Abstract P3-07-64: Association between gene variants in SULT1A1 and UGT1A4 and disease outcomes in patients enrolled in SWOG S0226 and treated with anastrozole alone or in combination with fulvestrant for metastatic breast cancer

Background: Anastrozole (A) blocks estrogen production by inhibiting the activity of CYP19 aromatase. Fulvestrant (F) blocks estrogen receptor (ER) signaling by competitive binding, leading to ER degradation by ubiquitination. SWOG S0226 ("Phase III Randomized Trial of Anastrozole versus Anastrozole and Fulvestrant (250mg LD) as First Line Therapy for Post Menopausal Women with Metastatic Breast Cancer," ClinicalTrials.gov Identifier:NCT00075764) demonstrated that combination of A+F is superior to A alone as first-line therapy for patients with ER positive metastatic breast cancer (Mehta et al, NEJM, 2012). Our functional preclinical studies have shown that single nucleotide polymorphisms (SNPs) in SULT1A1 and UGT1A4, drug conjugation enzymes that inactivate A and F, result in decreased enzyme activity toward these drugs (Edavana et al, DMD, 2013; Edavana et al Pharmgenomics Pers Med 2013). We therefore hypothesized that these SNPs will be associated with disease outcomes in S0226 patients due to altered drug levels.

Methods: Germline DNA was available for 295 (43.5%) patients enrolled in S0226 overall (157 on A and 138 on A+F). SNPs in SULT1A1 and UGT1A4 were determined either by direct sequencing or allele-specific PCR (TaqMan) assays.

Results: There was no difference in progression-free survival (PFS) or overall survival (OS) comparing patients with or without available germline DNA (p = 0.86 and 0.36, respectively). The SULT1A1 G902A allele (rs6839), which confers decreased mRNA and enzymatic activity, was associated with improved PFS (GG/GA vs. AA; HR 0.74, 95% CI 0.56-0.98, p=0.033) and OS (HR 0.70, 95% 0.50-0.98, p=0.039). In exploratory subset analyses of PFS, the SULT1A1 G902A association was similar across both treatment arms (A HR=0.75; 95% CI 0.51-1.10; A+F HR=0.73; 95% CI 0.48-1.11). For OS there was some evidence of a difference by treatment (A HR=0.60; 95% CI 0.38-0.96; A+F HR=0.82; 95% CI 0.50-1.32), though no significant interaction was evident (p=0.30).

The UGT1A4 G-163A promoter variant, which leads to decreased protein expression, was not associated with PFS (AA/AG vs. GG HR 0.88, 95% CI 0.68-1.14, p=0.33); however, this variant was associated with OS (HR 0.71, 95% CI 0.52-0.96, p=0.027). In subset analyses with OS, the difference was marginally stronger in the A arm (HR 0.63, 95% CI 0.42-0.97, p=0.035) compared to the A+F arm (HR 0.77, 95% CI 0.49-1.21, p=0.25), though the interaction was not significant (p=0.40).

Conclusion: SULT1A1 and UGT1A4 gene variants resulting in decreased enzyme activity were associated with better PFS, OS or both in patients enrolled in SWOG S0226. Planned validation studies correlating these SNPs with drug levels and disease outcomes in additional patient cohorts will establish their clinical utility in identifying patients who benefit from A and F alone or in combination.

Funding: Supported by NIH/NCI CA118981; NIH/NCI/NCTN grants CA180888, CA180819, and CA180863; and in part by AstraZeneca.

Citation Format: Kadlubar SA, Barlow WE, Mehta RS, Daniels JR, Albain KS, Vandengerg TA, Dakhil SR, Tirumali NR, Lew DL, Gralow JR, Livingston RB, Hortobagiyi GN, Hayes DF, Rae JM. Association between gene variants in SULT1A1 and UGT1A4 and disease outcomes in patients enrolled in SWOG S0226 and treated with anastrozole alone or in combination with fulvestrant for metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-64.

Retrospective analysis of salvage percutaneous cryoablation of hepatocellular cancer (HCC) in liver

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Background: We report our initial experience with percutaneous cryoablation of HCC in liver. Prior published series are limited. Methods: We treated 30 lesions in 23 patients (pts): Child-Pugh class A, 13 pts; B, 8 pts.; C, 2 pts Candidate pts had residual disease after intra-arterial chemotherapy. Probe placement (2.4 mm, Endocare) occurred under general anesthesia with restricted tidal volume to facilitate computer tomographic (CT) localization. An average 2.7 probes (range 1- 5) achieved an estimated margin of 0.5 cm visualizing the ice ball after two 10 min freeze cycles. Median follow-up was 342 days (range 30–947) Results: Tumors ranged from 1.3 to 5.8 cm. Three pts died within 30 days: 2 following intra-peritoneal hemorrhage despite control of bleeding and 1 from ischemic liver injury following a TIPSS for hydrothorax in a pt with refractory ascites. Two additional pts had hemorrhage with recovery. Risk of bleeding was associated with ascites (P = 0.013). One pt had cutaneous needle tract tumor seeding caused by needle repositioning prior to freezing. Survivors remained clinically stable at the 2–3 month follow-up. At the 2 month evaluation 29 lesions had no residual enhancement by CT. One lesion required a second cryoablation procedure.There were no recurrences in any target lesion (30–947 days). Thirteen pts are alive without recurrence of whom 6 had liver transplant with no (4) or < 5% (2) residual disease. Three pts have had recurrence in non-target liver and have died. Multiple tumors at baseline predicts for hepatic recurrence. Two pts have died from complications of cirrhosis, and 2 are lost to follow-up. Conclusions: Percutaneous cryoablation effectively manages selected hepatic HCC tumors. Cirrhotic pts with ascites have significant risk for hemorrhage. We recommend peri-procedure paracentesis and an immediate post-procedure CT.

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Effects of anti-phencyclidine and anti-(+)-methamphetamine monoclonal antibodies alone and in combination on the discrimination of phencyclidine and (+)-methamphetamine by pigeons

RATIONALE

Drug-specific monoclonal antibodies against phencyclidine (PCP) and (+)-methamphetamine [(+)-METH] should bind to these drugs to block their discriminative stimulus effects.

OBJECTIVES

To determine if mouse monoclonal antibodies against PCP and (+)-METH can block the discriminative stimulus effects of the drugs in pigeons.

MATERIALS AND METHODS

Pigeons were trained to discriminate among intramuscular injections of saline, 1 mg/kg PCP, and 2 mg/kg (+)-METH. After responding stabilized, cumulative dose-response curves were obtained for PCP and (+)-METH. Doses of an anti-PCP antibody at 620 mg/kg (anti-PCP mAb6B5) with a K (D) of 1.3 nM for PCP and no measurable affinity for (+)-METH and 1,000 mg/kg doses of anti-(+)-METH antibody (anti-METH mAb6H7) with a K (D) of 41 nM for (+)-METH and no measurable affinity for PCP were subsequently administered, first alone and later in combination after which the dose-response curves were redetermined.

RESULTS

When the antibodies were given alone, the anti-PCP antibody blocked the discriminative stimulus effects of PCP, but not those of (+)-METH, and the anti-(+)-METH antibody blocked the discriminative stimulus effects of (+)-METH, but not those of PCP. The anti-PCP antibody shifted the PCP dose-response curve further to the right and for a longer time than the anti-(+)-METH antibody shifted the dose response curve for (+)-METH. When the anti-PCP and anti-(+)-METH antibodies were administered on the same day, the discriminative stimulus effects of both drugs were completely blocked 1 day after antibody administration.

CONCLUSIONS

These experiments demonstrate the high specificity of the antibodies for the drugs to which they bind and show that monoclonal antibodies can be combined to antagonize the effects of more than one drug.

Hepatic chemoembolization combined with systemic infusion of 5-fluorouracil and bolus leucovorin for patients with metastatic colorectal carcinoma: A Southwest Oncology Group pilot trial

BACKGROUND

Rates of response to systemic chemotherapy among patients with advanced colorectal carcinoma rarely exceed 25- 30%, and complete responses are rare. The liver is the most common site of metastasis; however, regional therapies have not improved survival rates. The Southwest Oncology Group designed a clinical trial combining hepatic arterial chemoembolization with systemic infusion of 5-fluorouracil chemotherapy in an attempt to increase the complete response rate and prolong the time to disease progression.

METHODS

Patients with documented liver metastasis from colorectal carcinoma were treated with two or three cycles of chemoembolization using a collagen suspension with doxorubicin, mitomycin C, and cisplatin. Subsequently, systemic chemotherapy with continuous infusion of 5-fluorouracil and weekly leucovorin was initiated. Patients were assessed for response at 12-week intervals, with treatment continuing until disease progression.

RESULTS

Thirty-one eligible, evaluable patients were treated. One complete and 8 partial responses were observed, for an overall response rate of 29%. Fifty-eight percent of patients survived 1 year, and the median survival for the whole cohort was 14 months. The median time to progression was 8 months. Seven patients (23%) experienced Grade 4 toxicity and 21 patients (67%) had Grade 3 toxicity.

CONCLUSIONS

The response rate in this trial was comparable to that achieved with systemic chemotherapy consisting of a fluorinated pyrimidine-based regimen for patients with this disease. No improvement in complete response rate or time to progression was observed compared with the Southwest Oncology Group's experience with systemic therapy. The authors are not planning to study this regimen further as a treatment for patients with metastatic colorectal carcinoma.

The detection of changes in mammographic densities

We previously reported reductions in mammographic densities in women participating in a trial of a gonadotropin-releasing hormone agonist (GnRHA)-based regimen for breast cancer prevention. In our previous report, we compared (by simultaneous evaluation) three basic elements of mammographic densities. The purpose of the present study was to evaluate whether a standard (expert) method of measuring mammographic densities would detect such changes in densities and whether a novel nonexpert computer-based threshold method could do so. Mammograms were obtained from 19 women at baseline and 12 months after randomization to the GnRHA-based regimen. The extent of mammographic densities was determined by: (a) a standard expert outlining method developed by Wolfe and his colleagues (Am. J. Roentgenol., 148: 1087-1092, 1987); and (b) a new computer-based threshold method of determining densities. The results from both the expert outlining method and the computer-based threshold method were highly consistent with the results of our original (simultaneous evaluation) method. All three methods yielded statistically significant reductions in densities from baseline to the 12-month follow-up mammogram in women on the contraceptive regimen. The difference between the treated and the control group was statistically significant with the expert outlining method and was of borderline statistical significance with the computer-based threshold method. The computer-based results correlated highly (r > 0.85) with the results from the expert outlining method. Both the standard expert outlining method and the computer-based threshold method detected the reductions we had previously noted in mammographic densities induced by the GnRHA-based regimen.

Is cryosurgical ablation appropriate for treating hepatocellular cancer?

OBJECTIVE

To examine the feasibility and efficacy of cryosurgical ablation as treatment for patients with cirrhosis with unresectable hepatocellular carcinoma.

DESIGN

Retrospective case series.

SETTING

A tertiary public hospital and a cancer center.

PATIENTS

Twelve patients with cirrhosis with hepatocellular carcinoma (stage II, 2; stage III, 1; stage IVA, 7; stage IVB, 2).

INTERVENTIONS

Cryosurgical ablation of all identifiable tumors. Nine patients treated with curative intent were included in the survival analysis, and 3 were treated for palliation. Five patients were treated with preoperative intra-arterial chemoembolization.

MAIN OUTCOME MEASURES

Perioperative complications and the effects of tumor stage and chemoembolization were examined. Patient survival and disease-free interval were calculated by life-table analysis.

RESULTS

No perioperative deaths occurred and 1 patient had 2 postoperative complications: pneumonia and biloma. The mean survival has been 19 months after cryosurgical ablation and 29 months after diagnosis. Three of the 9 patients treated with curative intent died with recurrence at a mean of 17 months after cryosurgical ablation. Four patients are alive with recurrence at a mean of 19 months after cryosurgical ablation and 38 months after diagnosis. Two patients with stage II disease have no evidence of recurrence 10 and 32 months after cryosurgical ablation.

CONCLUSIONS

Cryosurgical ablation is feasible and safe for treatment of hepatocellular carcinoma in patients with cirrhosis. The technique is primarily palliative but may provide a possibility of cure in patients with lower-stage disease.

Prevalence of infection following hepatic chemoembolization with cross-linked collagen with administration of prophylactic antibiotics

PURPOSE

The authors present their experience with 494 hepatic chemoembolization (HCE) procedures in 236 patients with administration of a mixture of cross-linked collagen and chemotherapeutic agents. The prevalence of infectious complications was compared in patients who did and did not receive prophylactic administration of antibiotics as part of the HCE procedure.

PATIENTS AND METHODS

Fourteen HCE procedures in nine patients were performed without prophylactic antibiotics (PA). These patients underwent embolization with cross-linked collagen alone or with low-dose cisplatinum. All of the remaining 480 procedures in 227 patients were performed with PA.

RESULTS

One of the nine patients (11%) who did not receive PA experienced fatal sepsis within 24 hours of HCE. Of the 227 patients who did receive antibiotics, six (2.6%) developed hepatic abscess and no fatal sepsis was encountered.

CONCLUSION

Use of PA decreases the prevalence of infectious complications following HCE.

Hepatic chemoembolization: safety with portal vein thrombosis

PURPOSE

Nine patients with unresectable hepatic malignancy and portal vein thrombosis underwent hepatic chemoembolization.

PATIENTS AND METHODS

Six patients had primary malignancies (hepatocellular carcinoma in five, hepatoblastoma in one), and three had metastatic tumor (adenocarcinoma of the colon in two, glucagonoma in one). Chemoembolization was performed with 10 mg/mL of cross-linked collagen, 10 mg/mL of mitomycin, 3 mg/mL of doxorubicin, and 3 mg/mL of cisplatin. Each patient was treated until flow in the hepatic artery ceased completely.

RESULTS

All treatments were technically successful. Eight patients responded to treatment, including two long-term survivors (> 2 years). One patient died 31 days after treatment of progressive hepatic malignancy and atherosclerotic disease. No patient developed hepatic infarction or insufficiency as a result of treatment. Follow-up ranged from 1 to 26 months (mean, 13 months).

CONCLUSION

Portal vein thrombosis should not be considered an absolute contraindication to hepatic chemoembolization. Hepatic chemoembolization can be performed safely in the presence of adequate collateral circulation.

The role of adjuvant chemotherapy following cystectomy for invasive bladder cancer: a prospective comparative trial

We assigned 91 patients with deeply invasive, pathological stage P3, P4 or N+ and Mo transitional cell carcinoma of the bladder (with or without squamous or glandular differentiation) to adjuvant chemotherapy or to observation after radical cystectomy and pelvic lymph node dissection. For most patients chemotherapy was planned as 4 courses at 28-day intervals of 100 mg./M.2 cisplatin, 60 mg./M.2 doxorubicin and 600 mg./M.2 cyclophosphamide. A significant delay was shown in the time to progression (p = 0.0010) with 70% of the patients assigned to chemotherapy free of disease at 3 years compared to 46% in the observation group. Median survival time for patients in the chemotherapy group was 4.3 years compared to 2.4 years in the observation group (p = 0.0062). In addition to treatment groups, important prognostic factors included age, gender and lymph node status. The number of involved lymph nodes was the single most important variable. We recommend adjuvant chemotherapy for patients with invasive transitional cell carcinoma after definitive surgical resection.

Intraarterial administration of lidocaine for analgesia in hepatic chemoembolization

Hepatic chemoembolization (HCE) routinely results in severe pain requiring massive doses of intravenously administered narcotics. This study examines the efficacy and safety of lidocaine administered intraarterially for analgesia in HCE. In 45 HCE procedures, lidocaine was injected into hepatic arterial branches just prior to and during chemoembolization. Adjunctive analgesic doses given during the procedure and the need for a morphine sulfate drip infusion for postprocedural pain control were recorded and compared with those in 20 procedures performed previously without lidocaine. In procedures with lidocaine, an average of 0.13 mg of morphine sulfate and 1.3 mg of midazolam were required. This is significantly lower than the 11.7 mg of morphine sulfate and 3.7 mg of midazolam used during procedures without lidocaine. A postprocedural morphine drip infusion was required for control of severe pain in 16 of 20 (80%) procedures performed without lidocaine compared with nine of 45 (20%) of those performed with lidocaine. Peripheral blood levels of lidocaine were well below the toxic level, and no complications referable to lidocaine toxicity occurred. Marked reductions in the amount of narcotic analgesia in HCE procedures may be safely achieved with the administration of intraarterial lidocaine.

Unusual antiproliferative effects of transforming growth factors-beta 1 and beta 2 against primary cells from human tumors

Transforming growth factors beta 1 and beta 2 (TGF-beta 1 and beta 2), tested in a clonogenic assay against primary cells from human tumors, suppress proliferation to different extents. In nineteen of twenty-six cell cultures, proliferation was less than 50% of control with factor at 0.04 or 0.4 nM. Of these, TGF-beta 2 was more active than TGF-beta 1 in fourteen; and TGF-beta 1 was more active than TGF-beta 2 in five. In seven of the nineteen, proliferation was 0% with one or the other factor. In contrast, cisplatin was much less effective in inhibiting proliferation of some of the same cells even at 1,000 or more times the molar concentration of the factors. Surprisingly, when TGF-beta 1 and TGF-beta 2 were combined at equal concentrations, the antiproliferative effect of one was cancelled or markedly inhibited by the other.

Renal cisplatin chemoembolization with Angiostat, Gelfoam, and Ethiodol in the rabbit: renal platinum distributions

Renal platinum distributions were determined in rabbits after administration of 0.4 mL of 1 mg/mL cisplatin by intravenous infusion, by injections into the left renal artery with aqueous contrast material and with lipid contrast material (Ethiodol), and by chemoembolization of the left renal artery with concurrent administration of various concentrations of two collagen carriers, Angiostat collagen for embolization and Gelfoam gelatin. Renal platinum concentration was measured in tissue homogenates at 2 1/2 hours with atomic absorption spectrometry. Target-kidney platinum levels were 5.4 and 6.9 times the contralateral-kidney levels after intraarterial infusion of aqueous and lipid contrast media, respectively. With Angiostat and Gelfoam chemoembolization, renal platinum retention and collagen concentration were linearly related (r = .87 and .81, P less than .001). Target-kidney-contralateral-kidney platinum ratios were 57:1 for 30 mg/mL Gelfoam and 220:1 for 10 mg/mL Angiostat. The difference in regional drug retention for Angiostat versus Gelfoam reflects the stable fiber integrity of Angiostat.

Effect of antimicrobial protection on tolerance to hepatic chemoembolization with a fibrous collagen carrier

The effect of antimicrobial prophylaxis on tolerance to hepatic embolization and chemoembolization with collagen particles was examined in porcine liver. Embolization in the 36 animals consisted of hepatic artery injection of 3 mL of collagen (10 mg/mL) alone or combined with one to three drugs (cisplatin, mitomycin, and doxorubicin). Embolization was performed with or without antimicrobial protection, and the animals were killed at 5 days for gross and histologic evaluation of liver and for bacterial culture. When present, liver damage consisted of focal to whole-lobe necrosis. Liver damage was correlated with positive bacterial culture (P less than .002) and was reduced by antimicrobial protection. Vessel recanalization was inhibited by addition of drug to collagen (P less than .001) and by lack of antimicrobial protection (P less than .001). Perivascular necrosis was directly related to vessel size (P = .0001). Antimicrobial prophylaxis is recommended to enhance hepatic chemoembolization safety.

Collagen chemoembolization: pharmacokinetics and tissue tolerance of cis-diamminedichloroplatinum(II) in porcine liver and rabbit kidney

Pharmacokinetics of chemoembolization with a fibrous collagen carrier was studied in rabbit kidney and porcine liver models. Cisplatin (1 mg/ml) chemoembolization of liver and kidney was compared with i.v. and intraarterial cisplatin infusion. Tissue platinum concentration [Pt] was measured at 2.5 h by atomic absorption spectrometry. Renal platinum retention and Angiostat (collagen for embolization) concentration were linearly related (r = 0.87, p less than 0.001). At 10 mg/ml collagen for embolization, chemoembolized kidney [Pt] was 220 +/- 50 (SE; n = 4) times contralateral kidney [Pt], and 62 and 23 times renal [Pt] by i.v. and intraarterial infusion, respectively. At 10 mg/ml collagen for embolization, chemoembolized liver [Pt] was 2 times hepatic [Pt] by i.v. and intraarterial infusion. Since hepatic tumor vasculature is end arterial, chemoembolization should yield high [Pt] in tumor (as in kidney) but lower levels in normal liver.

Reevaluation of the maximum tolerated dose of continuous venous infusion of 5-fluorouracil with pharmacokinetics

5-Fluorouracil (5-FU) was administered as a continuous ambulatory venous infusion to 25 patients in a Phase I trial. The principal dose limiting toxic effect observed was mucositis. Skin rash and diarrhea occurred less frequently. Hematological toxicity was modest, and no hepatic toxicity was seen. One partial remission of 138 days duration was seen in a patient with metastatic breast carcinoma who was previously refractory to a 5-FU combination regimen. Patient tolerance of 5-FU delivered in this manner appeared highly variable. On the basis of this trial, we recommend that future studies evaluating the efficacy of long-term venous infusion of 5-FU should utilize a dosage of 450 mg/m2/day.

Transpancreatic catheterization of the right hepatic artery for chemoembolization using a new infusion system

The right hepatic artery was catheterized for chemoembolization in a patient with liver-dominant metastatic breast carcinoma and occlusion of the celiac artery by tumor compression. This was accomplished by use of a new coaxial infusion catheter-steerable guidewire system passed through the superior mesenteric artery and posterior pancreatic arcade.

Reassessment of the role of adjunctive surgical therapy in the treatment of advanced germ cell tumors

We treated 30 patients for stage B3 or B3C germ cell tumors between December 1978 and December 1983. After initial, high dose, platinum-based combination chemotherapy, all patients underwent adjunctive resection of all clinically evident residual disease. Residual malignant elements were found in the retroperitoneum in 35 per cent of 26 nonseminomatous germ cell tumor patients and in 40 per cent of those with residual lesions beyond the retroperitoneum following chemotherapy. After additional chemotherapy, including platinum plus etoposide for patients with residual malignant elements, 80 and 75 per cent of those with stages B3 and B3C disease, respectively, achieved a complete sustained remission at a mean followup of 30 to 38 months, respectively. The strongest predictors of ultimate treatment failure were the presence of extensive pulmonary disease at presentation and the finding of residual malignant elements in resected lesions. Of 4 patients with seminoma 3 achieved sustained complete remission, while 1 died of recurrent embryonal carcinoma. These data support the role of adjunctive resection of clinically evident residual lesions following initial platinum-based chemotherapy in advanced metastatic germ cell tumors, and demonstrate the efficacy of additional platinum-etoposide-based chemotherapy in the 35 to 40 per cent of patients who harbor residual malignant disease in resected lesions.

Correlation of meningioma hormone receptor status with hormone sensitivity in a tumor stem-cell assay

Several investigators have detected progesterone receptors in a high percentage of meningioma specimens and have noted progesterone receptors to be more common than estrogen receptors in these specimens. However, a functional significance of such hormone receptor positivity in control of meningioma growth has not been described. This paper describes a paired test of the estrogen and progesterone receptor assay as the biochemical assay and of the human tumor stem-cell clonogenic assay (HTSCCA) as the functional assay in 17 meningioma specimens. Only one (6%) of the 17 specimens was estrogen receptor-positive, while 11 (69%) of 16 specimens were progesterone receptor-positive. The HTSCCA revealed that only two (15%) of 13 specimens were sensitive to estradiol while five (31%) of 16 specimens were sensitive to progesterone. Comparison of progesterone results for the 15 specimens on which both hormone receptor assay and HTSCCA were performed revealed correlation in a majority of cases; four specimens were positive for both assays and five specimens were negative for both assays. No specimen that was negative for progesterone receptors was sensitive to progesterone by HTSCCA. These results suggest that the hormone receptor and sensitivity pattern of meningiomas may differ from that of breast cancer, and that progesterone addition or ablation may be a reasonable therapeutic approach for meningiomas.

Peripheral hepatic arterial embolization with crosslinked collagen fibers

Hepatic artery embolization with a nonimmunogenic, crosslinked microfibrillar collagen preparation (Angiostat, Collagen for Embolization, Target Therapeutics, Los Angeles, CA) was studied in mongrel dogs. Flow-directed technique was used to achieve complete distal arterial occlusion. Serial liver function evaluation demonstrated marked alterations at 48 to 72 hours, partial correction at one week, and resolution of abnormalities by one month. Restoration of large vessel blood flow was angiographically demonstrable at one week. Follow-up arteriograms showed no persistent arterial occlusion. Collagen was demonstrated in vessels of 20 to 250 micron. Recanalization was achieved by migration of endothelial cells around the collagen, development of a new vascular channel within an endothelial cell cleft, and subsequent complete removal of the collagen over a three- to four-month period. Three months after embolization with a single dose, normal hepatic vascular and tissue anatomy and hepatic function were restored completely. Repeated embolization at two weekly intervals was well tolerated.

Indium-111 oxine platelet survival in dogs: effect of doxorubicin and Dacron grafts

The cytotoxic chemotherapeutic agent doxorubicin was found to acutely decrease platelet survival times in beagle dogs as determined using platelets labeled with [111In]oxine. Recovery was rapid, with platelet survival times returning to normal within 3 wk of cessation of treatment. Doxorubicin (1.5 mg/kg i.v. every 3 wk for a total of four doses) also delayed the return of platelet survival times to normal when given to beagle dogs following placement of thoracoabdominal aortic Dacron grafts. It is not known whether or not this may have clinical significance.

Chemotherapy of small-cell carcinoma of lung: a randomized comparison of alternating and sequential combination chemotherapy programs

One hundred forty-seven eligible patients with small-cell carcinoma of the lung (SCCL) have been randomized to receive alternating (A) or sequential (S) combination chemotherapy. Initial treatment was with three cycles of VAM (A) or two cycles of POCC (S). VAM consists of VP16-213 200 mg/m2 intravenously (IV) day 1, Adriamycin (Adria Laboratories, Columbus, Ohio) 50 mg/m2 IV day 1, and methotrexate 30 mg/m2 IV day 1 repeated at 21-day intervals. POCC consists of cyclophosphamide 600 mg/m2 IV days 1 and 8, vincristine 1.5 mg/m2 (maximum, 2 mg) IV days 1 and 8, CCNU 60 mg/m2 po day 1, and procarbazine 100 mg/m2 po days 2 through 15. After initial treatment, all patients received whole brain radiation therapy (3,000 rad/10 fractions/2 wk). Patients with limited disease in addition received irradiation encompassing the tumor, hilar, mediastinal, and supraclavicular regions (5,000 rad/25 fractions/5 wk). After radiation, patients on arm A received POCC alternating with VAM; patients on arm S received POCC until progression when they were to be treated with VAM. The alternating arm was superior with respect to rate of complete remission (CR), median disease-free survival (MDFS), and median survival (MS). The advantage of alternating therapy was not as clearly demonstrated in the limited disease groups when interposition of involved field radiation delayed the initiation of the alternating schedule. In limited disease alone, comparing arm A with arm S, no statistically significant differences were noted. The CR rate was 42% v 54%, MDFS was 14 v 10 months, and MS was 16 v 10 months. In extensive disease, the CR rate was 44% v 20% (P = .03), MDFS was 6 v 4 months (P = .003), and MS was 10 v 7 months (P = .001). Improved treatment outcome in SCCL is achieved when combination chemotherapy regimens of similar effectiveness are administered in an alternating rather than sequential schedule.

Current status of adjuvant chemotherapy after radical cystectomy for deeply invasive bladder cancer

Between March, 1976, and December, 1982, 70 of 157 patients (45%) undergoing single-stage radical cystectomy with pelvic lymphadenectomy and urinary diversion with the intent to cure invasive bladder cancer were found to have pathologic Stage P3B, P4 and/or N + disease. Thirty-four of the 70 patients received adjuvant prophylactic chemotherapy after cystectomy and 36 patients were followed expectantly. From 1976 through 1977 adjuvant chemotherapy consisted of cyclophosphamide 1 Gm/M2 each month for six months; from 1978 through June, 1980, adjuvant chemotherapy consisted of cis-platinum 100 mg/M2 each month for four months with the exception of 1 patient treated more aggressively with combination chemotherapy (CISCA). Since July, 1980, a prospective study has been utilized in which patients were randomized into two groups, Group A receiving combination chemotherapy and Group B followed up expectantly; adjuvant chemotherapy appears to result in a slight delay in time to relapse but no influence in overall survival was observed.

Evaluation of membranes for plasmapheresis

Commercial flat-sheet microporous membranes were evaluated for potential use in plasmapheresis with a specially designed filtration module. Significant differences in filtration rates were observed with different membranes. Saline filtration data were not useful in predicting the capacity of the membranes to filter plasma from whole blood. For all membranes studied, no rejection of plasma proteins was detected. No activation or deactivation of clotting factors was detected as a result of filtration. In addition, little or no hemolysis was caused by filtration with the various membranes. Saline, cell-free plasma, platelet-poor plasma, and whole blood were perfused over a track-etched membrane and the resulting filtration rates were compared. The cell-free plasma filtration rate decreased significantly with time, probably owing primarily to protein adsorption in the membrane pores. Cell-free plasma and saline filtration data were used to calculate an apparent adsorbed layer thickness in the membrane pores. Perfusion of platelet-poor plasma and whole blood resulted in time-dependent filtration rates that were much lower than those obtained when cell-free plasma was perfused. Results of the study support recent theoretical models that postulate that the rate-limiting process for blood filtration is the formation of a layer of blood cells (particle polarization) on the membrane surface.

Patterns of failure in small cell carcinoma of the lung

The initial sites and frequencies of disease progression in 97 patients with small cell carcinoma of the lung treated in a Northern California Oncology protocol were analyzed. Among the extensive disease complete responders (25 patients), the chest was the most frequent initial relapse site (18 patients), followed by the liver (nine patients) and bone (six patients). For those patients who had a partial or no response to treatment, the chest was the most frequent site of persistent disease and the majority progressed in the chest initially. The addition of chest irradiation (5000 rad/5 weeks) to patients with limited disease significantly reduced the incidence of relapse (25%) and prolonged the disease-free interval in the chest in the complete responders, but did not affect the failure pattern in partial and nonresponders. All patients received prophylactic cranial irradiation and three limited disease patients (10%) and three extensive disease patients (4%) progressed in the brain.

Chemosensitivity of human neoplasms with in vitro clone formation. Experience at the University of Southern California - Los Angeles County Medical Center

We analyze experience with 600 specimens for in vitro chemosensitivity assessment of human neoplasms utilizing a soft agar colony-forming technique. Good test reproducibility is demonstrated. Disaggregation with collagenase enhances yield and does not alter chemosensitivity profiles. Therapeutic exposure to chemotherapy prior to biopsy reduces in vitro sensitivity to the specific agents used in vitro. The cyclophosphamide derivatives 4-hydroperoxycyclo phosphamide (4-HC) and phosphoramide mustard are active in vitro, and produce comparable rank order sensitivities among tested tumors. There is marked reduction of in vitro 4-HC sensitivity in patients with prior therapeutic cyclophosphamide exposure, supporting the use of this derivative in test systems. Rank order of test results among specimens is compared at 0.1 microgram and 10 microgram drug/ml. Substantial differences in rank order at these two dose levels are demonstrated, indicating that the in vitro test dose selected is an important variable.

Dose-effect and structure-function relationships in doxorubicin cardiomyopathy

The cardiomyopathy (CM) produced by the anticancer drug doxorubicin (DXR) (Adriamycin) provides a unique opportunity to analyze dose-effect and structure-function relationships during development of myocardial disease. We measured the degree of morphologic damage by ultrastructural examination of endomyocardial biopsy and the degree of performance abnormally by right heart catheterization in patients receiving DXR. Morphologic damage was variable but was proportional to the total cumulative DXR dose between 100 and 600 mg/m2. Performance abnormalities correlated weakly with dose, exhibited a curvilinear relationship, and had a "threshold" for expression. Catheterization abnormalities correlated well with morphologic damage (r = 0.57 to 0.78) in a subgroup of patients in whom exercise hemodynamics were measured, and this relationship also exhibited a curvilinear, threshold configuration. In DXR-CM myocardial damage is proportional to the degree of cytotoxic insult (DXR dose) while myocardial function is preserved until a critical dose or degree of damage is reached, after which myocardial performance deteriorates rapidly.

Filtration plasmapheresis in vivo

A continuous-flow filtration plasmapheresis system has been developed as an alternative to conventional techniques for conducting plasmapheresis from blood donors. The system was tested in two stages, nonreinfusion and continuous reinfusion. Donor safety, separation efficiency, and plasma quality were examined. These studies indicate that membrane plasmapheresis is feasible, safe to the donor, and yields sufficient plasma for either therapeutic or component therapy use.

Anthracycline-associated cardiac and renal damage in rabbits. Evidence for mediation by vasoactive substances

We tested the hypothesis that anthracycline-induced cardiac and renal damage is mediated by vasoactive substances. A 1-minute exposure to 5 micrograms per ml. of doxorubicin (DXR, Adriamycin) produced cardiac histamine release in isolated rabbit hearts. Under conditions in which histamine uptake and metabolism were impaired, the administration of DXR, 2 mg. per kg., over 1 minute was associated with elevations in arterial histamine and catecholamines. The chronic weekly administration of DXR produced severe cardiac and renal damage. The administration of combined histaminic and adrenergic blockade with diphenhydramine, cimetidine, phentolamine, and propranolol (DCPP) pre- and immediately post-DXR resulted in near total protection against DXR-mediated cardiac damage and prevented the majority of the renal lesions. The combined administration of diphenhydramine, cimetidine, phentolamine, and propranolol did not appear to be acting by mechanisms other than blockade of vasoactive amine receptors as cardiac uptake of DXR and the DXR antitumor response were not altered by diphenhydramine, cimetidine, phentolamine, and propranolol. This study demonstrates that anthracycline-associated cardiac and renal toxicity may be mediated by vasoactive substances and that anthracycline cardiomyopathy is potentially preventable.

Acute and chronic cardiovascular effects of doxorubicin in the dog: the cardiovascular pharmacology of drug-induced histamine release

We evaluated the acute hemodynamic effects of doxorubicin in the open-chest dog. Doxorubicin at doses of 1-4 mg/kg administered over 2 min produced profound hemodynamic changes that were similar to those produced by histamine. These changes persisted despite administering the drug as a slow infusion. Histamine release in peripheral tissues was documented by a marked increase in venous histamine levels following doxorubicin administration. The heart extracted histamine during a period when arterial levels were increased, as indicated by consistently low coronary sinus/aortic ratios. Secondary catecholamine release occurred in response to histamine and histamine-mediated hemodynamic effects. Immunoreactive prostaglandins E and F were increased in coronary sinus blood beginning 30 min after the initiation of a continuous infusion of doxorubicin, and increased slowly thereafter. H1- and H2-receptor blockade with diphenhydramine and cimetidine prevented the early (2-30 min postinfusion) effects of doxorubicin, and combined histaminergic and adrenergic blockade prevented the late effects. A dose of doxorubicin (1 mg/kg) that released histamine and catecholamines produced primary cardiac effects acutely and a cardiomyopathy when administered chronically. The release of vasoactive substances could be part of the pathogenetic mechanism of anthracycline cardiomyopathy.

Variables for predicting serious toxicity (vinblastine dose, performance status, and prior therapeutic experience): chemotherapy for metastatic testicular cancer with cis-dichlorodiammineplatinum(II), vinblastine, and bleomycin

Combination chemotherapy utilizing high-dose vinblastine, bleomycin, and cisdichlorodiammineplatinum(II) (CDDP) is effective treatment for metastatic testicular cancer. Unfortunately, it is frequently associated with serious toxicity. In a series of 14 patients receiving 65 treatment cycles, several variables were examined as putative risk factors for prediction of serious toxicity. These included drug dose normalized to body weight or surface area, interval since previous cycle, prior therapeutic experience with either radiation therapy or other cytotoxic chemotherapy, and Karnofsky performance status. The strongest determinant of serious toxicity was the vinblastine dose calculated according to body weight. The next most influential prognostic variables were the performance status and a history of previous treatment with either radiation therapy or chemotherapy. Serious toxicity may be anticipated at a frequency of 40% when vinblastine is administered at a total dose of 0.36 mg/kg with bleomycin and CDDP. In our group of patients, the nephrotoxicity of CDDP appeared to be cumulative despite intensive diuresis at the time of administration. Pulmonary toxicity was not observed. Modest reductions in vinblastine dose, especially in patients with poor performance status or a history of previous radiation or other chemotherapy, will substantially lower the frequency of serious toxicity.

Clinical spectrum of anthracycline antibiotic cardiotoxicity

Anthracycline derivatives may produce early or late cardiotoxic reactions in man. Early effects include: (a) pericarditis-myocarditis which can affect patients with no previous history of cardiac disease and which carries a high mortality rate ( approximately 20%); (b) left ventricular dysfunction which may lead to clinically significant heart failure in patients with limited cardiac reserve; and (c) arrhythmias, the most common of which is sinus tachycardia. Symptomatic supraventriclar tachycardia, heart block, and ventricular arrhythmias can occur, however, and may reflect primary effects on cardiac muscle or the conduction system. Late effects of anthracyclines are directly related to the degree of associated myocyte damage and include subclinical left ventricular dysfunction and overt heart failure. The implications for prognosis and further treatment are discussed for each of these entities and a common pathogenetic mechanism is proposed.

Anthracycline cardiomyopathy monitored by morphologic changes

Seventy-six endomyocardial biopsies obtained from 60 patients receiving adriamycin (ADM) and other anthracycline analogs were studied. The biopsies were studied by light and electron microscopy. Two main types of myocyte degeneration were consistently present, the lesions were focal, and inflammatory infiltrate was absent. The severity of pathologic changes was graded on a scale from 0 (normal) to 3 (marked abnormality). Twelve patients receiving previous mediastinal irradiation (600-5700 rads) showed a mean pathology grade (2.0 +/- 0.89) that was significantly higher than in those patients receiving a comparable dose of ADM but who were not irradiated (1.18 +/- 0.23) (P less than 0.01). This study indicated that radiation, even if remote, enhances ADM-induced cardiotoxicity and evokes a "recall" phenomenon of latent acute irradiation changes. Our data suggest that a specific, progressive, subclinical injury to the heart occurs with anthracycline therapy that cannot be detected reliably by conventional tests. Anthracycline-induced cardiotoxicity in rabbits, monkeys, and dogs shows the same basic cellular lesions as in man. The analogs, adria-DNA and rubidazone, also show lesions similar to those produced by ADM in the human heart. The endomyocardial biopsy is a reliable method for monitoring cardiac damage due to anthracyclines in man.

Invasive and noninvasive methods of assessing adriamycin cardiotoxic effects in man: superiority of histopathologic assessment using endomyocardial biopsy

Endomyocardial biopsies and cardiac catheterizations were performed in 55 patients treated with adriamycin (ADM). Eleven patients underwent serial invasive studies. In addition, most of these patients had systolic time interval determinations, echocardiograms, and electrocardiograms at the time of catheterization. The relationship of these various tests to cumulative dose of ADM and to the incidence of cardiac dysfunction was analyzed. Only pathologic assessment of ADM-induced myocardial damage showed a progressive stepwise increase in severity at successively higher doses of ADM. In addition, the incidence of myocardial dysfunction correlated well only with pathologic findings on biopsy. We conclude that standard noninvasive methods of assessing ADM cardiotoxicity are inadequate and that histopathologic assessment by means of endomyocardial biopsy is a valuable, reliable, and accurate technique.

Doxorubicin cardiomyopathy: evaluation by phonocardiography, endomyocardial biopsy, and cardiac catheterization

Right ventricular endomyocardial biopsy, right heart catheterization, and systolic time intervals were done in 33 adult patients receiving doxorubicin (AdriamycinTM). Doxorubicin administration was associated with a dose-related increase in the degree of myocyte damage, and 27 of 29 patients biopsied at doses greater than or equal to 240 mg/m2 had doxorubicin-associated degenerative changes identified on biopsy. The pre-ejection period to left ventriculr ejection time ratio (PEP/LVET) showed a threshold phenomenon and did not begin to increase until a total dose of 400 mg/m2 had been reached. Seven patients with catheterization-proven heart failure had a significantly greater amount of myocyte damage on biopsy than dose-matched control subjects (P less than 0.01). Preveious mediastinal radiation appeared to potentiate the doxorubicin-associated degenerative process. Mediastinal radiation and age greater than or equal to 70 years appeared to be risk factors for doxorubicin-associated heart failure. Dose limitation by combined clinical, noninvasive, invasive, and morphologic criteria offered an advantage over empirical dose limitation or dose limitation by PEP/LVET alone.

Role of radiation therapy in combination with chemotherapy in extensive oat cell cancer of the lung: a randomized study

After 3 months of chemotherapy with procarbazine, vincristine, cyclophosphamide, and CCNU, patients with extensive oat cell carcinoma of the lung were randomly allocated to receive 3000 rads of involved-field irradiation and further chemotherapy or to continue with chemotherapy only. In addition, all patients received 3000 rads of prophylactic whole-brain irradiation. The addition of involved-field radiation, as given in this trial, not only failed to improve survival but was unable to alter the pattern of sites of initial relapse. There were no cases of extension to the brain in 31 consecutive patients who received prophylactic whole-brain irradiation. This was in strong contrast to a preceding trial in which six cases of brain extension occurred among 19 patients who did not receive prophylactic whole-brain irradiation.

Injectable collagen for soft tissue augmentation

Collagen from allogenic and xenogeneic sources has been made soluble by controlled proteolytic digestion. The monomeric, telopeptide-poor collagen so prepared forms a cohesive mass when warmed to body temperature (upon injection), creating a structural basis for new soft connective tissue. We have treated 28 patients with human and/or bovine collagen injections for the correction of soft tissue contour defects, and we have followed them for 3 to 18 months. In most instances, there has been lasting and substantial correction of the defects treated. The complications have been few and transient.

Adriamycin cardiotoxicity: endomyocardial biopsy evidence of enhancement by irradiation

Endomyocardial biopsies were examined in 12 patients receiving total doses of Adriamycin from 90 to 445 mg/M2. These patients had also received previous mediastinal irradiation (from less than 600 to 5700 rad) over periods varying from 6 months to 14 years prior to the endomyocardial biopsy. Severity of pathological change in these 12 patients was compared with that of dose-matched control patients who had not received mediastinal radiation. The severity of the histopathologic changes was scored on a scale from 0 (normal) to 3 (marked abnormality). The mean score of the group receiving irradiation (2.0 +/- 0.89) was significantly higher than the score in those not irradiated (1.18 +/- 0.23) (p less than 0.001). Morphological demonstration of a "recall phenomenon" of latent radiation changes by Adriamycin was demonstrated in small intramyocardial vessels. This study indicates that radiation, even if remote, enhances Adriamycin-induced cardiomyopathy. Therefore, Adriamycin must be given cautiously in patients who have received previous mediastinal radiotherapy.

Chemotherapy of malignant histiocytosis in adults

Malignant histiocytosis is a fulminant neoplasm resistent to single agent chemotherapy and resulting in death within 6 months. Sixteen patients have received chemotherapy for this disorder between 1965-1975 at Stanford. Nine patients responded to chemotherapy. Responders had a median survival of 23 months from onset of symptoms and a significantly longer survival than non-responders (p = 0.03). The most promising responses were in seven patients treated with a combination of cyclophosphamide, adriamycin, vincristine and prednisone. Five of the seven responded, with two of the five later relapsing and dying, two having equivocal evidence of disease while on chemotherapy for 6 and 9 months, and one free of disease for 17 months after completing 8 months of chemotherapy. Three patients had central nervous system (CNS) relapses, two during peripheral remission. One of these had control of CNS disease with brain irradiation and intrathecal methotrexate, but all three eventually died. It is hoped that with combination chemotherapy and prophylactic CNS treatment, long term disease-free survivals will be achieved.

Combined modality treatment for oat cell carcinoma of the lung: a randomized trial 1,2,3

Twenty-three patients with oat cell cancer of the lung were randomized to receive chemotherapy with POCC (procarbazine, 100 mg/m2/day orally, Days 1-14; vincristine, 2 mg iv, Days 1 and 8; cyclophosphamide, 600 mg/m2 iv, Days 1 and 8; and CCNU, 60 mg/m2 orally, Day 1) or COM (cyclophosphamide, 2000 mg/m2 iv, Day 1; vincristine, 2 mg iv, Day 1; and methotrexate, 30 mg/m2 iv, Day 15). After two to three cycles of chemotherapy, all patients were to receive radiotherapy to initially involved sites and then have chemotherapy continued. Patients treated with POCC had a median survival of 14 months vs 10 months for those treated with COM (P = 0.055). Eight of 15 first sites of relapse were intrathoracic and five of these eight had received radiotherapy to that site. Six central nervous system (CNS) failures were evenly divided between the two chemotherapy programs. Thus, the CNS penetration of procarbazine and CCNU in the POCC combination did not prevent CNS relapse. All future patients will receive prophylactic brain radiotherapy.