Nonlinear optimal control for the multi-variable tumor-growth dynamics

The multivariable tumor-growth dynamic model has been widely used to describe the inhibition of tumor-cells proliferation under the simultaneous infusion of multiple chemotherapeutic drugs. In this article, a nonlinear optimal (H-infinity) control method is developed for the multi-variable tumor-growth model. First, differential flatness properties are proven for the associated state-space description. Next, the state-space description undergoes approximate linearization with the use of first-order Taylor series expansion and through the computation of the associated Jacobian matrices. The linearization process takes place at each sampling instant around a time-varying operating point which is defined by the present value of the system's state vector and by the last sampled value of the control inputs vector. For the approximately linearized model of the system a stabilizing H-infinity feedback controller is designed. To compute the controller's gains an algebraic Riccati equation has to be repetitively solved at each time-step of the control algorithm. The global stability properties of the control scheme are proven through Lyapunov analysis. Finally, the performance of the nonlinear optimal control method is compared against a flatness-based control approach.

A nonlinear optimal control method against the spreading of epidemics

To define a vaccination policy and antiviral treatment against the spreading of viral infections a nonlinear optimal (H-infinity) control approach is proposed. Actually, because of the scarcity of the resources for treating infectious diseases in terms of vaccines, antiviral drugs and other medical facilities, there is need to implement optimal control against the epidemics deployment. In this approach, the state-space model of the epidemics dynamics undergoes first approximate linearization around a temporary operating point which is recomputed at each time-step of the control method. The linearization is based on Taylor series expansion and on the computation of the associated Jacobian matrices. Next, an optimal (H-infinity) feedback controller is developed for the approximately linearized model of the epidemics. To compute the controller’s feedback gains an algebraic Riccati equation is solved at each iteration of the control algorithm. Furthermore, the global asymptotic stability properties of the control scheme are proven through Lyapunov stability analysis. This paper’s results confirm that optimal control of the infectious disease dynamics allows for eliminating its spreading while also keeping moderate the consumption of the related medication, that is vaccines and antiviral drugs.

A Nonlinear Optimal Control Approach for Multi-DOF Brachiation Robots

This paper proposes a nonlinear optimal control approach for mulitple degrees of freedom (DOF) brachiation robots, which are often used in inspection and maintenance tasks of the electric power grid. Because of the nonlinear and multivariable structure of the related state-space model, as well as because of underactuation, the control problem of these robots is nontrivial. The dynamic model of the brachiation robots undergoes first approximate linearization with the use of Taylor series expansion around a temporary operating point which is recomputed at each iteration of the control method. For the approximately linearized model, an H-infinity feedback controller is designed. The linearization procedure relies on the Jacobian matrices of the brachiation robots’ state-space model. The proposed control method stands for the solution of the optimal control problem for the nonlinear and multivariable dynamics of the brachiation robots, under model uncertainties and external perturbations. For the computation of the controller’s feedback gains an algebraic Riccati equation is solved at each time-step of the control method. The global stability properties of the control scheme are proven through Lyapunov analysis. The new nonlinear optimal control approach achieves fast and accurate tracking for all state variables of the brachiation robots, under moderate variations of the control inputs.

A Nonlinear Optimal Control Approach for a Lower-Limb Robotic Exoskeleton

The use of robotic limb exoskeletons is growing fast either for rehabilitation purposes or in an aim to enhance human ability for lifting heavy objects or for walking for long distances without fatigue. The paper proposes a nonlinear optimal control approach for a lower-limb robotic exoskeleton. The method has been successfully tested so far on the control problem of several types of robotic manipulators and this paper shows that it can also provide an optimal solution to the control problem of limb robotic exoskeletons. To implement this control scheme, the state-space model of the lower-limb robotic exoskeleton undergoes first approximate linearization around a temporary operating point, through first-order Taylor series expansion and through the computation of the associated Jacobian matrices. To select the feedback gains of the H-infinity controller an algebraic Riccati equation is solved at each time-step of the control method. The global stability properties of the control loop are proven through Lyapunov analysis. Finally, to implement state estimation-based feedback control, the H-infinity Kalman Filter is used as a robust state estimator.

A phase I trial of adoptive transfer of allogeneic natural killer (NK) cells in patients (pts) with advanced non-small cell lung cancer (NSCLC)

3001

Background: HLA-mismatched NK cells have been found effective in acute myeloid leukemia pts. Preclinical studies revealed that activated NK cells massively infiltrate lung tissue and improve recipient survival, suggesting a potential role in lung cancer therapeutics. We performed this phase I trial to evaluate safety and antitumor responses of allogeneic, in vitro activated and expanded NK cells in combination with chemotherapy (C) in pts with advanced NSCLC. Methods: Pts with unresectable locally advanced/metastatic NSCLC receiving 1st/2nd line C were eligible. Two relative donors for each pt were selected based on their HLA and KIR typing. CD56+ cells were isolated from 150ml of donor peripheral blood and cultured for 20–23 days with 20ng/ml interleukin-15 and 10-5M hydrocortisone. Activated and expanded NK cells, after sterility, phenotype, and function testing, were diluted in 500ml N/S 0.9% with 2% human serum albumin and administered i.v. for 1 hour 2 days after previous and 1 week prior next C. Premedication with corticosteroids and/or H1 inhibitors was allowed. The number of NK cells to be injected was up to 2x1011/dose for up to 4 doses. Pts and donors signed detailed informed consent. Results: Between 11/2007 and 11/2008 16 pts (performance status 0–1) were enrolled; 1 pt had rapid disease progression before treatment. Pts characteristics: M/F 12/4; histology: adenocarcinoma/squamous cell carcinoma 13/3; stage IIIb/IV 2/14; 1st/2nd line treatment 13/3; median age 64 years (range, 50–71). The number of doses administered was 2 (N=9 pts), 3 (N=2 pts), or 4 (N=4 pts). The number of cells injected varied from 0.2–29x106/Kg (mean 7.4x106±7.7x106). During and after injection of NK cells no side effect (local or systemic) was observed. With a median follow-up of 6 months (range, 1–14) 3 pts with partial response and 7 pts with disease stabilization were recorded. Conclusions: Adoptive transfer of allogeneic, in vitro activated and expanded NK cells in combination with chemotherapy is safe, even at the highest dose administered. Based on these encouraging results a randomized phase II trial is further justified.

No significant financial relationships to disclose.

Sarcomatoid differentiation of renal cell carcinoma: a clinical case with literature review

A small percentage (1-10%) of renal cell carcinomas (RCC) belongs to the sarcomatoid variant. These malignancies are aggressive with worse prognosis and unfortunately the results following immuno- and/or chemotherapy administration are discouraging. A 62-year-old Caucasian male with advanced renal cell cancer and sarcomatoid component treated with sunitinib is presented. Better understanding of prognostic and molecular markers might help the selection of patients with a chance of benefiting from administration of new targeted drugs.

Quality of life in metastatic breast cancer patients under chemotherapy or supportive care: a single-institution comparative study

The aim of the present study was to evaluate quality of life (QoL) parameters in patients with metastatic breast cancer (MBC) and assess the potential differences between patients receiving chemotherapy and those undergoing supportive care interventions. In total, 210 women with MBC were enrolled in this prospective, randomized, single-institution study. The primary outcome of the trial was QoL assessment, using the self-administered European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, version 3) and Quality of Life Questionnaire Breast 23 (QLQ-BR23) questionnaires. Quality of life was found to be statistically better (P = 0.008) in MBC patients receiving chemotherapy than those under only supportive care. Statistically significant differences in favour of chemotherapy were also found in functioning subscales, symptom single-item questions and sexual functioning. Our findings suggest that chemotherapy in MBC patients with good performance status is the more rational therapeutic approach in terms of QoL improvement.

Low-dose capecitabine in breast cancer patients with symptomatic bone marrow infiltration: a case study

BACKGROUND

The prognosis of patients with metastatic breast cancer and symptomatic bone marrow involvement is poor. The aim of treatment to these patients is palliation. In this study, we sought to determine the efficacy of therapy with low doses of capecitabine in this subgroup of patients.

PATIENTS AND METHODS

Five consecutive breast cancer patients with overt bone marrow involvement were treated by low doses of capecitabine in our department. Four out of five patients also received bisphosphonates to palliate skeletal symptoms. The influence of this therapeutic regimen on tumor response, blood count normalization and overall survival was analysed.

RESULTS

All patients except one responded in terms of their haematological profile within two months of the initiation of treatment. Duration of haematological response was 8+ months for all patients. In two of them, tumor response in other sites was evaluated as stable disease, in one as partial remission and in one as progressive disease. Two patients survived more than 22 months without bone marrow failure.

CONCLUSION

These initial results are very encouraging for this subset of patients with poor prognosis and limited life expectancy. The administration of capecitabine might be an efficient alternative treatment option. Our results merit further investigation.

Urachal mucinous adenocarcinoma: a case report

Adenocarcinomas account for 0.5-2% of all bladder cancers. Urachal carcinoma is a rare neoplasm which represents 0.01% of all cancers in adults and account for one third of bladder adenocarcinomas. A 65-year-old white man with an urachal mucinous adenocarcinoma is reported. None of the known predisposing risk factors for bladder cancer -such as tobacco use and professional exposure to chemicals -were identified in his past medical history. The patient suffered from multiple sclerosis for almost 11 years and in the last 6 years he was treated with low doses of mitoxantrone. He underwent a partial cystectomy and en block excision of the umbilical ligament and remains disease-free after one year. The development of this rare neoplasm should not be clearly dissociated from multiple sclerosis, either aetiologically sharing an unidentified common causative factor or due to its treatment with mitoxantrone.

Gemcitabine and oral vinorelbine as salvage treatment in patients with advanced anthracycline- and taxane-pretreated breast cancer

BACKGROUND

Despite progress achieved with new chemotherapeutic and endocrine agents, advanced breast cancer (ABC) remains a disease with poor prognosis. We sought to determine the efficacy of gemcitabine (GC) and oral vinorelbine (VB) in heavily preatreated ABC.

PATIENTS AND METHODS

Patients previously treated with anthracyclines and taxanes in the metastatic setting with progressive disease were eligible. Treatment consisted of VB (60 mg/m2, orally) and GC (1000 mg/m2, intravenous infusion), every two weeks of a 28- day cycle.

RESULTS

Thirty-one patients with ABC were enrolled. Toxicity was acceptable, mainly haematological. Three and 8 patients achieved a complete (9.6%) and partial (25.8%) response, respectively; ten patients (32.2%) had stable disease. Median time-to-progression was 5.3 months, while in responders 8.6 months. Median overall survival was 14 months.

CONCLUSION

Oral VB and GC is an active and well-tolerated combination in anthracycline/taxane-pretreated ABC, representing an interesting option in this poor prognosis group of patients.

Trastuzumab with taxanes in HER2-ECD(+), IHC/CISH(-) advanced and heavily pretreated, chemotherapy-refractory breast cancer patients: Findings from a case series

1089

Background: The “invisible” potential of a tumor is responsible for the discrepancy sometimes observed between favourable initial pathological profile and aggressive clinical course. We describe a series of Breast Cancer patients with refractory to standard chemotherapy advanced tumors without HER2-amplification/overexpression treated with trastuzumab (TZB). Methods: Twenty five patients progressing under anthracyclines and taxanes were selected on the basis of increased HER2-ECD levels at entry (>16 ng/ml) and lack of HER2-amplification/overexpression in the primary tumor documentation. In 22/25, TZB 6 mg/m2 with either docetaxel 75 mg/m2 q3w or paclitaxel 90 mg/m2 weekly were administered for six courses or less if toxicicity or progression was documented; TZB alone had to be continued thereafter until progression. Serial HER2-ECD were performed during therapy. Results: No objective response was noted; however, in 5 and 11 pts minor response and stabilization respectively was noted. All minor responders and stabilized patients experienced subjective improvement. Toxicity was acceptable. Median time to progression has not yet been reached, actually 5+mos; in 9 patients the progression-free period is 12 months from start of therapy. Median HER2-ECD declined from 54ng/ml at baseline to 14.3ng/ml at 28 weeks from treatment start. Conclusion: Although the sample size of this case-series is small, our findings suggest that, in HER2 negative patients with clinical aggressive behaviour and refractoriness to standard chemotherapy, HER2 positivity should be assessed by serum ECD levels and the addition of trastuzumab may be a valuable therapeutic option. However, these findings should be confirmed in larger number of patients.

No significant financial relationships to disclose.

Circulating regulatory T cells in advanced breast cancer patients

10567

Background: It has been recently shown that regulatory CD4+CD25bright T cells (Tregs) are increased in patients with several malignancies and this increase correlates with advanced stage and dismal prognosis. Breast cancer (BC) patients represent a heterogeneous population with unpredictable natural history, even at advanced stages. We sought to monitor advanced stage (III and IV) BC patients, overexpressing HER-2/neu (HER) or not, for circulating Tregs before, during and after the administration of chemotherapy, either alone or in combination with Trastuzumab. Methods: Determination of circulating Tregs was performed in 50 μl whole peripheral blood by a Lyse NoWash FACS procedure and staining for CD45, CD4 and CD25. Tregs were determined as the lymphocytes expressing lower CD4 within the CD4+ T cell compartment and higher CD25 expression compared to the CD4 negative lymphocytes. Clinical evaluation of the patients was done according to RECIST criteria. Results: 24 HER+ and 19 HER- stage III / IV BC patients have been compared to 14 healthy donors, before therapy. The percentage of Tregs among the CD4+ T cell population of HER+ patients was significantly increased compared to both HER- patients and healthy donors (8,74 ± 2,68 vs 6,07 ± 1,85 and 6,55 ± 1,49, respectively). Trastuzumab combined with chemotherapy resulted in a progressive decrease in the percentage of circulating Tregs, reaching normal levels after the fourth cycle of treatment (6,95 ± 1,17). On a per patient basis, decrease in Tregs correlated either with documented partial response or stable disease, while increased Tregs during treatment coincided with progressive disease. No statistically significant change in the percentage of Tregs after chemotherapy was observed in HER- patients. Conclusions: 1) Increased Tregs do not directly correlate with clinical stage in BC, as stage III and IV HER (+) and (−) patients exhibit significantly different Tregs profiles. 2) HER+ advanced BC patients exhibit increased percentages of circulating Tregs and respond to the combination of Trastuzumab and chemotherapy by decreased Tregs. This decrease is either due to a reduction of the tumor burden or neutralization of circulating HER antigen by Trastuzumab, or a combination of both.

No significant financial relationships to disclose.

Characterization of a subset of CD4+ T cells expressing CD161 in cancer patients and healthy individuals

20016

Background: CD161 is a glycoprotein expressed in >90% of NK and 25% of T cells in the peripheral blood of healthy individuals. Several NK receptors on T cells infiltrating tumors have been proven to negatively influence their effector function and therefore play a role in tumor escape. In this study, we investigated T cells expressing CD161 in the peripheral blood mononuclear cells (PBMC), tumor infiltrarting lymphocytes (TIL) or malignant effusions (ME) from patients with several types of cancer. Methods: Expression of CD161 in CD4+ or CD8+ (lacking CD56) T cells, was examined using four-colour flow cytometry. The proliferative capacity and potential cytokine production of purified CD4+CD161+CD56− cells, were studied after weak or strong stimulation, with or without costimulation, in the presence or absence of Interleukin-2 (IL-2). The possible regulatory function of activated CD4+CD161+CD56− cells on T cell allo-responses was also investigated. Results: CD4+CD161+CD56− T cells were significantly increased (P < 0.01) in TIL, either from tumor tissue (n = 8) or metastatic lymph nodes (n = 5), and ME (n = 25), compared to PBMC from both cancer patients (n = 36) and healthy individuals (n = 12). CD4+CD161+CD56− cells from all sources tested, have the same phenotypic characteristics: they comprise a memory T cell population (CD45RO+CD45RA−) expressing high CD28 and CD95 and low CD25, CD38 and HLA-DR. Co-stimulation via CD28 is important for induction of proliferation and production of large amounts of Th1 and Th2 cytokines (IFN-γ, TNF-a, GM-CSF, IL-4 and IL-10). Following co-stimulation, CD4+CD161+CD56− cells also exert a suppressive activity on autologous PBMC allo-responses. The latter effect does not require cell-to-cell contact and is mediated by soluble factors, including IL10, since neutralization of IL10 partially restored the immune response. Conclusions: CD4+CD161+CD56− cells represent a distinct memory T cell population that is significantly increased in TIL and ME in patients with cancer. These cells are capable of secreting large amounts of both Th1 and Th2 cytokines and might play an immunosuppressive role, mainly through IL-10 production, depending on the microenvironment in which they develop.

No significant financial relationships to disclose.

High efficacy and low toxicity of the combination of vinorelbine and capecitabine as second line treatment in metastatic breast cancer previously treated with taxanes and/or anthracyclines

10719

Background: Capecitabine and Vinorelbine have shown considerable activity given as single agent or in combination with other drugs. The aim of this single institution ph.II study is to evaluate the response to the combination of Capecitabine and Vinorelbine given as second line treatment in patients with metastatic breast cancer previously treated with taxanes and/or anthracyclines. Methods: The regimen consists of Capecitabine 2000 mg/m2 D1-D14 and Vinorelbine 20 mg/m2 D1,D8 q 3 weeks for six cycles. Evaluation of response was accomplished with CT scan after the third and sixth cycle. Patients with disease progression after cycle 3 are taken off protocol. Patients with gr 2/3 granulocytopenia are given G-CSF for all subsequent cycles and there is a 20% dose reduction in both drugs for patients with gr 4 granulocytopenia. Results: 30 pts have been enrolled so far; according to statistical planning the total number of accrued pts should reach 63. Median age 55 yrs (30–76), median ECOG PS 1 (0–2), pre/postmenopausal 6/24. Number of metastatic sites: 1 in 6 pts, 2 in 15 pts, 3 in 6 pts and 4 in 3 pts. A total of 146 cycles was administered. Overall response rate 50% with CR in 2 (6.7%) pts, PR in 13 (43.3%) pts. Stable disease was observed in 4 (13.3%) pts, 8 (26.6%) pts had progressive disease and 3 (10%) were non evaluable. Toxicity: anemia gr 2 in 2 (6.7%) pts and gr 3 in 1 (3.3%) ptn, thrombocytopenia gr2 in 2 (6.7%) pts, granulocytopenia gr 2/3 in 17 (56.7%) pts and gr4 in 1 (3.3%) ptn. Gr 1/2 nausea or vomiting was observed in 5 (16.6%) pts and gr 3/4 in 2 (6.7%) pts. Vinorelbine induced phlebitis in 3 (10%) pts, gr1/2 diarrhea in 3 (10%) and fungal infection of the nail beds in 2 (6.7%) pts. Conclusions: Preleminary results suggest that the Capecitabine and Vinorelbine combination is an active and safe regimen for second line metastatic breast cancer treatment. The study remains open to achieve the planned patient accrual.

No significant financial relationships to disclose.

First-line chemotherapy with fluorouracil-epirubicin-navelbine (FEN) combination in advanced breast cancer

BACKGROUND

A phase II study was carried out to determine the safety and efficacy of the combination of vinorelbine, epirubicin and 5-fluorouracil (FEN) as first-line chemotherapy in advanced breast cancer (BC).

PATIENTS AND METHODS

Thirty-four women with advanced BC, aged 32-75 years (median 59), previously untreated for recurrence, were enrolled in the study. The treatment consisted of fluorouracil 600 mg/m2 on day 1, epirubicin 75 mg/m2 on day 1 and vinorelbine 25 mg/m2 on days 1 and 8, every 3 weeks, up to a maximum of 9 cycles.

RESULTS

The efficacy appeared favourable with 18 objective responses (3 complete and 15 partial) and 9 disease stabilizations, giving an overall response rate of 53% (95% CI: 36-70). The median progression-free and overall survival was 6 and 18 months, respectively (95% CI: 4.8-7.8 and 16.2-22.2, respectively). Toxicity was acceptable; the main grade 3/4 toxicity was alopecia in 94% of patients, neutropenia in 44% and less frequently gastrointestinal toxicity (9%), anaemia (6%), mucositis (6%), thrombocytopenia (3%) and diarrhoea (3%). No treatment-related death occurred,

CONCLUSION

Our results suggest that FEN, as first-line chemotherapy, is an active and well-tolerated treatment for patients with advanced breast cancer.

Multiple cutaneous acral metastases in a woman with breast adenocarcinoma treated with pegylated liposomal doxorubicin: incidental or aetiological association?

This paper reports the case of a 45-year-old female with histologically documented, multiple cutaneous metastases in the palmar and plantar surface of the fingers and toes originating from a breast adenocarcinoma after treatment with a docetaxel and pegylated liposomal doxorubicin regimen. The rarity of such a metastatic pattern from breast cancer and the eventual association with the chemotherapy administered are thoroughly discussed.

Gemcitabine and docetaxel as first-line treatment for advanced urothelial carcinoma: a phase II study

The purpose of the study was to investigate the toxicity and efficacy of the combination of gemcitabine and docetaxel in untreated advanced urothelial carcinoma. Patients with previously untreated, locally advanced/recurrent or metastatic urothelial carcinoma stage-IV disease were eligible. Patients with Performance status: PS ECOG >3 or age >75 years or creatinine clearance <50 ml min(-1) were excluded. Study treatment consisted of docetaxel 75 mg m(-2) (day 8) and gemcitabine 1000 mg m(-2) (days 1+8), every 21 days for a total of six to nine cycles. A total of 31 patients with urothelial bladder cancer, 25 men and six women, aged 42-74 (median 64) years were enrolled. The majority of patients had a good PS (51.6%; PS 0). In all, 15 (48.3%) patients had locally advanced or recurrent disease only and 16 (54.8%) presented with distant metastatic spread, with multiple site involvement in 22.5%. Toxicity was primarily haematologic, and the most frequent grade 3-4 toxicities were anaemia 11 (6.7%) thrombocytopenia eight (4.9%), and neutropenia 45 (27.6%), with 10 (6.1%) episodes of febrile neutropenia. No toxic deaths occurred. A number of patients had some cardiovascular morbidity (38.7%). Nonhaematological toxicities except alopecia (29 patients) were mild. Overall response rate was 51.6%, including four complete responses (12.9%) and 12 partial responses (38.7%), while a further five patients had disease stabilisation (s.d. 16.1%). The median time to progression was 8 months (95% CI 5.1-9.2 months) and the median overall survival was 15 months (95% CI 11.2-18.5 months), with 1-year survival rate of 60%. In conclusion, this schedule of gemcitabine and docetaxel is very active and well tolerated as a first-line treatment for advanced/relapsing or metastatic urothelial carcinoma. Although its relative efficacy and tolerance as compared to classic MVAC should be assessed in a phase III setting, the favourable toxicity profile of this regimen may offer an interesting alternative, particularly in patients with compromised renal function or cardiovascular disease.

Simultaneous endometrioid ovarian and uterine carcinoma diagnosed after an in vitro fertilization procedure--case report and review of the literature

BACKGROUND

The presence of simultaneous carcinomas involving both the ovary and uterus is relatively uncommon, while the possible link between fertility drugs and carcinogenesis still remains controversial.

CASE

The case of a 40-year-old patient with simultaneous aggressive endometrioid carcinoma of the ovary and uterus a few months after the sixth attempt of in vitro fertilization is presented. The patient had de novo lung disease at surgery and diffuse metastatic spread to adjacent bone, subcutaneous tissue and the central nervous system (CNS) soon after a spectacular response to the primary paclitaxel/carboplatinum chemotherapy and while on maintenance and second-line chemotherapy, respectively.

CONCLUSION

The fulminating course of our patient might in part be attributed to the existence of advanced disease at presentation. Definite conclusions about the possible association with the previously performed assisted reproduction cannot be drawn but close clinical surveillance of such patients before, during and after infertility treatment is strongly warranted.

Non-allergic nature of docetaxel-induced acute hypersensitivity reactions

Based on observations of a discrepancy between 'hypersensitivity' reactions to docetaxel (DT) and the clinical features of allergic reactions, we explored the hypothesis that DT-induced acute hypersensitivity reactions (AHRs) have a non-allergic origin. Forty cancer patients receiving DT and 16 patients receiving other potentially allergenic chemotherapeutic agents were included in the study. All DT patients received standard pre- and post-medication. Before, during and after administration of the drugs, clinical symptoms and signs were recorded, and serial blood sampling was performed for the first 2 cycles for all patients or in all subsequent cycles in case of AHRs. Plasma histamine and serum tryptase, two established drug allergy markers, were measured. Seventy-five chemotherapy sessions were evaluable. Nine patients on DT, two on paclitaxel (PT) and one on pegylated doxorubicin experienced an AHR during the first course of chemotherapy. In all cases, heart rate remained stable or increased, while arterial pressure was unchanged or raised; no hypotension or bradycardia was noted. All episodes resolved with discontinuation of drug and did not reappear during a re-challenge with the same agent 30 min later. Tryptase levels were normal in all pre- and post-exposure samples (post-exposure: 11.32+/-35.63 microg/l, normal values <13.5 microg/l). In all but one AHR-free PT, pre- and post-exposure histamine concentrations remained normal (post-exposure: 2.86+/-11.88 nM, normal values <10 nM). No eosinophilia or basophilia was observed. We conclude that 'hypersensitivity' reactions to DT seem not to be histamine or tryptase mediated; thus, their allergenic nature should be questioned. The underlying mechanism may be related to other biological processes such as the release of vasoactive molecules or non-histamine/tryptase-mediated allergy. If the former is demonstrated by further study, the safety of DT administration will be confirmed, and the pre- and post-medication practice might be revisited.

Phase II study of pegylated liposomal doxorubicin (Caelyx®) and docetaxel as first-line treatment in metastatic breast cancer

BACKGROUND

The aim of this study was to determine the activity and safety of pegylated liposomal doxorubicin (PLD; Caelyx) and docetaxel combination as first-line treatment in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

Forty-four patients with a median age of 63 years were treated with PLD 30 mg/m(2) (day 1) and docetaxel 75 mg/m(2) (day 2) every 3 weeks for six cycles. Recombinant human Granulocyte Colony-Stimulating Factor (rhG-CSF) could be used in patients with grade > or =3 neutropenia after the first cycle.

RESULTS

Forty-two of 44 patients were assessable for response. The response rate (RR) was 64.3% (95% confidence interval 49.8% to 78.8%). Six patients (14.3%) achieved complete response (complete disappearance of all measurable and assessable disease lasting at least 4 weeks, no new lesions, no disease-related symptoms), partial response was observed in 21 patients (50%) > or =50% decrease of measureable disease lasting at least 4 weeks, no progression of assessable disease, no new lesions, no disease-related symptoms), eight patients had stable disease and seven patients progressive disease. Median disease-free and overall survival were not reached, but were in excess of 17 months (range 6-17 months). Twenty of the patients had received previous adjuvant chemotherapy (10 with epirubicin-containing regimen with a median cumulative dose of 400 mg/m(2)). Grade > or =3 neutropenia occurred in 18.4% and neutropenic fever in 9% of patients. Palmar-plantar erythrodysesthesia was observed in four patients. Dose reduction was necessary in seven patients. Two patients discontinued treatment: one due to prolonged grade 3-4 neutropenia and one due to neurotoxicity. No treatment-related deaths occurred.

CONCLUSIONS

The combination of PLD and docetaxel achieved high RRs with acceptable toxicity as first-line treatment in MBC.

In vivo synergism between docetaxel and gemcitabine in patients with metastatic breast cancer: General concepts and future perspectives

The docetaxel and gemcitabine combination is an active regimen as salvage therapy in taxane-resistant or taxane-refractory patients with metastatic breast cancer (MBC). We recently conducted a phase II study administering this combination to patients with MBC after docetaxel failure, with remarkably high response rates that could be attributed to an in vivo synergism between the two drugs. Women with MBC who were refractory or resistant to docetaxel monotherapy as first- or second-line treatment were recruited. Patients with progressive or stable disease after receiving a minimum of four cycles of docetaxel received gemcitabine 900 mg/m(2) on days 1 and 8 plus docetaxel 100 mg/m(2)on day 8, every 3 weeks. Forty-six percent of patients responded (three complete responses, 20 partial responses), while 28% had stable disease and 26% had progressive disease. Median duration of response was 6.07 +/- 2.43 months. Neutropenia was the only grade 4 toxicity, and reported in seven patients. Other grade 3 toxicities included neutropenia (12 patients), thrombocytopenia (seven patients), and anemia (one patient), while nonhematologic toxicities were easily manageable. These data outline the importance of a rational combination of existing, active chemotherapeutic agents for MBC, and broadens our perspectives for more effective combination regimens in various solid tumors in the future.

Evidence for in vivo synergism between docetaxel and gemcitabine in patients with metastatic breast cancer

BACKGROUND

The docetaxel and gemcitabine combination is active as salvage therapy in taxane-resistant/refractory patients with metastatic breast cancer (MBC). We conducted a phase II study to determine if this activity is due to an in vivo synergistic effect.

PATIENTS AND METHODS

Women with measurable MBC, who were refractory or resistant to docetaxel monotherapy as first- or second-line treatment, were enrolled. Patients with progressive disease (PD) or stable disease (SD) after receiving at least four cycles of docetaxel received gemcitabine 900 mg/m(2) on days 1 and 8 plus docetaxel 100 mg/m(2 )on day 8, every 3 weeks. Granulocyte colony-stimulating factor could be used prophylactically in patients who experienced grade 3/4 neutropenia after the first cycle.

RESULTS

Between January 1999 and March 2002, 173 courses of docetaxel and gemcitabine were administered to 50 patients. The median number of metastatic sites was two (range one to three). Forty-six percent of patients responded (three complete responses, 20 partial responses), whereas 28% had SD and 26% had PD. The median duration of response was 6.1 +/- 2.4 months. The median time to disease progression was 7.5 months (range 1-25) and the overall median survival was 15 months (range 3-57). Neutropenia was the only National Cancer Institute Common Toxicity Criteria grade 4 toxicity (in seven patients). Hematological grade 3 toxicities included neutropenia in 12 patients, thrombocytopenia in seven and anemia in one, while non-hematological toxicities were mild and manageable.

CONCLUSIONS

The high overall response rate of the docetaxel plus gemcitabine combination after docetaxel failure in patients with MBC can be attributed to an in vivo synergism between the two drugs. These data warrant confirmation in a randomized study.

Docetaxel in combination with mitoxantrone and granulocyte colony-stimulating factor as front-line chemotherapy in metastatic breast cancer: a multicenter phase II study

PURPOSE

To evaluate the activity and tolerance of docetaxel in combination with mitoxantrone and granulocyte colony-stimulating factor (G-CSF) as front-line treatment in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

Fifty-four previously untreated patients with MBC who had bidimensionally measurable disease were enrolled onto the study. Forty-eight (89%) patients had visceral metastases and nineteen (36%) had relapsed within twelve months following adjuvant chemotherapy. Docetaxel (100 mg/m2) was given on day 1 after appropriate premedication and mitoxantrone (20 mg/m2) on day 8. G-CSF (150 mcg/m2/d s.c.) was administered from day 2 to day 6 and from day 9 to day 15. The regimen was repeated every three weeks, on an outpatient basis.

RESULTS

In an intention-to-treat analysis, 9 (17%) CRs, 24 (44%) PRs, (overall response rate 61%; 95% confidence interval (CI): 48.1%-74.1%), 12 (22%) SD and 9 (17%) PD were observed. The median duration of response and the median time to tumor progression was 12.5 and 14 months, respectively. The overall median survival was 16.5 months, whilst the probability for one- and three-year survival was 61% and 35%, respectively. Grade 3-4 neutropenia occurred in 37 (69%) patients, and febrile neutropenia in 16 (30%); there was one death due to sepsis. Grade 3-4 thrombocytopenia occurred in four (8%) patients. Grade 2-3 neurosensory toxicity was observed in 8 (15%) patients and grade 2-3 asthenia in 24 (45%).

CONCLUSIONS

Docetaxel in combination with mitoxantrone and G-CSF support is an intensified and active front-line regimen for patients with MBC; despite its hematological toxicity, this regimen merits further comparison with other standard anthracycline- and/or taxane-based combinations.

Front-line treatment of advanced breast cancer with docetaxel and epirubicin: a multicenter phase II study

PURPOSE

In a previous phase I trial we evaluated the toxicity and determined the maximum tolerated doses of the docetaxel (D)-epirubicin (Epi) combination. We conducted a multicenter phase II study to evaluate the efficacy and tolerability of this regimen as front-line treatment in women with advanced breast cancer (ABC).

PATIENTS AND METHODS

Fifty-four women with ABC stage IIIB (4 patients) or IV (50 patients) received front-line treatment with Epi 70 mg/m2 on day 1 and D 90 mg/m2 on day 2. The median age was 55 years, performance status (WHO) was 0-1 in 49 patients and visceral disease was present in 45 (83%).

RESULTS

All patients were evaluable for toxicity and 50 for response. In an intent-to-treat analysis complete remission was observed in 5(9%) patients, partial remission in 31 (57%) (overall response rate 66%, 95% confidence interval: 54% 79%), stable disease in 9 (17%) and disease progression in 9 (17%). After a median follow-up of 11.5 months, the median duration of responses was 8 months, the median time to disease progression 11.5 months and the median survival has not yet been reached. The probability of one-year survival was 65%. Three hundred six cycles of treatment were administered (median 6 cycles per patient). Grade 3 and 4 neutropenia was observed in 8 (15%) and 31 (57%) patients, respectively, and febrile neutropenia in 19 (35%). Prophylactic rh-G-CSF was used in 45 (83%) patients or 226 (74%) cycles. Other hematologic or non-hematologic toxicities were usually mild. In five (9%) patients the left ventricular ejection fraction (LVEF) was decreased by more than 10% with the treatment. Two patients died during the treatment of respiratory failure without associated neutropenia.

CONCLUSIONS

The combination of docetaxel epirubicin is an effective and well tolerated front-line treatment in patients with ABC.

A phase II study of the effectiveness of docetaxel (Taxotere) in women with advanced breast cancer previously treated with polychemotherapy. Hellenic Cooperative Interhospital Group in Oncology

PURPOSE

The aim was to study the effectiveness of docetaxel (Taxotere) in patients with advanced breast cancer treated previously with polychemotherapy.

PATIENTS AND METHODS

Forty-nine patients received docetaxel (100 mg/m2; 1-h i.v. infusion) and corticosteroid premedication. Forty-one patients who had received previous anthracycline treatment were divided into anthracycline-refractory and anthracycline-resistant (early and late) groups.

RESULTS

Of 45 evaluable patients, 66.7% had a partial response (PR) and 2.2% a complete response (CR), giving an overall response rate (ORR) of 68.9%. The ORR in anthracycline-refractory patients was 60% versus 82.6% in anthracycline-resistant patients; the difference was not significant. The ORR in early-resistance patients was 62.5% versus 93.4% in late-resistance patients (0.05 < P < 0.1). The median response duration and overall survival was 8 months (range, 4-23 + months) and 11.5 months (range, 4-31 + months), respectively, in 39 patients treated previously for metastatic disease. For 295 courses, grade 3/4 neutropenia developed in 28.6% of patients (12.5% of courses) and was febrile in 26.5% of patients (6.1% of courses), including one septic death. Hypersensitivity reactions (HSR) developed in 16.3% of patients, and fluid retention developed in 34.7% of patients (11.9% of courses).

CONCLUSIONS

Docetaxel is an active second-line drug in advanced breast cancer. The time of relapse after cessation of anthracycline treatment may be a significant prognostic factor.

Salvage chemotherapy in anthracycline-pretreated metastatic breast cancer patients with docetaxel and gemcitabine: a multicenter phase II trial. Greek Breast Cancer Cooperative Group

PURPOSE

The activity of the docetaxel-gemcitabine combination in women with disease progression after initial chemotherapy for metastatic breast cancer (MBC) was investigated in a multicenter phase II study.

PATIENTS AND METHODS

Fifty-two patients with metastatic breast cancer who had disease relapse or progression after completion of an anthracycline-based front-line regimen were treated with gemcitabine 900 mg/m2 on day 1 and day 8 and docetaxel 100 mg/m2 on day 8. G-CSF 150 mucg/m2/d s.c. was given from day 9 to day 16 and the treatment was repeated every three weeks. The patients' median age was 57 years and the performance status (WHO) was 0 for 26, 1 for 20 and 2 for 6 patients. The treatment was second-line for 27 (52%) and > or = third-line for 25 (48%) patients. All patients were evaluable for response and toxicity.

RESULTS

Complete response occurred in seven (14%) patients and partial response in 21 (40%) for an overall response rate of 54% (95% confidence interval (95% CI): 40%-67%). Fifteen (29%) patients had stable disease and nine (17%) progressive disease. Of 25 patients previously treated with taxanes. 11 (44%) responded (1 CR, 10 PR). Interestingly, in four patients with disease progression while receiving docetaxel or paclitaxel monotherapy, the docetaxel + gemcitabine combination achieved partial responses. Responses were observed at all metastatic sites (local disease 62%, lymph nodes 58%, skin 44%, lung 47% and liver 36%) with a median duration of response of 3.6 months (range 1-16) and a median time to disease progression of eight months (range 2-18.5). Grade 3 neutropenia developed in 10 (19%) and grade 4 in five (10%) patients. Neutropenia was associated with infection in four patients without toxic deaths. Grade 3 thrombocytopenia developed in nine (17%) patients and grade 4 in two (4%). Non-hematologic toxicity was usually mild.

CONCLUSION

The docetaxel-gemcitabine combination is an active and well tolerated salvage treatment in patients with MBC. Previous treatment with taxanes does not preclude a good clinical response to this regimen.

Baldness and other correlates of sex hormones in relation to testicular cancer

There is evidence that sex hormones and intrauterine factors are involved in the etiology of testicular cancer. We evaluated the importance of perinatal and adult life correlates of sex hormones as risk factors for testicular cancer in a case control study of 97 incident, histologically confirmed cases, residents of the Greater Athens area and environs, who were diagnosed in the 3 specialized cancer hospitals and the major General Hospital in Athens during the 2 year period 1993-94. Cases were age-matched to 2 healthy controls from the same study base. Both cases and controls as well as their mothers were interviewed by the same investigator and the data were analyzed through conditional logistic regression. The odds ratio for testicular cancer was elevated among persons born after a pregnancy characterized by severe nausea. Among the adult life factors, higher body mass was associated with reduced risk, as was evidence of baldness. To the extent that nausea during pregnancy reflects higher levels of pregnancy estrogens on the one hand, and baldness is linked to androgens on the other, our data suggest that estrogens in the intrauterine life and androgens at later stages may have sequential opposing effects for the development of testicular cancer.

Cathepsin D concentration in tumor cytosols improves the accuracy of prognostic evaluation of primary breast cancer

One hundred and seventy three women were followed-up for a median of 62 months after surgery for Stage I-III breast cancer. The concentration of cathepsin D (CD) in tumor cytosols was compared to the standard prognostic factors for the disease and related to relapse free and overall survival and type of relapse. Three groups were identified with different prognostic profile. High CD levels significantly shorten DFS in both node-negative and node-positive patients; a correlation between high cathepsin D levels and locoregional relapse should also be noted. This marker should be included in the initial evaluation of breast cancer as an indicator of invasiveness.

Serum trypsin inhibitory capacity and alpha 1-antitrypsin levels in liver cirrhosis and hepatoma

alpha 1-Antitrypsin levels were measured in sera of 134 patients with cirrhosis and in 64 with cirrhosis and hepatoma. S-TIC was determined in 105 patients with cirrhosis and in 54 with cirrhosis and hepatoma. The mean alpha 1-at and S-TIC values in patients with cirrhosis were 369.59 +/- 14.072 mg% and 1,808 +/- 0.05 mg/ml respectively. In patients with cirrhosis and hepatoma the mean alpha 1-at level was 406.595 +/- 17.834 mg% and the S-TIC mean values was 2.064 +/- 0.82 mg/ml. Although these values are higher than those found in the healthy controls, the differences are not statistically significant.