Initial experience with using frameless image-guided radiosurgery for the treatment of brain metastases

AIM

Recent technologic advances have led to the development of frameless radiosurgery. We report our initial results using frameless image-guided radiosurgery for the management of brain metastases.

METHODS

Over a 2-year period, 16 patients harboring 28 lesions were treated in our institution. 12 of 16 patients were treated in a single fraction, but 4 patients were treated using fractioned stereotactic radiotherapy in 3-5 fractions. The maximum target diameter, as determined by T1 - weighted contrast - enhanced magnetic resonance imaging were < 4 cm in all patients. 8 patients (50%) received WBRT (3 Gy in 10 fractions to a total dose of 30 Gy) prior to stereotactic radiosurgery, and were treated with SRS for either lesion progression or new lesions. The total treatment volume for each patient was the sum of the treatment volumes for all treated metastases. The median total treatment volume was 18.63 cm(3) (range 1,85-47.03 cm3).

RESULTS

Median overall survival time of entire group were 10 months (95% confidence interval 7.470-12.530 months). Of the 3 (11.11%) lesions that showed complete response, all were associated with breast cancer. Partial response was seen in 8 (29.62%) cases. Stable disease was seen in 13 (48.14%) cases, but 3 (11.11%) cases showed progression of disease.

CONCLUSION

Further studies are needed to to match the treatment results with other available modalities to optimize and individualize care of patients with brain metastases.

Change in patient weight during platinum/paclitaxel-based chemotherapy for ovarian cancer: A Gynecologic Oncology Group study

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Background: Platinum/paclitaxel (P)-based chemotherapy is current treatment (tx) for advanced epithelial ovarian cancer (EOC). Previous studies suggest this regimen may induce weight change, which is a surrogate for body reaction to tx and may predict quality of life and clinical outcomes. We sought to explore the association between weight change during treatment and survival. Methods: A retrospective data review was conducted of 792 patients who participated in a Gynecologic Oncology Group (GOG) phase III randomized treatment trial (GOG 158) using cisplatin (Cis)/P vs carboplatin (Carbo)/P in optimal stage III EOC. Pretreatment body mass index (BMI) was calculated based on patient height and weight following surgery. Weight change during tx was defined as the ratio of body weight at completion of protocol therapy to pretreatment body weight. Progression-free survival (PFS) and overall survival (OS), classified by BMI or relative weight change, were estimated by Kaplan-Meier, and the associations between BMI, relative weight change and PFS and OS were assessed using Cox model controlled for known prognostic variables. Results: The median BMI was 24.9. There was no significant difference in PFS or OS related to BMI; however, there was a significant relationship between median OS and weight change as follows: >5% decrease = 48.0 months; 0–5% decrease = 49.3 months; 0–5% increase = 61.1 months; and >5% increase = 68.2 months (p = 0.006). The relative risk of death increased by 7% for each 5% decrease in body weight (HR = 0.93, 95% CI = 0.88–0.99; p = 0.013) adjusted for covariates. Results suggest more evident weight loss in the Cis/P arm than the Carbo/P arm during the first cycle of tx (−2.2 kg vs. −1.2 kg), and decreased weight was more likely to return to pretreatment level in the Carbo/P arm. Conclusions: Loss of body weight, but not BMI, during platinum/P-based chemotherapy is an indicator for poor OS in EOC patients. Cis/P may be associated with more weight loss compared to Carbo/P. This exploratory study supports the development of treatment strategies that minimize weight loss-producing toxicities to improve outcomes in this patient population.

No significant financial relationships to disclose.

Paclitaxel (1-hour) and carboplatin (area under the concentration-time curve 7.5) in advanced non-small cell lung cancer: a phase II study of the Fox Chase Cancer Center and its network

We previously reported a 62% response rate and 54% 1-year survival rate for paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) administered by 24-hour infusion in combination with fixed-dose carboplatin to treat patients with advanced non-small cell lung cancer (NSCLC). Myelosuppression proved dose limiting, but was substantially reduced by the routine use of granulocyte colony-stimulating factor during the second and subsequent cycles. Activity for paclitaxel 135 mg/m2 and 200 mg/m2 by 1-hour infusion every 3 weeks in patients with NSCLC, with minimal myelosuppression and the suggestion of a dose-response relationship, has been reported. In November 1994, we initiated a phase II trial in patients with advanced, measurable, chemotherapy-naive NSCLC using paclitaxel 175 mg/m2 given in 1 hour, and carboplatin dosed to a fixed target area under the concentration-time curve of 7.5 every 3 weeks. In the absence of grade 4 myelosuppression, paclitaxel was escalated on an intrapatient basis by 35 mg/m2 per cycle to a maximum dose of 280 mg/m2 by cycle 4. Granulocyte colony-stimulating factor was not routinely used. Of the 57 patients accrued, 44 (81%) are Eastern Cooperative Oncology Group performance status 1. The median patient age is 64 years. To date, 54 patients are fully evaluable for toxicity. In the first 20 evaluable patients accrued (cohort A), myelosuppression was tolerable, but cumulative peripheral sensory neuropathy proved dose limiting: grade > or = 1 in 15 (75%) patients and grade 3 in six (30%), generally occurring at paclitaxel doses > or = 215 mg/m2 and obligating at least three patients to be removed from study despite absence of disease progression. The protocol was consequently revised. The starting dose of paclitaxel was reduced to 135 mg/m2 with intrapatient dose escalations of 40 mg/m2 per cycle, to a maximum paclitaxel dose of 215 mg/m2, recapitulating the original dosing schema used in Fox Chase Cancer Center study 93-024. For the 35 patients enrolled in the second cohort (cohort B), treatment has been better tolerated. Of 21 evaluable patients, 13 (62%) have experienced peripheral sensory neuropathy, grade 3 in only one (5%) patient. Myelosuppression also has been less pronounced, with 44% grade 4 granulocytopenia and 38% grade > or =3 thrombocytopenia in cohort B compared with 70% and 50%, respectively, in cohort A. Of the first 22 patients accrued to cohort A, 12 (55%) had major objective responses. Median event-free survival is 24 weeks and median survival is 47 weeks. Of the 35 evaluable patients in cohort B, nine (26%) have had major objective responses. Median event-free survival is 22 weeks. It is too early to report median survival. Paclitaxel given by 1-hour infusion in combination with carboplatin at a fixed target area under the concentration-time curve of 7.5, although active in advanced NSCLC, is associated with problems that compromise its efficacy. Higher dose levels yield intolerable toxicity, evidenced by the incidence of neurotoxicity (rather than myelosuppression) that was dose and protocol limiting at paclitaxel doses exceeding 215 mg/m2. Lower doses, while more tolerable, appear to be associated with lower response rates.

Combination paclitaxel (1-hour) and carboplatin (AUC 7.5) in advanced non-small cell lung cancer: a phase II study by the Fox Chase Cancer Center Network

We have previously reported a 62% response rate and 54% 1-year survival rate for patients with advanced non-small cell lung cancer (NSCLC) treated with paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) by 24-hour infusion in combination with carboplatin, using area under the concentration-time curve dosing (FCCC 93-024). Myelosuppression proved dose limiting, but was substantially reduced by the routine use of granulocyte colony-stimulating factor during the second and subsequent cycles. Antitumor activity has been reported with minimal myelosuppression, with paclitaxel 135 and 200 mg/m2 given every 3 weeks by 1-hour infusion to patients with NSCLC. In November 1994, we initiated a phase II trial of paclitaxel 175 mg/m2 given over 1 hour, with carboplatin dosed to a fixed, targeted area under the concentration-time curve of 7.5 every 3 weeks. In the absence of grade 4 myelosuppression, paclitaxel was escalated on an intrapatient basis by 35 mg/m2 per cycle to a maximum dose of 280 mg/m2 by cycle 4. Granulocyte colony-stimulating factor was not routinely used. Eligibility stipulated advanced, measurable, chemotherapy-naive NSCLC. Of 47 patients accrued, 39 (83%) had Eastern Cooperative Oncology Group performance status 1. The median age was 64 years; 40 patients were evaluable for toxicity. Of the first 20 evaluable patients accrued (cohort A), myelosuppression was tolerable. Cumulative peripheral sensory neuropathy grade > or = 1 in 15 (75%) patients and grade 3 in six (30%), however, generally occurring at paclitaxel doses greater than 215 mg/m2, obligated removal from study of at least three patients, despite the absence of disease progression, and proved to be dose-limiting. Consequently, the protocol was revised: the starting dose of paclitaxel was reduced to 135 mg/m2, with intrapatient dose escalation of 40 mg/m2 per cycle to a maximum dose of 215 mg/m2, thus recapitulating the original dosing schema used in FCCC 93-024. To date, 25 patients have been enrolled in this second cohort (cohort B) and treatment has been better tolerated. Of 21 evaluable patients, 13 (62%) have experienced peripheral sensory neuropathy, but only one (5%) has been grade 3. Myelosuppression also has been less pronounced, with 33% grade 4 granulocytopenia and 13% grade > or = 3 thrombocytopenia in cohort B compared with 70% and 50%, respectively, in cohort A. Of the first 22 patients accrued to cohort A, 12 (55%) had major objective responses. Median event-free survival is 23 weeks and median survival is 47 weeks. Of 15 evaluable patients in cohort B, five (33%) have had major objective responses. It is too early to report survival data. In conclusion, paclitaxel by 1-hour infusion in combination with carboplatin at a fixed targeted area under the concentration-time curve of 7.5 is an active regimen in advanced NSCLC. Neurotoxicity, rather than myelosuppression, is dose and protocol limiting at paclitaxel doses exceeding 215 mg/m2.

Paclitaxel and carboplatin in the treatment of advanced non-small cell lung cancer

Based on the superior response rates (21% to 24%) of patients treated with single-agent paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) in Eastern Cooperative Oncology Group and M.D. Anderson Cancer Center trials in non-small cell lung cancer (NSCLC) and on the superior 1-year survival rates of NSCLC patients treated with carboplatin in a randomized study of cisplatin combination and analogues, we initiated a phase II trial of paclitaxel/carboplatin in patients with stage IV or effusion-positive stage III NSCLC. Eligibility stipulated chemotherapy-naive patients with measurable disease, good performance status, and adequate hematologic, hepatic, and renal function. Previous radiotherapy was restricted to < or = 30% of marrow-bearing bone. Paclitaxel was initially given at 135 mg/m2 over 24 hours followed by carboplatin dosed to a targeted area under the concentration versus time curve (AUC) of 7.5, with treatment repeated at 3-week intervals for six cycles. Granulocyte colony-stimulating factor was introduced during the second and subsequent cycles, with the paclitaxel dose sequentially escalated in 40 mg/m2 increments to a maximum dose of 215 mg/m2 in patients with less than grade 4 granulocytopenia and less than grade 3 thrombocytopenia. Of 54 patients enrolled, 30 currently are evaluable for response, 23 for toxicity. Myelosuppression has been the principal toxicity, with grade 3 or 4 granulocytopenia occurring in 70% of patients after the first cycle. After the introduction of granulocyte colony-stimulating factor, granulocytopenia decreased to 37% during the second cycle and then consistently to 20% or lower during subsequent cycles. Only 22% of cycles have been delayed for 1 week or more. Neutropenic fever has occurred in five (5%) of 100 evaluable cycles. Other grade 3 or 4 toxicities include thrombocytopenia (13%), anemia (9%), fatigue (9%), and hemorrhagic cystitis (1%). The paclitaxel dose was boosted to 215 mg/m2 in 12 (70%) of 17 patients by cycle 3 or 4. At an AUC of 7.5, the median first-cycle carboplatin dose was 434 mg/m2 (range, 293 to 709 mg/m2). The objective response rate is 50%, with three complete, 12 partial, and five minor responses. We conclude that the paclitaxel/carboplatin combination is active in advanced NSCLC and, with AUC-based dosing of carboplatin, can be given at 3-week intervals. Although dose limiting at a paclitaxel dose of 135 mg/m2, granulocytopenia can be reduced substantially with granulocyte colony-stimulating factor, allowing sequential dose escalation of paclitaxel to 175 mg/m2 and 215 mg/m2 in 70% of patients receiving three or more cycles.

Therapeutic effect of a radiolabeled monoclonal antibody on human ovarian cancer xenograft in nude mice

The therapeutic value of 131I-OC125, a radiolabeled monoclonal antibody directed against a human ovarian tumor associated antigen CA125, was examined in an ascites forming intraperitoneal human ovarian carcinoma nude mouse model. Nude mice were injected intraperitoneally with NIH:OVCAR3 cells. Twenty-one days after tumor transplantation, groups of animals were injected intraperitoneally as follows: Group 1 with 200 microCi of 131I-OC125 (n = 20), Group 2 with 200 microCi of 131I (n = 17), Group 3 with 200 microCi of 131I-IgG (n = 21), Group 4 with 60 micrograms of OC125 (n = 18), and Group 5 was left untreated (n = 21). Survival of the tumor-bearing animals was used as the endpoint of the experiment. Mean survivals were found to be 52 +/- 18 days for the 131I-OC125 group, 53 +/- 16 days for the 131I-IgG group, 49 +/- 13 days for the 131I group, 47 +/- 24 days for the OC125 group, and 47 +/- 15 days for the untreated control. These results would indicate no therapeutic advantage of 131I-OC125 over controls in this animal model. However, other approaches using single as well as multiple radiolabeled monoclonal antibodies need to be tested in this model in order to definitely establish the efficacy of this treatment modality.

Pulmonary nodules resembling bronchioloalveolar carcinoma in adolescent cancer patients

Pulmonary nodules morphologically indistinguishable from bronchioloalveolar carcinoma (BAC) were found in two adolescent cancer patients postchemotherapy. A solitary nodule was noted at thoracotomy for a single computerized tomography (CT) scan lesion in a 16-yr-old male, 6 yr after diagnosis of Ewing's sarcoma. A similar nodule was found in a 19-yr-old male coincident with resection of multiple lung metastases of a testicular germ cell tumor. Both lesions were discrete nodular masses (1 cm and 0.5 cm) consisting of atypical epithelial cells with a papillary and lepidic growth pattern and surrounded by histologically normal appearing lung. Immunohistochemistry of both cases was positive for laminoorganel (LO) antigen, which is found in normal type II pneumocytes, and one nodule showed carcinoembryonic antigen (CEA) staining. Quantitative DNA analysis in one case indicated aneuploidy. Thus the morphology, immunohistochemistry, and DNA content of these lesions suggest that they may represent early lung cancers despite the highly unusual clinical context. The extreme rarity of BAC in this age group makes this report significant in light of heightening concern about second malignancies in pediatric cancer patients and reports of chemically induced pulmonary adenomas in mice. It also underscores the importance of basing therapeutic decisions on a histologic diagnosis of lung nodules in cancer patients rather than assuming the presence of metastatic disease.

Chemotherapy drug resistance--a panel discussion

Considerable insight into the problem of drug resistance has emerged in the past few years. An understanding of why tumors develop drug resistance is now at hand both from theoretical points of view and from experimental and clinical data. Experimental models of drug resistance, particularly related to the surface P-glycoprotein, have been remarkably successful in teaching us why tumor cells in culture develop resistance to common therapeutic agents. In this panel discussion, the clinical relevance of these and other proposed mechanisms will be examined, with the hope of providing an up-to-date overview on this exciting field.

Radioimaging of human ovarian carcinoma xenograft in nude mice

Human ovarian carcinomas in nude mice were radioimaged using a well-characterized antibody against a tumor-associated antigen (CA 125) and three transplantable human ovarian carcinoma tumor lines: NIH:OVCAR 3, NIH:OVCAR 5, and NIH:OVCAR 9. Radioiodinated monoclonal antibody OC125 was used in these studies. In order to establish the optimal conditions for imaging, tumor/blood ratios were determined. Gamma scintigraphy of nude mice bearing subcutaneous transplants of human ovarian carcinomas 3-4 days after 131I-OC125 administration demonstrated selective localization of the radiolabeled monoclonal antibody by these tumors without need for any background subtraction techniques.

Intraperitoneal chemotherapy in the management of ovarian cancer

Initial phase I trials of intraperitoneal chemotherapy in ovarian cancer patients demonstrated that a pharmacologic advantage was achieved with the direct instillation of drugs into the peritoneal cavity. Recent trials have reported that approximately 30% of patients who have small-volume residual disease following induction chemotherapy will achieve a complete remission with intraperitoneal cisplatin. The demonstrated effectiveness and acceptable toxicity makes cisplatin the current drug of choice in the intraperitoneal therapy of ovarian cancer patients. Additional clinical studies are required to determine the role of combinations intraperitoneally, the necessity of intravenous sodium thiosulfate for use with intraperitoneal cisplatin, the activity of other agents, the optimum techniques to deliver intraperitoneal drugs, and the appropriate clinical situations where intraperitoneal therapy should be used in the overall management of ovarian cancer.

Sarcoma arising in a residual testicular teratoma after cytoreductive chemotherapy

A case of testicular teratoma metastasized to the retroperitoneum and after cytoreductive chemotherapy was noted to contain areas of frank sarcoma. Sarcomatous areas included embryonal rhabdomyosarcoma with a pattern of sarcoma botyroides, alveolar rhabdomyosarcoma, and fibrosarcoma. These areas differed markedly from areas of immature teratoma, which composed the remainder of the retroperitoneal lesion and which also characterized the primary tumor. These sarcomatous areas were characterized by numerous mitoses, marked cellular pleomorphism and diagnostic histologic, ultrastructural, and immunocytochemical features. Residual germ cell tumors following cytoreductive chemotherapy are traditionally categorized as teratoma only or teratoma with embryonal carcinoma or choriocarcinoma for therapeutic and prognostic reasons. This case does not conform to this simple categorization and raises serious questions concerning subsequent therapeutic decisions.