Phase II study of capecitabine and mitomycin C as first-line treatment in patients with advanced colorectal cancer

This study was designed to assess the safety and efficacy of capecitabine and mitomycin C (MMC) in previously untreated patients with advanced colorectal cancer (CRC). Patients received capecitabine 2500 mg m² day 1, orally divided in two doses of 1250 mg m⁻² in the morning and evening for 14 days every 21 days and MMC 7 mg m⁻² (maximum total dose 14 mg) as an intravenous bolus every 6 weeks for a total of four courses. The median age was 70 years (range 24–85) and the majority of patients (86.9%) were of performance status 1/2. The most common metastatic site was liver. In all, 84 patients were assessable for response. The overall response rate was 38% (95% CI: 27.7–49.3) and a further 33.3% of patients achieved stable disease over 12 weeks. There was good symptom resolution ranging from 64 to 86%. Grade 3/4 toxicity was as follows: hand–foot syndrome 19.7%; diarrhoea 10%; neutropenia 2.4%; infection 2.3%. Capecitabine and MMC have shown encouraging activity with a favourable toxicity profile, a convenient administration schedule, and could be considered for patients deemed unsuitable for oxaliplatin and irinotecan combinations.

Capecitabine in combination with mitomycin C in patients with gastrointestinal cancer: results of an extended multicentre phase-I trial

The aim of this study was to determine the dose-limiting toxicity (DLT) and establish the recommended dose for mitomycin C added every 3 weeks to the standard combination dose of capecitabine. Cohorts of at least three patients with pretreated gastrointestinal carcinoma received capecitabine 1000 mg m(-2) orally twice daily on days 1-14 plus i.v. bolus mitomycin C on day 1 at doses of 4, 6, 8 or 10 mg m(-2) (corresponding to dose levels I-IV). Cycles were repeated every 3 weeks. Two treatment cycles were considered for the evaluation of DLTs. Of the 53 patients enrolled, the majority had colorectal (n=27) or gastric (n=14) cancers. Patients had received a median of two lines of prior chemotherapy (34% with >/=3 lines and 87% with prior 5-FU-based therapy). At the recommended dose level (IV, n=30), grade 3 adverse events during cycles 1 and 2 were: anaemia (10%); leukopenia (3%); thrombocytopenia (3%); stomatitis/mucositis (3%); hand-foot syndrome (3%). Two patients experienced DLTs (mucositis, n=1; neutropenic fever, n=1), but there were no grade 4 events. The median dose intensity for capecitabine and mitomycin C was 100% during cycles 1 and 2 and only four patients required postponement of therapy. Of the 43 patients evaluable for efficacy, seven achieved partial and minor remissions (16%; 95% CI, 5-28%), and 12 patients (28%) had stable disease. The favourable safety profile and promising activity of the capecitabine/mitomycin C combination, even in heavily pretreated patients, warrant further evaluation in patients with advanced colorectal and gastric cancers.

Therapeutic effects of Lycium barbarum polysaccharide (LBP) on mitomycin C (MMC)-induced myelosuppressive mice

AIM

To investigate the therapeutic effects of Lycium barbarum polysaccharide (LBP) on mitomycin C (MMC)-induced myelosuppressive mice.

METHODS

Mice were intravenously injected with MMC 150 mg/kg for two consecutive days from day -1 to day 0 to produce severe myelosuppression, and then treated by s.c. injections of LBP (100 or 200 mg/kg/day) from days 0 to 6. Blood samples were collected from the tail veins of mice on days 7, 10, 12, 14, 17, 19, 21, 24 and 27, and peripheral white blood cells (WBC), red blood cells (RBC), hemoglobin (HGB) and platelet counts (PLT) etc. were monitored.

RESULTS

LBP at 100 mg/kg (LBP-L) on day 14 and LBP at 200 mg/kg (LBP-H) on days 10, 14, 17, 19 and 21, significantly ameliorated the decrease of peripheral RBC, HGB and hematocrit (HCT) of myelosuppressive mice compared to the control. LBP-L on days 12 and days 14 and LBP-H on days 10, 12, 14, 17, 19 and 21, significantly enhanced peripheral PLT recovery of myelosuppressive mice compared to the control. LBP-H on days 12, 17, 19 and 21, significantly inhibited the increase of mean platelet volume (MPV) of myelosuppressive mice compared to the control. LBP showed no obviously effect on neutropenia induced in mice by MMC.

CONCLUSION

LBP is effective on peripheral RBC and PLT recovery of MMC-induced myelosuppressive mice.

Permanent Corneal Edema Resulting From the Treatment of PTK Corneal Haze With Mitomycin

A 39-year-old man underwent phototherapeutic keratectomy via excimer laser for recurrent corneal erosions secondary to basement membrane dystrophy with the subsequent development of irregular astigmatism and central stromal opacity. The cornea was scraped and treated with 0.02% mitomycin C using a total of 14 drops over a period of 6 days. Corneal edema developed as a consequence of low endothelial cell count with dysfunctional cells. A corneal transplant restored acuity of 20/20 with binocular vision. It is believed that the underlying endothelium was exposed to toxic doses of mitomycin C sufficient to damage and destroy vital cells. The author reports this case not to criticize the use of mitomycin C in visually disabling post-phototherapeutic keratectomy or photorefractive keratectomy haze but to apprize colleagues of a potential pitfall. The author believes that the use of mitomycin C as a 1-time application at the end of surgery is a safe and valuable adjunct to recover vision when no other is known. However, continued topical application of mitomycin C to the central cornea, in the face of an epithelial defect or an epithelium with inadequate barrier function, increases the risk of endothelial damage.

Phase II study of irinotecan combined with mitomycin-C for advanced or recurrent squamous cell carcinoma of the uterine cervix: the JGOG study

OBJECTIVES

The efficacy and toxicity of combined therapy with irinotecan (CPT-11) plus mitomycin-C (MMC) were evaluated in patients with advanced or recurrent squamous cell carcinoma (SCC) of the uterine cervix.

METHODS

CPT-11 (100 mg/m(2)) was administered on days 1, 8, and 15 by intravenous (iv) infusion over 90 min, while MMC (10 mg/m(2) iv) was given on day 1. This regimen was repeated every 28 days and at least two courses were given.

RESULTS

Among 51 eligible patients (median age: 52 years; range: 25-72 years), 2 showed complete response (CR) and 24 showed PR, for an overall response rate (ORR) of 51.0% (95% confidence interval: 36.6-65.3%). In patients without prior chemotherapy, the ORR was 54.8% (38.7-70.2%). Twenty-five patients (Ib2:3, IIb:17, and IIIb:5) received this regimen as neoadjuvant chemotherapy and their ORR was 76% (54.9-90.6%). Twenty-two patients were able to undergo radical surgery after NAC. The major toxicity was neutropenia, which was grade 3-4 in 59% of the patients. Grade 3-4 thrombocytopenia and anemia were also seen in 26% of the patients each. The most common nonhematologic toxicity was diarrhea (grade 3-4 in 12%).

CONCLUSION

CPT-11 combined with MMC can be effective against advanced or recurrent SCC of the uterine cervix.

Randomized Phase III Trial of Pegylated Liposomal Doxorubicin Versus Vinorelbine or Mitomycin C Plus Vinblastine in Women With Taxane-Refractory Advanced Breast Cancer

Purpose

To compare the efficacy of pegylated liposomal doxorubicin (PLD) with that of a common salvage regimen (comparator) in patients with taxane-refractory advanced breast cancer.

Patients and Methods

Following failure of a first- or second-line taxane-containing regimen for metastatic disease, 301 women were randomly assigned to receive PLD (50 mg/m2 every 28 days); or comparator-vinorelbine (30 mg/m2 weekly) or mitomycin C (10 mg/m2 day 1 and every 28 days) plus vinblastine (5 mg/m2 day 1, day 14, day 28, and day 42) every 6 to 8 weeks. Patients were stratified before random assignment based on number of previous chemotherapy regimens for metastatic disease and presence of bone metastases only.

Results

Progression-free survival (PFS) and overall survival (OS) were similar for PLD and comparator (PFS: hazard ratio [HR], 1.26; 95% CI, 0.98 to 1.62; P = .11; median, 2.9 months [PLD] and 2.5 months [comparator]; OS: HR, 1.05; 95% CI, 0.82 to 1.33; P = .71; median, 11.0 months [PLD] and 9.0 months [comparator]). In anthracycline-naïve patients, PFS was somewhat longer with PLD, relative to the comparator (n = 44; median PFS, 5.8 v 2.1 months; HR, 2.40; 95% CI, 1.16 to 4.95; P = .01). Most frequently reported adverse events were nausea (23% to 31%), vomiting (17% to 20%), and fatigue (9% to 20%) and were similar among treatment groups. PLD-treated patients experienced more palmar-plantar erythrodysesthesia (37%; 18% grade 3, 1 patient grade 4) and stomatitis (22%; 5% grades 3/4). Neuropathy (11%), constipation (16%), and neutropenia (14%) were more common with vinorelbine. Alopecia was low in both the PLD and vinorelbine groups (3% and 5%).

Conclusion

PLD has efficacy comparable to that of common salvage regimens in patients with taxane-refractory metastatic breast cancer, thereby representing a useful therapeutic option.

The role of circulating immune complexes and biocompatibility of staphylococcal protein A immunoadsorption in mitomycin C-induced hemolytic uremic syndrome

Mitomycin-induced hemolytic uremic syndrome (HUS) is a life-threatening complication of this therapy, and increased levels of circulating immune complexes and hypocomplementemia have been found in some patients. We further characterize the role of immune complexes in mitomycin-HUS by showing that removal of these complexes by immunoadsorption with staphylococcal protein A columns correlates with temporal improvement in the microangiopathic hemolytic anemia in this disorder. Two immune complexes bound to the protein A column were identified: an 11S platelet-aggregating protein and a 15S non-platelet-aggregating protein. In addition, the patient had anaphylactoid reactions at the onset of immunoadsorption similar to first-use dialysis reactions that correlated with increases in complement 3a and 5a, interleukin-1 (IL-1), IL-6, and tumor necrosis factor levels. This case suggests that platelet-aggregating and complement-fixing circulating immune complexes are, in part, a proximate cause for mitomycin C-induced HUS. Therapy for mitomycin (HUS) with protein A columns should continue until circulating immune complexes reach undetectable levels and serum complement levels return to the normal range.

A randomised trial comparing 0.02% mitomycin C and limbal conjunctival autograft after excision of primary pterygium

BACKGROUND

Mitomycin C (MMC) and limbal conjunctival autograft (LCAU) are two known useful adjuvants in the prevention of pterygial recurrence. This study was conducted to compare the outcome of these two treatments.

METHODS

Prospective study on consecutive cases of primary pterygium (February 2001 to March 2002) randomised into two adjuvant groups: (1) intraoperative 0.02% MMC for 5 minutes or (2) LCAU. Patients were followed for recurrence (defined as fibrovascular tissue invading the cornea >1.5mm) and complications for a period of one year.

RESULTS

115 eyes in 114 patients who completed the study were randomised to receive MMC (n = 63) and LCAU (n = 52). There were 10 recurrences (15.9%) in the MMC group and only one recurrence (1.9%) in the LCAU group. There was a statistically significant difference in the recurrence rate between the two groups (p = 0.04). There were a total of three conjunctival cysts, three symblephara, one granuloma, and one dellen. No other visually significant complications were encountered in either group.

CONCLUSION

Although LCAU resulted in better one year success rates, it is technically more difficult and inapplicable in cases with previous limbal disturbance. Simple excision followed by MMC or LCAU are both safe and acceptable adjuvants for pterygium excision. Choice of adjuvant should be carefully made based on assessment of recurrence risk, local practices, and surgeon's expertise.

Chemotherapy-induced lung disease

The lung has significant susceptibility to injury from a variety of chemotherapeutic agents. The clinician must be familiar with classic chemotherapeutic agents with well-described pulmonary toxicities and must also be vigilant about a host of new agents that may exert adverse effects on lung function. The diagnosis of chemotherapy-associated lung disease remains an exclusionary process, particularly with respect to considering usual and atypical infections, as well as recurrence of the underlying neoplastic process in these immune compromised patients. In many instances, chemotherapy-associated lung disease may respond to withdrawal of the offending agent and to the judicious application of corticosteroid therapy.

Gemcitabine and mitomycin C in advanced pancreatic cancer: a single-institution experience

Despite chemotherapy, median survival of patients with advanced pancreatic cancer (APC) remains poor. Gemcitabine (GEM) remains standard treatment. Numerous phase II studies have suggested that combination therapies may improve response rates. Mitomycin C (MMC) when used as a single agent may have response rates comparable to other cytotoxic drugs. Therefore, MMC could be an interesting drug to be combined with GEM. This study aimed to assess the feasibility, toxicity and efficacy of GEM combined with MMC in patients with APC. Between April 1997 and January 2002, 55 consecutive patients were treated with GEM 800 mg/m2 i.v., days 1, 8 and 15, and MMC 8 mg/m2 i.v., day 1, every 4 weeks in an outpatient setting. Patient characteristics included: M/F 34/21, median age of 58 years, ECOG PS 0-2. A median of 3 cycles was administered. The most frequent toxicity was thrombocytopenia grade III/IV in 54% of patients. Ten patients experienced dyspnea+/-X-ray-proven pneumonitis (n=2). One of these patients developed a hemolytic uremic syndrome after the sixth application of MMC. There was one early death as a consequence of a stroke. The objective response rate was 29% (95% confidence interval: 17-43). Eighteen patients had stable disease resulting in an overall tumor growth control of 62%. Time to progression was 4.7 months and median overall survival was 7.25 months. We conclude that, except for thrombocytopenia, the combination of GEM and MMC is well tolerated. These results compare favorably to single-agent chemotherapy with GEM or the combination of 5-fluorouracil plus MMC. Furthermore, this regimen is cost-effective and, since it can be given on an outpatient basis, contributes to the quality of life.

Randomized phase II study comparing mitomycin, cisplatin plus doxifluridine with cisplatin plus doxifluridine in advanced unresectable gastric cancer

Various chemotherapies have been used to treat inoperable gastric cancer. Most combination therapies include cisplatin (CDDP) and fluoropyrimidine (5-FUs), which are thought of as key drugs. In the present study, we randomly compared mitomycin (MMC) and CDDP plus doxifluridine (5'-DFUR), which is an oral 5-FU and an intermediate metabolite of capecitabine (Xeloda), with CDDP plus 5'-DFUR in advanced unresectable gastric cancer. Regimen A was CDDP (70 mg/m2, by 2-hour intravenous drip infusion on day 1), MMC (7 mg/m2, injected intravenously on day 2), and oral 5'-DFUR (1200 mg/m2, on days 4 to 7, 11 to 14, 18 to 21 and 25 to 28; 3 days rest and 4 days administration). Regimen B was identical to regimen A without MMC.

RESULTS

The response rate was 25.0% (8/32 patients) in Regimen A, 17.2% (5/29) in Regimen B (p=0.541). The median survival time was 241 days in Regimen A and 179 days in Regimen B (p=0.498). In Regimen A, although no significant difference was observed, end points such as response rate and suvival improved. Thus, we concluded that a randomized controlled phase III study with more subjects should be conducted.

Evaluation of antitumor and toxic side effects of mitomycin C–estradiol conjugates

The antitumor and toxic side effects of mitomycin C-estradiol conjugates (EB-glu-MMC and E-glu-MMC) were evaluated in detail for solutions in propylene glycol and suspensions in 10% (v/v) propylene glycol. Tumor growth, body weight and number of leukocytes were examined after i.p. administration to sarcoma 180 solid tumor-bearing mice. Body weight and number of leukocytes were also examined in normal mice after i.p. administration of the solution. In solution dosage forms, the two conjugates had almost the same suppressive effect on tumor growth at 30 mg MMC eq./kg as MMC at 5 mg/kg, did not lower body weight significantly, but reduced the number of leukocytes at 30 mg MMC eq./kg. MMC, lethally toxic at 10 mg, significantly lowered the body weight and leukocyte number. In the suspension dosage forms, these conjugates had a greater suppressive effect on tumor growth at 50 mg MMC eq./kg than MMC at 5 mg/kg, and reduced the body weight and leukocyte number, with E-glu-MMC more toxic than EB-glu-MMC. The presence of the tumor itself influenced the body weight and leukocyte number. However, toxic side effects could be evaluated from the body weight and leukocyte number to almost the same extent between tumor-bearing and normal mice.

Chemoradiation with 5-fluorouracil and mitomycin C in the treatment of vulvar squamous cell carcinoma

OBJECTIVE

To investigate the acute and late toxicities associated with the use of chemoradiation therapy (CRT) with 5-fluorouracil (5-FU) and mitomycin C or mitomycin C alone for primary, adjuvant, and salvage therapy for vulvar cancer.

METHODS

Medical charts of 17 patients who received CRT with this regimen were reviewed. Toxicity was scored by 1998 standardized common toxicity criteria, Version 2.0, for acute toxicity and the RTOG/EORT Late Radiation Morbidity Scoring Schema for late toxicity. Median follow-up was 20 months (range: 5-74 months).

RESULTS

Six patients had grade 4 neutropenia. In three patients, life-threatening neutropenic sepsis developed after the second cycle of chemotherapy. Severe enterocolitis was a direct cause of death in two patients. In four patients, the second cycle of chemotherapy was cancelled because of severe toxicity associated with the first cycle. One patient had grade 4 skin toxicity in the vulvar-perineal area. Six patients had grade 3 and seven patients had grade 2 acute skin toxicity. Skin toxicity necessitated the interruption of CRT in nine patients at a median dose of 32.4 Gy (range: 16.2-48 Gy). One patient developed bowel perforation and colovaginal fistula 1.5 years after completion of CRT.

CONCLUSION

Chemoradiation therapy utilizing 5-FU and mitomycin C or mitomycin C alone in the treatment of vulvar cancer can be associated with a high incidence of morbidity and mortality. Strict attention to indications for treatment interruptions or chemotherapy dose adjustments is obligatory for safe delivery of CRT to these patients.

Limbal stem cell deficiency following topical mitomycin C treatment of conjunctival-corneal intraepithelial neoplasia

PURPOSE

To report a case of conjunctival-corneal intraepithelial neoplasia (CCIN) in an elderly African American patient treated with topical mitomycin C and the subsequent complication of limbal stem cell deficiency.

DESIGN

Interventional case report.

METHODS

A 92-year-old African American woman was diagnosed with CCIN in the right eye. Following incisional biopsy, the patient received five 1-week courses of 0.04% mitomycin C and was followed over a period of 10 months.

RESULTS

The CCIN regressed completely following mitomycin C therapy. Three months later, the patient developed recurrent nonhealing epithelial defects in the right cornea.

CONCLUSIONS

Conjunctival-corneal intraepithelial neoplasia may occur in the African American population. Although MMC is effective in eradicating CCIN, a limbal stem cell deficiency may complicate the treatment.

[The Czech experience in peritonectomy and hyperthermic perioperative cytostatic lavage in the treatment of peritoneal malignancy]

Peritoneal tumor dissemination has been considered as an incurable condition with fatal outcome. However cytoreductive surgery followed immediately by hyperthermic chemoperfusion has been described both for the treatment and prevention of locoregional cancer spread from various origins. This paper summarizes our experience in this field.

PATIENTS AND METHODS

28 patients were operated on for peritoneal dissemination of malignant tumors between 1999 and 2002 in the Surgical Department of the University Hospital Bulovka. Total or limited peritonectomy was carried out in these patients. In addition intraperitoneal perioperative hyperthermic chemoperfusion was performed using an electrolyte solution containing Mitomycin C, Cisplatin or Carboplatin. The perfusion was performed for 90 minutes, reaching a real hyperthermia of 41 to 43 degrees C.

RESULTS

The overall morbidity was high (85.7%), the perioperative mortality (30 days) was 10.7%. Only 3 (15.7%) of 19 patients in whom complete peritonectomy could be carried out died during the follow-up period of 3 months to 3.5 years.

CONCLUSION

There is an increasing evidence of both experimental and clinical studies showing the therapeutic and prophylactic usefulness of peritonectomy and perioperative hyperthermic chemoperfusion in patients with peritoneal carcinomatosis. However, well designed randomised trials are necessary to establish the role of this promising technique.

[Clinical experiences and results of application of mitomycin C in trabeculectomy]

BACKGROUND

Mitomycin C (MMC) used as an additive agent in glaucoma surgery has been shown to improve the postoperative results of intraocular pressure (IOP), but may also lead to higher incidences of postoperative wound healing disorders and of hypotonia with choroidal detachment. In this retrospective study the levels of IOP, the incidence of complications and changes of the visual acuity (VA) were monitored.

METHODS

A trabeculectomy was performed on 70 eyes (57 patients). During surgery MMC was applied in three different concentrations: 0.1 mg/ml MMC (n = 8), 0.2 mg/ml MMC (n = 53) and 0.4 mg/ml MMC (n = 9) for 2.5 minutes, respectively. Patients were reexamined one day, and at 3 and 12 months after surgery.

RESULTS

IOP was lowered with high statistical significance at all dates of control examination no matter what concentration of MMC had been used. At the time of discharge from hospital the success rate without additional topical glaucoma medication was 96 %, 78 % after 3 months and 68 % after 12 months. With glaucoma medication the success rate was 92 % after 3 months and 85 % after 12 months. Frequent complications were choroidal detachments in 40 % and hypotonia in 21 % of all cases. The VA did not change significantly during the follow-up period.

CONCLUSIONS

This study underlines the efficacy of MMC as an additive agent in glaucoma surgery. However, considerable complications may be expected. Considering the effectiveness and the complication rate a concentration of 0.2 mg/ml MMC should be preferred.

Combined local bladder hyperthermia and intravesical chemotherapy for the treatment of high-grade superficial bladder cancer

OBJECTIVES

To evaluate the effectiveness of combined local bladder hyperthermia and intravesical chemotherapy for the treatment of patients with high-grade (G3) superficial bladder cancer.

METHODS

Patients with G3 bladder tumors (Stage Ta or T1) were treated with combined intravesical chemotherapy with mitomycin-C and local radiofrequency hyperthermia of the bladder wall. The patients were treated with either a prophylactic protocol (40 mg mitomycin-C) after complete transurethral resection of all tumors or with an ablative protocol (80 mg mitomycin-C) when visible tumor was seen on video-cystoscopy or bladder biopsies were positive for carcinoma in situ.

RESULTS

Combined chemo-thermotherapy was administered to 52 patients with high-grade superficial bladder cancer (40 patients with Stage T1 tumor, 11 with Ta, and 3 with concomitant or isolated carcinoma in situ). At a median follow-up of 15.2 months (mean 23, range 6 to 90), no stage progression to T2 or disease-related mortality had occurred. The bladder preservation rate was 86.5%. The prophylactic protocol was administered to 24 patients. After a mean follow-up of 35.3 months, 15 patients (62.5%) were recurrence free. The bladder preservation rate was 95.8%. The ablative protocol was administered to 28 patients. Complete ablation of the tumor was accomplished in 21 patients (75%). After a mean follow-up of 20 months, 80.9% of these patients were recurrence free. The bladder preservation rate for the ablative group was 78.6%.

CONCLUSIONS

Combined local bladder hyperthermia and intravesical chemotherapy has a beneficial prophylactic effect in patients with G3 superficial bladder cancer. Ablation of high-grade bladder tumors is feasible, achieving a complete response in about three quarters of the patients.

A pilot study of neoadjuvant chemotherapy with mitomycin C, etoposide, cisplatin, and epirubicin for adenocarcinoma of the cervix

BACKGROUND

To evaluate the efficacy and toxicity of the combination of mitomycin C, etoposide, cisplatin, and epirubicin (MEPA) as neoadjuvant therapy for patients with cervical adenocarcinoma.

METHODS

Fourteen patients with cervical adenocarcinoma received neoadjuvant MEPA therapy followed by radical hysterectomy. The International Federation of Gynecology and Obstetrics stage was: IB1 in 2 patients, IB2 in 5, and IIB in 7. The MEPA regimen consisted of mitomycin C (15 mg/m2) on day 1, etoposide (70 mg/m2) on days 1 to 3, cisplatin (15 mg/m2) on days 1 to 5, and epirubicin (30 mg/m2) on day 1, with this course being repeated every 4 weeks. After two or three courses of chemotherapy, all patients underwent radical hysterectomy. Postoperative radiotherapy was given to 6 patients who showed risk factors at surgery.

RESULTS

Of the 14 patients, 7 had complete remission (CR) clinically, 6 had partial remission, and only 1 showed no change. Examination of surgical material revealed no residual disease in 6 patients, and microscopic residual disease (<5 mm) in 2 patients. The patients who had no residual disease or microscopic disease in their hysterectomy specimens showed a significantly longer survival than those with macroscopic residual disease (P = 0.012). The dose-limiting toxicity was myelosuppression. Of the 33 treatment cycles administered, leukopenia of grade 3 or more occurred in 70%,and thrombocytopenia of grade 3 or more occurred in 79%. There were no therapy-related deaths.

CONCLUSION

Although severe myelosuppression was also observed, there was a satisfactory response rate to MEPA therapy, which showed a good pathological CR rate.

Management of hypotony after trabeculectomy with mitomycin C

The purpose of this study was to determine the incidence and risk factors of hypotony and the effectiveness of medical and surgical treatment. A total 117 eyes of 103 patients that underwent trabeculectomy with mitimycin C (MMC) between 1993 and 2000 were reviewed. Hypotony was treated with the following methods in a stepwise manner: medical treatment, intrableb autologous blood injection, additional sutures to the scleral flap, necrotic bleb excision and advancement of the forniceal conjunctival flap. Hypotony developed in 30 eyes (25.6%) of 26 patients, among, which hypotonic maculopathy developed in 11 eyes (9.4%). The risk factors of hypotony were young age and primary open angle glaucoma. Because of no light sense, 6 of the 30 hypotonic eyes were not treated. Nineteen (79.2%) of the 24 treated hypotonic eyes were successfully managed. Five eyes, 3 with hypotony but maintaining visual acuity and 2 with follow-up loss, were not included in the success group. The mean intraocular pressure (IOP) before treatment, 2.5 +/- 1.2 mmHg, increased to 8.3 +/- 4.0 mmHg at 18.5 months follow-up. The stepwise treatment seems to be a useful method to manage hypotony after trabeculectomy with MMC.

Hepatic artery infusion using oxaliplatin in combination with 5-fluorouracil, folinic acid and mitomycin C: oxaliplatin pharmacokinetics and feasibility

BACKGROUND

Several studies have demonstrated the efficacy of systemic oxaliplatin (Oxa) in combination with 5-fluorouracil (5-FU) and folinic acid (FA) for the treatment of colorectal liver metastases (CRLM). However, nothing is presently known about the pharmacokinetics of Oxa administered via the hepatic artery and only very little about the feasibility and toxicity of Oxa used for hepatic artery infusion (HAI).

PATIENTS AND METHODS

We designed a phase II trial using Oxa in combination with 5-FU/FA and mitomycin C (MMC) for HAI treatment of patients with isolated non-resectable CRLM. Oxa (130 mg/m2) was delivered on day (d) 1 as a 120-min infusion followed by FA (140 mg/m2) for 10 min and 5-FU (480 mg/m2) for 120 min from d1 to d5 and MMC (7 mg/m2) for 30 min on d5 every 35 days. For Oxa pharmacokinetics, peripheral venous blood was collected before, during and after arterial infusion. Oxaliplatin was determined by liquid chromatography with post-column derivatization in blood ultra filtrate.

RESULTS

A total of 33 HAI cycles were administered to 5 patients with tolerable toxicity, which mainly consisted of grade I and II nausea, vomiting, leucopenia, thrombopenia and abdominal pain. During 4 cycles nausea/vomiting III degree occurred, during 3 cycles diarrhoea and abdominal pain III degree. No neurotoxicity > or = II degree and no catheter occlusion was observed. Staging showed 4 PR and 1 PD. Pharmacokinetic analysis revealed an AUC value of 85.3 micrograms x min/ml after HAI. Recalculating these values with the previously reported AUC value for systemic administration (161 micrograms x min/ml) revealed a liver extraction ratio of 0.47 for Oxa.

CONCLUSION

We conclude from our results that Oxa in combination with 5-FU/FA and MMC may be a feasible protocol for HAI treatment without major toxicity, especially avoiding higher grade neurotoxicity. This is probably attributable to the low systemic bioavailability of Oxa.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with cirrhosis: evaluation of two kinds of dosages of anticancer drugs and analysis of prognostic factors

BACKGROUND/AIMS

To evaluate the efficacy of TACE (transcatheter arterial chemoembolization) with use of low-dose versus conventional-dose anticancer drugs in hepatocellular carcinoma patients with cirrhosis and to analyze their prognostic factors.

METHODOLOGY

Eight-two patients with unresectable hepatocellular carcinoma underwent super-selective TACE. Patients in group A (n = 40) received low-dose anticancer drugs. Patients in group B (n = 42) were given conventional-dose of anticancer drugs. Tumor response and survival time in the two groups were compared. Cox proportion-hazards modeling was used to evaluate the relative importance of prognostic variables.

RESULTS

There was no significant difference between the two groups in initial tumor response (P < 0.05). The median survival in all patients was 18 months (mo). The median survival in groups A and B were 20 mo and 16 mo respectively. The cumulative survival rates at 6, 12, 18, 24, 30 mo were 68.4%, 57.6%, 38.4%, 26.6%, 19.9% in group A, and 62.6%, 43.8%, 31.9%, 26.5%, 26.5% in group B. There was no significant difference in survival between the two groups (P > 0.05). The factors influencing prognosis were Child-Pugh scores (P < 0.0001), tumor thrombus in the portal vein (P < 0.0001), tumor size (P < 0.0001), method of embolization (P < 0.0001), TACE times (P < 0.001). The dosage of anticancer drugs employed in TACE was not relevant to the survival rates (P = 0.883).

CONCLUSIONS

TACE with use of large-dose anticancer drugs does not significantly enhance the anticancer effects and survival compared that with lowdose anticancer drugs. The therapeutic effect of TACE was mainly attributed to embolization of the artery rather than to anticancer drugs.

Punctal-canalicular stenosis associated with mitomycin-C for corneal epithelial dysplasia

PURPOSE

To report a case of punctal-canalicular stenosis after topical mitomycin C use for corneal dysplasia. To the authors' knowledge, this association has not previously been described.

DESIGN

Observational case report.

METHOD

A 62-year-old woman was noted to have a right inferotemporal corneal dysplastic lesion. She received a topical course of mitomycin-C 0.04% four times a day, which subsequently invoked a toxoallergic reaction. One month later, the patient developed right-sided epiphora.

RESULTS

Probing demonstrated complete stenosis of the right lower canaliculus, 5 mm from the punctum.

CONCLUSION

Mitomycin-C use may lead to lacrimal apparatus fibrosis and symptomatic epiphora when inciting a toxoallergic reaction.

[Lung toxicity of trimodality chemoradiotherapy with mitomycin C, vindesine, and cisplatin followed by surgery for locally advanced non-small cell lung cancer]

To evaluate lung toxicity of mitomycin C containing chemotherapy regimen combined with thoracic radiotherapy, a retrospective study was carried out in patients with locally advanced non-small cell lung cancer who were enrolled in a randomized trial for chemoradiotherapy. Postoperative complications and pathological pulmonary toxicity were investigated in 7 surgical patients out of 306 enrolled patients who were treated with MVP combination chemotherapy and concurrent or sequential thoracic radiotherapy of 56 Gy. The 7 patients were 45-66 years old (median 50 years old), with 4 of stage IIIA, 3 of stage IIIB, 4 with adenocarcinoma, 2 with squamous cell carcinoma, and 1 with large cell carcinoma. Five patients were treated with 2 cycles and 2 with 3 cycles. Anti-tumor response was observed to be PR in 6 cases and NC in 1 case. In the chemoradiotherapy, pulmonary toxicity was observed at grade 1 in only 1 case. Postoperative complications consisted of a ruptured suture, chylothorax and empyema which were treated and healed in the 3 cases respectively. Pathological examination of the resected lung was performed in 6 cases, with revealed alveolitis in 3 cases and fibrosis in all cases in the radiation field. Three cases, however, showed slight alveolitis outside of the radiation field. In conclusion, as severe lung toxicity was not observed in the surgical cases after chemoradiotherapy including MMC, there appears to be no reason to exclude MMC from regimens for trimodality combination therapy.

[Two advanced gastric cancer patients who showed malignant ileus soon after administration of combination therapy of preoperative intra-peritoneal chemotherapy and gastrectomy]

Forty-eight patients with serosa-invaded advanced gastric cancer were administered to pre-operative intra-peritoneal chemotherapy to prevent peritoneal recurrence. There were no severe adverse effects from the intra-peritoneal chemotherapy. Of these patients, 2 showed malignant ileus shortly after intra-peritoneal chemotherapy and gastrectomy, and needed laparotomy because of dilatation of duodenum stump and liver dysfunction. The intestines and mesothelium showed diffuse thickness and hardness. We report the clinicopathological features of these cases and therapeutic limitation of intra-peritoneal chemotherapy.

Mitomycin C for the treatment of pharyngoesophageal stricture after total laryngopharyngectomy and microvascular free tissue reconstruction

OBJECTIVES

To assess the role of mitomycin C (MMC) in the management of pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction.

STUDY DESIGN

Five patients since 1998 underwent evaluation and treatment for pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction. The method of reconstruction included four tubed radial forearm free flaps and one jejunal free flap. All patients underwent barium swallow, computed tomography, and endoscopic examination and were proven to be free of recurrent disease.

METHODS

The patients were taken to the operating room. After dilation, the stenotic segment was exposed, and 1 mL of 0.4 mg/mL mitomycin-C was applied for 4 minutes using a cotton pledget. The patients were then followed clinically and with barium swallows for a minimum follow-up period of 18 months.

RESULTS

All five patients experienced improved swallowing ability. The need for further dilatations was either eliminated or lessened. All patients were happy with the treatment results. No complications occurred.

CONCLUSIONS

This small case series suggests that MMC is a safe and effective adjunctive treatment for pharyngoesophageal stricture after total laryngopharyngectomy and free flap reconstruction.

Phase III trial of gemcitabine and carboplatin versus mitomycin, ifosfamide, and cisplatin or mitomycin, vinblastine, and cisplatin in patients with advanced nonsmall cell lung carcinoma

BACKGROUND

The authors compared gemcitabine and carboplatin (GC) with mitomycin, ifosfamide, and cisplatin (MIC) or mitomycin, vinblastine, and cisplatin (MVP) in patients with advanced nonsmall cell lung carcinoma (NSCLC). The primary objective was survival. Secondary objectives were time to disease progression, response rates, evaluation of toxicity, disease-related symptoms, World Health Organization performance status (PS), and quality of life (QoL).

METHODS

Three hundred seventy-two chemotherapy-naïve patients with International Staging System Stage III/IV NSCLC who were ineligible for curative radiotherapy or surgery were randomized to receive either 4 cycles of gemcitabine (1000 mg/m(2) on Days 1, 8, and 15) plus carboplatin (area under the serum concentration-time curve, 5; given on Day 1) every 4 weeks (the GC arm) or MIC/MVP every 3 weeks (the MIC/MVP arm).

RESULTS

There was no significant difference in median survival (248 days in the MIC/MVP arm vs. 236 days in the GC arm) or time to progression (225 days in the MIC/MVP arm vs. 218 days in the GC arm) between the 2 treatment arms. The 2-year survival rate was 11.8% in the MIC/MVP arm and 6.9% in the GC arm. The 1-year survival rate was 32.5% in the MIC/MVP arm and 33.2% in the GC arm. In the MIC/MVP arm, 33% of patients responded (4 complete responses [CRs] and 57 partial responses [PRs]) whereas in the GC arm, 30% of patients responded (3 CRs and 54 PRs). Nonhematologic toxicity was comparable for patients with Grade 3-4 symptoms, except there was more alopecia among patients in the MIC/MVP arm. GC appeared to produce more hematologic toxicity and necessitated more transfusions. There was no difference in performance status, disease-related symptoms, or QoL between patients in the two treatment arms. Fewer inpatient stays for complications were required with GC.

CONCLUSIONS

The results of the current study failed to demonstrate any difference in efficacy between the newer regimen of GC and the older regimens of MIC and MVP. Cancer 2003;98:542-53.

Intumescent cataract after topical mitomycin-C for conjunctival malignant melanoma

PURPOSE

To present the clinical and histologic findings of a patient in whom intumescent cataract developed after successful topical mitomycin-C (MMC) chemotherapy for conjunctival melanoma originating from primary acquired conjunctival melanosis (PAM) with atypia.

DESIGN

Observational case report; follow-up at 30 months.

METHODS

In a patient with PAM and subsequent conjunctival melanoma that was successfully treated with topical MMC chemotherapy an intumescent cataract developed after two cycles of 0.04% MMC, each for 1 month.

RESULTS

After MMC chemotherapy pigmentation of the acquired melanosis vanished almost completely. Histopathology of the check-up specimen revealed local tumor control. Six weeks after the completion of the second cycle, an intumescent cataract developed. Cataract surgery was performed uneventfully. The patient was followed up for 30 months.

CONCLUSIONS

In selected cases, topical MMC chemotherapy is effective for treating conjunctival melanoma. Although severe complications are rare and usually transient, development of cataract may be observed. A prospective study should be initiated.

Postoperative concomitant irradiation and chemotherapy with mitomycin C and bleomycin for advanced head-and-neck carcinoma

PURPOSE

In a prospective randomized clinical study, simultaneous postoperative application of irradiation (RT), mitomycin C, and bleomycin was tested in a group of patients with operable advanced head-and-neck carcinoma. It was expected that the planned combined postoperative therapy would reduce the number of locoregional recurrences and prolong survival.

METHODS AND MATERIALS

A total of 114 eligible patients with Stage III or IV squamous cell head-and-neck carcinoma were randomized to receive postoperative RT alone (Group 1) or RT combined with simultaneous mitomycin C and bleomycin (Group 2). Patients were stratified according to the stage and site of the primary tumor and the presence or absence of high-risk prognostic factors. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included mitomycin C 15 mg/m(2) after 10 Gy and 5 mg of bleomycin twice a week during RT to the planned total dose of 70 mg.

RESULTS

At 2 years, patients in the radiochemotherapy group had better locoregional control (86%) than those in the RT alone group (69%; p = 0.037). Disease-free survival and overall survival was also better in the radiochemotherapy group compared with the RT-alone group (76% vs. 60%, p = 0.099; and 74% vs. 64%, p = 0.036, respectively). Patients who benefited from chemotherapy were those with high-risk factors.

CONCLUSION

The results of the present study indicate that concomitant postoperative radiochemotherapy with mitomycin C and bleomycin improves locoregional control and survival in patients with advanced head-and-neck carcinoma. The patients who benefited from chemotherapy were those with high-risk factors.

[Peritoneal mesothelioma: results of a complicated and aggressive procedure incorporating peritonectomy and intraperitoneal hyperthermic chemotherapy, and prospects derived from bench-to-bedside research]

Peritoneal mesothelioma (PM) is a rare primary peritoneal tumor conditioning a very poor quality of life and prognosis. Twenty eight patients (11 men and 17 women) with PM were referred to National Cancer Institute of Milan and submitted to 29 consecutive procedures of peritonectomy and intra peritoneal hyperthermic perfusion (IPHP). Five years overall survival, disease free survival and progression free survival have been 70, 63 and 51%, respectively. Morbidity and toxicity were 14 and 21% respectively. No mortality has been observed peritonectomy associated with IPHP is an effective approach to cure patients PM.

[Mitomycin-induced hemolytic-uremic syndrome]

HISTORY AND CLINICAL FINDINGS

A 58-year-old patient suffered from rapidly progressing renal insufficiency and 11 kg weight-loss three months after adjuvant treatment of a carcinoma of the lower bowel (G 2 T 3 N 1 M 0 ) with mitomycine C. At the point of hospitalisation the patient was anuric while suffering from pulmonary oedema, hemolytic anemia and thrombocytopenia.

INVESTIGATIONS

Computed tomography and bronchial endoscopy showed pulmonary haemorrhage. Recurrence of carcinoma or metastases were excluded. Renal biopsy revealed mesangiolysis and concentric intimaproliferation (onion skinning). Beside haemolytic anaemia and fragmentocytes toxic damage of the bone marrow was found.

TREATMENT AND COURSE

After one week treatment in the intensive care unit because of respiratory insufficiency recovery was observed under plasma separation and high dose corticosteroid therapy. Disease activity involved renal failure, bone marrow insufficiency, microangiopathic anaemia thrombopenia and pulmonary haemorrhage.

CONCLUSION

Lung involvement in the course of haemolytic uremic syndrome is rare and carries a high lethality. The case illustrates the need of detailed diagnostic for correct treatment of haemolytic uremic syndrome. If chemotherapy is required in patients with pre-existing or intercurrent renal failure dose adaptation is necessary to avoid dose-dependent toxicity of mitomycine C.

Long-term results of intrathoracic chemohyperthermia (ITCH) for the treatment of pleural malignancies

There is no standard treatment for patients with pleural malignancies. The aim of this prospective study was to investigate the toxicity and long-term results of a multimodality treatment consisting of surgery and intrathoracic chemohyperthermia (ITCH) for the treatment of patients with pleural malignancies. From January 1990 to August 2000, 24 patients with mesothelioma (n=17), fibrosarcoma (n=3), pleural adenocarcinoma (n=3) and thymoma (n=1) were included. The mesothelioma stages were T1 or T2 in 10 cases, and T3 or T4 in seven cases. After cytoreductive surgery, ITCH was carried out for over 60 min, at inflow temperatures less than 45 degrees C, either with mitomycin C (n=7) or cisplatin (n=5) or both (n=12). One patient died from major thoracic air leaks after major decortication and pleurectomy. Seven patients had complications, one pleural clotting necessitating reoperation. After a median follow-up of 89 months, the overall 1-year and 5-year survival rates were 74 and 27%, respectively. For T1 and T2 mesothelioma patients, the median survival was 41.3 months, and for T3 and T4 tumours, it was 4.5 months (P=0.001). The fibrosarcoma patients are alive with no evidence of recurrence at 24, 43 and 54 months. In the conclusion, the combination of surgery with ITCH with mitomycin and/or cisplatin is relatively safe. This procedure may offer unexpected long-term survival in a selected group of patients (T1 and T2 mesothelioma patients and fibrosarcoma patients).

Distal ureteral stenosis after early adjuvant intravesical mitomycin C application for superficial bladder cancer

We report a case of distal ureteral stenosis after transurethral resection of a small bladder tumor near the left ureteral orifice and early postoperative mitomycin C instillation for prevention of recurrence. The patient developed late recurrent stenosis of the ureteral orifice with histologic evidence of localized, severe benign inflammatory reaction. The recurrent stenosis was successfully managed by transurethral resection of the scar tissue and ureteric stenting. Although ureteral stenosis does occur after transurethral resection, the severity and time course of the stenosis in this case suggest an influence of the intravesical chemoprophylaxis used.

Mitomycin C eliminates the short-term intraocular pressure rise found following Molteno tube implantation

PURPOSE

Molteno implants remain popular for treating recalcitrant glaucomas. This study aimed to assess the effect of mitomycin C (MMC) use with Molteno tube implantation upon intraocular pressure (IOP) control and complication rates. In particular, the study aimed to assess any change that MMC might have upon the postoperative hypertensive phase.

METHODS

A retrospective case record study was conducted of all patients undergoing double plate Molteno implant surgery by one surgeon over 5 years. Eyes with recalcitrant glaucoma unresponsive to previous surgery, or deemed unlikely to succeed with trabeculectomy, underwent double plate Molteno tube implantation. Eyes that had MMC (0.3 mg/mL, 3 min) applied to Tenon's capsule over the secondary plate were compared with eyes that underwent surgery without adjunctive MMC application.

RESULTS

Twenty-seven eyes received MMC and were similar to 26 eyes not receiving MMC in terms of glaucoma subtype, age, sex, previous surgery, preoperative IOP and postoperative IOP lowering agents. Those not receiving MMC had raised IOP 31-90 days post implantation compared with MMC treated eyes (P < 0.01) and more often received oral antifibrosis medication (P < 0.05). Complications were no more common with MMC except for initial overdrainage. Significant systemic complications from the use of oral antifibrosis medication were common.

CONCLUSIONS

The findings suggest a useful role for MMC. Caution is advised in case selection for MMC use. Mitomycin C treatment over the secondary plate alone permits removal of this plate if MMC-related complications occur without requiring removal of the whole implant.

Phase II study of irinotecan and mitomycin C in 5-fluorouracil-pretreated patients with advanced colorectal and gastric cancer

The aim of this phase II study was to investigate the tolerance and efficacy of a second-line irinotecan/mitomycin C combination in patients with advanced gastric or colorectal cancer, pretreated with 5-fluorouracil. Forty patients who had received 5-fluorouracil-based chemotherapy for advanced disease or adjuvant 5-fluorouracil treatment were enrolled. Chemotherapy consisted of irinotecan 125 mg/m2 and mitomycin C 5 mg/m2, given every 2 weeks. Treatment was continued until progression or limiting toxicity occurred. Five partial responses (12.5%), 22 cases of stable disease (55%) and 13 of progression (32.5%) were registered, giving an overall response rate of 12.5% [95% confidence interval (CI), 4.2-26.8%] and an overall control of tumor growth in 67.5% (95% CI, 50.8-81.4%) of patients. Median progression-free survival was 5 months, median survival time 8 months, and 1-year probability of survival was 21.6%. Diarrhea and neutropenia affected 25% and 12.5% of patients respectively, with only 7.5% experiencing grade 3-4 toxicity. There were no chemotherapy-related deaths or hospitalizations. This combination regimen was shown to be moderately effective with substantially lower toxicity than irinotecan monotherapy in 5-fluorouracil-pretreated patients with advanced gastric or colorectal cancer. It may represent an attractive option in patients at high risk for developing specific irinotecan toxicity.

Mitomycin C-induced renal insufficiency: a case report

A 58-year-old normotensive male with normal renal function and gastric cancer underwent total gastrectomy and received adjuvant chemotherapy with mitomycin C (MMC) for 10 months. He developed anemia, hypertension, and renal function impairment 9 months after initiation of chemotherapy. Kidney biopsy showed thrombotic microangiopathy with marked mesangiolysis and expansion of the subendothelial space resulting in cystic dilation of the glomerular capillaries, and cellular atypia in the tubular cells. His renal function deteriorated gradually then stabilized after treatment with plasma exchange, antihypertensive agents, and antiplatelet agents. He had no sign of tumor recurrence after 3 years of follow-up. We suggest that patients receiving MMC should have their blood pressure and renal function closely monitored for the possibility of development of drug-induced renal insufficiency.

Unusual complication after immediate postoperative intravesical mitomycin C instillation

Immediate adjuvant Mitomycin C (MMC) instillation is routine practice in the treatment of superficial bladder cancer. Despite relative safety we describe a case of MMC extravasation after intravesical instillation. This resulted in severe continuous pain in the pelvic region without tendency of spontaneous healing, and required surgical debridement. To assess perivesical soft tissue injury prior to surgery MRI imaging turned out to be more accurate than computer tomography. Suggestions about how to avoid, diagnose and treat this symptomatic extravasation are made.

A randomized study of primary bleomycin, vincristine, mitomycin and cisplatin (BOMP) chemotherapy followed by radiotherapy versus radiotherapy alone in stage IIIB and IVA squamous cell carcinoma of the cervix

BACKGROUND

To determine whether neoadjuvant chemotherapy would improve disease control and clinical outcome of patients with locally advanced cervical cancer undergoing radiotherapy.

MATERIALS AND METHODS

Sixty-one patients with primary invasive squamous cell carcinoma of the cervix of stage IIIB or IVA were randomized to receive either three courses of chemotherapy followed by radiotherapy (CT + RT) or radiotherapy alone (RT). The chemotherapy regimen consisted of bleomycin, vincristine, mitomycin and cisplatin (BOMP). The radiotherapy was carried out by the use of a combination of external beam radiation and intracavitary brachytherapy.

RESULTS

The response rate of the chemotherapy (complete or partial response) in the CT + RT group was 72% (3 + 20 out of 32). The 5-year survival rates were 52% in RT group and 43% in the CT + RT group with no significant difference. Recurrence outside the irradiated field occurred in 17% (5 out of 29) in the RT group, whereas it was 25% (8 out of 32) in the CT + RT group.

CONCLUSION

Despite the high response rate of BOMP chemotherapy, the combination (CT + RT) failed to improve the survival of patients with locally advanced cervical cancer when compared with radiotherapy alone. It was also noteworthy that the incidence of distant metastasis was not reduced by the use of neoadjuvant chemotherapy.

A randomised study of protracted venous infusion of 5-fluorouracil (5-FU) with or without bolus mitomycin C (MMC) in patients with carcinoma of unknown primary

No standard regimen has been identified for patients with a carcinoma of unknown primary (CUP). This study compared protracted venous infusion 5-fluorouracil (PVI 5-FU) with or without mitomycin C (MMC) in patients with CUP in a multicentre, prospectively randomised study. 88 patients were randomised to PVI 5-FU (300 mg/m(2)/day for a maximum of 24 weeks) +/-MMC (7 mg/m(2) 6 weekly for four courses). The overall response rate was 11.6% for PVI 5-FU alone compared with 20.0% for PVI 5-FU plus MMC (P=0.29). Median failure-free survival (FFS) was 4.1 months for PVI 5-FU and 3.6 months for PVI 5-FU plus MMC (P=0.78) with an equivalent overall survival (OS) (6.6 versus 4.7 months, P=0.60). Symptomatic benefit was observed in most patients in each arm. PVI 5-FU is a well tolerated outpatient treatment regimen for patients with CUP, although the addition of MMC provides little extra benefit. PVI 5-FU may be a potential reference regimen in randomised trials with newer chemotherapy agents in patients with CUP.

Raltitrexed and mitomycin-C as third-line chemotherapy for colorectal cancer after combination regimens including 5-fluorouracil, irinotecan and oxaliplatin: a phase II study

BACKGROUND

To investigate the therapeutic value and safety of a third-line treatment with raltitrexed and mitomycin-C (MMC) in patients with advanced colorectal cancer (ACC) pretreated with combination regimens including 5-fluorouracil (5-FU), irinotecan (CPT-11) and oxaliplatin (L-OHP).

PATIENTS AND METHODS

A total of 21 patients (PS 1/2, 19/2; M/F 15/6; median age = 73) with ACC, all of whom had developed progressive disease while receiving or within 6 months of discontinuing two sequential chemotherapy lines with 5-FU, CPT-11 and L-OHP, were accrued in this study. At the time of their relapse, cytotoxic chemotherapy, consisting of intravenous raltitrexed 3 mg/m2 plus MMC 6 mg/m2 on therapeutic day 1, was initiated. Treatment courses were repeated every 4 weeks for a total of six courses unless there was prior evidence of progressive disease, unacceptable toxicity or patient refusal occurred.

RESULTS

All the patients were assessable for toxicity and 16 for response evaluation, having completed at least two courses of chemotherapy. The overall response rate was 0%. Seven patients (33.6%) had a stable disease and nine patients (43%) progressed. The median time to progression was 2.3 months (95% CI: 1.65-2.95%) and median overall survival (OS) 5 months (95% CI: 2.52-7.48%). No toxic deaths occurred. Third-line treatment tolerance was generally mild to moderate and easy to treat. WHO grade 3/4 anemia, neutro- and thrombocytopenia occurred in 9.5%, 4.7% and 4.7% of the patients, respectively. However, these toxicities did not have a significant impact on global quality of life.

CONCLUSION

Our data suggest that the association of raltitrexed and MMC in patients with ACC pretreated with combination regimens including 5-FU, CPT-11 and L-OHP is feasible and could contribute to increase patients' OS time. Further evaluation of this regimen seems to be warranted.

[Transarterial chemoperfusion of inoperable pancreas carcinoma and local recurrence]

BACKGROUND

To evaluate the side effects and tumor response of a locoregional transarterial chemoperfusion with Mitomycin C and Gemcitabine in advanced pancreatic cancer.

MATERIALS AND METHODS

Between October 2001 and August 2002, 16 patients were treated in 80 transarterial chemoperfusion sessions with a mean of 5 sessions per patient and a pause of 4 weeks between the sessions. The chemotherapy consisted of a combination of Mitomycin C (8.5 mg/m 2) and Gemcitabine (500 mg/m 2), administered within 1 hour. The tumor response was evaluated by MRT and CT and the quality of life by a patient questionnaire.

RESULTS

All patients tolerated the procedure well. The therapeutic outcomes were as follows: in 50 % (n=8) of patients, minor response with a decrease in size of the primary tumor and metastases up to 20 %; in 25 % (n = 4) of patients, stable disease; and in 25 % (n = 4) of patients, progressing metastases with stable primary tumor. Eleven patients (68.75 %) reported a good quality of life without impaired performance of their daily activities. Side effects were moderate and reversible between the treatment cycles. After one year 25 % of the patients were still alive.

CONCLUSION

Transarterial chemoperfusion is a minimally invasive treatment for pancreatic carcinomas and local recurrences with little side-effects and can be delivered on an outpatient basis. It might be indicated as potential neoadjuvant treatment before surgery or as palliative treatment to provide clinical benefits and to improve the quality of life.

Treatment of a patient with advanced esophageal cancer with a combination of mitomycin C and capecitabine: activation of the thymidine phosphorylase as active principle?

BACKGROUND

Both capecitabine, an oral prodrug of 5-fluorouracil (5-FU), and mitomycin C (MMC) have demonstrated activity as single agents in patients with gastrointestinal cancer. Furthermore, a combination of MMC with infusional 5-FU can induce tumor remission even in patients pretreated with 5-FU. Capecitabine and MMC act synergistically due to an upregulation of the thymidine phosphorylase activity by MMC in a human xenograft model.

PATIENT

We sought to exploit these preclinically observed effects in a patient with esophageal cancer who was progressive after a first-line radiochemotherapy with 5-FU and cisplatin. He was treated with a combination of MMC and capecitabine on a compassionate use basis. A rapid remission lasting for about 6 months was observed.

CONCLUSION

This is the first report on a combination therapy with capecitabine and MMC. The remission observed in our patient suggests that the preclinically observed synergy has clinical impact. This combination should be further investigated in prospective clinical trials.

Concurrent mitomycin C, 5-fluorouracil, and radiotherapy in the treatment of locally advanced carcinoma of the cervix: a randomized trial

PURPOSE

This is a prospective, Phase III multicenter randomized trial to assess the effectiveness of concurrent intravenous mitomycin C, oral 5-fluorouracil (5-FU), and radiotherapy (RT) in locally advanced carcinoma of the cervix.

METHODS AND MATERIALS

Between January 1988 and November 1994, 926 patients with locally advanced carcinoma of the cervix, FIGO Stage IIB-IVA, were entered into this study. The patients were randomized into four arms, as follows: Arm 1: conventional RT; Arm 2: conventional RT and adjuvant chemotherapy; Arm 3: conventional RT plus concurrent chemotherapy; Arm 4: conventional RT plus concurrent chemotherapy and adjuvant chemotherapy. Concurrent chemotherapy consisting of intravenous mitomycin C at 10 mg/m(2) was given on Days 1 and 29, and oral 5-FU at 300 mg/day was administered on Days 1-14 and 29-42 during RT. Adjuvant chemotherapy of 5-FU orally at 200 mg/day was given for three courses of 4 weeks, with a 2-week rest every 6 weeks. Six centers participated in the trial.

RESULTS

The median follow-up time was 89 months. Acute side effects were generally higher in concurrent arms, but most of the patients tolerated the treatment well. Bone marrow toxicity was also higher in concurrent arms. The 5-year actuarial disease-free survival (DFS) was 48.2%, 54.1%, 64.5%, and 59.7% for arms 1, 2, 3, and 4, respectively. The pattern of failure revealed a significant increase in locoregional recurrence in the nonconcurrent chemoradiotherapy arm. The local recurrence was 25.5%, 20.6%, 14.3%, and 17.6% for arms 1, 2, 3, and 4, respectively. The metastatic rates were not significantly different in all four arms. At the time of analysis, there were no increases in late side effects, especially in gastrointestinal and genitourinary systems.

CONCLUSIONS

Concurrent chemotherapy, mitomycin C, and 5-FU together with conventional RT showed an improved DFS rate when compared with conventional RT alone in patients with locally advanced carcinoma of the cervix.

Glaucoma-filtering bleb infections

PURPOSE OF REVIEW

To present a review of the current literature regarding the management of glaucoma-filtering bleb infections.

RECENT FINDINGS

With the increased use of intraoperative antifibrotic (eg, mitomycin and fluorouracil) as an adjunct to standard trabeculectomy, an increased incidence is seen of late-onset filtering bleb-related infections. These infections range from infections localized to the bleb (blebitis) to endophthalmitis. Risk factors for bleb-related infections include an inferior or nasally located bleb; presence of a high bleb or blepharitis; development of a late-onset bleb leak; use of antifibrotic agents; chronic antibiotic use; and performance of a trabeculectomy alone versus a combined procedure.

SUMMARY

The optimal treatment for bleb-related infections is evolving, but consensus is that a high degree of vigilance and aggressive treatment are key to minimizing the potentially blinding nature of this complication. It is important to note that those glaucoma procedures that provide the lowest intraocular pressure are often those that predispose to bleb-related infections.

Efficacy and safety of topical azelastine compared with topical mitomycin C in patients with allergic conjunctivitis

PURPOSE

To compare the efficacy and safety of topical azelastine with topical mitomycin C (MMC) in patients with allergic conjunctivitis.

METHODS

Sixty-three patients (29 male, 29 female; 34 in the age range of 6 to 65 years) with allergic conjunctivitis were enrolled in this study. The patients were randomly assigned to receive topical azelastine 0.02% (n = 31) or topical MMC (0.2 mg/10 mL) (n = 31) four times daily for 3 months. Follow-up examinations were done at 2 weeks to examine side effects of the medications and again at 4 weeks to assess the outcome of treatment. The eyes were examined for relief of symptoms, cure of signs, and the appearance of side effects with use of these drugs.

RESULTS

The mean age of the patients in this study was 34.8 +/- 17.3 years. The age of patients in the MMC group was significantly higher than patients in the azelastine group (mean +/- SD, 25.2 +/- 13.5 years). More patients in the MMC group had relief of symptoms like redness [25 (80.7%) in the MMC group versus 19 (55.9%) in the azelastine group; p= 0.033], photophobia [11 (35.5%) in the MMC group versus six (17.7%) in the azelastine group; not significant], discharge [17 (54.8%) in the MMC group versus 11 (32.3%) in the azelastine group; not significant], and foreign body sensation [21 (67.7%) in the MMC group versus 16 (47.1%) in the azelastine group; not significant], while more patients in the azelastine group had relief of lacrimation [14 (41.2%) in the azelastine group versus 10 (32.3%) in the MMC group; not significant] and pain [12 (35.3%) in the azelastine group versus eight (25.8%) in the MMC group; not significant]. The MMC group also showed a greater decrease in follicles [31 (100.0%) in the MMC group versus six (17.7%) in the azelastine group; p= 0.0001] and papillae [29 (93.6%) in the MMC group versus four (11.8%) in the azelastine group; p= 0.0001]. Both drugs were found to be equally effective in relieving itching [18 (58.1%) in the MMC group versus 18 (52.9%) in the azelastine group; not significant]. In the MMC group, 27 (87.1%) patients had conjunctival hyperemia, 28 (90.3%) patients had episcleritis, and 29 (93.6%) patients had irritation. The use of topical azelastine did not cause any adverse event.

CONCLUSIONS

Though this was a short-term study, we found topical MMC to be more effective than topical azelastine in the treatment of allergic conjunctivitis both in terms of relief of symptoms and resolution of signs. The use of topical MMC in low doses does not cause any significant adverse effect.

Liver metastasis of pancreatic cancer managed by intra-arterial infusion chemotherapy combined with degradable starch microspheres

A patient with liver metastasis of pancreatic cancer received chemotherapy using mitomycin C and degradable starch microspheres. The patient was a 52-year-old woman who had undergone surgery for cancer of the head of the pancreas in October 1996. She had stage III disease and was followed up as an outpatient on oral therapy with a combined uracil and tegafur preparation. In October 2000, abdominal computed tomography (CT) scans detected multiple liver metastases. Three courses of intra-arterial infusion of mitomycin C and microspheres (1000 mg) resulted in regression of her tumor and a decrease of tumor marker levels. After three more courses of this therapy, the patient developed bile duct necrosis and died of disseminated intravascular coagulation. As her metastases were controlled for about 7 months, hepatic arterial infusion of mitomycin C and degradable starch microspheres appears to be useful for treating liver metastasis of pancreatic cancer, but careful attention should be paid to the risk of severe complications such as bile duct necrosis.