Treatment of Advanced Soft Tissue Sarcomas with a Modified CYVADIC Protocol

33 consecutive patients with metastatic or locally recurrent soft tissue sarcoma were treated with a modification of the CYVADIC (cyclophosphamide, vincristine, Adriamycin, dacarbazine) protocol. In an attempt to enhance the response rate without increasing the toxicity, the dose of Adriamycin was raised to 60 mg/m2 and the dose of cyclophosphamide to 600 mg/m2 in each cycle. The dose of dacarbazine was decreased to 150 mg/m2/day for 5 days. Of 31 evaluable patients there were 4 complete responses (13%) and 9 partial responses for a total response rate of 39%. 11 patients (33%) had minimal response or stable disease. The response achieved with our dose modification was no better than that achieved in several series with conventionally dosed CYVADIC.

Chemo-immunotherapy in patients with metastatic melanoma using sequential treatment with dacarbazine and recombinant human interleukin-2: evaluation of hematologic and immunologic parameters and correlation with clinical response

We have treated 18 patients with metastatic malignant melanoma (MM) with high-dose IL-2 administered by continuous iv infusion in combination with dacarbazine (DTIC), and correlated the clinical response with various hematologic and immunologic parameters. Two regimens differing in the sequence of treatment were employed, and 1-6 treatment cycles were given, depending on patient response. Two patients had a complete response (CR, 46+m, 14m), two patients a partial response (PR, 16m,6m), one a minimal response and four had a stable disease lasting 2-7 months, thus the response rate (CR+PR) was 22%. None of the following parameters, tested prior to initiation of the therapy and 1-2 days after termination of each course of IL-2, correlated with the clinical response: WBC counts (total and differential), levels of blood CD4 and CD8 T cells, NK cells, monocytes and B cells, production of IL-1 and IL-1 inhibitor by monocytes, responsiveness to 3 mitogens, NK/LAK cell activity, and serum levels of IL-1 alpha, IL-2, soluble IL-2 receptor, and TNF alpha. The only prognostic parameter was the greater increase in the level of IL-2 receptor (Tac)-bearing lymphocytes in the responding patients after 1-3 cycles of IL-2. The data suggests that non-specific immune parameters have no prognostic value for patients undergoing IL-2-based immunotherapy.

Radiation therapy for locally advanced breast cancer: prognostic factors and complication rate

A retrospective analysis was carried out in 100 patients with locally advanced breast cancer without distant metastases treated by radiotherapy between 1960 and 1979. The primary tumor was irradiated to a total dose of 60 Gy in 76 patients and to doses ranging between 60 and 80 Gy in 24 patients. The regional lymphatics were treated with doses between 50 and 60 Gy. Following radiotherapy, chemotherapy was administered to 58 patients and hormonal therapy to 29, while 13 patients received no further therapy. Locoregional recurrences were documented in 29% and distant metastases in 49% of patients. The actuarial survival was 56% at 5 years, 21% at 10 years and 14% at 15 years. At 10 years 90% of the surviving patients had some degree of radiation damage.

Second line hormonal therapy with aminoglutethimide in metastatic breast cancer

One hundred and twenty patients with metastatic breast cancer, whose disease progressed on hormonal therapy with tamoxifen, were treated with aminoglutethimide. The overall response rate was 34% and the median duration of response 9.5 months. Response to aminoglutethimide was achieved in all metastatic sites except lung and brain. Even 25% of patients who had failed to respond to prior tamoxifen did respond objectively to aminoglutethimide. The actuarial survival for all patients at 30 months was 22%. Although initial toxicity was high (70%), side effects of aminoglutethimide were transient, and treatment had to be discontinued in only four patients. The results of this trial confirm that aminoglutethimide is an effective treatment in metastatic breast cancer.

Methylprednisolone versus metoclopramide as antiemetic treatment in patients receiving adjuvant cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy: a randomized crossover blind study

Nineteen women receiving their first cycle of adjuvant chemotherapy for early breast cancer were randomized between two antiemetic drugs: methylprednisolone (MPN) 125mg and metoclopramide (MCP) 20mg, both given by intravenous push as a single dose. The chemotherapy included: cyclophosphamide, methotrexate and 5-fluorouracil (CMF). The total response rates for MPN and MCP were: complete protection 11% versus 0% and partial protection 63% versus 11% of the patients, respectively (P = 0.007). Eighteen patients (95%) preferred MPN over MCP. Common side effects with both drugs were: drowsiness, headache and diarrhea. MPN is recommended as an antiemetic in patients receiving CMF adjuvant chemotherapy.

Cisplatin, bleomycin, and methotrexate (PBM) chemotherapy in locally advanced and metastatic head and neck cancer

Twenty-two patients with locally advanced or metastatic head and neck tumors received a total of 84 courses of a combination of cisplatin, bleomycin, and Methotrexate (PBM) for a median of four courses per patient (range, 1-7). Among these 22 patients there were four patients (18%) who achieved complete remission (CR) and 13 patients (60%) who had a partial remission (PR). The overall remission rate (CR + PR) thus reached 78%; five patients (22%) progressed while on therapy. The mean duration of objective response (CR + PR) was 8 months; CR lasted a median of 18 months (range, 2-48). Survival was not influenced by tumor histology or by previous surgery. The presence of locoregional disease did adversely affect survival from the onset of chemotherapy (P = 0.1). The rate of survival was also affected by primary tumor site; patients with nasopharyngeal primaries survived longer than all other patients (22 vs. 11 months, P = 0.06). Toxicity to chemotherapy consisted mainly of nausea and vomiting and stomatitis. Three patients developed fever while leukopenic. One patient experienced irreversible renal damage, and another suffered from bleomycin-induced pulmonary fibrosis. The high response rate obtained in our group of patients did not have a substantial impact on overall survival. Aggressive, multimodality approaches should be considered in the treatment of these patients when possible.

Systemic administration of doxorubicin-containing liposomes in cancer patients: a phase I study

A clinical study was designed to evaluate the tolerance of cancer patients to liposome-associated doxorubicin (L-DXR). The liposomes used contain phosphatidylglycerol, phosphatidylcholine, cholesterol, and DXR intercalated in the lipid bilayer, and have a mean size in the range of 0.3-0.5 microns. Thirty-two patients, most of them with primary or metastatic liver cancer refractory to conventional therapy, were entered into the study. A total of 69 courses of therapy was administered by intravenous infusion of a suspension of L-DXR (0.5-2.0 mg DXR/ml) in physiologic saline at an approximate rate of 2 ml/min given on a 3-week intermittent schedule. The L-DXR and phospholipid doses were escalated from 20 mg/m2 and 0.3 g/m2 to 120 mg/m2 and 3.2 g/m2 respectively. Treatment was generally well tolerated and acute toxic effects such as nausea and vomiting were mild and infrequent. Chills and fever (greater than 38.0 degrees C) were observed in three patients during infusion of L-DXR and in seven patients 6-12 h after the end of infusion. Median WBC nadir counts were 2700, 2300 and 700/microliters at 85, 100 and 120 mg/m2 respectively. All three patients receiving 120 mg/m2 developed grade 4 leukopenia and fever requiring intravenous antibiotics, and, in two of them, severe stomatitis (grades 3 and 4) was observed. Significant hair loss was apparent in all patients receiving doses higher than 50 mg/m2. The maximal tolerated dose of L-DXR appears to be 120 mg/m2, with leukopenia and stomatitis being the dose-limiting factors. While the subacute toxicity of L-DXR appears to be qualitatively similar to that of free DXR, its tolerance exceeds the recommended dose of free DXR (75 mg/m2) in the standard 3-weekly schedule.

Hepatic intraarterial antibiotic therapy for resistant hepatic abscesses

Liver abscesses present a severe problematic medical entity. The traditional treatment modality consists of surgical drainage, which cannot be accomplished in all circumstances. Other modes of therapy include systemic antibiotics or percutaneous catheter drainage under ultrasonography or computerized tomography. Despite new treatment regimes liver abscesses, to date, are a potentially lethal disease, with a mortality rate of about 50%. We report an innovative approach of high dosage intrahepatic arterial antibiotic infusion for the therapy of hepatic abscesses, which are resistant to conventional treatments. A patient who underwent mastectomy for breast carcinoma, developed liver metastases one year later. She was prescribed systemic chemotherapy for one year, but no antitumor response was evident. Since ther was no evidence for extra-hepatic metastases, intraarterial hepatic chemotherapy was instituted, using an Infusaid (Mi-400) implantable pump. Marked regression of liver metastases was observed. Therapy was withheld after 19 months because of biliary sclerosis development. At this stage, the patient developed liver abscesses, which were resistant to systemic antibiotic therapy. Intraarterial antibiotic therapy, using the implantable pump, was initiated. Following the treatment, a marked improvement in the patients' clinical condition was recorded and shrinkage of the abscesses was evident by ultrasonography. The patient was free of symptoms for three months, when she was readmitted with evidence of terminal metastatic disease and sepsis. It is suggested that intrahepatic arterial antibiotic therapy is an additional mode of treatment for patients with persistent liver abscesses which fail to respond to conventional treatment.

Methylprednisolone and chlorpromazine in patients receiving cancer chemotherapy: a prospective non-randomized study

Seventy-six consecutive patients receiving chemotherapy were evaluated for the antiemetic efficacy and side-effects of the combination of chlorpromazine (CPM) and methylprednisolone (MPN). All patients had previously received the same chemotherapy with metoclopramide in conventional dosage and experienced severe emesis. A significant antiemetic response was achieved in 70% of the patients, and in 28% of them the antiemetic protection was complete. The most common side effects were drowsiness, dry mouth and headache. The combination of CPM and MPN is effective, well tolerated and is recommended for outpatients receiving chemotherapy for cancer.

Chlorpromazine and dexamethasone versus high-dose metoclopramide and dexamethasone in patients receiving cancer chemotherapy, particularly cis-platinum: a prospective randomized crossover study

Sixty-nine patients with malignant tumors receiving cancer chemotherapy, 90% including cis-platinum, were evaluated in a randomized crossover study for the antiemetic efficacy and the side effects of two antiemetic regimens: chlorpromazine (CPM) 2.5 mg/kg in 5 doses plus dexamethasone (DXM) 0.2 mg/kg in 2 doses, and high-dose metoclopramide (HD-MCP) 10 mg/kg in 5 doses plus the same dose of DXM. In 69% of 173 courses of chemotherapy, antiemetic response was achieved, and in 26% emesis was completely prevented. There was no statistical difference in the response to the antiemetic regimens, but 65% of the patients who completed 3 courses of chemotherapy preferred HD-MCP plus DXM. The main side effects of the treatment were drowsiness, nervousness, diarrhea and extrapyramidal reactions. HD-MCP plus DXM is recommended as a first line antiemetic treatment in patients receiving cancer chemotherapy. Patients resistant to this treatment should receive CPM plus DXM treatment.

5-Fluorouracil, doxorubicin (adriamycin) and mitomycin-C (FAM) in advanced gastric cancer: observations on response, patient characteristics, myelosuppression and delivered dosage

Forty-four patients with advanced gastric adenocarcinoma were treated with the fluorouracil, adriamycin and mitomycin-C (FAM) regimen. One was excluded from response evaluation. Partial (PR) and minor (MR) response rates were 7 and 9% respectively. These patients enjoyed remission for a median of 7.0 months. Stabilization (S) occurred in 25% and lasted a median of 6.0 months. No response (NR) was associated with a median survival of 3 months (p less than 0.001). The predominant pretreatment factors to affect survival were diagnosis to treatment interval and initial CEA serum level. Performance status influenced survival less markedly. Toxicity was mainly myelosuppression, which resulted in death of one patient. 'Responders' had marrow suppression more frequently than NR. Comparison of PR + MR, PR + MR + S and NR patient groups showed median minimum WBC counts of 1.4 x 10(3), 2.6 x 10(3) and 4.3 x 10(3) per mm3 respectively. Leukopenia (less than 3,000/mm3) was associated with a median survival advantage of 9.5 versus 3.5 months (p less than 0.05) and did not depend significantly on given FAM dosage. The median dosage of FAM agents delivered to nonresponders was reduced. A trend of dose-response (including dose-survival) relationship was found but was inconclusive statistically.

Treatment of primary and metastatic liver cancer using an implantable chemoinfusion pump

Twenty evaluable patients with primary or secondary neoplastic liver involvement received FUDR (0.2 to 0.3 mg/kg per day) by continuous infusion to the hepatic artery for 14 days, every 4 weeks, through a surgically implanted Infusaid (USA) pump. In addition to FUDR, MMC (15 mg/m2 every 6 to 8 weeks) was given to 14 patients with colorectal cancer and one patient with breast cancer, and ADR, (40 mg/m2 every 4 to 6 weeks) was given to 5 patients with hepatocellular carcinoma. MMC and ADR were given as a bolus injection, through the pump sideport. Radiation therapy to the liver (2,000 rads in fractions of 180 to 200 rads each) was given to eight patients with colorectal carcinoma. In total, the 20 patients received 218 months of treatment and 580 injections. The overall remission rate (complete, partial and minor response) was 55%; one patient with a colorectal carcinoma achieved a CR and seven patients (35%) a PR; three patients (15%) had a MR, and in eight patients (40%) stabilization of disease was observed. Overall median survival was 12 months: 15.5 months for colorectal cancer patients and 7.5 months for patients with hepatocellular carcinoma. Toxicity consisted mainly of chemical hepatitis, mild to severe peptic disease and sclerosing cholangitis. Hematological toxicity was not observed. These data suggest that chemotherapy through the hepatic artery, while still experimental, may be considered for selected patients with tumor confined to the liver.

CA15-3 serum levels in breast cancer and other malignancies--correlation with clinical course

Serum levels of the breast cancer-associated tumor marker CA15-3 were evaluated in three patient groups: breast, colorectal and ovarian cancer and in healthy subjects. Of 51 blood samples obtained from 31 patients with metastatic breast cancer (Stage IV disease), 98% had marker levels greater than 30 u/ml and 86% had levels greater than 50 u/ml. In contrast, of 49 samples from 42 patients with Stage I-II disease, 45% had levels greater than 30 u/ml but only 6% had levels greater than 50 u/ml (mean 29.5 +/- 18 u/ml). The mean level of the CA15-3 antigen in patients with Stage IV breast cancer and responding to therapy was 79.8 +/- 27 u/ml, while the mean level in patients not responding to therapy was 134 +/- 66 u/ml (P less than 0.02). The mean serial changes in CA15-3 levels for those responding to therapy was -28.4% while the mean change for those not responding to therapy was +44%. The mean marker level for 26 patients with colorectal carcinoma was 29.8 +/- 29 u/ml; 23% of these patients had levels greater than 30 u/ml and 7% had levels greater than 50 u/ml. No substantial difference was seen in those with active compared with nonactive colorectal carcinoma. The mean marker level for 14 patients with active ovarian carcinoma was 83 +/- 62 u/ml. Of these patients, 78% had CA15-3 levels greater than 30 u/ml and 50% had levels greater than 50 u/ml. All healthy subjects (n = 22) had marker levels less than 30 u/ml. We compared CA15-3 and CEA blood levels in the same patient population; 86% of patients with metastatic breast cancer (Stage IV disease) had CA15-3 levels greater than 50 u/ml while only 72% of these patients had CEA levels greater than 5 ng/ml. These findings suggest that the CA15-3 assay reflects the clinical course of patients with advanced breast cancer and may be superior to CEA as a monitor of therapeutic efficacy.

Cyclophosphamide, adriamycin, DTIC and vincristine with methotrexate in the treatment of advanced soft tissue sarcomas

Twenty-eight consecutive adult patients with locally advanced (inoperable) or metastatic soft tissue sarcomas were treated with a chemotherapy regimen (CADOM) including cyclophosphamide, ADR, and DTIC on Day 1 of each course, and vincristine with intermediate-dose methotrexate (200 mg/m2) on Day 15 followed by leucovorin rescue. Twenty-four of the patients were evaluable for response and toxicity. Three (13%) achieved a CR after chemotherapy and 6 (25%) a PR. Two of the PRs were converted to CR after surgical removal of residual tumor. All five patients achieving a CR are alive 12 to 30 months after beginning chemotherapy. Median survival of patients achieving a PR was 18 months and of patients achieving an MR was 7 months. Three of five patients with sarcomas arising from the female genitalia achieved a CR. No treatment-related deaths occurred. There were five instances of leukopenia and fever. Nausea and vomiting, and alopecia were common. Stomatitis, muscle cramps, paralytic ileus, and peripheral neuropathy were occasionally observed. The addition of methotrexate did not improve the response rate when compared with our previous CYV ADIC protocol.

Involvement of heparanase in tumor metastasis and angiogenesis

The capacity of various blood-borne cells, whether normal or malignant, to extravasate was found to correlate with heparanase-mediated degradation of HS in subendothelial ECM. This degradation was stimulated by proteases or plasminogen and inhibited by native heparin and by various modified nonanticoagulant species of heparin. These heparins also induced a marked reduction in tumor cell metastasis and autoimmune diseases in experimental animals. Heparanase-mediated degradation of HS in ECM also released EC growth factors that are stored in ECM, most likely by high affinity binding to HS. Such growth factors were extracted from subendothelial ECM synthesized in vitro and from basement membranes of the cornea in vivo, and are structurally and functionally related to bFGF;bFGF binds to ECM and is readily released by incubation with either HS, heparin or low MW heparin fragments as well as by various normal and malignant cells and by heparanase-mediated degradation of ECM HS. In contrast, there was little or no release of growth-promoting activity upon incubation of ECM with hyaluronic acid, chondroitin sulfate or chondroitinase ABC. A model is proposed suggesting that regulation of capillary growth and neovascular response may result from displacement of an angiogenic protein (bFGF) from its storage sites within basement membranes.

Combination chemotherapy in metastatic tumors of unknown origin. 5-Fluorouracil, adriamycin and mitomycin C for adenocarcinomas and adriamycin, vinblastine and mitomycin C for anaplastic carcinomas

Twenty-nine evaluable patients with metastatic carcinomatosis in whom initial workup failed to reveal the primary site were entered into this trial. Patients with histological evidence of adenocarcinoma (n = 15) received FAM, while patients with anaplastic carcinomas (n = 14) were given AVM. Pretreatment characteristics were similar for the FAM- and AVM-treated patients with regard to age and sex, but 47% of patients on FAM had liver metastases as compared with 36% for the AVM group. Of the 14 patients on AVM, 1 (7%) achieved a complete response lasting 16 months, and 3 patients (22%) achieved a partial response for 10, 12 and 20 months, respectively. No patient on FAM reached a complete response, and only two patients (13%) showed a partial remission for 7+ and 24 months, respectively. The median survival for the AVM patients was 8.5 months, not significantly different from a median of 5 months for the FAM-treated group. AVM caused substantial myelotoxicity, resulting in five hospitalizations for leukopenia and fever; the FAM regimen was better tolerated with no episodes of leukopenic fever. AVM appears to be more effective than FAM in the treatment of carcinomas of unknown origin. A higher response rate was achieved with AVM, despite the fact that patients on this combination had undifferentiated carcinomas and a larger proportion of three or more metastatic sites (36 vs. 13% on FAM), and received a lower percent of the planned dose than did the FAM patients. Further clinical trials to fully establish the role of vinblastine in the treatment of metastatic carcinomatosis of unknown origin seem warranted.

The effects of ionizing irradiation on production of thromboxane and prostacyclin by the isolated perfused rat kidney

Exposure to whole body radiation is associated with prompt changes in urinary excretion of prostaglandins. We investigated the separate effects of radiation on rat kidney capillary and tubular system prostaglandin synthesis. Animals were irradiated to the left kidney area with a single dose of 15 Gy. One week later the rats were anesthesized, the renal artery, vein and ureter of the left kidney cannulated, and the kidney removed and perfused with Krebs-Henseleit physiological buffer at a rate of 10-12 ml/min. Effluent fluids were collected separately from the renal vein and from the ureter of irradiated and control (operated sham-irradiated animals) and were assayed by radioimmunoassays for thromboxane A2 (TXB2) and prostacyclin (6 keto PGF1 alpha). Histological examination of the irradiated kidneys showed no significant changes, and electron microscopy revealed minimal interstitial edema. In contrast to these minimal changes, TXB2 assays showed a significant increase both in the venous and ureter effluents. Following stimulation with angiotensin II in the perfusate, a further significant increase in TXB2 production was observed both by the capillary and the tubular systems. With 6 Keto PGF1 a slightly different response was seen. The basal production was increased only in the ureter effluent of the irradiated animals, while there were no changes in the release in the venous effluents. In parallel, radiation significantly increased the angiotensin II stimulated production capacity of prostacyclin by the tubular system. The response of the capillary system following irradiation may create imbalance between these two important substances and lead to the radiation effects in the renal tissue.

Chemotherapeutic and surgical induction of pathological complete remission and whole abdominal irradiation for consolidation does not enhance the cure of stage III ovarian carcinoma

Thirty-eight patients with stage III ovarian carcinoma were treated with a protocol consisting of an initial phase of induction of remission with cyclophosphamide, hexamethylmelamine, doxorubicin, and cisplatin (CHAD) combination chemotherapy and a second laparotomy for resection of residual tumors, followed by a consolidation phase with curative doses of whole abdominal radiation. Six patients (16%) had stage IIIA disease, ten (26%) IIIB, and 22 (58%) had stage IIIC disease. All patients received three to 14 courses of CHAD chemotherapy with a clinical response rate (complete [CR] and partial [PR]) of 91%. Thirty-three patients underwent the second operation. In 14 patients no residual tumor was found, and in another 11 residual tumors found were totally resected. Thus, 25 of 33 (76%) were classified as in pathological complete remission (PCR) after this operation. Whole abdominal irradiation was well tolerated, although 12 of 29 (42%) of the irradiated patients required more than a 2-week interruption of the treatment course because of leukopenia and/or thrombocytopenia. The actuarial 5-year survival and disease-free survival rates for the whole group were 27% and 17%, respectively, and for the 29 patients who received the complete sequence of the prescribed protocol treatments, 35% and 20%, respectively. A univariate analysis of clinical parameters showed that inherent biological features, such as histology and grade, were the most dominant factors affecting prognosis, and that neither the aggressive surgical approach employed, nor the high-dose whole abdominal irradiation, significantly affected the outcome. The long-term results suggest that although our combined modality protocol was well tolerated, it failed to enhance the cure of stage III ovarian carcinoma. The possible biological and therapeutic vectors affecting this outcome are discussed.

Prevention of human bladder tumor cell implantation in an in vitro assay

The high recurrence rate of bladder tumors can be reduced by prevention of tumor cell reimplantation on denuded urothelium following transurethral resection. This can be achieved by intravesical chemotherapy immediately after the resection of the bladder tumors. We have demonstrated, in an in-vitro system, the process of human bladder tumor cell implantation on a naturally produced extracellular matrix (ECM) which simulates the exposed bladder basement membrane and submucosa. Using this model we examined the efficacy of various cytotoxic agents in preventing tumor cell adhesion to the ECM. Human bladder tumor cell implantation was prevented following exposure of the cells to distilled water, epodyl or mitomycin C, and significantly reduced following one hour incubation in cisplatinum and doxorubicin. The maximal effect for each of these cytotoxic agents was reached within 30 to 60 minutes of treatment. Mitomycin C reached maximal effect within 10 minutes. In contrast, thiotepa did not cause a significant reduction in cell adherence to ECM as compared to untreated control cells.

High-dose metoclopramide and dexamethasone as an antiemetic in outpatients receiving chemotherapy for breast cancer. Second study

Forty-six outpatients with breast cancer who had experienced severe emesis as a result of chemotherapy were evaluated for the antiemetic efficacy of high-dose metoclopramide (HD-MCP) and dexamethasone (DXM). Chemotherapy consisted of: cyclophosphamide 600, methotrexate 40 and 5-fluorouracil 600 mg/m2 (CMF) given intravenously every 3 weeks. The dosage of antiemetic drugs was MCP 2 mg/kg and DXM 0.2 mg/kg given by slow intravenous drip 0.5 h before the administration of chemotherapy. 138 courses of combined chemotherapy--HD-MCP and DXM--were administered, with a mean of 3 courses and a range of 1-10 courses per patient. Complete protection--no nausea and no vomiting--was achieved in 17.7% of the courses. Partial protection--no vomiting with mild nausea or 1-3 episodes of vomiting--in 45.3% of the courses. The total antiemetic efficacy was 63%. The most common side effects were: drowsiness, dry mouth, restlessness and diarrhea. Sixteen patients (35%) refused to continue the antiemetic regimen because of the side effects. HD-MCP and DXM have antiemetic efficacy, but because of these side effects, further studies are required to determine the optimal dose of each of these drugs.

The effect of estradiol on human myelomonocytic cells. II. Mechanism of enhancing activity of colony formation

Elevated proportions of monocytes have previously been found in the blood of healthy women during the ovulation period as well as in other conditions associated with increased blood estradiol (E2). This phenomenon was explained, in part, by an augmenting effect which physiological concentrations of E2 may have on the development of granulocyte-macrophage (GM) colonies derived from normal peripheral blood mononuclear cells. To analyze this effect, we tested possible alternatives for the interaction between E2, colony-stimulating factor (CSF) and GM colony progenitor cells. E2 was found not to interact synergistically with CSF, but pre-treatment of the progenitor cells with E2 resulted in higher numbers of colonies in response to CSF. Moreover, E2 did not induce higher secretion of CSF but treatment with anti-CSF antibodies abolished the enhancing effect of E2. Based on these results, we suggest that the augmenting effect of E2 on GM colony formation is mediated by inducing the colony precursor cells to be more responsive to CSF. These findings may help to elucidate some of the complex relationships between estrogens, immune responses and hemopoiesis.

Interleukin 1 inhibitory activity secreted by a human myelomonocytic cell line (M20)

Culture supernatants from a myelomonocytic cell line (M20) were found to inhibit interleukin 1 (IL 1) activity in vitro. The factor, isolated from these supernatants, inhibited augmentation of phytohemagglutinin response of mouse thymus cells induced by IL 1 derived from several established cell lines. Various IL 1-dependent activities such as lymphocyte and fibroblast proliferation in vitro were also inhibited by the factor. The factor did not inhibit IL 2-induced or other proliferative responses not related to IL 1. Preliminary biochemical characterization of the factor indicated that the activity resides in a protein with a molecular mass of 52 kDa.

Adriamycin, vinblastine and mitomycin C as second-line chemotherapy in advanced breast cancer

Thirty-six evaluable patients with metastatic measurable breast carcinoma previously treated with CMF or CMFVP were given second-line chemotherapy with Adriamycin, vinblastine, and mitomycin C (AVM), as follows: Adriamycin 20 mg/m2 and vinblastine 6 mg/m2 by i. v. push on days 1, 8, and 15, and mitomycin C 10 mg/m2 i. v. on day 1, every 6 weeks. Ten patients (28%) achieved partial remission (PR) lasting a median of 10 months, and eight patients (22%) experienced improvement of a lesser level than PR. An additional nine patients (25%) had disease stabilization; in the remaining nine patients (25%), persistent disease progression was observed. The median survival from the onset of AVM was 7 months for all patients; patients with PR survived a median of 13 months. Myelotoxicity was substantial and frequently interfered with the optimal administration of AVM, especially in patients with skeletal metastases; four patients were hospitalized with leukopenia and fever; all recovered promptly; one death was probably related to thrombocytopenia and CNS bleeding. Our results with AVM are similar to the average response rate published in the literature with the use of Adriamycin as a single agent in previously treated patients with advanced breast cancer.

Growth of human mammary carcinoma cells from biopsy specimens in serum-free medium on extracellular matrix

A method developed for the initiation and maintenance in primary culture of human normal mammary epithelial cells was adopted for the growth of epithelial cells from 45 primary human breast tumors. The cells were grown on a naturally produced extracellular matrix (ECM) or on regular tissue culture plastic in a serum-free medium containing growth supplements and high-density lipoprotein (HDL). Successful enzymatic dissociation of the tumor biopsy into organoid structures and cell aggregates was crucial for subsequent cell attachment and growth. Fifty-five percent of the biopsy specimens were successfully dissociated and 87% of these gave rise to actively dividing epithelial cells forming monolayer cultures. In contrast, only 21% of the biopsies which were not optimally dissociated yielded growing cultures. Variations in sample size, duration of enzymatic digestion, and tumor composition affected the outcome of tumor dissociation. Omission of serum from the culture medium prevented the growth of fibroblasts, while plating on ECM greatly improved and in some cases was essential for cell attachment and subsequent outgrowth. The epithelial nature of the cells was verified by their cuboidal and closely apposed morphology and positive staining with antikeratin antibodies. The growth and subculture requirements and the expression of the B38.1 tumor marker were compared in human mammary epithelial cells derived from solid tumors, pleural effusion and normal breast tissue.

Aminoglutethimide as second line endocrine therapy in advanced breast cancer

Eighty five patients suffering from metastatic breast cancer, whose disease progressed on hormonal therapy with tamoxifen, were treated with aminoglutethimide. The overall objective response rate was 33%, with a median duration of response of 8 months. Even patients who failed to respond to tamoxifen responded to aminoglutethimide. Objective response was achieved in all metastatic sites, except for lung. Subjective improvement was observed in 75% of the patients. In spite of the fact that initial toxicity was high (70%), side effects of aminoglutethimide were transient, and treatment had to be discontinued in only 4 patients. The results of this trial indicate that aminoglutethimide is an important addition for the treatment of metastatic breast cancer, especially in patients with positive hormone receptors.

Detection of different interleukin-1 activities in human monocytes and monocytic cell lines

Culture supernatants from normal human monocytes, monocyte hybrid cell lines, and myelomonoblastic cell lines were tested for human interleukin-1 (IL-1) activity. In the present study, we report the detection of IL-1 secreted by several cell lines of monocyte origin and compare their biological and biochemical characteristics. IL-1 activity was tested by the regular assay of phytohemagglutinin (PHA) response of mouse thymus cells. IL-1 was found to be constitutively secreted by U937 and the M20 cell lines, as well as by three of the monocyte hybrid cell lines. The activity was always augmented following dialysis and did not require the presence of serum for its secretion. We compared the IL-1 activity of the myelomonoblastic M20 and hybrid 1C4 cell lines to that of normal monocytes. We found differences in the kinetics of IL-1 secretion, the pattern of activity following dilution of concentrated supernatants, and augmentation of activity by various inducers. The differences described may be explained by concomitant secretion of IL-1 inhibitory factors, as well as the secretion of activities other than IL-1. Preliminary biochemical analysis showed that all three cell sources tested shared some species of molecules characterized by gel filtration and ion-exchange chromatography. However, some species of molecules expressing IL-1 activity were unique to the cell lines and were not found in normal monocytes.

The mechanism of human bladder tumor implantation in an in vitro model

Implantation of tumor cells in the bladder following transurethral resection of superficial bladder tumors is believed to be one factor in the etiology of bladder tumor recurrences. Using an in vitro model system we have studied the initial interaction between bladder carcinoma cells and a naturally produced basement membrane-like substrate. Minced explants of superficial low grade human bladder tumors from 10 patients were plated into culture dishes coated with a naturally produced extracellular matrix (ECM). This ECM has been shown to resemble the human urothelial basement membrane and submucosa in its macromolecular composition and ultrastructural appearance. It was found that a firm attachment of the human bladder tumor cells occurred within one hour, reached a maximal value within 24 hours and was followed by flattening and proliferation of the plated cells. These results indicate that prevention of tumor implantation should be initiated in the first hour after transurethral resection of the bladder tumors. This assay can be used for the investigation of various treatments to prevent tumor implantation.

Prognostic factors affecting treatment results with combination chemotherapy in metastatic breast cancer

Seventy five patients suffering from metastatic breast cancer previously unexposed to chemotherapy were treated with Cyclophosphamide, Methotrexate and 5-fluorouracil (CMF) upon diagnosis of their first relapse. Dose Level I (85% or more of the planned dose) was given to 14 patients (19%); Dose Level II (66% to 84% of the planned dose) to 29 patients (39%); and Dose Level III (65% or less of the planned dose) to 32 patients (42%). Before initiation of treatment, 41 patients (55%) had a good performance status (PS greater than or equal to 80%) and 34 patients (45%) had a poor performance status (PS less than 80%) according to the Karnofsky scale. The overall response rate was 44%, including 17% complete responses. There was no significant correlation between response rates and the dose levels of chemotherapy. However, patients with a good performance status had a higher response rate (61%) compared with patients with a poor performance status (25%; p = 0.0025). The actuarial 3 year survival according to dose levels of CMF was 15%, 41% and 36% for Dose Levels I, II, and III, respectively (p = 0.34), but was 52% for patients with PS greater than or equal to 80% versus 14% for patients with PS less than 80% (p = 0.0001). These data indicate that the general condition of the patient at the time of initiation of CMF chemotherapy, as reflected by the performance status, may be of greater significance for the prediction of the ultimate treatment outcome rather than the total amount of chemotherapy delivered per se.

Parameters affecting the in vitro maturation of human monocytes to macrophages

In vitro maturation of human monocytes to macrophages was characterized by morphological criteria, cell size and lysosomal enzymes activity. Purified populations of monocytes were maintained in culture at either adherent or nonadherent conditions and their maturation to macrophages was observed in both cases. The addition of external factors such as hydrocortisone and vitamin D3 inhibited monocyte maturation. In the absence of external factors, nonadherent monocytes were inhibited in their maturation for up to 10 days when plated at crowded cell concentrations. In addition, the presence of human serum in the culture media had a higher inhibitory activity than similar concentrations of fetal calf serum. Supernates from crowded macrophages were also inhibitory for monocyte maturation. We suggest the possibility that cell crowding, as well as soluble factors found in the serum and probably secreted by macrophages, participate in the regulation of monocyte development by inhibiting their maturation. Once released from this inhibitory signal or environment, the monocytes mature to macrophages.

In vitro differentiation and establishment of cell lines derived from human myelomonocytic leukemia cells

Primary cultures of cells derived from 13 patients with acute myelomonocytic leukemia (AMML) were studied with particular emphasis on in vitro proliferation, cell differentiation and the mode for establishment of cell lines. Using irradiated human macrophage monolayers to assist cell growth, we obtained four new cell lines of myelomonocytic origin. All the cell lines were characterized for cytochemical markers and response to phorbol esters (TPA), a differentiation inducing agent. In the absence of any inducing agent, spontaneous differentiation of blast cells into mature macrophages-like cells occurred in 8 out of the 13 primary cultures. Thus, maturation induction by agents such as TPA is not always required in order to obtain leukemic cell differentiation in vitro. The regulation of cell proliferation and differentiation by cellular interactions and by extrinsic soluble products is discussed in detail, in the light of these findings.

Pleural effusion in breast cancer: influence upon clinical course and survival

The clinical course and outcome of 31 women suffering from breast carcinoma with documented pleural involvement was reviewed retrospectively. These 31 patients represent 14% of all patients with metastatic breast cancer seen in our Institution between 1977 and 1982. Most effusions were unilateral and ipsilateral to the affected breast, and the median interval from diagnosis of breast cancer to detection of pleural effusion was 32 months (range 0 to 84). In 55% of the patients, the effusion represented the first site of failure; in patients with known metastatic disease, the median interval from initial failure to the development of pleural effusion was 12 months. Local recurrence in the affected breast or chest wall very frequently preceded the onset of an ipsilateral effusion. Once pleural fluid developed, spread to other visceral organs was common. Treatment regimens were far from uniform and included systemic chemotherapy, hormone therapy or both, as well as intrapleural treatment; 10 of 22 patients (45%) given any form of therapy other than thoracentesis had a significant decrease in the amount of the effusion, including 3 patients with a complete response. The median survival of all patients from the onset of the effusion was 7 months (1-72); complete responders survived a median of 15 months whereas progressors had a median survival of 5 months only. Prognostic characteristics associated with a prolonged survival were: a unilateral effusion, ipsilateral to the primary tumor; effusion as first site of relapse, and mainly, an objective response to therapy. Although this is a small series, patients given both systemic and intracavitary treatment achieved best results.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthesis and receptor-binding affinity of fluorotamoxifen, a possible estrogen-receptor imaging agent

Aminotamoxifen was totally synthesized from p-nitrobenzoyl chloride via a Friedel-Crafts acylation. Then, by means of a Balz-Schiemann reaction, aminotamoxifen was converted into fluorotamoxifen. The triazene variation of this conversion, with a 25% yield, enables a rapid, one-step diazotization, incorporating a fluorine atom into the phenyl ring of the tamoxifen. This reaction may be useful for the preparation of low specific activity 18F-labeled tamoxifen, for distribution, and for estrogen-receptor studies. For these in vivo and in vitro studies, fluorotamoxifen was also synthesized from p-fluorobenzoyl chloride, and its chemical intermediates were compared with estradiol and hexestrol, for their receptor binding and competition, as well as for their uterotropic activity. It is demonstrated that tamoxifen and fluorotamoxifen are strong estradiol agonists and partial hexestrol agonists, while aminotamoxifen is a weak estradiol and hexestrol agonist.

The effect of estradiol on human myelomonocytic cells. 1. Enhancement of colony formation

Cyclic changes were observed in the content of blood monocytes during the menstrual cycle of normal women. Elevated blood monocytes were found during the ovulation period as well as in other conditions which are associated with increased blood estradiol (E2). To understand the possible association between E2 and monocytosis, we analysed the in vitro effect of E2 on the development of myelomonocytic colonies in culture. E2 in physiological concentrations was found to increase the number of colonies developed from peripheral blood mononuclear cells (PBM) of both females and males. The optimal concentration for the augmenting effect on males' PBM was lower than that for females. Mononuclear cells derived from cord blood, which yielded much higher numbers of colonies than adult PBM, also responded to the stimulatory effect of E2. Estrone and estriol were less effective than E2 in adult PBM. In contrast, progesterone, diethylstilbestrol and testosterone did not affect the number of colonies at the range of physiological concentrations tested. The anti-estrogen Tamoxifen did not inhibit the stimulatory effect of E2. The augmenting effect of E2 on monomyelocytic colony formation may explain at least in part the increase in blood monocyte content of women with high E2 as well as other phenomena of macrophage and granulocyte changes associated with the menstrual cycle.

High-dose metoclopramide as an antiemetic in patients receiving cis-platinum-based combination chemotherapy

Thirty-seven patients with advanced malignancies, who received cis-platinum-based combination chemotherapy, were evaluated for the antiemetic efficacy of high-dose metoclopramide. Most of the patients suffered from ovarian carcinoma. The dose of metoclopramide was 7.5 or 10 mg/kg per course. A total of 69 courses were given to 37 patients and in 22% of the courses, nausea and vomiting were eliminated altogether. In an additional 48% of the courses, a partial protection from chemotherapy-induced emesis was evident. No serious side effects were observed. The administration of high-dose metoclopramide is recommended for prevention of cis-platinum chemotherapy-induced emesis.

Platelet-tumor cell interaction with the subendothelial extracellular matrix: relationship to cancer metastasis

Dissemination of neoplastic cells within the body involves invasion of blood vessels by tumor cells. This requires adhesion of blood-borne cells to the luminal surface of the vascular endothelium, invasion through the endothelial cell layer and local dissolution of the subendothelial basement membrane. Platelets may participate in each of these steps and thus play a role in the pathogenesis of tumor cell metastasis. To learn more about the possible involvement of platelets we studied the interaction of platelets and tumor cells with cultured vascular endothelial cells and their secreted basement membrane-like extracellular matrix (ECM). Whereas the apical surface of the vascular endothelium lacks adhesive glycoproteins and hence protect the vessel wall against platelet and tumor cell adhesion, the underlying ECM constitute a highly adhesive and thrombogenic surface. Interaction of platelets with this ECM was associated with platelet activation, aggregation and degradation of heparan sulfate in the ECM by means of the platelet heparitinase. The activity of a similar enzyme has been previously correlated with the metastatic potential of various tumor sublines. Biochemical and scanning electron microscopy (SEM) studies have demonstrated that platelets may detect even minor gaps between adjacent endothelial cells and degrade the ECM heparan sulfate. This may expose a larger area of the subendothelium and facilitate subsequent adhesion of blood borne tumor cells. Platelets were also shown to recruit lymphoma cells into minor gaps in the vascular endothelium, that otherwise do not constitute a preferential site of invasion. It is suggested that the platelet heparitinase is involved in the impairment of the integrity of the vessel wall and thus play a role in tumor cell metastasis.

Combined modality treatment for stage III ovarian carcinoma

Thirty-eight Stage III ovarian carcinoma patients were treated with a combined modality protocol consisting of sequential initial surgery with a maximal tumor reduction, CHAD combination chemotherapy, second look reductive surgery and whole abdominal irradiation. Sixteen patients (42%) had minimal residual tumors (less than 2 cm) after initial surgery (Stage IIIA) and 22 (58%) had large residual tumors (greater than 2 cm) (Stage IIIB). The patients received 3-14 courses of CHAD combination chemotherapy, with a response rate (CR + PR) in the evaluable (Stage IIIB) patients of 91%. Twenty-eight patients had a second attempt of cytoreductive operation (10 Stage IIIA patients and 18 Stage IIIB patients). In 10 patients no residual tumor was found. In another 12 patients residual tumor (less than 2 cm) was found and completely resected, whereas in six patients a complete resection of large residual tumors (greater than 2 cm) was not possible. Twenty-one of the patients also completed a course of whole abdominal radiotherapy. Radiation was well-tolerated with the usual expected amounts of nausea, vomiting, diarrhea and transient leukopenia and thrombocytopenia. 11/21 (52%) of the patients relapsed within the first 18 months after completion of radiotherapy. The actuarial relapse-free survival at 36 months from completions of radiotherapy was 44%. The actuarial survival for the whole group from diagnosis was 43% at 3 years (70% for Stage IIIA and 41% for Stage IIIB). The data indicated that this combined modality protocol is both feasible and well-tolerated but its curative potential for patients with advanced ovarian carcinoma is as yet unknown.

Treatment of metastatic breast cancer with aminoglutethimide after progression on chemotherapy and/or hormonal therapy with tamoxifen

Sixty patients suffering from metastatic breast cancer, whose disease progressed on chemotherapy and/or hormonal therapy with tamoxifen, were treated with aminoglutethimide. The overall objective response rate was 33%, including 3% complete responses. The median duration of response was 8 months. Even patients who failed to respond to prior treatment modalities responded objectively to aminoglutethimide. Objective response was observed in all metastatic sites, except for lung. Subjective improvement was achieved in 70% of the patients. Although initial toxicity was high (67%), side effects of aminoglutethimide were transient, and therapy had to be discontinued in only 3 patients. The results of this study indicate that aminoglutethimide in combination with hydrocortisone is a very effective treatment for metastatic breast cancer, especially in patients with positive hormone receptors.

A new human ovarian carcinoma cell line: establishment and analysis of tumor-associated markers

In the present study we describe the establishment and characteristics of a new human tumor cell line (OV-1063) positive for carcinoembryonic antigen (CEA) originating from ovarian metastatic tumor cells. Analysis of the cultured cells during their in vitro adaptation period revealed while the primary culture exhibited a low proportion of CEA-positive cells, this proportion increased with culture passages and eventually more than 90% of the cells in the established line were CEA-positive. Thus, during the period of adaptation to in vitro growth, a selection for CEA-positive cells took place but the amount of CEA secreted per each positive cell seemed to be constant. Several tumor-associated characteristics were found positive on the established OV-1063 cell line. The in vitro growing cell line exhibited an abnormal chromosome pattern with a near-trisomy karyotype for some chromosomes, colony formation in soft agar as well as positive staining with a monoclonal antibody B38.1. Culture supernatants of the OV-1063 cells contained significant amounts of CEA as well as CA-125 antigen which is an ovarian-carcinoma-associated antigen.

Procarbazine, CCNU and vincristine (PCV) combination chemotherapy for brain tumors

12 patients with brain tumors were treated with a combination of procarbazine, CCNU (bis-2-chloroethyl-3-cyclohexyl-1-nitrosourea) and vincristine. 3 of 8 patients (37.5%) with primary brain tumors responded to chemotherapy, with a mean duration of 9.3 months. The mean survival of responders was 11.7 months, versus 3.6 months for nonresponders. 4 patients with metastatic brain tumors were also treated with the same combination chemotherapy; only 1, suffering from a lymphoma of the brain, responded partially.

Levels of fibrinogen/fibrin degradation fragment E and related substances in sera and effusions of patients with malignant disease

A radioimmunoassay (RIA) was developed and used to determine the level of fragment E [a fibrinogen/fibrin degradation product (FDP)] and of fragment-E-containing substances (FES) in sera and effusion fluids of patients with malignant diseases. Sera of patients with other diseases and sera of healthy individuals served as controls. Results were expressed as units/ml (U/ml), one unit being equivalent to 40 ng pure fragment E. Effusion fluids of both malignant and nonmalignant origin contained relatively high levels of fragment-E-containing substances, up to 7,500 U/ml. Normal sera had less than 30 U/ml, while sera of patients with a variety of neoplastic or nonneoplastic conditions contained larger amounts, reaching to hundreds and, in rare cases (some patients with rheumatoid arthritis), even thousands of U/ml. Some of the highest levels in the malignant sera were found in samples from patients with Burkitt's lymphoma and stomach cancer. About 10%-20% of the reactive material in effusions and 20%-40% in the sera consisted of fragment E. These results confirm earlier findings of high FDP levels in neoplasia. Given the higher accuracy of the radioimmunoassay and its suitability for large scale testing, it would appear worthwhile to continue such studies to explore the clinical usefulness of the RIA for fragment E.