A phase II trial of docetaxel in advanced non-small cell lung cancer

Twenty-nine patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) were treated with docetaxel. Ten patients had already received chemotherapy, the others had received no chemotherapy. Docetaxel was administrated i.v. over 60 min every 21 days at a dose of 100 mg/m2. Twenty-three patients were evaluable for response. There were no complete responses and eight partial responses. The overall response rate was 35% (28% in the intent to treat analysis). Median duration of response was 43 weeks and median time to progression 12 weeks. Neutropenic infections, neurotoxicity and asthenia were dose-limiting toxicities (6% of 118 cycles). The other main toxicities were asthenia in 48%, skin reactions in 31% and nail changes in 31% of the patients. Single-agent docetaxel appears to be active against both previously treated and untreated advanced NSCLC. Toxicity was acceptable but should be carefully monitored.

Effect of antiestrogen regimen on prostacyclin and thromboxane A2 in postmenopausal patients with breast cancer: evidence of significance of hypertension, smoking or previous use of estrogen therapy

To explore the mechanism(s) by which antiestrogens may protect against the development of cardiovascular disorders, we measured the production of vasodilatory, antiaggregatory prostacyclin (PGI2) and that of vasoconstrictive, proaggregatory thromboxane A2 (TxA2) before and after 6 months' use of antiestrogens in postmenopausal patients after operation for stage II breast cancer (n = 38). Urine samples were assayed by high performance liquid chromatography and radio-immunoassays for 2,3-dinor-6-ketoprostaglandin F1 alpha (= metabolite of PGI2, dinor-6-keto) and for 2,3-dinor-thromboxane B2 (= metabolite of TxA2, dinor-TxB2). In addition, in 35 of these 38 patients we assayed the capacity of platelets to produce thromboxane A2 during standardized blood clotting. The 4 patients using low-dose aspirin had low thromboxane production, and were excluded from further analysis of the data. An antiestrogen regimen consisting either of tamoxifen (n = 15) or of toremifene (n = 19) caused no changes in production of PGI2 or TxA2, or in their ratio, and in this regard, these antiestrogens behaved similarly. Hypertensive patients (n = 7) using different anti-hypertensive agents were characterized by reduced urinary out-put of dinor-6-keto (18.5 +/- 6.1 vs 35.5 +/- 18.5 ng/mmol, mean +/- SD, p < 0.05) and reduced platelet capacity to produce TxA2 (62.6 +/- 67.8 vs 134.6 +/- 75.6 ng/mL, p < 0.05). The patients (n = 15) who had used estrogen replacement therapy (ERT) up until diagnosis of breast cancer showed reduced dinor-TxB2 excretion (15.5 +/- 12.7 vs 29.9 +/- 20.9 ng/mmol, p < 0.05) before initiation of antiestrogens, and elevated dinor-6-keto output during the antiestrogen regimen (32.4 +/- 21.2 vs 22.7 +/- 8.7 ng/mmol, p = 0.07). Smokers (n = 6) had elevated dinor-TxB2 output before and during antiestrogen use. Thus we conclude that the cardiovascular protection provided by an antiestrogen regimen is unlikely to be mediated through vaso- and platelet active PGI2 and TxA2.

A combination of vinblastine and doxorubicin with interferon alpha

Advanced renal cell carcinoma still has poor overall treatment results, whatever chemotherapy is used. We treated 11 patients with advanced renal cell carcinoma with vinblastine (4 mg/m2) and doxorubicin (12 mg/m2) weekly, combined with recombinant IFN-alpha 2a given 3 x 10(6) IU s.c. three times per week during the first week, and 9 x 10(6) IU three times per week during the second week, and then on an ongoing basis 18 x 10(6) IU three times per week from the third week. The treatment of all patients had to be interrupted after 6 to 9 weeks because of leukopenia. Median survival was 6 months, and two partial responses were observed. We conclude that this regimen proved to be excessively toxic and failed to show significant advances compared with two-drug combination.

The effect of anti-oestrogens on cytokine production in vitro

Oestrogens can regulate immune functions, and due to this females have more effective immune responses than males. Oestrogens and anti-oestrogens enhance T-cell-dependent antibody production of B cells in vitro. The cytokine mediators which are behind oestrogen and anti-oestrogen induced effects are not yet known. The authors studied whether anti-oestrogens (tamoxifen and toremifene) can regulate PMA-induced cytokine production of B-, T- or myeloid cell lines. Anti-oestrogens, tamoxifen and toremifene, stimulated overall cytokine production on a B-cell line (Ball), whereas on a T-cell line (Molt-4) tamoxifen stimulated IL-1 beta, IL-6 and IFN-gamma production and toremifene inhibited it. Anti-oestrogens did not have any significant effect on cytokine production of myeloid cells.

Chemosensitivity of human melanoma metastases in mouse subrenal capsule assay--can it predict tumour response to combined cytostatic plus interferon therapy in metastatic melanoma?

We have analysed the chemosensitivity of 121 human melanoma metastases in the 6-day mouse subrenal capsule assay (SRCA). A total of 13 different chemotherapy regimens were analysed in four successive series. By the original criteria of the assay, 75% of tumours were sensitive to at least one regimen. The most effective combinations, giving sensitivity rates > 40%, were of dacarbazine, vincristine, and BCNU (DOB) with or without metronidazole, followed by cisplatin plus etoposide (Plat-VP16) combined with interferon. On the basis of the SRCA screening we developed a four-drug chemotherapy regimen combined with interferon for metastatic melanoma. Retrospectively analysed the assay correctly identified 77% of clinical responders and 54% of clinical non-responders. The overall predictive accuracy was 65%. Despite the limitations of the assay, it can be used for screening new drugs or combinations.

Cytokine therapy of malignant melanoma

Melanoma is a malignant neoplasia of melanocyte origin appearing mainly in the skin. About one third of all melanomas detected disseminate, with the metastatic spread occurring either via lymphatic or blood vessels. In the treatment of advanced melanoma the conventional chemotherapy or radiotherapy has not been very successful. Melanoma is known to have immunologically provocative features. In recent years immunological therapies, mainly cytokines, have been applied in the treatment of melanoma. The most widely used cytokines are Interferons and interleukin-2. These agents are used either alone or in combination with each other or with chemotherapeutics. Interferon and interleukin-2 therapies have yielded response rates of 15-20% on average, whereas combinations of immunotherapy and chemotherapy offer response rates as high as 50-60%. Unfortunately, average survival of patients with disseminated melanoma has been short, from 6 to 12 months. The immunotherapy approach has yielded some long-term responses and probably even a cure for a small proportion of patients. Understanding of basic mechanisms of tumour destruction by cytokines and new agents coming into clinical use will undoubtedly further improve treatment results.

Prophylactic filgrastim (G-CSF) during mitomycin-C, mitoxantrone, and methotrexate (MMM) treatment for metastatic breast cancer. A randomized study

Patients with metastatic breast cancer were randomly assigned to receive as second-line chemotherapy either MMM (mitomycin 8 mg/m2 day 1; mitoxantrone 8 mg/m2 days 1 and 22; methotrexate 35 mg/m2 days 1 and 22) alone or in combination with filgrastim (5 micrograms/kg s.c. days 4-17, 24-37). The courses were repeated every 42 days for a maximum of six courses. Thirty-one patients are evaluable for safety and efficacy. The 16 patients in the filgrastim arm received a total of 42 cycles compared with 34 cycles in the 15 control patients. Tumor responses were few in both patient groups (one partial response in the filgrastim group and two partial responses in control group). Nevertheless, a difference in survival was seen (filgrastim median 10.7 months, control median 6.5 months; p = 0.02 log rank). The treatment was well tolerated. Doses were reduced six times in the filgrastim arm and eleven times in the control arm. Grade IV neutropenia was seen in four patients in the filgrastim arm and in twelve patients in the control arm. The observed survival benefit needs to be confirmed in a larger patient group.

The CD4+/CD8+ ratio as a prognostic factor in patients with metastatic melanoma receiving chemoimmunotherapy

PURPOSE

As reported earlier, a chemotherapy regimen that consisted of dacarbazine, vincristine, lomustine, and bleomycin (DOBC) combined with natural leukocyte interferon (IFN) has been administered with favorable results to patients with metastatic melanoma. In this study, lymphocyte subsets (CD4+ and CD8+) were analyzed before and during treatment to elucidate if alterations in the CD4+/CD8+ ratio had any prognostic value.

MATERIALS AND METHODS

Blood samples were systematically obtained from 54 patients with metastatic melanoma who received this chemoimmunotherapy. The frequencies of peripheral-blood lymphocyte subsets were monitored by flow cytometry using the monoclonal antibodies OKT4 (CD4+, T-helper cells) and OKT8 (CD8+, T-suppressor cells).

RESULTS

Twenty-seven patients had a constantly increasing ratio, while the remaining 27 patients had a fluctuating or constantly decreasing ratio. The former group had a median survival time of 11.8 months, as compared with 6.5 months for the latter (P = .008, log-rank test). This difference was generated among patients who had an objective response. Responding patients with a constantly increasing ratio had a median survival time of 21.7 months, as compared with 10.2 months for patients with no constant increase in the ratio (P = .038, log-rank test). In nonresponders, no difference in survival was observed between the two groups.

CONCLUSION

The monitoring of early changes in the CD4+/CD8+ ratio can provide valuable information that predicts the prognosis of metastatic melanoma patients receiving chemoimmunotherapy.

Radiation therapy of intracranial malignant melanoma

Sixty-four consecutive patients with intracranial malignant melanoma were irradiated between January 1980--March 1994. The long-term results of the irradiation were analyzed. Four patients with intended radiation therapy interrupted were excluded from the survival analysis. The remaining sixty were divided into groups using the total dose of 40 Gy and normalized total dose at 3 Gy (NTD3Gy) with 30 Gy as cutpoints. These subgroups did not differ markedly as to sex, age, KPS, single vs. multiple metastases, extracranial disease, surgical intervention on brain, prior chemo and/or immunotherapy. Those with higher total doses to the tumour area had significantly better (P = 0.0006) survival. The median survival of the whole group was 4.1 months and those with NTD3Gy > 30 Gy survived the median time of 9.6 months, whereas those with NTD3Gy < or = 30 Gy had a median survival of 2.1 months. The survival difference existed also after the exclusion of those with previous craniotomy (median survival 11.9 months) and was 1.9 vs. 8.3 months when NTD3Gy > 30 Gy was the cutpoint between the groups. In a multivariate analysis, the NTD3Gy turned out to be the most significant prognostic factor (P < 0.0001). The results reveal that the total dose of radiotherapy in the treatment of cerebral metastases of malignant melanoma might have a greater impact on patients' prognosis than previously considered.

Radiosensitivity of mesothelioma cell lines

The present study was carried out in order to examine the radiosensitivity of malignant pleural mesothelioma cell lines. Cell kinetics, radiation-induced delay of the cell cycle and DNA ploidy of the cell lines were also determined. For comparison an HeLa and a human foetal fibroblast cell line were simultaneously explored. Six previously cytogenetically and histologically characterized mesothelioma tumor cell lines were applied. A rapid tiazolyl blue microtiter (MTT) assay was used to analyze radiosensitivity and cell kinetics and DNA ploidy of the cultured cells were determined by flow cytometry. The survival fraction after a dose of 2 Gy (SF2), parameters alpha and beta of the linear quadratic model (LQ-model) and mean inactivation dose (D(MID)) were also estimated. The DNA index of four cell lines equaled 1.0 and two cell lines equaled 1.5 and 1.6. Different mesothelioma cell lines showed a great variation in radiosensitivity. Mean survival fraction after a radiation dose of 2 Gy (SF2) was 0.60 and ranged from 0.36 to 0.81 and mean alpha value was 0.26 (range 0.48 - 0.083). The SF2 of the most sensitive diploid mesothelioma cell line was 0.36: less than that of the foetal fibroblast cell line (0.49). The survival fractions (0.81 and 0.74) of the two most resistant cell lines, which also were aneuploid, were equal to that of the HeLa cell line (0.78). The alpha/beta ratios of the most sensitive cell lines were almost an order of magnitude greater than those of the two most resistant cell lines. Radiation-induced delay of the most resistant aneuploid cell line was similar to that of HeLa cells but in the most sensitive (diploid cells) there was practically no entry into the G1 phase following the 2 Gy radiation dose during 36 h.

Tamoxifen and toremifene lower serum cholesterol by inhibition of delta 8-cholesterol conversion to lathosterol in women with breast cancer

PURPOSE

Long-term effects of tamoxifen and toremifene, a new antiestrogen that closely resembles tamoxifen, were investigated on serum lipids and cholesterol metabolism.

PATIENTS AND METHODS

The study group consisted of 24 postmenopausal Finnish women with advanced breast cancer from an international multicenter study of 415 patients. Cholesterol metabolism was evaluated by measuring the cholesterol precursor (delta 8-cholestenol, desmosterol, and lathosterol, reflecting cholesterol synthesis) and plant sterol (markers of cholesterol absorption) and cholestanol levels by gas-liquid chromatography.

RESULTS

Tamoxifen and toremifene lowered significantly serum low-density lipoprotein (LDL) cholesterol levels after 12 months of treatment by 16% and 15%, with no change in high-density lipoprotein (HDL) cholesterol or serum triglyceride levels. Serum delta 8-cholestenol was increased 40- and 55-fold during toremifene and tamoxifen treatment, respectively, while the increase of desmosterol less than doubled and was lacking for lathosterol by toremifene. Plant sterols and cholestanol were only inconsistently increased in serum.

CONCLUSION

Tamoxifen and toremifene inhibit the conversion of delta 8-cholestenol to lathosterol so that serum total and LDL cholesterol levels are lowered by downregulation of cholesterol synthesis. Thus, inhibition of the delta 8-isomerase may be the major hypolipidemic effect of these agents. Reduced risk of coronary artery disease will probably occur also during long-term toremifene treatment, because the drug reduces cholesterol and its synthesis, similarly to tamoxifen.

Response of subcutaneous and cutaneous metastases of malignant melanoma to combined cytostatic plus interferon therapy

A chemotherapy regimen consisting of dacarbazine (DTIC), vincristine, bleomycin and lomustine (CCNU) was combined with natural leucocyte interferon (IFN) in the treatment of 37 patients with cutaneous and subcutaneous metastases of malignant melanoma. Twenty-five also had concomitant lymph node, visceral, bone or brain metastases. Fifteen patients (41%) experienced complete response (CR) and 10 (27%) partial response (PR) of the superficial lesions. In addition, three patients were rendered surgically tumour-free after PR or disease stabilization during drug therapy. The median overall duration of response was 10.2 months (range 1-53 months). In disseminated disease, the combined therapy produced favourable results, particularly with regard to superficial lesions. It is also possible that this therapy may retard the growth of aggressive subcutaneous metastases in patients who have previously had multiple surgical procedures in an attempt to stabilize their disease. In a small proportion of patients, the long-term complete remission with the drug therapy alone, or in combination with surgery, suggests that this regimen might have been curative.

Randomised comparison of fluorouracil, epidoxorubicin and methotrexate (FEMTX) plus supportive care with supportive care alone in patients with non-resectable gastric cancer

A phase III randomised study, comparing treatment with fluorouracil, epidoxorubicin and methotrexate (FEMTX) with the best supportive care, was conducted in patients with unresectable or metastatic gastric cancer. During the period from July 1986 to June 1992, 41 patients were randomised to receive FEMTX or best supportive care. MTX was given in a dose of 1500 mg m-2 intravenously (i.v.) followed after 1 h by 5-FU 1500 mg m-2 i.v. on day 1; leucovorin rescue was started after 24 h (30 mg orally every 6 h for 48 h) and epidoxorubicin 60 mg m-2 i.v. was administered on day 15. In addition both groups received tablets containing vitamins A and E. Response rates for FEMTX were as follows: complete response (CR), 19% (4/21); partial response (PR), 10% (2/21); no change (NC), 33% (7/21); and progressive disease (PD), 24% (5/21). Response rates in the control group were: NC, 20% (4/20); and PD, 80% (16/20). Increased pain was observed in one patient in the treated group and in 11 patients in the control group within the first 2 months. WHO grade III/IV toxicity in the chemotherapy group was as follows: nausea/vomiting 40%, diarrhoea 10%, stomatitis 15%, leucopenia 50% and thrombocytopenia 10%. One possible treatment-related death was due to sepsis. The median time to progression in the FEMTX group was 5.4 months [95% confidence interval (CI) 3.1-11.7 months], but only 1.7 months in the control group (95% CI 1.2-2.7 months) (P = 0.0013). Similarly, the FEMTX group displayed significantly (P = 0.0006) prolonged survival compared with the control group, i.e. median survival 12.3 months (95% CI 7.1-15.6 months) vs 3.1 months (95% CI 1.6-4.6 months). In conclusion, FEMTX combined with vitamin A and E is a fairly well-tolerated treatment, giving a response rate of 29% in patients with advanced gastric cancer, and also prolonging patients' survival. It can be used as a reference treatment in testing new investigational combinations.

Risk of second cancers among lung cancer patients

The risk of a second cancer among lung cancer patients was investigated using Finnish Cancer Registry data from 1953 to 1989. Among the 36,528 patients with a primary cancer of the lung, 504 new cancers were diagnosed six months or more after the diagnosis of lung cancer, yielding a standardized incidence ratio significantly lower than expected (SIR = 0.81). A significant excess of cancers of the larynx (SIR = 2.10) and urinary bladder (SIR = 1.35) was observed Among lung cancer patients below 60 years of age, the risks of oesophageal cancer (SIR = 2.47) and kidney cancer (SIR = 2.48) were also significantly elevated. The risk of a second cancer among lung cancer patients increased with the length of follow-up, and there was some indication of an excess risk of oesophageal cancer and leukaemia among lung cancer patients subject to radiotherapy.

Enhanced expression of the tie receptor tyrosine kinase mesenger RNA in the vascular endothelium of metastatic melanomas

Angiogenesis of human melanomas has been the focus of intense interest since it was shown that the spread and prognosis of primary tumors is correlated with their vascularization (N. Weidner, J. P. Semple, W. R. Welch, and J. Folkman, N. Engl. J. Med., 324: 1-8, 1991). Basic fibroblast growth factor (bFGF) and its high-affinity receptor FGFR-1 have been implicated in melanoma growth and angiogenesis (R. Halaban, Y. Funasaka, J. Lee, J. Rubin, D. Ron, and D. Birnbaum, Fibroblast Growth Factors in Normal and Malignant Melanocytes, pp. 232-243. New York: The New York Academy of Sciences, 1991). We have studied the expression of the Tie endothelial cell receptor tyrosine kinase mRNA in skin and primary cutaneous melanomas as well as in their skin and brain metastases by in situ hybridization. The Tie probe hybridized very weakly with the vascular endothelium of capillaries of normal skin, while it was detected in larger arteries and veins as well as in capillaries around sweat glands. However, capillaries and medium-sized vessels within cutaneous and brain metastases of melanoma were strongly positive for Tie mRNA. In contrast, endothelial cells contained very little or no FGFR-1 transcripts, whereas abundant FGFR-1 mRNA was present in melanoma tumor cells and in fibrovascular stroma. In agreement with these findings, a Tie-specific amplified cDNA band was obtained by reverse transcription-polymerase chain reaction from melanoma metastases but not from normal skin. These results suggest a role for the Tie receptor in the angiogenesis associated with melanoma metastases.

Salvage therapies in women who fail to respond to first-line treatment with fluorouracil, epirubicin, and cyclophosphamide for advanced breast cancer

PURPOSE

We studied all salvage therapies given until death or the end of follow-up evaluation in women who failed to respond to the same first-line cytotoxic therapy for metastatic breast cancer.

PATIENTS AND METHODS

The study cohort consisted of 140 women who had received the fluorouracil, epirubicin, and cyclophosphamide (FEC) regimen for metastatic breast cancer. Eight patients were excluded. No exclusions with respect to disease site, performance status, or biochemical abnormalities were made. The median follow-up time was 29 months for surviving patients.

RESULTS

Most patients (88%) died during the follow-up period. Patients received a median of three salvage therapies (range, zero to eight) during the course of disease. Most courses (52%) were not assessable for response. Fifty-percent of courses consisted of chemotherapy: 35% of hormonal and 15% of combination of cytotoxic and hormonal therapies. The median duration of therapy (DT) ranged from 4 to 1 months, and decreased with advancing stages of therapy. Similarly, median time to treatment failure (TTF) ranged from 3 to 0.5 months. For unknown causes, patients who received second-line hormonal therapy fared better than those who received other forms of therapy. Of 366 analyzed courses, only one complete response (CR) and 18 partial responses (PRs) were observed (response rate, 11% for assessable and 5% for all courses). Stable disease for at least 3 months was found in 20% to 25% of courses. Most responses (n = 10) occurred during first salvage therapy, and no responses were observed after third salvage therapy.

CONCLUSIONS

Response rates for salvage therapies were low, and median treatment times short. The value of offering more than two salvage chemotherapy regimens to an unselected group of patients is questionable.

Epirubicin-sequential methotrexate-5-fluorouracil-leucovorin treatment in advanced cancer of the extrahepatic biliary system. A phase II study

A combination chemotherapy was used to treat patients with advanced cancer of the extrahepatic biliary system not amenable to surgical resection. Between February 1985 and April 1992, 22 consecutive patients entered into the study; 17 (11 with extrahepatic bile duct cancer and 6 with gallbladder cancer) were evaluable for response and toxicity. The treatment schedule was as follows: epirubicin 20 mg/m2 given as a bolus, followed by methotrexate 150 mg/m2 as a 30-minute infusion, 1 hour later 5-fluorouracil 600 mg/m2 as a 30-minute infusion. Leucovorin rescue (15 mg orally every 6 hours for eight doses) was started 24 hours after methotrexate. This course was administered once a week in 3 successive weeks followed by a 2 to 3 weeks rest period. A total of 174 courses was given. No objective tumor regression was observed. This regimen was well tolerated, the main toxicity being gastrointestinal. The median survival time for the 17 evaluable patients was 9 months.

Evidence for involvement of BRCA1 in sporadic breast carcinomas

The hereditary breast cancer gene BRCA1 previously has been localized to chromosome 17q21. We looked for evidence of involvement of this region of chromosome 17 in 130 sporadic breast cancers. Seventeen polymorphic sequence tagged site markers were examined in these tumors between the D17S250 and D17S579 loci to screen for deletions as measured by loss of heterozygosity. The smallest common region that was deleted occurred in the approximately 120-kilobase interval between the D17S846 and D17S746 loci within the BRCA1 region. Delineation of this commonly deleted area should accelerate attempts to identify the involved gene(s) and its relationship to BRCA1.

Mouse subrenal capsule assay chemosensitivity and DNA flow cytometry parameters of human melanoma metastases

Chemosensitivity was analyzed by mouse subrenal capsule assay (SRCA) in 103 human melanoma metastases 79 of which were also analyzed by DNA flow cytometry. The most effective combination was dacarbazine, vincristine, and carmustine (DOB), followed by cisplatin plus etoposide (Plat-VP16). By the original criteria of the assay, 35% of tumors were sensitive to DOB treatment while 15% responded to Plat-VP16. Chemosensitivity of DNA diploid and aneuploid tumors showed no significant difference; 35% of the aneuploid tumors were sensitive to DOB and 19% to Plat-VP16, whereas 41% and 13% respectively of the diploid tumors were sensitive. An association between DNA index and chemosensitivity was observed. Growth of the implant was observed in 44% of tumors with a DNA index above 1.5 receiving DOB treatment, whereas only 12% of tumors with an aneuploid DNA index < or = 1.5 grew. No significant difference was observed in the SPF of chemotherapy sensitive and insensitive tumors, though a tendency to lower SPF was observed in sensitive tumors.

High dose toremifene in advanced breast cancer resistant to or relapsed during tamoxifen treatment

Fifty patients with advanced breast cancer refractory to prior tamoxifen therapy were assigned to investigational treatment with high-dose toremifene administered 120 mg orally twice a day. Treatment was generally well tolerated. The majority (80%) of the patients had no side effects, and among the remaining 10 patients reported side effects were mostly mild and/or transient. Two objective tumor responses were observed: one complete response (CR), duration 6.2 months, and one partial response (PR), duration 8 months. The response rate was thus 4% (95% CI: 0.5 to 14%). In addition 3 patients experienced a mixed response, some metastatic sites responding, while at other sites disease progressed; 22 patients had disease stabilization for > 2 months. A subset analysis disclosed that a small subgroup of patients, including 7 patients in this study, who had achieved CR at some of the sites during preceding tamoxifen therapy, experienced a long progression-free time during high dose toremifene treatment. The median time to progression in this subgroup of patients was 9.4 months (95% CI: 3.8 to 9.4) as opposed to 2.1 months (95% CI: 2.0 to 2.8) for all the remaining 43 patients, which is a significant decrease in disease progression (p < 0.03). Such results reveal that although this kind of second-line hormonal treatment with high dose toremifene cannot be recommended for all tamoxifen failures, there might be a subset of patients, i.e. those who achieve CR in some lesion during tamoxifen therapy, who benefit from this type of treatment.