Abstract P1-15-20: DIetary REstriction as an adjunct to neoadjuvant ChemoTherapy for HER2-negative breast cancer: Final results from the DIRECT trial (BOOG 2013-04)

Background:

Short term fasting (STF) protects from toxicity, while enhancing the efficacy of chemotherapy in cancer bearing mice and is a promising strategy to enhance the efficacy and tolerability of chemotherapy in humans. A specifically designed low calorie, low amino acid substitution diet (“Fasting Mimicking Diet”, FMD) has similar effects in vivo during chemotherapy as STF. The DIRECT trial evaluates the impact of FMD on toxicity and efficacy of neoadjuvant chemotherapy in women with HER2-negative early breast cancer.

Patients and methods:

Eligible patients had histologically confirmed, HER2-negative, stage II/III early breast cancer, adequate bone marrow, liver and renal function, BMI > 19kg/m2 and absence of diabetes mellitus. Women receiving 8 neo-adjuvant AC-T courses (adriamycin/cyclophosphamide - docetaxel) or 6 FEC-T courses (5-fluorouracil, epirubicin and cyclophosphamide - docetaxel); day 1, q 3 weeks, were randomized to receive FMD or regular diet for 3 days prior to and at the day of chemotherapy and 3 days prior to surgery. The FMD group received no dexamethasone during the AC or FEC courses. The primary endpoint of the phase II part was feasibility and grade III/IV toxicity and of the phase III pathological complete response (pCR) rate. Additionally, in a side study increase in DNA damage in lymphocytes before and three hours after chemotherapy was compared between the 2 arms.

Results

From February 2014 to January 2018 131 patients from 11 participating Dutch centers were randomized, whereof 100 received AC-T and 31 received FEC-T. Sixty-six of the patients received FMD. Compliance to the diet was low as 32% fasted at least half of the cycles and 24% of patients fasted during all of cycles. The main reasons of non-compliance were food aversion induced by chemotherapy and the taste of the diet. Intention to treat grade III/IV toxicity was not significantly different between the standard arm (67,2%) and in the FMD arm (79,4%), although the majority of the toxicities in the FMD arm were assessed in patients that did not complete the FMD diet preceding the measurements. The total overall pCR rate was 12,8%, lower than assumed in the sample size calculation and would therefore need minimally a doubling in patient numbers to be able to reach the expected pCR difference between both arms. Due to the poor compliance, slow accrual rate and low overall pCR rate the DIRECT study terminated after completion of the phase II part. Subgroup analysis will be presented at SABCS. In a side study, DNA damage after chemotherapy was significantly less increased in lymphocytes in the FMD group as compared to the control group (p=0.043).

Conclusion

The effect of STF on toxicity and efficacy of chemotherapy was not established due to poor compliance, however STF by FMD reduced a transient increase in chemotherapy induced DNA damage. Close monitoring of patients by nutritionists with expertise in low calorie diets as well as diets with a more variable taste are probably needed to successfully examine the impact on adverse effects and tumor biology.

Citation Format: de Groot S, Lugtenberg RT, Welters MJ, Ehsan I, Vreeswijk MP, Smit VT, de Graaf H, Heijns JB, Portielje JE, van de Wouw AJ, Imholz AL, Kessels LW, Vrijaldenhoven S, Baars A, Meershoek-Klein Kranenbarg E, Duijm-de Carpentier M, van Leeuwen-Stok E, Putter H, Longo VD, van der Hoeven JJ, Nortier JW, Pijl H, Kroep JR. DIetary REstriction as an adjunct to neoadjuvant ChemoTherapy for HER2-negative breast cancer: Final results from the DIRECT trial (BOOG 2013-04) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-20.

Abstract P3-06-50: Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01)

Background: Thyroid hormones, regulators of metabolism and development in healthy tissue, stimulate tumor growth in vitro and are associated with breast cancer risk. We investigated the effect of chemotherapy on thyroid function and the extent to which it can predict the pathological response in patients with HER2 negative stage II/III breast cancer taking part in the NEOZOTAC phase III trial, randomizing between 6 cycles of neoadjuvant TAC chemotherapy with or without additional zoledronic acid. Moreover, we examined the impact of thyroid function on chemotherapy toxicity.

Methods: Serum samples of 38 of the 105 patients who participated in the side study of the NEOZOTAC trial were available for analyses. Serum free thyroxin (fT4) and thyroid stimulating hormone (TSH) levels were measured at baseline and compared with fT4 and TSH levels before the 2nd and 6th chemotherapy cycle. FT4 and TSH levels were also compared between subjects with and without pathological complete response (pCR). The relation between toxicity, per side effect of any CTC grade, and the variation in fT4 and TSH levels during chemotherapy was tested.

Results: Serum samples at baseline, before the 2nd chemotherapy cycle and at end of treatment were available for 31, 30 and 21 patients, respectively. In the total population, the mean baseline fT4 level was 16,0pmol/L and the mean TSH level 1,11mU/L. There were no differences between subjects solely treated with TAC chemotherapy and subjects treated with zoledronic acid as an adjunct to TAC with respect to the mean fT4 and TSH at each time point. Baseline TSH levels tended to be higher in patients who achieved pCR (p=0.035 univariate analysis and p=0.074 multivariate analysis) (Table 1). During 6 cycles of chemotherapy, fT4 levels decreased (p<0.000) and TSH levels increased significantly (p=0.019). Interestingly, the decrease of fT4 was significantly greater in patients without nausea, vomiting or sensory neuropathy, than in patients with those side effects (p=0.037, p=0.043 and p=0.050 respectively).

CharacteristicUnivariate analysisMultivariate analysis OR95%CIP valueOR95%CIP valueN stage: N0 vs. N+0.330.03-3.640.368T stage: <5cm vs. >5cm0.330.03-3.630.333ER receptor: Pos vs. Neg2.560.20-33.10.473fT40.780.43-1.420.4170.660.33-1.290.581TSH3.241.09-9.700.03517.30.76-3910.074Table 1. Univariate and multivariate logistic regression models of baseline characteristics and TSH and fT4 predictive of pCR.

Conclusion: TSH levels at baseline were higher in breast cancer patients with pCR. Chemotherapy blunts thyroid function, and a large decline of fT4 was associated with less side effects. These data suggest that thyroid hormones may interact with chemotherapy to modulate treatment (side-) effects in patients with breast cancer.

Citation Format: S de Groot, A Charehbili, L GM Janssen, E M Dijkgraaf, V THBM Smit, L W Kessels, A van Bochove, H WM van Laarhoven, E Meershoek-Klein Kranenbarg, A E van Leeuwen-Stok, G J Liefers, C JH van de Velde, J WR Nortier, J JM van der Hoeven, H Pijl, J R Kroep. Thyroid function is associated with the response to neoadjuvant chemotherapy in breast cancer patients: Results from the NEOZOTAC trial on behalf of the Dutch Breast Cancer Research Group (BOOG 2010-01) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-06-50.

PD04-02: Recovery of Ovarian Function in Breast Cancer Patients with Chemotherapy-Induced Amenorrhea Receiving Anastrozole in the Dutch DATA Study

Background: In early stage hormone receptor positive breast cancer, aromatase inhibitors (AIs) are established as adjuvant therapy for postmenopausal women. In daily practice AIs are also offered to patients with chemotherapy-induced amenorrhea (CIA). The impact of AIs on estrogen (E2) levels in these patients has not extensively been studied, although this could be very relevant for the efficacy and safety of the adjuvant hormonal treatment. The Dutch phase III DATA study is assessing the impact on disease-free survival of 3 vs. 6 years of anastrozole after 2–3 years of tamoxifen (N=1900 patients in total), and has included both postmenopausal patients and patients with CIA. The current analysis reports on the hormonal data in the CIA group.

Patients and methods: We identified patients from the DATA study < 55 years of age at randomization who had received adjuvant chemotherapy and developed CIA, and excluded patients with ovariectomy or use of LHRH agonist. Patients were considered as having CIA if they were in amenorrhea since 3 months before start of chemotherapy up to 6 months after start of chemotherapy, and did not resume menses during tamoxifen therapy. Patients were eligible if postmenopausal E2 levels were confirmed within the last three months before randomization. Plasma FSH and E2 levels were serially determined at 6-month intervals.

Results: A total of 285 patients with CIA were identified in the DATA study. Median age was 50.8 years (range 35.9 - 54.9). Results on E2 and FSH levels are presented in the Table. During treatment with anastrazole, FSH levels tended to increase over time and E2 levels didn't decline. Of note, FSH increased in nearly all patients with significantly elevated (premenopausal) E2 levels, in contrast to the pattern seen in spontaneous recovery of ovarian function. During follow-up, 4 patients had vaginal bleeding, 2 of them having postmenopausal E2 levels. In 8 (2.8%) patients E2 levels became ≥ 200 pmol/l (considered premenopausal) after 12–30 months use of AI. Using a more strict cutoff value of E2 (≥ 100 pmol/l), 62 (21.8%) patients had elevated levels of E2 during AI treatment. With 70 pmol/l as cutoff value, 117 (41.0%) patients had at some point during treatment an increased E2 level. Updated and detailed analyses will be presented at the meeting.

Abstract PD06-04: Relevant Impact of Central Pathology Review on Nodal Classification, but Not on the Association of Small Nodal Metastases with Breast Cancer Outcome. Results from the Dutch MIRROR Study

Background: Previously, we reported that isolated tumor cells, pN0(i+), or micrometastases, pN1mi, were associated with a reduced 5-year disease-free survival (DFS) rate among patients with favorable early-stage breast cancer who did not receive adjuvant systemic therapy (AST) (de Boer et al, NEJM 2009). In patients with pN0(i+) or pN1mi who received AST, DFS was improved. Patients were classified by N-status as determined after central pathology review and restaged according to the 6th AJCC classification. In real life, however, treatment decisions are based on the pathology reports performed by local pathologists. Therefore, in the present study we addressed the role of the central pathology review. Methods: In the MIRROR study, a total of 2707 patients were included. Involved women were operated for breast cancer in a(ny) Dutch hospital in 1998-2005, had favorable characteristics (tumor size 1-3 cm and differentiation grade I-II OR tumor size 1 cm irrespective of grade) and had undergone a sentinel node procedure with pN0(i+) or pN1(mi) as final N-status. A control group with low-risk node-negative disease was randomly selected from the years 2000 and 2001. We assessed the difference between the original N-status and N-status after central review. Further, in patients who had not received AST (n=1712), 5-year DFS was assessed according to the original N-status as well as the review N-status. Results: Of 856 patients with pN0 after central review, 0.4% patients were originally staged as pN0(i+). Of 819 patients with reviewed pN0(i+), 24% patients originally had pN0 and 20% patients pN1 mi. And, of 1032 patients with pN1mi after review, 3% patients had originally pN0 and 15% patients pN0(i+). Overall, central review changed the N-classification thereby in 20% of patients. In patients who did not receive AST, the 5-year DFS rates of cohorts based on central pathology review were 86% for pN0, 77% for pN0(i+) and 76% for pN1mi (P<0.001, pN0(i+) and pN1mi compared with pN0). According to the original staging, the 5-years DFS rates were 85% for pN0, 73% for pN0(i+) and 72% for pN1mi (P<0.001; pN0(i+) and pN1mi compared with pN0).

Conclusion: Central pathology review changed the N-classification in 20% of patients. On a population level the association of isolated tumor cells and micrometastases with breast cancer outcome remained unchanged. However, on an individual patient level, the upstaging of pN0 patients may be of clinical relevance. Quality control of pathology departments should therefore also include nodal staging of breast (and perhaps other) cancers.

Support: The Netherlands organization for health research and development (ZonMw) and the Dutch Breast Cancer TrialistsGroup (BOOG)

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD06-04.

[A patient with an extremely severe immunohaemolytic anemia due to diclofenac]

A 77-year-old male was diagnosed with immunohaemolytic anaemia. He presented with fever, jaundice and oliguric renal insufficiency. He had been taking diclofenac for three days. Additional examinations and tests revealed a Coombs-positive haemolytic anaemia and thrombopenia. The micro-card gel-agglutination test demonstrated antibodies against diclofenac metabolites. After discontinuation of diclofenac and short-term treatment with prednisone and haemodialysis for two days, the patient made an almost full recovery. Haemolytic anaemia caused by diclofenac is rare. It can be caused by autoantibodies against erythrocytes and complement-fixing antibodies that bind to erythrocytes only in the presence of diclofenac or its metabolites. A timely diagnosis-supported by the appropriate laboratory tests--is of critical importance in this rare but extremely serious complication of the use of diclofenac. The treatment consists of withdrawal of diclofenac and supportive measures, possibly in combination with immunosuppressants.

Aromatase and COX-2 expression in human breast cancers

We have investigated aromatase and the inducible cyclooxygenase COX-2 expression using immunocytochemistry in tumors of a series of patients with advanced breast cancer treated with aromatase inhibitors. Aromatase was expressed in 58/102 breast cancers. This is similar to the percentage previously reported for aromatase activity. Interestingly, aromatase was expressed in a variety of cell types, including tumor, stromal, adipose, and endothelial cells. Since prostaglandin E2 is known to regulate aromatase gene expression and is the product of COX-2, an enzyme frequently overexpressed in tumors, immunocytochemistry was performed on the tissue sections using a polyclonal antibody to COX-2. Aromatase was strongly correlated (P<0.001) with COX-2 expression. These results suggest that PGE2 produced by COX-2 in the tumor may be important in stimulating estrogen synthesis in the tumor and surrounding tissue. No correlation was observed between aromatase or COX-2 expression and the response of the patients to aromatase inhibitor treatment. However, only 13 patients responded. Nine of these patients were aromatase positive. Although similar to responses in other studies, this low response rate to second line treatment suggests that tumors of most patients were no longer sensitive to the effects of estrogen. Recent clinical studies suggest that greater responses occur when aromatase inhibitors are used as first line treatment. In the intratumoral aromatase mouse model, expression of aromatase in tumors is highly correlated with increased tumor growth. First line treatment with letrozole was effective in all animals treated and was more effective than tamoxifen in suppressing tumor growth. Letrozole was also effective in tumors failing to respond to tamoxifen, consistent with clinical findings. In addition, the duration of response was significantly longer with the aromatase inhibitor than with tamoxifen, suggesting that aromatase inhibitors may offer better control of tumor growth than this antiestrogen.

Effects of epoetin alfa on hematologic parameters and quality of life in cancer patients receiving nonplatinum chemotherapy: results of a randomized, double-blind, placebo-controlled trial

PURPOSE

This randomized, double-blind, placebo-controlled clinical trial assessed the effects of epoetin alfa on transfusion requirements, hematopoietic parameters, quality of life (QOL), and safety in anemic cancer patients receiving nonplatinum chemotherapy. The study also explored a possible relationship between increased hemoglobin and survival.

PATIENTS AND METHODS

Three hundred seventy-five patients with solid or nonmyeloid hematologic malignancies and hemoglobin levels < or = 10.5 g/dL, or greater than 10.5 g/dL but < or = 12.0 g/dL after a hemoglobin decrease of > or = 1.5 g/dL per cycle since starting chemotherapy, were randomized 2:1 to epoetin alfa 150 to 300 IU/kg (n = 251) or placebo (n = 124) three times per week subcutaneously for 12 to 24 weeks. The primary end point was proportion of patients transfused; secondary end points were change in hemoglobin and QOL. The protocol was amended before unblinding to prospectively collect and assess survival data 12 months after the last patient completed the study.

RESULTS

Epoetin alfa, compared with placebo, significantly decreased transfusion requirements (P =.0057) and increased hemoglobin (P <.001). Improvement of all primary cancer- and anemia-specific QOL domains, including energy level, ability to do daily activities, and fatigue, was significantly (P <.01) greater for epoetin alfa versus placebo patients. Although the study was not powered for survival as an end point, Kaplan-Meier estimates showed a trend in overall survival favoring epoetin alfa (P =.13, log-rank test), and Cox regression analysis showed an estimated hazards ratio of 1.309 (P =.052) favoring epoetin alfa. Adverse events were comparable between groups.

CONCLUSION

Epoetin alfa safely and effectively ameliorates anemia and significantly improves QOL in cancer patients receiving nonplatinum chemotherapy. Encouraging results regarding increased survival warrant another trial designed to confirm these findings.

Importance of local aromatase activity in hormone-dependent breast cancer: a review

The cytochrome P-450 enzyme complex aromatase is the rate-limiting step in the production of oestrogens. It catalyses the conversion of androgens to oestrogens. In the treatment of hormone-dependent breast cancer in postmenopausal women, aromatase is the target for treatment with aromatase inhibitors. Recently registered aromatase inhibitors like anastrozole, letrozole and exemestane have proven to be effective therapy for advanced breast cancer in postmenopausal patients failing to respond to treatment with tamoxifen. Intratumoural aromatase activity has predictive value for response to treatment with aromatase inhibitors. Attempts are being made to find an immunohistochemical technique to determine aromatase in tumour tissue, which may serve as a predictive factor. In situ oestrogen synthesis through local aromatase activity in the tumour and adjacent tissue is probably a very important growth-stimulating system in hormone-dependent breast cancer. This synthesis can be blocked with aromatase inhibitors. The regulation of aromatase activity and the cell types that contribute to this process are the subject of extensive research. There seems to be a complex interaction between malignant cells and adjacent cells in which factors such as IL-6 and its soluble receptor, TNF-alpha and prostaglandin E2 play an important role in stimulating aromatase activity.

Dose-dense epirubicin and paclitaxel with G-CSF: a study of decreasing intervals in metastatic breast cancer

Anthracyclines and taxanes are very effective drugs in the treatment of advanced breast cancer. With G-CSF support, the dose-intensity of this combination can be increased by reducing the interval between chemotherapy cycles, the so-called 'shortening of cycle time'. We treated 36 patients with advanced breast cancer in a multicentre phase I/II study. The treatment regimen consisted of epirubicin 75 mg m(-2) followed by paclitaxel 135 mg m(-2) (3 h) in combination with G-CSF. At least six patients were treated in each cohort and were evaluated over the first three cycles. Starting at an interval of 14 days, in subsequent cohorts of patients the interval could be shortened to 10 days. An 8-day interval was not feasible due mainly to incomplete neutrophil recovery at the day of the next scheduled cycle. In the 10-day interval cohort it was feasible to increase the paclitaxel dose to 175 mg m(-2). The haematological and non-haematological toxicity was relatively mild. No cumulative myelosuppression was observed over at least three consecutive cycles. In combination with G-CSF, epirubicin 75 mg m(-2) and paclitaxel 175 mg m(-2) could be safely administered every 10 days over at least three cycles, enabling a dose intensity of 52 and 122 mg m(-2) per week, respectively.

[Adjuvant systemic therapy for patients with resectable breast cancer: guideline from the Dutch National Breast Cancer Platform and the Dutch Society for Medical Oncology]

There is an abundance of evidence that adjuvant systemic therapy with chemotherapy or endocrine therapy results in better survival for all patients with resectable breast cancer. The absolute 10-year survival advantage however varies for the different patient groups. Therefore, for each individual patient the choice of adjuvant therapy must take into account the potential benefits and the possible side effects. A group of medical oncologists from the Dutch National Breast Cancer Platform (NABON) and the Dutch Society for Medical Oncology (NVMO) prepared a guideline for the treatment of patients with early resectable breast cancer. The criterium for choosing adjuvant systemic therapy for the individual patient is an expected increase in 10-year survival of 5% or more. In the guideline a difference is made between patients with and without axillary lymph node metastasis. In patients with axillary lymph node metastasis the choice for adjuvant systemic therapy depends on the following prognostic factors: menopausal status, age, and the presence of estrogen and progesterone receptors in the tumour. In patients without axillary lymph node metastasis the choice depends also on the following prognostic factors: the size of the tumour, the mitotic activity index, or the histopathologic grade of differentiation.

Randomized phase II study of FEC day 1 + 8 and FEC day 1 in patients with advanced breast cancer

BACKGROUND

Dose-intensive chemotherapy regimens without stem cell support have not resulted in an improved survival compared to standard dose regimens in patients with metastatic breast cancer. Combinations of an anthracycline, cyclophosphamide and 5 fluorouracil are still standard in such patients. The aim of this study was to investigate the two different schedules of epirubicin in a standard dose FEC regimen with respect to response and toxicity.

MATERIALS AND METHODS

Patients were randomly assigned to receive a day 1 + 8 schedule (5FU and CTX 500mg/m2 day 1, epirubicin 40 mg/m2 day 1 and 8) or a day 1 schedule (5FU, CTX 500 mg/m2 and epirubicin 80 mg/m2 day 1), q day 21, both given without hematopoietic growth factors. A total of 104 eligible patients were analyzed, 52 in each arm.

RESULTS AND CONCLUSIONS

A significantly higher relative dose-intensity was found for the day 1 schedule compared to the day 1 + 8 schedule. Although the trial was not set up to reliably detect a difference in response rate, this difference in relative dose-intensity in favour of the day 1 schedule does not suggest any improvement in response rate or duration of response for the day 1 schedule. Myelosuppression was severe in the day 1 + 8 schedule. We conclude that a day 1 + 8 FEC schedule has no advantage over a day 1 FEC schedule without hematopoietic growth factors in patients with metastatic breast cancer.

Extrapulmonary small-cell carcinoma: report of three cases and update of therapy and prognosis

Three male patients with extrapulmonary small-cell carcinoma originating from esophagus, pancreas and prostate are described. The patient with the esophagus tumor had a combined small-cell and undifferentiated carcinoma. The other two patients had a pure small-cell carcinoma. All patients were treated with primary combination chemotherapy consisting of etoposide and cisplatin followed in one patient by locoregional radiotherapy. The patients with the esophagus and the pancreas tumor showed a partial response; the patient with the prostate tumor achieved a complete remission but relapsed with brain metastasis. All patients are alive 7, 13 and 19 months, respectively after initiation of the therapy. As in pulmonary small-cell carcinoma, primary chemotherapy is the treatment of choice in extrapulmonary small-cell carcinoma.

Prospective randomized trial of docetaxel versus mitomycin plus vinblastine in patients with metastatic breast cancer progressing despite previous anthracycline-containing chemotherapy. 304 Study Group

PURPOSE

This phase III study compared docetaxel with mitomycin plus vinblastine (MV) in patients with metastatic breast cancer (MBC) progressing despite previous anthracycline-containing chemotherapy.

PATIENTS AND METHODS

Patients (n=392) were randomized to receive either docetaxel 100 mg/m2 intravenously (i.v.) every 3 weeks (n=203) or mitomycin 12 mg/m2 i.v. every 6 weeks plus vinblastine 6 mg/m2 i.v. every 3 weeks (n=189), for a maximum of 10 3-week cycles.

RESULTS

In an intention-to-treat analysis, docetaxel produced significantly higher response rates than MV overall (30.0% v 11.6%; P < .0001), as well as in patients with visceral involvement (30% v 11%), liver metastases (33% v 7%), or resistance to previous anthracycline agents (30% v 7%). Median time to progression (TTP) and overall survival were significantly longer with docetaxel than MV (19 v 1 weeks, P=.001, and 1 1.4 v 8.7 months, P=.0097, respectively). Neutropenia grade 3/4 was more frequent with docetaxel (93.1 % v62.5%; P < .05); thrombocytopenia grade 3/4 was more frequent with MV (12.0% v 4.1%; P < .05). Severe acute or chronic nonhematologic adverse events were infrequent in both groups. Withdrawal rates because of adverse events (MV, 10.1%; docetaxel, 13.8%) or toxic death (MV, 1.6%; docetaxel, 2.0%) were similar in both groups. Quality-of-life analysis was limited by a number of factors, but results were similar in both groups.

CONCLUSION

Docetaxel is significantly superior to MV in terms of response, TTP, and survival. The safety profiles of both therapies are manageable and tolerable. Docetaxel represents a clear treatment option for patients with MBC progressing despite previous anthracycline-containing chemotherapy.

[Fever due to antithyroid agents]

Three patients, females aged 62, 67 and 32 years, were presented with fever and sore throat and had severe agranulocytosis (granulocyte count < 100/microliter). All had Graves' disease and were being treated with thiamazole 30 mg once a day. Thiamazole was discontinued and treatment with antibiotics initiated. None of the patients received granulocyte-colony stimulating factor (G-CSF). The mean recovery time of granulocytes was 9 days and there were no fatalities. Patients who receive antithyroid agents should be warned against the serious and potentially lethal side effect of agranulocytosis.

[Taxoids in ovarian and breast carcinoma: the role of the medical profession and the government]

After registration in 1993/1995 of paclitaxel and docetaxel for the treatment of ovarian and mammary carcinomas, the costliness of these drugs caused Dutch hospitals to adopt different policies for their use. This prompted the Minister of Health to ask the professional group of oncological internists to draw up a guideline for the use of taxoids, following which the government decided to supply extra money for the hospitals to use according to this guideline. Meanwhile new, contradictory study results have become known, still unpublished and in part originating from studies not yet conclude. The pharmaceutical industry advocates terminating the current research and maintaining the existing indications. However, patients are entitled to unbiased, complete research findings. The pathway for introducing new expensive drugs should be as follows: the professionals determine the indications for the new drug, the government pays attention to the financial consequences. The pharmaceutical industries should have no voice in the relevant decision-making.

Hypopituitarism as a late complication of Plasmodium falciparum malaria: a possible relationship?

Plasmodium falciparum infection causes serious symptoms in the acute phase of the illness. Long-term sequelae are less common. In the following case report we describe a patient who developed hypopituitarism after a severe cerebral malaria infection, which was only recognized 17 years thereafter.

Carcino-embryonic antigen--no help with the differential diagnosis

Two patients who were referred because of an increase in serum carcino-embryonic antigen (CEA) were diagnosed after a number of years as having a medullary thyroid carcinoma. The relationship between CEA and medullary thyroid carcinoma is discussed. The serum level of CEA is neither sensitive nor specific enough to serve as a diagnostic tool. Its determination, however, is useful in the follow-up of patients with carcinoma of the breast, colo-rectal carcinoma and medullary thyroid carcinoma.

Phase I study using desferrioxamine and iron sorbitol citrate in an attempt to modulate the iron status of tumor cells to enhance doxorubicin activity

A novel approach to enhance the activity of doxorubicin is to increase the availability of cellular "chelatable" iron to participate in doxorubicin-mediated free-radical generation. To achieve this, we designed a regimen consisting of desferrioxamine (DFO, 50 mg/kg daily given as an i.v. infusion over 72 h) to increase cellular iron uptake. Thereafter, the combination of iron sorbitol citrate (ISC) and doxorubicin (as a single agent or as part of the CHOP regimen) was given. In a phase I study we investigated the toxicity of this regimen in nine patients with refractory malignant disease. Severe but reversible ocular toxicity (i.e., acute maculopathy) was observed in two patients. As these patients were the only ones who were pretreated with cisplatin, we caution against the use of DFO in cisplatin-pretreated patients. Severe phlebitis was encountered in five of nine patients. A partial remission was observed in two of four patients with refractory Non-Hodgkin's lymphoma who were treated with DFO, ISC, and doxorubicin as part of the CHOP regimen. We conclude that pretreatment with DFO and iron sorbitol citrate may be of benefit in the treatment of malignancies with doxorubicin-containing regimens, but ocular toxicity and severe phlebitis limits the use of DFO in this approach. The attachment of DFO to biocompatible polymers may be a method of overcoming the observed toxicity and warrants further study.

[Villous adenoma of Vater's papilla; a therapeutic dilemma]

After a cholecystectomy in 1980, local excision of a villous adenoma of the ampulla of Vater was performed in 1983 in a 69-year-old female; this had to be repeated in 1990 because of recurrence. In case of a tumour of this kind, pancreaticoduodenectomy should be considered because of the relatively high risk of recurrence or malignant degeneration. After a radical local excision regular duodenal endoscopy and if possible endoscopic ultrasonography should be performed.

A randomized trial of two doses of granisetron in the treatment of chemotherapy-induced emesis. Dutch results within a multinational study

Granisetron is a new serotonin-receptor antagonist with considerable activity in preclinical models and early clinical studies against drug-induced nausea and vomiting. In a randomized, double-blind trial, two dose levels of granisetron were compared with regard to their efficacy and safety if given to patients receiving emetogenic chemotherapy with or without cisplatin. The present paper reports the Dutch experience with 125 patients included in this international trial. The two dose levels (40 and 160 micrograms/kg given once i.v. prior to chemotherapy) were equally effective in preventing acute emesis and nausea (within the first 24 h); in the group receiving cisplatin doses of 50 mg/m2 or more, 39% of patients had a complete response (no vomiting and mild nausea at most), with a complete response rate of 82% in the patients receiving moderately emetogenic chemotherapy. Sixty-three percent of patients receiving highly emetogenic chemotherapy with a complete response within 24 h lost this response during the next 6 days, as did 20% of the other patients. Headache was the most frequently reported adverse event (18%), followed by constipation (6%) and dizziness (4%). All adverse events were mild and occurred equally frequently at both dose levels. Granisetron at 40 micrograms/kg i.v. given once is effective in the prevention of acute chemotherapy-induced emesis and nausea, in particular in patients receiving moderately emetogenic therapy.

Comparison of breast cancer mucin (BCM) and CA 15-3 in human breast cancer

The Breast Cancer Mucin (BCM) enzyme immunoassay utilizes two monoclonal antibodies (Mab), M85/34 and F36/22, for the identification of a mucin-like glycoprotein in serum of breast cancer patients. We have compared BCM with CA 15-3, another member of the human mammary epithelial antigen family. Serum BCM was evaluated in 151 and CA 15-3 in 134 patients with breast cancer, in 30 normal controls, in 9 pregnant women, and in 13 cancer patients (non-breast). Neither the normal controls nor the pregnant women had BCM levels greater than 25 U/ml. In contrast, 87 of 115 patients (75%) with metastatic breast cancer had BCM levels greater than 25 U/ml. All control persons had CA 15-3 levels less than 25 U/ml, but 2 out of 9 pregnant women (22%) had levels greater than 25 U/ml. Seventy-four out of 97 patients (76%) with metastatic breast cancer had CA 15-3 levels greater than 25 U/ml. A statistically significant correlation was found between BCM and CA 15-3 in the breast cancer patient group (r = 0.883, p less than 0.001, n = 134) and in the normal control group (r = 0.743, p less than 0.001, n = 30). BCM and CA 15.3 both showed no correlation with CEA in breast cancer patients (r = 0.060, n = 81; and r = 0.146, n = 78, respectively). BCM had a range of sensitivity similar to that of the CA 15-3 RIA. Our results suggest that BCM may be a useful new marker for monitoring the clinical course of patients with breast cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Once-daily dosing regimen for aminoglycoside plus beta-lactam combination therapy of serious bacterial infections: comparative trial with netilmicin plus ceftriaxone

PURPOSE

Once-daily dosing of aminoglycosides has been suggested to improve their efficacy and reduce their toxicity. To test the clinical validity of this suggestion, we conducted a prospective, randomized trial comparing a conventional multiple-daily-dosing regimen of netilmicin with once-daily administration of the same total daily dose of this aminoglycoside.

PATIENTS AND METHODS

We enrolled 141 predominantly elderly patients with severe bacterial infections. All patients received once-daily doses of 2 g ceftriaxone, in addition to netilmicin.

RESULTS

Patients randomized to either of the two dosing strategies were comparable regarding age, APACHE II score, concomitant diseases, infection site, and rate of culture-proven bacteremia. Netilmicin treatment did not differ significantly in mean daily dose per kg body weight and days of therapy between the two treatment arms. Compared to patients receiving conventional doses, patients treated with a once-daily dose had higher serum peak netilmicin levels and lower trough levels. Outcome of infection and mortality were not influenced by dosing strategy. Although the overall incidence of nephrotoxicity was similar in both groups (16%), the occurrence of nephrotoxicity in patients treated with once-daily doses of netilmicin was significantly shifted to those given prolonged treatment, i.e., beyond 9 days. Auditory toxicity was documented in one patient treated with conventional doses and two patients treated with once-daily doses.

CONCLUSION

Once-daily dosing of an aminoglycoside plus a long-acting cephalosporin in these patients constituted cost-effective and safe treatment for severe bacterial infections. Netilmicin-induced toxicity may be reduced by using once-daily dosing regimens and limiting the duration of treatment.

Mitoxantrone, methotrexate, and 5-fluorouracil (MMF) in hormone-refractory advanced breast cancer

Thirty-nine patients with metastatic breast cancer who had not received prior chemotherapy for metastatic disease were treated in a phase II trial with a combination of mitoxantrone (10 mg/m2), methotrexate (40 mg/m2) and 5-fluorouracil (600 mg/m2) i.v. every 3 weeks (MMF). Thirty-three patients could be evaluated with regard to response and toxicity. Objective response was observed in 33% (3/33 complete responses, 8/33 partial responses). Dominant sites of disease were bone (16 patients), liver (7 patients), skin/lymph node (7 patients), lung (1 patient) and breast (2 patients). Responses occurred in bone (4/16), liver (3/7) and skin/lymph node (4/7). Moderate to severe alopecia (grade 3-4 WHO criteria) occurred in 3/33 (10%) patients; moderate to severe nausea and vomiting in 2/33 (6%) patients. Haematological toxicity consisted of predominantly leukopenia. Leukopenia grade 3-4 (nadir below 2000 x 10(9)/litre) occurred in 22/33 (67%) patients; thrombocytopenia grade 3-4 (nadir below 50,000 X 10(9)/litre) occurred in 3 patients (9%). The MMF regimen appears to be effective. The non-haematological toxicity compares favourably with that of the more commonly used chemotherapy regimens, but the anti-tumour activity may be less.

Transsphenoidal microsurgery as primary treatment in 25 acromegalic patients: results and follow-up

Twenty-five patients with acromegaly were treated by transsphenoidal microsurgery. Fourteen patients (56%) were considered cured according to the following criteria: a. basal plasma GH less than 10 mU/l; b. glucose suppressed plasma GH less than or equal to 4 mU/l, and c. disappearance of TRH responsiveness if present preoperatively. Thirteen of the cured patients were re-evaluated after a mean follow-up period of 3.5 years (range 1.5 to 5.5 years). At that time, basal plasma GH was still less than 10 mU/l and glucose suppressed plasma GH was still less than or equal to 4 mU/l in all patients, indicating the practical value of our criteria. The remaining 11 patients (44%) received additional treatment by external pituitary irradiation and bromocriptine. Owing to surgery, 5 patients (20%) developed partial or panhypopituitarism.

Comparison of bioavailability in man of tamoxifen after oral and rectal administration

The bioavailability of tamoxifen from 40 mg suppositories was tested in six male volunteers and compared with that of tamoxifen (Nolvadex) tablets. Plasma concentrations of tamoxifen and its major metabolites, 4-hydroxytamoxifen and N-desmethyltamoxifen, were measured by extraction from plasma obtained at different times after administration, separated by HPLC, converted on-line to fluorescent phenanthrene derivatives and quantified with a fluorescence detector. The mean relative bioavailability from the suppositories was 28%; the addition of a surfactive agent diminished the bioavailability to 13%. Simulation of repeated administration of 40 mg suppositories suggests a mean steady state plasma concentration for tamoxifen of approximately 70 ng ml-1, i.e. 30% of the steady state value after simulated oral administration. Rectal administration of tamoxifen leads to a lower bioavailability than that by oral administration and therefore cannot be recommended when used in equivalent doses.

Bromocriptine treatment of prolactin secreting macroadenomas: a radiological, ophthalmological and endocrinological study

Twelve patients, six women and six men, with macroprolactinomas characterized by extrasellar extension and basal plasma prolactin levels greater than 6 U/l were treated with 10-20 mg bromocriptine daily in four divided doses for a mean period of 2.4 years (range 0.5-3.5 years). The following observations were made: Plasma prolactin levels fell dramatically in all patients and values in the low normal range were obtained in 10 patients. Tumour size was reduced by more than 75% in 11 patients and by 50-75% in one patient. Tumour-reduction was associated with the development of a partial empty sella in eight cases. In four cases the pituitary became visible. Diminished visual acuity (three patients), bitemporal hemianopia (three patients), unilateral or bilateral central scotomas (three patients) and oculomotor palsy (two patients) restored to normal. Hypogonadism (all patients), hypothyroidism (six patients) and hypocorticism (three patients) improved or normalized in most cases. It is concluded that in the medical treatment of macroprolactinomas 10-20 mg bromocriptine in four divided doses effectively reduces both plasma prolactin level and tumour size.

Buprenorphine versus domperidone in chemotherapy-induced emesis: a pilot study

A randomized double-blind cross-over study was performed to evaluate the possible anti-emetic effect of the partial opiate antagonist buprenorphine in comparison to domperidone in chemotherapy-induced nausea and vomiting. Emesis was of significantly shorter duration on domperidone treatment. Most patients preferred domperidone, mainly due to adverse side-effects of buprenorphine. Nevertheless, emesis in buprenorphine treatment was less disabling. Therefore, it might be useful to search for new alternatives in this group of drugs or to use them in a combination regimen of anti-emetic agents.

No effect of treatment with sodium valproate on plasma growth hormone in bromocriptine unresponsive acromegaly

Administration of sodium valproate for 6 months at a dose of 300 mg three times daily to 7 bromocriptine unresponsive acromegalic patients who all but one had been treated with pituitary surgery and/or radiotherapy in the past did not result in a significant reduction of the plasma growth hormone (GH) level or in any clinical improvement. It is concluded that sodium valproate is not suitable for the treatment of acromegalic patients who do not show a favourable response to bromocriptine.

Bromocriptine therapy in acromegaly: effects on plasma GH levels, somatomedin-C levels and clinical activity

Thirty-one patients with active acromegaly were treated with 10-20 mg bromocriptine daily for a period of 6-9 months. The clinical response was evaluated both by a subjective 'score of symptoms', and by a combined subjective and objective 'clinical and metabolic improvement score' (c-m score). The biochemical response was evaluated both by measurement of the mean of four plasma growth hormone (GH) determinations during the day and by measurement of plasma somatomedin-C (Sm-C) concentration. The clinical response as assessed by both methods showed a better correlation with changes in plasma GH levels (respectively r = 0.33; r = 0.50) than with changes in Sm-C levels (r = 0.20; r = 0.36). The study confirms that in some patients clinical improvement is not accompanied by a decrease of plasma GH concentration. However, it is not possible to identify a subgroup of patients who showed clinical improvement with a decrease of Sm-C levels, but whose plasma GH levels remained constant. It is concluded that measurement of plasma GH levels still appears to be the most useful biochemical assessment of disease activity in bromocriptine-treated acromegaly.

Changes of molecular forms of growth hormone in bromocriptine treated acromegaly in relation to changes of somatomedin-C and clinical response

Eleven patients with active acromegaly were treated with 10-20 mg bromocriptine daily for a period of 6-9 months. The clinical response was evaluated by a 'clinical and metabolic improvement score'. The biochemical response was evaluated by measurement of both the mean plasma growth hormone (GH) level during the day and the somatomedin-C (Sm-C) concentration. Before and at the end of the treatment period plasma samples were fractionated by Sephadex G-100 chromatography in order to study the effects of chronic bromocriptine treatment on the concentrations of total GH and its different molecular forms. The main observations may be summarized as follows: Three immunoreactive components were observed on Sephadex chromatography corresponding to molecular weight above 100 000 (big-big GH), 40 000-60 000 (big GH) and 20 000-22 000 (little GH). Bromocriptine treatment induced preferentially a reduction of little GH. There was a very good correlation between the decrease of little GH and total GH, and both were significantly correlated with the clinical response. The correlation between the decrease of Sm-C values and that of little and total GH as well as between the decrease of Sm-C and the clinical response was poor. It is concluded that a) measurement of little GH is not superior to the determination of total GH in the assessment of disease activity of bromocriptine treated acromegalic patients; b) both methods are superior to the measurement of plasma Sm-C levels; c) clinical response out of proportion ot the fall of total GH which can be explained by a preferential reduction of little GH, has not been observed in our investigations.

Changes in plasma GH levels and clinical activity during bromocriptine therapy in acromegaly. The value of predictive tests

Twenty-seven patients with active acromegaly despite previous treatment by surgery and/or radiotherapy received bromocriptine in a dose of 10-20 mg daily for a period of 6-9 months. The results of chronic bromocriptine treatment were evaluated by measurement of plasma growth hormone (GH) levels during the day and by subjective and objective criteria of clinical activity. The results of chronic bromocriptine treatment were also compared with four biochemical criteria obtained before treatment e.g. basal plasma prolactin (Prl) levels and the plasma GH response to oral administration of 2.5 mg bromocriptine respectively iv administration of 200 micrograms TRH and 500 micrograms somatostatin. The main observations may be summarized as follows: 1) The mean pre-treatment GH levels during the day ranged from 6-207 mU/1. Hyperprolactinaemia was present in 6 patients. 2) During bromocriptine treatment mean plasma GH levels decreased to less than 50% in 11 patients (GH responders) whereas in 19 patients changes of mean plasma GH and of subjective criteria of clinical activity were concordant. 3) Glucose tolerance improved significantly (P less than 0.01) in 10 GH-responders and the urinary hydroxyproline/creatinine ratio decreased significantly (P less than 0.05) in 8 GH-responders. 4) Five out of 6 patients with hyperprolactinaemia belonged to the group of GH-responders. 5) A single dose of 2.5 mg bromocriptine induced a more than 50% decrease of plasma GH in 8 of 11 GH-responders and in 5 of 16 GH non-responders.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma growth hormone suppressive effect of bromocriptine in acromegaly. Evaluation by plasma GH day profiles and plasma GH concentrations during oral glucose tolerance tests

In most studies reporting favourable results of chronic bromocriptine treatment in acromegaly, plasma GH levels are measured at fixed intervals during the day. Negative results are reported in one major study measuring plasma GH levels during oral glucose tolerance tests (Lindholm et al., 1981). This study does not mention the time interval between the last dose of bromocriptine and the performance of an OGTT, but due to the short duration of action of bromocriptine this may be critical. Therefore, in the present report the plasma GH suppressive effect of bromocriptine in acromegaly is studied using plasma GH day-profiles as well as OGTT's during continued bromocriptine administration and OGTT's at two different time intervals after the last dose of bromocriptine. Twelve patients with clinically active acromegaly were treated with 10-20 mg bromocriptine for 6-9 months. After 6-9 months during continued bromocriptine administration the plasma GH suppressive effect of bromocriptine was evaluated by the mean of four plasma GH determinations during the day and by the mean of seven plasma determinations during oral glucose tolerance tests (OGTT's) performed 1 h, 10 h and 34 h after the last dose. The percentage decrease of the mean plasma GH level during the day induced by chronic bromocriptine treatment showed a good correlation (r = 0.86, P less than 0.001) with the percentage decrease of the mean plasma GH level during OGTT, if the post-treatment test was carried out one hour after the last dose of bromocriptine.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in bone metabolism during treatment of acromegaly

Bone metabolism was studied in 17 acromegalic patients, who responded to either medical treatment with bromocriptine (12 patients), or to transsphenoidal surgery (5 patients). Parameters of bone turnover decreased, e.g. serum acid phosphatase (9.2 +/- 0.7 vs 8.1 +/- 0.6 U/l, P less than 0.05) and the ratio of hydroxyproline/creatinine (33.6 +/- 4.4 vs 18.3 +/- 2.0, P less than 0.01) in the urine. No changes were observed in parathyroid function or concentrations of calcitonin. Serum 1,25-dihydroxycholecalciferol decreased (32.6 +/- 3.6 vs 20.6 +/- 1.8 ng/l, P less than 0.01) and 24,25-dihydroxycholecalciferol increased (4.3 +/- 0.6 vs 6.7 +/- 1.0 micrograms/l, P less than 0.05). No correlation between the percentual changes in serum growth hormone levels and 1,25-dihydroxycholecalciferol was found, suggesting an indirect effect of growth hormone on the renal 25-hydroxycholecalciferol-1-alpha-hydroxylase. The possible mechanisms involved are discussed, including the effects of growth hormone and somatomedin on bone.

No acute effect of pimozide on the plasma GH levels in acromegaly

In 34 acromegalic patients either untreated or inadequately treated by surgery and/or radiotherapy the plasma GH levels and plasma Prl levels were determined during 8 h after the acute administration of the dopamine agonist bromocriptine and during 150 min after the administration of the dopamine antagonist pimozide. A 50% or more suppression of the basal GH levels was arbitrarily defined as a positive response. Seventeen patients displayed a positive response to bromocriptine, 17 patients displayed a negative response to bromocriptine. Plasma Prl levels were elevated in 6 of 17 bromocriptine responders and in 2 of 17 bromocriptine nonresponders. There was no difference in the plasma GH response to pimozide administration in the patients with a positive or a negative GH response to bromocriptine. With one exception there was in no patient a positive GH response to pimozide. In further experiments the plasma GH response to pimozide was measured during 11 h in 6 bromocriptine sensitive and 6 bromocriptine insensitive patients. Again no difference was found between bromocriptine responders and non-responders. There was also no difference in the Prl response to bromocriptine or pimozide between GH responders and GH non-responders. The Prl response to pimozide was blunted in comparison to a control group. The present study does not not lend support to the idea that there is a fundamental difference in the degree of hypothalamic dopaminergic control of GH or Prl secretion between bromocriptine sensitive and bromocriptine insensitive patients with acromegaly.

Acute lead poisoning with hemolysis and liver toxicity after ingestion of red lead

A case of acute lead poisoning in a 21-year old male following the single ingestion of a considerable amount of dried red lead is reported. The main clinical features were hemolysis and liver toxicity. The patient was successfully treated with calcium disodium EDTA.