Update on a phase II study of cyclophosphamide, etoposide and estramustine in patients with androgen independent prostate cancer

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Background: Oral therapy offers the tremendous advantage of independence and avoids all the catheter-related complications. Cyclophosphamide (C), etoposide (E) and estramustine (E) are active against androgen-independent prostate cancer (AIPC). The optimal dose and schedule of these agents have not been defined. Methods: Objectives are to evaluate the efficacy and safety of this triple drug regimen (CEE). Each treatment cycle consists of cyclophosphamide 50 mg/m2 p.o., etoposide 50 mg/m2 p.o. and estramustine 280 mg p.o. administered on days 1–14, every 28 days. Response was assessed by changes in size of measurable and non-measurable lesions (RECIST JNCI 92(3):205–216, 2000), and PSA levels (JCO 17(11):3461–7, 1999). Results: Twenty-nine subjects with AIPC were enrolled. 25 patients, who completed at least 2 cycles, are evaluable for toxicity and response. Median baseline characteristics: age 68 years (52–86); ECOG performance status 2 (0–3); PSA 148 ng/ml (26–2268); and 8 had prior chemotherapy. Total number of cycles administered: 98 with median of 3 cycles/patient. Response: PSA response: Out of 25 subjects, 7 (28%) had >50% decrease and 5 (20%) had >75% decrease, for an overall PSA response of 58%. Measurable disease: 13 patients had measurable lesions by RECIST criteria. One pt had a complete response (8%), seven had SD (54%) and there were 5 PD (38%). 44% of the subjects experienced an improvement in their ECOG performance status and 64% reported improvement in their level of pain. Toxicity: Grade 3–4: 36% neutropenia, 12% thrombocytopenia, 5% anemia. Four patients (27%) developed a thrombotic event. 3 with DVTs, two spontaneous and one after a 14-hours car trip. One subject with a strong history of cardiac complications had a myocardial infarction. Neutropenic fever requiring antibiotic use occurred in 2 patients. Conclusions: CEE is a well-tolerated, all oral, easy to administer and effective triple drug therapy for patients with metastatic androgen-independent prostate cancer.

No significant financial relationships to disclose.

Admission serum magnesium level does not predict the hospital outcome of patients with acute myocardial infarction

OBJECTIVE

To establish whether hypomagnesemia at admission predicts excessive morbidity, particularly cardiac arrhythmias, and mortality in patients with acute myocardial infarction.

METHODS

We compared hypomagnesemic and normomagnesemic patients with acute myocardial infarction in 517 patients admitted to the coronary care unit. The serum magnesium concentration, along with a large array of other parameters, was measured on admission to the emergency department. Other baseline attributes and variables related to the patients' hospital course were used to compare the 2 groups.

RESULTS

The 132 patients (25.9%) with low serum magnesium concentrations at admission (mean +/- SD, 0.61 +/- 0.06 mmol/L [1.48 +/- 0.15 mg/dL]) were comparable to the patients with normal serum magnesium concentrations (0.81 +/- 0.11 mmol/L [1.96 +/- 0.26 mg/dL]) except for a higher rate of prehospital use of diuretic agents (32.6% vs 22.5%, P = .02) and earlier presentation after onset of symptoms (mean +/- SD, 3.2 +/- 4.1 vs 4.8 +/- 6.6 hours, P = .003). There was no correlation between serum magnesium and potassium concentrations in the emergency department (r = 0.14). No difference was detected between the hypomagnesemic and normomagnesemic cohorts in rates of total mortality (18.9% vs 18.5%, P = .91), cardiac mortality (15.2% vs 15.3%, P = .99), atrial fibrillation (13.6% vs 13.8%, P = .97), ventricular tachycardia (18.2% vs 15.3%, P = .44), or ventricular fibrillation (15.2% vs 13.5%, P = .63). Management of the 2 cohorts was not different, except for higher rates of use of magnesium (17.4% vs 1.3%, P < .001) and potassium (59.8% vs 42.1%, P < .001) supplements and antiarrhythmic drugs (62.9% vs 48.7%, P = .005) in the hypomagnesemic patients. An endogenous rise in serum magnesium level was documented in a subgroup of 161 patients who had a repeated measurement (0.74 +/- 0.12 mmol/L [1.79 +/- 0.29 mg/dL] in the emergency department vs 0.77 +/- 0.09 mmol/L [1.88 +/- 0.23 mg/dL] in the coronary care unit, P < .001).

CONCLUSIONS

We conclude that hypomagnesemia is seen in approximately one fourth of patients with myocardial infarction, is not linked to hypokalemia, has some relationship to preadmission use of diuretic agents, is associated with early presentation to the hospital, and is not a predictor of increased morbidity or mortality.