A phase III study of high-dose intensification without hematopoietic progenitor cells support for patients with high-risk primary breast carcinoma

Patients with more than nine ipsilateral lymph node involvement or inflammatory breast cancer have a 5-year survival rate of approximately 50%. We studied the efficacy of high-dose intensification, comparing it with the standard dose chemotherapy for patients with high-risk primary breast cancer. Patients with inflammatory breast cancer or more than nine ipsilateral lymph node involvement without evidence of distant metastasis were randomized to receive either standard dose 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) every 3 weeks for nine courses (control) or six courses of FAC followed by two courses of cyclophosphamide (5.25 g/m2), etoposide (1,500 mg/m2), and cisplatin (165 mg/m2) (HDCVP). The study was terminated in 1998 because of slow accrual of patients. Forty-six patients were entered in the study. At 4 years, the overall survival was 72.8% (SE 11.9%) and 61.7% (SE 12.4%), and disease-free survival were 45.5% (SE 12.3%) and 33.7% (SE 11.9%) for the control and HDCVP groups, respectively (p = 0.757 and 0.720). With the small number of patients in our study, a small overall survival benefit of high-dose intensification compared with the standard therapy cannot be excluded. However, any substantial benefit is unlikely.

The detection and localization of monocyte chemoattractant protein-1 (MCP-1) in human ovarian cancer

Chemokines may control the macrophage infiltrate found in many solid tumors. In human ovarian cancer, in situ hybridization detected mRNA for the macrophage chemokine monocyte chemoattractant protein-1 (MCP-1) in 16/17 serous carcinomas, 4/4 mucinous carcinomas, 2/2 endometrioid carcinomas, and 1/3 borderline tumors. In serous tumors, mRNA expression mainly localized to the epithelial areas, as did immunoreactive MCP-1 protein. In the other tumors, both stromal and epithelial expression were seen. All tumors contained variable numbers of cells positive for the macrophage marker CD68. MCP-1 mRNA was also detected in the stroma of 5/5 normal ovaries. RT-PCR demonstrated mRNA for MCP-1 in 7/7 serous carcinomas and 6/6 ovarian cancer cell lines. MCP-1 protein was detected by ELISA in ascites from patients with ovarian cancer (mean 4.28 ng/ml) and was produced primarily by the cancer cells. Human MCP-1 protein was also detected in culture supernatants from cell lines and in ascites from human ovarian tumor xenografts which induce a peritoneal monocytosis in nude mice. We conclude that the macrophage chemoattractant MCP-1 is produced by epithelial ovarian cancer and that the tumor cells themselves are probably a major source. MCP-1 may contribute to the accumulation of tumor-associated macrophages, which may subsequently influence tumor behavior.

The immune system and gynaecological cancer

There have been major advances in our understanding of the cellular and humoral immune mechanisms involved in antitumour activities. The characterization of soluble mediators of the immune response and their synthesis as recombinant proteins has led to an explosion of research activity concerning their role as antitumour agents and also as contributors to the pathogenesis of cancer. It is evident that cytokine production is not restricted to cells of the immune system, and that cytokines are involved in a variety of cell regulatory processes ranging from embryonic development to tissue differentiation. Their production by immune cells may enable interactions between the immune system and other homeostatic systems of the body. The therapeutic role of some cytokines such as the interferons and IL-2 in the routine management of gynaecological cancers needs to be investigated further because of their promise as antitumour agents. The study of cytokine production and cytokine receptor expression by cancers is potentially of great therapeutic value. Identification of cytokines that contribute to tumour progression may paradoxically lead to the treatment of cancers by agents that antagonize their biological effects and to rationalization of future trials of cytokine therapy.

Effects of intraperitoneal recombinant interleukin-1 beta in intraperitoneal human ovarian cancer xenograft models: comparison with the effects of tumour necrosis factor

The effect of intraperitoneal (i.p.) injection of recombinant human interleukin-1 beta (rhIL-1 beta) was studied in three i.p. nude mouse xenograft models of human ovarian cancer (HU, OS, and LA). Intraperitoneal rhIL-1 beta administration led to a dose dependent replacement of peritoneal ascitic tumour with solid tumours attached to the peritoneum and intraabdominal viscera in two (HU and LA) out of the three xenograft models. In the third xenograft model (OS), low doses of rhIL-1 beta (10 ng day) promoted micrometastatic peritoneal implants of tumour, but higher doses of rhIL-1 beta (1 microgram day) had a marked antitumour effect. This was due to direct cytotoxicity for tumour cells and was not related to peritoneal neutrophil influx induced by rhIL-1 beta. Recombinant human TNF (rhTNF) also promoted tumour implantation in all three xenograft models, but its antitumour effects differed from rhIL-1 beta. TNF increased the survival of HU and LA bearing mice, but had no antitumour effect in the OS xenograft model. Analysis of peritoneal fluid and tumour xenografts showed that TNF induced murine IL-1 in the tumour bearing mice. The magnitude of IL-1 induction indicated that TNF induced IL-1 did not contribute significantly to its effects.

Tumour necrosis factor: roles in cancer pathophysiology

Tumour necrosis factor (TNF) is a pleiotropic cytokine with activities that extend beyond its antitumour effect. There is now increasing evidence that TNF can be either constitutively produced or induced in human tumours. Tumour cells may also lead to TNF induction in normal cells. Experimental studies implicate TNF in processes that contribute to cancer progression. These range from stimulation of cancer growth and metastasis, to metabolic and haematological disturbances, e.g. cancer cachexia, anaemia, and hypercalcaemia. Future cancer therapies may therefore involve neutralisation of TNF activity in cancer patients.

Antitumor activity of gamma-interferon in ascitic and solid tumor models of human ovarian cancer

We have investigated the action of recombinant human gamma-interferon (rHuIFN-gamma) against human ovarian cancer xenografts growing as ascites or as bulky solid i.p. tumors in nude mice. Both forms of the disease responded to i.p. rHuIFN-gamma with significant increases in mouse survival time, and in 2 of 3 ascitic models the mice were cured of peritoneal disease. The activity of rHuIFN-gamma was dose and schedule dependent, and xenografts derived from 3 different patients showed a heterogeneity of response. Peak i.p. levels of rHuIFN-gamma in nude mice bearing multiple i.p. solid tumors were similar to those found in ovarian cancer patients receiving i.p. rHuIFN-gamma, but clearance was more rapid in the mice. Rat gamma-interferon had no antitumor activity at the same doses and schedules although it had some biological activity in the nude mice. Histological examination of treated tumors revealed increased necrosis and loss of cellular organization with large areas of hypocellular epithelial mucin. These changes were preceded by a fall in tumor tryptophan and a rise in tumor kynurenine. We conclude that rHuIFN-gamma has a direct dose related antitumor effect on ovarian cancer xenografts that is preceded by increased metabolism of tryptophan.

Therapy of human ovarian cancer xenografts with intraperitoneal liposome encapsulated muramyl-tripeptide phosphoethanolamine (MTP-PE) and recombinant GM-CSF

Three intraperitoneal human ovarian cancer xenografts (OS, HU, and LA) were used to assess the antitumour activity of intraperitoneal therapy with liposome encapsulated MTP-PE. MTP-PE led to significant prolongation of survival in all three xenograft models, but with varying efficacy. In one tumour model (OS), 80% of mice were cured of tumour by twice weekly therapy for 4 weeks, whereas in another xenograft model (LA), the median survival time was approximately doubled compared to PBS injected and placebo liposome injected controls (median survivals: 30 vs 62.5 days respectively). The antitumor efficacy of MTP-PE did not correlate with the extent of peritoneal neutrophil infiltration after intraperitoneal therapy. Combined therapy with liposome encapsulated MTP-PE and recombinant murine granulocyte-macrophage colony stimulating factor led to increased survival of mice bearing the LA and HU xenografts, compared to tumour bearing mice treated with either agent singly.

Phase II trial of UFT in advanced colorectal and gastric cancer

A phase II trial of continuous oral therapy with UFT, a combination of uracil and the 5-fluorouracil analogue 1-(2-tetrahydrofuryl)-5-fluorouracil (Futraful, Ftorafur), was conducted in 40 patients with advanced colorectal cancer and 18 patients with advanced gastric cancer. Six partial responses were seen in the 36 evaluable patients with colorectal cancer (response rate 16.6%; 95% confidence limits 6.4-32.8%), and one partial response was seen in the 16 evaluable patients with gastric cancer (response rate 6%; 95% confidence limits 0.27-30.2%). The overall toxicity of the treatment was low, and all patients were treated as outpatients. The results suggest that oral UFT has comparable activity to standard regimes of 5-fluorouracil, and because of the convenience of oral administration is a useful therapy in the management of patients with advanced colorectal cancer.

Role of tumor necrosis factor in flavone acetic acid-induced tumor vasculature shutdown

Flavone acetic acid (FAA), a novel investigational antitumor agent, has been shown to cause early vascular shutdown in several experimental murine tumors, and this phenomenon is believed to be crucial to FAA's antitumor effects. However, the basis of this FAA-induced tumor vascular shutdown is unknown. In this study a radioactive tracer-clearance technique has been used as an objective indication of tumor blood flow to show that i.p. administered FAA induces a progressive and sustained reduction in blood flow in a colon 26 tumor growing s.c. in syngeneic mice. As early as 1 h after administration, there was a significant increase in the t1/2 clearance value for intratumorally injected 133Xe, reaching a peak at 3 h (117.3 +/- 36.4 versus 7.8 +/- 0.85 min for controls). Significant inhibition of blood flow was still apparent 48 h after a single injection of drug. This FAA-induced vascular shutdown was virtually abolished in tumor-bearing mice pretreated with an antiserum against tumor necrosis factor, while no such effect was observed in controls pretreated with nonimmune serum (t1/2 of 10.8 +/- 1.2 versus 65.6 +/- 8.0 min for controls). Furthermore, in vitro FAA was seen to induce tumor necrosis factor secretion from murine peritoneal cells and splenocytes. These studies suggest that FAA-induced tumor vascular shutdown in the colon 26 tumor is mediated by tumor necrosis factor.

Acute myeloid leukemia in elderly adults

One hundred and fifteen previously untreated adults aged over 60 years were referred to St Bartholomew's Hospital between 1978 and 1986 for management of acute myeloid leukemia (AML). Twenty-seven patients received symptomatic or palliative treatment only because combination chemotherapy was considered inappropriate. Eighty-eight patients received intensive chemotherapy with curative intent. There was a 48 per cent 'early death' rate and a 24 per cent incidence of resistant disease; complete remission (CR) was achieved in 25/88 patients (28 per cent). By multivariate analysis, a blast count less than 50 x 10(9)/l at presentation was the only factor predictive for achievement of CR whilst the latter and a presentation blast count less than 50 x 10(9)/l predicted for superior survival. Treatment was often curtailed on account of unacceptable toxicity; only 2/88 patients received the planned six cycles of treatment. Two patients died in CR. Four patients are alive in first CR at 3-9 years from treatment; one is alive in second CR following meningeal relapse. Overall survival was significantly worse than that of a contemporaneous group of adults aged 15-59 years treated at this hospital, but duration of CR was comparable. There are great difficulties involved in the intensive treatment of AML in elderly adults, but the major survival benefit gained by achieving CR should stimulate the search for better tolerated but still curative regimens.

Cells secreting tumour necrosis factor show enhanced metastasis in nude mice

A tumour cell may acquire the ability to invade and metastasise via heritable changes in its genome and/or changes in the local environment. Chinese hamster ovary (CHO) cells transfected with the gene for human TNF (CHO/TNF cells) showed a greatly enhanced ability to invade peritoneal surfaces and metastasise in nude mice compared with cells transfected by the vector alone. In situ hybridisation with a riboprobe for human TNF showed that the CHO/TNF cells were actively transcribing this cytokine after in vivo injection. Neutralising antibodies to human TNF, both whole IgG and F(ab)2 fragments, abrogated the enhanced metastatic activity of the TNF-secreting cells. Thus transfection of a cytokine/growth-factor gene can confer a metastatic phenotype on the recipient cell.

In situ detection of tumour necrosis factor in human ovarian cancer specimens

In situ hybridisation was used to study the local expression of tumour necrosis factor (TNF) mRNA in human ovarian tumours. In 8 of 14 ovarian cancers studied, a minority of cells in the epithelial areas of the tumour contained TNF mRNA. In individual high-power fields as many as 8% of cells were positive for TNF mRNA. Immunohistochemical studies on sequential sections and the morphology of the positive cells led to the conclusion that the ovarian tumour cells were transcribing the TNF gene. There was immunohistochemical evidence of the production of TNF protein by the tumour cells and TNF protein in a tumour lysate. The production of TNF by human ovarian cancer cells may influence the biology of the tumour, contribute to neoplastic progression and alter the response to therapy.

Paradoxical effects of tumour necrosis factor in experimental ovarian cancer

Recombinant human tumour necrosis factor (rhTNF) had anti-tumour activity against 2 of 3 human ovarian cancer xenografts growing intraperitoneally (i.p.) in nude mice, producing a moderate (2- to 3-fold) increase in mouse survival time. rhTNF therapy caused a marked influx of polymorphonuclear neutrophils into the peritoneal cavity during the first few days of daily therapy. This was accompanied by a decrease in the number of peritoneal macrophages and lymphocytes. rhTNF also caused an increase in peripheral blood neutrophils. With continuation of daily therapy, the peritoneal neutrophil influx diminished, with restoration of the macrophage and lymphocyte populations. After 2 to 3 weeks there was a small but significant increase in peritoneal Thy 1.2+ cells. In the peripheral blood, the neutrophilia was less marked than at the start of therapy. Mild myelosuppression was indicated by significant falls in haemoglobin and platelet counts. Within 24 hr of the start of therapy in the 2 responsive xenografts (HU and LA) tumour clumps in the peritoneum were surrounded by host inflammatory cells, and tumours fixed to the omentum were infiltrated by neutrophils and mononuclear cells. In both instances necrosis was evident by 4 to 7 days. The third xenograft (OS) grew although the rhTNF therapy induced the same inflammatory changes in the peritoneum. In contrast to its positive effect on the survival of tumour-bearing mice, rhTNF promoted the adhesion of tumour cells to the peritoneum and their establishment as tumour nodules below the mesothelial surface. This phenomenon was seen in all 3 xenografts including the OS xenograft which did not respond in any other way to rhTNF therapy.

Oral idarubicin in the treatment of acute myelogenous leukaemia and the blast phase of chronic myeloid leukaemia

Fourteen patients with poor-risk acute myelogenous leukaemia (AML) and five patients with accelerated phase/blast crisis chronic myeloid leukaemia (CML) were treated with 3 days of oral idarubicin (25 mg/m2/day). No complete remissions or return to chronic phase CML were observed. A fall in the peripheral blast count was seen in all patients with the first cycle of treatment, and with subsequent cycles in CML patients, but all responses were transient, with eventual reemergence of peripheral blasts. In some patients, there was a clear cut improvement in symptoms such as bone and splenic pain. Five of the AML patients and all of the CML patients were treated as out-patients. In this group of patients oral idarubicin was found to be a useful drug for palliative treatment.

Hairy cell leukemia--mediastinal involvement. A report of two cases and review of the literature

The clinical features of two patients with hairy cell leukemia involving the mediastinum are described. Both patients presented with acute chest pain 2-3 months prior to diagnosis being made. In one patient mediastinal disease was recorded only by computerized tomography of the thorax. There was good response of mediastinal disease to alpha-interferon in both patients, in spite of persisting bone marrow involvement with hairy cell leukemia.

Short-term therapy for acute myelogenous leukemia

Since 1978, 187 patients (age range, 15 to 59, median 44 years) have received short-term chemotherapy as part of three sequential open studies (B-IX, X, Xb) or a randomized clinical trial (B-XI). An intended six cycles of Adriamycin (ADR) (doxorubicin; Adria Laboratories, Columbus, OH), cytarabine (ara-C), and thioguanine (TG) were administered with as short an intercycle time as possible. No further therapy was administered. Complete remission (CR) was achieved in 118 of 187 patients (63%). On univariate and multivariate analyses achievement of CR correlated adversely with a low serum albumin at presentation and an antecedent marrow disorder. Forty-five patients continue in first remission between 15 months and 8 1/2 years, no relapses being seen after 3 1/2 years (median follow-up, 3 1/2 years). The median duration of remission was 1 year. M3 morphology, a blast count less than 100 x 10(9)/L, and absence of hepatosplenomegaly correlated favorably with remission duration. There was no difference in duration of remission between patients receiving 3, 4, 5, or 6 cycles. The best results overall were achieved in patients under the age of 40, with 43% projected to remain free of disease at 5 years. Fifty patients remain alive between 17 months and 9 years, the predicted actuarial survival being 25% at 5 years.

The enhancing and sensitizing effects of donor blood components, including dendritic cells, in a rat renal allograft model

In the DA-to-Lewis renal allograft model, donor whole blood enhanced renal allograft survival (14.5 +/- 7.6 days versus 6.9 +/- 0.6 days in controls [P less than 0.01]). The effect of individual cell components given in numbers equivalent to those present in the enhancing volumes of donor whole blood was studied. Immunization with donor red cells alone produced greater enhancement than that produced by whole blood (36.14 +/- 19.5 days [P less than 0.01]). B lymphocytes also enhanced allograft survival (16.0 +/- 3.9 days [P less than 0.01]). Although slight enhancement was observed with platelets (8.5 +/- 0.6 days) and 10(5) dendritic cells (8.4 +/- 0.5 days), in terms of allograft function dendritic cell immunization produced evidence of dose-dependent accelerated rejection. A similar finding was obtained with donor T cell immunization. Donor plasma had no effect. We conclude that, although donor blood has an overall enhancing effect on renal allograft survival in this model, the sensitizing and enhancing effects can be ascribed to individual types of cells.