Factors correlated with progression-free survival after high-dose chemotherapy and hematopoietic stem cell transplantation for metastatic breast cancer

CONTEXT

Women with breast cancer are the most frequent recipients of high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (autotransplants) in North America. Despite widespread use, controversy exists about the benefits of and appropriate patients for this therapy.

OBJECTIVE

To determine factors associated with disease progression or death after autotransplantation in women with metastatic breast cancer.

DESIGN

Analysis of data collected retrospectively (January 1989 to 1992) and prospectively (1992 through January 1995) for the Autologous Blood and Marrow Transplant Registry.

SETTING

Sixty-three hospitals in North America, Brazil, and Russia.

PARTICIPANTS

A total of 1188 consecutive women aged 18 to 70 years receiving autotransplants for metastatic or locally recurrent breast cancer, with a median follow-up of 291/2 months.

MAIN OUTCOME MEASURE

Time to treatment failure (disease progression, disease recurrence, or death) after autotransplantation.

RESULTS

Factors associated with significantly (P<.05) increased risk of treatment failure in a Cox multivariate analysis included age older than 45 years (relative hazard, 1.17; 95% confidence interval [CI], 1.02-1.33), Karnofsky performance score less than 90% (1.27; 95% CI, 1.07-1.51), absence of hormone receptors (1.31; 95% CI, 1.15-1.51), prior use of adjuvant chemotherapy (1.31; 95% CI, 1.10-1.56), initial disease-free survival interval after adjuvant treatment of no more than 18 months (1.99; 95% CI, 1.62-2.43), metastases in the liver (1.47; 95% CI, 1.20-1.80) or central nervous system (1.56; 95% CI, 0.99-2.46 [approaches significance]) vs soft tissue, bone, or lung, 3 or more sites of metastatic disease (1.32; 95% CI, 1.13-1.54), and incomplete response vs complete response to standard-dose chemotherapy (1.65; 95% CI, 1.36-1.99). Receiving tamoxifen posttransplantation was associated with a reduced risk of treatment failure in women with hormone receptor-positive tumors (relative hazard, 0.60; 95% CI, 0.47-0.87). Women with no risk factors (n = 38) had a 3-year probability of progression-free survival of 43% (95% CI, 27%-61 %) vs 4% (95% CI, 2%-8%) for women with more than 3 risk factors (n = 343).

CONCLUSION

These data indicate that some women are unlikely to benefit from autotransplantation and should receive this treatment only after being provided with prognostic information and in the context of clinical trials attempting to improve outcome.

Fatigue, pain, and depression in pre-autotransplant breast cancer patients

OBJECTIVES

The purpose of this study was to determine the influence of fatigue, pain, and depression on health status in breast cancer patients who had completed adjuvant chemotherapy and were scheduled for autologous bone marrow/peripheral blood stem cell transplant (AT).

MATERIALS AND METHODS

A predictive, correlational design was used. A convenience sample of 127 women with stages II, III, and IV breast cancer was recruited. The setting was an urban National Cancer Institute-designated comprehensive cancer center located in the Eastern United States. Standardized questionnaires and the Gaston-Johansson Painometer (POM) were used to measure the variables. The subjects completed questionnaires in the outpatient clinic. Relationships between the multiple dimensions of fatigue and pain, depression, and health status were examined. Hierarchical regression techniques were used to determine the variance in health status accounted for by fatigue, pain, and depression.

RESULTS

The subjects were age 22 to 60 years (Mean = 45; SD = 7.6), and primarily were married, white, Protestant, college educated, employed in a professional position, and had an average yearly household income of equal to or greater than $50,000. All subjects had previously received surgery and chemotherapy. Ninety-one percent of the participants reported fatigue as measured by the Fatigue Visual Analogue Scale. Forty-seven percent of the participants reported pain as measured by the Gaston-Johansson POM visual analogue scale. Fifty-four percent of the participants reported depression, ranging from mild to severe/high. Subjects reported a mean total perceived health status rating of 50.73 (SD 10.79). Fatigue, pain, and depression were all significantly correlated to each other and to total health status. Depression (P < .001) and pain (P < .01) significantly accounted for 64% (adjusted R2 = .60) of the variance in total health status. Fatigue (P < .05) and depression (P < .001) accounted for 42% (adjusted R2 = .36) of the variance in the perception of health status.

CONCLUSIONS

Women with breast cancer previously treated with chemotherapy and awaiting AT may experience fatigue, pain, depression, and alterations in health status. Pain and depression had a significant impact on a woman's total health status, whereas depression and fatigue had an influence on perceived health status. Of the different dimensions of health status, one's perceptions of health status had the strongest correlation to total health status (r = .84, P < .001). Healthcare professionals need to be aware of the effects of multiple symptoms on health status and to provide appropriate care to alleviate them.

Attenuation and immunogenicity of Deltacya Deltacrp derivatives of Salmonella choleraesuis in pigs

Six different isogenic Deltacya Deltacrp derivatives of a strain of Salmonella choleraesuis var. kunzendorf-chi3246 virulent for pigs were constructed by transposon-mediated deletion mutagenesis. These strains were evaluated for virulence and ability to elicit a protective immune response in young weaned pigs after oral administration and were compared to a commercially available vaccine which lacks the 50-kb virulence plasmid (vpl(-)). These derivatives were Deltacya Deltacrp vpl(+), Deltacya Deltacrp vpl(-), Deltacya Delta(crp-cdt) vpl(+), Deltacya Delta(crp-cdt) vpl(-), Deltacya Deltacrp pmi-3834 vpl(+), and Deltacya Delta(crp-cdt) pmi-3834. In experiments to evaluate safety, no significant adverse effects of any of the vaccine constructs were observed, except that two of the strains which carried the virulence plasmid (vpl(+)) caused a small, short-term elevation in maximum temperature compared to pretreatment temperature values. Orally immunized animals, except for those vaccinated with the Deltacya Deltacrp pmi-3834 vpl(+) strain or SC-54, developed significant serum antibody responses 21 days postvaccination as measured by enzyme-linked immunosorbent assay. No cell-mediated immune responses to heat-killed S. choleraesuis were noted at the same time point as measured with heat-killed bacteria as antigen in a lymphocyte proliferation assay. In an oral challenge exposure model with a highly virulent heterologous strain of S. choleraesuis, the Deltacya Deltacrp strains with deletions in pmi were not protective. As measured by morbidity scores, the responses to challenge of the pigs vaccinated with the other four Deltacya Deltacrp derivatives were significantly better than those of the nonvaccinated, challenged group. With the exception of temperature elevation and slight differences in diarrhea scores postchallenge, none of these strains differed significantly from each other in the other clinical parameters analyzed. While the commercial vaccine was protective by most of the parameters measured, it was not fully protective against challenge with virulent S. choleraesuis as judged by diarrhea scores and temperature elevation. Collectively, these data demonstrate that Deltacya Deltacrp derivatives, with or without the virulence plasmid but not with deletions in the pmi gene, are candidates for vaccines for protection against salmonellosis in pigs.

Infection by Heterodera glycines Elevates Isoflavonoid Production and Influences Soybean Nodulation

High-performance liquid chromatography and Sinorhizobium fredii USDA191 nodC-lacZ gene fusion were used to monitor changes in the isoflavonoid content of soybean roots infected with Heterodera glycines isolate TN1. Isoflavonoid concentrations in infected roots of both H. glycines-resistant Hartwig and susceptible Essex soybean were two to four-fold higher than those of uninfected roots 2 and 3 days after inoculation. The isoflavonoids produced activated the transcription of nodC-lacZ fusion. The most abundant isoflavonoids were identified as daidzein and genistein by HPLC and GC/MS. Heterodera glycines increased the number of nodules formed on Essex roots inoculated with B. japonicum (USDA110) but reduced shoot weight and decreased the net nitrogenase activity of the nodules. Heterodera glycines infection of resistant Hartwig did not affect the total number of nodules or their nitrogen- fixing capacity.

Pain, psychological distress, health status, and coping in patients with breast cancer scheduled for autotransplantation

PURPOSE/OBJECTIVES

To describe pain, psychological distress, health status, and coping that patients with breast cancer who were scheduled for autotransplantation experienced; the strength and direction of relationships among pain, psychological distress, health status, and coping; and the percentage of variance within the concept of health status that age, pain, psychological distress, and coping.

DESIGN

Descriptive, correlational.

SETTING

An urban, National Cancer Institute-designated comprehensive cancer center located in the eastern United States.

SAMPLE

A convenience sample of 83 female patients with breast cancer scheduled for autotransplantation. The population age ranged from 22-59 years (X = 44.47 years) and was comprised of 72 (88%) Caucasians, 6 (7%) African Americans, and 4 (5%) from other minorities.

METHODS

An oncology clinical nurse specialist in the outpatient medical oncology clinic collected the data during a regularly scheduled visit approximately 20 days prehospitalization for high-dose chemotherapy and autotransplantation. Data were collected using a demographic data from and self-report instruments (Gaston-Johansson Painometer, State-Trait Anxiety Inventory, Beck Depression Inventory, Medical Outcomes Study Short-Form General Health Survey, and Coping Strategies Questionnaire).

MAIN RESEARCH VARIABLES

Pain, psychological distress, health status, and coping.

FINDINGS

Although the subjects experienced low pain intensity, the range of reported pain intensity ratings was wide. Pain locations varied but were reported mainly in the vagina, chest, shoulder, and arm. Although subjects reported primarily mild depression and mild state anxiety, the range of depression and state anxiety scores was wide. Coping strategies used most frequently to deal with pain included positive coping statements, diverting attention, praying and hoping, increasing activity level, and ability to control and decrease pain. Subjects reported moderate total health status and low role functioning. Moderate, positive correlations were seen between state anxiety and depression and physical functioning and role functioning. Sixty-five percent of the variance in health status was explained by sensory pain depression, and catastrophizing.

CONCLUSIONS

Patients with breast cancer who are scheduled for autotransplantation may experience pain, psychological distress, and alterations in coping and perceived health status. Total pain intensity, sensory pain, depression, and catastrophizing appear to be important variables related to the patient's perceived health status.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to include assessment of pain, psychological distress, health status, and coping in their routine patient assessment prior to autotransplantation to provide appropriate care and make necessary multidisciplinary referrals. Future nursing research should be directed toward the implementation and evaluation of interventions that promote the use of comprehensive coping strategies to decrease pain, anxiety, and depression.

A phase I/II study of vinorelbine, doxorubicin, and methotrexate with leucovorin rescue as first-line treatment for metastatic breast cancer

PURPOSE

This study was performed to determine the maximum tolerated dose (MTD) and toxicity of vinorelbine when used in combination with doxorubicin and methotrexate with leucovorin rescue in women with metastatic breast cancer.

METHODS

Enrolled in the study were 23 women with metastatic breast cancer who had not received prior chemotherapy for metastatic disease. Patients treated at the first dose level received vinorelbine 20 mg/m2 on day 1, doxorubicin 40 mg/m2 on day 1, methotrexate 100 mg/m2 on day 1 and leucovorin 20 mg orally every 6 h for six doses beginning on day 2. Treatment was repeated every 21 days. The vinorelbine dose was escalated by 5 mg/m2 for patients treated at subsequent dose levels. The MTD was defined as the dose level at which fewer than one-third of patients enrolled experienced dose-limiting toxicity (DLT). When the MTD of vinorelbine had been determined, the doxorubicin dose was then escalated by 10 mg/m2 with the vinorelbine dose held at its MTD.

RESULTS

total of 98 courses of treatment (median of 4 per patient, range 2-8) were administered. The MTD of this regimen was found to be vinorelbine 25 mg/m2, doxorubicin 40 mg/m2, and methotrexate 100 mg/m2 with leucovorin rescue. At higher doses of vinorelbine, neutropenia, fatigue, arm pain, malaise, nausea and vomiting were dose-limiting. Higher doses of doxorubicin resulted in universal dose limiting neutropenia, and frequent nonhematologic DLT consisting of arm pain, malaise, stomatitis, nausea and vomiting. Amongst the 20 patients with measurable disease, there were 3 complete responses (15%, 95% confidence interval 3%-38%), 5 partial responses (25%, 95% confidence interval 9%-49%) and an overall response rate of 40% (95% confidence interval 19%-64%). The median survival was estimated to be 25 months from the start of chemotherapy.

CONCLUSIONS

Vinorelbine at 25 mg/m2 can be safely administered with doxorubicin at 40 mg/m2 and methotrexate at 100 mg/m2 with leucovorin rescue. Response rates observed with this regimen suggest that this combination of chemotherapeutic agents may not be more effective than the combination of vinorelbine and doxorubicin.

Survey of Fascioloides magna in farmed wapiti in Alberta

The formalin-ethyl acetate sedimentation procedure was used to detect ova of the giant liver fluke, Fascioloides magna, in feces of farmed wapiti in Alberta. Twenty (3.2%) of the 629 fecal samples examined contained ova of F. magna. Thirteen (33.3%) of the 39 farms surveyed had wapiti positive for F. magna. The presence of F. magna in farmed wapiti north of the North Saskatchewan River is confirmed, and 3 areas where the infection has become endemic are identified.

Long term follow-up of women treated with 16-week, dose-intensive adjuvant chemotherapy for high risk breast carcinoma

BACKGROUND

A Phase II study was performed evaluating the disease free and overall survival rates associated with a dose-intensive, 16-week, doxorubicin-based adjuvant chemotherapy regimen in women with breast carcinoma and > or = 10 involved axillary lymph nodes.

METHODS

Eligible patients underwent staging with computed tomography and bone scanning and were treated with a 16-week, dose-intensive chemotherapy regimen, comprised of 8 2-week courses of cyclophosphamide, 100 mg/m2 orally, on Days 1-7; doxorubicin, 40 mg/m2 intravenously (i.v.), on Day 1; methotrexate, 100 mg/m2 i.v., on Day 1 with leucovorin rescue, 10 mg/m2, every 6 hours for 6 doses orally on Day 2; vincristine, 1 mg i.v. on Day 1; 5-fluorouracil (5-FU), 600 mg/m2 i.v., on Day 2 over 2 hours; and 5-FU, 300 mg/m2/day continuous i.v. on Days 8 and 9. Tamoxifen, 20 mg daily, was administered to patients with estrogen receptor positive tumors treated after October 1988. All patients were offered locoregional radiation therapy.

RESULTS

Sixty-four women were treated on protocol. The median follow-up of 27 surviving patients was > 8 years at last follow-up. Three patients were lost to follow-up. The median time to progression was 54 months, the Kaplan-Meier estimate of event free survival at 5 years was 44% (95% confidence interval [CI], 31-56%), and the Kaplan-Meier estimate of overall survival at 5 years was 57% (95% CI, 44-69%). At 98 months the Kaplan-Meier estimate of freedom from recurrence was 31% (95% CI, 19-43%) and the Kaplan-Meier estimate of survival at 111 months was 36% (95% CI, 23-49%).

CONCLUSIONS

Despite the use of dose-intensive, doxorubicin-based, adjuvant chemotherapy, and intensive staging prior to study entry, the results of the current study are similar to those of previous reports for standard dose chemotherapy and appear inferior to those reported for high dose therapy.

Recent advances in systemic therapy for breast cancer

During the past year there have been a number of important advances in the area of systemic therapy for breast cancer. Combined chemoendocrine therapy has been shown to be more effective than tamoxifen alone in the adjuvant therapy of node-negative estrogen receptor-positive breast cancer. Preliminary results of a randomized trial suggest that the addition of paclitaxel to adjuvant AC (Adriamycin and Cytoxan) improves survival in patients with operable node-positive disease. In the treatment of metastatic disease, preliminary results of a randomized trial have shown docetaxel to be superior to doxorubicin in response rate. In hormonal therapy, third generation aromatase inhibitors have replaced megestrol acetate as second-line hormonal therapy in receptor-positive disease. There are promising recent data about anti-HER-2 antibody therapy and other new approaches. This article reviews these and other recent advances in the systemic therapy of breast cancer.

Sequence-dependent hematological toxicity associated with the 3-hour paclitaxel/cyclophosphamide doublet

Paclitaxel is active in metastatic breast cancer. Combination studies have demonstrated complex interactions between paclitaxel and other cytotoxic agents, including sequence-dependent cytotoxic, toxicological, and pharmacological effects. The principal objectives of this study were to determine the maximum tolerated doses of paclitaxel (3-h infusion) and cyclophosphamide (1-h infusion) administered every 3 weeks with granulocyte colony-stimulating factor (Filgrastim) and to determine if the sequence-dependent toxicological effects that have previously been observed with this combination when paclitaxel was administered over 24 h were evident when paclitaxel was administered over 3 h. Fifteen women with metastatic breast cancer were treated. Starting doses were 200 mg/m2 paclitaxel and 1600 mg/m2 cyclophosphamide, with granulocyte colony-stimulating factor (5 micrograms/kg/day) given s.c. beginning 24 h after chemotherapy. Doses of both drugs were escalated in cohorts of at least four patients. The sequence of drug administration was alternated with each consecutive patient and with each subsequent course of therapy in each individual patient, enabling the evaluation of sequence-dependent toxicological and pharmacological effects. Severe myelosuppression was the principal dose-limiting toxicity for this regimen, precluding dose escalation above 200 mg/m2 paclitaxel and 1600 mg/m2 cyclophosphamide, the maximum tolerated dose for this combination on this schedule. As has been previously demonstrated with this combination, when paclitaxel is administered over 24 h, the hematopoietic toxicity was sequence dependent. Paired analysis of toxicity data using each patient as her own control indicated more severe hematological toxicity in courses in which paclitaxel was administered first. There was no evidence of sequence-dependent effects on the pharmacokinetics of these drugs that might account for this phenomenon. The impact of drug sequencing on toxicity should be considered in the further development of combination therapy containing alkylating agents and paclitaxel, when the latter is administered over 3 h.

Peripheral blood progenitor cell mobilization: a clinical review

High-dose chemotherapy appears to confer a survival advantage on certain patients with lymphohematopoietic malignancies and may have a role in some solid tumors, notably germ cell and, possibly, breast cancer. Autologous bone marrow grafts adequately support high-dose therapy in many patients, but more-rapid engraftment is observed in those who are given mobilized peripheral blood progenitor cell grafts. The optimal method for mobilizing progenitor cells remains to be defined, but adequate numbers of cells can be obtained by apheresis after treatment with cytokines, chemotherapy, or a combination of both. The minimum number of progenitor cells that will result in rapid and durable engraftment from mobilized peripheral blood cell collections is probably between 2.5 x 10(6) and 5.0 x 10(6) CD34+ cells/kg, as determined by flow cytometry, a method not yet fully standardized among laboratories. Tumor cell contamination of peripheral blood progenitor cell grafts is less common, and there are fewer tumor cells than in matched bone marrow collections. Strategies for producing large numbers of stem cells by ex vivo expansion of small collections may be feasible in the near future. Such approaches may also reduce tumor cell contamination of the product.

Am I better off with out it?: a case study of a patient having a trans-tibial amputation after 52 years of chronic lower limb ulceration and pain

This case study looks at a 71-year-old man who had 52 years of chronic lower limb pain and ulceration secondary to radiotherapy for an osteosarcoma. It discusses some issues surrounding amputation in such a case and raises early preoperative involvement by a multidisciplinary amputee rehabilitation team as a mandatory arm of management.

Systemic therapy for breast cancer

Currently available information suggests that the optimal duration of adjuvant therapy for breast cancer patients with no involved axillary nodes is 5 years, though controversy about this recommendation persists. In postmenopausal patients, disease-free survival appears to be improved by the addition of combination chemotherapy to tamoxifen. Recently reported studies indicate that there is no benefit to dose escalation of cyclophosphamide in adjuvant therapy and that the risk of secondary leukemia may be increased. The combination of paclitaxel and doxorubicin has been reported in single-institution studies to produce high response rates but may also be cardiotoxic. Recent reports indicate that a pharmacokinetic interaction between these two drugs may cause these clinical findings. New agents that may be of utility in the management of advanced or primary breast cancer include novel hormonal agents, notably the aromatase inhibitors, and the bisphosphonates.

Issues relating to the inclusion of high-dose chemotherapy in breast cancer treatment guidelines

The development of guidelines for the use of high-dose chemotherapy in the treatment of breast cancer is a challenging task. The absence of large amounts of data from prospective, randomized, phase III clinical trials, and the variability of patient populations and treatment strategies in phase II studies mean that these guidelines have to be developed in the absence of conclusive clinical data. Nonetheless, the available information suggests strategies for incorporating this therapy into the care of certain patients with breast cancer.

Unique Immunogenic Proteins in Heterodera glycines Eggshells

Polyclonal antibodies were raised against Heterodera glycines eggshells to determine the feasibility of developing an immunoassay for H. glycines eggs. An indirect enzyme-linked immunosorbent assay (ELISA) was developed from anfisera collected 10 weeks after the initial injection. From serial dilutions of sonicated eggshells or whole eggs, a sensitivity of detection to 5 ng/ml sonicated eggshells or 1 egg of H. glycines was determined. The method of eggshell preparation had no effect on the antibodies produced; however, the antibodies cross-reacted with sonicated J2 of H. glycines and eggs of Meloidogyne incognita and H. schachtii. Most of the proteins in both life stages of H. glycines and eggs of M. incognita and H. schachtii had similar migration properties when separated on SDS-PAGE gels and stained with Coomassie blue. Western blot analysis, with antisera adsorbed with homogenized J2 of H. glycines, showed proteins that were specifically localized to eggshells of H. glycines. Monoclonal antibodies might provide a useful immunoassay where polyclonal antibodies lack sufficient specificity.

Characterization of flaA- and flaB- mutants of Serpulina hyodysenteriae: both flagellin subunits, FlaA and FlaB, are necessary for full motility and intestinal colonization

Motility of Serpulina hyodysenterlae is thought to play a pivotal role in the enteropathogenicity of this spirochete. To test this, a series of isogenic mutants containing specifically disrupted flagellar alleles (flaA1 and flaB1) were constructed and examined for virulence and ability to colonize the intestinal tract of mice. Mice challenged with the wild-type, parent strain showed a dose-related response to the challenge organism. In contrast, all flagellar mutant strains demonstrated aberrant motility in vitro and a significantly reduced ability to colonize and infect mice. To some extent, this degree of reduction in colonizing ability was dependent on the wild-type background strain used for mutant construction. A flaB1- strain generated from a 'laboratory isolate' was unable to colonize the mouse gut even at high challenge doses, although its parent was virulent for mice. However, when the same parent strain was 'animal-passed' prior to disruption of flaB1, the resulting flaB1- strain was able to transiently colonize the mouse gut and induce intestinal lesions. A comparison of a series of flagellar mutants constructed using the animal-passed parent strain further revealed that specific inactivation of flaB1 resulted in a more pronounced reduction in virulence and colonizing ability than that which occurred with two flaA1 mutants. Taken together, these data suggest that motility is an essential virulence factor of S. hyodysenteriae and that both sheath and core flagellin subunits, FlaA and FlaB, are necessary for full motility and intestinal colonization.

Nonlinear pharmacokinetics of cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide in patients with metastatic breast cancer receiving high-dose chemotherapy followed by autologous bone marrow transplantation

The pharmacokinetics of cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide has been evaluated in 12 patients with metastatic breast cancer undergoing high-dose chemotherapy followed by bone marrow transplantation. Each patient received an initial dose of 4 g/m2 of cyclophosphamide over 90 min to prime peripheral blood progenitor cells (the first course), and 3 weeks later, 6 g/m2 of cyclophosphamide with 800 mg/m2 of thiotepa by 96-hr infusion before marrow stem cell infusion (the second course). Whole blood cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide concentrations were measured by a GC-EIMS method using deuterium labeled compounds as internal standards. In addition, plasma and urine cyclophosphamide concentrations were determined by a GC assay. Whole blood concentrations of cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide vs. time data and urinary excretion of cyclophosphamide data from the first course were co-modeled using a one-compartment model with Michaelis-Menten saturable elimination in parallel with first-order renal elimination (N = 7) or first-order metabolic and renal elimination (N = 5) for cyclophosphamide and one-compartment model with first-order elimination for 4-hydroxycyclophosphamide/aldophosphamide. The parallelism between cyclophosphamide and 4-hydroxycyclophosphamide/aldophosphamide disposition curves implies that the pharmacokinetics of 4-hydroxycyclophosphamide/aldophosphamide is formation limited; only the fractional 4-hydroxycyclophosphamide/ aldophosphamide clearance rate (Clmet/Fmet) can be estimated. The mean Vmax and Km for cyclophosphamide were 0.78 microM/min and 247 microM, respectively. The mean nonrenal clearance (Clnr) of cyclophosphamide for five patients with apparent first-order elimination of cyclophosphamide was 67 ml/min. The mean Clmet/Fmet of 4-hydroxycyclophosphamide/aldophosphamide was 2982 ml/min. The mean renal clearance (Clr) of cyclophosphamide was 29 ml/min and 24 ml/min for the first course and the second course, respectively. The correlations between cyclophosphamide AUCs and 4-hydroxycyclophosphamide/aldophosphamide AUCs were sought for both drug courses. Blood and plasma cyclophosphamide concentrations were remarkably similar, indicating that cyclophosphamide partitions equally in the red cell and plasma volume. Computer simulation of the effect of potential alterations in Michaelis-Menten saturable elimination and renal clearance on 4-hydroxycyclophosphamide/aldophosphamide has been used to illustrate the complex relationship between the exposure to parent compound and active metabolite.

High-dose chemotherapy with autologous hematopoietic stem-cell support for breast cancer in North America

PURPOSE

To identify trends in high-dose therapy with autologous hematopoietic stem-cell support (autotransplants) for breast cancer (1989 to 1995).

PATIENTS AND METHODS

Analysis of patients who received autotransplants and were reported to the Autologous Blood and Marrow Transplant Registry. Between January 1, 1989 and June 30, 1995, 19,291 autotransplants were reviewed; 5,886 were for breast cancer. Main outcomes were progression-free survival (PFS) and survival.

RESULTS

Between 1989 and 1995, autotransplants for breast cancer increased sixfold. After 1992, breast cancer was the most common indication for autotransplant. Significant trends included increasing use for locally advanced rather than metastatic disease (P < .00001) and use of blood-derived rather than marrow-derived stem cells (P < .00001). One-hundred-day mortality decreased from 22% to 5% (P < .0001). Three-year PFS probabilities were 65% (95% confidence intervals [Cls], 59 to 71) for stage 2 disease, and 60% (95% Cl, 53 to 67) for stage 3 disease. In metastatic breast cancer, 3-year probabilities of PFS were 7% (95% Cl, 4 to 10) for women with no response to conventional dose chemotherapy; 13% (95% Cl, 9 to 17) for those with partial response; and 32% (95% Cl, 27 to 37) for those with complete response. Eleven percent of women with stage 2/3 disease and less than 1% of those with stage 4 disease participated in national cooperative group randomized trials.

CONCLUSION

Autotransplants increasingly are used to treat breast cancer. One-hundred-day mortality has decreased substantially. Three-year survival is better in women with earlier stage disease and in those who respond to pretransplant chemotherapy.

Specificity of effector T lymphocytes in autologous graft-versus-host disease: role of the major histocompatibility complex class II invariant chain peptide

Administration of the immunosuppressive drug cyclosporine after autologous bone marrow transplantation induces a systemic autoimmune syndrome resembling graft-versus-host disease (GVHD). This syndrome termed autologous GVHD has significant antitumor activity. Associated with autologous GVHD is the development of T lymphocytes that recognize major histocompatibility complex (MHC) class II determinants, including self. The present studies attempted to characterize and define the molecular specificity of the effector T lymphocytes in autologous GVHD induced in patients with metastatic breast cancer. The results suggest that the effector cells associated with human autologous GVHD are CD8+ T lymphocytes expressing the alpha/beta T-cell receptor. Additional studies show that the effector T cells recognize MHC class II antigens in association with a peptide from the invariant chain (CLIP). Pretreatment of autologous lymphoblast target cells with anti-CLIP antibody completely blocked lysis mediated by autologous GVHD effector T cells. On the other hand, force loading this peptide markedly enhanced the susceptibility of the target cells to recognition by the autoreactive T cells. The recognition of the MHC class II CLIP complex may account for the novel specificity of the effector T cells associated with human autologous GVHD. Moreover, identification of the target peptide may allow for the development of novel immunotherapeutic strategies to enhance the antitumor efficacy of autologous GVHD.

Metastatic breast cancer

The management of metastatic breast cancer continues to provide enormous challenges. The taxanes have significant activity in patients with resistant disease, and combination regimens are being evaluated as first-line therapy. The combination of paclitaxel and doxorubicin appears to have substantial activity, but troublesome cardiac toxicity has been noted in a recently reported study. Docetaxel has been shown to be very active in initial phase II evaluation, notably in women with anthracycline-resistant disease. The controversy over high-dose therapy continues, and its role in the management of metastatic breast cancer outside the confines of clinical trials remains unclear. The HER-2 protein appears to be a predictive factor for patients with metastatic disease. Antibody therapy directed at this target can produce responses in a proportion of patients. Bisphosphonates appear to be beneficial to patients with lytic bony metastases when administered in conjunction with cytotoxic or hormonal therapy.

Dual flaA1 flaB1 mutant of Serpulina hyodysenteriae expressing periplasmic flagella is severely attenuated in a murine model of swine dysentery

The motility imparted by the periplasmic flagella (PF) of Serpulina hyodysenteriae is thought to play a pivotal role in the enteropathogenicity of this spirochete. The complex PF are composed of multiple class A and class B polypeptides. Isogenic strains containing specifically disrupted flaAl or flaB1 alleles remain capable of expressing PF, although such mutants display aberrant motility in vitro. To further examine the role that these proteins play in the maintenance of periplasmic flagellar structural integrity, motility, and fitness for intestinal colonization, we constructed a novel strain of S. hyodysenteriae which is deficient in both FlaA1 and FlaB1. To facilitate construction of this strain, a chloramphenicol gene cassette, with general application as a selectable marker in prokaryotes, was developed. The cloned flaAl and flaB1 genes were disrupted by replacement of internal fragments with chloramphenicol and kanamycin gene cassettes, respectively. The inactivated flagellar genes were introduced into S. hyodysenteriae, and allelic exchange at the targeted chromosomal flaA1 and flaB1 loci was verified by PCR analysis. Immunoblots or cell lysates with antiserum raised against purified FlaA or FlaB confirmed the absence of the corresponding sheath and core proteins in this dual flagellar mutant. These mutations selectively abolished the expression of the targeted genes without affecting the synthesis of other immunologically related FlaB proteins. The resulting flaA1 flaB1 mutant exhibited altered motility in vitro. Surprisingly, it was capable of assembling periplasmic flagella that were morphologically normal as evidenced by electron microscopy. The virulence of this strain was assessed in a murine model of swine dysentery by determining the incidence of cecal lesions and the persistence of S. hyodysenteriae in the gut. Mice challenged with the wild-type strain or a passage control strain showed a dose-related response to the challenge organism. The dual flagellar mutant was severely attenuated in murine challenge experiments, suggesting that the FlaA1 and FlaB1 proteins are dispensable for flagellar assembly but critical for normal flagellar function and colonization of mucosal surfaces of the gastrointestinal tract. This strain represents the first spirochete engineered to contain specifically defined mutations in more than one genetic locus.

Cyclophosphamide and 4-Hydroxycyclophosphamide/aldophosphamide kinetics in patients receiving high-dose cyclophosphamide chemotherapy

Using a recently developed gas chromatography and mass spectrometry method to determine whole-blood cyclophosphamide (CP) and 4-hydroxycyclophosphamide/aldophosphamide (4-HO-CP/AP) concentrations, we investigated their pharmacokinetics in women receiving CP therapy. Patients (n = 18) received one or two courses of CP: (a) a 90-min i.v. infusion (4 g/m2) followed by a 96-h i.v. infusion (6 g/m2) in combination with high-dose thiotepa; or (b) a 96-h i.v. infusion (6 g/m2) in combination with high-dose thiotepa. Whole-blood exposures to CP [area under the whole blood concentration versus time curve (AUCCP)] and 4-HO-CP/AP (AUC4HOCP) between courses 1 and 2 were compared after normalization to dose (g/m2). A nonproportional increase was observed for the AUCCP between the first course [1112 micrometer. h/g/m2 +/- 14% coefficient of variation (CV)] and the second course (1579 micrometer . h/g/m2 +/- 28% CV) (P < 0.001). In contrast, the AUC4HOCP (27 micrometer . h/g/m2 +/- 25% CV) determined for the first course was 29% higher than the AUC4HOCP (21 micrometer . h/g/m2 +/- 26% CV) for the second course (P < 0.01). The interpatient whole-blood exposures to both CP and 4-HO-CP/AP were remarkably consistent in this patient population with percent CVs ranging from 14 to 28%. Because thiotepa (800 mg/m2) was administered simultaneously with CP during the second course of treatment, possible inhibition of CP metabolism by thiotepa was investigated using human liver microsomes in vitro. IC50 values determined for inhibition of CP metabolism in three individual liver donors ranged from 1.0 to 40 micrometer. However, the clinical relevance of this observation has not been established.