Prospective assessment of symptoms and quality of life in localized rectal cancer patients receiving chemoradiotherapy

504

Background: Neoadjuvant conformal chemoradiotherapy (CRT) is an important component of treatment for locally advanced rectal cancer, yet its morbidity has not been well characterized using quality of life (QOL) instruments. The present study attempts to establish a baseline distribution of QOL scores before, during, and after CRT and to correlate these changes with symptoms.

Methods: Patients undergoing 3-4 field neoadjuvant CRT for localized rectal cancer were prospectively enrolled at two institutions. Fifty patients completed the QOL instruments at three time points: pretreatment, week 4 of treatment, and 1 month post-treatment. QOL information was captured using three validated questionnaires, the EORTC QLQ-30, QLQ-38, and QLQ-29. Additionally, institutional symptom inventories and CTCAE toxicity data were collected.

Results: Average age was 59.2 years and 72% were men. During CRT, patients had a statistically significant decline in global QOL (70 to 60, p = 0.0024), which normalized (71) following completion of treatment. During therapy, patients also experienced a significant increase in GI symptoms (21 to 27, p = 0.028), urinary symptoms (16 to 30, p < 0.0001), male sexual dysfunction (23 to 34, p = 0.013), and chemotherapy related side effects (8 to 20, p = 0.0001). While these measures returned to baseline 1 month post-CRT, overall sexual function (25 vs. 37, p = 0.0062) and sexual enjoyment (53 vs. 67, p = 0.0070) remained persistently low compared to pretreatment levels. Diarrhea (27%) and proctitis (22%) were the most common grade 3 toxicities. Those patients who experienced grade 3 toxicity during treatment showed markedly decreased global QOL (mean difference = 34).

Conclusions: While rectal cancer patients experienced impaired QOL during neoadjuvant CRT, the vast majority of measures normalized one month after treatment. In contrast, significantly decreased sexual function and enjoyment persisted. This data can be used as a baseline to compare future neoadjuvant conformal CRT regimens and/or assess the toxicity and QOL of new RT modalities such as intensity modulated radiation therapy.

No significant financial relationships to disclose.

Phase II trial of neoadjuvant full-dose gemcitabine, oxaliplatin, and radiation (RT) in patients with resectable (R) or borderline resectable (BR) pancreatic cancer

239

Background: We previously developed a regimen of full dose gemcitabine (gem), oxaliplatin (ox) and RT to maximize systemic and loco-regional disease control in pancreas cancer (JCO 25:4587, 2007). A multi-institution phase II trial was conducted to test efficacy of this regimen as neoadjuvant therapy in R/BR disease.

Methods: Eligibility criteria included path confirmation, no metastasis, R/BR lesion, PS ≤2, and adequate organ function. Treatment consisted of 2, 28 day cycles of gem (1g/m2 over 30 min D1, 8, 15) and ox (85mg/m2 D1, 15) with RT during cycle 1 (30Gy in 2Gy fractions). Pts were then re-evaluated for surgery. Resected pts received 2 additional cycles of chemotherapy.

Results: 68 evaluable pts were treated at 4 centers in 2007-2010. Median age was 64 (42-83), 32 men, PS 0:1:2 in 40:26:2. Median tumor size 3.2 cm (1.4–7.8), lesion in head 49, body 9, tail 10, R in 24 and BR in 44. 66 pts (97%) completed cycle 1/RT and 61 (90%) cycle 2. Therapy related adverse events ≥ grade 3 in cycles1/2 included ANC (32%), plts (24%), GI (16%), biliary/cholangitis (15%). Best response in primary was partial (10%) or stable (81%). 20 pts not operated on protocol: 8 progression (4 local, 4 distant), 8 judged not resectable, 3 toxicity, 1 early death. Of 48 laparotomies,10 not resected due to vascular involvement (6) or M1 disease (4). Resection completed in 15 of 18 R pts (13 R0, 2 R1) and 23 of 30 BR pts (19 R0, 2 R1, 2 R2). 26 pts received post-op therapy. With median fu 11.3 mos (0.7-35), 42 pts are alive, 20 pts are NED. Median survival (OS) for all pts is 21.2 mos (95%CI 13.3-not defined [ND]), resected 31.1 mos (95%CI 13.7-ND), unresected 16.0 mos (95%CI 5.8-ND). Time to treatment failure (death, progression, toxicity, no resection) and OS in R pts are 9.1 mos (95%CI 2.4-23.8) and 31.1 mos (95%CI 9.8-ND) and in BR pts 5.5 mos (95%CI 2.4-11.8) and 18.0 mos (95%CI 13.3-ND). Correlation of pathologic response and outcome is ongoing.

Conclusions: Neoadjuvant therapy with full dose gem, ox and RT was possible in a large proportion of pts with localized pancreas cancer and resulted in a high percentage of R0 resections. Results are particularly encouraging given a majority of pts with BR disease.

[Table: see text]

CA 19–9 as a predictor of response and survival in patients with pancreatic cancer treated with gemcitabine and cisplatin based chemotherapy

15094

Background: Radiologic evaluation of the efficacy of chemotherapy (CT) regimens in pancreatic cancer is complicated by the retroperitoneal location and the desmoplastic nature of the tumor. The aim of this study was to evaluate the role of baseline CA 19–9 and the decrease in CA 19–9 after one cycle of CT as predictors of response, time to progression (TTP) , and overall survival (OS). Methods: We conducted 3 consecutive phase II trials evaluating gemcitabine and cisplatin based CT between 1997 and 2004. A retrospective chart review of the 111 patients yielded demographic data, best response status, TTP, OS, and CA19–9 levels. Response by CA 19–9 (R-CA19–9) was defined as a decrease of = 50% in CA 19–9 after the completion of the first cycle of chemotherapy. Results: The median age was 59 years with 60% males. Median performance status (PS) was 1. No significant difference was observed across the three trials with respect to age, sex, or PS. Baseline CA19–9 was known for 102 patients, and was dichotomized near the median as: < 1,000; and = 1,000 ng/mL. Lower baseline CA19–9 levels were not associated with higher radiologic response (RR) rate (p = 0.82): 22%, and 19%, respectively. Lower baseline CA19–9 was associated with longer OS, (p = 0.0057), as shown in a recent UK study. Median OS was 9.2, and 6.1 months, respectively. Similar results were observed for TTP, with p = 0.0146, and median TTP of 6.4 and 4.2 months, respectively. The change in CA19–9 from baseline to the end of treatment cycle 1 was available for 68 patients. The patients with R-CA19- 9 had a higher RR rate (29%) than did the other patients (24%), but not significantly so (p = 0.7495). The patients with R-CA19–9 had longer OS (median 8.7 vs 7.1 months) and longer TTP (median 7.1 vs 5.4 months), but not significantly so (p > 0.73 for each endpoint). Conclusions: Lower baseline CA19–9 (but not R-CA19–9 after treatment cycle 1) was positively associated with OS and TTP prognosis in our patient population. A 50% decrease in CA19–9 after the first cycle of chemotherapy was not a useful predictor of response, TTP, or OS.

No significant financial relationships to disclose.

A phase I study of oxaliplatin, full-dose gemcitabine and concurrent radiation therapy in patients with pancreatic cancer

4107

Background: We previously demonstrated safety and efficacy of full dose gemcitabine (GEM) and radiation therapy (RT) in patients (pts) with pancreatic cancer (PC). Our preclinical studies have shown that GEM with oxaliplatin (OX) preserves radiosensitization with synergistic cytotoxicity. To enhance local and systemic treatment effects, we initiated a study of OX and GEM with concurrent RT. Methods: Pts with untreated PC received up to 4 cycles of GEM day 1, 8, 15 and OX days 1, 15 repeated at 28 day intervals. RT (27 Gy in 1.8 Gy fractions to gross tumor volume with 1 cm margin) was given during cycle 1 and repeated in cycle 4. Surgery occurred after cycle 2 in resectable pts. Dose escalation was guided using time-to-event continuous reassessment method (TITE-CRM). Dose levels 1–4 GEM 1 g/m2 IV over 30 min and OX 40, 55, 70, 85 mg/m2 IV over 90 min; dose level 5, 6 OX dose remained 85 mg/m2 but infusion time for GEM 1 g/m2 was increased to 65, 100 min, respectively. Trial objective is to determine dose level associated with DLT thru cycle 2 in ≤ 20% of pts; planned accrual is 40 pts evaluable for DLT. Results: 40 pts have been enrolled (median age 63, men/women 26/14) with resectable (10), unresectable (27), and metastatic (3) PC. 29 pts have completed 2 cycles and 11 pts 4 cycles. After 2 cycles CA19–9 decreased > 50% in 14 of 24 evaluable pts (58%). Six of 8 explored pts underwent margin negative resection with 1 path CR and 2 with small residual microscopic foci only. Per RECIST, CT response of the primary lesion after 2 cycles included 3 PR, 23 SD and 1 PD. Two additional PR were seen after cycle 4. Thirty pts are presently evaluable for DLT; 7 pts have suffered DLT including grade 4 platelets (4), decline in PS (2), GI bleed (1) and grade 3 weight loss (1). Current estimated probability of DLT is 21% (95% CI 11%,34%) for dose level 3 and 24% (95% CI 13%,37%) for dose level 4. Conclusions: The addition of OX 70–85 mg/m2 days 1, 15 to full dose GEM based RT is tolerable and efficacious. A neoadjuvant phase II study in resectable PC using the MTD defined in this phase I study is planned. Supported by Sanofi-Aventis.

[Table: see text]

A dose attenuated schedule of irinotecan and capecitabine in combination with celecoxib in advanced colorectal cancer

3584

Background: The cyclooxygenase-2 (COX-2) enzyme is overexpressed in the majority of colorectal cancers. Inhibition of the COX-2 enzyme can sensitize colorectal cancer cells to the apoptotic effects of chemotherapeutic agents and block angiogenesis. This phase II study was undertaken to determine the effects of adding celecoxib to a dose attenuated irinotecan and capecitabine regimen. Methods: The primary objective was to estimate the objective response rate of patients with metastatic colorectal cancer treated with irinotecan, capecitabine, and celecoxib. Previously untreated patients, except for adjuvant therapy, with metastatic colorectal adenocarcinoma were eligible for this study. Patients received irinotecan 70 mg/m2 (over 30 minutes) on days 1 and 8, and capecitabine 2,000 mg/m2/day from day 1 to 14 of a 21-day cycle. Celecoxib was administered at a dose of 400 mg twice-daily starting on day -7 until termination from study. Results: A total of 51 patients (median age 58 years) have been enrolled on the study. The results presented are for the first 48 patients registered to the study. Median performance status was 1. A median number of 5.5 cycles (range 0- 18) were administered. In an intention to treat analysis, objective response rate was 50%. The median progression free survival was 6.9 months (90%CI; 4.7–8.2). Median survival is ≥19.4 months. No treatment related deaths were observed. The only grade 4 toxicity was diarrhea in 2 (4%) patients. Grade 3 toxicities were diarrhea (33%), hand-foot syndrome (8%), nausea (13%), vomiting (8%) and neutropenia (12%). Conclusion: Lowering the dose intensity of irinotecan in this study did not appear to compromise the treatment outcome and markedly improved the therapeutic index of this combination. Celecoxib can be safely administered in combination with irinotecan and capecitabine. Based on the observed progression free survival and response rate, the regimen has promising activity.

No significant financial relationships to disclose.

Phase II study of gemcitabine, cisplatin, and infusional fluorouracil in advanced pancreatic cancer

PURPOSE

This phase II study was undertaken to determine the efficacy of adding infusional fluorouracil (FU) to the chemotherapy doublet of gemcitabine and cisplatin in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

The eligibility criteria included histologically or cytologically confirmed adenocarcinoma of the pancreas that was either unresectable or metastatic. No prior gemcitabine therapy was allowed. Patients received a combination of gemcitabine 1000 mg/m2 intravenously (IV) on days 1, 8, and 15; cisplatin 50 mg/m2 IV on days 1 and 15; and FU 175 mg/m2/d from days 1 to 15 by continuous IV infusion. Cycles were repeated every 28 days. Objective tumor response and toxicity were evaluated according to the World Health Organization criteria.

RESULTS

A total of 47 patients (median age, 57 years; males, 59%) were enrolled. Sixteen patients had locally advanced (LA) disease, and 31 patients had metastatic disease. A total of 183 cycles of chemotherapy were administered. In patients with metastatic disease (n = 31), the probability of survival at 6 and 12 months was 66% and 34%, respectively. Objective partial response or stable disease was observed in 26% (90% confidence interval [CI], 0.14 to 0.41) and 61% (90% CI, 0.45 to 0.74) of patients, respectively. In patients with LA disease (n = 16), there were three partial responses (19%; 90 CI, 0.07 to 0.39). One patient in this group was successfully resected after FU-based radiotherapy. The most common grade 3 to 4 toxicities were neutropenia (60%), thrombocytopenia (42%), and anemia (26%). Thirteen patients were hospitalized for treatment-related complications.

CONCLUSION

The combination of gemcitabine, cisplatin, and infusional FU has significant activity in patients with advanced pancreatic cancer.

Phase I trial of radiation dose escalation with concurrent weekly full-dose gemcitabine in patients with advanced pancreatic cancer

PURPOSE

The primary objective of this phase I trial was to determine the maximum-tolerated dose of radiation that could be delivered to the primary tumor concurrent with full-dose gemcitabine in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

Thirty seven patients with unresectable (n = 34) or incompletely resected pancreatic cancer (n = 3) were treated. Gemcitabine was administered as a 30-minute intravenous infusion at a dose of 1,000 mg/m(2) on days 1, 8, and 15 of a 28-day cycle. Radiation therapy was initiated on day 1 and directed at the primary tumor alone, without prophylactic nodal coverage. The starting radiation dose was 24 Gy in 1.6-Gy fractions. Escalation was achieved by increasing the fraction size in increments of 0.2 Gy, keeping the duration of radiation constant at 3 weeks. A second cycle of gemcitabine alone was intended after a 1-week rest.

RESULTS

Two of six assessable patients experienced dose-limiting toxicity at the final planned dose level of the trial (42 Gy in 2.8-Gy fractions), one with grade 4 vomiting and one with gastric/duodenal ulceration. Two additional patients at this dose level experienced late gastrointestinal toxicity that required surgical management.

CONCLUSION

The final dose investigated (42 Gy) is not recommended for further study considering the occurrence of both acute and late toxicity. However, a phase II trial of this novel gemcitabine-based chemoradiotherapy approach, at a radiation dose of 36 Gy in 2.4-Gy fractions, is recommended on the basis of tolerance, patterns of failure, and survival data.

Phase II study of gemcitabine and cisplatin in the treatment of patients with advanced pancreatic carcinoma

BACKGROUND

Pancreatic carcinoma is considered among the most chemoresistant of human malignancies. The most commonly used cytotoxic single agents, 5-fluorouracil and 2'-deoxy-2',2'-difluorocytidine (gemcitabine), have objective response rates of less than 10% in large studies. Hypothesizing noncross resistance and a synergistic interaction between gemcitabine and cisplatin, early clinical studies have demonstrated significant activity with this combination in patients with several types of malignant disease. A Phase II study was undertaken to determine the efficacy of gemcitabine in combination with cisplatin in patients with locally advanced and metastatic pancreatic carcinoma based on these considerations.

METHODS

The eligibility criteria included histologically confirmed, locally advanced, unresectable or metastatic exocrine carcinoma of the pancreas with no prior gemcitabine therapy; prior adjuvant therapy was allowed provided the last day of therapy was at least 6 months prior to starting treatment; clinically measurable or evaluable disease; a Southwest Oncology Group scale performance status of 0-2; a life expectancy of > 12 weeks; and adequate bone marrow, hepatic, and renal function. A total of 42 patients, 4 patients with locally advanced, unresectable disease and 38 patients with metastatic disease, were treated and received a total of 211 cycles of therapy between May 1997 to March 1999. The median age of patients was 61.5 years. The patients were treated in the outpatient setting with a combination of gemcitabine 1,000 mg/M(2) intravenously over 30 minutes administered on Days 1, 8, and 15 of each cycle and cisplatin 50 mg/M(2) intravenously administered after gemcitabine infusion on Days 1 and 15 with adequate prehydration accompanied by adequate urinary output. Cycles were repeated every 28 days. Response and toxicity were assessed according to World Health Organization and standard criteria.

RESULTS

The complete and partial response rate among all 42 registered patients was 11 of 42 patients (26%; 95% confidence interval, 0.14-0.42). Stabilization of disease was seen in 15 patients (38%). Two additional patients with metastatic disease who achieved major responses to chemotherapy were rendered free of disease surgically, achieving a complete response status. The median overall survival was 7.1 months (95% confidence interval [CI], 6.3-9.1 months), with 64% of patients alive at 6 months and 19% of patients alive at 12 months. The median time to disease progression was 5.4 months (range, 0.9-20.8 months). Major toxicities were neutropenia and thrombocytopenia, with one episode of neutropenic fever.

CONCLUSIONS

The combination of gemcitabine and cisplatin appeared to have significantly greater activity than single-agent gemcitabine in this Phase II study, with tolerable toxicity. The antitumor activity of this combination needs to be confirmed in multi-institutional or comparative trials.

Phase II study of gemcitabine and cisplatin in the treatment of patients with advanced pancreatic carcinoma

BACKGROUND

Pancreatic carcinoma is considered among the most chemoresistant of human malignancies. The most commonly used cytotoxic single agents, 5-fluorouracil and 2'-deoxy-2',2'-difluorocytidine (gemcitabine), have objective response rates of less than 10% in large studies. Hypothesizing noncross resistance and a synergistic interaction between gemcitabine and cisplatin, early clinical studies have demonstrated significant activity with this combination in patients with several types of malignant disease. A Phase II study was undertaken to determine the efficacy of gemcitabine in combination with cisplatin in patients with locally advanced and metastatic pancreatic carcinoma based on these considerations.

METHODS

The eligibility criteria included histologically confirmed, locally advanced, unresectable or metastatic exocrine carcinoma of the pancreas with no prior gemcitabine therapy; prior adjuvant therapy was allowed provided the last day of therapy was at least 6 months prior to starting treatment; clinically measurable or evaluable disease; a Southwest Oncology Group scale performance status of 0-2; a life expectancy of > 12 weeks; and adequate bone marrow, hepatic, and renal function. A total of 42 patients, 4 patients with locally advanced, unresectable disease and 38 patients with metastatic disease, were treated and received a total of 211 cycles of therapy between May 1997 to March 1999. The median age of patients was 61.5 years. The patients were treated in the outpatient setting with a combination of gemcitabine 1,000 mg/M(2) intravenously over 30 minutes administered on Days 1, 8, and 15 of each cycle and cisplatin 50 mg/M(2) intravenously administered after gemcitabine infusion on Days 1 and 15 with adequate prehydration accompanied by adequate urinary output. Cycles were repeated every 28 days. Response and toxicity were assessed according to World Health Organization and standard criteria.

RESULTS

The complete and partial response rate among all 42 registered patients was 11 of 42 patients (26%; 95% confidence interval, 0.14-0.42). Stabilization of disease was seen in 15 patients (38%). Two additional patients with metastatic disease who achieved major responses to chemotherapy were rendered free of disease surgically, achieving a complete response status. The median overall survival was 7.1 months (95% confidence interval [CI], 6.3-9.1 months), with 64% of patients alive at 6 months and 19% of patients alive at 12 months. The median time to disease progression was 5.4 months (range, 0.9-20.8 months). Major toxicities were neutropenia and thrombocytopenia, with one episode of neutropenic fever.

CONCLUSIONS

The combination of gemcitabine and cisplatin appeared to have significantly greater activity than single-agent gemcitabine in this Phase II study, with tolerable toxicity. The antitumor activity of this combination needs to be confirmed in multi-institutional or comparative trials.

Combined-modality therapy in pancreatic cancer: current status and future directions

The use of chemotherapy with concurrent radiation therapy remains a standard treatment option for patients with unresectable or resected adenocarcinoma of the pancreas. This treatment strategy is based in large part on data from serial Gastrointestinal Tumor Study Group (GITSG) trials, which have included 5-fluorouracil (5-FU). Unfortunately, the majority of patients continue to succumb to the disease process. Recently, there has been a resurgence in clinical trials investigating alternative combined modality treatment strategies for patients with pancreatic cancer. In this review, we will summarize both the mature and more recent data pertaining to combined modality therapy for patients with unresectable or resected pancreatic cancer. Strategies utilizing concurrent gemcitabine, alternative radiation therapy techniques, and/or altered sequencing of therapies will be highlighted. Such modifications to the approach in use since the 1980s will need to be fully considered as clinical trials utilizing chemoradiotherapy regimens and new systemic agents or novel targeted therapies are designed.

Phase II study of liposomal doxorubicin in patients with advanced colorectal cancer

Doxil is a liposomal preparation of doxorubicin that results in prolonged pharmacologic exposure in vivo to the active agent. We sought to test the hypothesis that this new formulation would result in improved efficacy in patients with colorectal cancer. Patients with advanced colorectal cancer who had received prior therapy were eligible for the trial. Treatment consisted of Doxil 45 mg/m2 intravenously every 3 weeks. Seventeen patients entered the trial and they received a median of two cycles of treatment. None of the patients had a partial response to treatment. Stable disease was the best response, and one patient received therapy for 17 cycles before her disease progressed. The therapy was well tolerated, with only two patients having the dose decreased because of hand-foot syndrome. Four patients experienced allergic reactions during the infusion, but with appropriate premedication and slowing of the infusion, treatment was able to be resumed without difficulty. No greater than grade I neutropenia or thrombocytopenia developed in any patient. Although Doxil was well tolerated at this dose and schedule, it was not an active agent in this group of patients. Doxil alone or in combination with other agents is worthy of further study in cancers responsive to doxorubicin.

Cisplatin, cytarabine, caffeine, and continuously infused 5-fluorouracil (PACE) in the treatment of advanced pancreatic carcinoma: a phase II study

Encouraging results using cisplatin, cytarabine, and caffeine for the treatment of pancreatic carcinoma prompted a phase II study using these agents and adding continuous intravenous infusion (CI) 5-fluorouracil (5-FU) (PACE). Patients with advanced pancreatic adenocarcinoma who had not received prior cytotoxic therapy were eligible. Treatment consisted of the following: on day 1, the administration of cisplatin 100 mg/m2 IV, cytarabine 2 g/m2 IV every 12 hours x 2 doses, and caffeine 400 mg/m2 subcutaneously after each cytarabine dose; and on days 3 to 21, 5-FU 250 mg/m2/day given by CI. Cycles were repeated every 28 days. Thirty eligible patients were entered in the study. The median number of cycles received was three. Grade IV neutropenia and thrombocytopenia occurred in 53% and 27% of patients, respectively. Among 30 treated patients, complete remission (CR) was seen in 2 patients and partial remission (PR) in 3 patients, for an overall response rate of 16.7% (95% confidence interval 6.8-32.4%). The median survival was 5.0 months (range: 0.3-32.4 months) and 16.7% and 10% of patients were alive at 1 and 2 years. respectively. Changes in the serum level of CA 19-9 provided an early marker of response which translated in differences in survival. Those with increasing or decreasing/stable levels of CA 19-9 after the first cycle of therapy had median survivals of 1.7 and 8.3 months, respectively (p = 0.0002). Although PACE chemotherapy produced durable responses in pancreatic cancer, the toxicity was substantial. A modification of this regimen with newer, less toxic drugs may provide better results and reduced toxicity. Also, the monitoring of the serum CA 19-9 level may provide a means to assess response and predict survival.

Multidrug resistance phenotype in high grade soft tissue sarcoma: correlation of P-glycoprotein immunohistochemistry with pathologic response to chemotherapy

BACKGROUND

P-glycoprotein-mediated drug efflux has been implicated as an important mechanism of multidrug resistance (MDR) in cancer. Its role in chemotherapy resistance in soft tissue sarcoma is unclear.

METHODS

Tumor specimens prior to and following neoadjuvant chemotherapy from 29 cases of high grade soft tissue sarcoma were analyzed with 2 monoclonal antibodies (C494 and JSB-1) that recognize different epitopes of P-glycoprotein. Staining intensity was graded 0 = negative, 1 = equivocal, 2 = moderate, 3 = strong. Only cases with Grade 2 or 3 staining intensity with both antibodies were considered MDR positive. The resection specimens were evaluated for tumor necrosis postchemotherapy. Pathologic response was graded as good for <15%, moderate for 15-50%, or poor for >50% posttreatment tumor viability.

RESULTS

Of the 29 pretreatment specimens, 10 (34%) were MDR positive and 19 (66%) were MDR negative. Pathologic response to treatment was characterized as good in 6, moderate in 7, and poor in 16 patients. Of the MDR positive biopsies, 9 (90%) had poor response, compared with 7 (36%) in the MDR negative biopsy group (P = 0.0078). None of the cases with MDR positive biopsies had a good response, compared with 6 cases in which biopsies were MDR negative (32%) (P = 0.057). Only one MDR negative case became MDR positive posttreatment.

CONCLUSIONS

Expression of MDR phenotype is found in approximately one-third of high grade soft tissue sarcomas. These preliminary data show a significant correlation between MDR phenotype and poor pathologic response to chemotherapy, and suggest that MDR induction by chemotherapy in soft tissue sarcoma is an uncommon event.

Hepatic chemoembolization combined with systemic infusion of 5-fluorouracil and bolus leucovorin for patients with metastatic colorectal carcinoma: A Southwest Oncology Group pilot trial

BACKGROUND

Rates of response to systemic chemotherapy among patients with advanced colorectal carcinoma rarely exceed 25- 30%, and complete responses are rare. The liver is the most common site of metastasis; however, regional therapies have not improved survival rates. The Southwest Oncology Group designed a clinical trial combining hepatic arterial chemoembolization with systemic infusion of 5-fluorouracil chemotherapy in an attempt to increase the complete response rate and prolong the time to disease progression.

METHODS

Patients with documented liver metastasis from colorectal carcinoma were treated with two or three cycles of chemoembolization using a collagen suspension with doxorubicin, mitomycin C, and cisplatin. Subsequently, systemic chemotherapy with continuous infusion of 5-fluorouracil and weekly leucovorin was initiated. Patients were assessed for response at 12-week intervals, with treatment continuing until disease progression.

RESULTS

Thirty-one eligible, evaluable patients were treated. One complete and 8 partial responses were observed, for an overall response rate of 29%. Fifty-eight percent of patients survived 1 year, and the median survival for the whole cohort was 14 months. The median time to progression was 8 months. Seven patients (23%) experienced Grade 4 toxicity and 21 patients (67%) had Grade 3 toxicity.

CONCLUSIONS

The response rate in this trial was comparable to that achieved with systemic chemotherapy consisting of a fluorinated pyrimidine-based regimen for patients with this disease. No improvement in complete response rate or time to progression was observed compared with the Southwest Oncology Group's experience with systemic therapy. The authors are not planning to study this regimen further as a treatment for patients with metastatic colorectal carcinoma.

High-grade extraskeletal myxoid chondrosarcoma: a high-grade epithelioid malignancy

AIMS

Extraskeletal myxoid chondrosarcoma is typically a low-to-intermediate grade sarcoma that is associated with a prolonged clinical course. High-grade forms are rare and not well characterized. In this series we report the clinicopathological, immunohistochemical and ultrastructural findings in four cases of high-grade extraskeletal myxoid chondrosarcoma.

METHODS AND RESULTS

The patients were three men and one woman (ages 34-73 years) with tumours located in the thigh (two cases), paraspinal soft tissue and perineum. Three patients had metastases, one at 12 weeks, one at 10 months, and one at presentation of recurrent tumour. In the latter case the original tumour was low grade and became high grade when it recurred 3.5 years later. All three patients died of disease. One patient was lost to follow-up. The most striking histological feature in all four tumours was the presence of numerous large epithelioid cells. These cells were arranged in cords within myxoid matrix and in sheets devoid of matrix. Two tumours had areas of conventional extraskeletal myxoid chondrosarcoma intermixed with the high-grade areas. One tumour showed transition to high-grade spindle cell sarcoma. One tumour had cells with rhabdoid features. Immunohistochemically, two tumours focally expressed S100 protein, and one focally expressed EMA. All were negative with cytokeratin, desmin, smooth muscle actin, HMB45, CD31 and CD34. Ultrastructural features in three cases were compatible with chondrosarcoma; one tumour had aggregates of microtubules within rough endoplasmic reticulum, a characteristic feature of this tumour.

CONCLUSIONS

High-grade extraskeletal myxoid chondrosaroma is a rare and aggressive soft tissue sarcoma, and should be included in the differential diagnosis of other epithelioid malignancies.

Phase II study of CI-958 in colorectal cancer

PURPOSE

We completed a phase II trial of CI-958 (NSC 635371) in patients with advanced colorectal cancer given at a dose of 700 mg/m2 every 21 days.

METHODS

All 15 patients had metastatic disease and had been previously treated with one 5-fluorouracil-based regimen in an adjuvant (six) or metastatic (nine) setting.

RESULTS

None of the patients treated with CI-958 had an objective response to treatment. Median survival was 4.8 months after the start of treatment. Leukopenia was the major toxicity, but no patient experienced febrile neutropenia. An acute febrile reaction was seen after infusion in four of the first nine patients treated. This was abrogated by pretreatment with dexamethasone in the remaining patients.

CONCLUSIONS

CI-958 was not effective at this dose and schedule in patients with previously treated advanced colorectal cancer.

Evaluation of pyrazoloacridine in patients with advanced pancreatic carcinoma

PURPOSE

Pyrazoloacridine (PZA) is an acridine derivative selected for clinical development because of broad pre-clinical antitumor activity and solid tumor selectivity. Phase I evaluations with PZA have demonstrated predictable toxicity and suggested clinical efficacy. A phase II trial in patients with previously untreated advanced pancreatic cancer was conducted.

METHODS

PZA was administered at a dose of 750 mg/m2 intravenously over 3 hours every 21 days. Seventeen patients were treated receiving a total of 46 courses of PZA.

RESULTS

Of the 15 patients evaluable for response, no responses were observed (0% response rate, 95% confidence interval 0-22%). Major toxicities directly attributable to PZA included moderate neutropenia and mild neurotoxicity.

CONCLUSION

PZA at this dose and schedule of administration was inactive in patients with pancreatic carcinoma.

A phase II study of carboplatin and paclitaxel in the treatment of patients with advanced esophageal and gastric cancer

We initiated a phase II study to determine the efficacy of carboplatin and paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) in patients with advanced esophageal or gastric cancer. Objective tumor responses, duration of response, time to disease progression, overall survival, and toxicity profile are the end points evaluated in this study. The study includes patients with locally advanced metastatic or recurrent esophageal or gastric cancer with no history of prior chemotherapy or radiation treatment. Patients are required to have a performance status of 0 to 2 and no organ failure. Staging diagnostics include computed tomography scans and endoscopic ultrasound when appropriate. Starting dose of paclitaxel is 200 mg/m2, and carboplatin is given to achieve an area under the concentration-time curve of 5.0. Dose escalation is attempted if nadir counts permit. Seventeen patients have registered so far. Of those, three are not evaluable for efficacy analysis: one has not been on study long enough to be assessed for response and the other two are not assessable for objective tumor response. Three patients with gastric cancer have achieved partial responses. Two of five patients with esophageal cancer responded (partial response) to this treatment. Dose escalation by one step was feasible in approximately half the patients. There were no episodes of neutropenic fever. Carboplatin and paclitaxel given on an outpatient basis is well tolerated and an interesting regimen for the treatment of patients with advanced gastric or esophageal cancer.

Cytogenetic aberrations and DNA ploidy in soft tissue sarcoma. A Southwest Oncology Group Study

We performed cytogenetic analysis and determined DNA content by flow cytometry (FCM) on freshly disaggregated tumor biopsies from 45 patients with soft tissue sarcomas (STS). Cytogenetically aberrant clones characterized 30 (67%) tumors, with the remaining 15 yielding normal karyotypes with or without nonclonal aberrations. No tumors with multiple unrelated clones were observed. Among the 30 tumors with clonally abnormal karyotypes, 21 (70%) had near-diploid stemlines, six were near-triploid and three were near-tetraploid. Ten of the clonally aberrant tumors contained nonrandom chromosomal translocations characteristic of histologic subtypes. Overrepresentation of chromosomes 7 and 8 were common numerical aberrations. Structural aberrations most often involved chromosomes 1, 7, 9, 12, and 14. Clustering of breaks in 9p resulting in partial loss of the short arm was frequent. Unstable aberrations including rings, dicentrics, large markers, small numbers of double minutes, and telomeric associations were seen in nine tumors. With FCM, 27 (60%) tumors had aneuploid DNA content and 18 (40%) were DNA diploid. Of those 18 DNA diploid tumors, 11 showed clonal karyotypic aberrations. In addition, apparent discrepancies between the results of the cytogenetics and FCM with respect to ploidy pattern were seen in 13 samples; 11 had DNA content in the peritriploid to peritetraploid range but the corresponding karyotype was normal or near-diploid. When the findings of the cytogenetics and DNA content analyses were combined, an abnormal cell population by one or both methods was detected in 38 (84%) tumors. The concurrent application of standard cytogenetics and DNA ploidy by FCM provide complementary information confirming a high incidence of genetic alterations in STS.

Flow cytometric analysis of P-glycoprotein expression and drug efflux in human soft tissue and bone sarcomas

Twenty-two fresh surgical specimens of human sarcomas (soft tissue and bone) from 20 patients were analyzed by flow cytometry for the expression of drug resistance-related P-glycoprotein (P-gp) and cellular daunorubicin (DNR) accumulation with or without the presence of DNR efflux blockers. Single-cell suspensions prepared from the tumor specimens were analyzed by dual-color flow cytometry after reaction with MRK-16 (anti-P-gp) and anti-CD45 (pan-leukocyte) antibodies. MRK-16 reactivity of tumor cells was evaluated after exclusion of CD45-positive cells by electronic gates. Parallel samples were incubated with DNR alone or in combination with DNR efflux blockers, verapamil (VPL), or dipyridamole (DPD) for determination of cellular DNR accumulation and the effect of the efflux blockers. Extensive heterogeneity was observed in both P-gp expression and DNR accumulation of the tumor specimens examined. Eight of the 22 tumor specimens had significant numbers of P-gp-positive cells. In three of the eight P-gp-positive tumors, cellular DNR accumulation was significantly increased by co-incubation with the efflux blockers VPL or DPD. These results indicate that both quantitative and functional analysis of P-gp expression may be essential in determining the cellular drug resistance phenotype of tumor cells and its correlation with therapeutic outcome.

Phase II study of pyrazoloacridine in patients with advanced colorectal carcinoma

PURPOSE

Pyrazoloacridine (PZA) is an acridine derivative selected for clinical development because of broad preclinical antitumor activity and solid tumor selectivity. Phase I evaluations with PZA have demonstrated predictable toxicity and suggested clinical efficacy. A phase II trial in patients with previously untreated advanced colorectal cancer was conducted.

METHODS

PZA was administered at a dose of 750 mg/m2 intravenously over 3 h every 21 days to patients who received a total of 31 courses of PZA.

RESULTS

In 15 patients evaluable for response, no responses were observed (0% response rate, 95% confidence interval 0-22%). Toxicity to PZA consisted of myelosuppression and neurotoxicity that was treatment-limiting in several instances.

CONCLUSION

PZA at this dose and schedule of administration is inactive in patients with colorectal cancer.

Primary embryonal rhabdomyosarcoma of long bone. Case report and review of the literature

We report a case of primary embryonal rhabdomyosarcoma of long bone, presenting as a lytic destructive bone tumor in the right femoral diaphysis of a 7-year-old girl. To our knowledge, this is only the third report of this entity. The neoplasm was a pure embryonal rhabdomyosarcoma with numerous rhabdomyoblasts. Immunohistochemistry confirmed the diagnosis: The cells were reactive with antibodies directed against desmin, muscle-specific actin, and myoglobin. No other neoplastic mesenchymal component was present within the tumor. Although rare, primary rhabdomyosarcoma, along with Ewing's tumor and osteosarcoma, should be considered in the differential diagnosis of malignant bone tumors in childhood.

Systemic adjuvant chemotherapy for soft tissue sarcomas

Adjuvant chemotherapy for soft tissue sarcoma remains investigational. Continued study of multidisciplinary treatment programs in high-grade sarcomas in formal clinical trials remains a priority. The National Cancer Institute is currently conducting a randomized trial of postoperative adjuvant doxorubicin and ifosfamide as compared with observation in high-grade sarcoma. The completion and outcome of this trial will contribute to this ongoing debate. Finally, a better understanding of the biology of soft tissue sarcoma that determines subsequent clinical course may serve as a foundation for further investigation.

Ifosfamide and etoposide in the treatment of advanced soft tissue sarcomas

Ifosfamide is an active chemotherapeutic agent in the treatment of soft tissue sarcoma. This Phase II study attempted to evaluate the efficacy of the addition of etoposide to ifosfamide administered to patients with recurrent or metastatic soft tissue sarcoma. Treatment consisted of etoposide 100 mg/m2, followed by ifosfamide 2.0 g/m2, daily, for 4 consecutive days. Mesna was administered for uroprotection. Cycles were repeated at 21-day intervals or upon recovery from toxicity. Two partial responses were observed in 19 evaluable patients (response rate 10.5%, 95% confidence interval, 7% to 14%). Response durations were brief at 2 and 6 months. In a subset of 10 patients with gastrointestinal leiomyosarcoma, no responses were observed. Toxicity was generally mild, consisting primarily of myelosuppression and controllable nausea and emesis. No episodes of hematuria were observed. Overall survival for all eligible patients was 10 months (range: 0.2 to 34.7+ months). Etoposide, in this dose and schedule, failed to enhance the activity of ifosfamide in adult soft tissue sarcoma. Additionally, this experience and a review of the literature, suggest that ifosfamide has little activity against gastrointestinal leiomyosarcomas. Continued efforts are needed to identify novel agents with efficacy against these resistant tumors.

Cytogenetic findings in 19 malignant bone tumors

BACKGROUND

The majority of karyotypes observed in osteosarcomas (OS) and chondrosarcomas (CS) are complex. Specific chromosomal abnormalities have not yet been characterized in either tumor except for a ring chromosome in parosteal OS. The purpose of this study was to determine recurrent chromosomal abnormalities and establish a possible correlation between the cytogenetic changes and the pathologic findings.

METHODS

Ten OS and nine CS were cytogenetically analyzed. Tumor samples were obtained from patients having a resection or incisional biopsy. Cytogenetic study of short term cell cultures included harvesting and G-banding, which were performed by routine methodologies.

RESULTS

Clonal abnormalities were observed in six OS and six CS. Modal chromosome numbers ranged from near diploid to near tetraploid in both types of tumors. The structural rearrangements observed in OS involved mostly chromosomes 1, 2, 6, 12, and 17. Nonreciprocal translocations were the most frequent event. Two OS had a single clonal abnormality involving 11p15 and 14q32, respectively. Double minute chromosomes were observed in three cases. In CS, the most frequent structural abnormalities were nonreciprocal translocations and deletions involving numerous chromosomes. Rearrangements of 1p together with other abnormalities were observed in four CS.

CONCLUSIONS

The karyotypes were usually complex consisting of numerical and structural changes, particularly in high grade tumors. Rearrangements of 11p15 and 14q32 in OS and possibly 1p in CS were found as primary cytogenetic aberrations. Cytogenetic analysis in more cases of OS and CS together with molecular studies are necessary to characterize further the consistent genetic changes in these tumors.

Phase II trial of piroxantrone for advanced or metastatic soft tissue sarcomas. A Southwest Oncology Group study

Piroxantrone is an anthrapyrazole compound undergoing phase II testing in a variety of diseases. The anthrapyrazoles are a series of compounds synthesized with the intent of maintaining the broad antitumor activity of anthracyclines, but with lessened cardiac toxicity. The Southwest Oncology Group (SWOG) conducted a phase II trial of piroxantrone in advanced soft tissue sarcoma. Treatment consisted of piroxantrone 150 mg/M2 administered intravenously over 1 hour every 21 days. Twenty-five eligible patients were registered to the trial. Twenty-three patients received treatment and are fully evaluable for response and toxicity. Two partial responses were seen for an overall response rate of 9% (95% confidence limit 1%-28%). Abnormal cardiac ejection fraction occurred in five patients, and fatal congestive heart failure developed in one patient on study. Toxicities other than cardiac were tolerable. Based on the observed response rate and cardiac toxicity, further trials of piroxantrone in the treatment of soft tissue sarcoma do not appear warranted.

Development and optimization of tissue preparative methodology for DNA content analysis of soft tissue neoplasms

Data regarding DNA content parameters in soft tissue sarcoma is limited. Development and optimization of tissue specific preparative techniques for DNA flow cytometry was undertaken prior to routine DNA content analysis of soft tissue neoplasms; 154 soft tissue tumors were studied. Dissociation dependent differences in cellular yields, viabilities, maintenance of DNA aneuploid populations, coefficients of variation, and DNA index supported the need for these developmental studies. Fifty-six of eighty-nine patients had DNA aneuploid soft tissue sarcomas. A relationship between DNA aneuploidy and grade was seen in this series with 38% with low grade, 59% with moderate grade, and 69% with high grade tumors demonstrating DNA aneuploid populations (P < 0.005). The mean S-phase fraction for DNA diploid and aneuploid sarcomas was 7.2% and 13.3%, respectively (P < 0.001). When classified by histologic grade of the primary tumor, a greater percentage of metastatic lesions were DNA aneuploid (4 of 7 grade 2 lesions, and 15 of 16 grade 3 lesions). Decreases in cellular yields and rate of DNA aneuploidy were observed in a subgroup of patients with localized high grade sarcoma treated preoperatively, as compared to patients treated with initial surgery. Prospective correlation of DNA content parameters to prognosis and response to cytotoxic therapy are now possible and are ongoing.

Deletion of chromosome 13 in osteosarcoma secondary to irradiation

The cytogenetic analysis of a radiation-induced osteosarcoma in a 31-year-old male is presented. Complex karyotypic changes with numerical and structural abnormalities, including a del(13)(q12.3q21.1), were observed. This deletion may indicate that loss of RB1 gene (locus in 13q14) may be involved in the development of radiation-induced osteosarcoma.

DNA content parameters of paraffin-embedded soft tissue sarcomas: optimization of retrieval technique and comparison to fresh tissue

DNA content analysis of formalin fixed paraffin embedded (FFPE) tissue permits determination of the influence of DNA content on the prognosis in cohorts of patients for whom the clinical outcome is known. Of key importance in such an analysis is the accuracy of DNA content determination. Variations in the quality of DNA histograms from FFPE tissues of different types prompted a comparative evaluation of the preparative methodology of FFPE soft tissue sarcomas for DNA flow cytometry. Following deparaffination and rehydration of fixed tissue, and prior to fluorochrome staining, tissue blocks of 15 DNA aneuploid soft tissue sarcomas were subjected to repeated experimental (time x concentration) enzyme exposures. The goal of these studies was to define the optimal tissue specific retrieval technique with the coefficient of variation, maintenance of DNA aneuploidy, and DNA index as endpoints. After optimizing the technique, the DNA content of 50 soft tissue neoplasms derived from FFPE specimens was compared to the corresponding fresh surgical tissue. The observed 14 percent error rate in the determination of DNA ploidy status suggest limited utility for FFPE tissue in prospective therapeutic trials of soft tissue sarcoma.

A common cytogenetic abnormality and DNA content alterations in dedifferentiated chondrosarcoma

Dedifferentiated chondrosarcoma is an uncommon and aggressive variant of chondrosarcoma. The authors report the flow cytometric characteristics and cytogenetic findings in culture of two cases of dedifferentiated chondrosarcoma. The first case was DNA diploid by flow cytometry but had cytogenetic abnormalities consisting of breaks in the short arms of both chromosomes 1, resulting in deletion in one homolog and recombination in the other. In addition, cells from this tumor showed a balanced translocation between chromosomes 4 and 5, deletion of chromosome 9, and monosomy for chromosome 10. The second case was DNA aneuploid and more complex cytogenetically but had, in common with the first case, rearrangement and translocation at the same band on chromosome 1. These cytogenetic changes are compared with abnormalities previously reported for chondrosarcoma. Possible relationships between the nonrandom chromosomal abnormalities and subclassification among chondrosarcomas are discussed.