Combination of pegylated liposomal doxorubicin plus gemcitabine in heavily pretreated metastatic breast cancer patients: Long-term results from a single institution experience

The combination of Pegylated Liposomal Doxorubicin (PLD) plus Gemcitabine (GEM) has been previously investigated in the treatment of metastatic breast cancer (MBC). PLD is a doxorubicin formulation with prolonged circulation time and better tissue distribution. GEM is a nucleoside analog with nonoverlapping toxicity compared to PLD. The aim of our study was to assess efficacy, toxicity, and long-term outcome of this combination. Patients with heavily treated MBC were retrospectively analyzed. Chemotherapy consisted of PLD 25 mg/m² and GEM 800 mg/m² day 1, on a three-week schedule. Cardiac function was evaluated baseline and during treatment. Radiological response was graded according to RECIST criteria v1.1. Toxicity was scored according to CTCAE v4.0. Progression-free survival (PFS) and overall survival (OS) were evaluated. From 2001 to 2014, 122 pts were included. Median age was 55 (range: 28-84). Median previous treatment schedules in the metastatic scenario were 3 (range: 1-15). Most patients received prior anthracyclines (85%). Median number of metastatic sites was 2 (range: 1-7). Median number of cycles delivered was 5 (range: 1-36). Overall response rate was 31% (5% complete responses; 26% partial responses). Stable and progressive diseases were observed in 32% and 26% of patients. Grade ≥3 neutropenia was observed in 29 patients (24%). Grade ≥3 hand-foot syndrome was detected in 17 patients (14%), mostly since cycle 3 (88%). Median cumulative PLD dose was 125 mg/m² . At a median follow-up of 101 months, median PFS and OS were 7 and 22 months, respectively. PLD-GEM combination achieves remarkable long-term outcomes with an acceptable toxicity profile in patients with MBC.

Intraoperative radiotherapy electron boost followed by moderate doses of external beam radiotherapy in resected soft-tissue sarcoma of the extremities

PURPOSE

To analyze the patterns of failure and the toxicity profile of intraoperative electron beam radiotherapy (IOERT) after resection of soft tissue sarcomas of the extremities (STS).

PATIENTS AND METHODS

Forty-five patients with extremity STS were treated with IOERT and moderate-dose postoperative radiotherapy (45-50 Gy). Twenty-six patients were treated for primary disease (PD) and 19 patients for an isolated recurrence (ILR). Tumor size was >5 cm (maximum diameter) in 36 patients (80%), and high-grade histology in PD patients was present in 14 patients (54%). In nine patients, IOERT was used alone, due to previous irradiation or patient refusal. Chemotherapy (neoadjuvant and/or adjuvant) was mainly given to high-grade tumors.

RESULTS

Nine patients relapsed in the extremity (20%), and 12 patients in distant sites (28%). Actuarial local control at 5 years was 88% for patients with negative/close margins and 57% for patients presenting positive margins (P=0.04). Five patients (11%) developed neuropathy associated with the treatment. Extremity preservation was achieved in 40 patients (88%). With a median follow-up of 93 months (range: 27-143 months) for the patients at risk, 25 patients remain alive (a 7-year actuarial survival rate of 75% for PD and 47% for ILR; P=0.01).

CONCLUSIONS

IOERT combined with moderate doses of external beam irradiation yields high local control and extremity preservation rates in resected extremity STS. Peripheral nerves in the IOERT field are dose-limiting structures requiring a dose compromise in the IOERT component to avoid severe neurological damage.

Second-line chemotherapy with irinotecan and vinorelbine in stage IIIB and IV non-small-cell lung cancer: a phase II study

The purpose of this study was to evaluate the efficacy and tolerance of combined irinotecan and vinorelbine in previously treated patients with stage IIIB and IV non-small-cell lung cancer (NSCLC). Thirty-three patients with NSCLC (7 stage IIIB and 26 stage IV) were enrolled. All had been previously treated with cisplatin, paclitaxel, and gemcitabine as first-line chemotherapy. In addition, 24 patients had received radiotherapy. Irinotecan (300 mg/m(2)) was administered on day 1 and vinorelbine (30 mg/m(2)) on days 1 and 14, every 4 weeks. Partial response was achieved in 3 patients (9%; 95% CI: 2-24%), stable disease (SD) in 13 (39%; 95% CI: 23-58%), whereas 17 patients progressed (51%; 95% CI: 33-69%). Median event-free survival was 10 weeks and median overall survival was 25 weeks. Three patients were event free at the end of the study with a follow-up of 40, 73, and 75 weeks. Toxicity was mild, with leukopenia grade III-IV in 8.6% of cycles. No episodes of diarrhea III-IV were observed. Three patients died early after administration of this combination, one of them in the context of severe leukopenia and thrombocytopenia. Approximately 50% of patients treated with CPT-11 and vinorelbine in combination show partial response or stable disease with minimal toxicity.

[Anesthesia for the patient with cancer]

Surgery and radiotherapy provide the basis for local and regional control of cancer. The cancer patient has special characteristics that have implications for anesthesia. Tumors may involve the airways and affect ventilation, hemodynamics and intracranial pressure. Remote tumors can occur in endocrine cancer and in paraneoplastic syndromes. Other systemic complications of the cancer patient include hemostatic changes, immunosuppressant anemia and altered metabolism. Radiotherapy causes changes with anesthetic implications when treatment is directed at the head and neck, mediastinum, lung or surgical area. Chemotherapy is associated with non-specific toxic effects such as mucositis, aplasia and immunosuppression, alopecia and vascular injury; in addition, each chemical has other more specific toxic effects. Chemicals that are toxic for the heart and lungs have the greatest implications for anesthesia. Preoperative assessment should ascertain the effects caused by both the tumor and its treatment. Preparation for surgery includes improving nutrition and possibly inserting a venous port. Management during surgery depends on type of intervention and the patient's physical status, as they will determine the need for invasive monitoring and vessel access. The patient can be given antiemetic and antithrombotic prophylaxis. Important issues in postoperative care are the need for adequate analgesia; provision of early nutrition; antibiotic, antithrombotic and antiemetic prophylaxis; and prevention of ulcers caused by pressure.

[Intensive chemotherapy in the treatment of patients with metastatic breast cancer]

PURPOSE

Phase II study with intensive chemotherapy and autologous stem cells support in patients with metastatic breast cancer.

METHODS

Forty-nine patients were treated with high-doses of two cytotoxic drugs and support with stem cells obtained from several leukapheresis without movilitation. The cells were reinfused forty-eight hours after finishing the administration of chemotherapy.

RESULTS

Twenty-one patients (47%, CI-95%: 32.4-63.3%) achieved a complete remission. The objective responses rate was 73% (CI-95%: 57.2-85%). Overall and progression-free survival up to 4 years were 31% and 20%, respectively. Ten patients remain progression-free among 17 and 46 months. The most frequent extramedullary toxicity was hepatic and renal. Three patients (6%) died during the procedure.

CONCLUSIONS

Intensive chemotherapy with hematopoietic support yields, with a moderate toxicity, a high objective response and complete remission rate. A small group of patients achieves a long progression-free survival.

Cisplatin, mitomycin, and vindesine followed by intraoperative and postoperative radiotherapy for stage III non-small cell lung cancer: final results of a phase II study

Sixty-two patients with stage III non-small cell lung cancer (NSCLC) were treated with neoadjuvant chemotherapy consisting of cisplatin 120 mg/m2 day 1, mitomycin 8 mg/m2 day 1, and vindesine 3 mg/m2 days 1 and 14. Each cycle was repeated every 4 weeks for a total of 1 to 6 cycles (median, 3 cycles). Resection was attempted 4 to 5 weeks after the last course of chemotherapy. Intraoperative radiation therapy (IORT) (10-15 Gy) was delivered during surgery and postoperative external beam radiotherapy (EBRT) (46 Gy) was begun 4 weeks after surgery. Fifty-five patients (25 IIIA, 30 IIIB) were evaluable. Only partial responses occurred (64%), and 29 patients (53%) underwent resection. Complete resection rates were 85% (12/14) and 40% (6/15) in stage IIIA and IIIB, respectively (p = 0.01). In 3 of 29 patients (10%), no tumor was found in the resected specimen. There was one chemotherapy-related death and three postoperative-related deaths. The median survival time was 10 months, and the 5-year survival rate was 29 and 7% for stage IIIA and stage IIIB, respectively (p = 0.3). High complete resection rates and modest increase in 5-year survival have been observed in stage IIIA NSCLC. Although a number of stage IIIB patients can be made technically resectable, the low complete resectability rate reflects the lack of survival benefit in these patients.

Results of two sequential phase II studies of interleukin-2 (IL2) in metastatic renal cell carcinoma and melanoma: high-dose continuous intravenous IL2 infusion and subcutaneous IL2 administration in combination with alpha interferon

The results of two sequential trials, the first one with high dose interleukin 2 (IL2) by continuous intravenous infusion and the second one with subcutaneous IL2 and alpha-interferon (alpha IFN), performed in consecutive patients with metastatic melanoma and renal carcinoma at the Clinica Universitaria de Navarra are presented. In the high-dose continuous IL2 trial, recombinant IL2, 18 x 10(6) IU/m2, was administered daily by continuous infusion five days a week for two weeks, and the treatment cycle was repeated after a rest of 2 weeks. Twenty two patients were treated and objective responses were observed in 3 (13.3%). Toxicity was frequent and severe, and all but one required dose reduction. The mortality rate was 9% (2/22). In the subcutaneous IL2 and alpha IFN trial, subcutaneous IL2, 4.8 x 10(6) IU/m2, was administered daily, five days a week, for 3 consecutive weeks. IL2 dose was given every 8 hours on the first day and every 12 hours on the second day, as a loading induction dose. Concomitant alpha-IFN, 3 x 10(6) IU/m2 was given subcutaneously once a day on days 1, 3 and 5 weekly each week for the duration of IL2 therapy. Of the 24 patients treated with this combination, 3 partial responses were noticed (12.5%) and the toxicity was mild to moderate. These results suggest that both, IL2 alone or IL2 in combination with alpha-IFN are minimally active and that any improvement in tolerance might impair its antitumor activity.

High-dose BCNU and autologous progenitor cell transplantation given with intra-arterial cisplatinum and simultaneous radiotherapy in the treatment of high-grade gliomas: benefit for selected patients

A phase II study of postoperative high-dose carmustine (HDBCNU), intracarotid cisplatin (CDDP), and radical radiotherapy in patients with high-grade glioma was performed. Patients underwent 4-6 consecutive days of blood hematopoietic progenitor cell (HPC) apheresis without prior mobilization. Chemotherapy included intracarotid CDDP, 60 mg/m2, and BCNU, 900 mg/m2. HPC were infused 48 h after HDBCNU. Whole brain irradiation, up to 50 Gy, was started on the 8th day after HPC infusion. With a median follow-up time of 44 months, median overall survival was 15.5 months. Eight patients (23.5%) are alive free of disease 2-6 years after treatment (seven out of 25 patients with glioblastoma multiforme and one out of nine patients with anaplastic astrocytoma). Survival was influenced by young age, good performance and complete surgical resection. Two patients (5.8%) died of therapy-related complications. Acute hematological toxicity of HDBCNU was moderate, with a full recovery on day 26. No acute pulmonary or hepatic toxicity was found. Late severe neurological toxicity was observed in one third of patients surviving beyond 2 years. We conclude that HDBCNU, 900 mg/m2, intracarotid CDDP and radical radiotherapy appear to benefit some patients with high-grade gliomas, and phase III studies should preferentially select young patients with resectable tumors.

Combined treatment in superior sulcus tumors

From January 1988 to August 1992, 18 patients (pts) with the established diagnosis of non-small cell lung cancer of the superior sulcus have been treated with a multidisciplinary approach, which includes 1-3 cycles of neoadjuvant chemotherapy (MVP or MCP regimens) followed by simultaneous preoperative chemotherapy and external beam irradiation. Radical surgery plus intraoperative radiotherapy (IORT) was planned 4-5 weeks after the end of the preoperative protocol. Tumor stages were IIIA (9 pts) and IIIB (9 pts). Tumor characteristics included rib and vertebral involvement in 15 and 4 pts, respectively. Fatal toxicity was present in 3 pts (16.6%). Resectability rate was 76.4%. Pathologic findings disclosed complete response (pT0) in 70.5% of the surgical specimens and viable tumor (pT+) in 29.5%. With a median follow-up of 24+ months (2-52+), 4-year actuarial local control, and overall survival rates are 91% and 56.2%, respectively. Four-year actuarial overall survival according to pathologic response was 87.5% for pT0 patients and 20% for pT+ patients. We conclude that this regimen promotes a high rate of pT0 as well as better than expected local control and survival rates. The presence of a pT0 specimen seems to correlate with the patient outcome.