days of each week concurrent with RT to a total dose of 70 Gy in 35 fractions over 7 weeks. Primary endpoint of the study was toxicity. Results: All 12 patients were able to complete therapy. Treatment delays and/or dose modifications were needed in 7 patients. Treatment related toxicities included 6 patients with grade 3 mucositis and 5 patients with grade 3 dysphagia. Other grade 3 toxicities included 3 patients with dehydration and 1 patient each with leucopenia, constipation, nausea and vomiting, and odynophagia. Percutaneous gastrostomy (PEG) tubes were required in 5 patients. Complete response to chemoradiation was seen in 9 patients, 2 patients obtained partial response, and 1 patient progressed. Median progression free and overall survivals have not been reached with a median follow-up of 21 months. Conclusions: Cis and cap administered concurrently with RT has manageable toxicities and is active in patients with locally advanced unresectable HNSCC.

No significant financial relationships to disclose.

A randomized phase II trial comparing every 3-weeks carboplatin/paclitaxel with every 3-weeks carboplatin and weekly paclitaxel in advanced non-small cell lung cancer

BACKGROUND

The optimal schedule of taxane administration has been an area of active interest in several recent clinical trials.

METHODS

To address a pure schedule question, we randomized 161 patients with advanced stage IIIB or IV non-small-cell lung cancer (NSCLC) to either paclitaxel 225 mg/m2 every 3 weeks x 4 cycles or 75 mg/m2/week x 12 (cumulative dose on each arm = 900 mg/m2). Both arms received concurrent carboplatin AUC 6 every 3 weeks x 4 cycles.

RESULTS

The two arms were well-balanced in terms of known prognostic factors. The overall response rate and survival outcomes were similar on the two arms. There was significantly more grade 3/4 thrombocytopenia and grade 2-4 anemia on the weekly arm but less severe myalgias/arthralgias and alopecia. No difference in the rates of peripheral neuropathy was observed; however, patients on the every 3 weeks arm reported significantly more taxane therapy-related side-effects on the functional assessment of cancer therapy taxane subscale.

CONCLUSIONS

This randomized trial exploring schedule-related issues with carboplatin/paclitaxel confirms the versatility of this regimen.

Phase I and pharmacologic study of sequential topotecan, carboplatin, and etoposide

Inhibition of topoisomerase I by topotecan results in a compensatory increase in topoisomerase II levels associated with increased in vitro sensitivity of tumors to etoposide. Maximum synergy has been observed for the sequence of topotecan followed by etoposide. This is the pharmacologic rationale for the sequence of topotecan 0.4 mg/m(2) per day for 7 days continuous i.v. infusion, carboplatin i.v. on day 8, and etoposide 50 mg per day p.o. days 9 through 20. The carboplatin dosage was escalated from an AUC of 4 to 5 to 6 (Calvert formula). Up to six treatment cycles were administered at 28-day intervals. Eligible patients had metastatic non-small cell lung cancer (NSCLC) or extensive disease small lung cell lung cancer (SCLC), no prior chemotherapy, performance status 0-2, and adequate organ function. Follow-up was twice weekly in the first cycle for CBC and for topotecan and etoposide concentrations. Follow-up, thereafter, was weekly. Tumor response was assessed after two and six cycles and then as clinically indicated. At carboplatin AUCs of 4 and 5, no NCI grade 4 toxicity was observed in cycle 1 in cohorts of three patients each. At the AUC of 5, two patients experienced dose-limiting events after cycle 3, one grade 4 neutropenia lasting >3 days (no fever) and one failure to recover an absolute neutrophil count >1500/microl by day 35. This was, therefore, deemed the maximal tolerable dose. Number of treatment cycles per patient ranged between 1 and 6, and three patients completed six cycles. All patients were male, age 47-71, with NSCLC in one and SCLC in six. The patient with NSCLC had progressive disease after one cycle. One complete and three partial responses were observed in five patients with SCLC. Mean steady-state plasma concentrations during topotecan infusion ranged from 0.73 to 1.69 ng/ml, and mean etoposide concentrations ranged from 60 to 230 ng/ml. This sequence of topotecan, carboplatin, and etoposide appeared tolerable and active. Neutropenia was the dose-limiting toxicity.

Extensive stage small cell lung cancer

Small cell lung cancer is a rapidly proliferating, biologically aggressive form of lung cancer that has a short survival without treatment. Chemotherapy is the foundation of the therapeutic approach to patients with small cell lung cancer. Most patients present with extensive disease, and, although few patients are cured, significant improvement in survival is possible with modern chemotherapy. The role of radiation therapy in extensive disease is palliative, and surgery has little role in patient management. The standard chemotherapy regimen for patients with small cell lung cancer has become either cisplatin or carboplatin with etoposide. Second-line chemotherapy regimens are moderately effective in patients previously responding to initial chemotherapy. Newer chemotherapy agents show promise, but few randomized trials have been completed in extensive disease. Physicians should be encouraged to include their patients with extensive small cell lung cancer in the evolving clinical trials.

Carboplatin/Etoposide/Paclitaxel in the Treatment of Patients with Extensive Small-Cell Lung Cancer

The purpose of this study was to examine the safety and efficacy of carboplatin/etoposide/paclitaxel in patients with untreated stage IV non-small-cell lung cancer (NSCLC) and extensive small-cell lung cancer (SCLC). Carboplatin was administered intravenously (i.v.) at an area under the curve (AUC) of 6 with etoposide at either 80 or 100 mg/m2 i.v. days 1-3 and paclitaxel at 175 or 200 mg/m2 i.v. over 3 hours along with 5 g/kg of granulocyte colony-stimulating factor subcutaneously on days 4-18, repeated every 3 weeks for 6 courses. Thirty-one patients (five NSCLC and 26 SCLC) entered into this phase I study. The median age was 63 (range, 42 to 74 years), with 24 males and seven females. The recommended dose level for phase II testing was carboplatin AUC = 6, etoposide 80 mg/m2 days 1-3, and paclitaxel 175 mg/m2 over 3 hours. With seven patients at this level, 14% had grade 4 neutropenia, 14% had grade 4 thrombocytopenia, none had grade 2/3 neurotoxicity, and no toxic deaths occurred. One of five (20%) patients with NSCLC responded, and 19 of 22 (86%) evaluable SCLC patients experienced a response to therapy. SCLC patients had a median survival of 10 months. The combination of carboplatin/etoposide/paclitaxel has significant activity with acceptable toxicity in patients with extensive SCLC.

Efficacy of targeted chemoradiation and planned selective neck dissection to control bulky nodal disease in advanced head and neck cancer

PURPOSE

To determine the efficacy of targeted chemoradiation with the radiation plus platinum (RADPLAT) protocol and planned selective neck dissection in patients with N2 to N3 nodal disease associated with upper aerodigestive tract carcinoma.

METHODS

Analysis of 52 patients with N2a, N2b, or N3 disease involving 60 heminecks treated with intraarterial cisplatin, 150 mg/m2, and intravenous sodium thiosulfate, 9 g/m2, on days 1, 8, 15, and 22; radiation therapy, 180 to 200 cGy per fraction for 35 fractions (total dose, 68-74 Gy); and planned neck dissection (33 of 35 procedures were selective).

RESULTS

Of the 56 evaluable heminecks, a clinical complete response was achieved in 33 (59%). Within this group, 16 neck dissections were performed, none of which yielded disease on pathological examination. A clinical partial response was obtained in 21 heminecks, of which 18 subsequently had a neck dissection, yielding disease on pathological examination in 14. In all cases, it was possible to completely excise all adenopathy with clear margins on pathological examination. The rate of regional disease control among the 56 evaluable heminecks was 91% (51/56) (median follow-up, 36 months). Four failures were associated with uncontrolled disease at other sites, and 1 was an isolated neck recurrence.

CONCLUSION

Selective neck dissection appears to be an effective adjunct to targeted chemoradiation in controlling N2 to N3 neck disease.

Therapeutic drug monitoring of 21-day oral etoposide in patients with advanced non-small cell lung cancer

The purpose of this study was to prospectively test a pharmacodynamic model for therapeutic drug monitoring of 21-day oral etoposide. In our previous studies, etoposide trough concentrations on this schedule were related to the hematological toxicity, expressed as WBC and neutrophil counts at the nadir. The following pharmacodynamic model estimated the absolute neutrophil count at the nadir (ANCn) based on the etoposide concentration (Ec) and the pretreatment count (ANCp): ANCn=0.32(1 + ANCp x e(-2.47 x Ec)). Patients were treated with 40 mg/m2/day etoposide p.o. x 21 days and 100 mg/m2 cisplatin i.v. on day 1. All patients had non-small cell lung cancer stage IIIB or IV, had a performance status of 0-2, and had a median age of 66 (range, 42-80). Etoposide was measured in the plasma on day 8 by high-performance liquid chromatography, and dosage adjustments were made for the remainder of the course. We targeted for grade 3 neutropenia (ANCn, 500 to 999/microl) and attempted to avoid grade 4 neutropenia (ANCn, <500/microl). Of 25 patients entered, 22 were evaluable for therapeutic drug monitoring in the first course. Three patients developed grade 3 neutropenia, and seven patients developed grade 4 neutropenia. Etoposide concentrations were significantly correlated with ANCn in the first course (r=-0.50, P < 0.02). For those patients whose dosages were not changed, the estimated correlation between predicted and actual ANCn was 0.77 (P < 0.01). No evidence of significant bias of the pharmacodynamic model was detected. The etoposide dosages were increased in 12 patients and were not changed in the remaining patients. The precision of the model was good in patients whose dosages were not changed but poor in patients whose dosages were increased. The actual observed ANCn was compared with the predicted ANCn based on the pharmacodynamic model. The prediction was considered accurate if the predicted and actual ANCn values were within 500/microl of each other. Using this margin, the ANCn was accurately predicted in 10 of 22 patients. Etoposide concentrations >0.3 microg/ml on this schedule were significantly correlated with combined grades 3 and 4 neutropenia (P < 0.0001). In conclusion, the pharmacodynamic model is statistically sound when applied to a population of patients. However, when applied to individual patients for therapeutic drug monitoring, the model lacks precision and accuracy.

Efficacy of targeted supradose cisplatin and concomitant radiation therapy for advanced head and neck cancer: the Memphis experience

PURPOSE/OBJECTIVE

To evaluate the feasibility, response rates, and toxicity of a Phase II study using targeted supradose cisplatin and concurrent radiation therapy in unresectable Stage III-IV head and neck squamous cell carcinoma.

METHODS AND MATERIALS

Sixty patients presenting between 6/93-9/94 were enrolled, 44 (73%) of whom had T4 and/or N2-N3 nodal disease. All patients were treated with rapid targeted superselective intraarterial infusions of cisplatin (150 mg/m2 weekly x 4) and simultaneous sodium thiosulfate intravenously (9 g/m2) for systemic neutralization of cisplatin. Concurrent (day 1) daily radiation therapy was delivered to the primary tumor and overt nodal disease to 66-74 Gy while the uninvolved lower neck received 50 Gy, at 2.0 Gy/fraction.

RESULTS

Fifty-one (85%) patients completed the full RADPLAT protocol as planned. Fifty-seven of 60 patients were evaluable for response. Histological (n = 50) or clinical (n = 7) assessment of primary site revealed a complete response (CR) in 52 patients, partial response (PR) in 4, and stable disease (SD) in 1. Of the 40 patients presenting with nodal metastases, pathological (n = 31) or clinical (n = 6) assessment revealed a CR in 25, PR in 11, and SD in 1, while 3 were unevaluable. Overall, for both primary site and nodal disease, CR was attained in 44 (75%), PR in 12 (23%), and SD in 1 (2%) of the 57 evaluable patients. Only 2 (4%) of 57 evaluable patients have recurred above the clavicle, 1 in the primary site and 1 in the regional lymph nodes. Twelve patients (23%) have failed in distant sites. Grade III/VI toxicity has included gastrointestinal in 6, hematologic in 6, mucosal in 12, vascular in 4, and neurological in 4 patients.

CONCLUSION

Concurrent radiation therapy and targeted supradose cisplatin (i.e., RADPLAT) can be safely delivered with high response rates and excellent loco-regional control in advanced Stage III/IV head and neck squamous cell carcinoma.

Free-riding and the prisoner's dilemma: problems in funding economic analyses of phase III cancer clinical trials

PURPOSE

Both economic and clinical data on new agents are important to policy-makers who approve pharmaceuticals for widespread use. Randomized clinical trials have been used to evaluate both clinical results and total medical costs associated with new agents. With new expensive pharmaceutical agents, early assessments of economic benefit have taken on greater importance to physicians and patients. Who should provide financial support to these integrated economic and clinical analyses in clinical trials? Here we describe issues that hinder funding of economic analyses and propose potential support mechanisms.

RESULTS

The Cancer and Leukemia Group B (CALGB), a large, national cooperative group of academic and community hospitals in the United States, designed a non-small-cell lung cancer (NSCLC) treatment trial to compare two widely used supportive care regimens that varied 20-fold in cost. One important objective of this trial was to compare the cost-effectiveness of the two regimens. While funding for the clinical trial was supported by grants from the National Cancer Institute and the pharmaceutical companies involved in the trial, no specific funding agency was willing and/or able to provide financial support for the economic analyses. After 2 years of planning, the clinical trial was retracted when the funding for the economic analyses could not be secured. The prisoner's dilemma, individual reluctance to support a common social good, explains the lack of funding.

CONCLUSION

Economic theory predicts difficulties in evaluating cost-effectiveness of new pharmaceuticals and reluctance to support economic analyses of clinical trials. Economic analyses will require new sources of funds that will not take scarce resources from clinical trials groups. Options for funding include a new federal agency, coordinated work by existing agencies, or academic centers for economic analysis.

Phase II study of prolonged oral etoposide in combination with intravenous cisplatin in advanced non-small cell lung cancer

The objectives of the study were to evaluate the combination of cisplatin and prolonged oral etoposide for response rate, survival, and toxicity. The treatment regimen consisted of etoposide (50 mg/m2/day) p.o. for 21 consecutive days and cisplatin (100 mg/m2) i.v. on day 1 every 28 days for up to six courses. Patients with Stage IIIB or IV non-small cell lung cancer who had not received prior chemotherapy and had an ECOG performance status of 0-2 were eligible if they had normal bone marrow, liver and renal functions. Patients were followed weekly for toxicity including complete blood counts. The total number of patients entered in the study was 60, of whom 56 were male and four female, 40 white and 20 African Americans. Median age was 64 years (range, 39-77). Performance status 0, 1, and 2 was present in five, 39, and 16 patients, respectively. Fourteen patients had Stage IIIB and 46 Stage IV disease. A total of 142 treatment courses were administered (median 2, range 1-6). Three patients had a complete response and 19 patients had a partial response for an objective response rate of 37% (95% confidence interval, 31-43%). Median survival was 5 months (range, 1-39+). Neutropenia was the major toxicity with Grade 4 occurring in 25 patients after the first course. The following percent of patients experienced severe or life-threatening hematologic toxicity (Grade 3 and 4 combined) over all courses: leukopenia, 73%; neutropenia, 73%; anemia, 42%; and thrombocytopenia, 37%. Three patients died of neutropenic sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytotoxic effects of alpha- and gamma-interferon and tumor necrosis factor in human bladder tumor cell lines

We investigated the activity of alpha-interferon (alpha-IFN), gamma-interferon (gamma-IFN) and tumor necrosis factor-alpha (TNF-alpha) in a panel of ten human bladder tumor cell lines. All cytokines were tested at concentrations of 100-10,000 U/ml in a clonogenic assay system. We found that alpha-IFN was active against five of the ten lines while gamma-IFN was only active against one line. TNF was active against five of the ten lines. Maximum synergisms were obtained between the alpha-IFN and TNF, occurring in nine of the ten cell lines. We conclude that alpha-IFN and TNF are active as single agents and synergistic when used together in vitro in human bladder tumor cell lines.

Pharmacodynamics of prolonged oral etoposide in patients with advanced non-small-cell lung cancer

PURPOSE

This study was undertaken to investigate the pharmacodynamic relationship between etoposide drug levels on 21-day oral treatment courses and hematologic toxicities in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Thirty-two patients with stage IIIB or IV NSCLC were treated with oral etoposide 50 mg/m2/d for 21 consecutive days in combination with cisplatin 100 mg/m2 on day 1. Treatment was repeated every 28 days for up to six courses. Patients had not received previous chemotherapy and had a performance status of 0 to 2. Patients were monitored weekly while on treatment for compliance with oral etoposide and toxicity, including complete blood cell counts, and a blood sample before the daily etoposide dose (drug trough levels). Etoposide concentrations were measured in the plasma by high-performance liquid chromatography (HPLC).

RESULTS

Three patients achieved a complete response (CR) and 10 patients a partial response for an objective response rate of 41% (95% confidence interval, 24% to 58%). The median survival was 4 months (range, 1 to 23). Neutropenia was dose-limiting, and two patients died of neutropenic sepsis. Pharmacodynamic correlations for drug concentrations and hematologic toxicities were available for 27 patients and a total of 76 treatment courses, and correlations were significant for graded hematologic toxicity and nadir counts of leukocytes, neutrophils, hemoglobin, and platelets. The grade of infection (77 courses) was also related to drug levels. Using data from 27 initial courses, a pharmacodynamic model was developed to estimate the nadir leukocyte or neutrophil count (WBCn, ANCn) based on the pretreatment count (WBCp, ANCp) and the etoposide concentration (Ec) as follows: WBCn = 0.35 (1 + WBCp x e-1.12 x Ec) and ANCn = 0.32 (1 + ANCp x e-2.47 x Ec).

CONCLUSION

Etoposide concentrations are related to the resulting hematologic toxicities. It is possible to predict nadir counts in the first course by a pharmacodynamic model. The above equations need to be validated prospectively and may be useful in future studies of prolonged oral etoposide.

Pharmacodynamics of three daily infusions of etoposide in patients with extensive-stage small-cell lung cancer

The objectives of this study were to define the pharmacodynamics of etoposide and to develop potentially useful models (1) to estimate the plasma clearance using a limited number of samples and (2) to describe the relationship between clearance and the dose-limiting toxicity. A total of 17 patients with extensive-stage small-cell lung cancer were treated with 150 mg/m2 etoposide daily for 3 consecutive days and with 100 mg/m2 cisplatin on day 3 only. Both drugs were given intravenously over 1 h. Treatment was repeated every 21 days for up to six courses. All patients were newly diagnosed (no previous chemotherapy or irradiation) and had a performance status of 0-2. Six patients achieved a complete response as confirmed by repeat bronchoscopy and five patients showed a partial response, for an overall objective response rate of 65% (95% confidence interval, 38%-87%). The median survival was 8 months (range, 1-24+ months). The dose-limiting toxicity was neutropenia. Etoposide pharmacokinetics were measured during the first course and determinations were repeated during courses 3 or 4 and 6. Complete blood counts were obtained weekly. Correlations for etoposide clearance and hematologic toxicities were evaluated for 17 initial courses and for an overall number of 33 courses. Pharmacodynamic correlations were significant for graded hematologic toxicities, as well as nadirs of leukocytes, neutrophils, and platelets for the initial courses and for all courses. To reduce the requirement for numerous blood samples, a limited sampling model was developed to estimate the area under the concentration versus time curve (AUC) with the following equation: AUC = 15.45 + 3.86 x C2 + 7.10 x C4, where C2 and C4 represent the etoposide concentrations at 2 and 4 h, respectively. The total plasma clearance was calculated as the dose divided by the AUC; correlations with toxicity were better for clearance expressed in milliliters per minute than for that expressed in milliliters per minute per square meter of body surface area. The absolute neutrophil count at the nadir (ANCn) can be estimated by the following pharmacodynamic model, which is based on 33 courses: ANCn = -0.399 + 0.024 x Ecl, where Ecl represents the etoposide clearance expressed in milliliters per minute. Further studies are necessary to validate both models prospectively.

Clonal growth requirements of human bladder tumor cell lines

We have serially investigated the role of nutrients and growth factors for their ability to support the clonal growth of human bladder tumor cell lines. Five established human bladder tumor cell lines were selected for study of their requirements for clonogenic growth in semisolid cultures. We identified an "optimal medium" to be Alpha MEM medium, 15% horse serum, five micrograms/ml. of transferrin, five micrograms/ml. of insulin and 30 ng./ml. of epidermal growth factor. The "optimal assay" enhanced the growth of human bladder tumor cell lines 2.5 times compared to the standard clonogenic assay. The resulting medium is less complicated to maintain, less expensive and supports the growth of human bladder tumor cell lines better than the standard clonogenic assay.

5-Fluorouracil infusion and mitomycin combination chemotherapy in the management of patients with advanced non-small-cell lung cancer

We have carried out a phase II study evaluating the activity of a 5-fluorouracil drug combination in patients with advanced non-small-cell lung cancer. Patients were given 60 mg/m2 of methotrexate i.v. on day 1. On day 2, 750 mg/m2 of 5-fluorouracil was administered as a 24-h infusion daily for 3 days. Also on day 3, 10 mg/m2 of mitomycin was given i.v. along with folinic acid. Folinic acid was started on day 3 initially at a dose of 25 mg/m2 intravenously every 6 h for three doses, followed by a 2-h infusion of 200 mg/m2 daily on days 3 and 4. Therapy was repeated every 28 days. Fourteen of 35 patients (40%) experienced a partial response to chemotherapy. The median survival of the entire group was 19 weeks. Mucositis was a common side effect but severe leukopenia, anemia, renal insufficiency, and skin ulceration were rare. This study demonstrated that 5-fluorouracil infusion therapy has activity in advanced non-small-cell lung cancer but the responses are not durable. Further studies evaluating differing dose schedules and alternate 5-fluorouracil infusion-based drug combinations seems warranted.

Combination versus sequential single-agent chemotherapy in the treatment of patients with advanced non-small cell lung cancer

We have carried out a randomized phase III study in 105 patients with advanced non-small cell lung cancer, comparing a four-drug cisplatin-mitomycin-based combination chemotherapy regimen to sequential single-agent therapy. The combination chemotherapy regimen consisted of mitomycin C (10 mg/m2), vinblastine (5 mg/m2), methotrexate (40 mg/m2), and cisplatin (40 mg/m2) given every 28 days. Sequential single-agent chemotherapy consisted of mitomycin C (10 mg/m2) monthly until progression followed by vinblastine (5 mg/m2) every 2 weeks until progression followed by methotrexate (40 mg/m2) weekly until relapse. Patients failing either regimen were followed with supportive care. The objective response rate for the sequential single-agent therapy was 19% versus 25% for the combination chemotherapy group (P greater than .5). The median survival for the single-agent group was 166 days and 191 days for the combination chemotherapy group. Overall survival was not statistically different between the two groups (P greater than .5). Leucopenia, anemia, and prolonged anorexia with nausea and vomiting were more common in the combination chemotherapy group compared to the single-agent group. This study failed to demonstrate a sufficient therapeutic benefit in the face of the added toxicity for the combination chemotherapy regimen compared to sequential single-agent therapy.

Evidence for depressed humoral immunity to Pneumocystis carinii in homosexual males, commercial plasma donors, and patients with acquired immunodeficiency syndrome

Heterosexual controls were found to have significantly higher titers of immunoglobulin G antibody to Pneumocystis carinii than did patients with the acquired immunodeficiency syndrome (AIDS) and P. carinii pneumonitis, human immunodeficiency virus (HIV) antibody-positive or -negative homosexual male "gay bar" patrons, and HIV antibody-positive or -negative commercial plasma donors. The T-helper/T-suppressor lymphocyte ratios of HIV antibody-negative homosexual male gay bar patrons were slightly depressed (mean = 1.31 +/- 0.54) compared with those of heterosexual controls (mean = 1.79 +/- 0.32). In addition to other recognized factors, preexisting humoral as well as cell-mediated immune deficits before infection with HIV may help to explain the prevalence of and morbidity and mortality associated with P. carinii pneumonitis in AIDS patients.

Detection of small cell lung cancer bone marrow involvement by discontinuous gradient sedimentation

Marrow involvement by small cell lung cancer (SCLC) is detected in 10-23% of patients at initial diagnosis by marrow aspirate and biopsy techniques. To improve the detection and potentially monitor marrow involvement by SCLC we have attempted to concentrate malignant cells with clonogenic potential on a discontinuous density gradient (DDG). The bone marrow from 43 patients with SCLC (36 with histologically negative marrow aspirates and biopsies) were separated on a Ficoll-based DDG. Samples were also separated by conventional Ficoll-diatrizoate (FD) (density, 1.077) gradient sedimentation. The cellular interphase from three fractions (F X) corresponding to specific densities 1.050 (F X 1), 1.055 (F X 2), and 1.060 (F X 3) as well as cells separated by Ficoll-diatrizoate (F X FD) centrifugation were isolated and 2.5 X 10(5) cells from each fraction were cultured in 2 ml of 0.3% agar in McCoy's media with 10% fetal calf serum, 2.5 micrograms transferrin, 1 microgram insulin, and 1% penicillin-streptomycin. Colony growth was assessed after 14 days of culture at 37 degrees C and 6% CO2. Tumor colony growth was seen in eight of 36 (22%) patients with histologically negative marrows as well as in four of seven (57%) patients with known involvement. Mean colony growth per 2.5 X 10(5) cells for all 12 patients was 4.3 colonies for F X 1; 8.8 for F X 2; and 2.7 for F X 3. In contrast mean growth from the F X FD was 1.0 colonies. Cells with clonogenic potential could be demonstrated from F X 2 and F X 3 in seven of 12 and eight of 12 patients, respectively; in F X FD four of 12 patients had tumor growth. We conclude that separation of marrow samples by DDG concentrates malignant cells with clonogenic potential at least 8-fold compared to FD separation and that the sensitivity of the clonogenic assay in detecting marrow involvement by SCLC is enhanced by DDG sedimentation.

Effects of N-trifluoroacetyladriamycin-14-valerate (AD-32) on human bladder tumor cell lines

We have compared the in vitro activity of N-trifluoroacetyladriamycin-14-valerate (AD-32) and doxorubicin hydrochloride (ADR) on the clonal growth of human bladder tumor cell lines (HBTCL). In order to determine the relatively toxicity of ADR and AD-32 on hematopoietic stem cells, CFU-GM assays were set up using 10 normal human bone marrow samples. The mean lethal dose for 50% of the colonies (LD-50) for ADR was 1.6 +/- 1.4 microM and that for AD-32, 3.9 +/- 4.9 microM (P less than 0.55), suggesting that these agents have similar bone marrow toxicity. Both drugs produced enhanced inhibition of clonal growth of HBTCL with increasing C X Ts. The spectrum of activity of the two drugs was similar against a panel of seven HBTCL. The activity of ADR was inhibited at 4 degrees C while the activity of AD-32 was unaffected by temperature. ADR was more effective against HBTCL in the log growth phase than the plateau phase while the reverse was found using AD-32. Verapamil was found to enhance the activity of both ADR and AD-32 against a HBTCL (T24), found to be resistant to both agents. The lipophilic properties of AD-32, along with its enhanced activity when used over prolonged periods of time and its activity against tumor cells in the plateau phase, suggest that AD-32 could be useful in the management of patients with superficial bladder cancer.

Skeletal surveys in multiple myeloma. Radiologic-clinical correlation

Thirty-three patients with multiple myeloma were studied with serial skeletal surveys, serum immunoglobulin levels, and postabsorptive urinary hydroxyproline (Spot-HYPRO) determinations. Twenty receiving chemotherapy were also followed with skeletal surveys in order to evaluate bone response to treatment. A close association was found between skeletal findings and changes in immunoglobulin levels with positive correlation in 71% of the patients. A similar association was found between skeletal disease and Spot-HYPRO level changes in 65%. Five of 12 patients (42%) with partial or complete clinical response to chemotherapy, demonstrated improvement in the appearance of skeletal lesions. Positive correlation between the roentgenographic changes and clinical markers of myeloma as well as therapeutic response, indicates that skeletal surveys are useful and effective in monitoring patients with multiple myeloma.

Anticancer drug activity in human bladder tumor cell lines

A panel of ten human bladder tumor cell lines were tested for drug sensitivity to ten standard or investigational anticancer drugs using a tumor colony assay. The activity of these anticancer agents in vitro was then compared with the clinical activity of these agents in bladder cancer. Drug activity was found in only five of the ten cell lines. In only 9 of 100 drug assays was the inhibition of colony growth lower than 30% of the controls. The activity of the more active anticancer drugs in bladder cancer (i.e., methotrexate and cisplatin) was not predicted using the tumor colony assay. Overall, the low level of activity of most anticancer drugs tested paralleled the clinical experience of drug resistance found in human bladder cancer.

In vitro and in vivo activity of two second generation platinum analogs in murine bladder cancer

The activity of cis-diamminedichloroplatinum(II) was compared to two second generation platinum analogs, cis-diammine-1,1-cyclobutane dicarboxylate platinum(II) and cis-dichlorotransdihydroxybisisopropylamine platinum(IV) in the N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide-induced murine bladder tumor model and a tumor colony assay. Murine drug testing revealed that all three drugs were active against the MBT-2 tumor line, although cis-diamminedichloroplatinum(II) was more active than its analogs. All drugs produced enhanced inhibition of clonal growth with increasing drug exposure times. Cis-diamminedichloroplatinum(II) was more active against MBT-2 cells in the plateau growth phase versus the log growth phase after a one hour drug exposure. Similar differential activity depending upon the proliferative state of MBT-2 was not seen with the two platinum analogs. These two platinum analogs have somewhat less activity in vivo and in vitro than cis-diamminedichloroplatinum(II) and would be predicted to be less effective clinically in human bladder cancer than the parent compound.

Effect of concentration and time of drug exposure on clonal growth of murine bladder cancer

The use of a tumor colony assay was evaluated for its ability to predict anticancer drug response in an N[4-(5-nitro-2-furyl)-2-thiazolyl] formamide mouse bladder tumor model. One-hour and continuous drug exposure were compared to determine what effect altering drug concentration and time of exposure would have on the predictability of the tumor colony assay in the murine model. Ten anticancer drugs were tested in the murine model, and tumor cells removed from control mice were used for in vitro drug testing. One-hour and continuous drug exposure (using the one-hour drug level) were performed simultaneously and the in vitro and in vivo data compared. Using one-hour drug incubation in the tumor colony assay resulted in a true positive predictive rate of 54 per cent and a true negative predictive rate of 70 per cent. Continuous drug incubation overestimated drug sensitivity resulting in a drop in the predictability of the tumor colony assay. We conclude that using one-hour drug exposure the tumor colony assay is predictive of chemotherapeutic drug response in this murine bladder tumor model.

Combination chemotherapy with mitomycin-C, cisplatin, and vinblastine in the treatment of non-small-cell lung cancer

The drug combination of mitomycin-C, cisplatin, and vinblastine was administered to 30 patients with stage III non-small-cell lung cancer. All patients had a performance status of 50% or greater, had evaluable disease, and had not received previous chemotherapy. The overall response rate was 37% with responses seen in 7 of 18 (39%) squamous cell and 3 of 11 (27%) patients with adenocarcinoma of the lung. Mean survival was greater by 2 months in those patients with an objective response to chemotherapy (8.1 vs 5.5). Drug-associated gastrointestinal toxicity was the most common side effect observed. This three-drug combination appears to be an active regimen in the treatment of non-small-cell bronchogenic carcinoma; however, altered dosage schedules should be examined in order to decrease drug-related toxicity.

Pneumocystis carinii antigenemia in adults with malignancy, infection, or pulmonary disease

A counterimmunoelectrophoresis test for Pneumocystis carinii antigenemia was employed to assess the extent of subclinical infection or colonization with this agent in adults with infection, pulmonary disease, or malignancy and in healthy homosexual men. Antigenemia was detected in 6 of 208 (3%) of normal controls, 3 of 28 (11%) of patients with pulmonary infection, 3 of 33 (9%) of those with chronic lung disease, 1 of 36 (3%) of patients with lung cancer, 7 of 271 (3%) of afebrile subjects with malignancy, 6 of 19 (32%) of febrile patients with malignancy, 2 of 22 (9%) of those with nonpulmonary infection, and 0 of 21 (0%) of healthy young homosexual men. These data suggest that P. carinii is a common commensal or saprophyte that becomes clinically significant only when host defenses are impaired. Antigenemia may occur intermittently during various disease states in the absence of positive clinical signs and should alert the physician to subacute infection or colonization. Treatment appears advisable when clinical data and counterimmunoelectrophoresis results concur.

Combination chemotherapy with mitomycin C, methotrexate, cisplatin, and vinblastine in the treatment of non-small cell lung cancer

The combination of mitomycin C, methotrexate, cisplatin, and vinblastine was administered to 45 patients with unresectable non-small cell lung cancer. Thirty-nine patients satisfied criteria for assessment of response to chemotherapy. All patients had a performance status of greater than 50%, had evaluable disease, and had not received previous chemotherapy. The overall response rate was 54% with responses seen in 12 of 19 squamous cell, 8 of 16 adenocarcinoma, and 1 of 4 undifferentiated large cell lung cancer patients. Median survival was increased by 3 months in those patients with an objective response to chemotherapy. Drug-associated toxicity was rare, but apparent mitomycin C-related pulmonary fibrosis was observed in two patients. This four-drug combination was shown to be an active regimen in the treatment of non-small cell bronchogenic carcinoma.

Pharmacokinetics of mitomycin C in non-oat cell carcinoma of the lung

The disposition kinetics of the cancer chemotherapeutic agent mitomycin C have been studied in six male patients receiving mitomycin C in combination with cisplatin and vinblastine for non-oat cell carcinoma of the lung. Following rapid IV administration of mitomycin C (10 mg/m2), serum concentration-time course data were biexponential, with biologic half-lives of 46.2 +/- 12.1 min (mean +/- SD). Pharmacokinetic analysis of data by the CSTRIP and NONLIN digital computer programs generated parameters which suggested extensive distribution (V area = 656.8 +/- 169.8 ml X kg-1, mean +/- SD) and, as reported for other alkylating agents, rapid elimination (total body clearance = 10.3 +/- 3.2 ml X kg-1 X min-1, mean +/- SD). Interpatient variations in pharmacokinetic parameters were relatively small, suggesting that close monitoring of mitomycin C therapy might be unnecessary in patients with normal renal and hepatic function.

Incidence of Pneumocystis carinii antigenemia in ambulatory cancer patients

Although the existence of subclinical Pneumocystis carinii infection in pediatric patients with solid tumors or hematologic malignancies has been documented, similar data are lacking in adults. In addition, data are needed to define the epidemiology of this agent in adult malignancies to assess the validity of the methodology employed in antigen detection, and to elucidate the value of these methods in the diagnosis, prophylaxis, and prognosis of P carinii infection in adults with cancer. The study was designed to determine the incidence of P carinii antigenemia in ambulatory patients with solid tumors or hematologic malignancies. The authors also sought to determine if antigenemia as detected by a counterimmunoelectrophoresis test correlated with any clinical parameter. Patients included in the study were ambulatory, asymptomatic, afebrile, adult cancer patients seen in the clinic for follow-up or treatment. Coded sera were electrophoresed against high-titered rabbit antiserum to P carinii organisms. Two hundred forty-seven patients were studied, including 172 hematologic malignancies (average age, 57 years), 109 men and 63 women; 75 solid tumors (average age, 55 years), 39 women and 36 men. One hundred three healthy adults served as controls. Only five patients had positive antigen (2%). All of these patients had hematologic malignancies and were women. None of the control sera were antigen-positive. We conclude that the incidence of P carinii antigenemia in asymptomatic adults with neoplastic disease is extremely low. A positive P carinii antigen in the absence of clinical symptoms most likely represents subclinical infection. Positive antigen does not always indicate active disease, but probably reflects mobilization of antigen during generalized inflammatory response or possible pulmonary insult. In making the decision to treat consideration should be given to clinical presentation and history.

Reversed-phase high-performance liquid chromatographic determination of mitomycin C in human serum

A reversed-phase high-performance liquid chromatographic method is presented by which the cancer chemotherapeutic agent, mitomycin C, may be measured in human serum. A mobile phase of methanol:water (35:65) passed through a mu-Bondapak C-18 column at a rate of 1.0 ml/min produced a sharp, symmetrical band for mitomycin C. An improved serum extraction procedure, using a reversed-phase sample preparation cartridge, proved to be efficient and reproducible. Recovery over a concentration range of 10-100 ng/ml was 81.6% with a between-day coefficient of variation of 4.6% (n = 5). The within-day coefficient of variation at 50 ng/ml was 5.6% (n = 10). Ultraviolet detection at a wavelength of 365 nm was sensitive to serum concentrations of 10 ng/ml. Serum concentration-time course data from lung cancer patients receiving mitomycin C by rapid intravenous injection are presented.

Total and nondialyzable hydroxyproline excretion in Stage D2 prostate cancer

Hydroxyproline is excreted in urine as a breakdown product of normal bone turnover: A dialyzable (D) fraction (90% of total) reflects active bone destruction and a nondialyzable (ND) fraction reflects bone growth/regrowth. In metastatic prostate cancer where blastic osseous metastases predominate, disease progression on bone scan correlated with elevation of both total hydroxyproline excretion (7.84 + 1.28, P less than 0.001) and the ND urinary level (0.94 +/- 0.20, P less than 0.01). In patients with a serially stable/improving scan, urinary excretion of each fraction (2.18 + 0.27 and 0.27 +/- 0.01) was similar to that of men with no evidence of disease. For Stage D2 prostate cancer, these two markers satisfactorily monitor osseous activity in the intervals between serial bone scintigraphy.

Use of tumor colony assay in clinical oncology

We have evaluated the usefulness of the tumor colony assay in predicting chemotherapeutic drug response in our cancer patient population. We found that a wide variety of human tumors will produce clonal growth in this in vitro assay. Low growth rates in many of the common human tumors, however, severely restrict the utility of this assay in a large number of cancer patients. A retrospective analysis using the assay to predict anticancer drug response revealed a true-positive predictive rate of 63% and a true-negative predictive rate of 96%. We conclude that if growth stimulants can be developed to enhance clonal growth without altering the predictability of the assay, the tumor colony assay could prove to be extremely useful in selecting appropriate chemotherapy for individual cancer patients.

The postabsorptive hydroxyproline in the long-term evaluation of patients with breast cancer

The postabsorptive urinary hydroxyproline excretion test (Spot-HYPRO) was evaluated for its usefulness in reflecting the presence or absence of bone metastasis in 75 women with breast cancer. A comparison was made between the Spot-HYPRO values and bone disease, as documented by bone scanning supported by skeletal x-rays. Breast cancer patients with skeletal metastasis had 3-4-fold elevations in Spot-HYPRO above the control values (P less than 0.001). Mild elevations were noted in breast cancer patients without skeletal metastasis (P less than 0.025). Thirty patients received serial Spot-HYPRO and bone scans for 6 to 48 months (average, 24 months). There was a 90% correlation between changes in Spot-HYPRO and simultaneous changes on bone scan. Elevations in Spot-HYPRO preceded changes found on bone scan by an average of 3 months. The authors conclude that the Spot-HYPRO is a simple, convenient, and accurate method of documenting and following bone metastasis in patients with breast cancer.

Total, dialyzable, and nondialyzable postabsorptive hydroxyproline. Values in patients with cancer

The postabsorptive urinary total (T), dialyzable (D), and nondialyzable (ND) hydroxyproline (HYPRO) tests were evaluated to determine whether the patterns of excretion varied according to the predominance of osteoblastic v osteolytic bone involvement in 58 patients with neoplastic disease. In patients with osteolytic lesions from multiple myeloma, elevated T and D levels with normal ND HYPRO values were observed, along with elevated D/ND ratios. In prostate cancer, the T, D, and ND values were all elevated and the D/ND ratio was normal. Patients with Hodgkin's disease had elevated T, D, and ND HYPRO levels, and the D/ND ratio was in the range of patients with prostate cancer. The data suggest that these collagen markers may be useful in the long-term evaluation of these neoplasms in patients.

The use of a tumor colony assay in predicting chemotherapeutic drug response in murine bladder cancer

A tumor colony assay (TCA) was evaluated for its ability to predict anticancer drug responses in an N-[4-(5-nitro-2-furyl)-2-thiazolyl]-formamide (FANFT)-induced murine bladder tumor (MBT) model. Ten anticancer drugs were evaluated in vivo and in vitro using four MBT cell lines (40 drug responses). Using the optimum criteria for drug response, the TCA accurately predicted drug responses in the murine model 65% of the time with a true-positive predictive rate of 54% and a true-negative predictive rate of 70%. Drug testing tumor cells immediately on removal from the mouse resulted in a true-positive predictive rate of 77% and a true-negative predictive rate of 100%. The authors conclude that the TCA can predict response to chemotherapy in the MBT model and may be useful in screening investigation compounds for the subsequent evaluation in this murine bladder tumor model.

Use of the tumour colony assay in the evaluation of patients with bladder cancer

In this study we examined the ability of tumour specimens derived from bladder barbotage to produce cluster/colony formation in a tumour colony assay. In 114 bladder washings from 65 patients and 15 control subjects, we found that cluster and colony formation was highest from bladder washings obtained from patients with biopsy proven bladder cancer who were not on intravesical chemotherapy. Growth rates were extremely low, restricting the usefulness of the in vitro assay in its present form. This study suggests that improvements in the growth rates in the tumour colony assay will be necessary before this system can have real value in monitoring transitional cell carcinoma of the bladder.

In vitro characterization of four N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT) induced mouse bladder tumors

Four longterm murine bladder tumor cell lines were established in vitro. The 4 lines were initiated from primary N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT) induced murine bladder tumors arising in C3H/He mice. Each was maintained as a solid tumor in syngeneic mice for at least 30 generations before initiation in tissue culture. The cell lines MBT-2, MBT-8, MBT-409 and MBT-683, have been subcultured over 75 times in vitro for 18 months. They are all epithelial, grow in islands on plastic Petri dishes before confluent growth and form colonies in soft agar suspension culture. Morphologic studies indicate that all 4 lines have epithelial characteristics and karyotypic studies indicate that all lines have polyploidy and marker chromosomes. Population doubling times range from 10 to 26 hours and are consistent for each line.

The clonogenic growth of cells derived from bladder barbotage in patients with transitional cell carcinoma of the bladder: a preliminary report

Tumor cells obtained from bladder washings in 41 patients with transitional cell carcinoma of the bladder and 15 control subjects were analyzed for their ability to produce cluster and/or colony formation in a tumor stem cell assay. In vitro cell growth was correlated with the presence of tumor at the time of bladder washing, tumor grade and treatment status. Of 34 bladder washings from patients with biopsy-proved transitional cell carcinoma 88 per cent produced cluster and/or colony formation. Specimens from patients not currently receiving intravesical chemotherapy at the time of bladder barbotage produced colonies in 54 per cent of the cases, compared to 25 per cent from patients receiving therapeutic or maintenance therapy. Higher grade tumors produced more viable cells at bladder barbotage but clonal growth rates were independent of histologic grade. We conclude that bladder barbotage may serve as a source of cells for chemotherapeutic drug testing in patients with transitional cell carcinoma of the bladder. Bladder washings also may be useful as a source of tumor cells for monitoring the in vivo growth potential of bladder cancer in the tumor stem cell assay.

Time- and concentration-dependent inhibition of the clonogenic growth of N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide-induced murine bladder tumor cell lines by cis-diamminedichloroplatinum(II)

The influence of the concentration and time of exposure to cis-diamminedichloroplatinum on the inhibition of the clonogenic growth of three N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide mouse bladder tumor cell lines was evaluated in a tumor colony assay. Drug testing was performed in the murine model, and tumor cells were removed from the animals for in vitro testing. Murine drug testing revealed marked cis-diamminedichloroplatinum sensitivity of all three mouse bladder tumor lines. One-hr incubation in cis-diamminedichloroplatinum was an adequate time of drug exposure to produce in vitro colony survival curves predictive of in vivo sensitivity to the drug. Furthermore, it was found that 6- to greater than 24-hr exposure to the drug was required to produce colony survival curves in the tumor colony assay predictive of tumor sensitivity. High drug concentrations using 1-hr drug incubation or continuous incubation in drug both produced colony survival curves predictive of tumor sensitivity. Both methods, however, would require higher products of the drug concentration multiplied by time curves than could theoretically be clinically achievable in the murine model. Until pharmacokinetic data on cis-diamminedichloroplatinum are available in this murine model, higher drug sensitivity boundaries than are presently being used for other chemotherapeutic agents will have to be utilized when testing these mouse bladder tumor cell lines for their sensitivity to cis-diamminedichloroplatinum in a tumor colony assay.

Growth characteristics of N-[4-(5-nitro-2-furyl)-2-thiazolyl]-formamide (FANFT)-induced mouse bladder tumor lines in a human tumor stem cell assay

Four N-[4-(5-nitro-2-furyl)-2-thiazolyl]-Formamide (FANFT)-induced mouse bladder tumor (MBT) lines were tested for their ability to form colonies in a tumor stem cell assay. Anticancer drug testing was done using this assay to determine whether reproducible colony survival curves could be be produced. All four cell lines produced colonies at 10--14 days, whether taken from culture or murine tumor. Cloning efficiencies ranged from 0.29% to 1.93% from culture and from 0.005% to 0.05% from the murine source. Growth characteristics were described. Cells from colonies were histologically similar to the original cells plated. A linear relationship existed between the number of cells plated and the number of colonies produced. In vitro drug studies were reproducible and correlated with in vivo data. Therefore, MBT lines can be used for in vitro drug testing in a tumor stem cell assay and may be useful in selecting active chemotherapeutic agents in the murine tumor model.

Postabsorptive urinary hydroxyproline test in patients with metastatic bone disease from breast cancer

Postabsorptive urine hydroxyproline (HYPRO) excretion ("spot" HYPRO test) was compared with the 24-hour urine excretion of HYPRO in 45 patients with breast cancer and nine normal subjects on a low-gelatin diet. A good correlation was observed between the results of these two tests in both groups. Patients with skeletal metastasis showed a higher spot HYPRO value than those without bone involvement and the number of lesions by bone scanning correlated with the values of spot HYPRO. In 20 of 22 patients with bone metastasis followed up for three to 19 months, spot HYPRO values correlated well with the evolution of bone disease. We conclude that the spot HYPRO test is a simple, inexpensive, and accurate method for the diagnosis and follow-up of patients with skeletal metastasis from breast cancer.

The postabsorptive urinary hydroxyproline (spot-HYPRO) in patients with multiple myeloma

The simple postabsorptive urine hydroxyproline (Spot-HYPRO) with dialyzable and non-dialyzable (ND) fractions was measured in 28 patients with multiple myeloma. Myeloma patients with bone disease had higher total Spot-HYPRO and dialyzable fractions (P less than 0.001) than myeloma patients without bone disease or controls. The ND fraction of the Spot-HYPRO was elevated in myeloma patients with renal disease as compared with myeloma patients without renal disease and controls (P less than 0.01). Follow-up studies of ten myeloma patients demonstrated a close correlation between Spot-HYPRO and the dialyzable fraction and the evolution of bone disease. The Spot-HYPRO and its dialyzable fraction constitute a simple, inexpensive, and accurate test for the diagnosis and follow-up of the skeletal disease in patients with multiple myeloma.

Zinc metabolism in sickle cell anemia

Zinc metabolism was studied in 34 patients with sickle cell anemia in a steady state and in six patients during sickle cell crisis. The patients in steady state were found to have significantly lower plasma levels and higher urinary levels of zinc than the 50 healthy adults in the control group. During sickle cell crisis the plasma zinc levels dropped to a mean value of 0.54 microgram/microL. These results support the concept that zinc deficiency occurs in sickle cell anemia and that further drops occur in the serum zinc levels during sickle cell crisis.