Access to Genetic Testing Impacts Oncologists´ Decisions on Ovarian Cancer Personalized Treatment: Lessons Learned From a National Program in Greece

Background: State health insurance authorities in Greece do not reimburse genetic testing for cancer predisposition. The Hellenic Society of Medical Oncology has launched and carries out a national program covering genetic testing for BRCA1/2 mutations detection, with the financial support of pharmaceutical industry. Aim: This analysis evaluates how, during this program, access to genetic testing transformed the oncologists' therapeutic approach toward their ovarian cancer patients and how the results impacted treatment decisions concerning PARP inhibitors. Adoption of testing by healthy relatives and timing of testing in the disease continuum were also evaluated. Methods: Adult patients with high-grade epithelial ovarian carcinoma, irrespectively of family history or age at diagnosis were eligible for this program. Genetic counseling was recommended before testing, and both were offered at no financial cost. First degree family members of pathogenic mutation carriers were also offered free counseling and testing. Results: From March 2015 through January 2018, 708 patients were enrolled and tested. One hundred and forty seven (20.7%) mutation carriers were identified, 102 (14.4%) in BRCA1 and 45 (6.3%) in BRCA2 gene. Testing was more often pursued at initial diagnosis (61%) than at recurrence (39%), as recorded for 409 patients with available relevant information. During the 1st year of the program, average monthly tests performed were 25.1, while during the 3rd year this number increased to 34.3 tests per month. Among patients who tested positive for deleterious BRCA1/2 mutations, relapse was reported in 58 patients, 94.8% of which (n= 55) received treatment with the PARP inhibitor olaparib as per its indication. Family members of 21 patients (14.3%), out of the 147 who tested positive, received genetic counseling and testing for the mutation identified in the context of the program. Conclusion: Free access to genetic testing for BRCA1/2 for ovarian cancer patients and genetic consultation facilitates testing uptake, affects common clinical practice & has major impact on patients and their families. Still, diffusion of genetic information and broader testing of family members require further efforts by the oncological community.

Mucinous breast carcinoma with tall columnar cells

Mucinous carcinoma of the breast represents 1%-4% of all breast cancers. The World Health Organization classification divides this type of tumour into three different subtypes: mucinous carcinoma, mucinous carcinoma with tall columnar cells (mucinous cystadenocarcinoma and columnar cell mucinous carcinoma) and signet ring cell carcinoma. A 74-year-old woman presented a tumour with inflammatory features in the upper outer quadrant of her left breast, 7 cm in diameter. The core biopsy showed infiltrating ductal carcinoma of no specific type. The tumour-node-metastasis clinical staging was T4cN3M0 (Stage IIIC). She received neoadjuvant chemotherapy, underwent left mastectomy with radical axillary resection and subsequently received radiotherapy and chemotherapy. The histological examination of the surgical specimen revealed two solid tumors in the tail of Spence, which corresponded to adenocarcinoma with high columnar cells. The patient died 16 months after the diagnosis, suffering from pulmonary metastases and anterior chest wall infiltration. A review of the literature revealed only 21 reports of mucinous carcinoma of the breast with tall columnar cells, including our case. This is only the third time that the specific histological type of columnar cell mucinous carcinoma has been reported in the literature.

Complete remission of a reccurrent mesenteric liposarcoma with rare histological features following the administration of trabectedin

The present study describes a rare case of a mesenteric liposarcoma that resulted in a complete remission (CR) following treatment with trabectedin (Yondelis^®). The patient presented with abdominal pain and fever. An abdominal mass was identified that corresponded to a mixed-type high-grade mesenteric liposarcoma with wide areas of necrosis, areas of dedifferentiation and features of a leiomyosarcoma. Three months after the removal of the first mass, the patient underwent a second laparotomy, followed by treatment with doxorubicin and ifosfamide. Subsequently, the patient was started on therapy with trabectedin and a CR was noted following only four cycles of therapy. The best responses that are reported in the literature for cases of liposarcoma treated with trabectedin are mostly for liposarcomas of the myxoid/round cell type and are mainly partial responses. In the present study, trabectedin was used for the treatment of a mesenteric liposarcoma of mixed morphological features and a CR was achieved.

P4-11-15: Increased Propability of Triple Negative Breast Cancer (TNBC) in Premenopausal Patients after Exogenous Hormonal Intake (EHI)

Purpose: HRT is a known risk factor for breast cancer (BC) among post-menopausal women. Our knowledge in relation to EHI (estrogens and/or progestin) and BC among pre-menopausal women is scarce. We have studied whether previous EHI influences BC phenotype, clinical and pathologic characteristics and correlation with other known BC risk factors.

Patients and methods: A prospective analysis (data recorded upon patients first presentation) of an electronic database at a tertiary cancer centre was performed. Patients’ demographics, risk factors for BC (smoking, alcohol use, obesity, family history), clinical profile, EHI parameters (duration, cause) and the tumors’ histopathology (type, grade,ER/PgR and HER2 by IHC and FISH) were analyzed. Premenopausal patients without an EHI history consisted control group.

Results: Out of 938 patients treated for BC between 2006 and 2010, 333(35,5%) were premenopausal and 131(39%) of them reported any use of hormones. Median age was identical (43 years,range:20–57) among premenopausal patients with and without EHI history. Mean duration of use was 28 months (range:1–180). Causes of EHI were contraception (35%), pregnancy(17%), menstrual abnormalities(17%) and medically assisted fertilization(17%). Smoking, alcohol use and obesity didn't differ among two groups. Family history for BC was more common (31, 3% vs. 22,8%, p=0,08)among women with EHI. No correlation was found among duration of use and the time of cancer diagnosis, while the mean time from the cessation of hormones to cancer diagnosis was 13 years(range:1–32). Only 18% of breast cancers were diagnosed within the first 5 years after exogenous hormones cessation.

TNBC was found to be significantly increased among premenopausal women with a history for EHI (23,6% vs. 13,4%, p=0,016). This increase was independent of the existence of positive family history for BC (p=0,61). EHI conferred a twofold increase in the risk for a TNBC (OR=1,99 p=0,019). No other clinical or histopathologic parameter showed any difference among the two groups.

Conclusion: Prior use of exogenous hormones, for any cause and irrespective of the coexistence of other risk factors and family history, increases the probability of a triple negative breast cancer diagnosis by twofold. Whether this represents a trend of a changing epidemiology in the types of BC in prior hormone users vs. nonusers, poses an extremely challenging hypothesis to be verified in large epidemiologic studies — given the young age and the treating difficulties of this patient population.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-15.

Abstract P6-10-06: Metachronous Contralateral Breast Cancer (CBC) Has More Aggressive Biology and Clinical Characteristics Compared to Synchronous Bilateral Breast Cancer (BBC)

Purpose: Bilateral breast cancer is an uncommon clinical entity. There is no specific treatment strategy and controversial issues concerning diagnostic criteria, management and classification exist.

Method: In order to address some of these issues, a prospective analysis (data recorded upon patients first presentation) of an electronic breast cancer database at a tertiary cancer centre was performed. Patients’ epidemiologic characteristics, clinical profile, genomic analysis information and the tumours’ histopathology were analyzed.

Results: Out of 900 patients treated for breast cancer between 2006 and 2009, 44 diagnosed with bilateral disease (5% of total)having a median age of 53 years(range 32-73). 16 of them (36%)suffered from synchronous disease and 28 (64%)from metachronous { >3 months apart between the initial diagnosis and subsequent contralateral breast tumour).

Genetic analysis revealed 3 patients with inherited breast cancer syndromes (2 with BRCA1 and one with CDH-1 mutation). Among those with synchronous BBC 63% (10/16)were postmenopausal, 50% (8/16)had a positive family history for breast cancer and upon initial diagnosis 80% (13/16)of them presented with early stage disease (stages I,II).Contralateral disease was diagnosed incidentally. In contrast to these patients with synchronous BBC,57% of the patients (16/28)with metachronous CBC were premenopausal and 68% (19/28)had advanced disease (stages III,IV) upon the second diagnosis. Etrogens’ use didn't differ among the two groups, obesity was more common in patients with metachronous CBC, and smoking in the synchronous BBC patients.

Of the 88 tumours, 81(92%) were invasive, with ductal adenoCa being the more common (53% of specimens).

Of synchronous BBC tumours 12/16 (75%)were HR+ positive and 80%(13/16) expressed the same biologic features bilaterally. Of the metachronous tumours, upon initial diagnosis,26% were triple negative and only 7% were found with HER2 amplification, compared with 41% and 26% respectively in the second diagnosis. Conclusions: Synchronous BBC is less prevalent than Metachronous CBC, has more favourable characteristics (earlier stage at diagnosis, hormonal receptor positivity), and occurs mainly among postmenopausal women with positive family history.

Metachronous CBC is more common in premenopausal women and has a tendency to change its biological and clinical characteristics to a more aggressive phenotype (triple negative, HER2 amplification) between initial and latter diagnosis.

If this phenomenon is a result of previously given chemo/radio-therapy or it reperesents the natural evolution to a second primary, remains a challenging question to be answered.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-10-06.

Abstract PD09-02: Prognostic Effect of Obesity on Breast Cancer

Background: Body mass index (BMI), prior estrogen use, and family history have been described as risk factors for invasive breast cancer. Our purpose was to investigate the influence of obesity on established prognostic pathologic and molecular characteristics of breast cancer. Material and methods: Five-hundred and twelve female consecutive breast cancer patients of mean age 53±11 years were included in this study. Data were recorded in a prospective electronic databank upon first presentation. Risk factors (BMI, family history, prior estrogen use, menopausal status, parity, metabolic syndrome, smoking, alcohol, hypertension, hyperlipidaemia and diabetes) as well as histologic characteristics (TNM, nodal status, grade, LVI) and tumor phenotype (ER, PR, Cerb-B2) were obtained. Patients with a BMI<27 were considered of normal weight whereas patients with a BMI≥27 were considered as obese. Univariate and logistic regression analysis were performed. Results: The 2 groups did not differ for age (p=ns). Patients with a BMI≥27 were more frequently node positive, had a higher incidence of grade 3, LVI positive tumors and had more often a positive family history of breast cancer (P<0.05). On the contrary, patients with a BMI<27 reported more frequently prior estrogen use and were more commonly nulliparous (P<0.05). Regression analysis confirmed that in patients with BMI<27 age and menopausal status were associated with node positive disease, independently of tumor phenotype, grade, LVI, family history, estrogen use and parity (0.951, 95%CI 0.91-0.99 and 3.232, 95%CI 1.2-8.5). Using the same analysis, in patients with BMI≥27 LVI was associated with node positive disease, independently of all other factors (5.253, 95%CI 1.1-26.9).

Discussion: Different risk factors appear to influence lean and obese breast cancer patients. Patients with BMI<27 more frequently have a history of estrogen use and nulliparity. Age and menopausal status are independently associated with node + disease in lean patients. Obese patients (BMI>27) have more frequently positive family history and more aggressive histology (node +, grade 3, LVI+). LVI in obese patients appears to be independently associated with node + disease.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD09-02.

Relationship between lymphovascular invasion (LVI) and prognostic markers in different subtypes of breast cancer

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Background: Prognostic and predictive factors for invasive breast cancer (BC) are well established. LVI was added to the list of prognostic factors for node negative patients (St.Gallen 2006). The aim of this study was to investigate the relationship of LVI with known prognostic markers and its role on different subtypes of breast cancer. Methods: 367 patients with primary BC were evaluated in this study. Tumoral and peritumoral breast tissue was examined for LVI. The patient's age, menopausal status, tumor histology, tumor size, histologic grade, lymph node (LN) involvement, hormone receptor (HR) status and HER-2 status were determined as markers of prognosis. The association of LVI with the aforementioned markers was evaluated using multiple logistic regression analysis. Results: The distribution of the patients was as follows: 40.9% were HR + and HER-2 - (luminal type), (32.4%) were triple negative, 26.7% were HER-2 Positive (9.5% of them were HER-2 + and HR -, while 17.2% were HER-2 + and HR+). Almost half of the patients (48.8%) had one or more positive nodes. Multiple analysis revealed that histologic grade, LN involvement and HER-2 positivity were independently associated with LVI. Patients with histologic grade II and III had 5.31 (95% CI: 1.14–24.75) and 7.03 (95% CI: 1.47- 33.53) times greater odds for LVI respectively compared to those with grade I. Patients with one or more than three nodes involved had 3.95 (95% CI: 2.13–7.33) and 6.29 (95% CI: 3.14–12.63) times greater odds for LVI respectively compared with node negative tumors. Furthermore, HER-2 positive patients had almost twofold likelihood for LVI (OR=1.80, 95% CI: 1.02–3.16). The effect of HER-2 positivity on LVI was independent of HR status. Age, menopausal status, tumor histology, tumor size and HR status were not significantly associated with LVI. Conclusions: LVI shows a close relationship with known markers of poor prognosis as histologic grade, and LN invasion. More aggressive tumors as HER-2 + tumors have a significantly higher probability of LVI, which may be used as an indicator of more aggressive behavior of the primary tumor.

No significant financial relationships to disclose.

Chemotherapy improves low performance status lung cancer patients

The aim of the present study was to determine the potential benefit of conventional cisplatin-based chemotherapy on patients with advanced nonsmall cell lung cancer (NSCLC) and poor performance status (PS), defined as 60-70 on the Karnofsky scale. Retrospective analysis was carried out of a randomised trial performed in advanced NSCLC where 485 patients received three courses of gemcitabine+ifosfamide+cisplatin induction chemotherapy. Of the patients, 80% had good PS (Karnofsky 80-100) and 20% poor PS. Response rates were 38 and 28%, respectively. Clinical improvement, defined as achieving a good PS during chemotherapy, was observed overall in 25% of the poor PS patients, with rates of 38, 20 and 14%, respectively, in case of response, no change and progression. PS improved more quickly in the responders. Survival of patients with poor PS was significantly worse, but survival of responders was similar, irrespective of the initial poor or good PS. Although nonfatal toxicity was almost similar, there were more toxic deaths (including vascular and cardiac fatalities) in the poor PS patients (9.2 versus 2.1%). In conclusion, combination chemotherapy is associated with clinical improvement in a substantial number of patients with advanced nonsmall cell lung cancer of poor performance status.

First-line chemotherapy with docetaxel and cisplatin in metastatic breast cancer

The purpose of this study was to evaluate the efficacy and tolerance of combined treatment with docetaxel-cisplatin as first-line chemotherapy in patients with metastatic breast cancer (MBC). Consecutive eligible chemonaive patients received docetaxel 75 mg/m(2) on day 1 and cisplatin 75 mg/m(2) on day 2 every 3 weeks for 6 cycles, with prophylactic recombinant human granulocyte colony-stimulating factor (rHuG-CSF) on days 4-11. Thirty-two patients (64%) had received prior adjuvant chemotherapy; these included 16 (32%) who had received anthracyclines. In 50 evaluable patients with a median age (range) of 56 (31-72) years, the overall response rate was 68% (95% CI, 55-81%), with 7 (14%) complete and 27 (54%) partial responses. Stable and progressive disease was observed in 10 (20%), and 6 (12%) patients, respectively. The median duration of response was 10 months, and the median time to progression was 39 weeks. Grade 3/4 hematological toxicity included--neutropenia in 9 patients (18%), anemia in 2 (4%) and thrombocytopenia in 1 (2%). One patient (2%) with febrile neutropenia required hospitalization. Grade 3/4 nonhematological toxicities included nausea/vomiting in 18%, nephrotoxicity in 14%, asthenia (4%), and neurotoxicity (2%). Toxicity was common in older patients (>56 years). There were no treatment-related deaths. A combination of docetaxel-cisplatin with rHuG-CSF support is well tolerated and effective as first-line chemotherapy in MBC.

Survival is better predicted with a new classification of stage III unresectable non-small cell lung carcinoma treated by chemotherapy and radiotherapy

The 1997 International staging system (ISS) classification separated stage III non-small cell lung cancer (NSCLC) into stages IIIA and IIIB. In a previous study including unresectable NSCLC initially treated with chemotherapy, we analysed survival according to tumour (T) and node (N) stages and derived a classification into stages IIIbeta (T3-4N3) and IIIalpha (other TN stage III) that had a better discrimination on survival distribution. The aim of this study was to validate these results in a further set of patients. Patients with unresectable stage III NSCLC included in a phase III trial assessing the role of increased dose chemotherapy (SuperMIP: mitomycin 6 mg/m2, ifosfamide 4.5 g/m2, cisplatin 60 mg/m2, carboplatin 200 mg/m2) in comparison to standard chemotherapy MIP (mitomycin 6 mg/m2, ifosfamide 3 g/m2, cisplatin 50 mg/m2), before thoracic irradiation (60 Gy in 30 fractions over 6 weeks) were the subject of this study. Survival distributions were assessed by the method of Kaplan-Meier. Survival comparisons were made by the log-rank test. Multivariate analyses using Cox regression models, included all potential prognostic factors for survival with a P-value <0.2 in univariate analysis. According to the 1997 International staging system classification, 328 eligible patients were included in the study. There was no imbalance between the two arms. Five parameters were significantly associated (P < or = 0.05) with survival in univariate analysis: European lung cancer working party (ELCWP) staging (IIIalpha[n = 294 pts] versus IIIbeta [n = 46]), Karnofsky index, weight loss, platelet count and haemoglobin level. These variables as well as the 1997 ISS staging, white blood cell (WBC) count, LDH and sodium levels were included in a multivariate analysis. Two models were constructed, including either the ELCWP or the 1997 ISS. In model 1 (ISS included), Karnofsky index (HR 0.69; 95% confidence interval (CI) 0.47-1.00; P = 0.05) and haemoglobin (HR 1.49; 95% CI 1.11-1.99; P = 0.007) were found significant. In model 2, including ELCWP staging, two variables were associated with survival: ELCWP staging (HR 1.68; 95% CI 1.20-2.35; P = 0.002) and haemoglobin (HR 1.54; 95% CI 1.15-2.07; P = 0.01).

CONCLUSION

In initially unresectable stage III NSCLC treated by chemotherapy and radiotherapy, we validated the results of our previous study. The classification into stages IIIbeta (T3-4N3M0) and IIIalpha (other TN stage III) better discriminates the patients in term of survival than the 1997 ISS classification.

A phase III randomised study comparing two different dose-intensity regimens as induction chemotherapy followed by thoracic irradiation in patients with advanced locoregional non-small-cell lung cancer

PURPOSE

The aim of this study was to determine the role of chemotherapy dose intensity in patients with initially unresectable non-metastatic non-small-cell lung cancer (NSCLC), with survival as primary end point, by testing two different regimens as induction chemotherapy followed by thoracic irradiation.

PATIENTS AND METHODS

Patients had pathologically proven NSCLC, an initially unresectable non-metastatic tumour without homolateral malignant pleural effusion, no prior history of malignancy and had received no prior therapy. Treatment was randomised for chemotherapy between three courses of MIP (mitomycin C 6 mg/m2; ifosfamide 3 g/m2; cisplatin 50 mg/m2) or SuperMIP (mitomycin C 6 mg/m2; ifosfamide 4.5 g/m2; cisplatin 60 mg/m2, carboplatine 200 mg/m2), followed by chest irradiation (60 Gy; five times per week, for 6 weeks). If the tumour became resectable after chemotherapy, surgery was performed, followed by mediastinal irradiation.

RESULTS

A total of 351 patients were eligible: 176 in the MIP arm and 175 in the SuperMIP arm, with 43% and 51% stages IIIA and IIIB, respectively. There was a significantly higher objective response rate with SuperMIP (46%) compared with MIP (35%) (P=0.03) [95% confidence interval (CI) for the difference between the response rates, 1% to 22%]. After induction chemotherapy, surgery was performed in 54 (15%) patients (27 per arm) and chest irradiation in 203 (57%) patients (102 in the MIP arm and 101 in the SuperMIP). In terms of survival, there was no statistically significant difference between the two study arms (P=0.16), with median survival times of, for MIP and SuperMIP, respectively, 12.5 (95% CI 10.1-14.9) and 11.2 (95% CI 9.7-12.8) months. Haematological toxicity and dosage reductions were higher with SuperMIP, which was nevertheless associated with a significantly increased absolute dose intensity.

CONCLUSIONS

High dose-intensity induction chemotherapy does not improve survival in initially unresectable non metastatic NSCLC.

Vinorelbine and Cisplatin for Metastatic Breast Cancer: A Salvage Regimen in Patients Progressing After Docetaxel and Anthracycline Treatment

PURPOSE

To assess the antitumor efficacy and safety of a combination of vinorelbine (VNR) and cisplatin in patients with metastatic breast cancer previously treated with anthracyclines and docetaxel.

PATIENTS AND METHODS

Thirty-six patients with assessable metastatic breast cancer previously treated with anthracyclines and docetaxel (adjuvant n = 1, palliative n = 20, both n = 15) were studied. Cisplatin was given at 75 mg/m2 on day 1 followed by 25 mg/m2 VNR on days 1 + 8 in a 5-minute i.v. infusion. Courses were repeated every 3 weeks. Treatment was continued until disease progression, excess toxicity, or patient refusal. Patients were classified according to their response to anthracyclines according to criteria published previously: 1) Anthracycline and/or docetaxel resistant were patients who progressed during treatment with anthracyclines and docetaxel or within 4 months after cessation of treatment (metastatic). In addition, adjuvant patients who progressed within 6 months after completion of chemotherapy belong to this group. 2) Anthracycline and/or docetaxel relapsed were either metastatic patients who responded initially and then progressed after 4 months of completing an anthracycline- and docetaxel-based chemotherapy or patients who progressed after 6 months from completion of anthracycline/docetaxel-based adjuvant chemotherapy.

RESULTS

Two patients (5.6%) achieved a complete response (CR) and 15 patients (41.6%) achieved a partial response (PR), for an overall response rate (OR) of 47.2% (95% confidence interval, 31-63). Of 18 patients relapsed to anthracycline/docetaxel, 2 had a CR (11%) and 8 a PR (44.4%), giving an objective response of 55.5%. Stable disease (SD) was observed in one patient (5.5%); seven patients had progressive disease (PD) (39%). Among the 18 resistant patients, 7 PRs (39%) were observed (p = 0.5), one patient (5.5%) had stable disease, 10 patients (55.5%) progressed. The median time to progression (TTP) was 16 weeks and median overall survival 36 weeks. Relapsed patients had a longer TTP than resistant patients (24 vs. 8 weeks, p = 0.05) but similar survival (48 vs. 24 weeks, p = 0.173). All patients were assessed for toxicity. The main toxicity was neutropenia grade 3 and 4 in 47% of patients. Febrile neutropenia requiring hospitalization was absent. There were no treatment-related deaths. Thrombocytopenia grade 3 and 4 occurred in four patients (11%). Phlebitis, orthostatic hypotension, and asthenia, all reversible, were observed in 3% of patients, respectively.

CONCLUSION

This cisplatin/VNR regimen is well tolerated and active in patients who failed anthracyclines and docetaxel treatment. The response rate, TTP, and survival data are high and indicate that cisplatin/VNR may have a place as salvage treatment in this group of patients. If these results can be verified in multi-institutional trials, this combination of drugs would merit investigation as part of a first-line therapy in breast cancer.

Vinorelbine and docetaxel as first-line chemotherapy in metastatic breast cancer

PURPOSE

To evaluate the efficacy and tolerability of a combination of vinorelbine (VNR) and docetaxel (DOC) as first-line chemotherapy in patients with metastatic breast cancer.

PATIENTS AND METHODS

The study group comprised 40 women with untreated metastatic breast cancer with visceral (85%) and bone (70%) metastases. Of the 40 patients, 24 (60%) had previously received adjuvant chemotherapy, which had included anthracyclines in 12 patients (30%). Treatment consisted of VNR 25 mg/m(2) on days 1 and 5, and DOC 75 mg/m(2) on day 1 every 3 weeks. Depending on the neutrophil nadir (grade 3 or 4 neutropenia by WHO criteria) recombinant human granulocyte colony-stimulating factor (G-CSF) 5 micro g/kg on days 2-4 and 6-13 was given for all subsequent treatment cycles.

RESULTS

The overall response rate (ORR) was 40% (95% confidence interval, CI 15-65). Six patients (15%) achieved a complete response (CR) and ten patients (25%) achieved a partial response (PR). Stable disease (SD) was observed in six patients (15%), and 18 patients (45%) had progressive disease (PD). The median duration of response was 8 months and the median predictive time to progression (TTP) was 6 months. The main toxicity was neutropenia grade 3 and 4 in 28 patients (70%). Febrile neutropenia requiring hospitalization occurred in 12 patients (30%). Grade 3 or 4 anemia was seen in two patients (5%) and grade 3 or 4 thrombocytopenia was seen in one patient (2.5%). Severe nonhematologic toxicity, except alopecia, was uncommon and included stomatitis in two patients (5%), vomiting in two (5%) and diarrhea in one (2.5%). There were no treatment-related deaths.

CONCLUSIONS

The combination of VNR and DOC at the doses used in this study showed moderate activity as first-line chemotherapy in metastatic breast cancer. Neutropenia was considerable despite G-CSF administration.

A three-arm phase III randomised trial assessing, in patients with extensive-disease small-cell lung cancer, accelerated chemotherapy with support of haematological growth factor or oral antibiotics

The European Lung Cancer Working Party (ELCWP) designed a 3-arm phase III randomised trial to determine the role of accelerated chemotherapy in extensive-disease (ED) small-cell lung cancer (SCLC). Eligible patients were randomised between the 3 following arms: (A) Standard chemotherapy with 6 courses of EVI (epirubicin 60 mg m(-2), vindesine 3 mg m(-2), ifosfamide 5 g m(-2); all drugs given on day 1 repeated every three weeks. (B) Accelerated chemotherapy with EVI administered every 2 weeks and GM-CSF support. (C) Accelerated chemotherapy with EVI and oral antibiotics (cotrimoxazole). Primary endpoint was survival. 233 eligible patients were randomised. Chemotherapy could be significantly accelerated in arm B with increased absolute dose-intensity. Best response rates, in the population of evaluable patients, were, respectively for arm A, B and C, 59%, 76% and 70%. The response rate was significantly higher in arm B in comparison to arm A (P = 0.04). There was, however, no survival difference with respective median duration and 2-year rate of 286 days and 5% for arm A, 264 days and 6% for arm B and 264 days and 6% for arm C. Severe thrombopenia occurred more frequently in arm B but without an increased rate of bleeding. Non-severe infections were more frequent in arm B and severe infections were less frequent in arm C. Our trial failed to demonstrate, in ED-SCLC, a survival benefit of chemotherapy acceleration by using GM-CSF support.

Control of irinotecan-induced diarrhea by octreotide after loperamide failure

Diarrhea is a well-recognized side effect of chemotherapy, which affects the quality of life and when refractory is potentially life threatening. Irinotecan (CPT-11) is associated with an elevated incidence of chemotherapy-induced diarrhea and subsequent morbidity. Standard antidiarrheal treatment is based on high-dose loperamide, but this agent is associated with a significant failure rate. Octreotide is active against chemotherapy-induced diarrhea caused by fluoropyrimidines and irinotecan, with a distinct mechanism of action. We administered octreotide in a phase I trial in 37 patients who received irinotecan and experienced loperamide-refractory diarrhea, 23 of whom experienced grade III-IV diarrhea and were treated with loperamide. The 13 patients in whom to loperamide failed to control diarrhea received octreotide, with a high response rate (92%). We conclude that octreotide is effective against loperamide-refractory diarrhea resulting from irinotecan-based chemotherapy.

Prevention of vinorelbine phlebitis with cimetidine. A two-step design study

One hundred eighteen patients with various malignancies received a total of 847 vinorelbine (VNR) infusions, during 25 of which episodes of vinorelbine phlebitis occurred (1 in each of the 25 patients concerned). Venous irritation was graded with reference to the scale devised by Rittenberg et al. To prevent these 25 patients against further venous toxicity, we pretreated them with cimetidine 200 mg i.v. prior to VNR administration in subsequent cycles of chemotherapy. In most (19, or 76%) complete prevention of recurrent phlebitis was observed, while partial prevention was observed in 5 patients (20%). Treatment was unsuccessful in 1 patient. In 127 VNR infusions given after cimetidine prophylaxis only 7 (6%) episodes of phlebitis occurred. These data show that i.v. administration of cimetidine prior to vinorelbine infusion can successfully prevent recurrence of phlebitis in patients who have shown venous irritation upon prior VNR treatment, at a rate of 94%.

Phase III randomized trial comparing moderate-dose cisplatin to combined cisplatin and carboplatin in addition to mitomycin and ifosfamide in patients with stage IV non-small-cell lung cancer

A phase III randomized trial was conducted in patients with metastatic NSCLC, to determine if, in association with mitomycin (6 mg m(-2)) and ifosfamide (3 g m(-2)), the combination of moderate dosages of cisplatin (60 mg m(-2)) and carboplatin (200 mg m(-2)) - CarboMIP regimen - improved survival in comparison with cisplatin (50 mg m(-2)) alone - MIP regimen. A total of 305 patients with no prior chemotherapy were randomized, including 297 patients assessable for survival (147 in the MIP arm and 150 in the CarboMIP arm) and 268 patients assessable for response to chemotherapy. All but eight (with malignant pleural effusion) had stage IV disease. There was a 27% (95% CI, 19-34) objective response (OR) rate to MIP (25% of the eligible patients) and a 33% (95% CI, 24-41) OR rate to CarboMIP (29% of the eligible patients). This difference was not statistically significant (P = 0.34). Duration of response was not significantly different between both arms. There was also no difference (P = 0.67) in survival: median survival times were 28 weeks (95% Cl, 24-32) for MIP and 32 weeks (95% Cl, 26-35) for CarboMIP, with respectively 1-year survival rates of 24% and 23% and 2-year survival rates of 5% and 2%. The main toxicities consisted in emesis, alopecia, leucopenia and thrombocytopenia, that were, except alopecia, significantly more severe in the CarboMIP arm. Our trial failed to demonstrate a significant improvement in response or survival when patients with metastatic NSCLC were treated, in addition to ifosfamide and mitomycin, by combination of moderate dosages of cisplatin and carboplatin instead of moderate dosage of cisplatin alone. The results support the use of a moderate dose (50 mg m(-2)) of cisplatin in combination with ifosfamide and mitomycin for the chemotherapy of this disease.

Vinorelbine and cisplatin in metastatic breast cancer patients previously treated with anthracyclines

PURPOSE

To assess the antitumor efficacy and safety of a vinorelbine and cisplatin combination in patients with metastatic breast cancer previously treated with anthracyclines.

PATIENTS AND METHODS

Fifty-three patients with assessable metastatic breast cancer with previous exposure to anthracyclines (adjuvant n = 6, palliative n = 47) were studied. Cisplatin 75 mg/m2 on day 1 was given followed by 25 mg/m2 vinorelbine (VNR) on days 1 + 8, in a five-min i.v. infusion. Courses were repeated every three weeks on an outpatient basis. Treatment continued until disease progression, excess toxicity or patient refusal. Patients were classified according to their response to anthracyclines: anthracycline refractory patients were patients who had never responded under an anthracycline regimen. Anthracycline resistant patients were either metastatic patients who progressed within four months of completing anthracycline-based chemotherapy or patients who progressed within six months of completion of an anthracycline adjuvant treatment. Patients who progressed four months after the end of an anthracycline regimen in metastatic setting or six months after the end of an anthracycline regimen in adjuvant setting were considered as patients previously treated with anthracyclines and were called 'relapsed'.

RESULTS

Four patients (8%) achieved a complete response (CR) and twenty-two patients (41%) achieved a partial response (PR) with an overall response rate (OR) of 49% (95% confidence interval (CI): 35-63). Stable disease (SD) was observed in five patients (9%), twenty-two patients had progressive disease (PD). Responses according to previous sensitivity to anthracycline were as follow: 5 refractory patients achieved a PR from 14 patients (36%). Seven of sixteen resistant patients responded (44%), six with PR and one with CR. Among 23 'relapsed' patients, 14 responses were observed (61%), with 3 CR and 11 PR. There was no statistical difference in RR among the three groups. The median duration of response for all patients was 7 months, the median time to progression (TTP) 5 months and median overall survival 12 months. All patients were assessed for toxicity. The main toxicity was neutropenia grade 3 and 4 in 49% of patients. Febrile neutropenia requiring hospitalization was uncommon (2 patients). There were no treatment related deaths. Despite potential overlapping neurologic toxicities of the two drugs, only eight patients (15%) developed neuropathy, which was, however, mild (grades 1 and 2).

CONCLUSIONS

This cisplatin VNR regimen is well tolerated and active in patients who failed anthracyclines. The response rate, TTP and survival data are encouraging and indicate that cisplatin VNR may have a place as second-line treatment alternative to taxanes or other less active regimens. If these results can be verified in multi-institution trials, this combination of drugs would merit investigation as first-line therapy in this patient population.

Optimal timing (Preemptive versus supportive) of granulocyte colony-stimulating factor administration following high-dose cyclophosphamide

PURPOSE

The aim of this study is to compare various time schedules of granulocyte colony-stimulating factor (G-CSF) treatment in a clinical model of patients who received high-dose cyclophosphamide (HDCY 45 g/m2) for the treatment of an underlying malignancy in order to investigate the optimal time (preemptive vs. supportive) of G-CSF initiation upon the incidence and duration of cytopenias and related parameters, such as incidence of febrile episodes, antibiotic use, duration and cost of G-CSF administration and overall clinical benefit and cost effectiveness of various schedules used.

PATIENTS AND METHODS

Seventy-two courses were given in a sequential cohort study. G-CSF was administered either 24, 48, 72, 96 h after chemotherapy (preemptive treatment) or upon the onset of leukopenia (WBC </=1,000/ microl) (supportive treatment). Study parameters were compared among the various groups as well as to a control group who received HDCY without G-CSF support.

RESULTS

(1) Patients who received G-CSF early (24, 48 h) had a shorter duration of leukopenia (WBC </=1,000/ microl) compared to those who received G-CSF at a later stage (72, 96 h) or as supportive treatment (p < 0. 05). However the duration of neutropenia (ANC </=500/ microl) or thrombocytopenia (platelets </=20,000/ microl) was not affected by the different time schedules of treatment. (2) Patients who received G-CSF early (up to 72 h) had less febrile days with neutropenia in comparison to late treatment (>96 h), supportive and control groups (p < 0.05). The cost of antibiotics was also in favor of the early treatment group. The median duration of febrile days of the delayed (>72 h) treatment groups and antibiotic cost was similar to those in patients who did not receive G-CSF at all. (3) When G-CSF was given preemptively a shorter time was required to reach normal WBC (5,000/ microl) in comparison to the sup- portive and control group. This was due to a prolonged WBC recovery rather than to an early onset of leukopenia (tail effect). A delayed leukopenia recovery occurs as administration of G-CSF is delayed. (4) As a result the required length of G-CSF treatment to reach normal WBC (5,000/ microl) was shorter in the early treatment group and the cost from G-CSF use was less in that group in comparison to the late (>72 h) and supportive groups which indicated an increased cost without clinical benefit over controls.

CONCLUSIONS

G-CSF administration after HDCY has a similar effect upon the incidence and duration of severe leukopenia and thrombocytopenia. However, severe leukopenia is shorter when G-CSF starts up to 72 h after HDCY. The length of G-CSF administration and its cost is also in favor of early initiation of treatment as well as the number of febrile days and antibiotic use. Delayed (>72 h) or supportive treatment indicate more febrile episodes, antibiotic use and higher cost when compared to the early groups. Late (>72 h) or supportive G-CSF administration in this study indicates no benefit versus no treatment in relation to length of leukopenia, febrile days, antibiotic use and overall treatment cost.

A comparison of methods of calculation for estimating carboplatin AUC with a retrospective pharmacokinetic-pharmacodynamic analysis in patients with advanced non-small cell lung cancer. European Lung Cancer Working Party

We retrospectively analysed the data obtained in a large randomised trial performed in 505 eligible patients with advanced non-small cell lung cancer. Its purpose had been to compare a combination of carboplatin (200 mg/m2) and cisplatin (60 mg/m2) with or without the addition of ifosfamide. The present retrospective analysis assessed two ways of dosing carboplatin: according to body surface area (mg/m2) or to the estimated targeted area under the concentration versus time curve (AUC). Two different methods were used in the latter calculation: the Calvert formula using the Cockroft approximation to evaluate the glomerular filtration rate and the Chatelut equation. There was an excellent linear correlation between them. With the Chatelut method, the calculated administered AUC were lower. Whichever method was used, carboplatin AUC was not significantly associated with antitumour response rate nor patient survival. A statistically significant increase in haematological toxicity, mainly thrombopenia, was observed with an increase in the AUC. This effect was observed whatever AUC variable was considered, i.e. total dosage at course one, total dosage during the first three chemotherapy courses or dose intensity during the first three courses. The effect remained highly significant after adjustment for treatment arm. We conclude that for a moderate carboplatin dose in non-small cell lung cancer, the therapeutic index could be improved if dosage is calculated according to the AUC.

The anti-emetic efficacy of tropisetron plus dexamethasone in patients treated with high-dose chemotherapy and stem cell transplantation

Among the most distressing symptoms experienced by patients who have undergone high-dose chemotherapy and stem cell transplantation are nausea and vomiting. The chemotherapy regimens used in high-dose conditioning protocols are highly emetogenic. The 5HT3 receptor antagonists are very effective in the prevention and abolition of nausea and vomiting resulting from chemotherapeutic drugs. One of them, tropisetron, is a selective antagonist of serotonin 5HT3 receptors with proven efficacy against emesis. Dexamethasone is also known as an effective agent against nausea and vomiting. The addition of dexamethasone to a 5HT3 receptor antagonist is synergistic, as has been shown in many trials with highly emetogenic drugs. The aim of the present trial was to study the efficacy and safety profile of the combination of tropisetron and dexamethasone in controlling nausea and vomiting in patients receiving megatherapy prior to stem cell transplantation. We studied 31 patients. All of them were evaluable for response and toxicity. The majority of patients achieved complete or major protection against acute vomiting (71-83%), and 67-84% of the patients had no or mild nausea. The combination was tolerated well, and only a minority of patients reported side effects. Among them the most common were headache (in three patients) and constipation. No patient withdrew from the study because of toxicity. It has become evident from our data that the administration of 5 mg tropisetron daily in combination with 20 mg dexamethasone for 8 days can prevent the acute emesis otherwise experienced by patients receiving high-dose chemotherapy as conditioning in stem cell transplantation programmes.

A phase II study of flutamide in ovarian cancer

A phase II study of flutamide was conducted in 24 patients with stage III and IV ovarian cancer who failed chemotherapy and who had measurable disease. Flutamide was administered at a dose of 100 mg three times daily continuously until evidence of progression. Partial response observed in 1 of the 23 evaluable patients (4.3%) lasted 3 months. Two patients had stable disease (8.7%) for 7 and 8 months. The remaining 20 patients had progression of disease within 3 months. Toxicity was mild.

Predictive factors affecting mobilization and peripheral blood stem cell (PBSC) collection using single apheresis (SA) for rescuing patients after high-dose chemotherapy (HD.CHE) in various malignancies

We have investigated factors that affect the efficiency of single apheresis (SA) before transplant and define groups of patients that may require more than one collection for hematologic support. A consecutive series of 56 patients with hematologic malignancies and solid tumours had peripheral blood stem cells (PBSC) collected following mobilization with colony-stimulating factors (CSF) alone or after conventional chemotherapy (CHE) or high-dose cytoxan (HD.CY) followed by CSF. The efficiency of SA was assessed by total mononuclear cell number (MNC) in the harvest, CD34+ cells and colony-forming units (CFU). Linear regression analysis was performed to determine factors that affect SA yield as assessed by the above parameters. Thirty-five patients were mobilized once, 13 patients twice, six patients required three, one required four and one required five aphereses. Suboptimal mobilization and collection by SA occurred in patients with extended previous radiotherapy (RT) and patients older than 50 years. The number of CHE cycles given in the past also had an adverse effect on SA efficiency. In contrast, disease status, bone marrow infiltration by malignant cells, type of CHE, time since last CHE and mobilization regimen used were not significantly related to the collection efficiency by SA. Age, extent of previous RT and amount of CHE given prior to mobilization define the patients who require more than one SA course for support regardless of the underlying disease, BM status or mobilization regimen used. In such patients a plan for multiple aphereses should be scheduled in advance.

Peripheral blood progenitor cell (PBPC) transplantation with a single apheresis in patients with lymphoma, myeloma and solid tumors

The aim of this study was to investigate if a single apheresis after peripheral blood progenitor cell (PBPC) mobilization can be used to rescue patients receiving high dose chemotherapy (HD.CHE) as treatment for an underlying malignancy. Eighteen consecutive patients who were admitted to the transplant unit for treatment were leukapheresed following mobilization with one of the following protocols: group I: rHuG-CSF alone, group II: conventional chemotherapy (C.CHE) + rHuG-CSF or rHuGM-CSF and group III: high dose cytoxan (HD.CTX) + rHuG-CSF. The optimal day for leukapheresis was determined by following white blood cell counts (WBC), mononuclear cell counts (MNC) and CD34+ cell counts daily. Granulocyte-macrophage colony-forming cells (GM-CFC) assay was performed at the leukapheresis product and prior to reinfusion. All patients proceeded directly to ablative therapy according to their underlying malignancy. PBPC from single apheresis were reinfused to all patients and cytokines started 24 h after infusion. Hematologic recovery after HD.CHE was the parameter used to ensure successful engraftment. We have been able to recover adequate number of PBPC for transplantation with a single apheresis in all patients. The number of infused cells were for groups I, II and III: (1) median number of MNC 4.7, 3.58 and 2.79 x 10(8)/kg, respectively (2); median number of CD34+ cells 4.4, 2.8, 2.7 x 10(6)/kg, respectively. The median apheresis day was 6, 16 and 16, respectively. Recovery times to granulocyte count > 0.5 x 10(9)/ L was 9 d (range 9-12) and to platelets > 20 x 10(9)/L was 12 d (range 1-135); 17/18 patients have engrafted successfully independent of the mobilization method used. These data suggest that sufficient PBPC can be harvested at a single leukapheresis for hemopoietic rescue after myeloablative therapy. Rapid hematologic recovery occurs when cytokines alone after conventional or HD.CHE are used for mobilization. Results of collection products and hematopoietic recovery are independent of the mobilization technique used.

Relation between hematological recovery and number of transplanted mononuclear cells in patients after high dose chemotherapy with peripheral blood stem cell rescue

The aim of the study is to investigate the relation between the hematological recovery in patients after high dose chemotherapy and peripheral blood stem cell (PBSC) rescue and the number of reinfused previously collected stem cells assessed by the number of mononuclear cells (MNCs), CFU-GMs and CD34(+) cells in th harvest. Forty nine patients mobilized with different techniques were transplanted. Our data indicate that the number of reinfused MNCs and CFU-GMS has a statistical significant relationship with the duration of leukopenia and thrombocytopenia following high dose chemotherapy and PBSC rescue in patients with various malignancies.

A phase II study of ondansetron as antiemetic prophylaxis in patients receiving high-dose polychemotherapy and stem cell transplantation

The field of high-dose chemotherapy with stem cell transplantation has been expanded recently as a treatment for solid tumors and hematological malignancies. Severe emesis remains one of the main extramedullary side-effects of high-dose regimens during the first week of treatment. Traditional antiemetics such as chlorpromazine, diazepam, and phenothiazines are extensively used but are unable to control emesis. The new antiemetic ondansetron, a serotonin receptor (5HT3) antagonist appears to be superior to these drugs for cisplatin-induced emesis. The study we present here is an attempt to control emesis following high-dose regimens, during bone marrow or peripheral stem cell transplantation, with ondansetron. To our knowledge no other paper has reported the efficacy of this antiemetic in such group of patients. A total of 29 patients who received highly emetogenic polychemotherapy as conditioning regimens for bone marrow transplantation were treated with ondansetron, which was given as an 8-mg i.v. short infusion prior the initiation of treatment and every 6 h thereafter for 3 days, and an 8-mg dose every 8 h for 5 additional days. All the patients had previously been treated with chemotherapy and were evaluable for response and toxicity. Complete and major protection of vomiting on day 1 was achieved by 76% of the patients, 58% on day 2 and 52% on day 3. Nausea was absent or mild in 79% of patients on day 1, 45% on day 2 and 41% on day 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Central venous catheter-related infections after bone marrow transplantation in patients with malignancies: a prospective study with short-course vancomycin prophylaxis

Infections associated with double-lumen central venous catheters (CVCs) in patients undergoing BMT are presented. We prospectively studied infections occurring with 46 CVCs in 40 patients with malignancies during and up to 30 days after BMT. We randomised patients with insertions of CVCs to receive either a short course of vancomycin 500 mg x 3 peri-operatively (16 CVCs) or no VCM (11 CVCs). Six per cent of CVCs in the group with vancomycin prophylaxis became infected with Gram positive microorganisms compared with 55% in the control group (P < 0.05). Next, 19 patients with CVCs were all given prophylaxis, so finally 35 patients were given vancomycin compared with 11 patients with no vancomycin. In a total of 11 CVC-related infections, 79% of the microbiological isolates were staphylococci, all of which were sensitive to vancomycin. Vancomycin prophylaxis reduced the number of infected CVCs to 11% compared with 45% (P < 0.05) and bacteraemias to 6% compared with 45% (P < 0.01). All infections responded to antibiotic treatment. Prophylactic short-duration vancomycin during insertion of CVCs may reduce the incidence of line-associated infections and Gram positive bacteraemias in patients undergoing BMT.