Pulmonary Carcinoid Presenting as Multiple Subcutaneous Nodules

A 60-year-old female presented with a one-year history of multiple enlarging tender subcutaneous nodules. Initial biopsy demonstrated a poorly differentiated adenocarcinoma. Mammography showed multiple nodular breast lesions. After the patient failed to respond to tamoxifen, a second biopsy demonstrated a metastatic carcinoid tumor. Further search revealed a single small pulmonary nodule, which on aspiration biopsy proved to be a carcinoid tumor. The patient failed to respond to treatment with streptozotocin and 5'-fluorouracil. Therapy with leucovorin calcium and 5'-fluorouracil then produced a partial response.

Chemotherapeutic Management of Small Bowel Adenocarcinoma Associated with Crohn's Disease

Four patients with metastatic primary small bowel adenocarcinoma associated with Crohn's disease were successfully treated with low dose combination chemotherapy consisting of 5-fluorouracil, leucovorin and irinotecan with or without gemcitabine. Benefits included prolonged survival, objective responses, response of resistant tumors, downstaging, and a successful secondary complete resection (Ro) with a durable remission.

Laboratory based low dose combination chemotherapy + bevacizumab for recurrent refractory and unresectable gastric cancer

14133

Twenty consecutive prospectively registered patients with refractory or Stage IV gastric cancer were treated with GFLIP (Bruckner el al ASCO 2002;2005). The last 10 upon relapse were treated with GFL[OX]T and Bevacizumab, substituting oxaliplatin (OX) 30→40 mg/M2, taxotere (T) 30→40 mg/M2 for cisplatin in the q2wk schedule. One or both regimens produced; objective responses for 15 patients including 5 complete (radiologic, tumor markers, PET responses) and 2 surgical downstaging resulting in resection or successful completion surgery; 3 patients had stable disease greater than 4 months with subjective benefit, gemcitabine was given at 400→500 mg/M2 as tolerated (→), 2 failed both regimens. One-year actuarial survival was 75%, two-year survival was 25%. All 20 lived more than six months. The level of activity, multiple crossover responses, responses with both regimens, a number of long remissions (long survival after 5FU cisplatin and GFLIP failed) and clinical downstaging allowing further surgery identify both regimens either individually or in sequence as deserving systematic investigation. The utility of low doses (responses), unusual clinical benefits, quality of life and safety offer possible advantages compared to standard dose regimens.This strategy appears to reduce and delay the limiting toxicity of the irinotecan (I) 80 mg/M2, cisplatin (P) 40 mg/M2 OX/T which are conventionally treatment limiting drugs. The regimens were designed based on laboratory evidence of low dose drug interaction including reversal of resistance to conventional drugs (applicable to both pancreatic and gastric cancer (Janat et al, Amer Asso Cancer Res 1999). After clinical demonstrations of high response rates and reversal of resistance against refractory pancreatic cancer (Bruckner et al, AntiCancer Res and ASCO 2005). The regimens were offered to patients with recurrent previously treated and refractory gastric cancer and then based on initial exceptional responses to high risk patients with poor prognosis due to clinical complications of their gastric cancer.

No significant financial relationships to disclose.

Pilot study of a specific dietary supplement in tumor-bearing mice and in stage IIIB and IV non-small cell lung cancer patients

Previously, a specific dietary supplement, selected vegetables (SV), was found to be associated with prolonged survival of stage III and IV non-small cell lung cancer (NSCLC) patients. In this study, several anticancer components in SV were measured; the anticancer activity of SV was assessed using a lung tumor model, line 1 in BALB/c mice. SV was also used in conjunction with conventional therapies by stage IIIB and IV NSCLC patients whose survival and clinical responses were evaluated. A daily portion (283 g) of SV was found to contain 63 mg of inositol hexaphosphate, 4.4 mg of daidzein, 2.6 mg of genistein, and 16 mg of coumestrol. Mouse food containing 5% SV (wt/wt) was associated with a 53-74% inhibition of tumor growth rate. Fourteen of the 18 patients who ingested SV daily for 2-46 months were included in the analyses; none showed evidence of toxicity. The first lead case remained tumor free for > 133 months; the second case showed complete regression of multiple brain lesions after using SV and radiotherapy. The median survival time of the remaining 12 patients was 33.5 months, and one-year survival was > 70%. The median survival time of the 16 "intent-to-treat" patients (including ineligible patients) was 20 months, and one-year survival was 55%. The Karnofsky performance status of eligible patients was 55 +/- 13 at entry but improved to 92 +/- 9 after use of SV for five months or longer (p < 0.01). Five patients had stable lesions for 30, 30, 20, 12, and 2 months; two of them, whose primary tumor was resected, used SV alone and demonstrated an objective response of their metastatic tumors. In addition to the two lead cases, eight patients had no new metastases after using SV. Three patients had complete regression of brain metastases after using radiotherapy and SV. In this study, daily ingestion of SV was associated with objective responses, prolonged survival, and attenuation of the normal pattern of progression of stage IIIB and IV NSCLC. A large randomized phase III clinical trial is needed to confirm the results observed in this pilot study.

Irinotecan combined with gemcitabine, 5-fluorouracil, leucovorin, and cisplatin (G-FLIP) is an effective and noncrossresistant treatment for chemotherapy refractory metastatic pancreatic cancer

BACKGROUND

Single agents have only modest activity as treatment for metastatic pancreatic cancer with response rates of less than 10% and median survivals of less than 6 months. Evaluations of single-agent gemcitabine and rubitecan as second-line treatment for relapsed pancreatic cancer have reported good patient tolerability and median survivals of 3.85 months and 4.7 months, respectively. Regimens incorporating two drugs have demonstrated encouraging activity and clinical impact compared with single-agent therapy. G-FLIP is a regimen designed to incorporate four active single agents into a tolerable and active combination. This analysis is a retrospective evaluation of the efficacy and safety of the G-FLIP regimen as second-line chemotherapy in a series of consecutively treated patients with metastatic pancreatic cancer.

METHODS

G-FLIP was administered over 48 hours and repeated every 2 weeks. Day 1 treatment consisted of sequentially administered gemcitabine 500 mg/m(2), irinotecan 80 mg/m(2), leucovorin 300 mg, 5-fluorouracil (5-FU) 400 mg/m(2) bolus followed by infusional 5-FU 600 mg/m(2) over 8 hours. Day 2 treatment consisted of leucovorin 300 mg and 5-FU 400 mg/m(2) bolus, followed by cisplatin 50 to 75 mg/m(2), and then infusional 5-FU 600 mg/m(2) over 8 hours.

RESULTS

Thirty-four patients with histologically confirmed metastatic pancreatic cancer were consecutively treated. The median patient age was 64.5 years (range 41-82 years) and all patients had objective disease progression on prior therapy: 32 patients had disease progression with gemcitabine and 31 had disease progression with a gemcitabine/5-fluorouracil/cisplatin combination. Grade 3-4 hematological toxicities included anemia (23%), thrombocytopenia (53%), and neutropenia (38%). There were no grade 3-4 neutropenic fevers, treatment-related mortalities, or withdrawals. Nonhematological grade 3-4 toxicities were rare: nausea/vomiting (3%), neurotoxicity (3%), nephrotoxicity (6%), and diarrhea (3%). Based on RECIST criteria a partial response (PR) was attained in eight patients (24%) and seven patients had stable disease (SD). Seven and six patients who attained a PR or SD, respectively, had disease progression with prior gemcitabine-based therapy. The median time to disease progression for all 34 patients was 3.9 months and 5.9 months for the eight patients who attained a PR. Median overall survival for all 34 patients was 10.3 months.

CONCLUSION

Adding a single new drug such as irinotecan to the same first-line chemotherapy combination upon disease progression may be an important alternative to switching to different drug classes for treatment of relapsed/resistant cancer. The promising clinical outcomes and moderate toxicity associated with G-FLIP in this heavily pretreated group warrant development of this novel regimen including tests as first-line therapy in patients with diseases likely to be responsive to the drugs contained in this combination.

Therapy for regionally unresectable pancreatic cancer

Chemoradiotherapy for unresectable LAPA is associated with a median survival time of 9 months or more and manageable toxic side effects. Experience with RT-FSP provides evidence that chemoradiotherapy may extend survival time with or without resection. Chemoradiotherapy or entry into clinical trials is the standard for LAPA. The next generation of clinical trials for LAPA will incorporate newer agents, such as gemcitabine and irinotecan into chemoradiotherapy regimens. Novel agents, such as matrix-metaloproteinase inhibitors, transcription factor inhibitors, antiangiogenic factors, cyclooxegenase-2 inhibitors, and agents that target the K-ras point mutations associated with 90% of pancreatic cancers, are in early phases or clinical development and may have activity for micrometastic or minimal residual disease. Lower toxicity makes these drugs attractive agents for maintenance therapies. The multitude of new agents provides hope to patients and a welcome challenge for further investigation.

Treatment of metastatic pancreatic adenocarcinoma: a comprehensive review

The current standard therapy for metastatic pancreatic adenocarcinoma is the single-agent gemcitabine, by the increasingly used fixed rate infusion of 10 mg/m2/min. There is strong reason to anticipate that additional benefits will accrue with gemcitabine-based combination chemotherapy. Gemcitabine and CPT-11 are synergistic with many drugs and non-cross-resistant with each other. Rigorous clinical investigations will be performed in an effort to identify optimal drug sequence and schedules for these novel combinations.

Long-term follow-up of twenty patients with adenocarcinoma of the pancreas: resection following combined modality therapy

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Pancreatic duct cell carcinoma with positive 111In Octreotide uptake

Duct cell adenocarcinomas may produce neuroendocrine markers such as pancreatic polypeptide, gastrin and gastrin releasing hormones. A 53 year old patient, with a history of insulin dependent diabetes, was found to have a pancreatic mass which was later pathologically demonstrated to be a duct cell adenocarcinoma. The tumor produced elevated circulating neuroendocrine markers specifically gastrin and pancreatic polypeptides. An 111In Octreotide imaging showed definite uptake of Octreotide by the tumor. The patient was subsequently treated with Somatostatin analog which resulted in the reduction of some of the circulating endocrine markers. The patient had essentially six months of asymptomatic clinical remission but then she relapsed. Octreotide scanning could be useful for selected patients with pathologic diagnosis of duct cell adenocarcinoma, because some tumors may have neuroendocrine features and can be imaged, and might even respond to Somatostatin analog therapy.

Eccrine sweat gland carcinoma: a case report and review of diagnosis and treatment

Carcinomas of the skin appendices are rare neoplasms but for prognostic reasons it is important to differentiate them from the indolent squamous and basal cell carcinomas, as their behavior is more aggressive. We report on a case of eccrine sweat gland carcinoma that displayed all the typical features of those neoplasms. The patient sought medical attention after a lesion in his foot, already present for four years, began to enlarge and developed satellite lesions. The pathological diagnosis was made only after the lesion was initially misdiagnosed as basal cell carcinoma of the skin. Multiple chemotherapeutic regimens and radiation therapy were administered with only temporary benefit. The patient developed distant metastatic disease but survived with metastases for three years. He died nine years after the initial lesion developed in his foot and five years after the diagnosis. The diagnosis of sweat gland carcinomas can be facilitated by histochemical stains. In contrast to squamous and basal cell carcinomas of the skin, these are generally positive for the carcinoembryonic antigen (CEA). Once metastatic, these neoplasms are only infrequently, and usually briefly, responsive to either chemotherapy or radiotherapy and new treatments are urgently needed. Early recognition of the entity may allow more timely treatment.

Phase I/II study of stage III and IV non-small cell lung cancer patients taking a specific dietary supplement

This phase I/II study evaluates the influence of selected vegetables (SV) that contain known antitumor components on the survival of stage III-IV non-small cell lung cancer (NSCLC) patients. All patients were treated with conventional therapies. SV was added to the daily diet of 5 stage I patients in the toxicity study group (TG) and 6 stage III and IV patients in the treatment group (SVG), but not to the diet of 13 stage III and IV patients in the control group (CG). Age, Karnofsky performance status (KPS), and body mass index of SVG and CG patients were comparable at entry. KPS declined in the CG patients (79 +/- 8 to 55 +/- 11) but improved in the SVG patients (75 +/- 8 to 80 +/- 13) one to three months after entry. Weight change in the CG, SVG, and TG patients was -12 +/- 5%, -2 +/- 2%, and +4 +/- 4%, respectively. The median survival time and mean survival of the CG patients were 4 and 4.8 months, but in the SVG patients they were 15.5 and 15 months (p < 0.01). No clinical signs of toxicity were found in the TG patients in the 24-month study period. Adding SV to the daily diet of NSCLC patients was found to be nontoxic and associated with improved weight maintenance, KPS, and survival of stage III and IV NSCLC patients.

Use of an ex vivo ATP luminescence assay to direct chemotherapy for recurrent ovarian cancer

Chemotherapy for recurrent ovarian carcinoma (ROC) produces response rates of 10-80% depending on the prevalence of platinum resistance. Most patients relapse within 1 year and median progression-free survival (PFS) is generally no more than 6 months. Previous pretherapeutic chemosensitivity assays mostly failed to improve the outcome of patients with ROC. Newly developed ATP assays show promising retrospective correlation with clinical outcome. We report here the first results of ATP assay-directed chemotherapy in patients with ROC. Therapy was selected by the ATP tumor chemosensitivity assay (ATP-TCA) in a prospective open-label pilot trial for ROC. Objective response rate (ORR), PFS and overall survival (OAS) of the first 25 evaluable patients were retrospectively compared with those of 30 others having similar characteristics who were treated empirically within the same period. The actuarial median observation times were 80 weeks for the ATP-TCA group and 83.5 weeks for the control group, respectively. In the control group, a 37% ORR [two complete responses (CR) and nine partial responses (PR)] was followed by a median PFS of 20 weeks and a median OAS of 69 weeks, mainly related to the use of single-agent chemotherapy. The ORR in the ATP-TCA group was 64% (eight CR and eight PR) (p=0.04) with the majority of responses (11 of 16) achieved with novel combinations. The median PFS in this group was 50 weeks (p=0.003) and the median OAS was 97 weeks (p=0.145). Survival of responding patients was similar in both groups. Chemotherapy guided by the ATP-TCA produced a greater benefit with regard to both ORR and PFS in platinum-refractory patients. ATP-TCA-directed chemotherapy for ROC compares favorably with chemotherapy chosen by a clinician and often leads to the choice of novel drug combinations. These promising results now warrant confirmation by prospective randomized trials.

Mitoxantrone combined with paclitaxel as salvage therapy for platinum-refractory ovarian cancer: laboratory study and clinical pilot trial

This report describes preclinical and early clinical investigations of the mitoxantrone/paclitaxel combination (NT) for patients with platinum-refractory ovarian cancer. The preclinical activity of NT was studied ex vivo, evaluating native tumor specimens with the ATP tumor chemosensitivity assay. Of 24 tumors tested, 20 (83%) were sensitive to NT, whereas 7 (29%) responded to mitoxantrone and 8 (33%) responded to paclitaxel. In the majority of tumors assayed (19 of 24), potentiating or major independent effects between both agents were found. Subsequently, a clinical pilot trial of NT was initiated for patients with platinum-refractory ovarian cancer. Patients had failed one to four (median, two) prior chemotherapy regimens. In 11 cases, NT was administered every three weeks with 8 mg/m2 mito-xantrone and 180 mg/m2 paclitaxel (NT-I). Seven patients were treated biweekly with 6 mg/m2 mitoxantrone and weekly with 100 mg/m2 paclitaxel (NT-II). During 92 NT courses, myelosuppression with leucopenia, anemia, and thrombocytopenia was the limiting toxicity, occurring more frequently with NT-II. No patient required hospitalization due to any life-threatening complication. Five complete and nine partial remissions were observed with both NT-I and NT-II, accounting for an overall 78% response rate, with a median progression-free survival of 40 weeks. One patient showed early progression during therapy. Currently, three patients (NT-I, two; NT-II, one) have died due to progressive relapsed ovarian cancer, so that the median overall survival is not reached after a median follow-up of 40.5+ weeks. Both schedules were found to be equal in terms of response rate and overall survival. NT is highly active and practical for salvage treatment of ovarian cancer. NT-II may be preferred due to both clinical activity and patients' acceptance. However, NT-I seems to be a less myelotoxic alternative. Both schedules warrant further clinical investigation.

Combined modality therapy for stage II and stage III pancreatic carcinoma

PURPOSE

To study the outcome achieved with three-drug chemotherapy and split-course external-beam radiotherapy as a treatment for unresectable stage II and III pancreatic carcinoma.

PATIENTS AND METHODS

Radiotherapy was given in three cycles of 2 Gy/d on days 1 to 5 and 8 to 12 (total dose, 54 Gy) concurrently with fluorouracil (FU) 1,000 mg/m2/d by continuous infusion for 4.5 days, streptozocin (STZ) 300 mg/m2 on days 1, 2, and 3 and cisplatin (P) 100 mg/m2 on day 3 of each every-28-day cycle. Subsequent treatment consisted of leucovorin (LV) 200 mg/m2 and FU 600 to 1,000 mg/m2 every 14 days.

RESULTS

The median survival time for the 35 patients was 15 months and 26% of patients were alive at 24 months. Fifteen patients (42.8%) had objective responses to therapy. Six (17%) had a complete response (CR). Three of nine patients with partial responses (PRs) achieved a radiographic CR within the next 3 months. Nine patients underwent attempts at surgical resection: five were resected (median survival time, 31 months; range, 12.8 to 44.7+), two had no residual disease found at complete resection, and three others also had a complete resection. Of four others who could not be resected, three underwent intraoperative radiotherapy and one had occult metastatic disease. Of primary tumors, 91% did not produce either back pain or local gastrointestinal complications for 2 years. The rates of severe side effects were stomatitis 15%, anemia 14%, granulocytopenia 6%, and thrombocytopenia 6%.

CONCLUSION

Palliation and survival compare favorably with other series, including many surgical series. The response findings encourage studies of both unresectable and (as neoadjuvant therapy) resectable tumors.

Correlation of the clinical response to chemotherapy in breast cancer with ex vivo chemosensitivity

Chemotherapy for breast cancer is given on the basis of empirical information from clinical trials, an approach which falls to take into account the known heterogeneity of chemosensitivity between patients. Previous attempts to determine chemosensitivity ex vivo have been disappointing, but in this study results from a newly developed tumor chemosensitivity assay (TCA) have been correlated prospectively with patient response. In this study, we have used heterogeneity data for standard regimens obtained from 116 breast TCAs to set sensitivity/resistance thresholds which were then used to interpret the results from those with known clinical responses. Assay evaluability was 97% in surgical biopsies. Clinical follow-up of stage III/ IV assessable disease was obtained from 27 breast tumors which were successfully tested for chemosensitivity, including 13 needle biopsies. The ATP-TCA assay predicted response correctly in 22 out of 29 (76%) tumors with clinically evaluable disease, suggesting that it is capable of predicting outcome in individual patients. Assays were performed in seven patients before and after chemotherapy using residual or recurrent tumor tissue. Four cases with initial sensitivity showed a decrease in sensitivity within 6 months of starting chemotherapy, while two others without clinical resistance were still sensitive by TCA. All nine courses of therapy given on the basis of TCA sensitivity resulted in partial or complete responses. Controlled trials of TCA-directed treatment against standardized empirical therapy should be conducted before this technology is widely adopted to assess its impact on rates of response, survival and the cost of treatment.

Tumor markers in patients with pancreatic carcinoma

BACKGROUND

Tumor markers are putative prognostic indicators for patients with carcinoma, but have not heretofore been evaluated in patients with Stage II and III pancreatic carcinoma.

METHODS

Patients with Stage II (n=9) and Stage III (n=25) unresectable regional adenocarcinoma of the pancreas were treated with combined modality therapy. Treatment consisted of split course radiotherapy and simultaneous combination chemotherapy with fluorouracil infusion, streptozotocin, and cisplatin. Prior to treatment, patients free of both infection and jaundice provided blood for CA 19-9, carcinoembryonic antigen (CEA) and CA 125 assays.

RESULTS

The overall median survival of Stage II patients was 21.1 months. Due to the small number of Stage II patients with markedly abnormal assays, it was not possible to test for a statistically significant association between pretreatment tumor assays and survival. Among patients with Stage III pancreatic carcinoma, a CA 19-9 assay of 2000 u/ML or less identified a group of 16 patients with a median survival of 12.8 months. In contrast, 8 Stage III patients with a CA 19-9 assay of greater than 2000 u/mL had a median survival of 8 months and only 1 patient survived for 1 year (P=0.020, log rank test; P=0.010, Wilcoxon test). Among Stage III patients, a comparison of those with a normal assay versus any degree of abnormal assay failed to provide prognostic information. Analyses based on a combination of CA 19-9 and CA 125 assays provided additional powerful prognostic information: (P=0.002, log rank test; P=0.005, Wilcoxon test). CEA assays failed to provide information alone or in combination with the CA 19-9 assay. After adjusting for the CA 19-9 assay in multivariate analyses, neither performance status nor tumor size were significant prognostic variables for patients with Stage III cancers.

CONCLUSIONS

Pretreatment CA 19-9 assays provide powerful independent and objective prognostic information.

Tumor markers in patients with pancreatic carcinoma

BACKGROUND

Tumor markers are putative prognostic indicators for patients with carcinoma, but have not heretofore been evaluated in patients with Stage II and III pancreatic carcinoma.

METHODS

Patients with Stage II (n=9) and Stage III (n=25) unresectable regional adenocarcinoma of the pancreas were treated with combined modality therapy. Treatment consisted of split course radiotherapy and simultaneous combination chemotherapy with fluorouracil infusion, streptozotocin, and cisplatin. Prior to treatment, patients free of both infection and jaundice provided blood for CA 19-9, carcinoembryonic antigen (CEA) and CA 125 assays.

RESULTS

The overall median survival of Stage II patients was 21.1 months. Due to the small number of Stage II patients with markedly abnormal assays, it was not possible to test for a statistically significant association between pretreatment tumor assays and survival. Among patients with Stage III pancreatic carcinoma, a CA 19-9 assay of 2000 u/ML or less identified a group of 16 patients with a median survival of 12.8 months. In contrast, 8 Stage III patients with a CA 19-9 assay of greater than 2000 u/mL had a median survival of 8 months and only 1 patient survived for 1 year (P=0.020, log rank test; P=0.010, Wilcoxon test). Among Stage III patients, a comparison of those with a normal assay versus any degree of abnormal assay failed to provide prognostic information. Analyses based on a combination of CA 19-9 and CA 125 assays provided additional powerful prognostic information: (P=0.002, log rank test; P=0.005, Wilcoxon test). CEA assays failed to provide information alone or in combination with the CA 19-9 assay. After adjusting for the CA 19-9 assay in multivariate analyses, neither performance status nor tumor size were significant prognostic variables for patients with Stage III cancers.

CONCLUSIONS

Pretreatment CA 19-9 assays provide powerful independent and objective prognostic information.

Ascorbic acid (vitamin C) improves the antineoplastic activity of doxorubicin, cisplatin, and paclitaxel in human breast carcinoma cells in vitro

Utilizing a microplate ATP bioluminescence assay, two human breast carcinoma cell lines, MCF-7 and MDA-MB-231, were tested against doxorubicin (DOX), cisplatin (DDP), and paclitaxel (Tx) alone and in combination with ascorbic acid (Vit C). In both cell lines, Vit C exhibited cytotoxic activity at high concentrations (i.e. 10(2)-10(3) microM). Both cell lines also were resistant to DOX. MCF-7 was found to be DDP-resistant, MDA-MB-231 was moderately sensitive to DDP. Both cell lines were strongly sensitive to Tx. Vit C both at non-cytotoxic (1 microM) and moderately cytotoxic concentrations (10(2) microM) improved the cytotoxicity of DOX, DDP, and Tx significantly. Combination effects between Vit C and DDP or Tx were partly synergistic and partly additive or subadditive whereas a consistent synergism was found between Vit C and DOX. The mechanisms by which Vit C potentiates the cytostatics studied are yet unclear and should be evaluated further.

Heterogeneity of in vitro chemosensitivity in perioperative breast cancer cells to mitoxantrone versus doxorubicin evaluated by a microplate ATP bioluminescence assay

Apart from clinical trials, mitoxantrone (MX) is rarely used in breast cancer (BC) due to the anticipated anthracycline cross-resistance. We have examined this drug versus doxorubicin (DOX) using data obtained from in vitro microplate ATP tumor chemosensitivity assays (ATP-TCA) of BC cells which were derived from 55 chemotherapy-naive patients at time of primary surgery. Both drugs were tested at 6 different concentrations ranging from 6.25% to 200% peak plasma concentration in vivo (PPC). Differences between DOX and MX observed for mean IC50, IC90, and a sensitivity index (SI) were not statistically significant. In vitro response rates were 44% for DOX and 52% for MX. 34 of 52 eligible assays (65%) showed comparable activity of both drugs whereas a lack of cross-resistance was observed in the remaining 18 (35%) tumors as indicated by differences for SI. Cumulative concentration-response plots of tumors responding in vitro with a > or = 50 percent or > or = 90 percent tumor cell inhibition showed a strong dose-dependence for both DOX and MX at concentrations which normally can be achieved within clinical tumors (i.e. 6.25%-50% PPC). At higher concentrations, however, cytotoxicity of DOX and MX could not be improved by further in vitro dose escalation. Moreover, a substantial proportion of BC specimens (DOX: 48.1%; MX: 40.4%) did not experience a > or = 90 tumor cell inhibition at 200% PPC. In conclusion, in vitro results obtained by ATP-TCA indicate that there is no cross-resistance between MX and DOX in a substantial proportion of BC patients. This may be clinically useful and suggests that combinations including MX should be tested in patients clinically resistant to DOX containing regimens. Since both drugs produced sigmoidal concentration-response curves, dose escalation beyond a certain point may not produce increased sensitivity.

In vitro activity of titanocenedichloride versus cisplatin in four ovarian carcinoma cell lines evaluated by a microtiter plate ATP bioluminescence assay

Titanocenedichloride (MKT 4) is a novel anticancer drug with a broad spectrum of activity in mammalian tumors. We investigated the anticancer efficacy of MKT 4 versus cisplatin and its chemomodulation by buthionine sulfoximine (BSO) in four different human ovarian carcinoma (OvCA) cell lines derived from both primary (A2780. OTN 14) and recurrent tumors (SKOV-3 and OV-MZ-1b) using an in vitro microplate ATP bioluminescence assay (ATP-TCA). Sensitivity against cisplatin was higher in A2780 and OTN 14 compared with MKT 4, whereas the opposite was found in SKOV-3 and OV-MZ-1b cells. In A2780, SKOV-3 and OV-MZ-1b, the cytotoxicity of both agents could be effectively improved by BSO with supraadditive effects observed for MKT 4 in all three cell lines. In OTN 14, however, BSO treatment failed to increase the cytotoxicity of both cisplatin and MKT 4. These results suggest antineoplastic activity of MKT 4 in cisplatin-sensitive and mainly in cisplatin-resistant OvCA cells which can be significantly modulated by BSO-mediated glutathione depletion. Since antineoplastic activity of both cisplatin and MKT-4 observed in OTN 14 could not be reversed by BSO, other mechanisms of drug resistance different from the glutathione redox cycle are likely to be important for both metal compounds.

Taxol inhibits growth of mesothelioma xenografts

BACKGROUND

In vitro tests measuring inhibition of adenosine triphosphate activity predicted three mesothelioma xenografts would be sensitive to taxol.

PURPOSE

The in vivo therapeutic efficacy of taxol was tested in nude mice carrying the subcutaneous tumors.

METHODS

Once tumor growth reached 100mm3 in size, intraperitoneal taxol, 30 mg/kg, on a day 1, 4, and 8 schedule, was administered to mice bearing subcutaneous mesothelioma xenografts.

RESULTS

Taxol inhibits the growth of all three cell lines. It produces actual tumor regression including some complete responses.

CONCLUSIONS

Taxol is an active drug against mesothelioma. The in vitro cell lines and the in vivo system are useful tools for screening and developing new treatments for mesothelioma.

TCA-100 tumour chemosensitivity assay: differences in sensitivity between cultured tumour cell lines and clinical studies

The BATLE LE TCA-100 tumour chemosensitivity assay has been used to evaluate chemotherapeutic drug sensitivity of cultured tumour cell lines. Studies were performed using test drug concentrations calibrated to discriminate sensitivity and resistance of clinical specimens. Strong sensitivity which appeared to be inconsistent with clinical experience was detected for some drugs and cell lines. Findings of strong sensitivity were consistent with basic differences between sensitivity testing cultured cell lines and clinical specimens. Results with cell lines frequently may not apply directly to clinical applications. Characterization of differences between cell lines and clinical specimens may assist in application of cell line findings to clinical trials.

A somatostatin analogue (SMS 201-995) alters the toxicity of 5-fluorouracil in Swiss mice

The somatostatin analogue 201-995 (SMS), given in a short treatment schedule, 1 microgram/mouse, days 1-4, increased the lethal toxicity of a single, day 2, low lethal dose of 5-fluorouracil (FU), 400-500 mg/kg, in Swiss mice. The analogue did not change the time course of toxic deaths and produced neither autopsy evidence of increased gastrointestinal nor of increased bone marrow toxicity. Paradoxically, the analogue protected the peripheral white blood cell count (WBC). The nadir was only half as severe in the animals treated with SMS in addition to FU. The mechanism responsible for more frequent deaths due to combining SMS with FU is unknown. That brief administration of SMS in combination with marginally lethal, intensive therapy can produce unexpected increase in animal deaths bears consideration because these drugs are sometimes given simultaneously to patients, either fortuitously or in trials designed to limit the gastrointestinal side effects of FU.

Survival after combined modality therapy for pancreatic cancer

Twenty consecutive patients with unresectable, locally advanced pancreatic cancer were treated with split courses of radiotherapy (RT) and simultaneous multidrug chemotherapy consisting of 5 fluorouracil, continuous infusion, streptozotocin, and cisplatin. A separate, retrospective study identified a group of 28 contemporary patients with less advanced pancreatic cancers, all of which were successfully resected. The survival rate of the two groups were similar over the first 2 years, although it initially favored the unresectable group. This pattern of survival among patients treated with combined modality therapy provides a basis for new studies. At the two clinical extremes, these include treatment of unresectable tumors previously considered ineligible for this treatment and initial treatment before resection of stage I tumors.

Circulating pancreatic polypeptide in patients with adenocarcinoma of the bile duct

Using radioimmunoassay methods, the blood of patients with pancreatic tumors was screened for circulating polypeptide hormones. This screening discovered pancreatic polypeptide in abnormally high concentration in the serum of six of seven patients with adenocarcinomas of the bile duct. The assay appears to be very sensitive finding excessive residual pancreatic polypeptide production after palliative resections. Serum pancreatic polypeptide assays warrant evaluation as an aid in the diagnosis and management of patients with bile duct tumors.

Combined modality therapy increasing local control of pancreatic cancer

Twenty patients with inoperable locally advanced Stage II and III pancreatic cancer were treated with combined modality therapy. Radiotherapy consisted of split courses of 2000 cGy each and, as needed, an additional 1400 cGy, separated by 2-week intervals. Simultaneous multidrug regimen chemotherapy consisted of 5-fluorouracil, continuous infusion, 1 g/m2 days 1-5; streptozotocin, 300-500 mg/m2 days 1, 2, 3; and cisplatin, 100 mg/m2 day 3 of every 4-week radiotherapy course (RT-FSP). Primary tumors decreased more than 50% in volume in 11 of 20 patients. Computed tomography scans demonstrated apparent complete disappearance of the primary tumor in 7 patients. Only 3 patients had tumor regrowth within the radiotherapy field, all after the end of radiotherapy. Local control improved as measured by increased frequency of tumor shrinkage and decreased frequency of primary tumor growth, recognizing the limitations of a pilot study and comparisons to best historical results achieved with standard short 5-fluorouracil schedules and radiotherapy. Successful local control largely eliminates the most common cause of refractory pain and may decrease the need for some forms of early palliative surgical intervention. Tumor shrinkage sometimes downstages tumors, creating frequent investigational opportunities for either elective extirpative surgery or intraoperative radiotherapy. This pilot experience also supports testing of expanded eligibility staging criteria for combined modality treatment and testing of new drugs as part of 5-fluorouracil-radiotherapy-based regimens.

Treatment of a large high-grade neurofibrosarcoma with concomitant vinblastine, doxorubicin, and radiotherapy

A patient with neurofibromatosis developed a large inoperable malignant schwannoma on the posterior neck. The tumor underwent complete local regression following combined-modality treatment with radiotherapy, vinblastine, and doxorubicin. Vinblastine may be effective in combined-modality therapy.

Clostridium difficile diarrhea induced by cancer chemotherapy

Four patients had diarrhea due to Clostridium difficile after receiving chemotherapy for cancer. None of the patients had received antibiotics for at least 4 weeks before the onset of diarrhea. At the time of admission of any of these four patients no outbreak of diarrhea was noted on the ward. Each patient was admitted with the acute onset of diarrhea after receiving chemotherapy, at different times of the year. Diarrhea was clinically important and was associated with dehydration, toxemia, and blood in the stool in all cases. Diagnosis of C difficile was confirmed by endoscopic examination, positive biopsy specimen, and positive test for toxin in the stool. All patients recovered after undergoing specific treatment. Drugs not believed to carry serious risk to the bowel mucosa may facilitate proliferation of C difficile. Patients with severe diarrhea after receiving chemotherapy, particularly those with blood in the stool, should be promptly tested for C difficile even in the absence of a history of antibiotic administration. Early and specific treatment can prevent additional morbidity and reduce cost of care.

Folate biochemical modulation regimen for the treatment of gastric cancer

Twenty patients with metastatic gastric cancer were treated with methotrexate (MTX, M), 100 to 160 mg/m2 at 0 h, and, in sequence, 5-fluorouracil (FU, F), 600 to 1000 mg/m2 at 4 h; leucovorin (LV, L), 200 mg/m2 at 18 h, then 20 mg/m2 every 6 h x 12; 5-fluorouracil, 600 mg/m2 at 19 h; and high-dose cisplatin (DDP, P), 100 mg/m2 at 20 h. In addition, they were treated with a continuous 5-fluorouracil infusion, 1000 mg/m2/24 h from 18 h to 114. There were 8 complete and 6 partial responses among the 16 patients with measurable tumors. Five patients, each with one remaining clinical site of disease, received supplementary regional therapy: three received intraperitoneal therapy, two received hepatic arterial therapy. Intraperitoneal therapy and hepatic artery therapy each produced one complete response. Median survival was 16 months for all patients, and 25% survived 2 years. In comparison with matched patients, both response rates and survival improved twofold.

Hexamethylmelamine for the treatment of ovarian cancer--the Mount Sinai experience

Two regimens were tested, CHAP I and CHAP II, the latter, a hexamethylmelamine dosage-intensive regimen, first as second line (salvage) therapy and then as primary therapy. Both produced the most successful results achieved in the Mount Sinai series up to the time of their introduction, when compared to their predecessor regimens: CAP, AP and P. In an overall interim comparison, CHAP II was significantly superior to historical AP and CAP as primary therapy, as was CHAP I vs. AP in several important subgroups compared as part of a randomized trial. CHAP II overall progression-free survival was improved in spite of added new sensitive test methods. Salvage therapy also improved markedly with the addition of intensive hexamethylmelamine. Several biological and treatment characteristics strongly influenced outcome, especially young age and adding hexamethylmelamine. Other possible factors included: poor tumor grade, poor performance status, and extent of surgical debulking, even to intermediate residual, 2-6 cm size [CHAP II only]; extensive (optimum) surgery [CHAP I only]. The hexamethylmelamine-containing regimens interact favorably with some of these factors, better than did the preceding regimens. Five-year follow-up analyses weakened slightly for extensive surgery, intermediate size and poorly differentiated tumors. It confirmed and strengthened several findings favoring CHAP I & II, the hexamethylmelamine-containing regimens.

Effective chemotherapy for gastrointestinal tumors. 21st Symposium on Recent results in chemotherapy of malignant diseases (Chairmen: J. van de Loo, V. Diehl) of the Gesellschaft zur Bekämpfung der Krebskrankheiten Nordrhein-Westfalen (GBK), Düsseldorf, June 1989

Chemotherapy can achieve approximately 50% rates of response, survival advantage or both for every type of gastrointestinal tumor. Findings favor adjuvant therapy for all high-risk tumors. Test-worthy candidate regimens possibly increase safety and efficacy, and challenge traditional choices of treatment for patients with either unresectable or metastatic disease. They create many new options and an unprecedented order of complexity. Treatments remain to be compared and integrated. Efforts to assess the impact of patient characteristics, cost and safety are preliminary at best, and critical to rational usage. There are as yet no perfect regimens, only a series of options supported by incomplete but clearly more promising findings than heretofore. These include: biochemical modulation for gastric and colonic cancer; chemotherapy as a radiotherapy adjuvant for esophageal, rectal, anal, and pancreatic cancer; and immunotherapy for gastric and colorectal cancer. Selective application of endocrine therapy, circadian time schedules or regional therapy may augment safety and quality of life. While response rates have probably improved, their exact frequency, quality and effect on survival are incompletely characterized. Investigations, offer the best way to deal with the options and speed progress, in the context of building upon apparent best therapies.

Dose-dependent leucovorin efficacy with an intermittent high-dose 5-fluorouracil schedule

Sixteen patients with metastatic carcinoma of the colon were treated with a regimen of leucovorin 200 mg/m2, given as a 10-min infusion followed by a median dose of 833 mg/m2 (range 500-1000 mg/m2) 5-fluorouracil every two weeks. For the 16 patients with proven metastatic disease, two-year survival exceeds 50%. Responses were: 2 complete; 4 partial; 4 minor; 3 progression; and 3 not evaluable but without progression to date. Toxicities include: 8 (50%) leukopenia; 9 (56%), 1 severe thrombocytopenia; 9 (56%), 2 severe, diarrhea; 9 (56%), 3 severe, nausea/vomiting; 8 (50%), 1 severe, stomatitis; 7 (44%) conjunctivitis; 6 (38%) alopecia; and 13 (81%), 3 severe, neurotoxicity. Leucovorin appears to exert a dose-dependent beneficial effect on both the response and survival produced by the intermittent high-dose 5-fluorouracil schedule. This benefit first appears to increase substantially when the leucovorin dose is increased from 120 to 200 mg/m2. Findings identify a testable candidate regimen for selected good risk patients. Full selection criteria remain to be identified.

Complete remission of refractory small cell carcinoma of the pancreas with cisplatin and etoposide

A case of unusually large widespread metastatic small cell carcinoma of the pancreas is presented. The patient remains in complete remission 50 months after the diagnosis and initiation of combination chemotherapy using a schedule consisting of etoposide (150 mg/m2) intravenously (IV) on days 1 to 3 and cisplatin (100 mg) IV on day 2. Initial chemotherapy with streptozotocin, 5-fluorouracil, and methotrexate, doxorubicin, cyclophosphamide, and lomustine (MACC) had been unsuccessful.

Treatment of advanced refractory ovarian carcinoma with a gonadotropin-releasing hormone analogue

Leuprolide acetate, a gonadotropin-releasing hormone analogue, produced a variety of beneficial therapeutic responses in five patients with ovarian carcinoma. Four patients had failed intensive chemotherapy with alkylating agents, cisplatin, and Adriamycin. All had one or more clinical conditions that precluded treatment with cytotoxic agents and characteristics associated with resistance to hormone therapy. Our findings support evaluation of expanded eligibility criteria for new hormonal therapy in cases of refractory ovarian carcinoma.

The modulation of fluorouracil with leucovorin in metastatic colorectal carcinoma: a prospective randomized phase III trial. Gastrointestinal Tumor Study Group

A total of 343 patients with previously untreated metastatic measurable colorectal carcinoma were studied to evaluate the impact on toxicity, response, and survival of leucovorin-modulated fluorouracil (5-FU). A maximally tolerated intravenous bolus loading course regimen of 5-FU alone (500 mg/m2 x 5 days every 4 weeks with 25 mg/m2 escalation) was compared with a high-dose leucovorin regimen (600 mg/m2 of 5-FU with 500 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest) and with a similar low-dose leucovorin regimen (600 mg/m2 of 5-FU with 25 mg/m2 of leucovorin weekly for 6 weeks with a 2-week rest). The dose-limiting toxicity for the two 5-FU and leucovorin regimens was gastrointestinal, specifically diarrhea; severe diarrhea was seen frequently, and treatment-related toxicity was implicated in the demise of 11 of the patients (5%). Significant improvements in response rates were observed with a response rate of 33 of 109 (30.3%) on the high-dose leucovorin regimen (P less than .01 v control); 13 of 107 (12.1%) on the 5-FU control; and 21 of 112 (18.8%) on the low-dose leucovorin regimen. A trend toward longer survival in the 5-FU plus high-dose leucovorin regimen was observed. In this study, leucovorin was shown to significantly enhance the therapeutic effect of 5-FU in metastatic colorectal carcinoma.

Schedule and dosage modification of a cyclophosphamide, hexamethylmelamine, doxorubicin, cisplatin combination chemotherapy regimen for refractory ovarian cancer

A cyclophosphamide, hexamethylmelamine, doxorubicin and cisplatin (CHAP II) regimen produced median survival of 15 and 17 months. All patients had prior chemotherapy, 26 with cisplatin in the former group, and 27 without cisplatin in the latter group. Treatment employed both a novel sequential schedule of cisplatin (usually in the evening) 24 h before cyclophosphamide-doxorubicin and novel stepwise escalation, first of doxorubicin, then of hexamethylmelamine until either nadir white blood counts fell to 1000-1500/mm3 or platelets to 75,000-100,000/mm3. Compared to prior Mount Sinai experience: (i) survival was significantly improved; (ii) with and without prior cisplatin, response rates approached a significant improvement, 12% and 29% complete and 24% and 35% partial. Five of seven additional patients with progression during unmaintained remission also responded, two with pathologically complete remissions. Findings suggest: (i) the importance of maximum dose intensity in ovarian cancer treatment; (ii) the responsiveness of patients failing first line treatment to dose intensive treatment; (iii) the possible importance of schedule, and sequential or circadian timing of cisplatin, and other drugs; (iv) and testing revised clinical criteria of resistance to drugs.

Modulation and intensification of a cyclophosphamide, hexamethylmelamine, doxorubicin, and cisplatin ovarian cancer regimen

For 61 patients with stage III-IV carcinoma of the ovary, chemotherapy consisted first of cisplatin 50 mg/m2 on day 1, cyclophosphamide 500 mg/m2 on day 3, doxorubicin 50 mg/m2 on day 3, and hexamethylmelamine 100 mg/m2 on days 4-15 every 4 weeks. The dosages of doxorubicin and hexamethylmelamine were increased by 60 and 100%, respectively, until the nadir white blood cell counts fell to 1.0 x 10(9)/L. This regimen was less neurotoxic and nephrotoxic than other intensive treatments and produced better therapeutic effects than did the immediate preceding Mount Sinai regimens: 1) The overall median survival was 43 months and progression-free survival was 25 months; 2) the greatest benefit occurred among patients under 50 years of age; 3) regression of large tumors increased in frequency, with 33% of tumors 2-6 cm and 16% of tumors larger than 6 cm converted to either pathologically proved remission or microscopic disease; and 4) for the first time, partial surgical debulking producing residual tumors less than 6 cm in size improved early survival.

Primary treatment of regional and disseminated pancreatic cancer with hexamethylmelamine, mitomycin C and 5-fluorouracil infusion

Hexamethylmelamine, mitomycin C and 5-fluorouracil infusion (HexMF) achieved a median survival of 9 months for the 45 patients with either metastatic stage III or unresectable stage II carcinoma of the pancreas. Fifteen percent survived 2 years. Of 32 patients with measurable tumors, 7 had partial and 3 had minor responses (31%); an additional 44% has stable disease for 3 months or more. Response was associated with a 17-month median survival. These findings are indications for further evaluation of both dosage-intensive 5-fluorouracil infusions alone and HexMF as an alternative to streptozotocin- or adriamycin-containing regimens. Patients with nonmeasurable disease are candidates for survival-oriented phase III studies.

Leucovorin and 5-fluorouracil as a treatment for disseminated cancer of the pancreas and unknown primary tumors

Chemotherapy with leucovorin (100 to 200 mg) and 5-fluorouracil (30 mg/kg) every 2 wk produced four (three complete) objective responses among a group of eight patients with early metastatic pancreatic primary and unknown cancers. Complete remissions were associated with exceptionally long durations of survival, one in a patient failing prior combination chemotherapy. This treatment warrants testing because of its ease, scientific rationale, and the large population of patients with early metastatic pancreatic cancer for whom there is no accepted treatment. Early metastatic disease is defined as small metastatic lesions not immediately life threatening found in a physiologically intact patient. Controlled trials, demonstrating benefit associated with other 5-fluorouracil-containing regimens for patients with nonmetastatic stages of pancreatic cancer, provide a rationale for extending testing of leucovorin and 5-fluorouracil to other early stages of pancreatic cancer.

Extrahepatic obstructive jaundice due to colorectal cancer

A prospective registry of patients with obstructive jaundice referred for percutaneous bile duct drainage found six patients with extrahepatic obstruction due to colorectal cancer in a 21-month period. This cause of jaundice in patients with colorectal cancer is not uncommon, and deserves routine diagnostic consideration, even in the presence of intrahepatic metastases. Percutaneous biliary drainage was beneficial for four of the six patients.