Primary effusion lymphoma (PEL) in HIV-negative patients--a distinct clinical entity

Primary effusion lymphoma (PEL) is a recently described rare type of non-Hodgkin's lymphoma occurring almost exclusively in HIV infected people. Human herpesvirus 8 (HHV-8), has been linked with PEL, and a causative relationship has been suggested. In the vast majority of PEL cases Epstein-Barr virus (EBV) has been found in the tumour cells. We describe here an elderly human immune deficiency (HIV) seronegative man with intractable chest pain and pleural effusion. The diagnosis of malignant lymphoma was suggested cytologically and confirmed histologically following pleural biopsy. No lymphadenopathy or organ involvement with lymphoma was found. Systemic chemotherapy with a modified CHOP regimen with G-CSF support gradually led to the resolution of the chest pain and ultimately resulted in a complete clinical remission (CCR). The presence of HHV-8 was demonstrated by PCR using paraffin-embedded tissue samples from the involved pleura, whereas EBV-associated genetic material was absent. The patient remained in CCR for 18 months and died of an unrelated cause (cerebrovascular event). Only 11 other cases with clinical and virological features similar to those of our patient have been reported in the literature. Analysis of these rare cases suggests HIV-negative EBV-negative PEL to be a distinct clinical entity with epidemiological features resembling classical KS and supports an EBV-independent role for HHV-8 in the pathogenesis of PEL.

[Case report on therapy with granulocyte stimulating factor in diabetic foot]

Several pathogenetic factors such as peripheral neuropathy, vasculopathy and infection are responsible for the development of diabetic foot ulcerations. An important factor contributing to the high infection risk in diabetic patients is a defect in neutrophil granulocytes. Deficiencies in neutrophil chemotaxis, phagocytosis and respiratory burst activity with the decrease of the super- and peroxids are known to be associated with diabetes. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil function. A 78-year old patient with non-insulin-dependent diabetes presented with ulcerations of both big toes and a malum perforans on the right sole. He also had generalized arteriosclerosis as well as a polyneuropathy with a dry foot and typical foot deformation as well as decreased in sensitivity. Intensive local care for 35 days led to no improvement of the ulcerations. Then G-CSF (Neupogen) was administered in a total dose of 165 million IU over 11 days; the daily dose varied between 15-30 million IU depending on the absolute leucocyte count. In addition 500 mg of oral ciprofloxacin (Ciproxin) was given b.i.d. This treatment led to a significant improvement of the lesions. Within 11 days cost analysis suggests G-CSF may be a cost-effective addition to antimicrobial therapy in diabetic foot infection.

Phase I dose escalation study of topotecan combined with alternating schedules of paclitaxel and carboplatin in advanced solid tumors

BACKGROUND

Combining topotecan with other cytotoxics has been problematic due to marrow suppression. A phase I trial was initiated to identify the optimal sequence and maximum-tolerated dose of topotecan in combination with paclitaxel and carboplatin.

PATIENTS AND METHODS

Patients with advanced cancer and performance status ECOG < or = 2. The starting dose was paclitaxel 175 mg/m2 day 1, carboplatin AUC 6.0 day 1, and topotecan 0.5 mg/m2 daily day 1-5 (early sequence). The next course of paclitaxel and carboplatin administration was delayed to day 5 (late sequence). Treatment was repeated every three weeks. After determining maximum-tolerated dose without cytokines, granulocyte colony-stimulating factor (G-CSF) was added and further dose escalation was pursued.

RESULTS

Fifty-one patients were entered; men: women ratio 30:21. Dose-limiting toxicity (DLT) for the early sequence was neutropenia at doses paclitaxel mg/m2/carboplatin AUC 5/topotecan mg/m2 (PCT) 175/5/0.75 for four to five days. DLT for the late sequence was neutropenia at PCT doses of 175/5/ 1.0 for four days. G-CSF 5 microg/kg subcutaneously starting day 6 permitted further topotecan dose escalation. After adding G-CSF, late sequence DLT was neutropenia at doses 175/5/1.25 for four days. Forty-six patients were evaluable for response and of those, there were thirteen partial responses.

CONCLUSIONS

The late sequence resulted in less toxicity and was better tolerated. The early sequence maximum-tolerated dose (MTD) was 175/6/0.5 for five days. The late sequence MTD was PCT 175/5/0.75 for five days. The late sequence MTD with G-CSF was 175/5/1.0 for four days. The recommended phase II PCT dose is the late sequence 175/5/1.0 for four days with G-CSF.

Morning granulocytopenia in a case of Graves' disease

A 65-year-old woman with Graves' disease presented marked diurnal changes in white blood cell (WBC) and granulocyte counts. Granulocyte count was low and sometimes decreased to 0.2-0.3 x 10(9)/l in the early morning and increased in the afternoon irrespective of her thyroid status. She did not develop sore throat or fever during the investigation period. The present study indicates that these unusual diurnal changes in WBC and granulocyte counts should be considered in the differential diagnosis of agranulocytosis in Graves' disease patients treated with an antithyroid drug.

Results of an outpatient-based stem cell allotransplant program using nonmyeloablative conditioning regimens

Using nonmyeloablative, immunosuppressive, fludarabine (FLU)-based conditioning regimens, we have performed allogeneic peripheral blood stem cell transplants in 26 patients (8 with chronic myelogenous leukemia, 6 with acute myelogenous leukemia, 10 with acute lymphoblastic leukemia, 1 with myelodysplasia, and 1 with thalassemia major). Conditioning consisted of FLU/busulphan/cyclophosphamide/cyclosporin-A (CyA)/methotrexate, or FLU/melphalan/CyA/methotrexate. The median granulocyte recovery time to 0.5 x 10(9)/l was 11 days, whereas the median platelet recovery time to 20 x 10(9)/l was 12 days. Twelve patients did not need red blood cell transfusions, and 8 did not need platelet transfusions. In 21 individuals (81%), the procedure could be completed fully on an outpatient basis. Follow-up times range between 30 and 600 days: one patient failed to engraft and recovered endogenous hemopoiesis; six out of 26 patients developed acute graft-versus-host disease (GVHD) whereas 7/22 developed chronic GVHD. Twelve patients (46%) have died, nine of them with a relapsing disease and three with GVHD; median post-transplant survival (SV) was 300 days, whereas the 12-month SV was 42%. The 100-day mortality was 3.8% and the transplant-related mortality was 11.5%. This procedure is substantially less costly than its counterpart, using in-hospital myeloablative conditioning regimens, and it may represent another approach in the management of patients requiring an allogeneic stem cell transplant.

Secondary prophylactic G-CSF (filgrastim) administration in chemotherapy of stage I and II Hodgkin's lymphoma with ABVD

The purpose of this study was to determine the effect of granulocyte colony-stimulating factor (filgrastim, G-CSF) for maintenance of chemotherapy dose-intensity in patients with stage I or II Hodgkin's lymphoma treated with six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). Fifty-six patients with stage I or II Hodgkin's lymphoma treated with ABVD were eligible for secondary prophylactic G-CSF administration because of neutropenia (absolute neutrophil count < 1 x 10(9) /L) causing treatment delay or febrile neutropenia. Patients received 300 microg (total dose) of G-CSF (filgrastim) subcutaneously on days 3 to 7 and 17 to 21 of each cycle in order to prevent dose reduction or delay in subsequent cycles of treatment continuing the G-CSF until completion of chemotherapy. Results showed that 30 (54%) of the patients required the use of G-CSF, 26 (47%) during the first or second cycle. After G-CSF administration delay in chemotherapy did not occur in 25 patients, whereas delays in the fifth or sixth cycle occurred in four patients. Despite treatment with G-CSF, one patient had febrile neutropenia. Dose intensity greater than 90% of that planned was delivered to more the 85% of patients.

IN CONCLUSION

Secondary prophylactic G-CSF administration was necessary in more than half of patients with stage I or II Hodgkin's lymphoma during chemotherapy with ABVD. The use of G-CSF allowed maintenance of chemotherapy schedule and dose intensity in the majority of patients.

Pharmacodynamics and pharmacokinetics of single doses of subcutaneous pegylated human G-CSF mutant (Ro 25-8315) in healthy volunteers: comparison with single and multiple daily doses of filgrastim

Ro 25-8315 is produced by conjugation of rhG-CSF mutant with polyethylene glycol (PEG). The purpose of this study was to examine the pharmacodynamics and pharmacokinetics of Ro 25-8315 in comparison with Filgrastim (rhG-CSF). Subjects received single subcutaneous doses of Ro 25-8315 ranging from 10 to 150 microg/kg using a double-blind, randomized, placebo-controlled design. Filgrastim was administered as a single dose (5 or 10 microg/kg) and, following a 14-day washout period, daily for 7 days. Ro 25-8315 increased absolute neutrophil count (ANC) by 6- to 8-fold and CD34+ cell count more than 30-fold at the highest doses tested. Single doses (60-150 microg/kg) of Ro 25-8315 and multiple doses of Filgrastim had similar effects on ANC and CD34+, although Ro 25-8315 had a greater effect on CFU-GM. The pharmacokinetics of Ro 25-8315 were dose-dependent, with peak concentrations and area under the serum concentration-time curve (AUC) increasing 100-fold over the range of doses studied. Time to reach peak concentration (T(max)) and half-life of Ro 25-8315 averaged 20-30 hr at all doses, approximately three times longer than with Filgrastim. Adverse events were not serious and occurred with similar frequency with both products. Pegylation of rhG-CSF mutant results in more desirable pharmacokinetic properties and a longer duration of action with effective increases in ANC and measures of peripheral blood progenitor cell mobilization for at least 1 week.

Carcinoma of an unknown primary site: a chemotherapy strategy based on histological differentiation--results of a prospective study

BACKGROUND

To evaluate the efficacy and toxicity of a chemotherapy strategy based on histological differentiation, for patients with carcinoma of unknown primary site.

PATIENTS AND METHODS

Forty-eight patients were prospectively included in the trial. Thirty patients with poorly-differentiated carcinoma or poorly-differentiated adenocarcinoma (group A) received a combination of cisplatin and etoposide. Patients with a responsive or stable disease after two cycles received the same regimen plus bleomycin, ifosfamide and G-CSF. Eighteen patients with well- or moderately-differentiated carcinoma (group B) received cisplatin, continuous infusion 5-fluorouracil (5-FU) and alpha-interferon. Treatment was maintained in case of response or stable disease for up to six cycles.

RESULTS

The overall response rate (RR) for the entire group is 43% (95% confidence interval (CI): 35.9%-50.1%): seven CR and five PR in group A (RR = 40%) and six CR and two PR in group B (RR = 44%). Grade 4 leucopenia was observed in 22 (46%) patients and sepsis in 3 (6%). Median survival is 9.4 months (range 5-13.7 months) and 16.1 months (range 11.8 20.3 months), respectively.

CONCLUSIONS

This chemotherapy strategy is one way to achieve high response rates, particularly for patients with well- or moderately-differentiated adenocarcinoma usually considered poorly chemosensitive.

The pharmacokinetics and pharmacodynamics of high-dose paclitaxel monotherapy (825 mg/m2 continuous infusion over 24 h) with hematopoietic support in women with metastatic breast cancer

PURPOSE

We evaluated the pharmacokinetics and pharmacodynamics of high-dose paclitaxel (HDP) monotherapy (825 mg/m2 continuous infusion over 24 h) with peripheral blood progenitor cell (PBPC) and G-CSF support in 17 women with metastatic breast cancer.

METHODS

Pharmacokinetic and pharmacodynamic data were collected in 17 women entered in a phase II trial of sequential HDP, and high-dose melphalan and cyclophosphamide/thiotepa/carboplatin.

RESULTS

The maximal plasma concentration (Cmax), area under the plasma concentration time curve (AUC), apparent clearance (Clapp), duration of plasma concentration above 0.05 microM (t > 0.05 microM) for paclitaxel were (means SD): 9.11 +/- 7.45 microM, 145 +/- 88 microM x h, 8.06 +/- 2.90 l/h per m2 and 82.4 +/- 31.2 h, respectively. There was a significant correlation between the plasma paclitaxel concentration at 1 h (r2 = 0.87), 12 h (r2 = 0.85) and 23 h (r2 =0.92) and the AUC (P < 0.0001). Duration of neutropenia was brief (median 3 days, range 0-5 days) and neutrophil recovery occurred earlier (median 6 days, range 0-7 days) than could be attributed to infused PBPC. Median nadir count for platelets was 66 x 10(9)/l (range 13-160 x 10(9)/l). Pharmacodynamic analysis showed no correlation between pharmacokinetic parameters (Cmax, AUC, t > 0.05 microM) and time to neutropenic nadir, duration of neutropenia, platelet count nadir and grades of neuropathy or mucositis. In ten patients in whom detailed neurologic and nerve conduction studies were performed, linear regression analysis showed a significant correlation between pre- and post-HDP treatment total neuropathy scores (r2 = 0.46, P = 0.03).

CONCLUSIONS

HDP (825 mg/m2 continuous infusion over 24 h) did not appear to be myeloablative. The degree of neurotoxicity subsequent to HDP was associated with the degree of baseline neuropathy but was not predictable from pharmacokinetic parameters.

Granulocyte colony stimulating factors: how different are they? How to make a decision?

Two granulocyte colony stimulating factors (G-CSFs) are available for clinical use in Europe: filgrastim (Neupogen) and lenograstim (Granocyte). The purpose of this literature review is to study how they differ, the clinical implications of these differences (especially in terms of efficacy) and the economic impact of these differences. From a chemical point of view the two molecules are not identical. Their amino acid sequence is different and one is glycosylated, whereas the other is not. The important question to ask is what these structural differences mean for the patient. It appears that glycosylation has important consequences in terms of efficacy. Several recent comparative studies, both in vitro and in vivo, in animals and in humans, reinforce this idea which was often shared intuitively by physicians. In economical terms, in hospitals where the exact dosages are used (150 microg/m2 or 19.2 million units (MU)/m2 for Granocyte, and 5 microg/kg or 0.5 MU/kg for Neupogen), the choice of G-CSF must be made according to the daily cost of treatment which, for an average patient, means comparing the price of 325 microg of Neupogen and of 255 microg of Granocyte. This is in fact equal to comparing the price per MU of each product. In hospitals where one vial per patient per day is used whatever be their weight or body surface area, the price per MU and the price per vial should be considered together, puting into perspective the potential therapeutic benefit for patients, one vial of Granocyte 34 containing more MU than one vial of Neupogen 30.

Clinical practice and future needs in recombinant human granulocyte colony-stimulating factor treatment: a review of randomized trials in clinical haemato-oncology

Recombinant human granulocyte colony-stimulating factor (rHuG-CSF) may have a significant impact on preventing infections associated with chemotherapy-induced neutropenia, as well as shortening time to tree lineage engraftment following high-dose chemotherapy and progenitor transplantation. However, the scientific literature documenting evidence-based practice is insufficient and often misinterpreted. This review presents data and discusses the evidence for actual clinical practice in the use of rHuG-CSF in conventional cyclic chemotherapy, either prophylactic or therapeutic, and high-dose therapy, either in priming for mobilization or post-transplantation. In the past decade, many reports have based their conclusions on surrogate markers, and it is time to move towards evaluation of clinically relevant factors. Data must be generated prospectively based on current clinical practice, and several issues must be considered and evaluated to define the true clinical benefit of rHuG-CSF with or without stem-cell support. Evaluation should include complications and needs for resources as well as impact on toxicity and efficacy of conventional or high-dose chemotherapy.

A phase II study of dose-intense ifosfamide plus epirubicin with hematopoietic growth factors for the treatment of patients with advanced soft tissue sarcomas; a novel sequential schedule

PURPOSE

The efficacy and feasibility of a novel sequential schedule of high-dose ifosfamide (HD-IFO) and full-dose epirubicin (EPI) with granulocyte colony-stimulating factor (G-CSF) was evaluated in adult patients with soft tissue sarcomas (STS).

METHODS

Since November 1995, 22 chemotherapy-naive patients have been treated. HD-IFO was given as a continuous infusion at a total dose of 14-18 g/m2 per cycle, with mesna, over 6 to 8 days, q 3 weeks, twice. EPI was administered subsequently as an i.v. bolus at a total dose of 120-160 mg/m2, on days 1-2, q 2 weeks, twice. G-CSF was planned for each course of treatment as a daily subcutaneous injection for 7 days, starting 24 h after the end of the treatment. After the first four cycles, patients were evaluated for surgery and patients with locally inoperable or metastatic disease received further chemotherapy up to a maximum of eight cycles.

RESULTS

The response of 19 patients could be assessed. One complete response (CR) and six partial responses (PRs) were achieved for an overall response rate of 37% (95% confidence interval, 15-59%). Noteworthy is that two of the six leiomyosarcoma patients responded to the HD-IFO treatment. The median survival period was 15 months. Most common toxicities included myelosuppression, nausea and vomiting, and stomatitis. Six patients were hospitalized for complicated nadir fever. No severe renal and CNS toxicities were seen. Transient gross hematuria occurred in six patients and affected treatment in only one case. There were no treatment-related deaths.

CONCLUSIONS

By the protraction of continuous infusion of HD-IFO over 6 to 8 days, ifosfamide-induced acute renal toxicity is avoided, while G-CSF support allows the delivery of the planned dose intensity in most of the patients. Although manageable in an oncology setting, the hematologic toxicity of such a regimen remains substantial. Moreover, in terms of efficacy and median survival, this regimen showed no benefits over a conventional-dose anthracycline-ifosfamide schema. Further evaluations of this novel ifosfamide-epirubicin schedule are not warranted, even if the HD-IFO regimen could be taken forward specifically for leiomyosarcomas in a phase II trial.

Concurrent administration of vinorelbine with human recombinant granulocyte-macrocyte stimulating factor

Thirty-three patients with incurable neoplasms resistant to standard therapy received vinorelbine 10 mg/m(2)/day by continuous infusion with concurrent administration of rHGM-CSF 4 microg/m(2)/day. The duration of the vinorelbine infusion was individualized; the infusion was continued until early evidence of hematopoietic toxicity was noted. The concurrent administration of GM-CSF permitted a substantial increase in dose intensity of the anti-cancer agent without a corresponding increase in drug toxicity. There was no evidence that the anti-tumor effect of vinorelbine was compromised by the concurrent administration of GM-CSF.

Sequential analysis of CD34+ and CD34- cell subsets in peripheral blood and leukapheresis products from breast cancer patients mobilized with SCF plus G-CSF and cyclophosphamide

Administration of stem cell factor (SCF) has been proven to enhance cytokine-induced mobilization of CD34+ hematopoietic progenitor cells (HPC) into the peripheral blood (PB). The aim of the present study was to explore in a homogeneous group of 22 uniformly treated breast cancer patients: (1) the kinetics of mobilization into PB of both CD34+ and CD34- cell subsets, including dendritic cells, in sequential samples obtained from day +7 up to day +12 after mobilization; and (2) the composition of the CD34+ and CD34- cell subsets present in the two leukapheresis products obtained for each patient. The following CD34+ and CD34- subsets were analyzed: early CD34+ HPC, erythroid-, myeloid- and B-lymphoid-committed CD34+ precursor cells, mature T, B and NK cells, monocytes, neutrophils, eosinophils, basophils, and dendritic cells (DC) including three subsets of lin-/HLADR+DC (CD16+, CD33high and CD123high). Our results show that the absolute number of PB CD34+ HPC progressively increases from day +7 onwards. As far as the CD34- PB leukocyte subsets are concerned, monocytes (CD14+) displayed the earliest recovery after mobilization predicting neutrophil recovery 1 day in advance. The number of CD34+ HPC collected in a single leukapheresis product was always > or = 1.4 x 10(6) cells/kg body weight. No significant changes were observed between the two leukapheresis sessions either as regards their composition in CD34+ HPC subsets or their CD34- leukocyte populations except for a higher ratio of both CD34+ erythroid/CD34+ myeloid HPC (0.35 +/- 0.13 vs 0.30 +/- 0.13; P = 0.04) and neutrophils/monocytes (1.58 +/- 2.1 vs 0.69 +/- 0.27; P = 0.009) found for the first leukapheresis. Interestingly, the overall number of dendritic cells (DC) was higher in the second leukapheresis (1.06 +/- 0.56 vs 1.9 +/- 0.46; P = 0.02) due to a selective increase of the CD16+ antigen-presenting cells. In summary, our results show that the combination of cyclophosphamide, G-CSF and SCF is highly effective for stem cell mobilization, with differences observed in the mobilization kinetics of the different hematopoietic cell subsets analyzed.

Serial granulocytapheresisunder daily administration of rHuG-CSF: effects on peripheral blood counts, collection efficiency, and yield

BACKGROUND

An option for treatment of severe infections in neutropenic patients is the transfusion of granulocytes from donors stimulated with rHuG-CSF. The schedule of rHuG-CSF-stimulated granulocyte donations and the quality of the components remain controversial. This study was done with the intention of ensuring daily granulocyte support with therapeutic cell numbers, while keeping the patients' allogeneic exposure as low as possible.

STUDY DESIGN AND METHODS

Granulocyte collection with multiple consecutive leukapheresis procedures under daily rHuG-CSF administration and with hydroxyethyl starch as sedimenting agent were prospectively studied. Complete blood counts of the donors, collection yield, and efficiency were analyzed.

RESULTS

Products (n = 259) from 76 donors were examined. The median peripheral blood WBC and neutrophil counts were 28.1 g per L and 24.1 g per L, respectively, and they were significantly higher on Day 5 of collections than on Days 1 to 3. Platelet counts and Hb levels decreased steadily. Collection yields increased over time from 4.9 to 6.7 x 10(10) neutrophils. Side effects of cytokines and aphereses did not exceed World Health Organization grade II status.

CONCLUSION

Repetitive daily rHuG-CSF administration-even under daily leukapheresis procedures-results in a continuing increase in WBC and neutrophil levels and thus leads to increased collection yields. Side effects are tolerable, although Hb and platelet levels should be monitored closely.

Intensive postremission chemotherapy in Taiwanese adults with acute myelogenous leukemia

Intensive postremission chemotherapy has produced disease-free survival comparable to that of bone marrow transplantation in patients with acute myelogenous leukemia (AML), but its efficacy was unknown in Taiwan. We assessed the efficacy of intensive postremission chemotherapy, consisting of high-dose arabinoside-C (HiDAC) with or without transplantation of peripheral blood stem cells, in 33 AML patients from a single institute in Taiwan. Toxic reactions, treatment outcome, prognostic factors, and the size of the peripheral blood stem-cell harvest after HiDAC were analyzed. After a median follow-up of 21 months, 18 patients remained in continuous complete remission. The actuarial leukemia-free survival at 4 years was 51%. Relapse occurred in 12 patients, at a median of 12 months after initial diagnosis. All 6 patients with acute promyelocytic leukemia remained disease free after HiDAC therapy. Age, sex, and number of remission-induction or intensive consolidation chemotherapy courses had no effect on the risk of relapse. Intensive postremission chemotherapy can effectively prolong the duration of remission in young (< 60 years of age) adults with AML.

Docetaxel and epirubicin plus G-CSF as mobilizing treatment to support high-dose chemotherapy in breast cancer

BACKGROUND

In order to combine an active regimen with a simultaneous efficient mobilization of peripheral blood precursor cells (PBPC), we explored the combination of Docetaxel 75 mg/m2 and Epirubicin 120 mg/m2 with G-CSF 5 mcg/Kg/day s.c. to mobilize PBPC in breast cancer patients to support high-dose chemotherapy (HDC).

PATIENTS AND METHODS

Forty patients were enrolled: 27 high risk and 13 metastatic. The entire procedure, including chemotherapy and PBPC collection, was on an outpatient basis.

RESULTS

The median day of starting apheresis was day +10 (range 10-12) and the average value of circulating CD34+ cells at peak was 175/microliter (range 33-403). The median yield of CD34+ cells per apheresis was 8.76 x 10(6)/Kg (range 1.83-27.87). None of the patients developed side effects which required hospitalization. All patients enrolled successively received HDC as consolidation treatment. High risk patients received one and metastatic patients two HDC with PBPC reinfusion. All patients obtained a complete engraftment. No significant differences between high-risk and metastatic patients were observed.

CONCLUSIONS

Our study suggests that the combination of Docetaxel, Epirubicin, and G-CSF is feasible, safe and efficient outpatient mobilizing treatment for patients with breast cancer receiving HDC.

Phase I trial of ifosfamide and 24-h infusional paclitaxel in pelvic malignancies: a Gynecologic Oncology Group study

OBJECTIVE

The goal of this work was to develop a combination chemotherapy regimen consisting of ifosfamide and paclitaxel to be evaluated in the management of gynecologic malignancies.

METHODS

The Gynecologic Oncology Group conducted a Phase I trial of the regimen, initially with paclitaxel (24-h infusion) delivered on Day 1 and ifosfamide (1 h) administered (with Mesna) over the subsequent 4 days. All patients received granulocyte colony-stimulating factor (G-CSF) starting 24 h after the Day 5 chemotherapy. Treatment was repeated on a 28-day schedule. A cohort of patients also received the alternate sequence of ifosfamide (4 days) followed by paclitaxel.

RESULTS

Twenty-two patients were evaluated. Even at the lowest dose level tested (paclitaxel 135 mg/m(2) followed by ifosfamide 1 g/m(2)/day x 4 days) grade 4 neutropenia was almost universal, despite the routine use of G-CSF. The alternate drug administration sequence resulted in marrow suppression of similar severity.

CONCLUSION

The combination of 24-h infusional paclitaxel with ifosfamide delivered over 4 days results in severe neutropenia, despite the administration of G-CSF, and is not recommended for further evaluation. In view of the known activity of the two agents in several malignancies, including cervix cancer, it would be reasonable to investigate the delivery of the agents employing alternative treatment schedules predicted to result in less severe marrow suppression (e.g., 3-h infusional paclitaxel).

Oral combination chemotherapy in conjunction with filgrastim (G-CSF) in the treatment of AIDS-related non-Hodgkin's lymphoma: evaluation of the role of G-CSF; quality-of-life analysis and long-term follow-up

In 1993 we reported the efficacy and toxicity profile of an oral combination regimen administered to 18 patients with AIDS-related lymphoma (NHL-1 study). We observed a 61% response rate; 39% one-year survival rate; nearly two-thirds of patients developed > or = grade 3 leukopenia; and 28% of cycles were associated with febrile neutropenia. These results prompted us to shorten the duration of therapy and to add G-CSF to ameliorate the myelosuppression. Twenty patients with biopsy-proven AIDS-related lymphoma were treated with three 6-week cycles of oral chemotherapy consisting of lomustine (CCNU) 100 mg/m2 on day 1, cycles no. 1 and 3; etoposide 200 mg/m2 days 1-3; cyclophosphamide and procarbazine both 100 mg/m2 days 22-31; and G-CSF 5 microg/kg subcutaneously days 5-21 and days 33-42 (NHL-2 study). The following analyses were undertaken: (1) evaluation of toxicity and efficacy parameters for patients in the current (NHL-2) study; (2) analysis of the clinical role of G-CSF by (historical) comparison with the NHL-1 study of the same regimen without G-CSF; (3) quality-of-life assessments using the Functional Living Index-Cancer (FLIC) and Brief Symptom Inventory (BSI) instruments for all 38 patients (NHL-1+2); and (4) long-term follow-up for all 38 patients. In the current study the overall objective response using ECOG criteria was 70% (95% CI, 50-90%) with 6 CRs (30%) and 8 PRs (40%). The median survival duration was 7.3 months (range: 0.5-51+ months). One patient developed CNS relapse. There were no significant differences with respect to demographics or prognostic factors between the patient populations of the NHL-1 study and the current study (P > 0.2 for each factor). Myelosuppression was the major toxicity in both studies. In the current study versus the NHL-1 study, although the lower incidences of grade 3/4 myelosuppression (51% vs. 64%) and febrile neutropenia (17% vs. 28%) on a per cycle basis were not statistically significant, fewer patients (40% vs. 60%) were affected. However, the severity of myelotoxicity was lessened with the addition of G-CSF, measured in terms of the discontinuation of therapy, myelotoxic deaths, and freedom from grade 3/4 myelotoxicity ( P < 0.02). The number of hospitalizations for febrile neutropenia (7 in the NHL-2 study vs. 13 in the NHL-1 study) was also significantly different (P < 0.05). Quality-of-life analysis confirmed no significant functional or psychological deterioration during therapy except for patients experiencing febrile neutropenia, whose functional capacity deteriorated (P < 0.04). The 1-year, 18-month, and 2-year survival rates for the combined studies (38 patients) were 32%, 21%, and 13%, respectively. At time of death 49% of patients were free from progression of their lymphoma. Administration of the oral regimen has resulted in 13% of patients surviving two years, and half of patients surviving free from progression of their lymphoma. This regimen is efficacious and considerate of patient quality-of-life issues. The addition of G-CSF to the regimen decreases the frequency of hospitalization for febrile neutropenia.

Long-term follow-up after allogeneic granulocyte colony-stimulating factor--primed bone marrow transplantation

Granulocyte colony-stimulating factor (G-CSF) priming increases the number of progenitor cells in harvested bone marrow (BM) and has been used for allogeneic transplantation. Primed bone marrow (pBM) seems to offer faster engraftment than steady-state BM, but the stability of such engraftment has been questioned. The incidence of graft-versus-host disease (GVHD) and disease relapse after pBM, compared with such incidence after BM or peripheral blood progenitor allotransplantation, has not been established. We studied the long-term outcome (median follow-up, 24 months) of sibling matched allografting with G-CSF pBM. Seventeen patients received pBM from matched sibling donors primed with G-CSF 10 microg/kg per day for 2 days before BM harvest. Conditioning consisted of total body irradiation and cyclophosphamide (CY); busulfan and CY; or total lymphoid irradiation, CY, and antithymocyte globulin. All infused grafts contained > or = 3.5 to 4 x 10(8) mononuclear cells per kilogram. Ten of 17 patients received methotrexate as part of their GVHD prophylaxis. International Bone Marrow Transplant Registry definitions for engraftment were used. Control subjects consisted of 112 consecutive patients who received allogeneic transplantation at our institution with steady-state BM; control subjects for length of hospitalization consisted of the subset of patients who underwent transplantation during 1996. Neutrophil engraftment occurred a median of 7 days earlier in primed bone marrow transplantation (pBMT) patients when compared with steady-state BMT patients; this shortened hospitalization by a median of 11 days. The peritransplant mortality rate was 18% in pBMT patients and 25% in BMT patients (not significant). The rate of GVHD of grade > II and the rate of relapse were almost identical in pBMT and BMT patients (GVHD: 18% and 19%, respectively; relapse: 14% and 13%, respectively). There were 4 transplant-related deaths within the first 100 days; 1 patient died of disease relapse on day 470. Twelve patients remained alive on days 430 through 1522 after BMT. Results showed that pBM allografts resulted in more rapid engraftment and shorter hospitalization. All patients maintained stable donor engraftment. In this cohort of patients, G-CSF pBMT resulted in rates of GVHD, disease relapse, and peritransplant mortality that were similar to those produced by conventional BMT.

Intensive-dose ifosfamide and etoposide with filgrastim for cytoreduction before peripheral blood stem cell collection in patients with advanced ovarian cancer

OBJECTIVE

To evaluate the antitumor activity and toxic effects of intensive-dose ifosfamide plus etoposide with filgrastim given as stem cell mobilization therapy before high-dose chemotherapy for recurrent or persistent ovarian cancer.

METHODS

We studied 32 patients with epithelial ovarian cancer who had a positive second-look laparatomy or recurrent disease. Ifosfamide was given at 10 g/m2 (total dose) by continuous infusion over 72 h; etoposide was given at 150 mg/m2 in 2-h infusions every 12 h during the same 72-h period; and filgrastim was given at 10 microg/kg/day subcutaneous injection from day 5 through completion of stem cell harvest.

RESULTS

Nine (64%) of the 14 patients assessed responded to the treatment. The target stem cell dose was achieved with a median of 1 apheresis (range 1-5 aphereses). Nonhematologic toxicity was limited to grade 2 nephrotoxicity in one patient and grade 2 hepatic toxicity in three patients.

CONCLUSIONS

In this patient group, intensive-dose ifosfamide plus etoposide with filgrastim was well tolerated and produced antitumor activity.

Granulocyte colony-stimulating factor given to donors before apheresis does not prevent aplasia in patients treated with donor leukocyte infusion for recurrent chronic myeloid leukemia after bone marrow transplantation

We conducted 2 sequential studies of donor leukocyte infusion (DLI) in 26 patients with chronic myeloid leukemia in hematologic relapse after unmodified allogeneic bone marrow transplantation. In the first study, cells for DLI were collected from 13 donors who were not treated with granulocyte colony-stimulating factor (G-CSF) (group 1). In the second study, cells were collected from 13 donors who received G-CSF before apheresis (group 2) in an attempt to avoid aplasia after DLI. Patients in group 2 received 550-fold more CD34+ cells than those in group 1. We found no significant difference in the incidence (31% versus 22%), onset time (41 vs. 48 days), or duration (15 vs. 14 days) of cytopenia after DLI in the 2 groups. G-CSF given to donors before collection of cells did not prevent aplasia. These findings support the hypothesis that the pathogenesis of aplasia after DLI is not restricted to the destruction of recipient hematopoietic cells but also involves failure of donor hematopoiesis by undefined mechanisms.

Comparison of granulocyte colony-stimulating factor (G-CSF)--mobilized peripheral blood progenitor cells and G-CSF--stimulated bone marrow as a source of stem cells in HLA-matched sibling transplantation

HLA-identical bone marrow or stem cell transplantation from a sibling is the preferred treatment for patients with chronic myelogenous leukemia, bone marrow failure syndromes, relapsed acute leukemia, and specific inborn errors of metabolism. Several groups have shown that granulocyte colony-stimulating factor (G-CSF)--mobilized peripheral blood progenitor cells (PBPCs) obtained from HLA-matched siblings are effective in reconstitution of marrow function after marrow ablative conditioning therapy. To evaluate whether G-CSF treatment before bone marrow harvest leads to enhanced recovery of PBPC counts and recovery from limited graft-versus-host disease (GVHD), we assessed the outcome of a sequential cohort of patients treated identically and then given either G-CSF--mobilized PBPCs or G-CSF--stimulated bone marrow from HLA-identical siblings. We show that the time to neutrophil engraftment is identical in the 2 cohorts, whereas platelet engraftment is earlier with the use of PBPCs. The incidence of acute GVHD was decreased, and that of chronic GVHD significantly decreased, in the group receiving bone marrow. Overall survival was not different between the 2 groups. Thus, G-CSF--stimulated bone marrow offers a source of stem cells that allows for early neutrophil engraftment with a decreased risk of GVHD.

A phase I trial of AUC-directed carboplatin with infusional doxorubicin and ifosfamide plus G-CSF in patients with advanced gynecologic malignancies

The effect of the addition of G-CSF to carboplatin, ifosfamide and doxorubicin (CIA) at the maximally tolerated dose (MTD) was studied in a phase I clinical trial. Nine patients with incurable solid tumors were treated: six endometrial and epithelial ovarian cancers, one colon cancer with pelvic masses and two unknown primary cancers. The carboplatin dose was calculated using the Calvert formula and administered in a standard 30-min intravenous infusion. The initial carboplatin dose was AUC 4.0 mg/ml per min. Fixed doses of ifosfamide (1.25 g/m2 per day), mesna (1.0 g/m2 per day, and doxorubicin (15 mg/m2 per day) were combined and given as a 4-day continuous intravenous infusion in an attempt to decrease nonhematologic toxicity. The dose-limiting toxicity of CIA was myelosuppression, mainly neutropenia and thrombocytopenia. Nonhematologic toxicities were hemorrhagic cystitis, weakness, fatigue, and nausea and vomiting. The MTD for CIA was established at the first dose level of carboplatin (4.0 mg/ml per min). Following this, G-CSF was added to the regimen in an unsuccessful effort to escalate the carboplatin dose. Free and total carboplatin pharmacokinetics were determined using flameless atomic absorption spectroscopy. There was one complete response and one partial response among eight evaluable patients. Both responding patients had advanced ovarian cancer. We conclude that carboplatin dose intensification beyond an AUC of 4.0 mg/ml per min is not made feasible by the addition of G-CSF to infusional doxorubicin and ifosfamide in patients with advanced gynecologic cancer.