A randomized phase II study comparing erlotinib versus erlotinib with alternating chemotherapy in relapsed non-small-cell lung cancer patients: the NVALT-10 study

BACKGROUND

Epidermal growth factor receptor tyrosine kinase inhibitors (TKIs) administered concurrently with chemotherapy did not improve outcome in non-small-cell lung cancer (NSCLC). However, in preclinical models and early phase noncomparative studies, pharmacodynamic separation of chemotherapy and TKIs did show a synergistic effect.

PATIENTS AND METHODS

A randomized phase II study was carried out in patients with advanced NSCLC who had progressed on or following first-line chemotherapy. Erlotinib 150 mg daily (monotherapy) or erlotinib 150 mg during 15 days intercalated with four 21-day cycles docetaxel for squamous (SQ) or pemetrexed for nonsquamous (NSQ) patients was administered (combination therapy). After completion of chemotherapy, erlotinib was continued daily. Primary end point was progression-free survival (PFS).

RESULTS

Two hundred and thirty-one patients were randomized, 115 in the monotherapy arm and 116 in the combination arm. The adjusted hazard ratio for PFS was 0.76 [95% confidence interval (CI) 0.58-1.02; P = 0.06], for overall survival (OS) 0.67 (95% CI 0.49-0.91; P = 0.01) favoring the combination arm. This improvement was primarily observed in NSQ subgroup. Common Toxicity Criteria grade 3+ toxic effect occurred in 20% versus 56%, rash in 7% versus 15% and febrile neutropenia in 0% versus 6% in monotherapy and combination therapy, respectively.

CONCLUSIONS

PFS was not significantly different between the arms. OS was significantly improved in the combination arm, an effect restricted to NSQ histology.

STUDY REGISTRATION NUMBER

NCT00835471.

Platinum-based combination chemotherapy in the treatment of older non-small cell lung cancer (NSCLC) patients (pts): Is there a role for Complete Geriatric Assessment (CGA)? Final results from the prospective multicenter NVALT-3 study

e20547

Background: Nearly 50% of NSCLC pts are aged over 70 years, but only few receive combination chemotherapy. CGA is often advocated to assess the benefits and risks of chemotherapy in older pts. Methods: A total of 182 NSCLC pts ≥ 70 years with stage IIIb/IV disease were randomized to 4 cycles carboplatin/gemcitabine (CG) or carboplatin/paclitaxel (CP). Primary endpoint was change in QoL at week18. At baseline, CGA was performed with nine different tests. Toxicity (tox) was scored using NCI-CTC v2. Tox related outcomes were defined as all grade III/IV tox, SAEs, ≥ grade II neurological or neuropsychiatric (NP) tox and the ability to finish all cycles. Relationship of CGA and QoL scores with tox endpoints were investigated. Results: Median age was 74 yrs (70–87). PS was 0 in 30%, 1 in 54% and 2 in 17%. Median OS was 8.6 mo (95% CI, 7.2–10.2) for CG and 6.9 mo (95% CI, 5.6–10.0) for CP. Median PFS was 4.7 mo (95% CI, 3.9–5.8) for CG and 4.5 mo (95% CI, 4.1–5.3) for CP. One year survival was 29% (95% CI, 21–41%) for CG and 23% (95% CI, 16–35%) for CP. There was no difference in the change in global QoL between arms. Quality-adjusted survival curves were not different. PS was prognostic, but not different for both arms. Pts with better Activities of Daily Living (ADL), instrumental ADL, or physical functioning were more likely to finish all chemotherapy cycles. Pts with worse emotional or role functioning or Geriatric Depression Score were more likely to experience NP tox. None of the CGA or QoL summary scores were associated with the occurrence of the other tox endpoints at p< 0.01. Conclusions: Carboplatinum based combination chemotherapy in older NSCLC pts is feasible. The choice for adding paclitaxel or gemcitabine to carboplatin cannot be made based on effects on QoL. CGA predicts toxicity to a limited extent but does not add substantial information to PS.

No significant financial relationships to disclose.

Cetuximab in combination with concurrent chemoradiotherapy (CRT) in locally advanced non-small cell lung carcinoma (NSCLC): A feasibility study

7540

Background: Despite modest benefits from CRT regimens in patients with locally advanced NSCLC, more efficacious treatment options are needed. Cetuximab, a monoclonal antibody that selectively binds to the epidermal growth factor receptor, has demonstrated activity in patients with metastatic NSCLC. This trial was initiated to assess the feasibility of combining cetuximab with concurrent CRT. Methods: Patients with non-operable locally advanced NSCLC received cetuximab (400 mg/m2 on day 1, 250 mg/m2 q1w from weeks 2–6) in combination with cisplatin (6 mg/m2 q1d from weeks 2–6), and RT (66 Gy in 24 fractions from weeks 2–6). Results: Between April and July 2008, 12 consecutive, eligible patients entered the study. The mean age was 61 years (range: 43–77) and 50% were male. Baseline NSCLC staging was: IIb (1 patient), IIIa (5 patients), and IIIb (6 patients). Treatment was generally well tolerated. Acne-like rash and radiation esophagitis were the most common side effects (grade ≤3 according to CTCAE v 3.0) (see table). No unexpected toxicities were observed. Early-response monitoring using PET-CT scans was performed 4 weeks after the last fraction of RT in 10/12 patients. A metabolic response was seen in 50% (complete: 3 patients; partial: 2 patients) of patients. One patient showed progressive disease. Conclusions: Cetuximab added to CRT in patients with NSCLC was generally well tolerated and produced promising early clinical responses. A randomized phase II study comparing CRT with CRT and cetuximab is ongoing.

[Table: see text]

[Table: see text]

A randomized placebo-controlled phase III study of docetaxel/carboplatin with celecoxib in patients (pts) with advanced non-small cell lung cancer (NSCLC): The NVALT-4 study

8005

Background: Cox-2 is overexpressed in NSCLC tumors and has a negative impact on survival. It is involved in proliferation and angiogenesis. The hypothesis is that celecoxib by inhibiting Cox-2 enzyme will prolong survival and may increase response to chemotherapy. Methods: We performed a phase III study with planned sample size of 540 pts. Included were pts with pathologically proven NSCLC, no prior chemotherapy, PS=0–2, measurable disease, adequate organ functions. Excluded were pts with CHF NYHA class II-IV, atherosclerotic diseases, gastrointestinal bleeding, symptomatic brain metastases and chronic use of NSAIDs (defined as 1 wk for >3 wks per yr or more than 21 days throughout the year). Acetylsalicylic acid (ASA) ≤ 150 mg/d was allowed. Pts were treated with docetaxel 75 mg/m2;, carboplatin (AUC = 6 mg/ml.min) every 3 wks for 5 cycles and randomized for celecoxib (cel) 400 mg bd, starting on day 1 for 3 years or placebo (plac) 400 mg bd. Stratification was by WHO PS (0–1 vs. 2), stage (IIIB vs. IV), ASA (yes vs. no) and hospital. Primary endpoint was overall survival. Results: From July 2003 until Dec 2007 561 pts were randomized (cel 281 pts, plac 280 pts). Median follow-up was 36 months (mo). Median (range) age 61 yrs(33–84), M/F 63/37%, PS 0/1/2 45/48/6%, adeno/large cell/squamous/other 48/27/18/7%, stage IIIB/IV 17/83%, 11% of pts used acid ≤ 150 mg/day. Reason to end treatment (cel/plac arm) was therapy completed (51/45%), PD (17/22%), adverse events (8/10%), death (8/8%). Toxicity was mild and no increase in cardiovascular events were observed in cel arm. CR, PR, SD, PD in cel/plac arm was 0/1%, 33/26%, 35/40%, 14/19%, respectively. Response rate in evaluable pts was better in the cel arm (p=0.05). Median PFS (95% CI) was 5,5 mo ( 4,3 - 6,8), OS was 8,3 mo (7,5 - 8,8), not different for both arms. HR stratified by ASA and PS for PFS and OS was 0,94 (0.79–1.13) and 0.95 (0.79–1.15), respectively. Conclusions: Addition of celecoxib to first line chemotherapy improves response rate but not progression-free interval or overall survival.

No significant financial relationships to disclose.

Can baseline complete geriatric assessment (CGA) predict toxicity in elderly non-small cell lung cancer (NSCLC) patients (pts) receiving combination chemotherapy? Results from the first 100 pts in the prospective multicenter NVALT-3 study

7537

Background: Nearly 50% of NSCLC pts are aged over 70 years, but only few receive combination chemotherapy. Undertreatment results from a fear of associated toxicities. CGA may predict which patients are prone to toxicities, and thus allow patient selection for such treatment. Methods: A total of 182 NSCLC pts = 70 years with stage IIIb/IV disease were randomized to 4 cycles carboplatin/gemcitabine (group 1) or carboplatin/paclitaxel (group 2). Before treatment, CGA was performed using the following instruments: WHO Performance Scale (PS), Charlson comorbidity index (CCI), Cumulative Illness Rating Scale-Geriatrics (CIRS-G), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Timed “Up&Go” (TUG), Mini-Mental State Examination (MMSE), Geriatric Depression Score (GDS-15), Groningen Frailty Indicator (GFI). Toxicity was scored using NCI-CTC v2. Toxicity related outcomes were defined as all grade III/IV toxicities, toxicity related SAEs, = grade II neurological toxicity and the ability to finish all cycles. Results: In the first 100 pts mean age was 75 yrs (range 70–85). PS was 0 in 30%, 1 in 56% and 2 in 14%. 57% completed all 4 cycles. 11% stopped treatment prematurely due to toxicity and 12% due to PD. Overall, grade III/IV toxicity occurred in 66% of pts, toxicity related SAEs in 12%, and 35% experienced = grade 2 neurological toxicity (n=13 group 1, n=22 group 2). Median (range) baseline CGA scores were as follows: CCI 1.0 (0–7), CIRS-G 3.0 (0–14), ADL independent 72%, IADL independent 50%, TUG 12.0 sec.(5–40), MMSE 29 (19–30), GDS-15 normal (score 0–4) 71%, GFI 3.0 (0–10). Multivariate logistic regression indicated that, for experiencing toxicity related SAEs CIRS-G provided extra information, for experiencing neurological toxicities MMSE was predictive and for finishing all cycles, IADL provided extra information in addition to PS and stage. Conclusions: CGA can predict toxicity in elderly NSCLC pts receiving combination chemotherapy. Data on all 182 patients will be presented.

No significant financial relationships to disclose.

Foscan uptake and tissue distribution in relation to photodynamic efficacy

Clinical photodynamic therapy (PDT) schedules are based on the assumption that optimum drug-light intervals are times at which there is a maximum differential between photosensitiser retention in the tumour and surrounding normal tissue. However, vascular-mediated effects contribute to tumour destruction by PDT; therefore, plasma sensitiser levels and endothelial cell drug exposure could also be important determinants of PDT response. The purpose of this study was to investigate the influence of tumour, tissue and plasma concentrations of the photosensitiser Foscan (meta-tetrahydroxyphenylchlorin, mTHPC) on PDT response. Groups of BalbC nude mice, bearing human mesothelioma xenografts (H-MESO1) were injected (i.v.) with a single dose of (14)C-labelled mTHPC, or with two doses, separated by 72 h. Drug levels in plasma, tumour and normal tissues were measured at 5 min to 120 h after drug administration. The PDT tumour and skin responses were evaluated by illuminating separate groups mice at intervals of 5 min to 120 h after injection of Foscan (nonlabelled). Drug levels in both tumour and skin increased during the first 24 h after a single injection, and remained almost constant for at least 120 h. The second injection produced a further, rapid increase in mTHPC levels in tumours and skin, with steady state being maintained from 20 min to 120 h. By contrast, PDT response of both tumours and skin were maximal for illumination at 1-3 h after drug, with very little response when illumination was given 48-120 h after drug. There was no significant correlation between tumour or skin drug level and PDT response. There was, however, a significant correlation between plasma drug levels and tumour or skin response, excluding an initial distribution time of 20 min. These studies demonstrate a pronounced disassociation between tumour drug levels and optimum drug-light intervals for PDT response with Foscan. We suggest that the PDT effect, in both tumours and normal tissues, is largely mediated via vascular damage and that the selectivity of PDT is not based on differential tumour drug uptake.

Relationship between irreversible alopecia and exposure to cyclophosphamide, thiotepa and carboplatin (CTC) in high-dose chemotherapy

Reversible alopecia is a commonly observed, important and distressing complication of chemotherapy. Permanent alopecia, however, is rare after standard-dose therapy, but has occasionally been observed after high-dose chemotherapy with cyclophosphamide, thiotepa and carboplatin (CTC). We evaluated the relationships between total exposure to these three compounds and their different metabolites in the high-dose CTC regimen, and the subsequent development of irreversible alopecia. Twenty-four patients received two or three courses of high-dose CTC, each followed by peripheral blood progenitor cell transplantation. Plasma levels of cyclophosphamide, its active metabolite 4-hydroxycyclophosphamide, thiotepa, its active metabolite tepa, and carboplatin were determined, and the area-under-the-plasma concentration-versus-time curves (AUC) of the compounds were calculated. Eight of the 24 patients included in the study developed permanent alopecia, while seven had normal hair regrowth and nine patients developed incomplete and/or thin hair regrowth. The carboplatin AUC and the summed AUC of thiotepa and tepa were both significantly associated with increasing irreversibility of hair loss. These results suggest that high exposure to carboplatin and the sum of the thiotepa and tepa exposure may lead to the development of permanent alopecia. This knowledge could guide therapeutic drug monitoring in order to prevent the occurrence of permanent alopecia and thereby improve the patients' quality of life.

High sensitivity of radiolabelled antimyosin scintigraphy in assessing anthracycline related early myocyte damage preceding cardiac dysfunction

In antimyosin scintigraphy was evaluated at various cumulative anthracycline dose levels in order to early identify patients with severe cardiac injury and increased long-term risk of cardiac dysfunction. Twenty-four patients receiving standard doses of 60-75 mg.m(-2) doxorubicin or 90-112.5 mg.m(-2) epirubicin were followed at baseline, low (two cycles), middle (four cycles), and high (six cycles) cumulative dose using (111)In antimyosin 48 h heart-to-lung ratio (HLR), left ventricle ejection fraction (LVEF) and peak filling rate (PFR). At a low cumulative dose only HLR was significantly increased (P=0.0001); at middle dose HLR (P<0.0001) and LVEF (P=0.0054), but not PFR, were significantly changed, and at high dose HLR (P<0.0001), LVEF (P=0.0001) and PFR (P=0.033) all changed significantly. Concerning individual results, HLR became abnormal in 18 patients (75%) at low, 22 (92%) at middle, and 24 (100%) at high cumulative dose whereas LVEF and PFR remained within normal limits in all patients. It is concluded that myocyte damage appears to precede left ventricle systolic and diastolic dysfunction in anthracycline treatment. (111)In antimyosin scintigraphy is very sensitive in detecting myocardial damage after cumulative dose levels even as low as 120-150 mg.m(-2) doxorubicin or 180-225 mg.m(-2) epirubicin.

Randomized trial of high-dose chemotherapy and hematopoietic progenitor-cell support in operable breast cancer with extensive lymph node involvement: final analysis with 7 years of follow-up

BACKGROUND

The aim of this study was to present an update of overall (OS) and disease-free survival (DFS) and to evaluate the correlation between outcome and pathological findings at surgery in a randomized trial of high-dose chemotherapy following neoadjuvant chemotherapy and surgery in high-risk breast cancer patients.

PATIENTS AND METHODS

Ninety-seven women <60 years of age with breast cancer and extensive axillary lymph node involvement received three courses of FE120C (5-fluorouracil 500 mg/m2, epirubicin 120 mg/m2, cyclophosphamide 500 mg/m2) followed by surgery. Eighty-one patients were randomized to receive either a fourth FE120C course alone or a fourth FE120C course followed by high-dose chemotherapy (cyclophosphamide 6 g/m2, thiotepa 480 mg/m2, carboplatin 1600 mg/m2). We performed a univariate analysis on possible prognostic factors and analyzed the sites of relapse.

RESULTS

After a median follow-up of 6.9 years, 47 (48%) patients were alive, of whom 36 (38%) were without disease. Sixty patients relapsed after treatment. One patient died of myelodysplastic syndrome, without a relapse. In intention-to-treat analysis, the 5-year DFS rates were 47.5% in the conventional treatment arm and 49% in the high-dose arm, and the 5-year OS rates were 62.5% and 61%, respectively. In the univariate analysis, the clinical T-stage before chemotherapy and the number of tumor-positive axillary lymph nodes after induction chemotherapy (P = 0.027) were significant prognostic factors for OS. The same factors (both P = 0.06) plus the estrogen receptor (P = 0.08) were borderline significant factors for DFS.

CONCLUSIONS

After a median follow-up of 6.9 years there was no difference in OS or DFS rates between the two treatment groups. The number of tumor-positive axillary lymph nodes after induction chemotherapy and the clinical T-stage before chemotherapy were significant factors for OS.

Phase II study of vincristine, bleomycin, mitomycin C and cisplatin (VBMP) in disseminated squamous cell carcinoma of the uterine cervix

The objective of this study was to study the antitumor activity of the vincristine, bleomycin, mitomycin C and cisplatin (VBMP) scheme in patients with disseminated squamous cell carcinoma of the uterine cervix and to document its toxicity. VBMP consisted of vincristine 1.4 mg/m2 (max. 2 mg) i.v. day 1, bleomycin 15 mg/day by continuous i.v. infusion on day 1 + 2, mitomycin C 6 mg/m2 i.v. day 3 and cisplatin 50 mg/m2 i.v. day 4, and was given every 4 weeks. Bleomycin was withdrawn from the schedule after a cumulative dose of 300 mg (210 mg in patients over 60). Thereafter VMP continued (V + M day 1, P day 2) with the same interval. A median number of 4.5 (range 2-13) treatment cycles was given to 50 fully evaluable patients, 26 with only distant metastases (group A) and 24 with pelvic disease also (23 previously irradiated) (group B). All patients were < 70 years old, had a Karnofsky index >/=60, and measurable metastatic lesions outside previously irradiated areas. They all had normal organ functions and gave informed consent. Response in group A was 54% (31% complete), in group B 25% (all partial), 40% in all. Median time to progression in group A was 20 weeks and in group B 15 weeks; median survival was 42 weeks in group A, 32 weeks in group B, 37 weeks for all patients. Hematologic toxicity was cumulative and the majority of patients needed blood transfusions. Nonhematologic toxicity was acceptable, but in one patient pulmonary toxicity might have contributed to death. Although it is active, it is unclear whether this regimen is superior to cisplatin alone.

EUROSCAN, a randomized trial of vitamin A and N-acetylcysteine in patients with head and neck cancer or lung cancer. For the EUropean Organization for Research and Treatment of Cancer Head and Neck and Lung Cancer Cooperative Groups

BACKGROUND

Preclinical evidence suggests that retinoids and antioxidants may prevent or delay the occurrence of cancer in the upper or lower airways, but such effects have not been reliably established in clinical studies. To assess the chemopreventive effects of vitamin A (retinyl palmitate) and N-acetylcysteine, we conducted a large randomized intervention study in patients with head and neck cancer or with lung cancer, most of whom had a history of smoking.

METHODS

From June 1988 through July 1994, a total of 2592 patients (60% with head and neck cancer and 40% with lung cancer) were randomly assigned to receive 1) retinyl palmitate (300000 IU daily for 1 year followed by 150000 IU for a 2(nd) year), 2) N-acetylcysteine (600 mg daily for 2 years), 3) both compounds, or 4) no intervention. All statistical tests were two-sided.

RESULTS

Of the patients, 93.5% had smoked tobacco at sometime in their lives (and 25% continued to smoke after cancer diagnosis). After a median follow-up of 49 months, 916 patients were reported with an event (recurrence, second primary tumor, or death). No statistically significant difference was observed in overall survival or event-free survival between patients who received retinyl palmitate and patients who did not. Similarly, no difference was seen in overall survival or event-free survival between patients who received N-acetylcysteine and patients who did not. There was a lower incidence of second primary tumors in the no intervention arm, but the difference was not statistically significant.

CONCLUSION

A 2-year supplementation of retinyl palmitate and/or N-acetylcysteine resulted in no benefit-in terms of survival, event-free survival, or second primary tumors-for patients with head and neck cancer or with lung cancer, most of whom were previous or current smokers.

Diffuse large B-cell non-Hodgkin lymphomas: the clinical relevance of histological subclassification

In the REAL classification the diffuse large B-cell non-Hodgkin lymphomas (NHL) are grouped together, because subclassifications are considered to lack both reproducibility and clinical significance. Others, however, claim that patients with an immunoblastic NHL have a worse prognosis than patients with other types of diffuse large B-cell NHL. Therefore, we investigated the prognostic and clinical significance of histological subclassification of diffuse large B-cell NHL in a uniformly treated series of patients. For this retrospective study, all patients diagnosed as having an immunoblastic (IB) B-cell NHL by the Lymphoma Review Panel of the Comprehensive Cancer Center Amsterdam (CCCA) between 1984 and 1994, and treated according to the guidelines of the CCCA, were analysed. Patients with a centroblastic polymorphic subtype (CB-Poly) or centroblastic (CB) NHL by the Lymphoma Review Panel who were treated in the Netherlands Cancer Institute during the same period according to CCCA guidelines were used as reference groups. All patients' records were reviewed. Clinical parameters at presentation, kind of therapy and clinical outcome were recorded. All available histological slides were separately reviewed by two haemato-pathologists. One hundred and seventy-seven patients were included in the study: 36 patients (20.3%) with an IB NHL, 69 patients (39%) with a CB-Poly NHL and 72 patients (40.7%) with a CB NHL. The patients with an IB NHL tended to be older and presented more often with stage I or II and one extranodal site than patients with a CB and CB-Poly NHL. None of the subtypes showed a clear preference for localization in a particular site. The patients with IB or CB-Poly NHL showed a significantly worse prognosis than patients with CB NHL, with a 5-year overall survival for patients with CB NHL of 56.3% and for patients with IB or CB-Poly NHL 39.1% and 41.6% respectively. The 5-year disease free survival was 53.2% for the patients with CB, 32% for the patients with CB-Poly and 26.9% for the patients with IB NHL. A multivariate analysis showed that histological subtyping was of prognostic significance independent of the International Prognostic Index. This finding merits further exploration in prospective studies in order to judge the value of subclassification of large B-cell NHL as a guideline in therapy choice.

Randomised trial of high-dose chemotherapy and haemopoietic progenitor-cell support in operable breast cancer with extensive axillary lymph-node involvement

BACKGROUND

Uncontrolled studies suggest that high-dose chemotherapy is beneficial in patients with breast cancer and multiple metastases to the axillary lymph nodes. Many physicians accept this treatment as standard care. We aimed to assess adjuvant high-dose chemotherapy in breast cancer in a phase II randomised trial.

METHODS

97 women aged younger than 60 years, who had breast cancer with extensive axillary-node metastases (confirmed by a tumour-positive infraclavicular lymph-node biopsy), received three courses of up-front chemotherapy (FE120C). This regimen consisted of cyclophosphamide 500 mg/m2, epirubicin 120 mg/m2, and 5-fluorouracil 500 mg/m2 once weekly for 3 weeks. After surgery, stable patients or those who responded to chemotherapy were randomly assigned conventional therapy (fourth course of FE120C, followed by radiation therapy and 2 years of tamoxifen [40 patients]) or high-dose therapy (identical treatment but an additional high-dose regimen and peripheral-blood progenitor-cell [PBPC] support after the fourth FE120C course [41 patients]). This high-dose regimen comprised cyclophosphamide 6 g/m2, thiotepa 480 mg/m2, and carboplatin 1600 mg/m2. The primary endpoint was overall and disease-free survival. All analyses were by intention to treat.

FINDINGS

No patients died from toxic effects of chemotherapy. With a median follow-up of 49 (range 21-76) months, the 4-year overall and relapse-free survivals for all 97 patients were 75% and 54%, respectively. There was no significant difference in survival between the patients on conventional therapy and those on high-dose therapy.

INTERPRETATION

High-dose therapy is associated with substantial cost and acute toxic effects, but also has potentially irreversible long-term effects. Until the benefit of this therapy is substantiated by large-scale phase III trials, high-dose chemotherapy should not be used in the adjuvant treatment of breast cancer, apart from in randomised studies.

Malignant effusions contain lysophosphatidic acid (LPA)-like activity

BACKGROUND

Lysophosphatidic acid (LPA) and sphingosine-1-phosphate (S1P) are bioactive phospholipids with mitogenic and growth factor-like activities that act via specific cell-surface receptors present in many normal and transformed cell types. LPA has recently been implicated as a growth factor present in ascites of ovarian cancer patients. The presence of LPA-like activity and the hypothesis that levels of this bioactivity in effusions of ovarian cancer patients are higher than those in effusions of other cancer patients was studied.

MATERIALS AND METHODS

A neurite retraction bioassay in a neuroblastoma cell line previously developed for in vitro detection of LPA activity on cell lines was employed and bioactivity was expressed in virtual LPA-equivalent levels. LPA-equivalent levels were tested in effusions of 62 patients with a range of malignancies, including 13 ovarian cancer patients. Biochemical and clinical parameters were evaluated for correlations with LPA-equivalent levels.

RESULTS

Average LPA-equivalent levels were 50.2 microns (range 5.4-200) for all patients, and 94.5 microns (range 15-200) for ovarian cancer patients (P = 0.004). There were no additional independent significant correlations between LPA-equivalent levels in effusions and a range of other biochemical and clinical characteristics.

CONCLUSION

These data suggest a role for LPA-like lipids in the peritoneal spread of ovarian cancer and possibly that of other predominantly intraperitoneal malignancies.

Does tumour uptake of Foscan determine PDT efficacy?

Preferential retention of photosensitizers in tumours has always been one of the major goals in the search for new photosensitizers and has determined the design of clinical trials with respect to the interval between drug administration and illumination. The purpose of this study was to investigate the importance of tumour and plasma concentrations of Foscan (mTHPC, meta-tetrahydroxyphenylchlorin) in relation to PDT effect. Both pharmacokinetic and tumour response studies were carried out in mice bearing s.c. RIF1 tumours. mTHPC was injected in 1 or 2 doses of 0.3 mg x kg-1. For distribution studies, 14C-labelled mTHPC was given 5 min to 48 hr before determination of plasma and tumour drug levels. Non-labelled sensitizer was used to determine the PDT efficacy for illumination at 5 min to 48 hr after drug administration. PDT efficacy was greatest for illumination at 1 to 3 hr, and for an interval of 48 hr there was no significant tumour-growth delay. In contrast, mTHPC tumour drug levels reached a maximum 6 hr after injection and remained high for 48 hr. A comparison of pharmacokinetics and response studies revealed no significant correlation between tumour mTHPC levels and tumour response. There was, however, a significant correlation between plasma drug levels and tumour response for time intervals of 1 to 48 hr. This association may imply that PDT protocols should use shorter drug-light intervals in combination with lower drug doses. This would increase safety and decrease the extent and duration of normal tissue photosensitization.

Role of recombinant interferon-gamma maintenance in responding patients with small cell lung cancer. A randomised phase III study of the EORTC Lung Cancer Cooperative Group

This study was undertaken to determine if recombinant interferon-gamma (rIFN-gamma) given every other day as maintenance therapy could prolong the survival of patients with small cell lung cancer (SCLC) who achieved a complete or nearly-complete response to induction therapy. A secondary endpoint was to assess the toxicity of alternate day doses of this treatment. One hundred and seventy seven patients in complete or nearly-complete response following chemotherapy with or without thoracic radiotherapy were studied. Patients were randomised to receive either rIFN-gamma 4 million units (0.2 mg) subcutaneously every other day for 4 months or observation. One hundred and twenty of the 127 registered patients were eligible; 59 patients received IFN and 61 patients without maintenance therapy were followed. Alternate day IFN was reasonably well tolerated by the majority of patients, but in 12% substantial non-haematological toxicity (including flu-like syndrome) occurred. One of 3 patients with pneumonitis died after having received 3.6 mg IFN. The median survival time from the date of randomisation was 8.9 months for the IFN arm and 9.9 months for the observation arm. rIFN-gamma at the dose and schedule used in this study failed to prolong response duration and survival in SCLC patients in complete or nearly-complete response. The toxicity seen with every other day doses of IFN was less than that reported with daily dosing. The hypothesis that this agent may increase the deleterious effects of radiation on normal lung tissue was supported by the development of pneumonitis in 3 cases of whom 1 had a fatal outcome. The results do not warrant further studies with rIFN-gamma on maintaining response in SCLC.

Randomized trial of alternating versus sequential radiotherapy/chemotherapy in limited-disease patients with small-cell lung cancer: a European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group Study

PURPOSE

To evaluate the effectiveness of alternating or sequential schedules of cyclophosphamide, doxorubicin, and etoposide (CDE) chemotherapy and irradiation in patients with previously untreated small-cell lung cancer (SCLC).

MATERIALS AND METHODS

A total of 335 eligible patients were randomized between five courses of CDE chemotherapy followed by thoracic irradiation 50 Gy in 20 daily fractions (S) and the same total dose of chemotherapy and irradiation split into four courses of five daily fractions delivered on days 14 to 21 of the second and subsequent chemotherapy courses (A). Patients had a median age of 61 years (range, 33 to 75); 224 (66%) were male; the Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 0 or 1 in 311; and 254 had weight loss less than 10%.

RESULTS

The overall median survival duration was 15 months, with 62% (95% confidence interval [CI], 57% to 67%) 1-year, 25% (95% CI, 20% to 30%) 2-year, and 14% (95% CI, 10% to 18%) 3-year survival rates. There was no significant difference between the arms. The median survival time was 14 months in A and 15 months in S. One-year survival was 60% in A (95% CI, 53% to 67%) and 64% in S (95% CI, 57% to 71%); 2-year survival was 26% in A (95% CI, 19% to 33%) and 23% in S (95% CI, 16% to 30%); and 3-year survival was 12% in A (95% CI, 6% to 18%) and 15% in S (95% CI, 9% to 21%). World Health Organization (WHO) grade 3 and 4 neutropenia occurred in 90% of A and 77% of S patients (P < .001) and WHO grade 3 and 4 thrombocytopenia in 33% of A and 20% of S patients (P < .001). Rates of other acute and late toxicities were similar in both arms. Hematologic toxicity compromised treatment dose delivery; less than 50% of A patients received greater than 95% of prescribed chemotherapy and 77% their full radiation course, compared with 60% and 93% for arm S (P < .009). Local relapse was the site of first failure in 60% of all patients and 75% of these suffered an in-field relapse; no difference could be seen between the two arms.

CONCLUSION

This trial failed to confirm the superiority of an alternating schedule of delivery. For this combination of chemotherapy and irradiation, hematologic toxicity compromised treatment delivery and could have contributed to the overall result. The poor rates of local control are disappointing and require intensification of the radiation therapy strategy.

Evaluation and follow-up of patients with N1-3 M0 or NXM1 prostate cancer in phase III trials

OBJECTIVES

The aim of this discussion is to review the design and conduct of phase III trials in metastatic prostate cancer, to seek ways of improving their study design, accuracy, relevance to clinical practice, acceptability to patients, and ease of participation by clinicians. We also aim to try to set uniform definitions for the evaluation of the different endpoints used in clinical trials on metastasized prostate cancer.

METHODS

The work was started by correspondence between the participants in the group for the year before the consensus meeting. Two comprehensive questionnaires were circulated and the answers were distributed to all the members of the group. The statements were finalized during the consensus meeting.

RESULTS

There were some differing opinions concerning the methods of evaluation of endpoints for follow-up, such as time to tumor progression and time to treatment failure. After the consensus conference, there were no major disagreements within the group.

CONCLUSIONS

The aim of phase III trials is to influence clinical management. To obtain a credible result they require a sound statistical basis with appropriate power and encompassing patients from small urologic practices as well as large or academic institutions. However, deviation from routine practice may affect the accrual rate, and the trial procedure should therefore be as similar as possible to routine management. Trials inevitably involve extra work and cost. Both should be kept to a minimum to encourage participation and hasten a timely conclusion. It is mandatory to create uniform ways of designing and evaluating clinical trials in prostate cancer.

Carboplatin and paclitaxel in patients with advanced ovarian cancer: a dose-finding study

Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) combined with cisplatin seems the new standard of care for ovarian cancer patients. Since carboplatin lacks the neurotoxicity of cisplatin with an equal antitumor activity against ovarian cancer, it was chosen as the next logical step for combination chemotherapy with paclitaxel. In 46 patients an alternating dose-escalation trial has been performed. The maximum tolerated doses are carboplatin 500 mg (area under the concentration-time curve of 9) and paclitaxel 200 mg/m2 given every 3 weeks. The dose-limiting toxicity is thrombocytopenia, which emerges in the later stages of the treatment. A true platelet-sparing effect of the combination seems highly probable. The antitumor activity of the combination equals that reported for the new standard paclitaxel/cisplatin treatment. Further phase III studies are warranted.

Pharmacokinetics of paclitaxel and carboplatin in a dose-escalating and dose-sequencing study in patients with non-small-cell lung cancer. The European Cancer Centre

PURPOSE

To investigate the pharmacokinetics and pharmacodynamics of paclitaxel (P) and carboplatin (C) in a sequence-finding and dose-escalating study in untreated non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Fifty-five chemotherapy-naive patients with NSCLC were entered onto the pharmacokinetic part of a large phase I trial in which P was administered as a 3-hour infusion at dosages of 100 to 250 mg/m2, and C over 30 minutes at dosages of 300 to 400 mg/m2. Patients were randomized for the sequence of administration, first C followed by P or vice versa. Each patient received the alternate sequence during the second and subsequent courses.

RESULTS

The most important hematologic toxicity encountered-was neutropenia. Hematologic toxicity was not dependent on the sequence in which P and C were administered, but there was cumulative neutropenia. Nonhematologic toxicities consisted mainly of vomiting, myalgia, and arthralgia. No sequence-dependent pharmacokinetic interactions for the P area under the concentration-time curve (P-AUC), maximal plasma concentration (P-Cmax), or time above a threshold concentration of 0.1 mumol/L (P-T > or = 0.1 mumol/L) were observed. However, there was a significant difference for the metabolite 6 alpha-hydroxypaclitaxel AUC (6OHP-AUC). Higher 6OHP-AUCs were observed when C was administered before P. The mean plasma ultrafiltrate AUC of C (CpUF-AUC) at the dosage of 300 mg/m2 for the sequence C-->P was 3.52 mg/mL.min (range, 1.94 to 5.83) and 3.62 mg/mL.min for the sequence P-->C (range, 1.91 to 5.01), which is not significantly different (P = .55). Of 45 assessable patients, there were five major responders (three complete responders and two partial responders). Four of five responses occurred at dosages above dose level 4 (P 175 mg/m2 + C 300 mg/m2). The median survival duration was best correlated with the P dose (4.8 months for doses < 175 mg/m2 v 7.9 months for doses > or = 175 mg/m2, P = .07; P-T > or = 0.1 mumol/L, 4.8 months for < 15 hours v 8.2 months for > or = 15 hours, P = .06).

CONCLUSION

There was no pharmacokinetic-sequence interaction between C and P in this study. A clear dose-response relation with respect to response rate and survival was observed. The pharmacokinetic parameter P-T > or = 0.1 mumol/L was related to improved survival in this study.

Mobilisation of blood progenitor cells with ifosfamide and etoposide (VP-16) in combination with recombinant human G-CSF (Filgrastim) in patients with malignant lymphomas or solid tumours

The mobilisation characteristics of ifosfamide and etoposide followed by Granulocyte Colony-Stimulating Factor fGCSF, filgrastim) were analysed in 17 patients with malignant lymphoma and 24 patients with solid tumours, with respect to the optimum time to harvest progenitor cells and to the yields of progenitor cells that could be achieved. In addition, we analysed patient characteristics which could influence the size of the progenitor cell harvest. Clinical parameters which were co-related with the size of the circulating progenitor cells (CPC) harvests were: the dose of G-CSF, dose of if osfamide, sex, age, diagnosis and extent of pretreatment. CPC were mobilised with 3 g/m2 (n = 11) or 4 g/m2 (n = 30) ifosfamide on day 1 and etoposide 100 mg/m2/day, on days 1-3 i.v., followed by daily s.c. injections with filgrastim 5 micrograms/kg (n = 26) or 10 micrograms/kg (n = 15) from day 4. The maximal progenitor cell harvest was achieved on either day 12 or day 13 after the start of the ifosfamide/etoposide course. The median number of leukaphereses necessary to harvest the target quantity of 3 x 10(6) CD34+ cells/kg body weight was 1 (range 1-9). Thirteen/41 (32%) of the patients did not achieve the target yield of 3 x 10(6) CD34+ cells/kg. By multivariate analysis, the dose of GCSF and prior irradiation were associated with the number of progenitor cells harvested, while all other parameters, induding the dose of if osfamide and number of previous chemotherapy courses, were not. Sixteen patients received two or more mobilisation courses. Despite the fact that the same mobilisation schedule was used, the progenitor cell yields after the first mobilisation course did not predict the results after the subsequent mobilisation courses, indicating that unknown transient factors may significantly influence the CPC yield.

A randomized study of high-dose split course radiotherapy preceded by high-dose chemotherapy versus high-dose radiotherapy only in locally advanced non-small-cell lung cancer. An EORTC Lung Cancer Cooperative Group trial

BACKGROUND

The treatment results of radiotherapy in stage III non-small-cell lung cancer are very poor. Several phase II studies showed that neoadjuvant chemotherapy followed by radiotherapy was feasible in this patient group and suggested that treatment outcome might improve. A randomized phase II study was performed addressing the response rate and morbidity of high-dose split course radiotherapy (RT) versus the same radiotherapy preceded by high-dose chemotherapy (CT) in patients with stage III non-small-cell lung cancer.

PATIENTS AND METHODS

Seventy eligible patients were randomized in this study. CT consisted of cisplatin 100 mg/m2 days 1 and 22, and vindesine 3 mg/m2 on days 1, 8, 22 and 29. Radiotherapy started on day 43 in the combined arm and immediately in the RT-only arm. The primary tumour and the regional nodes were treated by 30 Gy/10 fractions/2 weeks and after the split by a second course of 25 Gy/10 fractions/2 weeks. In the combined arm a third CT cycle was planned during the split between RT courses.

RESULTS

In the CT + RT arm 34 patients were evaluable for response and toxicity and 30 patients in the RT only arm. After completion of treatment 7 patients had a complete response (2 in the CT plus RT arm, 5 in the RT alone arm) and 26 patients a partial response (13 in the CT plus RT arm, 13 in the RT alone arm) for an overall response rate of 52% (95% CI 39%-65%). Acute toxicity was worse in the combined treatment arm with grade 4 leucocytopenia in 8 patients and thrombocytopenia grade 4 in one patient. Three patients had reversible renal toxicity grade 2. There was one toxic death in the RT plus CT arm. There was no enhancement of acute or late radiation pulmonary or oesophageal toxicity. Time to progressive disease (median 30 vs. 35 weeks) and overall survival time (median 12 months) were equal in both treatment arms.

CONCLUSION

High-dose radiotherapy preceded by high-dose chemotherapy was more toxic than radiotherapy alone and did not result in this study in any benefit in terms of response rate, time to progressive disease and overall survival.

Differential expression of DNA topoisomerases in non-small cell lung cancer and normal lung

DNA topoisomerases are ubiquitous nuclear enzymes, and important targets of cancer chemotherapy. Expression of topoisomerase genes is often correlated with in vitro chemosensitivity. We investigated the expression of the topoisomerase genes in normal lung and non-small cell lung cancer. Expression of topoisomerase II-alpha, topoisomerase II-beta, and topoisomerase I genes has been assessed in tumor samples of 60 patients who underwent operation for a non-small cell lung carcinoma, by RNase protection assay, and by immunohistochemistry. The expression of topoisomerase II-alpha gene was either undetectable or very low in normal lung, while most NSCLC expressed readily quantifiable levels of this gene. No alteration of the topoisomerase II-alpha gene was found by Southern blotting in the NSCLC samples. In contrast to topoisomerase II-alpha, topoisomerase II-beta was expressed in most normal as well as in tumor tissue samples, at a similar level. The levels of expression of both topoisomerase II isoforms was lower than that of human lung cancer cell lines. The results of the topoisomerase II mRNA expression were confirmed by immunohistochemistry. Whereas topoisomerase II-alpha staining was mainly limited to the nucleus, staining with topoisomerase II-beta antibody was exclusively observed in nucleoli. Topoisomerase I was localized in the nuclei and expression was mainly limited to tumor cells. By RNase protection, topoisomerase I expression in NSCLC samples was in the range of that of human lung cancer cell lines. The expression of the topoisomerase genes did not seem to be coordinated. In tumor cells, there was a positive association between expression of topoisomerase II-alpha and Ki-67, a marker of cell proliferation, as assessed by immunohistochemistry, but not with topoisomerase II-beta or topoisomerase I. Clinical characteristics of the patients, and their survival did not appear to be correlated to the level of expression of any of the topoisomerase genes, although a trend towards a shorter survival was observed in patients whose tumors expressed relatively high topoisomerase II-alpha mRNA levels.

IN CONCLUSION

(1) the two isoforms of topoisomerase II are differentially expressed in normal lung and NSCLC cells; (2) higher topoisomerase II-alpha expression is associated with higher cell proliferation in NSCLC; (3) the expression of topoisomerase II-alpha and topoisomerase I, but not of topoisomerase II-beta, was higher in tumor cells compared to normal lung. Given the differential expression of topoisomerases in normal lung and tumors, research of more potent and specific topoisomerase inhibitors might prove beneficial in non-small cell lung cancer. Immunohistochemistry may be indicated in prospectively investigating the correlation between expression of topoisomerases and results of chemotherapy treatment.

Paradigm: towards an integrated platform for registration of patients in clinical trials

A generalised registration-randomisation package, known as paradigm, has been developed by the Netherlands Cancer Institute and the MRC Cancer Trials Office initiated in association with the EORTC within the EuroCODE project and partially funded by the European Community. This randomisation software takes into account requirements of four major data centres in Belgium, France, The Netherlands and the UK and is suitable for use at further European Clinical Trial data centres to enable remote entry of patients into trials. The system became operational at the start of 1994, and is now in use at three hospitals and data centres.

Dose-finding and sequencing study of paclitaxel and carboplatin in non-small cell lung cancer

A dose-finding study was set up to identify the optimal dose of the combination of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and carboplatin for phase II studies in patients with advanced chemotherapy-naive non-small cell lung cancer (NSCLC). The influence of drug sequence on the toxicity and pharmacokinetics of both agents was also assessed. To develop an ambulatory regimen for palliation of advanced NSCLC, paclitaxel was infused over 3 hours with standard premedication and carboplatin over 30 minutes. Cycles were repeated every 4 weeks. At each dose level, at least six patients were randomized to receive either paclitaxel followed by carboplatin or the reverse sequence. In the second and following cycles the alternate sequence was administered. The pharmacokinetics of both paclitaxel and carboplatin were compared in the first two cycles in at least two patients per dose level. Sixty-two patients have been entered in this study. Paclitaxel was increased from 100 mg/m2 in 25 mg/m2 increments up to a maximum of 225 mg/m2 combined with a fixed carboplatin dose (300 mg/m2). Thereafter, the drug doses were increased to a maximum of 400 mg/m2 carboplatin and 250 mg/m2 paclitaxel. In 243 cycles, the most frequent side effects were neutropenia, alopecia, and mild emesis. Only one patient developed a major hypersensitivity reaction to paclitaxel. Bone pain, myalgia, and peripheral neurotoxicity occurred more frequently at paclitaxel doses above 200 mg/m2. No significant differences in toxicity or in the pharmacokinetics of either drug were observed between the two drug sequences. The pharmacokinetics of paclitaxel were nonlinear and consistent with saturation. At the highest paclitaxel dose (250 mg/m2 with carboplatin 350 mg/m2) a toxic death due to severe leukopenia, thrombocytopenia, and hemorrhage occurred. Safe doses for phase II trials in untreated NSCLC are 200 mg/m2 paclitaxel with 300 mg/m2 carboplatin. Of 50 evaluable patients, five of the six major responses were observed at paclitaxel doses of 175 mg/m2 and above, which suggests a dose-response relationship for paclitaxel in NSCLC.

Paclitaxel plus carboplatin in the treatment of ovarian cancer

Second-line treatment with paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) may achieve remissions in patients suffering from ovarian cancer who have failed primary chemotherapy with cisplatin- or carboplatin-based regimens. Introduction of paclitaxel in combination with cisplatin into the first-line treatment strategy was therefore the next logical step in the development of chemotherapy against ovarian cancer. Data already have shown that this may result in better survival. Since carboplatin may replace cisplatin, the combination of paclitaxel with carboplatin seemed a further necessary step. We therefore embarked on a dose-finding study of paclitaxel and carboplatin. Fourteen patients with International Federal of Gynecology and Obstetrics stage III and IV ovarian cancer with a median age of 55.5 years entered this study of escalating doses of either carboplatin or paclitaxel. Doses of carboplatin could be escalated from 300 to 450 mg/m2 and paclitaxel could be escalated from 125 to 175 mg/m2 without dose-limiting myelosuppression. At the highest dose level reported here, only transient short-lived leukopenia was observed. Other toxicities consisted of nausea and vomiting, peripheral neurotoxicity, and arthralgia, all mild. In the first 14 patients, 10 of whom are evaluable, complete remissions were seen in two patients and partial remissions in six. This study will escalate the doses of paclitaxel and carboplatin further. This treatment is well tolerated and yields satisfactory antitumor results.

Bone marrow reconstitution after high-dose chemotherapy and autologous peripheral blood progenitor cell transplantation: effect of graft size

BACKGROUND

Peripheral blood progenitor cell transplantation is rapidly replacing autologous bone marrow transplantation as hematological support after high-dose chemotherapy for lymphoma or solid tumors. Controversy exists concerning the number of progenitor cells required for rapid and sustained bone marrow recovery, and as to which of the widely available methods for estimating this number should be employed.

METHODS

Forty consecutive patients with solid tumors or lymphomas received high-dose chemotherapy followed by autologous peripheral stem cell reinfusion. All stem cell harvests had been performed after mobilization with standard-dose chemotherapy followed by 300 micrograms G-CSF daily. Hematopoietic reconstitution was studied in relation to pertinent patient characteristics, to the size of the graft (in terms of the total number of mononuclear cells (MNC), the number of granulocyte/macrophage colony-forming units (CFU-GM) and the number of CD34+ cells, and to the use of G-CSF after stem cell reinfusion.

RESULTS

Both the numbers of CFU-GM and CD34+ cells reinfused, but not those of the MNC, correlated with granulocyte and platelet recovery. Patients who received at least 5 x 10(6) CD34+ cells/kg body weight achieved platelet transfusion independence on day 12 after reinfusion (range: day 7-37), significantly earlier than patients who had received less (p = 0.001). Thirty patients who received G-CSF (300 micrograms s.c. daily) after reinfusion achieved granulocyte recovery (> or = 500 x 10(6)/l) on day 9 (range: day 8-12), while this took a median of 15 days (range: day 10-28) in 10 consecutive patients not receiving G-CSF (p = 0.0003). In one patient who had received 1.4 x 10(6) CD34+ cells/kg, secondary bone marrow failure developed 3 months after transplantation. Reinfusion of cryopreserved autologous bone marrow was followed by prompt recovery.

CONCLUSION

Peripheral stem cells, mobilized by moderate-dose chemotherapy and G-CSF, lead to rapid and durable engraftment after high-dose chemotherapy when at least 3-5 x 10(6) CD34+ cells/kg are reinfused. Lower numbers may also be satisfactory, but are associated with slower granulocyte and platelet recoveries. A moderate dose of G-CSF after reinfusion significantly hastens granulocyte recovery without interfering with platelet recovery.

Preliminary results of two dose-finding studies of paclitaxel (Taxol) and carboplatin in non-small cell lung and ovarian cancers: a European Cancer Centre effort

Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) given as a 24-hour infusion, and carboplatin have activity in advanced non-small cell lung cancer (NSCLC) and ovarian cancer. Two dose-finding studies were initiated to identify the optimal doses for the paclitaxel/carboplatin combination when paclitaxel is given in a 3-hour infusion. The fact that the pharmacologic interaction between paclitaxel and cisplatin increases the toxicity of paclitaxel when cisplatin is given before it also prompted an investigation of the influence of drug sequence on toxicity and pharmacokinetics in the NSCLC trial. Thirty-three patients with advanced NSCLC and 11 with advanced ovarian cancer previously untreated by chemotherapy have been enrolled to date. In the NSCLC trial escalating doses of paclitaxel were given in combination with a fixed carboplatin dose of 300 mg/m2, while both drugs were escalated in the ovarian cancer study. In both studies paclitaxel was infused over 3 hours and carboplatin over 30 minutes, and cycles were repeated every 4 weeks. The most frequent side effect has been neutropenia, although this did not result in any infectious episodes. Alopecia and mild emesis also have been frequently encountered. Mild skin reactions have been reported in a few patients. Bone pain and myalgia occur more frequently at the highest paclitaxel doses. No difference in toxicity has been observed thus far between the two drug sequences in the NSCLC study. Both studies are still accruing patients as the maximum tolerated doses of paclitaxel in combination with carboplatin have not yet been reached (carboplatin 300 mg/m2 with paclitaxel 175 mg/m2 in the NSCLC study; carboplatin 400 mg/m2 with paclitaxel 150 mg/m2 in the ovarian cancer study). An investigation of maximum tolerated doses with granulocyte colony-stimulating factor support is planned thereafter.

Platinum-based chemotherapy in non-small cell lung cancer: the experience of the European Organization for the Research and Treatment of Cancer

The history of chemotherapy for non-small cell lung carcinoma is one of very slow progress. Consequently, the categories of patients who will ultimately benefit from this modality are still debated. Recent European Organization for Research and Treatment of Cancer studies show that there is less concern about the importance of platinum as an ingredient of combination regimens or as an adjunct to radiotherapy. The presence of cisplatin is related to better response and survival in patients with locoregional and distant metastatic disease.

Radiosensitization by cytotoxic drugs. The EORTC experience by the Radiotherapy and Lung Cancer Cooperative Groups

A three-arm randomized trial was performed to assess the acute and late toxicity and the impact on survival of the combination high-dose, split-course radiotherapy with 30 mg/m2 cisplatin (cDDP) weekly, with 6 mg/m2 cisplatin daily compared to radiotherapy alone in patients with non-small cell lung cancer (NSCLC). The study started in May 1984 and was closed in May 1989 after 331 patients were randomised. The analysis was performed after a minimum follow-up period of 22 months. Radiotherapy (RT) consisted of 30 Gy, 10 fractions, five fractions a week; then a 3-week split followed by 25 Gy in 10 fractions. Nausea and vomiting were increased for a majority of the patients in the combined treatment arms during treatment. There was no addition of bone marrow suppression, renal dysfunction or esophagitis. Increase of late radiation damage was not observed. Local control (= absence of local progression) was improved for patients treated according to the daily cisplatin arm. This has lead to an improvement in overall survival. There was no effect in time to distant metastasis due to the combined modality. The treatment influence was confirmed in the multivariate analysis.

CONCLUSION

local control and survival can be improved by combining radiotherapy with daily low-dose cisplatin in patients with inoperable NSCLC.

Phase II trial for intraperitoneal cisplatin plus intravenous sodium thiosulphate in advanced ovarian carcinoma patients with minimal residual disease after cisplatin-based chemotherapy--a phase II study of the EORTC Gynaecological Cancer Cooperative Group

On the basis of its efficacy against ovarian carcinoma and its safe peritoneal administration, cisplatin administered by the intraperitoneal route was studied in a phase II multicentric trial. 34 patients with good performance status and residual disease less than 1 cm were treated with a 90 mg/m2 dose (60 mg/m2 at first cycle), administered in the abdominal cavity every 3 weeks for at least four cycles. In case of haematological or renal toxicity, intravenous sodium thiosulphate was perfused simultaneously with intraperitoneal cisplatin with protective intent. 25 patients were evaluable for response: 3 patients had pathological complete response and 1 patient had a microscopic disease (16% response rate in evaluable patients). Systemic toxicity was mild, and sodium thiosulphate clearly protected against leucopenia (6 patients) and renal toxicity (8 patients). Local side-effects were evaluable in 34 patients with 2 cases of infectious peritonitis, 1 of wound infection and 2 of haemorrhage. Of the 147 evaluable chemotherapy cycles, nine resulted in partial and one in total inflow obstruction, for which 4 patients needed surgical procedures for catheter-related complications, and 1 patient died of acute abdominal complications after such a procedure. We conclude that 90 mg/m2 intraperitoneal cisplatin has activity in pretreated patients with minimal residual disease, and that thiosulphate protects against haematological and renal toxicities. Only a randomised study can demonstrate a true benefit, which will have to be balanced with the toxicity of intraperitoneal drug administration.

Maintenance chemotherapy in small-cell lung cancer: long-term results of a randomized trial. European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group

PURPOSE

The present study investigates the role of short chemotherapy (five cycles) versus prolonged (12 cycles) chemotherapy in small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Six hundred eighty-seven patients with SCLC were registered in a multicenter study to receive five cycles of chemotherapy consisting of cyclophosphamide 1 g/m2 on day 1, doxorubicin 45 mg/m2 on day 1, and etoposide 100 mg/m2 on days 1, 3 and 5 (CDE), every 3 weeks. Four hundred thirty-four nonprogressing patients after five cycles of chemotherapy were randomized either to receive seven further cycles of the same chemotherapy or to follow-up.

RESULTS

The response rate of 585 assessable patients was 79%, with 36% attaining a complete response. Toxicity was mainly hematologic, with 16 toxic deaths (2.4% of all eligible patients), 13 of which were due to sepsis. Median survival time from registration of all patients was 326 days (396 and 267 days for limited and extensive disease, respectively) with 3.2% of patients alive at 5 years. No difference in survival between the two arms was observed, with the same number of 5-year survivors in both arms. The patients randomized to the maintenance arm had a progression-free survival (PFS) duration approximately 2 months longer than the patients randomized to follow-up (median of 177 days v 114 days from randomization; P = .0004). Among patients with a partial response who were randomized to receive maintenance chemotherapy, 12 achieved a complete response after 12 cycles. More patients in the follow-up arm than in the maintenance arm received subsequent treatment on progression and responded more frequently to that treatment. Twelve patients developed second malignancies (seven non-small-cell lung cancers).

CONCLUSION

Prolonged chemotherapy does not offer a better chance of cure than short chemotherapy (five cycles) and does not prolong survival in patients with SCLC. Short, combination chemotherapy appears to be a reasonable choice for standard treatment of SCLC and for attempts to improve the cure rate of this disease.