[Study of cancer-associated asthenia: foundation of the ASTHENOS group]

Asthenia in cancer patients is a highly controversial subject. A distinct definition of asthenia in medical literature is lacking as well as its prevalence and incidence. Also, no simple tools for its diagnosis are available. Moreover its etiopathogenesis is complex and multifactorial, thereby making therapeutic approaches difficult. Recently, a Spanish group has been set up for the study and treatment of asthenia in cancer patients. This paper reports on its establishment, objectives and first conclusions.

Phase I trial of weekly irinotecan combined with UFT as second-line treatment for advanced colorectal cancer

The aim of this study was to determine the maximum-tolerated dose (MTD) and dose-limiting toxicity (DLT) of weekly Irinotecan (CPT-11) plus UFT, and to assess the antitumour activity of this combination as second-line chemotherapy in patients with advanced colorectal carcinoma, 31 patients with measurable advanced colorectal carcinoma were treated. Cohorts of 3 patients received increasing dose levels of the combination. Levels 1 to 4 included a fixed dose of oral (p.o.) UFT (250 mg/m(2)/day) for 21 days of a 28-day cycle combined with increasing intravenous (i.v.) doses of CPT-11 (80, 100, 110 and 120 mg/m(2)) on days 1, 8 and 15. Levels 5 and 6 included a higher fixed dose of oral UFT (300 mg/m(2)) combined with increasing i.v. doses of CPT-11 (100 and 110 mg/m(2)) on days 1, 8 and 15. 147 courses were administered. MTD were reached at level 4 (2 cases of grade 4 diarrhoea and 1 grade 3 asthenia), and level 6 (1 grade 4 diarrhoea, 1 grade 3 diarrhoea and 1 grade 3 febrile neutropenia). Responses in 30 evaluable patients were: 3 partial responses (10%), 15 stable disease (50%) and progressive disease in 12 patients (40%). Median time to progression was 4.5 months (95% Confidence Interval (CI): 3.4-6.6 months) and median survival was 11 months (95% CI: 7.9-14.1 months). The recommended doses for phase II trials are: (a) CPT-11 110 mg/m(2) i.v. on days 1, 8 and 15 every 28 days plus UFT 250 mg/m(2) p.o. on days 1 through to 21 or (b) CPT-11 100 mg/m(2) and UFT 300 mg/m(2).

Combination chemotherapy with docetaxel plus vinorelbine in metastatic breast cancer patients with prior exposure to anthracyclines

PURPOSE

To evaluate the anti-tumor activity and tolerance of docetaxel plus vinorelbine in metastatic breast cancer (MBC) patients previously treated with anthracyclines.

PATIENTS AND METHODS

Fifty patients with MBC were treated with docetaxel 75 mg/m2 (subsequently reduced to 60 mg/m2) plus vinorelbine 30 mg/m2 (subsequently reduced to 24 mg/m2). both on day 1, every 3 weeks, for a maximum of six cycles. All patients had previously received anthracyclines as adjuvant treatment (< 12 months disease-free interval) or first-line therapy for MBC. Thirty-seven patients had received at least one prior regimen for MBC. Twenty-five patients had prior high-dose chemotherapy with stem-cell rescue. Thirty patients had multiple metastatic sites. Liver and lung disease were the predominant metastatic site in 31 patients.

RESULTS

Forty-nine patients were assessable for response. Nineteen patients achieved a partial response and four a complete response (overall response rate, 46%; 95% confidence interval (95% CI): 32%-60%). Fourteen patients (28%) had stable disease on treatment. Median Kaplan-Meier estimated progression-free and duration of response times are 21 and 29 weeks. Median survival time is 47 weeks. Hematological dose-limiting toxicity, prompted a 20% dose reduction for both drugs after the first thirteen patients were treated. Neutropenia > or = grade 3 occurred in nineteen (34%) patients, neutropenic fever in 15 (7) courses, and mucositis > or = grade 3 in 6 (3%) courses.

CONCLUSIONS

The combination of docetaxel plus vinorelbine on day 1 every 3 weeks is feasible and active in MBC patients with prior anthracycline exposure. This regimen is safe, well-tolerated and convenient for the patients.

Cost-analysis of high-dose chemotherapy and peripheral blood stem-cell support in patients with solid tumors

BACKGROUND

The use of High-dose chemotherapy (HDC) with peripheral blood stem cells (PBSC) rescue in the treatment of solid tumors is controversial, and may be an important determinant of HDC and PBSC use in the future. Until the use of these procedures is proven through disease-free survival and overall survival compared with standard-dose chemotherapy, the associated cost is also under discussion.

PATIENTS AND METHODS

We evaluate 27 consecutive patients with solid tumors who underwent HDC and PBSC rescue, through an accurate review of medical records and cost estimate for each patient.

RESULTS

Median age was 45 years. Fifteen had breast cancer, six non-Hodgkin's lymphoma and six other solid tumors. The mean hospital length of stay was 21 days and mean cost was 21,445 US dollars (21,232 euro). Mean cost was clearly lower for the 9 patients treated within phase III trials, 17,571 US dollars (17,747 euro) than for the remaining 18 patients, treated in phase I-II trials, 22,747 US dollars (22,975 euro) (P < 0.001). The distribution of costs shows that wages and pharmacy account for 72% of total cost. The distribution of pharmacy costs per patient shows that chemotherapy (56% of pharmacy costs) and antibiotics (26%) account for most of the cost of medication.

CONCLUSIONS

Our cost estimates agree with those of most countries with national health insurance programs, and are lower than those from the USA. As wages and pharmacy account for more than 70% of the costs, the great different among the costs estimates compared are due essentialy to doctors fees or salary and drugs utilization. Anyway, taking HDC with PBSC rescue as a model for a therapy that is more aggressive than standard, and that is associated to a possible survival improvement in indications such as relapsed high-grade non-Hodgkin's lymphoma, an adequate cost analysis is crucial both to measure cost-effectiveness and to establish payment to health care providers.

Increasing dose intensity of cisplatin-etoposide in advanced nonsmall cell lung carcinoma: a phase III randomized trial of the Spanish Lung Cancer Group

BACKGROUND

The authors designed this randomized, controlled trial to assess whether dose intensification of a cisplatin-etoposide combination (PE), achieved by shortening the interval between chemotherapy cycles, would improve response rate and survival. The maximum tolerated dose of PE was administered in either 3- or 4-week cycles to patients with advanced nonsmall cell lung carcinoma (NSCLC).

METHODS

One hundred twenty-three patients were randomized into two groups. The dose-intense arm received cisplatin 35 mg/m2 and etoposide 200 mg/m2 on Days 1-3 every 4 weeks. The dose-dense arm received the same schedule every 3 weeks along with 5 microg/kg of recombinant human granulocyte macrophage-colony stimulating factor (rhGM-CSF) administered subcutaneously on Days 4-13.

RESULTS

Patient characteristics were well balanced in both treatment arms. Fifty-four percent of patients were classified as Stage IIIB. A 32% increase in relative dose intensity was achieved in the dose-dense arm compared with the dose-intense arm. The response rates were 32% in the dose-intense arm and 27% in the dose-dense arm (P = 0.9). The median overall survival was higher in the dose-dense arm, 9 versus 7.2 months (P = 0.2). The main toxicity was myelosuppression, although the administration of GM-CSF significantly reduced the percentage of patients with Grade 4 granulocytopenia (53% vs. 78%). Fifty-four percent of the patients in the dose-intense arm and 35% of those in the dose-dense arm developed febrile neutropenia (P = 0.07). There were ten (8%) treatment-related deaths, three (4%) in the dose-intense arm and seven (12%) in the dose-dense arm (P = 0.3); three deaths in each arm were due to febrile neutropenia.

CONCLUSIONS

The dose-intensification achieved in the dose-dense PE regimen did not correlate with significant improvements in response rate or survival and cannot be recommended in the light of the diversity of new drug combinations available today. However, the use of rhGM-CSF significantly reduced the incidence of severe granulocytopenia.

Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients

The purpose of the study is to present our experience and compare the results of the three types of ports used as a central venous access and performed in the radiology suite. Between March 1989 and November 1993 we performed 288 implantations (100 Implantofix Seldinger, 100 plastic Hickman port, and 88 stainless steel Port-a-cath) for chemotherapeutic treatment on the same number of patients diagnosed as having cancer. In all cases access was obtained via a subclavian vein (the left one in 185 cases and the right one in 103). All the system ports were implanted in the radiology suite. In all cases the procedure was successfully performed. Complications occurred in 26.3% of cases, most notably thrombosis in 13 cases (4.5%) and infection in 12 cases (4.1%). Duration of the port systems placement varied between 17 and 1467 days (a mean of 315 days). A total of 133 systems have been removed to date, 80 (60.%) due to termination of chemotherapy, and 53(40%) for treatment of complications. Significant differences (complications and port duration time) were not observed between the three types of reservoir used. Subcutaneous ports are safe, comfortable, and effective devices for central venous access.

Thioether excretion, urinary mutagenicity, and metabolic phenotype in smokers

In 81 healthy individuals (51 smokers and 30 nonsmokers) biological indicators of internal exposure to electrophiles derived from tobacco smoke through metabolism were evaluated. Subgroups of smokers have been established in relation to the amount and type of tobacco smoked. Acetylator and hydroxylator phenotypes have been used as biomarkers of genetically determined susceptibility to cancer development. Urinary concentrations of thioethers (UT) and mutagenicity, with S9 mix for microsomal activation (MI-S9), were higher in smokers in relation to the level of tobacco consumption, but not to the type of tobacco. The "Slow acetylators-rapid oxidizers" category was not significant from the "rapid acetylators-rapid oxidizers" for values of UT and MI-S9. Data suggest that the biomarkers of exposure used in this study lack the necessary specificity to ascertain genetically determined susceptibility to cancer induced by tobacco smoking.

Diet and the risk of breast cancer in Spain

A case-control study of the role of diet in the cause of breast cancer was conducted between 1988 and 1991 in Navarra, North Spain; 100 women with breast cancer and 100 hospital controls admitted during the same period were interviewed, using a food frequency-consumption questionnaire. Cases reported significantly lower consumption of fruits, vegetables and fish; relative risk (RR) for persons in the lowest tertile of consumers was: fruits, RR = 3.83, confidence limit (CL) = 9.12-1.66, P = 0.01; vegetables, RR = 1.92, CL = 4.57-0.80, P = 0.09; fish, RR = 0.32, CL = 6.31-0.83, P = 0.05. The risk increased for persons in the highest tertile of processed meat intake, RR = 3.20, P = 0.05. Nutrient intakes for individuals were estimated by multiplying the nutrient content of a selected typical portion size for each specified food item by the frequency that the food was used per month, and adding these estimates for all food items. Cases reported significantly less frequent consumption of vitamin C (ascorbic acid) and monounsaturated fatty acid; after controlling for total calorie intake, the RR was estimated for consumption of vitamin C (RR = 0.40, CL = 0.2-0.9), and monounsaturated fatty acid (RR = 0.30, CL = 0.1-1.08).

[Wilm's tumor in adults. Review of the literature on prognostic factors and treatment]

The incidence of adult Wilms' tumor is difficult to determine but the lesion is rare. The prognosis is poorer than in children, but in adults is often diagnosed at a higher clinical stage and with an unfavorable histologic type. There may be other reasons for the poor prognosis as well. A 33-year-old woman with metastatic disease (bilateral kidney tumors, pulmonary and multiples lymph nodes metastases) is described. Treatment with chemotherapy consisted of doxorubicin, ifosfamide and etoposide which resulted in complete remission that persisted for only three months. The factors that probably contributed to rapid progression included un favorable histology (predominant nodular blastematous elements which were anaplastic) and advanced disease. The precise histologic diagnosis was late precluding to plan the correct treatment.

[Combined concomitant chemotherapy and radiotherapy with or without surgery in the treatment of non-metastatic squamous carcinoma of the esophagus]

Between June 1986 and October 1992 two prospective non-randomized and consecutive therapeutic schemes with a curative intent of non-metastatic squamous cell carcinoma of the esophagus were developed. The first scheme consisted of concomitant administration of chemotherapy (cisplatin and 5-fluorouracil, 2 cycles) and radiotherapy (30 Gys) after surgery (esophagectomy) (14 evaluable patients). Without surgery, a higher dose of chemotherapy (4 cycles) and radiotherapy (55 Gys) was given on the second scheme (12 evaluable patients). Complete histological response was 42.6% for the first scheme and 50% for the second one. Toxicity was moderate in both schemes. Palliation was important in the second scheme. Actuarial survival was 28% at 1 year for the first scheme and 71% for the second one. Operative mortality was 27%. Concomitant chemoradiotherapy might be a therapeutic choice for locoregional control of squamous esophageal carcinoma.

5-Fluorouracil, folinic acid, epidoxorubicin and cisplatin (FLEP) combination chemotherapy in advanced measurable gastric cancer. A phase II trial of the Spanish Cooperative Group for Gastrointestinal Tumor Therapy (TTD)

BACKGROUND

Metastatic disease is a common problem in gastric cancer and the development of better chemotherapeutic regimens is a clear priority in gastrointestinal oncology.

PATIENTS AND METHODS

Ninety consecutive, previously untreated patients with unresectable or measurable metastatic gastric cancer were included in a multicenter phase II trial with a combination of folinic acid (200 mg/m2) and 5-fluorouracil (400 mg/m2) days 1-3, with epidoxorubicin (60 mg/m2) and cisplatin (100 mg/m2) on day 2.

RESULTS

A total of 376 courses of FLEP were given, with a median of four courses per patient. Objective responses were observed in 32 (35%) patients (CI at 95%: 25.7%-46.3%). Eight (9%) patients experienced clinical complete remissions. Median time to progression was 25 weeks for the entire group of patients and 38 weeks for responders. Myelosuppression was the primary toxicity. WHO grade 3 leukopenia appeared in 26 patients (29%). Ten presented episodes of febrile neutropenia requiring hospitalization, but no toxic deaths were observed. Grades 3 and 4 thrombocytopenia were seen in 8 and 1 patients, respectively. Median survival time was 8 months for all treated patients and 11 months for responders.

CONCLUSIONS

The FLEP regimen is an active combination in advanced gastric cancer with moderate toxicity that warrants further testing in a phase III trial.

Sister chromatid exchanges, proliferating rate index, and micronuclei in biomonitoring of internal exposure to vinyl chloride monomer in plastic industry workers

The frequency of micronuclei (MN), sister chromatid exchange (SCEs), and the proliferating rate index in peripheral blood lymphocytes from 93 individuals were measured. Fifty-two of the individuals were workers in the plastics industry where they were exposed to vinyl chloride monomer while the remaining 41 individuals served as a control group. In our results, an increase of SCEs and MN, as well as inhibited cell kinetics, was observed in the group of exposed workers. Of the tests used, SCE was found to be the most sensitive endpoint for indicating a biological response. However, since methods for restricting the MN analysis to only cells at risk (i.e., second generation interphase cells) were not used, this statement requires verification.

[Myocardial infarction after mediastinal radiotherapy of Hodgkin's disease]

A 30 years old man having Hodgkin's disease was treated successfully by means of chemotherapy and radiotherapy. Two years after treatment he developed a myocardial infarction that was ascribed to the atherosclerosis-inducing effects of radiations.