Circulating breast-derived DNA allows universal detection and monitoring of localized breast cancer

BACKGROUND

Tumor-derived circulating cell-free DNA (cfDNA) is present in the plasma of individuals with cancer. Assays aimed at detecting common cancer mutations in cfDNA are being developed for the detection of several cancer types. In breast cancer, however, such assays have failed to detect the disease at a sensitivity relevant for clinical use, in part due to the absence of multiple common mutations that can be co-detected in plasma. Unlike individual mutations that exist only in a subset of tumors, unique DNA methylation patterns are universally present in cells of a common type and therefore may be ideal biomarkers. Here we describe the detection and quantification of breast-derived cfDNA using a breast-specific DNA methylation signature.

PATIENTS AND METHODS

We collected plasma from patients with localized breast cancer before and throughout treatment with neoadjuvant chemotherapy and surgery (N = 235 samples).

RESULTS

Pretreatment breast cfDNA was detected in patients with localized disease with a sensitivity of 80% at 97% specificity. High breast cfDNA levels were associated with aggressive molecular tumor profiles and metabolic activity of the disease. During neoadjuvant chemotherapy, breast cfDNA levels decreased dramatically. Importantly, the presence of breast cfDNA towards the end of the chemotherapy regimen reflected the existence of residual disease.

CONCLUSION

We propose that breast-specific cfDNA is a universal and powerful marker for the detection and monitoring of breast cancer.

A multiparous pregnant woman receiving chemotherapy for breast cancer

Cancer is the second leading cause of death in women during the childbearing years. Breast can cer is the most common malignancy presenting during pregnancy and lactation. Treatment with antineoplastic agents in this group of patients is problematic due to their potential teratogenicity. A case report is presented of a pregnant woman who received neo-adjuvant chemotherapy for locally advanced carcinoma of the breast. The patient received a total of four courses of cyclophospha mide, doxorubicin and 5-fluorouracil, before deliv ery of a child healthy in all systems. We discuss the use of cytotoxic drugs during pregnancy and indi cate some of the dilemas facing the treating physi cian. The authors join in the call for the establish ment of an international registry of children born to mothers who receive cytotoxic drugs during pregnancy.

Protease-activated receptors (PARs) in cancer: Novel biased signaling and targets for therapy

Despite the fact that G protein-coupled receptors (GPCRs) mediate numerous physiological processes and represent targets for therapeutics for a vast array of diseases, their role in tumor biology is under appreciated. Protease-activated receptors (PARs) form a family which belongs to GPCR class A. PAR1&2 emerge with a central role in epithelial malignancies. Although the part of PAR1&2 in cancer is on the rise, their underlying signaling events are poorly understood. We review hereby past, present, and future cancer-associated PAR biology. Mainly, their role in physiological (placenta-cytotophobalst) and patho-physiological invasion processes. The identification and characterization of signal pleckstrin homology (PH)-domain-binding motifs established critical sites for breast cancer growth in PAR1&2. Among the proteins found to harbor important PH-domains and are involved in PAR biology are Akt/PKB as also Etk/Bmx and Vav3. A point mutation in PAR2, H349A, but not R352A, abrogated PH-protein association and is sufficient to markedly reduce PAR2-instigated breast tumor growth in vivo as also placental extravillous trophoblast (EVT) invasion in vitro is markedly reduced. Similarly, the PAR1 mutant hPar1-7A, which is unable to bind PH-domain, inhibits mammary tumors and EVT invasion, endowing these motifs with physiological significance and underscoring the importance of these previously unknown PAR1 and PAR2 PH-domain-binding motifs in both pathological and physiological invasion processes.

Abstract P4-05-08: Oncotype Dx assay in BRCA positive ER positive breast cancer patients

Background:

Oncotype DX is a 21-gene RT-PCR assay which quantifies the likelihood of breast cancer recurrence and the potential benefit of chemotherapy in patients with early stage, ER positive, Tamoxifen treated breast cancer. Breast cancer in BRCA carriers is considered more aggressive. The aim of our study was to evaluate whether Oncotype Dx recurrence score distribution is different in breast cancer patients with inherited BRCA mutation.

Methods:

The Oncotype DX assay has been used at Hadassah Medical Center since 2004 on specimens from over 450 patients. We analyzed and compared clinicopathological characteristics and Oncotype Dx recurrence scores of BRCA carriers versus non- BRCA or unknown status of BRCA patients.

Results:

Ten patients had validated inherited BRCA mutation, five of them are BRCA1 carriers and five BRCA2 carriers. There were no significant differences in the clinicopathological characteristics between the two groups. Oncotype Dx recurrence score distribution between low, intermediate and high risk groups was not significantly different. The mean recurrence score was 18.48 for the non- BRCA or unknown status of BRCA patients and 22.8 for the BRCA carriers patients. This difference was not statistically significant.

Conclusion:

Estrogen receptor positive breast cancer tumors from BRCA carriers does not display a significantly different Oncotype Dx recurrence score result distribution.

These preliminary data suggest Oncotype Dx assay might be used to help tailor treatment in this subset of patients, although further follow up is needed.

All patients evaluated for oncotype_DX  All evaluated (except BRCA+) n = 456BRCA positiveP valueAgeMean57.4557.60.7 Median5857  Range56 (25-81)34 (42-76) T stageT167.7%70%0.9 T230.7%30%  T31.6%0% Tumor sizeMean1.71.360.2 Median1.51.26  Range7.8 (0.2-8)1.3 (0.7-2) GradeGrade 1-278.8%60%0.15 Grade 321.2%40% RSLow50%40%0.57 Intermediate39.8%40%  High10.2%20% RSMean18.4822.80.16 Median17.522.5  Range64 (0-64)27 (12-39) 

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-05-08.

Fertility and pregnancy in patients under age 38 following chemotherapy for breast cancer

e11541

Background: Chemotherapy improves breast cancer outcome, but may impact fertility. Post chemotherapy fertility rates range between 10–90% among studies. Fertility post chemotherapy is most often assessed by rate of menstruation resumption- an indirect method of evaluating childbearing potential. It is noteworthy that future pregnancy is a woman's first concern not menses preservation. Variability in fertility rates along with limited data on post chemotherapy pregnancies led us to undertake this single institute retrospective study evaluating fertility and pregnancy post chemotherapy in ≤ 38 y old breast cancer patients. Methods: We reviewed medical records of 222 consecutive stage II-IIIB breast cancer patients diagnosed, treated and followed at Sharette Institute of Hadassah-Hebrew University Medical Center from 1990–2004. Inclusion criteria included age ≤ 38 years, ≥3 cycles of standard metothrexate or adriamycine based chemotherapy, metastasis-free 12 months post chemotherapy initiation or one year following GnRH analog withdrawal. Patients diagnosed with infertility prior to breast cancer diagnosis (data present for part of patients), bilateral oophorectomy or patients surviving ≤3 years from diagnosis were excluded. Patient pregnancy preference was not recorded. Fertility was defined as resumption of recurrent menses or pregnancy anytime during follow up. In case of recurrence, date of recurrence diagnosis was assigned as date of last follow up. Results: Cohort included 65 patients. Mean age 32.5±4 ys (20.3–38.5) Almost all patients (95.4%), 38 ys or younger, preserve menses following chemotherapy, and 33.9% become pregnant. Most of patients who did not conceive post chemotherapy (66.1%), were under a familial status not promoting pregnancy; 44% of all women who did not give birth post chemotherapy had at least 3 offspring at the time of diagnosis and 83% out of all women who did not have any offspring by the end of follow up were single. Conclusions: This data suggest that pregnancy potential may be even higher than our actual finding, since pregnancy is most probably not attempted by multiparous or most single patients, whom cultural constrains affect their decisions. It seems prudent to offer the subgroup of unmarried women fertility preservation.

No significant financial relationships to disclose.

Improvement in survival of breast cancer patients with synchronous metastases

1063

Background: Less than 10% of breast cancer patients are diagnosed with metastatic disease upon initial diagnosis. Once metastases are detected, median survival ranges between 18 and 24 months. Many new chemotherapy agents, hormonal therapy, monoclonal antibodies and supportive care options were presented during the last decade. Although a few randomized trials have demonstrated improvement in survival for various agents, it has not been clear whether the overall survival of these patients has improved. In this study, we analyzed the survival of patients diagnosed with metastatic breast cancer in during the 1990’s Methods: We have analyzed 874 patients diagnosed with breast cancer at our Institute in the years 1991–1994 and 1102 patients in 1996–1999. Tumor characteristics, treatments, and the outcomes of these patients were compared. We used Kaplan-Meier, Wilcoxon test and Cox proportional hazard in order to investigate variants between the 2 groups. Results: After excluding all women with no evidence of metastatic disease at diagnosis, we analyzed 96 patients. No major difference in tumor characteristics was found between the group of patients diagnosed in the early 1990’s and the group diagnosed in the late 1990’s. We found a significant relationship between the period of diagnosis of metastatic breast cancer and survival: median survival was 19 months for the first group and 35 months for the second group (p=0.0398, 95% C.I), with 5-year overall survival rates 8% for patients diagnosed in the early 1990’s and 25% for patients diagnosed in the late 1990’s, p=0.0497. Two years survival was 25% and 60% respectively, although insignificant, p = 0.0941. Although there was no significant difference in number of chemotherapy courses given in the 2 groups, many more new generation treatments were used for the late 90th group. The Hazard of death within 5 years for patients treated with at least one new generation protocol was 0.53, p= 0.004. Conclusions: This study suggests that there has been significant survival improvement in breast cancer patients diagnosed with synchronous metastasis during the second half of the 1990’s. This improvement can be explained by the introduction of new treatments agents and strategies during the last decade

No significant financial relationships to disclose.

Changes in psychological distress of women in long-term remission from breast cancer in two different geographical settings: a randomized study

GOALS OF WORK

Psychological distress and coping styles in women diagnosed with stages I and II breast cancer have attracted substantial clinical and research attention over the last several decades. The contradictory and, at times, controversial findings stimulated the present randomized research whose purpose was to explore the possibility and probability of predicting which variables affect the psychological distress level of women with breast cancer 1 to 5 years after diagnosis (time period 1) and 6 to 8 months after period 1 (time period 2).

PATIENTS AND METHODS

The study was conducted in two large oncology centers in Graz, Austria, and Jerusalem, Israel, with a sample population comprising 424 patients.

MAIN RESULTS

The only variables that significantly predicted change in the psychological distress levels (Grand Severity Index, GSI; except for the GSI level during period 1) were Fighting Spirit (Mental Adjustment to Cancer, MAC) in the Graz sample and Perceived Family Support (PFS) in the Jerusalem sample. These results are discussed in relation to other findings.

CONCLUSIONS

In light of these findings, it is highly important to preliminarily identify women with less adaptive psychological coping mechanisms and to provide them with efficacy tools for behavioral and cognitive changes within their own network of social and health resources.

Do different cultural settings affect the psychological distress of women with breast cancer? A randomized study

Breast cancer is the most common malignant disease among women in developed countries. In Austria and Israel, it accounts for 15% and 18%, respectively, of all cancers and 30% of all cancers in women. The purpose of this study, conducted in Graz, Austria, and Jerusalem, Israel, was to determine whether different geographical and cultural settings differentially affect the psychological distress of women who have survived breast cancer and why. The dependence of psychological distress on psychosocial variables such as quality of life, body image, impact of cancer and coping styles was examined at time 1 in a randomized sample of 424 breast cancer women who were disease-free at the time of the study and were surveyed 1-5 years after diagnosis. The most contributing variables to the level of psychological distress in both populations were: the number of stressful life events during last year, financial problems and feeling uncomfortable with the body. Regarding coping styles, mental adjustment to cancer was the principal contributor to psychological distress level [determined by the Grand Severity Index (GSI) scores] in the Graz group, while intrusion was the principal contributor to the GSI level in the Jerusalem group.

Effects of age on coping and psychological distress in women diagnosed with breast cancer: review of literature and analysis of two different geographical settings

Age-related differences in emotional distress were examined by studying two random samples (N=424) of women diagnosed with early stages of breast cancer in Graz, Austria and Jerusalem, Israel. We found that psychological distress, coping abilities, and different perceptions of illness are attributable to socialization differences of age experience according to young (49 or younger), intermediate (50-64) and old (65 and older) age groups. Patients were interviewed at home to obtain sociodemographic and medical background data. They also completed five standardized instruments (Brief Symptom Inventory, Psychological Adjustment to Illness Scale, Impact of Events Scale, Mental Adjustment to Cancer, and Perceived Family Support). A two-way MANOVA for all the demographic variables yielded significant main group (Graz vs. Jerusalem) effect (P<0.0001), significant main age effect (P<0.0001) and significant interaction (group by age) effect (P<0.001). Examination of the contribution of the age category to the level of the coping variables showed a different pattern in each group. The psychological distress variables revealed that, in the Jerusalem sample, there is a tendency toward decreasing distress levels with age and, in the Graz sample, elevated scores for the intermediate-age group. Age was found to be related to the level of Global Severity Index (GSI) and to the variables correlated to the GSI level. Psychological intervention should be guided to the different age groups.

Recombinant thyroid-stimulating hormone in differentiated thyroid cancer

Recombinant TSH is effective in providing exogenous TSH stimulation for patients with differentiated thyroid cancer on thyroid hormone-suppressive therapy. It allows for detection of thyroid remnant and metastases by radioiodine scan and by serum thyroglobulin determination. The sensitivity and image quality of the WBS are similar after rTSH and after THSH withdrawal in the majority of patients. The equivalent 100% sensitivity of rTSH- and withdrawal-stimulated serum thyroglobulin measurement alone in identifying patients with radioiodine uptake outside the thyroid bed [38] may eventually lead to more extensive use of serum thyroglobulin testing after rTSH, with more selective application of radioiodine WBS [39]. Currently, a phase IV trial is in progress to evaluate the efficacy of rTSH-stimulated thyroglobulin levels as the primary modality for long-term follow-up of low risk thyroid cancer patients. The use of rTSH prevents the morbidity, metabolic impairment and the risk of tumor progression associated with THST withdrawal, because of shorter exposure time to elevated TSH [38]. Furthermore, it decreases the radiation exposure of healthy tissues due to faster iodine clearance in euthyroidism. rTSH is well tolerated, with transient nausea in 10.5% and headache in 7.3% of patients. No antibodies specific to rTSH were documented, even after multiple courses of the drug. Currently, rTSH is suggested for patients who do not respond to hormone withdrawal or cannot tolerate hypothyroidism. For patients with low risk of tumor recurrence, rTSH-stimulated testing may be used at 6-12 months after postoperative I-131 ablation and with a repeat cycle of rTSH one year later, followed by testing every 3-5 years. In high risk patients, one set of negative I-131 scan and thyroglobulin test results after hormone withdrawal are recommended before using rTSH testing, because of a greater sensitivity of the withdrawal scan and because rTSH is not currently approved for subsequent I-131 therapy often indicated in these patients [24]. Subsequently, two cycles of rTSH testing are recommended at 6-12 month intervals, followed by testing every 1-3 years for at least the first decade after initial diagnosis. The cost of this commercially available form of rTSH has been considered a major impediment to its common use; however, this should be weighed against the loss of productivity of working hours related to withdrawal [40]. In the therapeutic setting, rTSH is the only acceptable option in a subgroup of patients with hypopituitarism, ischemic heart disease, a history of "myxedema madness," debilitation due to advanced disease, or inability to elicit TSH elevation due to continued production of thyroxine by thyroid remnant or metastatic tumor [33,38]. In conclusion, recombinant TSH facilitates the management of patients with differentiated thyroid carcinoma. It increases the sensitivity of thyroglobulin testing during thyroid hormone suppression therapy and enables radioiodine uptake for whole-body scan and occasionally for radioiodine therapy, without the need for prolonged THST withdrawal and its associated hypothyroidism, reduced quality of life and risk of tumor progression.

Correlation of toxicity with pharmacokinetics of pegylated liposomal doxorubicin (Doxil) in metastatic breast carcinoma

BACKGROUND

Doxil (ALZA Corp., Mountain View, CA) is a formulation of doxorubicin in polyethylene-glycol coated liposomes with a prolonged circulation time and unique toxicity profile. As yet, the effect of the dose schedule on toxicity and the correlation of toxicity with pharmacokinetics have not been directly addressed.

METHODS

The objectives of this study were to examine the toxicity profile and pharmacokinetics of various dose schedules of Doxil in a group of patients with metastatic breast carcinoma (MBC) previously treated with chemotherapy. Forty-five patients received a total of 268 courses of Doxil (median per patient, 5; range, 1-19). Six dose schedules were investigated: 35 mg/m2 every 3 weeks (11 patients), 45 mg/m(2) every 3 weeks (5 patients), 50 mg/m(2) every 4 weeks (5 patients), 60 mg/m(2) every 4 weeks (6 patients), 65 mg/m(2) every 5 weeks (6 patients), and 70 mg/m(2) every 6 weeks (12 patients). Doxil pharmacokinetics was examined in 24 of these patients at the dose levels of 35, 45, 60, and 70 mg/m(2).

RESULTS

Stomatitis was dose related, with higher incidence and severity at doses of 60-70 mg/m(2). Skin toxicity in the form of palmar-plantar erythrodysesthesia (PPE) developed usually after two or more courses of treatment and was schedule dependent with shorter dosing intervals leading to increased frequency and severity of skin manifestations. Myelosuppression, mainly as leukopenia/neutropenia, was dose dependent but mild and uncomplicated in most cases. Hair loss was infrequent (< 7%) and always of limited extent. Despite high cumulative doses up to 1500 mg/m(2), cardiac toxicity was observed in only 1 patient who received prior mitoxantrone and mediastinal radiotherapy. Objective responses, improvements, and durable stabilizations were observed in 9, 6, and 14 patients, respectively, indicating significant antitumor activity of Doxil in previously treated MBC patients. Doxil pharmacokinetics was well described by a monoexponential elimination curve with a long T(1/2) (median, 79 hours), a slow clearance (median, 40 mL/hour), and a small volume of distribution (median, 3.9 L). Cmax (peak plasma concentration) and AUC (area under the concentration*time curve) increased linearly with dose with a statistically significant correlation. Correlation analysis of dose and pharmacokinetic parameters with Doxil toxicites revealed that stomatitis grade and leukocyte nadir were correlated strongly with dose and Cmax, and weakly with AUC, whereas PPE grade was correlated significantly with only 1 parameter, T(1/2).

CONCLUSIONS

The toxicity of Doxil is dose and schedule dependent and well correlated with pharmacokinetic parameters. Pharmacokinetic guidance of Doxil dosing may be a useful tool.

Genetic testing of breast and ovarian cancer patients: clinical characteristics and hormonal risk modifiers

OBJECTIVES

Carriers of the mutations 185delAG and 5382insC in the BRCA1 gene and 6174delT in the BRCA2 gene have a substantial life-time risk for breast and ovarian cancers (BC and OC). The aim of the study was to identify the clinical features and the hormonal risk modifiers in mutation carriers and the implication in suggested guidelines for treatment decisions in BRCA1/2 carrier patients.

STUDY DESIGN

Breast and/or ovarian cancer patients from the Oncology and Cancer Genetic clinics were tested for the three Ashkenazi founder mutations: 87 patients were identified as carriers of one of these mutations. Clinical presentation and age at onset were correlated with the mutations, in patients with bilateral BC or BC and OC, the length of time that elapsed between the diagnosis of the two cancers was recorded. We compared BC and OC patients with regard to ages at menarche, first pregnancy and menopause, number of pregnancies and deliveries, the use of oral contraceptives, hormonal replacement therapy and fertility treatments.

RESULTS

The carriers of the three BRCA1/2 Ashkenazi founder mutations did not differ in clinical presentation nor age at onset. Forty-three patients (74.1%) of 58 BC patients were diagnosed between the ages 30 and 50, only four (6.9%) patients were diagnosed after age 60. Of BC patients diagnosed before age 35, 63.6% developed second BC as compared to 25.5% of those diagnosed after age 35. Ovarian cancer was diagnosed after age 45 in 89.7% of the patients, only one patient was diagnosed under the age of 40. Oral contraceptives use was documented in 61.3% of BC patients as compared to 11.8% of OC patients. Other hormonal factors did not differ between the two groups.

CONCLUSIONS

The carriers of the three Ashkenazi founder mutations should be considered at the same risk for BC and for OC and treatment options should be the same. Mutation carriers diagnosed with BC before the age of 35 are at a very high risk for developing second breast cancer. Most ovarian cancers in carriers were diagnosed after age 45, and prophylactic oophorectomy should be postponed to the age of 45. Oral contraceptives might elevate the risk of BC in mutation carriers.

MDR1 gene expression in primary and advanced breast cancer

P-glycoprotein (Pgp)-associated multidrug resistance (MDR) is related to intrinsic and acquired cross resistance to anthracyclines, vinca alkaloids, and other antineoplastic antibiotics. Expression of MDR1 is widely considered to play an important role in conferring resistance to adjuvant chemotherapy in women with breast tumor cells in women with disseminated disease, although data supporting this view is, at best, conflicting. The expression of MDR1 gene and its gene product, P-glycoprotein, was investigated in primary and advanced breast cancers (both previously untreated and previously treated on specific treatment protocols) to assess the role of P-glycoprotein in determining responsiveness to adjuvant chemotherapy. Expression was assessed by immunohistochemistry, reverse transcription-PCR (RT-PCR), Northern Blot and Western Blot. MDR1 mRNA was detected in 40% of the breast cancers tested by RT-PCR with 40 cycles of PCR amplification. When reducing the PCR amplification cycles to 28, the MDR1 gene expression signal disappeared from breast cancers of the highest expressers; however, known MDR1 positive control normal tissues, such as adrenal, kidney, and liver continued to show an expression product. Western and Northern blots failed to demonstrate the MDR1 gene product, P-glycoprotein, in these breast cancers. In contrast, physiologic levels of P-glycoprotein was clearly detected in normal adrenal, kidney, and liver by these techniques. Immunohistochemistry confirmed that breast carcinoma cells lacked P-glycoprotein expression; however, interstitial mononuclear cells, morphologically consistent with lymphocytes or macrophages did show immunostaining in some of these breast tumors. MDR1 gene expression identified by RT-PCR was not correlated either with response to paclitaxel therapy (29 patients able to be evaluated, p = 0.34, Fisher Exact Test) or overall survival (32 breast cancer patients with clinical follow-up information, p = 0.336, log rank). In conclusion, P-glycoprotein was not expressed in breast carcinoma cells at significant levels, although it was expressed in stomal lymphocytes or macrophages. These results suggest that P-glycoprotein does not play a significant role in multidrug resistance of breast cancer.

Thrombin receptor overexpression in malignant and physiological invasion processes

Although the involvement of soluble and matrix-immobilized proteases in tumor cell invasion and metastasis is well recognized, the role of proteolytically activated cell surface receptors has not been elucidated. We report here that thrombin receptor, a member of the protease-activated receptor family, is preferentially expressed in highly metastatic human breast carcinoma cell lines and breast carcinoma biopsy specimens. Introduction of thrombin receptor antisense cDNA considerably inhibited the invasion of metastatic breast carcinoma cells in culture through a reconstituted basement membrane. During placental implantation of the human embryo, thrombin receptor is transiently expressed in the invading cytotrophoblasts. These results emphasize the involvement of thrombin receptor in cell invasion associated with tumor progression and normal embryonic development.

Phase II study of liposomal doxorubicin in refractory ovarian cancer: antitumor activity and toxicity modification by liposomal encapsulation

PURPOSE

A phase II study of liposomal doxorubicin was conducted in patients with ovarian cancer who failed to respond to platinum- and paclitaxel-based regimens. Liposomal doxorubicin was selected as a result of its superior activity against ovarian cancer xenografts relative to free doxorubicin and activity in refractory ovarian cancer patients that was noted during the phase I study.

PATIENTS AND METHODS

Thirty-five consecutive patients were accrued in two institutions (22 in one and 13 in the other). All had progressive disease after either cisplatin or carboplatin and paclitaxel, or at least one platinum-based and one paclitaxel-based regimen. Patients received intravenous (I.V.) liposomal doxorubicin 50 mg/m2 every 3 weeks with a dose reduction to 40 mg/m2 in the event of grade 3 or 4 toxicities, or a lengthening of the interval to 4 weeks (and occasionally to 5 weeks) with persistence of grade 1 or 2 toxicities beyond 3 weeks.

RESULTS

Nine clinical responses (one complete response [CR], eight partial responses [PRs]) were observed in 35 patients (25.7%), with seven of these having been confirmed by two consecutive computed tomographic (CT) measurements. The median progression-free survival was 5.7 months with an overall survival of 1.5 to 24+ months (median, 11 months). Although 13 patients experienced grade 3 or 4 nonhematologic skin and mucosal toxicities (either hand-foot syndrome or stomatitis), with dose modifications, the treatment was very well tolerated. Nausea that was clearly attributable to the drug, hair loss, extravasation necrosis, or decreases in ejection fraction did not occur.

CONCLUSION

Liposomal doxorubicin has substantial activity against ovarian cancer refractory to platinum and paclitaxel. The responses achieved with liposomal doxorubicin were durable and maintained with minimal toxicity. This liposomal formulation should be evaluated further in combination with other drugs in less refractory patients.

The role of psychological variables in a group of melanoma patients. An Israeli sample

This study examined whether there is a difference in the psychological distress and/or coping modes of patients with early localized malignant melanoma. The authors compared the patients diagnosed at stages IA and B of the disease with those diagnosed at stages IIA and B. The population consisted of 100 melanoma patients who agreed to take part in a study of adjustment to chronic disease. The patients were individually interviewed at home and completed six self-reports. Three of the reports assessed psychological outcome, two assessed coping, and one assessed support systems. No substantial differences were found between the patients treated at stages I and II on any of the psychological measures, despite the fact that those with greatest thickness and depth (stage IIB) are at higher risk of recurrence. The women showed greater distress than the men, confirming earlier observations made in patients with colon cancer.

Ovarian cysts in premenopausal and postmenopausal tamoxifen-treated women with breast cancer

OBJECTIVE

Our purpose was to investigate the frequency of ovarian cysts in tamoxifen-treated breast cancer patients.

STUDY DESIGN

The study population included 95 consecutive tamoxifen-treated premenopausal and postmenopausal women with breast cancer who were followed up by the outpatient clinic at the Hadassah University Hospital between September 1990 and June 1992. Tamoxifen was administered orally (20 mg/day). All patients underwent a pelvic examination and vaginal ultrasonography with a 5 MHz vaginal probe.

RESULTS

During the study 11 of 95 tamoxifen-treated breast cancer patients (11%) had ovarian cysts. Five cysts were detected in postmenopausal women (6.3% of the postmenopausal women) and six in premenopausal women (37.5% of the premenopausal women). In postmenopausal and premenopausal women the mean tamoxifen treatment interval was 19.4 +/- 7.8 months (range 4 to 48 months) and 28 +/- 6.1 months (range 12 to 54 months), respectively (p = 0.41). In 8 of the 11 patients the ovarian cystic enlargement disappeared after cessation of tamoxifen treatment. Two patients underwent laparotomy because of persistent cysts and the third because of a rapidly growing myoma. The three cysts were found to be benign.

CONCLUSION

Ovarian cysts are a common side effect of tamoxifen treatment. The ovarian cysts can develop in tamoxifen-treated premenopausal as well as postmenopausal women with breast cancer. Most of the tamoxifen-associated cysts disappear after tamoxifen treatment is abandoned.

Liposomal doxorubicin: antitumor activity and unique toxicities during two complementary phase I studies

PURPOSE

The purpose of our studies was to define the maximal-tolerated dose of liposomal doxorubicin (DOX-SL; Liposome Technology Inc, Menlo Park, CA), a doxorubicin formulation of polyethyleneglycol-coated liposomes, characterize the toxicities associated with this formulation, and evaluate any indication of antitumor activity within a phase I setting.

PATIENTS AND METHODS

Two separate phase I studies were conducted following the initial human pharmacokinetic testing at one of the sites (Hadassah). The starting dose of 20 mg/m2 at the University of Southern California was just below the dose without toxicity in the pharmacokinetic study. At Hadassah, the phase I starting dose was just above their earlier safe single doses, 60 mg/m2. Both studies involved cohorts of at least three patients and redosing every 3 to 4 weeks. To determine the recommended dose for phase II trials, an additional level of 50 mg/m2 every 3 weeks was explored, and the level of 60 mg/m2 every 4 weeks was expanded.

RESULTS

A total of 56 patients receiving 281 courses of DOX-SL was accrued and evaluated for toxicity. Hand-foot (H-F) syndrome and stomatitis are the two main dose-limiting factors of DOX-SL. Stomatitis was dose-limiting for high single doses of DOX-SL greater than 70 mg/m2. Skin toxicity manifested primarily as H-F syndrome was dose-limiting for repetitive dosing, but acceptable at either 50 mg/m2 every 3 weeks or 60 mg/m2 every 4 weeks. Attenuation of acute subjective symptoms and lack of alopecia were generally observed. Patients with carcinomas of the breast, ovary, prostate, and head and neck were among those showing objective antitumor responses or improvement based, in part, on blood levels of tumor markers.

CONCLUSION

The toxicity profile of DOX-SL differs prominently from that of the free drug administered by bolus or rapid infusion and with some differences, resembles that of prolonged continuous infusion. This finding, as well as the antitumor activity observed, supports wide phase II testing of DOX-SL in solid tumors.

Paclitaxel (Taxol) in heavily pretreated ovarian cancer: antitumor activity and complications

OBJECTIVE

To analyze the efficacy and toxicity of Taxol in patients with ovarian cancer who had failed at least two previous chemotherapy treatment regimens.

PATIENTS AND METHODS

Sixty-eight patients with advanced pretreated ovarian cancer, with either measurable or evaluable disease who were shown to have disease progression were entered on a National Cancer Institute sponsored 'compassionate' treatment referral center protocol and received intravenous infusion of Taxol over 24 hours 135 mg/m2, (after steroid-containing premedication) repeated every 3 weeks and continued while showing no evidence of progression.

RESULTS

Of the 68 patients enrolled, 10 patients (15%) had a partial response and one assessable by marker only had improvement of disease. In addition, 27 others (40%) were stable on continued Taxol for a median time of 6.4 months and CA-125 decreased in 20 patients out of 59 patients with elevated baseline CA-125s. Twenty-seven patients progressed while receiving 1-6 cycles of treatment. Three patients were not evaluable for response. Neutropenia and its complications occurred primarily during the first two cycles of Taxol treatment. Febrile episodes requiring antibiotic treatment occurred in 44% of patients which is a higher incidence than in prior series.

CONCLUSIONS

Taxol as a single agent has modest activity in heavily pretreated ovarian cancer patients but appears to be useful and is subjectively well tolerated by many. The high incidence of infection in comparison with other series of patients with ovarian cancer treated with chemotherapy suggests this pretreated patient population has enhanced susceptibility to develop complications from neutropenia. Safer treatment in this advanced setting should include more aggressive use of cytokines and/or less myelosuppressive regimens (e.g. shorter Taxol infusions).

Progressive muscle relaxation and guided imagery in cancer patients

The aim of this study was to gather information on the immediate and long-term effects of six sessions of group Progressive Muscle Relaxation with Guided Imagery on the psychological distress of self-referred cancer patients. Patients' psychological distress and coping with cancer were assessed by three self-reports: the Multiple Locus of Control, the Impact of Events Scale (IES), and the Brief Symptom Inventory (BSI). Of the 123 patients who started group therapy, 37 dropped out during its course. The 86 patients who completed the intervention showed marked improvement on both BSI and IES, an improvement maintained over the next 6 months in 58 patients who continued assessment through the followup period.

Prolonged circulation time and enhanced accumulation in malignant exudates of doxorubicin encapsulated in polyethylene-glycol coated liposomes

In preclinical studies, a doxorubicin liposome formulation containing polyethylene-glycol (Doxil) shows a long circulation time in plasma, enhanced accumulation in murine tumors, and a superior therapeutic activity over free (unencapsulated) doxorubicin (DOX). The purpose of this study was to characterize the pharmacokinetics of Doxil in cancer patients in comparison with free DOX and examine its accumulation in malignant effusions. The pharmacokinetics of doxorubicin and/or liposome-associated doxorubicin were analyzed in seven patients after injections of equivalent doses of free DOX and Doxil and in an additional group of nine patients after injection of Doxil only. Two dose levels were examined, 25 and 50 mg/m2. When possible, drug levels were also measured in malignant effusions. The plasma elimination of Doxil followed a biexponential curve with half-lives of 2 and 45 h (median values), most of the dose being cleared from plasma under the longer half-life. Nearly 100% of the drug detected in plasma after Doxil injection was in liposome-encapsulated form. A slow plasma clearance (0.1 liter/h for Doxil versus 45 liters/h for free DOX) and a small volume of distribution (4 liters for Doxil versus 254 liters for free DOX) are characteristic of Doxil. Doxorubicin metabolites were detected in the urine of Doxil-treated patients with a pattern similar to that reported for free DOX, although the overall urinary excretion of drug and metabolites was significantly reduced. Doxil treatment resulted in a 4- to 16-fold enhancement of drug levels in malignant effusions, peaking between 3 to 7 days after injection. Stomatitis related to Doxil occurred in 5 of 15 evaluable patients and appears to be the most significant side effect in heavily pretreated patients. The results of this study are consistent with preclinical findings indicating that the pharmacokinetics of doxorubicin are drastically altered using Doxil and follow a pattern dictated by the liposome carrier. The enhanced drug accumulation in malignant effusions is apparently related to liposome longevity in circulation. Further clinical investigation is needed to establish the relevance of these findings with regard to the ability of liposomes to modify the delivery of doxorubicin to solid tumors and its pattern of antitumor activity.

Clinical studies of liposome-encapsulated doxorubicin

Initial clinical studies with doxorubicin entrapped in the bilayer of phosphatidylglycerol-rich liposomes were hindered by the avid reticuloendothelial system (RES) uptake and by drug leakage from circulating liposomes. In contrast, recent tests of a doxorubicin formulation of polyethyleneglycol-coated liposomes (Doxil) in cancer patients indicate that the drug pharmacokinetic properties are significantly altered, with a prolonged distribution half-life of approximately 2 days. Plasma fractionation studies show that nearly all the drug measured in plasma is in liposome-encapsulated form. The dose of Doxil has been escalated from 25 to 60 mg/m2. Stomatitis is the most significant toxicity, and skin toxicity, in the form of hand-foot syndrome, may complicate the repeated administration of Doxil. A number of objective antitumor responses in a variety of malignancies have been observed, indicating that Doxil is an active antitumor compound. Polyethyleneglycol-coated liposomes show a distinct advantage over previous liposome formulations directed at the RES and appear to be a promising drug delivery system for doxorubicin.

Protracted drug infusions in cancer treatment: an appraisal of 5-fluorouracil, doxorubicin, and platinums

The feasibility to deliver chemotherapeutic agents by protracted i.v. infusion has greatly increased in the recent past. Indwelling ports, longer lasting central venous catheters requiring less than daily maintenance 'flushing', surgical expertise in placement, use in analgesia and nutrition, and 'smart' pump technology have all contributed to their increasing popularity. Justification for use of infusions in cancer chemotherapy has been slow in appearing with few studies proceeding to the comparative stage. This review will focus on three drugs in common use in cancer treatment, with the purpose of appraising the role of such infusions in cancer therapeutics and of deriving some lessons that might be applicable to other drugs or to drug development in general. For fluorouracil and doxorubicin the rationale and clinical findings favoring further development of infusion regimens is particularly strong. In the case of platinum compounds, some toxicologic advantages have emerged, but other measures designed to protect against the toxicities of cisplatin compete with infusion regimens in this regard. The therapeutic potential for this form of drug delivery, therefore, appears still confined to a subset of patients. Stronger rationales for the use of protracted infusions may be forthcoming from pharmacodynamic findings as in the case of etoposide, combined modality therapy with radiation for FU and cisplatin, biochemical modulation for FU, and reversal of multidrug resistance and its modulation for doxorubicin. While awaiting research into these areas of clinical and pre-clinical investigations, the role of infusion appears most evident in the cardiotoxicity protection of anthracyclines, and in further efficacy exploration (through dose or modulation) of FU. Both mechanistic and pharmacologic considerations could also provide additional stimulus for development of new formulations such as long circulating liposomes, and drugs more suitable for oral administration.

Successful administration of low molecular weight heparin in a patient with heparin-induced thrombocytopenia and coumarin-induced skin necrosis

A case of heparin-induced thrombocytopenia and skin necrosis induced by coumarin is reported in a 58-year-old female patient suffering from metastatic breast adenocarcinoma and deep vein thrombosis. The thrombosis resolved after treatment with low molecular weight heparin and the thrombocytopenia recovered within a few days. The occurrence of both these rare complications in the same patient has not been previously reported in the literature. We present a review of these complications and their current treatment.

A preliminary report of a pilot randomized trial comparing cyclophosphamide, methotrexate and 5-fluorouracil with cyclophosphamide, mitoxantrone and 5-fluorouracil in the adjuvant therapy of stage II breast cancer with four or more positive axillary nodes

Thirty-eight patients with stage II breast cancer with four or more positive axillary lymph nodes were randomized to receive CMF (cyclophosphamide, methotrexate and 5-fluorouracil, every 3 weeks) or CXF (cyclophosphamide, mitoxantrone and 5-fluorouracil, every 3 weeks). Pretreatment characteristics were similar for both groups. The actuarial 5 year disease-free survival (DFS) was 36% for the CMF group and 23% for the CXF group. The actuarial 5 year survival was 60% for the CMF arm and 66% for the CXF arm. These differences were not statistically significant. Partial alopecia was observed in 42% of patients in the CMF arm and in 100% of those receiving CXF (p = 0.0002). No episodes of leucopenic fever were observed in patients receiving CMF, while they were present in 53% of patients treated with CXF (p = 0.0006). No stomatitis occurred in the CMF group, but it was observed in 90% of patients who received CXF (p < 0.0001). Treatment with CXF had to be discontinued in two patients because of toxicity. In this small group of patients with poor prognosis, it seems that CXF at the doses given here is more toxic but not more effective than CMF, as represented by a similar DFS and survival.

Recurrence-associated mortality in patients with differentiated thyroid carcinoma

Differentiated thyroid carcinoma (DTC) is associated with prolonged natural history, and even recurrent tumor is not necessarily followed by increased mortality. Prognostic factors and different treatment strategies, therefore, are difficult to assess. One hundred and fifty-seven patients were followed in our clinic. In an attempt to predict mortality from this tumor, we evaluated the risk factors in 36 patients who presented with recurrent disease. Ten of these patients died. Age above 40 years at initial diagnosis was the predominant risk factor associated with 44% mortality after recurrence. Male sex, lack of radioiodine treatment, and distant site of initial recurrence were all associated with a trend towards increased mortality. Tumor histology and local invasion or extent of initial surgical treatment failed to affect mortality. In conclusion, this approach may be used to identify those patients who will die from their disease, despite currently available treatment. It remains to be seen, however, if new treatment protocols can be developed to improve the prognosis of these patients.

The effect of tamoxifen on the endometrium

Tamoxifen is one of the most important treatments for breast cancer, especially in postmenopausal patients. It acts primarily as an anti-estrogenic agent, due to its cytoplasmic estrogen receptor binding capacity. However, it also exerts a mild estrogenic effect. Since the prolonged use of estrogen has been reported to increase the rate of benign and malignant changes in the endometrium, we evaluated whether there is a correlation between tamoxifen therapy and endometrial benign and malignant conditions. The study group comprised 95 patients with breast cancer who were treated with tamoxifen. No control group was examined. Patients underwent vaginal ultrasonography and endometrial biopsy in order to evaluate any changes in the endometrium occurring during tamoxifen therapy. Pathological changes were observed in 14 patients, 13 of whom were treated with tamoxifen for more than 12 months. Of these women, 3 were diagnosed with endometrial cancer, 3 had mild dysplasia, 3 had endometrial hyperplasia, and 4 had a benign endometrial polyp. Our findings indicate a significant correlation between long-term tamoxifen administration and endometrial proliferation. We therefore recommend that women treated with tamoxifen for more than 12 months have an annual vaginal ultrasonography and endometrial biopsy.

Scintigraphic evaluation of patients with thyroid carcinoma--therapeutic approaches

The therapeutic approach to patients with differentiated thyroid carcinoma has become a major issue of controversy in the last decade. The major aspects are the surgical resection and adjuvant therapy, particularly the need for thyroid ablation following surgery. According to the risk group definition suggested by Cady in 1979, low risk patients may be subjected to lobectomy only, then placed on thyroxine treatment and followed clinically with thyroglobulin determination. High risk patients should undergo total thyroidectomy and 131I ablation. Follow-up should include thyroxine treatment and an annual whole body 131I scan. In the event of residual thyroid tissue or functional metastases, 131I treatment is to be given.

Biliary and pancreatic metastases of breast carcinoma: is surgical palliation indicated?

Obstructive jaundice developed in a patient concomitantly with the diagnosis of breast carcinoma. Abdominal exploration disclosed a metastatic tumor in the head of the pancreas, the distal bile duct, and the gallbladder. A cholecystectomy and choledochojejunostomy were performed and later, because of intestinal obstruction, the patient underwent gastrojejunostomy. Pathological examination demonstrated metastatic lobular carcinoma of breast with strongly positive staining for estradiol. Additional hormonal therapy has been given to the patient since the operation. The patient is alive 16 months after the diagnosis of her disease. This case suggests that a vigorous diagnostic approach should be adopted in every jaundiced patient with metastatic breast cancer in order to exclude causes of jaundice other than diffuse metastatic involvement of the liver. Patients with extrahepatic biliary metastasis should be treated by aggressive surgical treatment, combined with systemic therapy which can offer them significant palliation and better survival.

Cisplatin, bleomycin, and methotrexate (PBM) chemotherapy in locally advanced and metastatic head and neck cancer

Twenty-two patients with locally advanced or metastatic head and neck tumors received a total of 84 courses of a combination of cisplatin, bleomycin, and Methotrexate (PBM) for a median of four courses per patient (range, 1-7). Among these 22 patients there were four patients (18%) who achieved complete remission (CR) and 13 patients (60%) who had a partial remission (PR). The overall remission rate (CR + PR) thus reached 78%; five patients (22%) progressed while on therapy. The mean duration of objective response (CR + PR) was 8 months; CR lasted a median of 18 months (range, 2-48). Survival was not influenced by tumor histology or by previous surgery. The presence of locoregional disease did adversely affect survival from the onset of chemotherapy (P = 0.1). The rate of survival was also affected by primary tumor site; patients with nasopharyngeal primaries survived longer than all other patients (22 vs. 11 months, P = 0.06). Toxicity to chemotherapy consisted mainly of nausea and vomiting and stomatitis. Three patients developed fever while leukopenic. One patient experienced irreversible renal damage, and another suffered from bleomycin-induced pulmonary fibrosis. The high response rate obtained in our group of patients did not have a substantial impact on overall survival. Aggressive, multimodality approaches should be considered in the treatment of these patients when possible.

Right ventricular outflow tract obstruction due to extracardiac tumors. A report of three cases diagnosed and followed up by echocardiographic studies

Echocardiography has become a valuable diagnostic tool in various clinical conditions. Its use for the detection of extracardiac tumors has seldom been reported. The majority of these descriptions are of single case reports. We have recently encountered three patients (two with lymphomas and one with seminoma) who presented with signs and symptoms suggestive of right ventricular outflow tract obstruction. Two-dimensional echocardiography enabled the prompt diagnosis of extracardiac tumors compressing the heart. Moreover, echocardiography proved to be an excellent noninvasive tool for assessing the success of therapy for mediastinal tumors.

Diffuse large cell non-Hodgkin's lymphoma: results of M-BACOD combination chemotherapy

Twenty-seven adult patients with diffuse large cell lymphoma were treated with the M-BACOD regimen during the period 1980-86. Of these, 24 (89%) had advanced Stage III-IV disease by clinical staging and only 3 (11%) had limited disease. CR was achieved in 14 patients (52%), all of whom had advanced disease prior to therapy. The remaining 13 patients (48%) achieved only PR. Of the entire group of 27 patients, 11 (41%) died, 12 (44%) are still in CR, and 4 (15%) have relapsed and are still alive with PR. Of the 14 patients who achieved CR, 1 relapsed, but is currently in PR, showing minimal disease. All of these 14 patients are alive (11 months to 6 years post therapy), and 13 (93%) still remain in CR with a median time of CR of 45 months. Of the 13 patients who only achieved PR, 11 (85%) relapsed and died within a median time of 3.6 months, and 2 patients remain in PR. The above results are similar to those obtained in larger series recorded from other centers. In the light of improved results obtained with new regimens and ABMT, we have now adopted the MACOP-B regimen for treating aggressive lymphoma and have entered an ABMT program for patients with predictable poor prognostic features.

Combination chemotherapy in metastatic tumors of unknown origin. 5-Fluorouracil, adriamycin and mitomycin C for adenocarcinomas and adriamycin, vinblastine and mitomycin C for anaplastic carcinomas

Twenty-nine evaluable patients with metastatic carcinomatosis in whom initial workup failed to reveal the primary site were entered into this trial. Patients with histological evidence of adenocarcinoma (n = 15) received FAM, while patients with anaplastic carcinomas (n = 14) were given AVM. Pretreatment characteristics were similar for the FAM- and AVM-treated patients with regard to age and sex, but 47% of patients on FAM had liver metastases as compared with 36% for the AVM group. Of the 14 patients on AVM, 1 (7%) achieved a complete response lasting 16 months, and 3 patients (22%) achieved a partial response for 10, 12 and 20 months, respectively. No patient on FAM reached a complete response, and only two patients (13%) showed a partial remission for 7+ and 24 months, respectively. The median survival for the AVM patients was 8.5 months, not significantly different from a median of 5 months for the FAM-treated group. AVM caused substantial myelotoxicity, resulting in five hospitalizations for leukopenia and fever; the FAM regimen was better tolerated with no episodes of leukopenic fever. AVM appears to be more effective than FAM in the treatment of carcinomas of unknown origin. A higher response rate was achieved with AVM, despite the fact that patients on this combination had undifferentiated carcinomas and a larger proportion of three or more metastatic sites (36 vs. 13% on FAM), and received a lower percent of the planned dose than did the FAM patients. Further clinical trials to fully establish the role of vinblastine in the treatment of metastatic carcinomatosis of unknown origin seem warranted.