An Intensive Treatment with Mitoxantrone and Ifosfamide in Second-Line Therapy of Epithelial Ovarian Cancer

Aims and background

Both mitoxantrone (DHAD) and ifosfamide (IFO) have given promising results when administered as single agents in advanced ovarian cancer pretreated with platinum compounds. The aim of this I.T.M.O. group pilot trial was to evaluate, in a selected population of ovarian cancer patients, the efficacy and tolerability of the following intensive second-line regimen: DHAD, 12 mg/m2 i.v., day 1; IFO, 4,000 mg/m2 i.v., days 1 and 2; Mesna, 800 mg/m2 i.v. t.i.d., days 1 and 2. Filgrastim (5 μg/kg/day i.m.) was given from day 6 to day 19 to reduce the expected neutropenia. Cycles were repeated every 21 days.

Methods

Nineteen platinum-pre-treated patients were enrolled and 14 were evaluated for tumor response; the disease of 5 patients was not measurable clinically or radiologically.

Results

Seven responses were observed (3 CRs), with a median response duration of 5 months. The median time to treatment failure and overall survival for all 19 patients was respectively 8 and 13 months. Anemia was observed in all of the treated patients (grade 3–4 in 9 cases). Only 6 of the 19 patients ended the five planned cycles of chemotherapy without any delay.

Conclusions

Although DHAD plus IFO induced a considerable number of objective responses, the limited response duration time to treatment failure, and overall survival as well as the reported side effects suggest that this is not a recommended regimen for the palliative treatment of ovarian cancer patients undergoing second-line chemotherapy.

Peripheral Neurotoxicity following High-Dose Cisplatin with Glutathione: Clinical and Neurophysiological Assessment

The use of high-dose cisplatin is limited by development of severe peripheral neurotoxicity and gradual worsening of renal function. In an ongoing study of high-dose cisplatin glutathione has been employed with the aim of preventing major cisplatin-induced toxicities. Neurotoxicity was examined in detail in 32 patients with ovarian cancer treated with cisplatin (160 mg/m2) and cyclophosphamide (600 mg/m2) every 3-4 weeks for five courses. In addition to serial complete neurological examination, sensory action potentials (SAPs) and motor conduction velocities (MCVs) were also assessed. We confirmed the development of a predominant sensory involvement, characterized by mild distal paresthesias and decrease in vibratory sensibility and in deep tendon reflexes, with a slight reduction of SAPs, observed after three courses of treatment. After five courses, distal paresthesias and disesthesias, decreased proprioception and loss of vibratory sensibility with ataxic signs, absence of deep tendon reflexes, unobtainable SAPs and only moderately reduced MCVs were seen. We did not observe any case of disabling neuropathy. There was a tendency to a more severe involvement of peripheral nerves in patients aged more than fifty. The 3 patients presenting the most serious neuropathy were the oldest in the whole group. Low degree of neurotoxicity observed in this study supports a glutathione protection against cisplatin-induced neurotoxicity. As the urinary excretion of platinum indicated no changes in the renal clearance of cisplatin following repeated courses, the lack of drug accumulation and high plasma peak due to preserved renal function might explain the reduced neurotoxicity observed.

A Case of Hyperthyroidism due to Metastasis of a Thyroid Carcinoma

A case of hyperthyroidism, which developed in a patient affected by thyroid carcinoma a few days after thyroidectomy, is described. The symptomatology was caused by a bone metastasis at the left ischiopubic branch, which had a high iodine-uptake capacity and was sensitive to metabolic radiotherapy. Pulmonary metastases were also present; they had a distinct low affinity for iodine and showed no response to repeated administrations of 131I. The case is evaluated on the basis of the evolution of the clinical picture and the hormone dosages administered in a follow-up period of 3 years.

Correlation between Clinical Response to Bilateral Oophorectomy, Estrogen Receptors and Urinary Androgen Excretion in 49 Patients with Advanced Breast Cancer

The aim of this study was to find out if it is possible to predict the clinical response to bilateral oophorectomy in premenopausal patients with advanced breast cancer. Two methods of determination were used before oophorectomy: 1) the presence of estrogen receptors in the tumor tissue; 2) the urinary concentration of androgens. The clinical response to oophorectomy was evaluated after a six-month follow-up. Determinations carried out on 49 patients showed that a significant correlation exists between clinical response to oophorectomy and androgenic activity alone or in combination with estrogen receptors when both tests give concordant results.

Malignant Peritoneal Mesothelioma

Eight cases of peritoneal malignant mesothelioma observed at the Istituto Nazionale Tumori of Milan from 1972 to 1978 are reported. The clinical features of the cases clearly point out the diagnostic difficulties, the inadequacy of the treatment and the poor prognosis of this neoplasia. The authors maintain that more complete epidemiologic studies and more adequate therapeutic programs could modify the prognosis for this neoplasm.

Primary Retroperitoneal Tumors

Seventy-five cases of primary retroperitoneal tumors observed at the Istituto Nazionale Tumori of Milan during the period 1932 to 1973, 56 of which had a histopathologic classification (51 malignant and 5 benign), are reported. By examination of the diagnostic and therapeutic criteria employed and the survival data (9 of the 51 malignant cases were alive at 3 years, and 3 of these were alive at 5 years), the authors point out the difficulty of an early diagnosis and, therefore, of a radical surgery, the need for a programmed therapy, and the importance of the angiographic examination in the diagnostic strategy.

Hormonal and Receptor Status in Postmenopausal Women with Endometrial Carcinoma before and after Treatment with Tamoxifen

Twenty-four patients with endometrial carcinoma received tamoxifen (Nolvadex) for 7 days. Before and after administration, circulating hormones (estradiol, testosterone, progesterone, gonadotropins FSH and LH) were evaluated. Estrogen (ER) and progesterone receptors (PgR) in neoplastic tissue were also assayed. Our results show a net increase in PgR content and a signicant decrease in gonadotropin levels after the treatment. The authors suggest that clinical trials be conducted using tamoxifen and progestins for adjuvant therapy after surgery of endometrial carcinoma and for the therapeutic approach of advanced carcinoma.

A Preliminary Clinical Experience with Reduced Glutathione as Protector against Cisplatin-Toxicity

A total of 16 consecutive patients (15 with ovarian cancer and 1 with unknown adenocarcinoma) were treated with a standard regimen including cisplatin and cyclophosphamide or with the same regimen in combination with reduced glutathione as potential protective agent against cisplatin nephrotoxicity, in a non-randomized study. Reduced glutathione (1500 mg/m2) was administered prior to each cisplatin administration (90 mg/m2) to seven patients for a maximum of five consecutive courses. A standard hydration protocol without diuretics was used. The patients received a total of 33 courses with glutathione. Glutathione was well tolerated, since it did not produce appreciable side effects. Cisplatin and glutathione combination did not produce unexpected toxicity. Two patients treated with standard regimen without glutathione developed a transient nephrotoxicity. The severity of myelosuppression was reduced following glutathione administration. Moreover, the therapeutic efficacy was not impaired by glutathione pretreatment.

Changes in Receptor Status after Treatment with Tamoxifen in Endometrial Cancer

Estrogen (ER) and progesterone receptor (PgR) status was determined in 41 women with operable endometrial cancer before and after administration of tamoxifen (TAM). The first sample was obtained by hysteroscopy to ensure a precise biopsy of neoplastic tissue; the second was done on the surgical specimen. PgR content was significantly increased after TAM treatment and this data was compared with the degree of tumor differentiation.

Clinical Response to Chemotherapy and Hormone Therapy as First Treatment after Therapeutic Ovariectomy in Advanced Breast Cancer Patients

The results of chemotherapy and hormone therapy, administered after relapse of the disease, were evaluated in 106 patients with homogeneous clinical characteristics who were subjected to bilateral ovariectomy for advanced breast cancer, whether the response to castration was favorable or not. In spite of an unfavorable response to the ovariectomy, 40.0% of the patients responded to hormone therapy, whereas 31.5% of the cases did not benefit from the successive hormone therapy, although they had responded to ovariectomy. In contrast, 65%, after favorably responding to ovariectomy, showed regression of the neoplasm after chemotherapy for the relapse. This apparent discordance of the results could be due to the fact that response to castration is not the only valid parameter to identify hormone dependence of a breast cancer and/or that the breast cancer is composed, in various proportions, of hormone-sensitive and chemo-sensitive cells. The predominance of one of these 2 components could determine the response of the neoplasm to therapy. The authors conclude that a more extensive and accurate hormone typing of the patient could give more precise indications for the appropriate therapy.

Topography and Clinical Characteristics of Malignant Tumors of the Urachus

Nine patients with urachal tumors have been reevaluated. There were 5 men and 4 women, whose ages ranged from 6 to 72 years. Surgery was performed in 4 cases, radiotherapy was used in 2 cases, and the remaining 3 cases were judged to be beyond therapeutic help. Three years after treatment, also all cases subjected to therapy were dead. The diagnostic delay, the inadequacy of treatment, and therefore the absolutely unfavorable prognosis of these tumors are discussed.

Relationship between Steroid Receptors (As Continuous Variables) and Response to Adjuvant Treatments in Postmenopausal Women with Node-Positive Breast Cancer

In current clinical practice for breast cancer patients, estrogen (ER) and progesterone receptor (PgR) concentrations, quantified by the dextran-coated charcoal assay, are categorized by an arbitrary cutoff into a negative or positive status. However, although the results obtained with this approach are easy to interpret, such a representation could oversimplify the relationship between ER and PgR content and patient outcome and imply an assumption of monotonicity, which is generally expected but rarely proven. We evaluated the relationship between ER and PgR content (considered on a continuous scale) and clinical outcome, using a flexible statistical model, in a group of postmenopausal patients with N-positive operable tumors who were submitted to surgery and different adjuvant treatments (tamoxifen or CMF). Univariate analysis indicated that in the tamoxifen-treated group, ER level, number of metastatic nodes (pN) and age, but not PgR, were significant indicators of clinical outcome (p=0.032, p=0.021 and p=0.029, respectively). Multivariate analysis indicated that in this group of patients there was no interaction between variables, and in the final model for disease-free survival (DFS) only ER and pN were retained with an overall predictive ability of the regression model of 0.723, as evaluated by Harrell's c. However, pN markedly contributed to the predictive ability of the model with respect to ER, since a marked decrease in Harrell's c statistic (c=0.582) was observed when pN was removed from the model. In the CMF-treated group, only pN affected clinical outcome. When the estimated DFS curves obtained from the final Cox regression models were plotted according to four values of ER (in the tamoxifen-treated group) or three values of pN (in the CMF-treated group) we observed that in the tamoxifen-treated group patients with an ER concentration equal to 0 fmol/mg cytosol protein had the worst prognosis, whereas a marked improvement of the expected DFS was observed for patients with a low but detectable ER level (generally classified as ER-negative because falling below the conventional cutoff value of 10 fmol/mg cytosol protein). Our results seem to suggest that the use of steroid receptor concentrations on a continuous scale, instead of dichotomous “status”, is to be preferred in the choice of adequate therapeutic strategies.

A Prediction Model for Breast Cancer Recurrence after Adjuvant Hormone Therapy

Hormone therapy with tamoxifen has long been the established adjuvant treatment for node-positive, estrogen–receptor-positive breast cancer in postmenopausal women. Since 30–40% of these patients fail to respond, reliable outcome prediction is necessary for successful treatment allocation. Using pathobiological variables (available in most clinical records: tumor size, nodal involvement, estrogen and progesterone receptor content) from 596 patients recruited at a comprehensive cancer center, we developed a prediction model which we validated in an independent cohort of 175 patients recruited at a general hospital. Calculated at 3 and 4 years of follow-up, the discrimination indices were 0.716 [confidence limits (CL) 0.641, 0.752] and 0.714 (CL 0.650, 0.750) for the training data, and 0.726 (CL 0.591, 0.769) and 0.677 (CL 0.580, 0.745) for the testing data. Waiting for more effective approaches from genomic and proteomic studies, a model based on consolidated pathobiological variables routinely assessed at relatively low costs may be considered as the reference for assessing the gain of new markers over traditional ones, thus substantially improving the conventional use of prognostic criteria.

Vascular endothelial growth factor in node-positive breast cancer patients treated with adjuvant tamoxifen

In 212 postmenopausal women with node-positive oestrogen receptor-positive (ER(LBA)) breast cancer subjected to radical surgery and adjuvant tamoxifen, the risk of 6-year relapse increased with increasing values of intratumoral vascular endothelial growth factor (VEGF) in patients whose tumours had a low/intermediate ER(LBA) content compared to patients with high-ER(LBA) tumours. These findings indicate that tumour progression, activated or sustained by high VEGF levels, may be counteracted in high-ER(LBA) cancers by tamoxifen, which in contrast fails to contrast the metastatic potential in low-ER(LBA) tumours.

Time-dependent relevance of steroid receptors in breast cancer

PURPOSE

To analyze the time-dependent prognostic role of the investigated variables, considered, when appropriate, on a continuous scale, for the purpose of evaluating and describing the interrelationships between clinically relevant patient and tumor characteristics (age, size and histology, and estrogen receptor [ER] and progesterone receptor content) and the risk of new disease manifestation.

PATIENTS AND METHODS

We applied a flexible statistical model to a case series of 1,793 patients with axillary lymph node-negative breast cancer with a minimal potential follow-up of 10 years. To avoid a potential confounding effect of adjuvant treatment, only patients given local-regional therapy until relapse were considered.

RESULTS

ER content and tumor size (adjusted for all the other covariates) showed a time-dependent relationship with the risk of new disease manifestations. In particular, ER content failed to show a prognostic effect within the first years of follow-up; thereafter, a positive association with risk of relapse was observed. For tumor size, within the first years of follow-up, the risk of relapse was directly related to size for only tumors up to 2.5 cm in diameter; thereafter, the impact on prognosis progressively decreased.

CONCLUSION

The availability of a long follow-up on a large breast cancer series, as well as the use of innovative statistical approaches, allowed us to explore the functional relation between steroid receptors and clinical outcome and to generate a hypothesis on the involvement of ER in favoring long-term metastasis development.

Dose intensification of platinum compounds with glutathione protection as induction chemotherapy for advanced ovarian carcinoma

Based on previous clinical experience indicating the tolerability and efficacy of high-dose cisplatin with glutathione protection in the treatment of advanced ovarian cancer, this study was undertaken to explore the efficacy and feasibility of an alternative high-dose, platinum-based approach including a combination of high-dose cisplatin plus carboplatin as induction chemotherapy of advanced ovarian carcinoma and intervention surgery. Fifty consecutive eligible patients with untreated stage III or IV epithelial ovarian cancer received 40 mg/m(2) cisplatin daily on days 1-4 and 160 mg/m(2) carboplatin on day 5. The cycle was repeated after 28 days. Patients received glutathione (2,500 mg) before each cisplatin or carboplatin administration and standard intravenous hydration. After 2 courses of induction chemotherapy, the patients underwent surgical reevaluation with debulking, when possible, followed by a further 3 cycles of 120 mg/m(2) cisplatin (i.e. 40 mg/m(2) daily for 3 consecutive days plus 600 mg/m(2) cyclophosphamide on day 3) except in instances of lack of response. All eligible patients were assessed for response and toxicity. The toxicity was moderate with lack of significant nephrotoxicity. Neurotoxicity and ototoxicity were acceptable and in no patient was treatment discontinued for those toxic effects. Myelotoxicity was somewhat more severe than that observed with our previous study with high-dose cisplatin and probably related to the addition of carboplatin. Of the 40 responsive patients, 23 (46%) had a pathological complete response and 4 (8%) had a clinical complete response (without second-look laparotomy). The efficacy of the present protocol was also documented by overall survival (median survival >48 months), which appeared to be better than expected with the current therapy in this group with advanced/bulky disease. The impressive efficacy suggests a possible contribution of reduced glutathione itself in improving the outcome, as supported by preclinical studies. The results of this study should be placed in context with current platinum-based therapy including paclitaxel.

Combined sequential approach in locally advanced breast cancer

BACKGROUND

The interaction between primary and adjuvant chemotherapy is a crucial point in the treatment of locally advanced breast cancer.

OBJECTIVE

To evaluate the therapeutic efficacy of a sequential treatment with primary anthracyclines and adjuvant CMF in this patient subset.

DESIGN

Prospective cohort study.

PATIENTS

Eighty-eight breast cancer patients, stage T3b-T4 abc, N0-2, M0.

RESULTS

From February 1991 to July 1994, 88 consecutive patients with locally advanced breast cancer were treated at the Istituto Nazionale Tumori, Milano, with full-dose doxorubicin (75 mg/m2) or epirubicin (120 mg/m2) for three cycles followed by surgery, adjuvant chemotherapy with i.v. CMF for six cycles and local radiotherapy +/- Tamoxifen. A high rate of objective responses (70%), but a low incidence of pathologic complete remission (2%), were observed following primary treatment with single-agent anthracyclines. Frequency of responses was not associated with tumor estrogen or progesterone receptors status, Mib-1 or grading. In 28 patients (32%) conservative surgery could be performed. At a median follow-up of 52 months, relapse free survival and overall survival are 52% and 62%, respectively. A multivariate analysis demonstrated a significant favorable prognosis in patients with limited nodal involvement at surgery and negative Mib-1 values. This drug sequence failed to significantly ameliorate the long term results in this unfavorable patient subset and more effective drug regimens and innovative therapeutic strategies are needed.

Is steroid receptor profile in contralateral breast cancer a marker of independence of the corresponding primary tumour?

We compared oestrogen receptor (ER) and progesterone receptor (PgR) profiles between primary and corresponding contralateral breast cancer (CBC) to investigate whether CBC should be considered relapse of a primary or as a feature of the multicentric origin of breast cancer. We adjusted for patient age, menopausal status, histology and adjuvant therapy. In spite of the general application of a cut-off value to dichotomise ER and PgR, we considered them as continuous variables. Moreover, we considered as synchronous cancers only simultaneously occurring lesions. For 399 patients, ER and PgR receptor levels in primary and CBC did not differ significantly, but were significantly correlated within the same patient. The correlation was higher for synchronous than for metachronous lesions when considering ER, but not PgR. The correlation between ER and PgR levels in the same tumour (primary or CBC) appeared stronger than the correlation of either receptor type (ER or PgR) between primary and CBC. Age, histology and adjuvant treatment affected ER concentration, whereas age, menopausal status and histology affected PgR concentration. The analysis indicated that primary and CBC tend to be characterised by a similar steroid receptor profile. The finding may support the hypothesis of CBC as a second primary arising in a common predisposing milieu, rather than a primary-dependent contralateral lesion. In this light, the clinical management of patients with a bilateral breast cancer should be similar to that of a unilateral breast cancer.

Gene expression of DNA topoisomerases I, II alpha and II beta and response to cisplatin-based chemotherapy in advanced ovarian carcinoma

DNA topoisomerases, nuclear enzymes that regulate DNA topology, are recognized as the primary targets of effective anti-tumor drugs. These enzymes may also have a role in the repair of DNA damage induced by alkylating agents and platinum compounds; therefore, their expression may be a determinant of tumor response to chemotherapy. Our study was undertaken in an attempt to establish a correlation between the enzyme expression and response of ovarian cancer to cisplatin-based chemotherapy. The expression of topoisomerase I, II alpha and II beta genes was assessed by RNase protection assay in tumor specimens obtained from 37 untreated patients with advanced epithelial ovarian cancer at initial surgery and from 13 pre-treated patients at subsequent laparotomy. The expression levels were compared with those found in 5 specimens from benign ovarian tissue and 5 specimens from normal ovarian tissue. The expression levels in untreated patients were used to establish a correlation with response to high-dose cisplatin therapy. A significant intertumor variability of mRNA expression was noted for all the genes examined. However, a comparison of median values indicated a remarkable increase of expression in malignant tumors over benign or normal tissues only for topoisomerase II alpha. This change is not related to alterations or amplification of topoisomerase II alpha gene. Interestingly, a correlation was found between tumor response to chemotherapy and the expression level of the isoform alpha (but not of topoisomerase II beta and topoisomerase I). The observed correlation suggests a contribution of the enzyme in determining tumor sensitivity. Alternatively, increased expression levels of the alpha isoenzyme gene in responsive tumors might reflect higher fractions of proliferating tumor cells that may be more drug-sensitive than resting cells.

Receptor status variation in primary breast cancer and subsequent accessible relapse

To better understand the prognostic relevance of change in steroid receptor status, during the clinical course of breast cancer, we analysed the variation of estrogen and progesterone receptor (ER, PgR) status in a series of 532 primary tumors and metachronous accessible recurrences in individual patients. A more consistent variation was observed in patients with a receptor-positive primary (ER(+) or PgR(+)) than in those with a receptor-negative tumor (ER(-) or PgR(-)). Forty-four percent of PgR(+) and 24% of ER(+) tumors became negative, whereas only 20% of ER(-) or PgR(-) became positive. The changes were independent of tumor stage and menopausal status. However, steroid receptor variation appeared to be related to the interval between the primary tumor and relapse. In fact, the changes from ER(+) to ER(-) were more frequent in patients with a disease-free survival of less than 1 year, whereas changes from ER(-) to ER(+) occurred more often in patients with a disease-free survival of more than 3 years. Moreover, we observed a decrease in the number of ER(+) tumors following hormone treatment and a decrease in ER(-) tumors following chemotherapy. However, such variations did not reach statistical significance. Irrespective of the type of adjuvant therapy, the presence of at least one receptor (in particular, PgR) in the metachronous lesion was correlated with a long median time to relapse and to death. Our results confirmed the predictive relevance of receptor status of the primary lesion on relapse and survival and suggest the predictive relevance of receptor status of the metachronous lesion on post-relapse survival.

A comparative study of p53 gene mutations, protein accumulation, and response to cisplatin-based chemotherapy in advanced ovarian carcinoma

The p53 protein is a multifunctional transcriptional regulator involved in cellular response to DNA damage and has been implicated as a putative determinant of sensitivity of tumor cells to cytotoxic agents. Since the p53 gene becomes inactivated in over one-half of advanced ovarian carcinoma, in this study we have examined the relationships between p53 gene alterations, p53 immunoreactivity, and response to cisplatin-based chemotherapy in ovarian cancer patients. All patients had advanced (FIGO stage III or IV) ovarian carcinoma and, with one exception, were untreated at the time of collection of tumor specimens. After initial debulking surgery, patients received high-dose cisplatin therapy. Tumor samples were analyzed for p53 gene mutations and for p53 protein accumulation, and the findings were correlated with tumor responsiveness. Of the 33 tumors examined, p53 gene mutations were found in 20 cases, including 15 missense mutations, 2 deletions, 2 nonsense mutations, and a base substitution at splice site. Twenty tumors showed positive immunostaining for p53. Only missense mutations were associated with positive immunostaining. In addition, p53 overexpression was detected in five tumors in the absence of mutations. Most (12 of 14) of the missense mutations associated with p53 protein stabilization were found refractory to therapy, as well as tumors overexpressing wild-type p53 (4 of 5). A significant correlation has been found between p53 accumulation, type of mutation (i.e., missense mutations), and pathological response to cisplatin-based therapy. In conclusion, the present results are consistent with a role of p53 as a determinant of chemosensitivity of ovarian carcinoma.

An I.T.M.O. group study on second-line treatment in advanced epithelial ovarian cancer: an attempt to identify clinical and biological factors determining prognosis

The aim of the present study was to determine the activity of a combined regimen of mitoxantrone (DHAD) and ifosfamide (IFO) and identify clinical and biological factors with prognostic importance for the second-line treatment of ovarian cancer. The following factors were investigated for their prognostic importance: age, disease sites, platinum responsiveness, histological grade, the presence of clinically/radiologically detectable versus not detectable disease, residual disease volume after first surgery, p53 protein, c-erbB-2 oncoprotein and laminin receptor. 72 patients entered the trial. DHAD and IFO therapy led to a 15% response rate among the 47 cases with clinically/radiologically detectable disease (1 complete and 6 partial responses), with a median response duration of 4 months. The response rate was significantly different according to platinum responsiveness (4% objective responses in platinum-resistant versus 27% in platinum-sensitive disease). The time to treatment failure (TTF) and overall survival (OS) were affected by the presence of clinically detectable disease at study entry (median TTF 4 months in the presence of clinically/radiologically detectable disease versus 9 months if the disease was not similarly detectable, P = 0.02; median OS 10 months versus 21 months, P = 0.01). Initially overexpressed in only a few tumours, the c-erbB-2 oncoprotein became overexpressed in 36% of platinum-resistant tumours; this modulation did not occur in platinum-sensitive tumours. Furthermore, laminin receptor was expressed in 77% of platinum-sensitive versus 39% of platinum-resistant patients. There were no differences in p53 protein expression according to drug responsiveness.

Control of Nausea and Vomiting by Granisetron in Ovarian Cancer Patients Treated with Different Cisplatin-Based Regimens

Aims

The study evaluated the safety and efficacy of granisetron as an antiemetic drug in ovarian cancer patients treated with cisplatin-based chemotherapy.

Study design

Two groups of consecutive patients were considered: the first (Group A) with advanced disease, receiving 4-day cisplatin therapy in a 40 mg/m2 daily dose; the second (B), with minimal disease after radical surgery at high risk of recurrence, treated by single-day chemotherapy with a 90 mg/m2 dose. In both groups, 3.0 mg of granisetron was administered as a 10 min. intravenous infusion, 30 min. before cisplatin infusion. The treatment schedule included in all patients the administration of 125 mg i.v. of methylprednisolone 2 h before chemotherapeutic infusion. No further doses of granisetron were allowed within each 24 h study period for breakthrough nausea and vomiting. Assessment for nausea and vomiting was made at 24 h intervals through the 6-day study period for both groups using a diary card.

Results and conclusion

In group A, 25 patients were collected and evaluated; in group B, 25 were recruited and 13 evaluated. In both groups, excellent control of nausea and vomiting was achieved, since in group A we had a global major antiemetic efficacy of granisetron in 69.2% of patients (54.4% complete control and 14.8% major control); in group B, global major efficacy was present in 83.3% of cases (31.6% complete control and 51.7% major control). The antiemetic effect in the days following antiblastic treatment lasted longer in group A.

The intramuscular administration of granulocyte colony-stimulating factor as an adjunct to chemotherapy in pretreated ovarian cancer patients: an Italian Trials in Medical Oncology (ITMO) Group pilot study

No published data are available concerning the activity and tolerability of intramuscularly administered granulocyte colony-stimulating factor (G-CSF) in humans. To fill this gap, 19 patients with advanced ovarian cancer previously treated with at least one first-line chemotherapy cycle received the following myelosuppressive regimen: mitoxantrone (DHAD) 12 mg m-2 i.v. on day 1; ifosfamide (IFO) 4 g m-2 i.v. on days 1 and 2; mesna 800 mg m-2 i.v. t.i.d. on days 1 and 2. G-CSF (Filgrastim) was given at a dose of 5 micrograms/kg/day i.m. from day 6 to day 19, its pharmacokinetics being assessed in five patients. The neutrophil nadir was observed after a mean period of 8 days, and the neutrophil count was < 1.0 x 10(3) mm-3 for a mean of 6 days during the cycle of chemotherapy. The neutrophil count fell after the withdrawal of G-CSF on the 19th day of treatment. The difference in absolute neutrophil count between day 19 and day 21 was statistically significant (P = 0.0001); nevertheless, at day 21 no WHO grade 3-4 neutropenia was reported. DHAD and IFO were respectively given at 95% and 93% of the planned dose. The pharmacokinetics of G-CSF i.m. seems to be similar to that of the drug given subcutaneously. No evidence of cumulative myelosuppression was observed. G-CSF was well tolerated and no complications were observed at the injection sites. In conclusion, if the results obtained in this pilot study regarding the activity of i.m. G-CSF are confirmed by a randomised trial, the intramuscular administration of G-CSF could become a valid alternative for patients who dislike the subcutaneous route and who are being treated with chemotherapy that does not induce profound thrombocytopenia.

Goserelin in premenopausal advanced breast cancer: clinical and endocrine evaluation of responsive patients

Medical ovariectomy with goserelin is an alternative to surgical oophorectomy. To evaluate the relationship between tumor regression and endocrine changes induced by therapy, 40 premenopausal patients with advanced breast cancer were given 3.6 mg of goserelin subcutaneously fortnightly for the first 4 doses and every 28 days thereafter. We have made a particular analysis of the clinical and endocrine profile of responsive patients. Objective responses were observed in 17 of the 38 evaluable patients (45%), 6 cases achieving complete remission. Serum estradiol was suppressed in castrated women, although there was a tendency towards an increase in serum follicle-stimulating hormone over time. No statistically significant difference was observed in the hormonal profiles of patients experiencing a complete or partial response. Our experience confirms that goserelin is as effective as oophorectomy and that there is a clear correspondence between clinical response and drug-induced estrogen suppression.

In vitro cytotoxic activity of Taxol and Taxotere on primary cultures and established cell lines of human ovarian cancer

The activity of Taxol and Taxotere was evaluated on three established cell lines and 19 primary cultures of human ovarian cancers and compared with that of cisplatin and doxorubicin. The cytotoxic activity of the different drugs was assessed with a clonogenic assay in cell lines and with a proliferative assay (based on [3H]thymidine [3H-dT] incorporation of cells grown in double-layer agarose for four days) in primary tumor cultures. The two assays run in parallel on the OVCA432 cell line provided similar ranking of activity for all the drugs. Taxotere was more cytotoxic than Taxol in two cell lines and showed the same degree of activity in one cell line. Moreover, the two drugs were more cytotoxic than cisplatin and doxorubicin in all cell lines. In primary cultures both Taxol and Taxotere were less active than cisplatin and doxorubicin. An activity by at least one of these two compounds was seen in 9 of 19 cases. Taxol was more frequently active than Taxotere and generally more potent. A direct relationship was observed between the proliferative activity of the tumor cell population and response to Taxol and/or Taxotere. In fact, cell lines that were highly sensitive to Taxol and Taxotere displayed 3H-dT labeling index (LI) values much higher than those observed in primary cultures (39% to 45% versus 0.2% to 12.6%). Again, primary cultures sensitive to Taxol and/or Taxotere were characterized by a median 3H-dT LI value about three times higher than that observed in resistant cultures (8.0% versus 2.6%).

Urinary testosterone as a marker of risk of recurrence in operable breast cancer

We investigated the role of urinary testosterone levels as a marker of risk of recurrent disease in 113 operable breast cancer patients (70 premenopausal, 43 postmenopausal). Twenty-four-hour urine collections for testosterone measurement were obtained before surgical treatment, between 20-40 days thereafter, and then every 6 months for 5 years. The cutoff values to separate 'high testosterone (A+)' from 'normal testosterone (A-)' were 8.0 micrograms/24 h in premenopause and 4.9 micrograms/24 h in postmenopause. Urinary testosterone levels were considered high when they exceeded the cutoff value in at least 2 of the first 3 measurements (pretreatment, post-treatment, 6 months) of each patient. According to the aforementioned criterion, 33 patients (29.2%) had high testosterone levels, which were associated to axillary node involvement in 16 patients. Thirteen of the latter relapsed during the 5-year follow-up period (5/7 in premenopause, 8/9 in postmenopause). Relapse-free survival (RFS) curves were drawn only for node-positive patients owning to the small number of recurrences observed in the node-negative group. In premenopausal node-positive patients, RFS was significantly different for patients presenting high and normal urinary testosterone levels (77% vs 28%, respectively; logrank test, p < 0.006). In postmenopausal node-positive patients, RFS was also different between the two groups (54% vs 11% in 'high' and 'normal' excretors, respectively) but the difference was not statistically significant. The present findings suggest that urinary testosterone is a prognostic indicator of early breast cancer recurrence in node-positive patients.

High-dose cisplatin and cyclophosphamide with glutathione in the treatment of advanced ovarian cancer

BACKGROUND

On the basis of preliminary results achieved with a high-dose cisplatin regimen including glutathione as chemoprotector, the efficacy and toxicity of the new regimen was further evaluated in a larger series of patients with advanced ovarian cancer (stage III and IV).

PATIENTS AND METHODS

The study included patients with bulky or extensive residual disease after primary laparotomy or with bulky inoperable tumor masses. A total of 79 patients were treated with up to five courses of high-dose cisplatin (40 mg/m2 daily in normal saline, for four days) plus glutathione (2500 mg as a short-term infusion before cisplatin), together with cyclophosphamide (600 mg/m2 as an i.v. bolus on day 4). A standard i.v. hydration consisting of a total of 2000 ml of fluids without diuretics was employed.

RESULTS

All eligible patients, who received a total of 345 courses, were assessed for response and toxicity and 52 received the planned five courses of the protocol. Forty-five patients (57%) achieved complete clinical responses and 20 (25%) had partial remissions for an overall response rate of 82%. The response rate was critically dependent on tumor size before chemotherapy. Thirty-eight of 45 patients who had complete clinical responses underwent second-look laparotomy, and 29 had pathological complete responses (37%). Seventeen of these 29 patients subsequently relapsed (median disease-free interval, 12 months; range, 6-45). With a median follow-up time of 44 months, the median survival for the 79 analyzed cases was 40 months. The toxicity of the regimen was moderate. Nausea/vomiting was the most severe acute toxicity. Myelotoxicity was acceptable, with severe leukopenia and thrombocytopenia (grade 4) occurring in 8% and 3% of patients, respectively. Nephrotoxicity was minimal with a transient increase (to < 2 mg/dL) in serum creatinine in only 6 patients (8%). Peripheral neurotoxicity and ototoxicity were the most significant long-term toxicities. The severity of these side effects (grade 3 WHO neurotoxicity occurred in only 4% of patients) was apparently less than has been reported with other high-dose cisplatin regimens. Neurotoxicity required discontinuation of therapy in three patients after four courses. Most affected patients had complete or partial recovery of symptoms with time.

DISCUSSION

The efficacy and tolerability of the regimen confirm the feasibility of this new approach including glutathione in order to increase cisplatin dose intensity. The superiority of this regimen over standard induction therapy should be confirmed in randomized trials.

Adjuvant hormone treatment and chemotherapy in postmenopausal women with operable breast cancer: a retrospective analysis

Two hundred consecutive postmenopausal women with operable breast cancer and metastatic axillary nodes were treated during the period January - December 1981 with adjuvant chemotherapy (CMF) or hormonal treatment (tamoxifen). The distribution of receptor status (estrogen or progesterone), number of axillary metastatic nodes (less than = 3 or greater than 3), surgical treatment and size of the primary tumor were homogeneous in both groups. Receptor status and number of axillary lymph nodes were correlated with adjuvant treatment efficacy. Ten-year disease-free survival (DFS) was higher in the TAM-treated (72%) than in the CMF-treated group (52%) (p less than 0.01). In patients with less than = 3 axillary metastatic nodes, those treated with TAM had a higher DFS rate than those treated with CMF (75% vs 59%, p less than 0.01). There was no difference in DFS between CMF-and TAM-treated groups within the greater than 3 metastatic lymph node patients. In ER + primary tumors, DFS was higher in the subset treated with TAM (62%) than with CMF (51%) (p less than 0.05), whereas no difference in DFS was observed in ER- patients between the two treatment groups. Considering the TAM group, DFS was better (p less than 0.01) for ER+ cases than for ER- cases only at 5 years of observation. In the CMF group, DFS was not influenced by ER status. PgR content did not affect DFS in either adjuvant treatment group.

A feasibility study of cisplatin administration with low-volume hydration and glutathione protection in the treatment of ovarian carcinoma

Glutathione (GSH) is a sulfur-containing nucleophile that protects against cisplatin-induced renal toxicity without reducing the antitumor activity of the cytotoxic agent. To document further the clinical role of GSH in improving the outcome of cisplatin-containing regimens, the feasibility of the GSH/cisplatin combination using a low-volume hydration protocol was evaluated in untreated ovarian cancer patients. Twelve patients at stage III (minimal residual disease) and 23 with localized disease at high risk for recurrence were treated with cisplatin (90 mg/m2, i.v. in 250 ml of normal saline over 30 min) and cyclophosphamide (600 mg/m2 i.v.) every 3 weeks. GSH (5 g in 200 ml of normal saline) was administered by a short-term infusion (15 min) prior to cisplatin. The hydration protocol consisted of 1 liter of fluids without diuretics. The treatment was well tolerated; no nephrotoxic or neurotoxic manifestations were observed. The renal excretion of cisplatin (23%) at 24 hours following infusion was lower than expected using a standard i.v. hydration protocol. No reduction of renal elimination of cisplatin could be detected in subsequent courses, thus suggesting a minimal degree of impairment in renal function. In the series of evaluable patients (11) with stage III disease, 9 had complete pathological response. In the series of patients with no clinically detectable disease initially, all were disease-free at treatment completion. Taken together with previous observations, these results support the view that the use of GSH is a successful approach in the attempt to optimize cisplatin treatment, providing a new modality of drug administration for out-patient treatment.

Efficacy and safety of high-dose cisplatin and cyclophosphamide with glutathione protection in the treatment of bulky advanced epithelial ovarian cancer

Recent efforts to improve the response rates in advanced ovarian cancer with the use of high-dose cisplatin have been limited by unacceptable toxicity. Based on experimental and clinical studies indicating that reduced glutathione (GSH) is a protective agent against cisplatin-induced toxicity, a new high-dose regimen including GSH as a chemoprotector was designed in an attempt to improve the efficacy and therapeutic index of cisplatin. A total of 40 consecutive patients with stage III (bulky) and IV ovarian carcinoma were treated with cisplatin (40 mg/m2 daily for 4 consecutive days) and cyclophosphamide (600 mg/m2 i.v. on day 4). The treatment was repeated every 3-4 weeks for five courses unless progression or severe toxicity occurred. Before each cisplatin administration, patients received GSH (1,500 mg/m2) i.v. over 15 min, with a standard i.v. hydration (2,000 ml fluid) without diuretics. Debulking surgery was initially attempted in 18 patients and, after 2-3 courses, in 16 patients; it could not be carried out in 6 patients. Three patients were not evaluable for response because they prematurely discontinued their treatment. In all, 23 patients (62%) achieved complete clinical remission (negative second-look laparotomy in 16), with an overall (complete + partial) response rate of 86%; 2 patients achieved disease-free status following second surgery. Nausea/vomiting was the most severe acute toxic effect; myelosuppression was acceptable. Renal impairment was effectively prevented by GSH. Neurotoxicity that was not associated with motor dysfunction was the most significant cumulative toxicity in patients (24/32) receiving 4-5 courses. The results of this study indicate that the use of GSH is a safe new method for high-dose cisplatin administration. This regimen is well-tolerated and very effective in ovarian cancer patients with bulky disease and warrants further evaluation.

Long-term relapses in breast cancer patients

The authors examined 100 cases of long-term relapses of breast cancer arising more than 5 years after radical mastectomy and 100 cases of early relapses (within 3 years). Precautional radiotherapy or chemotherapy had not been performed during these intervals. Histologic type did not appear important. Long-term relapses were relatively less frequent than early relapses at the level of the locoregional lymph nodes (P less than 0.01). Other investigations were directed to the eventual importance of hormones on the incidence of long-term relapses. Since many of the cases were not recent and therefore no data were available as regards hormone receptors, it was impossible to base the study on the latter. The incidence of long-term relapses was considerably lower in postmenopausal than in premenopausal patients and lower than the incidence observed for early relapses (P less than 0.04). This finding could be attributed to a hormonal effect. Therapeutic oophorectomy determines relatively better results in cases with long-term relapses, but their survival does not appear to be significantly better than that of cases with early relapses. Among the patients with long-term relapses, the N - cases at the time of mastectomy were relatively more numerous than observed among cases with early relapses (P less than 0.04). This finding, which also explains the relatively minor frequency of long-term relapses in locoregional lymph nodes, reduces the prognostic importance of the histologic status of axillary lymph nodes, as is well known for patients with hormonal receptors.

Clinical response and survival according to estrogen receptor levels after bilateral ovariectomy in advanced breast cancer

Estrogen receptor levels were determined at the time of ovariectomy in 71 premenopausal women with advanced breast cancer. Three groups of estrogen receptor concentration were established: less than 10 fmol/mg cytosol protein (group 1), between 10 and 25 fmol/mg cytosol protein (group 2), and more than 25 fmol/mg cytosol protein (group 3). The frequency of clinical response to ovariectomy was low in group 1 (17.4%), high in group 3 (79.4%), and intermediate in group 2 (35.7%). Median survival was poor in group 1 (18.5 months) and better in groups 2 (33.0 months) and 3 (32.5 months). These results were independent of disease stage and neoplastic localization.

Complete remission after ovariectomy for advanced breast cancer correlated with estrogen receptor status and urinary androgen excretion

Our previous work showed urinary androgen excretion (A) as well as estrogen receptor (ER) to predict clinical response and survival after ovariectomy for advanced breast cancer. We here compare the complete responders with the partial responders to ovariectomy. The likelihood of CR (55% of responders) rather than PR was not strongly dependent on the location of metastases or on the ER/A status (though as noted previously there were no responses at all in the ER-/A- group), but CR did appear to increase survival.

Urinary androgens and tumor estrogen receptor as predictors of ovariectomy response and of survival in advanced breast cancer

Estrogen receptor (ER) status and urinary androgen (A) concentration were simultaneously determined in 50 premenopausal patients submitted to bilateral ovariectomy for advanced carcinoma of the breast. When both the hormonal parameters were positive (ER+ A+), the response to castration was favorable in 87.5% of the cases, with a survival rate of 39% at 5 years. No patient responded to the therapy when both the parameters were negative (ER- A-); none of them was alive at 5 years. An intermediate response (more than 50%) and survival rate at 5 years (more than 20%) was obtained in the group of patients with at least one of the two parameters positive (ER+ A-, or ER- A+). These responses were independent of the topography of neoplastic localizations and the length of the disease-free interval.

Correlation between estrogen receptor levels and clinical response to ovariectomy in premenopausal women with advanced breast cancer

From 1974 to 1980, according to a controlled clinical trial, 66 premenopausal women with advanced breast cancer underwent bilateral ovariectomy (BO). Of the hormonal parameters evaluated, the present study deals with estrogen receptors (ER). The relation between the presence or the absence of ER and clinical response was evaluated, without considering their concentration in neoplastic tissue. The response was evaluated in relation to threshold values of 5 fmol/mg protein (considered at the time of the study the cut-off value of negativity and positivity) and 10 fmol/mg protein (recently found to be a more accurate cut-off value). The results of BO in relation to different receptor status showed an analogous response. Furthermore, the higher the receptor concentration, the better the response to BO, especially when the concentration was higher than 25 fmol/mg protein.

Prognostic Evaluation of Estrogen Receptors and Urinary Androgens in Ovariectomy for Advanced Breast Cancer

Eighty patients with advanced breast cancer were characterized by estrogen receptor (ER) status and by urine androgen (A) metabolites. After ovariectomy, patients with positive hormonal parameters were treated with hormonal therapy and patients with negative parameters were treated with chemotherapy. The results of the follow-up confirm that the survival is higher in patients with positive hormonal parameters (ER +, A+). In this group, the patients with increased urine androgen excretion (i.e. A+) apparently had a better long-term survival than ER + cases.

Long-Term Response to Ovariectomy in 35 Premenopausal Patients with Advanced Breast Cancer, Treated in Coherence with Hormonal Tests

Thirty-five premenopausal patients with metastasized or locally advanced breast cancer underwent ovariectomy. At relapse, after surgery, they were treated with hormone therapy or chemotherapy, according to hormonal tests carried out before the castration. Five-year survival, computed with the actuarial method, confirmed the better prognosis of the hormone-dependent patients and also an improved prognosis in the patients treated with hormone therapy after ovariectomy. Furthermore, chemotherapy proved more efficacious: an increased survival was observed in the non-hormone-dependent patients.

[Effect of ovariectomy on bone metastases of breast cancer: analysis of radiographic pictures]

The radiograms of the skeleton of 41 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance and progression of osteolytic lesions, corresponded to a clinical progression of the disease. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy.

Oophorectomy in Advanced Breast Cancer: Clinical Radiologic Correlations

The radiograms of the chest and skeleton of 49 patients with advanced breast cancer treated with bilateral ovariectomy were reviewed. The modifications in the secondary localizations and/or their appearance after castration were compared with the findings of the clinical examination. Appearance or progression of intrathoracic lesions, like the appearance or progression of osteolytic lesions, corresponded to a progression of the disease in other sites. Osteoblastic evolution of osteolytic lesions and the appearance of osteoblastic lesions in bones undamaged before ovariectomy were signs of a favorable response to therapy. The response of chest and bone metastases is usually rather early, and the first radiographic survey should be performed about 3 months after ovariectomy.