M-Veca (Methotrexate, Vinblastine, Epidoxorubicin and Carboplatin) in the Treatment of Advanced Urothelial Carcinoma

Aims and Background

Urothelial cancer is a chemosensitive disease. However, cisplatin or anthracycline-containing regimens still provoke severe toxicity mainly due to reduced renal function and poor performance status (PS) of patients. The aim of this study was to verify the possibility of substituting carboplatin for cisplatin and epirublcin for doxorubicin in the M-VAC regimen in order to reduce toxicity and improve patient tolerance.

Methods

Twenty patients with advanced urothelial tract tumors were treated with a chemotherapeutic regimen composed of methotrexate (30 mg/mq iv on days 1, 15, 22), vinblastine (3 mg/m2 iv on days 2, 15, 22), epidoxorubicin (35 mg/m2 iv on day 2) and carboplatin (250 mg/m2 iv on day 2) every four weeks (M-VECA). All patients had bidimensionally measurable disease.

Results

Of the 18 evaluable patients, 3 (17 %) obtained complete response and 7 (33 %) obtained partial response (50 % overall response). The median duration of response was 50 weeks (range, 28-88+). Grade III-IV toxicity (leukothrombocytopenia and mucositis) was observed in 20 % of cases. Nevertheless, recovery was prompt in all but 2 patients with poor PS who died of nadir sepsis.

Conclusions

M-VECA was an effective regimen for the treatment of patients with metastatic urothelial tumors and was safely employed in patients with a good PS. However, the possibility of substituting carboplatin for cisplatin as neoadjuvant therapy for less advanced stages needs further investigation in randomized studies.

Mitoxantrone, L-Leucovorin and 5-Fluorouracil: An Effective and Well Tolerated First-Line Treatment for Advanced Breast Cancer

Aims and background

The combination of mitoxantrone plus leucovorin/fluorouracil in heavily pretreated patients with advanced breast cancer has shown significant activity and extremely good tolerability. The aim of this study was to evaluate the activity of this combination in patients not previously submitted to chemotherapy.

Methods

From May 1993 to December 1995 we treated 80 patients with advanced breast cancer with a combination of mitoxantrone, l-leucovorin and 5-fluorouracil. All patients had histologically or cytologically proven breast cancer, WHO performance status 0–3, normal hematological parameters and normal serum bilirubin. Prior chemotherapy for metastatic disease was not allowed, whereas adjuvant CMF (cyclophosphamide, methotrexate and 5-fluorouracil) or adjuvant anthracycline (doxorubicin or epirubicin) therapy was allowed; a single prior hormone treatment was permitted. Chemotherapy consisted of mitoxantrone 12 mg/m2 i.v. day 1, l-leucovorin 150 mg/m2 i.v. days 1, 2 and 3 and 5-fluorouracil 350 mg/m2 i.v. days 1, 2 and 3. The courses were repeated every 3 weeks.

Results

Objective response (CR + PR) was observed in 46/80 (57%) patients (95% CI, 46%–68%). Complete response (CR) was observed in 21/80 cases (26%). Response was observed in 14/24 (58%) patients with soft tissues as the dominant site of disease, in 22/34 (65%) patients with visceral involvement and in 10/22 (45%) of those with bone as the dominant site of disease. The median duration of response and survival was 9 months (range, 3–16) and 22 months (range, 2–48+), respectively. Toxicity was very manageable, with grade 4 leukopenia and thrombocytopenia in 6/80 (7.5%) and 1/80 (1.25%) patients, respectively, and negligible non-hematological toxicity.

Conclusions

The combination of mitoxantrone, 5-fluorouracil and high-dose l-leucovorin is a safe and effective regimen for first-line treatment of advanced breast cancer.

Subcutaneous recombinant interleukin-2 plus alpha interferon and vinblastine in metastatic renal cell carcinoma

The management of metastatic renal cell carcinoma (RCC) constitutes a therapeutic challenge and no standard therapy has yet been established. This phase II study aimed to verify the efficacy and tolerability of subcutaneous low dose recombinant interleukin-2 (IL-2) plus alpha interferon (IFN) and vinblastine (VLB) in patients with metastatic RCC. Twenty-three evaluable adult patients were enrolled in the study. A total of 19 patients were previously subjected to radical nephrectomy and four had been treated with adjuvant immunotherapy. The I-nest frequent metastatic sites were lung/pleura, bone, liver, lymph nodes, and abdominal mass. The following treatment schedule was administered: VLB at 6 mg/m(2) on day 1: IL-2 at 4.5 million IU twice daily from day 1 to 5 and day 8 to 12; IFN at 3 million IU three times weekly intramuscularly. The therapy was recycled every 21 days, except for the IFN which was administered continuously. Five patients demonstrated remission (21.6%) including one complete response persisting for 6 months, and four partial responses with a duration of 41+, 20, 8, and 18+ months. Moreover, 15 patients (65%) showed stable disease for 4-20 months (median 6 months), and three patients progressed. Overall median survival of the 23 patients was 11 months, with 27+ months for responders, 11 months for patients with stable disease, and 8 months for patients with rapid progression. Regressions occurred in lung, pleura, bone, and abdominal mass. Treatment was relatively well tolerated and easily manageable. This study was mainly administered as outpatient care. This study confirms the manageability and tolerability of subcutaneous IL-2 used in association with IFN alpha and chemotherapy. Even though a minority of patients responded, the duration of responses and the high percentage of long stable diseases represent the most interesting aspect of this study.

Subcutaneous recombinant interleukin-2 plus chemotherapy with cisplatin and dacarbazine in metastatic melanoma

The aim of our study was to verify the efficacy and tolerability of subcutaneous low doses of interleukin-2 with cisplatin and dacarbazine for malignant melanoma. 24 patients were included. The following schedule was used: cisplatin (CDDP) 100 mg/m2 day 1; darcarbazine (DTIC) 375 mg/m2 days 1-5; recombinant interleukin-2 (rIL-2) 4.5 million IU x 2/day days 13-17 and 20-24. The therapy was recycled every 28 days. 10 patients obtained clinical remission (42%), with 2 complete responses (8%) persisting for 12 and 15+ months, and 8 partial responses (35.5%) with a median duration of 5 months. Median survival of all 24 patients was 8 months, 13 months for responders and 6 months for non-responders. Responses were seen predominantly in lymph nodes (48%) and skin-soft tissue (38%), but were also seen in the liver (29%) and lung (14%). Treatment was relatively well tolerated and toxicity was mainly related to chemotherapy.

Iatrogenic Pneumocephalus in a Man with Undifferentiated Nasopharyngeal Carcinoma. A Case Report

A case of pneumocephalus in a 45-year-old male with undifferentiated rhinopharyngeal carcinoma is described. The patient was initially subjected to radiotherapy and then to transmaxillary resection and a second course of stereotactic radiotherapy for recurrent disease. Lastly, the patient was treated with chemotherapy because of local-regional disease progression. After two cycles of cisplatin, adriablastine and bleomycin, the patient suddenly entered in coma. Cerebral CT scan evidenced the presence of air in the frontal and lateral cornua, in the subarachnoid space of the base cisternae extending to the 7th cervical vertebra. After 8 months of a clinical stationary condition, the patient died. The various treatments used are critically reviewed, and modern therapeutic approaches for the neoplasm and the toxicity involved are discussed. We conclude that in nasopharyngeal carcinoma, for patients who relapse after radiotherapy, successive local-regional therapies (surgery, re-irradation) should be carefully evaluated to avoid demolishing treatments, which are burdened with severe side effects that might influence the quality of life with only slight improvement of overall survival. Furthermore, the presence of persistant aqueous rhinorrhea in these patients should be carefully evaluated, because it could be an early symptom of a cerebrospinal fluid leak.

Results of a clinical multicentric randomized phase-ii study of nonsmall cell lung-cancer treated with vinorelbine Cisplatin versus vinorelbine alone

From July 1992 to December 1993, 62 patients with non-small cell lung cancer (NSCLC) were admitted to a multicentric randomized study. The patients were treated with vinorelbine (V) alone at a dose of 25 mg/m(2)/i.v. weekly or with V at a dose of 25 mg/m(2)/i.v. on day 1 and 8 plus cisplatin at a dose of 80 mg/m(2)/i.v. on day 1 every 3-4 weeks (VP). An objective response was observed in 42% of patients treated with VP versus 12.5% of those treated with vinorelbine alone (p=0.038). There was no significant difference in the median survival duration between the two groups (38 versus 30 weeks for VP and V, respectively). Toxicity was tolerable but more severe in the VP regimen. These data suggest that V is an active agent in NSCLC and that the VP regimen may yield results comparable to other cisplatin combinations for treatment of these tumors.

Subcutaneous ril-2 in advanced melanoma and kidney carcinoma

The aim of the present study was to verify the efficacy and tolerability of a treatment protocol using subcutaneous administration of rIL-2. Eighteen patients with metastatic disease were treated: 10 with renal carcinoma and 8 with malignant melanoma. The drug was administered as follows: 9 million UI/mq twice daily for two days followed by 1.8 million UI/mq twice daily for five days/week for six consecutive weeks. Of the 15 patients evaluated for clinical response, all completed treatment without rIL-2 dose modifications. No complete response was obtained. One patient with malignant melanoma and 1 with renal carcinoma (13%) had partial response (soft tissue and lymph nodes respectively) which lasted 3 and 4 months. Six patients with renal carcinoma and 3 melanoma patients had stable disease (60%) which lasted 6 months (median). Toxicity was moderate and spontaneously reversing after stopping treatment. Haemato-immunological modifications and pharmacokinetic study of this modality of rIL-2 treatment were also examined.