Effective treatment of advanced multiple myeloma refractory to alkylating agents

Nonsecretory multiple myeloma in a 26-year-old man with acquired immunodeficiency syndrome, presenting with multiple extramedullary plasmacytomas and osteolytic bone disease

High grade B-cell lymphoma and leukemia have been well described in patients with the acquired immunodeficiency syndrome (AIDS). Malignant transformation of more differentiated lymphoid cells has not been well described in these patients. We report a 26-year-old man with AIDS-associated multiple myeloma, who had a highly unusual presentation and clinical course. A review of the literature indicates that monoclonal gammopathy in patients seropositive for the human immunodeficiency virus (HIV) is common. Multiple myeloma and extramedullary plasmacytomas, diseases that are extraordinarily rare in young persons, are now being reported in patients with AIDS and should be added to the list of neoplastic diseases now associated with HIV infection.

Infusion of vincristine and doxorubicin with oral dexamethasone as first-line therapy for multiple myeloma

32 previously untreated patients with multiple myeloma received vincristine, doxorubicin ('Adriamycin'), and dexamethasone (VAD) as first-line therapy. The overall response rate was 84%, with 28% of all patients entering complete remission. Response was rapid, with near-maximum response occurring after two courses of treatment and rapid improvement in bone-marrow function. Median response duration was 18 months and this seemed to be unaffected by initial prognostic criteria or by degree of remission achieved. The projected median survival was 44 months, with 75% of all patients and 83% of responders being alive at 2 years. Side-effects due to steroids were common, but there was only 1 treatment-related death. The high response rate and lack of toxicity offer an advantage over other forms of initial treatment, although other strategies will be necessary to prolong the duration of response.

Hemibody irradiation. An effective second-line therapy in drug-resistance multiple myeloma

The authors report the results of treatment of 41 patients with melphalan-resistant multiple myeloma using single half-body irradiation (HBI) or double half-body irradiation (DHBI). Patients were grouped using prognostic classification reported by the Medical Research Council. Patients in group I and II showed the best response to therapy with reduction in serum of urinary paraprotein and improvement in symptoms, most notably a marked reduction in bone pain. In these groups five patients have survived over 2 years after therapy. The therapeutic response appeared better in those patients who received DHBI as opposed to those whom treated with single HBI. Patients in group III did not achieve prolonged survival but effective relief of bone pain was a consistent finding in these patients also. Thus HBI represents an alternative to combination chemotherapy as second-line treatment of patients with melphalan-resistant multiple myeloma. A comparative study of HBI versus combination chemotherapy is now indicated to establish which therapeutic approach is most effective.

The cost of chronic dialysis in multiple myeloma

The complications and costs of chronic dialysis in 4 patients with renal failure due to multiple myeloma are presented. In three patients the paraprotein responded to chemotherapy though without recovery of renal function. These three patients are alive after 18, 16 and 15 months of dialysis, the other dying after 7 months. Hospital admissions ranged from 26 to 74 days per year with infections accounting for 54 to 87% of admission days, 62.5% of which occurred during the first three months of dialysis treatment, with an incidence of 2.4 to 6.9 admissions episodes per year. An in-house audit of our chronic dialysis patients indicated that treatment of myeloma patients is 5-33% more expensive. The extra cost in such high risk patients is mostly due to the greater number and longer duration of hospital admissions for infection. The other extra costs (in decreasing value) of blood products, antibiotics and chemotherapy are relatively small in comparison to in-patient treatment.

Doxorubicin: effect of different schedules on toxicity and anti-tumor efficacy

The risk of congestive heart failure restricts the clinical use of doxorubicin to cumulative doses of 450-550 mg/m2, when it is given using high-dose rapid intravenous application. As the high peak serum levels which follow rapid administration seem to be correlated with cardiotoxicity, application schedules leading to lower peak serum concentrations have been developed. This paper reviews the influence of those schedules on cardiotoxicity, non-cardiac toxicities, pharmacokinetic data and antineoplastic efficacy. While the reduction of cardiotoxicity by long-term application schedules is well documented, much less can be said about the antitumor effect of those schedules. Controlled studies dealing with this problem are needed. This review provides a base for that purpose.

Intermediate-dose (25 mg/m2) intravenous melphalan for patients with multiple myeloma in relapse or refractory to standard treatment

Intermediate-dose (25 mg/m2) intravenous melphalan has been evaluated in 34 multiple myeloma patients refractory to standard chemotherapies. The median time from diagnosis to entering of patients into the study was 27 months (range 7-71 months). A response was obtained in 12/34 patients (35%). 4 of 12 responding patients have relapsed and 2 of these have died; 8 responders have not relapsed and are still alive. The median duration of survival after 28 months of follow-up has not yet been reached in the group of patients responding to treatment. However, the overall median duration of survival for the 34 patients entered into the study was 8 months. The median duration of response was 16 months. Toxicity was limited to leukopenia, thrombocytopenia, nausea and vomiting. This lack of severe toxicity allowed us to administer the drug on an outpatient basis. The response rate and the low toxicity observed in this group of patients are encouraging and suggest that intermediate-dose intravenous melphalan is an effective and safe second line treatment for patients with multiple myeloma not responding to conventional treatment.

Treatment of multiple myeloma with carboquone-prednisolone

18 previously untreated patients with multiple myeloma were entered in a clinical study of a combination chemotherapy, carboquone (CQ) and prednisolone (P) (CQ-P). Response was observed in 44% of patients treated with CQ-P judged by the criteria for response to chemotherapy. The median survival time was 33 months. Serious toxic reactions seldom occurred. The results suggest that the combination of CQ-P has efficacy in the treatment of multiple myeloma and could have a role among primary chemotherapeutic regimens for the disease. Further clinical trials should be conducted to establish a new drug combination in which CQ is included.

In vitro studies of ways to overcome resistance to VAMP--high dose melphalan in the treatment of multiple myeloma

Myeloma colonies (MY-CFUc) from 7/24 patients undergoing treatment with VAMP (vincristine, adriamycin and methyl prednisolone) and high dose melphalan (HDM) were melphalan-resistant. It was not possible to conclude that VAMP induced melphalan resistance in MY-CFUc, but that resistance is endogenous in some myeloma cell populations. In 12/13 of the same patients of whom four had MY-CFUc which were melphalan resistant, the sensitivity of MY-CFUc and GM-CFUc to busulphan was similar. Thus resistance of MY-CFUc to melphalan did not confer resistance to busulphan. MY-CFUc from 1/7 of a second group of patients were adriamycin-resistant. This resistance was removed when the cells were treated with a combination of verapamil (3 micrograms/ml) and adriamycin. Verapamil also enhanced the toxicity of adriamycin to MY-CFUc from two patients where there was no evidence for adriamycin resistance. In these three patients the sensitivity of both MY-CFUc and GM-CFUc was similar after treatment with verapamil. Verapamil did not affect the uptake or efflux of 3H-daunorubicin in sensitive and resistant RPMI-8226 cells (myeloma) and peripheral blood mononuclear cells from a normal donor; neither did it affect the binding of 3H-daunorubicin to nucleic acid. It is concluded that verapamil may be a useful adjuvant to VAMP chemotherapy and that busulphan may provide an alternative to melphalan in patients whose myeloma cells are melphalan resistant.

VAD chemotherapy for refractory multiple myeloma

Thirty-four patients with refractory multiple myeloma were treated with 4-d continuous infusions of vincristine and adriamycin in combination with 4-d pulsed high-dose dexamethasone (VAD). Of 31 evaluable patients, 16 entered a complete remission (50%) and three a partial remission (10%). No difference in response rate was observed between primary refractory and relapsed patients. The median response duration was 9 months and the median survival of the responding patients was 12 months versus 4 months for the non-responders. Ten patients have currently survived longer than 360 d, of which six are stable in complete remission without therapy. All responding patients showed a remarkable improvement of their performance status and 70% of these patients became pain-free. Bacterial infection was the major complication and was probably due to the intensive corticosteroid programme. Severe myelosuppression was rarely observed. Irrespective of the response to VAD, a high beta 2-microglobulin of 4 micrograms/ml or more was a bad prognostic parameter. As early relapses were seen especially in this group of patients, in the patients with a plasma-cell LI% of 3 or more, and in patients with previous anthracyclin treatment, early consolidation, with, for instance, high dose melphalan, might improve the prognosis for these patients.

Pulsed high dose oral prednisolone in relapsed or refractory multiple myeloma

Seventeen unselected patients with relapsed or refractory multiple myeloma were treated with oral prednisolone 60 mg per m2 for five consecutive days with nine-day treatment-free intervals. Of the fourteen patients who completed at least six courses of treatment there were five good responses (Chronic Leukemia-Myeloma Task Force Criteria), five partial responses and four failures. Median survival (all seventeen patients) was between 19 and 20 months. Eight patients achieved plateau phase (median duration 9 months). Eleven patients showed improved performance status and four became free of transfusion support. The commonest side-effect was bacterial pulmonary infection. Peptic ulceration occurred in two patients despite prophylactic ranitidine. Other steroid-related side-effects were mild and well tolerated. This study provides further evidence for the efficacy of higher dose steroid regimens in relapsed or refractory myelomatosis and confirms that durable remissions may be achieved. Responders show a gratifying improvement in quality of life and are spared the many toxicities of combination cytotoxic chemotherapy. Further studies of high dose steroid regimens in first-line therapy, especially in patients with bone marrow suppression, are clearly merited.

Leptomeningeal plasmacytosis. Case report and considerations on treatment

We describe a 68-year-old patient with a plasma cell leukaemia in haematological remission presenting with massive intracranial leptomeningeal plasmocytic infiltration (LPI) and hydrocephalus. He was treated with skull irradiation and a combination of intraventricular and lumbar intrathecal therapy with methotrexate. Neurologic improvement and clearance of plasma cells from the cerebrospinal fluid was reached after 2 weeks of treatment but prolonged follow-up was interrupted by a lethal gastro-intestinal haemorrhage, 6 weeks after starting the therapy. From previously reported cases it is known that LPI almost always occurs in either high-grade plasmocytomas or plasma cell leukaemia. These data suggest that therapy of LPI should be the same as in other leukaemias with leptomeningeal infiltration.

Problems of myeloma in a community

The presenting features of 120 consecutive cases of myeloma diagnosed in a single unit were examined. Screening tests on routine laboratory samples increased the detection rate but did not significantly reduce the percentage of cases presenting with late stage disease. Morbidity was closely related to the incidence of bone involvement already present at diagnosis. About one fifth of cases had reported suspicious symptoms for some considerable time before further investigation was forthcoming. Almost half had 'benefitted' by having concurrent disease which often led to the discovery of myeloma at an early stage. These findings, together with the wide variety of symptomatology and few physical signs, stressed the critical importance of having a high index of suspicion and thus taking suitable blood samples without unnecessary delay.

Infused vincristine and adriamycin with high dose methylprednisolone (VAMP) in advanced previously treated multiple myeloma patients

Forty-five patients with relapsed or refractory multiple myeloma received continuous infusions of vincristine (0.4 mg total dose daily for 4 days) and adriamycin (9 mg m-2 daily for 4 days) with a high dose of methylprednisolone (1 g m-2 i.v. or p.o. daily by 1 h infusion), the VAMP regimen. Sixteen (36%) responded, with a median duration of remission of 11 months and median survival of 20 months. Major toxicities encountered were infective and cardiovascular. Two smaller groups of myeloma patients were treated with high dose methylprednisolone (HDMP) alone, or VAMP plus weekly low dose cyclophosphamide (Cyclo-VAMP). HDMP produced short responses in 25% of patients with less toxicity than VAMP. Cyclo-VAMP was used in a highly selected group of patients who had previously responded to high dose melphalan. It was well tolerated and produced responses in 61% of this group.

Multiple myeloma of the serosa coat

We report on a 47-year-old male patient with IgA-kappa plasmacytoma, who 12 months subsequent to diagnosis developed marked ascites. On light and electron microscopy morphologically identical plasma cells with bizarre intracytoplasmatic material were found in the bone marrow, pleural exudate, and ascites fluid. This kind of extramedullary spread is extremely rare and usually resists therapy. The mean survival rate for the 9 patients with malignant plasmacellular ascites whose cases have been documented so far was 2 months. After progression under VCMP regimens our patient has been successfully treated over a period of more than 4 years with i.v. VP16 monotherapy with additional intermittent local administration of methotrexate and systemic poly-chemotherapy according to the VAD scheme.

VBAMDex chemotherapy in advanced multiple myeloma

In a phase II study 28 patients with advanced multiple myeloma were treated with a five drug regimen consisting of vincristine, BCNU, adriamycin, melphalan and dexamethasone. 11 out of 13 patients without prior chemotherapy showed significant remissions (greater than 25% tumor cells mass reduction), 7 of them had more than 75% TCM reduction. Out of 15 additional patients resistant to previous chemotherapy, 13 had significant remissions, including 9 patients with greater than 75% TCM reduction. No tumor progression was observed in either group of patients. The median follow-up of all patients was 12.75 months. 4 patients relapsed. Toxicity mainly related to the bone marrow was observed in 14 patients. This regimen might offer a promising alternative for the treatment of advanced multiple myeloma, but still has to be tested in a prospective randomized trial.

Reversal of drug-resistance in multiple myeloma with verapamil

In vitro testing with a new doxorubicin resistant myeloma cell line revealed the reversal of drug resistance with as little as 100 ng/ml of verapamil (a calcium channel blocker), a dose easily achievable in humans. A first patient with IgG kappa myeloma is presented in whom resistance to VAD (vincristine/doxorubicin infusion plus dexamethasone) chemotherapy was reversed with the administration of verapamil. A subsequent clinical study has been initiated. The potential for further evaluation of calcium channel blockers in multiple myeloma is discussed.

Experience with the Portacath

Fifty Portacaths have been inserted in patients undergoing prolonged outpatient chemotherapy, most for haematological disease. Twenty-one are still working at a median duration of 12 months (range 1-27) and a further 15 were functioning normally at the time of the patients death (median survival 6 months). Four functioning Portacaths have been removed, three suspected of causing septicaemia and one believed erroneously to have occluded. Ten have ceased to function and nine of these have been removed. The causes of these failures are nearly all avoidable and are discussed in detail; many occurred early in our experience. With careful attention to detail and with management by trained and interested staff, the Portacath is a safe and reliable device for intermittent vascular access.

Plasma cell dyscrasias: current status

This is a review of the current status of the monoclonal gammopathies (plasma cell dyscrasias). We begin with the recognition of a monoclonal protein in serum and urine. We briefly discuss the differential diagnosis of the monoclonal gammopathies. Clinical and laboratory findings as well as the management of multiple myeloma are addressed. Future approaches for the treatment of myeloma are provided. The variant forms of multiple myeloma, including smoldering myeloma, plasma cell leukemia, nonsecretory myeloma, IgD myeloma, osteosclerotic myeloma, solitary plasmacytoma of bone, and extramedullary plasmacytoma, are briefly reviewed. Diagnosis and treatment of Waldenström's macroglobulinemia are presented. The recognition and differential diagnosis of the heavy-chain diseases (gamma, alpha, and mu) are included. Monoclonal gammopathy of undetermined significance ("benign" monoclonal gammopathy) is presented in detail. Amyloidosis is not included in this review.

Intratumoral measurement and plasma pharmacokinetics of intravenously administered melphalan. Report of a patient with plasmacytoma

In a human case of plasmacytoma we studied plasma and tumor concentrations of melphalan given intravenously. Intratumoral concentration of melphalan was similar to plasma concentration 60 min after the end of infusion.

Cellular and plasma adriamycin concentrations in long-term infusion therapy of leukemia patients

To determine whether long-term adriamycin (ADM) infusions resulted in cellular ADM concentrations at least comparable to those observed after bolus injections, ADM cellular and plasma concentrations were measured in 18 patients with leukemia. ADM was administered at 30 mg/m2 per day for 3 days, either as bolus injections or as 4-, 8-, or 72-h infusions. Negligible accumulation of plasma ADM was observed. Peak plasma ADM concentrations after bolus injections were 1640 +/- 470 ng/ml (n = 7). Maximum levels were 176 +/- 34 ng/ml during 4-h infusion (n = 5); 85 +/- 50 ng/ml during 8-h infusion (n = 4); and 47 +/- 5 ng/ml (n = 2) after 72-h infusion. ADM concentrations in nucleated blood and bone marrow cells correlated well (r = 0.82, n = 47). ADM accumulated in leukemic cells up to 30-100 times the plasma concentrations. The shorter the administration time-span, the higher the peak leukemic cell concentration and the greater the loss of drug immediately after the end of the administration. The final cellular ADM half-life was approximately 85-110 h. After long-term infusion and bolus injection of the same dose, similar areas under the curve for plasma or leukemic blast cell ADM concentrations were attained. Since comparable therapeutic efficacy was observed in all regimens, the antileukemic effect appeared not to be related to the peak plasma concentrations, while acute toxicity phenomena decreased with increasing duration of the infusion. Long-term ADM infusion deserves more attention in the treatment of patients with anthracyclines.

High-dose chemoradiotherapy with syngeneic bone marrow transplantation for multiple myeloma: a case report and literature review

We had the opportunity to treat a patient with progressive heavily pretreated multiple myeloma with high-dose chemoradiotherapy with hematopoietic rescue by syngeneic bone marrow transplantation. The patient was a 53-year-old male who had previously received melphalan, prednisone, 1,3-bis (2-chloroethyl)-l-nitrosourea (BCNU), vincristine, and standard radiation therapy. At the time of bone marrow transplantation, he had increasing bone pain, increasing M-protein (IgG kappa), and a bone marrow diagnostic of myeloma. The transplant regimen consisted of cyclophosphamide, 60 mg/kg intravenously for 2 days, and total body irradiation--1,200 rads given as 200-rad fractions, twice daily for three days. The transplant course was complicated by confusion, herpes simplex mucositis, fever, and two episodes of idiopathic diffuse interstitial pneumonia. Over the next 2 years the patient did well and was in immunologic and bone marrow complete remission. Unfortunately, 3 years after treatment, the myeloma relapsed with detectable M-protein. Three and one-half years after transplant, clinical relapse occurred with bone pain and lytic lesions necessitating additional radiation and chemotherapy. Salvage therapy has produced clinical improvement and the patient is alive almost 4 years from transplant and almost 7 years from diagnosis. Although intense chemoradiotherapy did not cure this patient, substantial control of a refractory tumor was observed. This case, together with other cases of intense therapy for myeloma which are reviewed in this paper, support the concept of high-dose therapy and should foster further investigation of high-dose therapy.

VAD protocol for treatment of advanced refractory multiple myeloma

Twenty-three patients with advanced refractory multiple myeloma were treated with a combination chemotherapeutic regimen consisting of four-day continuous infusion of vincristine and doxorubicin plus intermittent high-dose dexamethasone (VAD). All patients included in the study were heavily pretreated with cytostatics and radiotherapeutic measures, and generally presented in poor general condition. In 3 of the 16 evaluable patients (18%) a response, and in 7 patients (44%) an improvement as defined by a reduction in tumor mass by more than 50% was achieved. Six patients had progressive disease. Evaluation of survival for responders (15 mos) versus non-responders (2 mos) by the landmark method seems to confirm the relative therapeutic efficacy of the VAD protocol in refractory multiple myeloma. The somewhat inferior response rate as well as the occurrence of considerable toxicity in several cases (when compared to the recent M. D. Anderson trial) may be related to differences in clinical features and pretreatment status of the two studies' population.

Potential value of vintristine-adriamycin-dexamethasone combination chemotherapy (VAD) in refractory and rapidly progressive myeloma

10 patients with myeloma refractory to alkylating agents were treated with either 4-d pulses of high-dose dexamethasone therapy, or 4-d pulsed high-dose dexamethasone in combination with 4-d continuous infusions of vincristine and adriamycin (VAD). 8 patients were evaluated after a median duration of treatment of 2.3 courses (range 1 to 4). 6 of the 8 evaluable patients achieved reduction in serum and/or urine paraprotein levels with a mean reduction in serum paraprotein of 74.1%. There was a concomitant improvement in wellbeing in these responding patients. 2 evaluable patients failed to show biochemical or clinical response (1 treated with VAD, 1 high-dose dexamethasone). 2 patients currently survive 390 d and 180 d, respectively, on continuing therapy. 8 patients died with a mean duration of survival of 99 d (range 10 to 246 d). We conclude that the use of VAD chemotherapy in patients with refractory myeloma confers both a worthwhile remission of disease symptoms and biochemical evidence of disease regression, and that trials of VAD as primary treatment for myeloma are indicated.

VAD chemotherapy--toxicity and efficacy--in patients with multiple myeloma and other lymphoid malignancies

Thirty-three patients with multiple myeloma (11 untreated, 15 refractory and seven relapsed patients) have received vincristine and adriamycin infusion therapy with oral dexamethasone (VAD). The median number of course received was five. In addition 16 patients with lymphoid malignancy have received a median of four courses of VAD. Three patients who relapsed after VAD have received further VAD therapy making 52 patient treatments assessable for toxicity. Ten per cent had nausea, 4 per cent vomiting, 4 per cent total alopecia, 25 per cent constipation, 33 per cent paraesthesiae, 8 per cent proximal myopathy, 33 per cent dyspepsia, 23 per cent proven bacteraemia, and 19 per cent chest infections. Infections were not usually associated with neutropenia. Shingles was seen in four patients with myeloma, but none of the patients with lymphoid malignancy. The response rate in myeloma was 9/11, for previously untreated patients, 3/7 for relapsed, and 8/15 for refractory patients. Responses have been seen in other lymphoid malignancies-1/2 patients with relapsed acute lymphoblastic leukaemia had a complete remission. Two out of seven patients with chronic lymphocytic leukaemia achieved a partial remission, and a further three had a clinical improvement. Three out of six patients with non-Hodgkin lymphoma and one patient with macroglobulinaemia achieved a partial remission.

Monoclonal gammopathy and multiple myeloma in the elderly

The term 'benign monoclonal gammopathy' indicates the presence of a monoclonal protein in persons without evidence of multiple myeloma, macroglobulinaemia, amyloidosis, lymphoproliferative disease, or other related disorders. The term 'monoclonal gammopathy of undetermined significance' (MGUS) is preferable because it is not known at diagnosis whether an M-protein will remain stable and benign or develop into symptomatic multiple myeloma or related disorders. Immunoelectrophoresis and immunofixation of the serum and urine are necessary to determine the presence and type of M-protein. At the Mayo Clinic, follow-up data have been gathered for more than 13 years on 241 patients with an initial benign monoclonal gammopathy. Nineteen per cent of these patients developed multiple myeloma, macroglobulinaemia, amyloidosis, or related diseases during the follow-up period. There is no reliable technique for differentiating a patient with a benign monoclonal gammopathy from one who will subsequently develop a serious disease. It is necessary to follow these patients indefinitely. Important in the complete understanding of the elderly patient with monoclonal gammopathy are the following: clinical manifestations, laboratory findings, and differential diagnosis of multiple myeloma; the course and prognosis and the induction therapy and treatment of multiple myeloma; newer therapeutic approaches; and the management of complications such as hypercalcaemia, hyperuricaemia, renal failure, bacterial infections, skeletal disease, and neurological problems.

Multiple myeloma treated with high dose intravenous melphalan

High dose melphalan (HDM, 140 mg/m2 i.v.) has been evaluated in 58 patients under 63 years with multiple myeloma. Among previously untreated patients 11/41 (27%) entered a complete remission (CR: no measurable myeloma protein and a normal bone marrow) and 21 (51%) entered a partial remission (more than 50% reduction in myeloma protein and improvement in all other features). Median duration of remission is 19 months. Two patients who had responded to previous conventional treatment entered CR after HDM. Among 15 patients who had failed on previous chemotherapy the response rate was 66% including two CRs. However, in this group all patients have relapsed within 1 year. Profound myelosuppression, moderate nausea, vomiting, mucositis and diarrhoea with reversible alopecia occurred in all patients. There were 10 deaths within 2 months of treatment mainly due to sepsis and haemorrhage. In a subsequent study, high dose methyl prednisolone (1 g/m2 daily for 5 d) has been added to HDM. Response rates are similar with 6/22 (27%) CR, 13/22 (59%) PR and 2/22 NR but there was only one early death, reflecting improvements in medical management. The high CR rate is an encouraging feature of this approach which is now to be the basis of a prospective trial sponsored by the Medical Research Council in which HDM, with and without steroids, is compared to the best available conventional therapy (the MRC VI Myelomatosis trial).

Renal failure and the histopathological features of myeloma kidney reversed by intensive chemotherapy and peritoneal dialysis

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Continuous infusion or intravenous bolus: what is the rationale for doxorubicin administration?

In order to achieve a better therapeutic index of anticancer drugs, numerous authors are using continuous infusion therapy rather than classical intravenous bolus injection. In the case of doxorubicin or daunorubicin numerous experimental data have been published, which could provide a rationale to this clinical problem. However, due to the variety of the approaches used, the results are inconsistent and no definitive conclusion can be drawn. Several clinical phase I and II trials have been performed since 1980; they show that the toxicity of doxorubicin may be reduced by the use of continuous infusion, but the preservation of the efficacy of the drug has never been proved. Comparative phase III trials are required before this schedule of administration become routine procedure for this drug.

Interferons in the treatment of multiple myeloma

A review of the clinical studies in which interferons have been involved has shown that they may have a role in the treatment of multiple myeloma. Twelve studies, each of which involved at least 10 evaluable cases (352 in total) with various dose schedules involving leukocyte, lymphoblastoid and recombinant alpha-IFNs, reported 8-33% objective responses. The response duration was rather short but, in a few cases, it lasted for more than a year. In addition to a decrease in the levels of M-protein and/or urine Bence-Jones protein, a decrease in the number of plasma cells in the bone marrow, disappearance of bone pain, healing of bone lesions, increase of hemoglobin and/or restoration of normal immunoglobulins were observed. Higher doses of recombinant alpha-interferons seemed to exert a stronger effect. No clear difference in response rate was observed between myeloma which had been previously treated and that which was not treated. At least clinically, therefore, there seems to be no cross-resistance between alpha-interferons and conventional anti-tumor drugs. A randomized study comparing low-dose leukocyte interferon with intermittent high-dose melphalan-prednisone has given a lower response rate for interferon. Beta- and gamma-interferons have not yet been extensively studied. They have been used at low doses producing an objective response in 7% of 68 and 2% of 45 evaluable cases, respectively. Since the myelosuppression of interferons is transient and, after discontinuation of interferon therapy, peripheral blood cells usually recover within a week, it may be possible to use interferon in combination with agents that have strong myelosuppressive effects provided there is no synergism.

A new anthracycline regimen for prolymphocytic leukemia? Study of a case report with flow cytometric implications

A case of prolymphocytic leukemia (PL) is reported, which showed a good response to a new antiblastic schedule (4-epidoxorubicin-asparaginase-dexamethasone) in spite of the resistance to other chemotherapy regimens. However during the course of the disease it was possible to observe the terminal appearance of a small aneuploid cell population in the peripheral blood of the patient and, in the same time, the clinical condition deteriorated considerably. The significance of this neoplastic progression and the pros and cons of aggressive chemotherapy regimens remain to be carefully evaluated in PL and related disorders.

The efficacy and toxicity of VAD in the treatment of myeloma and related disorders

Impressive results have recently been reported in 29 cases of advanced refractory myeloma treated with 4-d infusions of Vincristine and Adriamycin (VAD). We report our own experience with this protocol in 13 cases of myeloma and related lymphoproliferative disorders. In 2 of these cases, VAD was used as first line treatment. Objective responses were seen in two-thirds of cases and the major complication of therapy was infection, predominantly bacterial in nature.

Treatment of alkylating resistant multiple myeloma with vincristine, BCNU, doxorubicin and prednisone (VBAP)

A total of 33 evaluable patients with multiple myeloma refractory to alkylating agents were treated with the regimen vincristine, BCNU, doxorubicin, and prednisone (VBAP) at 3-week intervals in a single institution for a 5-yr period. An overall response rate of 21.2% was achieved (9% objective plus 12.2% improvement). Treatment was well tolerated. The overall median survival was 7.5 months. However, responding patients attained a median survival of 27.4 months vs. 5 months for similarly treated nonresponding subjects (P = 0.051). These results indicate that VBAP is an effective treatment for a proportion of patients with advanced refractory multiple myeloma.

Doxorubicin/vinblastine and doxorubicin/cyclophosphamide combination chemotherapy by continuous infusion

Fifty-two patients received one of two doxorubicin (DOX)-based admixtures; DOX plus cyclophosphamide (CTX) or DOX plus vinblastine (VBL) administered as a continuous 24-hour infusion for protracted periods. Compatibility and stability of the two-drug admixture was established for a minimum of 7 days. Twenty patients on the DOX/CTX admixture were infused for a median of 20 days (range, 7-56 days). DOX/VLB was infused in 32 patients for a median of 18 days (range, 5-48 days). Dose limiting toxicity was leukopenia observed in 14/52 patients; 4/20 on DOX/CTX and 10/32 on DOX/VLB. Additional toxicities observed included stomatitis (15%) and subclavian vein thrombosis (23%). Tumor responses were observed in 11 patients, including 6/13 breast cancer; 2/2 hepatoma; 2/4 sarcoma and 1/1 ovarian cancer. Responses were relatively short-lived and no responses were noted in known anthracycline resistant tumors. Admixtures of chemotherapeutic agents represents a novel, but feasible, mechanism for delivery of multiple drugs with an infusion schedule and can be considered for Phase III comparative clinical trials.