Interferon alfa-2a and fluorouracil in the treatment of patients with advanced esophageal cancer

Topical Chemotherapy for Treating Ocular Surface Squamous Neoplasia with a Combination of Interferon α-2b and 5-Fluorouracil

Introduction

This study evaluated the efficacy of combined interferon α-2b (IFNα2b) and 5-fluorouracil (5-FU) as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this retrospective study, 27 eyes with OSSN followed by topical application of combined IFNα2b and 5-FU were examined. Reported outcome measures were tumor response, visual acuity, time to complete resolution, recurrence and treatment complications.

Results

Twenty-six patients (17 male, 9 female) had a mean age of 63.9 (median, 67; range 22–83) years. Complete tumor response was observed in 24 eyes (88.9%). Three eyes (11.1%) showed partial response to the chemotherapy agents and later underwent surgical tumor removal. The median time to complete resolution was 6 (mean, 6.1; range, 3–11) weeks. Of these, the patients received between one to three cycles of 5-FU therapy (median, 2; mean, 1.8). Complications noted were transient irritation at 5-FU cycle (11 eyes, 40.7%). There was no tumor recurrence at mean follow-up of 16.1 (median, 12; range 6–38) months.

Conclusions

Combination therapy of IFNα2b and 5-FU was a safe and effective treatment, inducing a short duration of administration and low recurrence rate for OSSN.

Trial Registration

Retrospectively registered, UHCT22048.

Interferon Alpha-Expressing Oncolytic Adenovirus for Treatment of Esophageal Adenocarcinoma

INTRODUCTION

Esophageal adenocarcinoma (EAC) has increased in incidence in Western countries, and its poor prognosis necessitates the development of novel therapeutics. We previously reported the potential of conditionally replicative adenoviruses (CRAd) as a novel therapeutic treatment for this disease. To further augment the therapeutic effectiveness of our cyclooxygenase-2 (Cox2) controlled CRAd in EAC, we inserted an interferon alpha (IFN) transgene into the viral genome that is expressed upon viral replication. In this manuscript, we analyze the cytotoxic and oncolytic effects of an IFN-expressing oncolytic adenovirus in EAC and the role of the Cox2 promoter in providing for selective replication in human tissues.

METHODS

An infectivity-enhanced IFN-expressing CRAd (5/3 Cox2 CRAd ΔE3 ADP IFN) and other control viruses were first tested in vitro with cell lines. For the in vivo study, EAC xenografts in nude mice were treated with a single intratumoral dose of virus. An ex vivo analysis with live tissue slices was conducted using surgically resected EAC patient specimens.

RESULTS

Expression of IFN significantly enhanced the cytotoxic and oncolytic effect of a Cox2-promoter controlled CRAd. This virus showed significant tumor growth suppression in a xenograft model. Furthermore, in human EAC samples, the promoter-controlled virus demonstrated selective replication in cancerous tissues, leaving normal esophageal tissue unaffected.

CONCLUSION

An IFN-expressing CRAd driven by the Cox2 promoter has strong oncolytic effects as well as cancer-specific replication. Our novel vector possesses critical characteristics that make it a potential candidate for clinical translation to treat EAC.

Combination of interferon-α and 5-fluorouracil induces apoptosis through mitochondrial pathway in hepatocellular carcinoma in vitro

Many clinical reports have proven that the combination therapy of interferon-alpha plus 5-fluorouracil is remarkably effective for advanced hepatocellular carcinoma (HCC). However, the mechanism of this therapy is not well understood. Here, we demonstrated that the combination therapy synergistically inhibited the growth of Fas-negative HCC cells, arrested cell-cycle progression and induced apoptosis. Moreover, the combination therapy significantly increased the protein expression of caspase-8, activated Bid and cytochrome c. Meanwhile, the expression of anti-apoptotic gene Bcl-xL was reduced and intracellular calcium elevated obviously during the early stage of treatment. Therefore, mitochondrial pathway was involved in the apoptosis of Fas-negative HCC cells induced by IFN-α/5-FU and Ca(2+) partially promoted the beneficial effect against HCC.

Interferon-inducible guanylate binding protein (GBP)-2: a novel p53-regulated tumor marker in esophageal squamous cell carcinomas

TP53 mutations are common in esophageal squamous cell carcinomas (SCC). To identify biological markers of possible relevance in esophageal SCC, we (i) searched for genes expressed in a p53-dependent manner in TE-1, an esophageal SCC cell line expressing the temperature-sensitive TP53 mutant V272M, and (ii) investigated the expression of one of those genes, the interferon-inducible Guanylate Binding Protein 2 (GBP-2), in esophageal SCC tissues. Clontech Human Cancer 1.2 arrays containing 1,176 human cancer gene-related sequences were used to identify differentially expressed genes in TE-1 cells at permissive (32 degrees C) and nonpermissive (37 degrees C) temperatures. The expression of GBP-2 and IRF-1, its main transcriptional regulator, was analyzed by immunohistochemistry in a retrospective series of 41 esophageal SCC cases with a clear transition zone from noncancer, apparently normal epithelium to invasive cancer. The expression of the GBP-2 gene is consistently increased in TE-1 at 32 degrees C in a p53-dependent manner, as confirmed by inhibition of p53 expression by RNA interference. Increase in GBP-2 is accompanied by an increase in protein levels of IRF-1, the main transcriptional regulator of GBP-2, and in the formation of complexes between p53 and IRF-1. GBP-2 expression is significantly higher in esophageal SCC than in adjacent normal epithelium (p<0.01), in which GBP-2 staining is limited to the basal layer. Our results suggest that p53 up-regulates GBP-2 by cooperating with IRF-1. The association of GBP-2 expression with proliferative squamous cells suggests that GBP-2 may represent a marker of interest in esophageal SCC.

Pharmacotherapy for oesophagogastric cancer

Gastric cancer is the seventh and oesophageal cancer the ninth most common cancer in the UK, and >50% of patients present with locally advanced or metastatic disease. The incidence of oesophageal and oesophagogastric junctional tumours is increasing, making these important disease entities to understand and research. Despite improvements in surgical and peri-operative supportive care, 3-year overall survival with surgery alone for resectable disease is still poor. Outcomes in localised oesophageal cancer are improved with pre-operative chemotherapy, and in gastric cancer with peri-operative treatment or post-operative chemoradiotherapy. Oesophageal squamous cell carcinoma can be treated with definitive chemoradiotherapy as an alternative to surgery. While survival in patients presenting with metastatic disease is improved with the addition of systemic chemotherapy, median survival remains <1 year. Patients who are otherwise fit can be offered chemotherapy and this is superior to best supportive care. Regimens including a platinum and an anthracycline agent are favoured by the results of randomised trials. No standard second-line therapy has emerged. New research into taxanes has shown promising anti-cancer activity, and novel areas of investigation include incorporation of agents targeting vascular endothelial growth factor or epidermal growth factor receptor into standard regimens. This review focuses on the clinical trial evidence that dictates the optimal management of localised and advanced oesophagogastric cancer, focusing on pharmacotherapy. We examine areas of current research and highlight future therapeutic directions.

Interferon receptors and the caspase cascade regulate the antitumor effects of interferons on human pancreatic cancer cell lines

BACKGROUND

Interferons (IFNs) have antiproliferative effects on tumor cells. The apoptotic effects and sensitization to chemotherapy conferred by IFN therapy, however, are not clearly understood. The aims of the present study were to explore the apoptotic effects of IFNs in human pancreatic cancer cell lines and to attempt to define their ability to synergistically enhance sensitivity to 5-fluorouracil (5-FU) and gemcitabine, a mechanism that depends on the expression of IFN receptors.

METHODS

Human pancreatic cancer cells were cultured alone or in combination with the chemotherapeutic agents 5-FU and gemcitabine. Differential dosages of IFN-alpha, -beta, and -gamma were also added to the cell lines concomitantly during a period of 24 to 96 hours. The cell line viability and effects of treatment were examined using the methylthiazol tetrazolium assay and single-stranded DNA apoptosis assay. The expression of IFN receptors was determined using immunohistochemistry. Caspase-8 inhibitor was used to block the caspase cascade.

RESULTS

The antiproliferative and apoptotic effects of IFNs were most profoundly demonstrated on those cells that expressed the respective IFN receptor. The apoptotic effects provided by the interferons, however, were blocked by caspase-8 inhibition. The addition of IFNs significantly enhanced the cytotoxic effects of 5-FU and gemcitabine in those cell lines that expressed the corresponding IFN-alpha, -beta, or -gamma receptors.

CONCLUSIONS

This study on pancreatic cancer cell lines has demonstrated that IFNs mediate apoptosis through IFN receptors and the caspase cascade. Enhanced cytotoxicity occurred when IFNs were combined with 5-FU and gemcitabine.

Combination of IFN- and 5-Fluorouracil Induces Apoptosis through IFN-α/β Receptor in Human Hepatocellular Carcinoma Cells

Purpose: Several studies showed the effectiveness of combination therapy with IFN-α and 5-fluorouracil (5-FU) for advanced hepatocellular carcinoma. However, only little is known about the underlying mechanism of combination therapy. In the present study, we examined whether apoptosis through IFN-α/β receptor (IFN-α/βR) was associated with the effects of combination therapy.

Experimental Design: HuH7, PLC/PRF/5, HLE, and HLF were treated with IFN- (500 units/mL), 5-FU (0.5 μg/mL), or their combination for 10 days. In addition, IFN-α/βR gene transfer with combination therapy was done.

Results: Ten-day treatment by combination therapy resulted in &gt;80% cell growth inhibition. Terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling analysis showed synergistic effects for combination therapy on PLC/PRF/5, HLE, and HLF. Concordant results were obtained with DNA fragmentation. Moreover, there was an evidence showing that changes in the expression of Bcl-2 family lead to apoptosis. On the other hand, the expression of IFN-α/βR and up-regulation of α-phospho–signal transducer and activator of transcription 1, IFN regulatory factor-1 by combination therapy were observed in all cell lines. Furthermore, IFN-α/type 2 IFN receptor long form–transfected HuH7 cells treated with combination therapy showed strong DNA fragmentation compared with nontransfected or transfected with IFN-α- and 5-FU-treated HuH7.

Conclusions: Our results showed that combination of IFN-α plus 5-FU strongly induced cell growth inhibition of human hepatocellular carcinoma cells and indicated that oneof the direct mechanisms of combination therapy may in part be attributable to alterations in induction of apoptosis through IFN-α/βR.

Comparative Antitumor Activity of 5-Fluorouracil and 5’-Deoxy-5-Fluorouridine in Combination with Interferon-α in Renal Cell Carcinoma Cell Lines

OBJECTIVES

Although interferon-alpha (IFNalpha) and interleukin-2 are used in the treatment of advanced renal cell carcinoma (RCC), the rate of efficacy is about 15% and not satisfactory. Therefore, a more effective treatment is being investigated. In this study, we examined the combined effects of IFNalpha and 5-fluorouracil (5-FU) as well as 5-deoxy-5-fluorouridine (5'-DFUR), a produrg of 5-FU, in vitro.

MATERIALS AND METHODS

Four RCC cell lines (OCUU1, OCUU3, OCUU4, OCUU5) were established at our laboratory from RCC patients. OS-RC-2, RCC10RGB, TUHR14TKB, TUHR4TKB, A498 and Caki-1 were obtained from a commercial source. The sensitivity of the 10 RCC cell lines to 5-FU and 5'-DFUR was evaluated using MTT assay. The IC50 value for the cytostatics was expressed as the concentration at which growth was inhibited by 50% as compared with the control value. Thymidine phosphorylase (TP), the enzyme that converts 5'-DFUR into 5-FU and 5-FU into FdUMP, was estimated by ELISA.

RESULTS

When the 10 RCC cell lines were divided into the low TP expression group and high TP expression group at 2.0 U/ml protein, TP expression was not enhanced by IFNalpha in all 4 cell lines in the low TP expression group. Antitumor effects were not enhanced by IFNalpha in 3 out of 4 cell lines for 5-FU and in all 4 cell lines for 5'-DFUR. On the other hand, in the high TP expression group, TP expression was enhanced by IFNalpha in 5 out of 6 cell lines, and antitumor effects were enhanced by IFNalpha in 5 out of 6 cell lines for 5-FU and in all 6 cell lines for 5'-DFUR. In addition, there was a significant correlation between TP expression and sensitivity to 5-FU and 5'-DFUR in all RCC cell lines.

CONCLUSIONS

These results suggested that TP may be useful as a predictive factor in combination therapy with IFNalpha and 5-FU or 5'-DFUR, which may be a promising treatment for advanced RCC.

Multiple Management Modalities in Esophageal Cancer: Combined Modality Management Approaches

The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.

Potential of interferon-alpha in solid tumours: part 2

The second part of this review examines the use of recombinant interferon-alpha (rIFNalpha) in the following solid tumours: superficial bladder cancer, Kaposi's sarcoma, head and neck cancer, gastrointestinal cancers, lung cancer, mesothelioma and ovarian, breast and cervical malignancies. In superficial bladder cancer, intravesical rIFNalpha has a promising role as second-line therapy in patients resistant or intolerant to intravesical bacille Calmette-Guérin (BCG). In HIV-associated Kaposi's sarcoma, rIFNalpha is active as monotherapy and in combination with antiretroviral agents, especially in patients with CD4 counts >200/mm(3), no prior opportunistic infections and nonvisceral disease. rIFNalpha has shown encouraging results when used in combination with retinoids in the chemoprevention of head and neck squamous cell cancers. It is effective in the chemoprevention of hepatocellular cancer in hepatitis C-seropositive patients. In neuroendocrine tumours, including carcinoid tumour, low-dosage (</=3 MU) or intermediate-dosage (5 to 10 MU) rIFNalpha is indicated as second-line treatment, either with octreotide or alone in patients resistant to somatostatin analogues. Intracavitary IFNalpha may be useful in malignant pleural effusions from mesothelioma. Similarly, intraperitoneal IFNalpha may have a role in the treatment of minimal residual disease in ovarian cancer. In breast cancer, the only possible role for IFNalpha appears to be intralesional administration for resistant disease. IFNalpha may have a role as a radiosensitising agent for the treatment of cervical cancer; however, this requires confirmation in randomised trials. On the basis of current evidence, the routine use of rIFNalpha is not recommended in the therapy of head and neck squamous cell cancers, upper gastrointestinal tract, colorectal and lung cancers, or mesothelioma. Pegylated IFNalpha (peginterferon-alpha) is an exciting development that offers theoretical advantages of increased efficacy, reduced toxicity and improved compliance. Further data from randomised studies in solid tumours are needed where rIFNalpha has activity, such as neuroendocrine tumours, minimal residual disease in ovarian cancer, and cervical cancer. A better understanding of the biological mechanisms that determine response to rIFNalpha is needed. Studies of IFNalpha-stimulated gene expression, which are now feasible, should help to identify molecular predictors of response and allow us to target therapy more selectively to patients with solid tumours responsive to IFNalpha.

Phase II clinical trial of 13-cis-retinoic acid and interferon-alpha-2a in patients with advanced esophageal carcinoma

BACKGROUND

Interferon in combination with 5-fluorouracil has been shown to be active in squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus. 13-cis-retinoic acid (CRA) has chemopreventive activity in SCC of the head and neck, and, in combination with interferon, has antitumor activity in SCC of the skin and cervix.

METHODS

The activity and toxicity of CRA and interferon-alpha-2a (IFN) in patients with advanced esophageal carcinoma was evaluated in a Phase II single institution trial. Patients had unresectable or metastatic AC or SCC of the esophagus. One prior chemotherapy regimen was allowed. IFN was given by daily subcutaneous injection at a dose of 3 million U and CRA was taken orally at a dose of 1 mg/kg/day in 2 divided doses. Treatment was given in cycles of 4 weeks and continued until documented disease progression.

RESULTS

Of the 19 patients entered, 15 were evaluable for response and toxicity. One patient was evaluable for response only and one patient was evaluable for toxicity only. Evaluable patients were predominantly male (15 patients), and had AC (13 patients). All had AJCC Stage IV disease and 12 were pretreated. Patients completed an average of two cycles of therapy (range, one to six cycles) prior to progression of disease. National Cancer Institute Common Toxicity Criteria Grade 3/4 toxicity was notable for nausea (25%) and fatigue (31%). No major objective responses were recorded. Eleven patients with AC and 3 patients with SCC had rapid progression of disease. One patient with AC was found to have a minor response for 22 weeks and 1 patient with AC had stable disease for 45 weeks.

CONCLUSIONS

This regimen had no significant activity in patients with advanced AC of the esophagus. Further evaluation of IFN plus CRA, using this dose and schedule, is not recommended. In comparison with prior trials of this therapy, a surprising amount of severe nausea and fatigue was observed in this trial.

The role of chemoradiotherapy in maintaining quality of life for advanced esophageal cancer

From May 1996 to July 1996, three male patients with advanced esophageal cancer with complete obstruction were treated with concurrent chemoradiotherapy. The first two courses of chemotherapy using 5-Fluorouracil (500 mg/m2) and Leucovorin (200 mg/m2) on day one through day five were given concurrently with radiotherapy. After completion of radiotherapy, four more courses of chemotherapy using the same regimen were given every four weeks. The total dose of irradiation using six MV linear accelerator given to the primary tumor was 5,000 cGy in 28 fractions. All three patients had relief of their obstruction with complete regression of the tumor after the completion of their treatment. All patients improved clinically and were able to remain symptom-free until the time of their death. The first patient survived for 12 months and died of respiratory failure because of his chronic obstructive pulmonary disease. The second patient also survived 12 months but died of liver metastasis. The third patient lived for 10 months and died of aspiration pneumonia.

Phase II clinical trial with 5-fluorouracil, recombinant interferon-alpha-2b, and cisplatin for patients with metastatic or regionally advanced carcinoma of the esophagus

BACKGROUND

Recombinant interferon-alpha (IFN) augments the cytotoxicity of both 5-fluorouracil (5-FU) and cisplatin in vitro. A phase II study of 5-FU and IFN resulted in response rates of 25-27% in patients with metastatic esophageal carcinoma.

METHODS

A Phase II trial was initiated to determine the clinical utility of a three-drug combination (FIP) in patients with regionally advanced or metastatic esophageal carcinoma. Eligibility included biopsy-proven Stage III or IV squamous cell carcinoma or adenocarcinoma of the esophagus with no prior chemotherapy, adequate performance status, nutritional status, bone marrow, hepatic and renal function, and signed informed consent. Patients were treated in the exact sequence of IFN==>cisplatin==>5-FU. Patients received 5-FU, 750 mg/m2/day for 5 days followed by weekly bolus therapy at the same dose; cisplatin, 100 mg/m2 on Day 1, followed by weekly therapy, 25 mg/m2 over the course of 1 hour; and IFN, 10 MU subcutaneously 3 times/week beginning on Day 1. All patients received sargramostim (granulocyte-macrophage colony-stimulating factor, Escherichia coli-derived), 5 micrograms/kg subcutaneously 5 times/week. No patients received radiotherapy.

RESULTS

Twenty-four patients were enrolled; 23 were eligible, and 1 was excluded on pathology review (patient was found to have a leiomyoblastoma). The demographics of the population were: median age, 63 years (range, 43-73 years); 18 male patients; squamous cell carcinoma: adenocarcinoma ratio, 22:1, and Stage III:IV ratio, 10:13. Grade 3-4 National Cancer Institute Common Toxicity Criteria toxicities included: leukopenia (13), thrombocytopenia (14), and infection (9). Grade 3 diarrhea, mucositis, and vomiting occurred in 6 patients, 4 patients, and 1 patient, respectively. There were two instances of sudden death, likely related to tumor progression. Major responses occurred in 15 of 23 patients (65%; 95% confidence interval, 43%, 85%) (1 complete response, 14 partial responses). The median survival was 8.6 months; with a median follow-up of 26 months, estimated 30-month survival was 31%.

CONCLUSIONS

This regimen, although moderately toxic, has substantial activity in metastatic and regionally advanced squamous cell carcinoma of the esophagus. Further investigations should be conducted to determine the role of IFN in the treatment of esophageal carcinoma.

Review of adjuvant chemotherapy for gastric cancer

Controlled randomized studies that compared surgery alone to adjuvant chemotherapy for gastric cancer were reviewed. The amount of residual tumor after surgery, selection of drug regimens, compliance with drug administration, and trial design seem to be responsible for the success of adjuvant chemotherapy. Though there are few beneficial regimens of adjuvant chemotherapy with statistical significance, single drug therapy with mitomycin C (MMC) and combination therapy with 5-fluorouracil (5FU) and methyl-CCNU, MMC/5FU/cytosine arabinoside (MFC), and 5FU/Adriamycin/MMC (FAM) seem to have potential survival benefit for patients with curative surgery. Incorporation of new drugs into adjuvant or neoadjuvant chemotherapy might open a new aspect of multimodality therapy for gastric cancer.

Phase II trial of chemotherapy, external and intraluminal radiation plus surgery for oesophageal cancer

A pilot study was performed to assess the feasibility of combining 5-fluorouracil, recombinant alpha-2b-interferon, external radiation therapy and intraluminal high dose rate brachytherapy with surgery in patients with locally advanced esophageal carcinoma. 5-fluorouracil, 750 mg m-2, was administered via continuous 5-day infusion beginning day 1 and weekly thereafter; interferon, 10 mu subcutaneously, was administered three times per week beginning day 1 and sargramostin, 5 micrograms kg-1, was administered on days without 5-fluorouracil. External radiation began on day one using 1.5 daily fractions to 55.5 Gy. Intraluminal brachytherapy was delivered concomitantly once each week for 5 fractions of 4 Gy. None of the first eight patients went to surgery. The external radiation was changed to 1.5 Gy BID to 45 Gy followed by BID intraluminal radiation to 15 Gy. Of the last four patients, there was one case of radiation myelitis. It was found that successful surgery was not possible and excessive toxicities, including radiation myelitis, occurred with this aggressive regimen.

A phase II trial of interferon alpha-2A, 5-fluorouracil, and cisplatin in patients with advanced esophageal carcinoma

BACKGROUND

The combination of 5-fluorouracil (5-FU) and cisplatin has moderate antitumor activity in the treatment of metastatic epidermoid carcinoma of the esophagus. The authors have recently shown activity for the combination of 5-FU and interferon-alpha 2a (IFN-alpha) in both esophageal epidermoid and adenocarcinoma. A Phase II trial, therefore, was undertaken to evaluate the antitumor activity of the three-drug combination of IFN-alpha, 5-FU, and cisplatin in unresectable or metastatic esophageal carcinoma.

METHODS

Twenty-seven patients with locally advanced or metastatic carcinoma of the esophagus were treated. No prior chemotherapy was allowed. Twelve patients had epidermoid carcinoma (44%) and 15 patients had adenocarcinoma (56%). Patients received IFN-alpha at a dose of 3 x 10(6) units/day given daily by subcutaneous injection on days 1 to 28, 5-FU at a dose of 750 mg/m2/day for 5 days by continuous intravenous infusion on days 1 to 5, and cisplatin at a dose of 100 mg/m2 on day 1. Treatment was recycled every 28 days, and after the first three cycles, cisplatin was administered only on alternate cycles. Twenty-seven patients completed a median of 4 cycles (range, 1-13 cycles), and 26 patients were evaluable for response.

RESULTS

Major responses were observed in 13 patients (50%, 95% confidence intervals, 31-69%), including two complete responses (8%). The response proportion in epidermoid carcinoma (8 of 11 patients, 73%) was higher than the response proportion in adenocarcinoma (5 of 15 patients, 33%). The median duration of response was 29 weeks (range, 11-74 weeks), similar in epidermoid carcinoma and adenocarcinoma. Toxicity was moderately severe but manageable with dose attenuations. Grade 3/4 hematologic toxicity was observed in 41% of patients and grade 3/4 nonhematologic toxicity was observed in 26% of patients. IFN-alpha was reduced to either a 3- or 5-day a week schedule because of fatigue and/or myelosuppression in 12 patients (44%). There were two treatment-related deaths (7%).

CONCLUSION

In this Phase II trial, the combination of IFN-alpha, 5-FU, and cisplatin had substantial antitumor activity in esophageal carcinoma with apparently greater antitumor activity in epidermoid carcinoma than adenocarcinoma. A larger confirmatory trial comparing this treatment to conventional 5-FU and cisplatin is warranted for epidermoid carcinoma. In future chemotherapy trials, the response assessment for epidermoid and adenocarcinoma should continue to be stratified.

A phase II trial of alpha-interferon and 5-fluorouracil in patients with advanced carcinoid and islet cell tumors

BACKGROUND

5-Fluorouracil (5-FU) has shown modest single-agent activity in patients with carcinoid or islet cell tumors. Alpha interferon (alpha-IFN) has also shown modest single agent activity in these diseases, although biologic responses have been far more prevalent than have objective tumor regressions. The combination of alpha-IFN and 5-FU has demonstrated enhanced activity in several gastrointestinal malignancies.

METHODS

Twenty-one patients with advanced neuro-endocrine tumors (14 with carcinoid tumors, 7 with islet cell carcinomas) were treated with alpha-IFN and 5-FU in a Phase II study. 5-Fluorouracil was administered by intravenous bolus injection at an initial dose of 400 mg/m2/day for 5 consecutive days. After a 1-week break, 5-FU then was administered weekly by intravenous bolus at a dose of 750 mg/m2. Alpha interferon administration was begun on Day 1 of 5-FU at a daily dose of 3 x 10(6) U subcutaneously and continued for the duration of the trial.

RESULTS

Of the 14 carcinoid patients with carcinoid tumors, 1 experienced a partial response (7%; 95% confidence interval [CI] 0-20%) that lasted for 6 months. Eight of the patients with carcinoid tumors achieved stable disease for a median of 6 months (range, 2-10 months). One of the patients with islet cell tumors (14%; 95% CI 0-39%) achieved a partial response that persisted after 8 months; 4 patients with islet cell tumors had stable disease for a median of 13 months (range, 4-27+ months). Even at this relatively low dose of alpha-IFN, 14 of 21 patients required a dose reduction in the alpha-IFN (13 for fatigue, 1 for ataxia). Three patients experienced myelosuppression of greater than Grade 3, and three patients had diarrhea of greater than Grade 3. One patient experienced dose-limiting hand-foot syndrome.

CONCLUSIONS

These results suggest that the combination of 5-FU and alpha-IFN does not have any clear superiority over the individual agents alone; 5-FU appears to reduce patient tolerance of alpha-IFN when given on a daily schedule. Further investigations are needed to identify active agents in the treatment of neuroendocrine malignancies.

Combined treatment modalities in esophageal cancer. Should chemotherapy be included?

The poor prognosis of esophageal carcinoma patients after treatment with local modalities (surgery/radiotherapy) is well known. The purpose of this review is to assess the question whether addition of chemotherapy to local treatment of squamous cell carcinoma of the esophagus has had any beneficial effect on treatment results. In the absence of a sufficient number of randomized trials addressing this issue, data mainly from single-arm studies are discussed. Compiled data from studies on preoperative chemotherapy, preoperative chemoradiation and chemoradiation without surgery suggest that addition of chemotherapy to local treatment (surgery/radiotherapy) might increase short-term survival (2 years) compared to local therapy alone. In the case of chemoradiation without surgery this conclusion is strengthened by results from randomized trials. In general lack of long-term follow-up data limits conclusion whether to recommend the inclusion of chemotherapy into treatment of esophageal cancer or not. Treatment results, however, from studies utilizing combination chemotherapy given concomitant with radiotherapy support the contention that well-designed randomized trials with long-term follow-up should be performed. Outside controlled trials, however, surgery or radiotherapy should still be regarded as standard treatment modalities.

Biologic agents as biochemical modulators: pharmacologic basis for the interaction of cytotoxic chemotherapeutic drugs and interferon

Biochemical modulation of cytotoxic cancer chemotherapeutic agents is one means of enhancing the activity and selectivity of antitumor drugs. Traditionally this approach has utilized detailed information regarding a particular enzymatic reaction or biochemical pathway to develop potential modulating agents. In contrast, the reported clinical therapeutic activity of IFN in combination with cytotoxic agents has prompted a reexamination of the biochemical actions of the cytokine. Interferon elicits a number of cellular actions that might contribute to its pharmacologic activity, including both direct antitumor effects and host-mediated actions. The best understood are those related to the cytotoxicity of the fluoropyrimidine antimetabolites and include enzymatic reactions involved in fluoropyrimidine metabolic activation, catabolism, and interaction with its target enzyme. However, even in this instance, a mechanistic association of a specific pharmacologic action with therapeutic activity remains to be determined. These studies demonstrate that cytokines and other biologic agents may exert specific biochemical modulations that augment (or potentially attenuate) the activity of the cytotoxic chemotherapeutic agents.

Low serum alpha-fetoprotein level in patients with hepatocellular carcinoma as a predictor of response to 5-FU and interferon-alpha-2b

BACKGROUND

A Phase II clinical trial was conducted to evaluate the efficacy of intravenous fluorouracil (5-FU) and subcutaneous recombinant interferon-alpha-2b (rIFN-alpha-2b) in the treatment of hepatocellular carcinoma (HCC) and to define factors that might be predictive of a response to treatment.

METHODS

Twenty-nine patients were registered on the protocol. 5-FU was administered as a continuous intravenous (i.v.) infusion (dose = 750 mg/m2) for 5 consecutive days. rIFN-alpha-2b was administered subcutaneously (SC) (dose = 5 x 10(6) um/m2) once a day on days 1, 3, and 5 of the 5-FU infusion. The treatment was repeated at 14-day intervals. Responses were assessed at the end of one course of therapy, which was equivalent to four treatments.

RESULTS

Of the 28 patients evaluable for response, 5 (18%) had a partial response, and 1 (4%) had a minor response. Responses lasted from more than 2 to more than 24 months (median, 11.5 months). Ten (36%) patients experienced no response, and 12 (43%) had progressive disease. The 6 responders were part of a group of 16 patients who had pretreatment levels of serum alpha-fetoprotein (AFP) of 50 ng/ml or less and a group of 8 whose tumors involved 50% or less of the liver parenchyma. Mucositis, which occurred in 54% of the patients, was the most common toxicity associated with the treatment regimen. Diarrhea and dermatitis were observed in 16% and 17% of the patients, respectively; fatigue, thrombocytopenia, granulocytopenia, neurologic toxicity, and nausea and vomiting were not commonly seen.

CONCLUSIONS

The regimen of i.v. 5-FU and SC rIFN-alpha-2b was well tolerated and induced durable partial response in 31% (5 of 16) of patients with HCC who had low levels of serum AFP and in those with 50% or less of liver replacement. In contrast, the treatment regimen was ineffective in patients with HCC who had high levels of serum AFP or extensive liver disease.

Treatment of carcinoma of the esophagus with 5-fluorouracil and recombinant alfa-2a-interferon

BACKGROUND

Combinations of 5-fluorouracil (5FU) and recombinant alfa-2a-interferon (IFN) are synergistic in vitro and have demonstrated activity in colorectal carcinoma, renal cell carcinoma, and urothelial tumors.

METHODS

A Phase II trial of the combination of 5FU, 750 mg/m2 daily x 5 followed by weekly bolus therapy, and IFN, 9 MU subcutaneously three times per week, was initiated in patients with esophageal carcinomas. Patients were required to have biopsy-proven squamous cell or adenocarcinoma of the esophagus, locally advanced or metastatic disease beyond the scope of surgical resection, and adequate performance status, renal, hepatic, and bone marrow function.

RESULTS

Twenty-one patients were enrolled; one patient was inevaluable for response because he had received prior chemotherapy, but was evaluated for toxicity. Eleven patients had metastatic disease, and 10 had locally advanced disease. Thirteen patients had squamous cell carcinoma and 8 adenocarcinoma. Toxicities were acceptable with no serious diarrhea and only two cases of serious stomatitis, although a greater than expected incidence of neurologic toxicity was observed. There were five responders (25%) including two patients with advanced or locally advanced disease rendered pathologically free of disease. One patient, initially considered surgically unresectable, was able to undergo a total thoracic esophagectomy after responding to treatment with 5FU/IFN, at which time only a single microscopic focus of carcinoma in situ was found. She remains alive and free of disease at 18+ months. A second patient who presented with metastatic disease and nearly complete obstruction of the esophagus regained normal swallowing function after treatment with 5FU/IFN; rebiopsy of all lesions revealed the patient to be pathologically free of disease. He survived over 2 years.

CONCLUSIONS

This regimen employing a single cytotoxic agent has activity in esophageal carcinoma. Strategies employing biochemical modulation deserve additional investigation in the treatment of esophageal carcinoma.