Phase I and II trials of subcutaneously administered rIL-2, interferon alfa-2a, and fluorouracil in patients with metastatic renal carcinoma

Purpose: A phase I followed by a phase II trial utilizing rIL-2, IFNα, and 5-FU were conducted in patients with unresectable and/or metastatic renal cell carcinoma. Methods: Treatment consisted of: rIL-2 at 5.0 × 10⁶ IU/m² SQ on days 1–5 for 4 weeks, rHuIFNα-2a at 5.0 × 10⁶ U/m² SQ on days 1, 3, and 5 for 4 weeks, and 5-FU by IV bolus on days 1–5 during week 1. In the phase I study, patients were treated at varying doses of 5-FU: I-none, II-250 mg/m², III-300, and IV 375. A phase II trial was then conducted utilizing the same schedule and maximum tolerated dose (MTD) for 5-FU. Results: Twenty patients were entered into the phase I trial. Dose-limiting toxicity included grade III nausea and vomiting, and one sudden cardiac death. The MTD for 5-FU was determined to be 300 mg/m². In the phase II trial, a median of two cycles of therapy was administered to 25 evaluable patients. Toxicity was moderate and consisted primarily of fevers, chills, fatigue, nausea/vomiting, and anorexia. Grade IV thrombocytopenia, consistent with ITP, developed in one patient each on the phase I and phase II trial. Seven partial responses were seen among 25 patients treated in the phase II trial for a 28% (CI 12–49%) response rate. Conclusions: The addition of 5-FU to rIL-2 and rHuIFNα-2a appears to increase the toxicity of this therapy. Randomized trials will be required to determine if efficacy is enhanced. Received: 1 May 2000 / Accepted: 21 September 2000     

Antitumoral activity of oxaliplatin/cisplatin-based combination therapy in cisplatin-refractory germ cell cancer patients

Purpose: Only 20–30% of patient with advanced germ cell tumors, relapsing after standard first-line therapy, are curable with current second-line cisplatin-based regimens. New salvage combinations incorporating new active agents are needed. We report the toxicity/tolerance of a new salvage regimen based on the oxaliplatin (Eloxatin)/cisplatin combination, evaluated in patients with recurrent, mostly cisplatin-refractory germ cell tumors. Patients and methods: Thirteen patients were enrolled in this study. All except one had received cisplatin-based chemotherapy. Eight had progressive disease as the best response on their last platinum-based chemotherapy, and three had potentially sensitive tumors. The median interval since the last platinum-based chemotherapy was 6 months (range: 1–36 months). One untreated patient with poor prognosis was also enrolled. Twelve patients had pathological markers [median α-fetoprotein 14 800 ng/ml (58–10⁶), median human chorionic gonadotrophin β subunit 7000 IU/ml (37–723 700)]. Patients received either oxaliplatin (130 mg/m²) and cisplatin (100 mg/m²) every 3–4 weeks (Bi regimen, four patients), or the same regimen combined with one to four of the following cytotoxic agents: ifosfamide, epirubicin, vinorelbine, methotrexate, dactinomycin, etoposide and bleomycin (BiC regimen, 9 patients). Treatment was individualized according to each individual patient's pretreatment and clinical characteristics. Results: Seven objective responses were obtained (overall response rate = 54%), all with the BiC regimens (two complete and five partial responses). Two patients with recurrent disease achieved a long-term complete response lasting over 5 years. Four partial responders were seen in the eight cisplatin-refractory tumors, lasting 4–8 months. All objective responses had a corroborating major decrease in tumor marker blood levels (median decrease: 99.7%). The median survival for the whole group was 8 months. The commonest severe toxicity was hematological (grade 4 neutropenia in 78% and thrombopenia in 74% of the BiC cycles). Conclusion: Our combined salvage regimen induced significant antitumoral activity in recurrent, cisplatin-refractory germ cell tumors. Oxaliplatin merits further evaluation as a component of combination therapy for this disease. Received: 12 February 1999 / Accepted: 28 June 1999     

Tandem and triple high-dose chemotherapy with autologous stem cell rescue in metastatic breast cancer

The purpose of this phase II study was to evaluate the therapeutic efficacy and toxicity of a tandem or triple high-dose chemotherapy (HDC) with autologous peripheral blood stem cell transplantation (PBSCT) in patients with metastatic breast cancer (MBC) as first line chemotherapy. Conventional chemotherapy consisted of two cycles of epirubicin 120 mg/m² and ifosfamide 7500 mg/m² in the case of tandem HDC and one cycle of paclitaxel 135 mg/m², epirubicin 90 mg/m² and ifosfamide 6000 mg/m² in the case of triple HDC. Tandem HDC was composed of two cycles of epirubicin 180 mg/m², ifosfamide 12000 mg/m² and carboplatin 900 mg/m². In the case of triple HDC, paclitaxel 180 mg/m², etoposide 1500 mg/m² and thiotepa 600 mg/m² was added as the third cycle. Patients with tandem HDC (n = 20) were evaluable for both survival and toxicity, and patients with triple HDC (n = 21) only for toxicity because of short-term follow-up. Both tandem and triple HDC were well tolerated and could be safely administered. Non-hematological WHO grade 3 or 4 toxicities were mucositis (8), temporary renal insufficiency (1), myocardial infarction (1), and neuropathy (1). No toxic death occurred. The Kaplan-Meier estimates for 44-months without progression and the overall survival were 12% and 38% respectively. The median survival was 22 months (95% CI: 7.4–51.7 months) and the median progression-free interval 14 months (95% CI: 5.1–43.7 months). In a population with an unfavorable prognosis, tandem HDC showed similar efficacy as to that described in other phase II studies. Triple HDC seems not to improve patient outcome compared to tandem HDC, but a long-term follow up is required. Received: 20 April 1998 / Accepted: 6 August 1998     

Pegylated doxorubicin for primary cutaneous T-cell lymphoma: a report on ten patients with follow-up

Purpose: Pegylated liposomal doxorubicin (PEG-DOXO) was found to be effective in primary cutaneous T-cell lymphomas (CTCL). The present observation reports on follow-up and relapse-free interval in patients with CTCL. Methods: Ten patients (one female, nine male) aged 50–78 years (mean 66.7 years) with relapsing or recalcitrant CTCL, stage I b (n=3), II a (2), II b (3), IV a (1), and IV b (1) were treated with PEG-DOXO 20 mg m⁻² once a month with an upper limit of 400 mg or eight infusions to induce a clinical response. There was one drop out after a single infusion because of a capillary leak syndrome. Results: In nine patients with PEG-DOXO the best response was a complete response (CR) in five patients and a partial response (PR) in four patients. The final outcome was CR in six, PR in two, stable disease (SD) in one, and progressive disease (PD) in another patient. The overall response rate (CR + PR) was 80% (of ten patients). The follow-up was 2–22 months (mean 12.8 ± 7.1 months). The overall survival was calculated as 19.8 ± 7.4 months with eight out of ten patients still alive. Response duration was 15.2 ± 3.9 months, disease-free survival 13.3 ± 6.1 months, event-free survival 16.7 ± 9.0 months, and progression-free survival 18.2 ± 6.5 months. Four patients (stage I b and II b) achieved 12–19 months of disease-free survival. The follow-up after the first course with PEG- DOXO was 2–22 months (mean 12.8 ± 7.1 months). The survival rate after 12 months of follow-up was 80% (n=5). One patient free of relapse died after 12 months because of pulmonary embolism not related to disease or treatment. Another patient died 1 month after a second course of PEG-DOXO in an advanced tumor stage of CTCL. The most frequent side effects of treatment were anemia and lymphopenia without the need of supportive treatment or dose-reduction. Only one patient developed toxicity of grade 4 (anemia). Conclusions: These results indicate that patients with relapsing or recalcitrant CTCL can achieve an 80% response rate with PEG-DOXO and long-term remissions. Received: 26 April 2000 / Accepted: 9 June 2000     

Repeated administration of short infusions of bendamustine: a phase I study in patients with advanced progressive solid tumours

Purpose: The cytotoxic agent bendamustine combines a purine-like benzimidazol and bifunctionally alkylating nitrogen mustard group. The drug has clinical antitumour activity in lymphoma, myeloma and breast cancer. In earlier dose-finding studies, the clinically tolerated dose for single-bolus bendamustine was 215 mg/m²; for fractionated therapy on 4 consecutive days it was 85 mg/m². Anticholinergic symptoms, myelosuppression and cardiac dysrhythmia were dose-limiting. Our trial was designed to define the maximum tolerated dose of a short infusion schedule and to establish a recommended dose for ongoing and future clinical studies. Methods: Patients with refractory malignant tumours qualified for the trial after written informed consent had been obtained. Bendamustine was given as a 30-min iv. infusion on days 1 and 8 of a 4 week cycle, with a starting dose of 100 mg/m² and an increment per group of 20 mg/m². Results: Nineteen patients (13 male, 6 female; median age 57 years, range 37–74 years) were treated for one to two cycles with up to 180 mg/m² bendamustine. At 160 mg/m², fatigue grade 3 (NCI Common Toxicity Criteria) and dryness of the mouth grade 3 occurred in 2 patients, diarrhoea grade 3 in 1 patient; another patient with a history of myocardial infarction and arrhythmia developed a reversible total atrioventricular block after the first administration of 160 mg/m² bendamustine. Other events, such as nausea/vomiting, loss of appetite, fever or chills, were not dose-limiting. Haematological toxicity was mild, except for sudden and long-lasting grade 3–4 lymphocytopenia, which occurred in all treatment cycles. Opportunistic infections were not observed. Conclusions: The maximum tolerated dose of a days-1 and -8 schedule of bendamustine, given as a 30-min i.v. infusion, is 160 mg/m²; mouth dryness and fatigue are dose-limiting. The recommended dose for future trials is 140 mg/m². Received: 11 May 1999 / Accepted: 18 July 1999     

A phase II trial of dose-intensive interleukin-2 in metastatic renal cell carcinoma

Purpose: High-dose bolus interleukin-2 (IL-2) is currently the sole agent approved by the Food and Drug Administration for the treatment of advanced renal cell carcinoma. This phase II study was designed to evaluate the clinical activity and toxicity spectrum of a regime consisting of dose-intensive IL-2 in both previously treated and untreated patients with advanced renal cell carcinoma. Patients and methods: Twenty eligible, sequential patients received IL-2 at a dose of 24 mIU m⁻²dose⁻¹ (1.33 mg m⁻²dose⁻¹) every 8 h on days 1–5 and 15–19, for a maximum of 28 boluses. Patients achieving stable disease or a response were treated every 10 weeks for a maximum of five cycles/year. Results: Out of 20 study participants 8 patients (40%; 95% confidence interval, 18.5%–61.4%) demonstrated a response. Three of these responses were complete (CR; 15%) while 5 were partial (PR; 25%) and about 75% of the responses occurred in patients with extensive tumor burdens. All 3 CR continue to respond after 28+ to 30+ months. With a median follow-up time of 26 months, the median overall survival duration for all patients is 18.0 months (95% confidence interval 12–24 months). Response was observed to correlate significantly with the IL-2 dose intensity. A dose intensity below 1440 mIU m⁻² year⁻¹ and at least 1440 mIU m⁻²year⁻¹ correlated highly with failure to achieve CR and the successful achieving of CR respectively (P < 0.01). An analysis of the present study database in the context of five previous similar trials demonstrated a significant correlation between IL-2 dose intensity and response rate by regression analysis (r ² = 0.89; P < 0.019). Finally, all toxicities were reversible once the dosing had concluded. Conclusions: IL-2 dose intensity appears to represent a significant determinant of successful clinical outcomes. This dose-intensive approach led to a high proportion of durable responses. Further evaluation of this regimen is warranted. Received: 25 September 1998 / Accepted: 13 November 1998     

Salvage chemotherapy with mitoxantrone, fludarabine, cytarabine, and cisplatin (MIFAP) in relapsing and refractory lymphoma

Purpose: The aim of the study was to evaluate the feasibility and efficacy of the combination of mitoxantrone, fludarabine, cytarabine, and cisplatin (MIFAP) in patients with prognostically unfavorable recurrent and refractory Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Methods: Forty-six patients (median age 43 years, range 18–63) with relapsed (n=15) or refractory (n=31) malignant lymphoma were enrolled (HD, n=13; low-grade/transformed NHL, n=4; high-grade NHL, n=29). A total of 39 patients (85%) showed multiply relapsed diseases with a duration of prior remission of <12 months (n=8) or had lymphoma being resistant to prior chemotherapy (n=31). The MIFAP therapy consisted of fludarabine (15 mg/m², q. 12 h, day 1–4), cytarabine (50 mg/m² by continuous infusion (CI) over 22 h, day 1–4), cisplatin (25 or 30 mg/m² by CI over 24 h, day 1–4), and mitoxantrone (4 mg/m², day 2–5). Results: Thirteen patients (28%) achieved complete remission (CR) and 15 patients (33%) partial remission (PR), for an overall response (OR) rate of 61%. Twenty-two patients responding to MIFAP (10 CR, 12 PR) have been consolidated by high-dose therapy (HDT) with hematopoietic stem cell transplantation (SCT). After a median follow-up of 12 months, 16 patients are in continuous CR (CCR) (n=14) or CCRu (unconfirmed) (n=2). The median duration of event-free survival (EFS) and overall survival (OS) were 6.5 and 19.3 months, respectively. Probabilities of EFS and OS after 3 years were 19% and 40%. Responders consolidated by subsequent HDT showed rates for 3-year EFS and OS of 40% and 66%, respectively. Unfavorable prognostic factors for EFS by univariate analysis were refractory lymphoma and the presence of B-symptoms. Significant prognostic factors for OS were NHL, refractory lymphoma, B-symptoms, and bone marrow involvement. The major toxicities were leukocytopenia and thrombocytopenia of the World Health Organization (WHO) grade IV in nearly all courses (median duration 10 and 11 days). In contrast, non-hematological side effects were moderate, predominantly of WHO grades I and II. Treatment-related mortality with MIFAP was 4% (two patients with septicemia by Aspergillus fumigatus). Conclusions: MIFAP is an effective salvage protocol for patients with poor-risk recurrent or refractory HD and NHL. The observed toxicity seems to be acceptable considering the unfavorable prognosis and intensive pretreatment. The results in patients responding to MIFAP and afterwards undergoing HDT with autologous stem cell support are even comparable to those published in patients with prognostically more favorable diseases. Received: 12 October 2000 / Accepted: 8 November 2000     

Correlation between granulocyte/macrophage-colony-forming units and CD34+ cells in apheresis products from patients treated with different chemotherapy regimens and granulocyte-colony-stimulating factor to mobilize peripheral blood progenitor cells

We examined the efficiency of disease-specific “standard” chemotherapies epirubicin, cyclophosphamide (EC); cyclophosphamide, vincristine, doxorubicin, etoposide, prednisolone (CHOEP); epirubicin, ifosfamide (EPI/IFOS) for peripheral blood progenitor cell (PBPC) mobilization in comparison to well-characterized mobilization protocols, i.e. etoposide, ifosfamide, cisplatin, epirubicin (VIPE) and dexamethasone, carmustine, etoposide, cytarabine, melphalan (DexaBEAM). Twenty-seven patients with various malignancies underwent 75 apheresis procedures for PBPC collection. Median cell yields from all 75 aphereses were 1.18 × 10⁵ mononuclear cells/kg [range (0.28–3.7) × 10⁸], 1.4 × 10⁵ granulocyte/macrophage-colony-forming units (CFU-GM)/kg [range (0.2–11) × 10⁵] and 3.3 × 10⁶ CD34⁺cells/kg [range (0.35–17.7) × 10⁶. CD34⁺/CD90⁺ cells could be mobilized by all mobilization regimens used. The difference observed in the mobilization of CD34⁺ cells was only of low significance when the mobilization regimens were compared, whereas the mobilizations of MNC and CFU-GM were significantly different between the groups. Breast cancer patients treated with the VIPE regimen (including pretreated women) had a significantly higher CFU-GM rate than patients treated with EC (P = 0.0005). Mobilized CD34⁺ PBPC were correlated with CFU-GM in all apheresis products. The linear correlation coefficients differed for the various mobilization groups: DexaBEAM (r=0.9, P < 0.0001), VIPE (r = 0.68, P = 0.0024), CHOEP (r = 0.52, P = 0.022), EPI/IFOS (r=0.34, P=0.11) and EC (r=0.23, P=0.2). We conclude that clonogenic assays can provide additional information about the autotransplant quality, particularly when alternative or new mobilization regimens are being investigated. Received: 7 January 1998 / Accepted: 24 February 1998     

Mechanisms of resistance to methotrexate in childhood acute lymphoblastic leukemia: circumvention of thymidylate synthase inhibition

Purpose: In about 25% of patients suffering from acute lymphoblastic leukemia (ALL) treatment failures occur that are most likely due to development of resistance to methotrexate (MTX). Blasts from patients with ALL were evaluated for MTX uptake, formation of long-chain MTX polyglutamates (MTX-Glu₅₊₆), cytotoxicity and thymidylate synthase inhibition by MTX and compared to blasts from patients with acute myelogenous leukemia (AML). Methods: Radioactively labeled MTX-Glu _n were analyzed by means of HPLC. Thymidylate synthase activity was measured by a tritium-release assay. Cytotoxicity was determined by trypan blue exclusion. Results: In most ALL blasts (n = 9) large amounts of MTX-Glu₅₊₆ (1.06–7.03 pmol/10⁷cells) and high cytotoxicity (43.5%–92.7%) were found, while in others small amounts of MTX-Glu₅₊₆ (0.0–0.39 pmol/10⁷cells) caused only weak cytotoxicity (6.0%–27.9%) (n = 5, 2 relapsed patients). Resistance to MTX in blasts from AML patients (n = 5) was also caused by reduced synthesis of MTX-Glu₅₊₆ (0.0–0.42 pmol/10⁷cells). In contrast, some ALL blasts (n = 7, 4 relapsed patients) were able to survive MTX treatment despite large amounts of MTX-Glu₅₊₆ (1.5–5.05 pmol/10⁷cells) and extensive thymidylate synthase inhibition. Conclusions: Since the majority of ALL patients were examined at first diagnosis, an inherent mechanism of resistance seems most likely. We propose a mechanism based on the switch of thymidylate synthesis to the salvage pathway. Received: 30 October 1998 / Accepted: 6 April 1999     

High-dose chemotherapy with peripheral blood stem cell transplantation for patients with advanced ovarian cancer

Purpose: We report the results of high-dose chemotherapy (HDC) with peripheral blood stem cell transplantation in twenty-one patients with primarily advanced or relapsed ovarian cancer. Methods: Twenty-five women underwent stem cell collection, and 21 were finally treated with different regimens of HDC containing cyclophosphamide, etoposide, carboplatin, and treosulfan. The patients received cyclophosphamide ± cisplatin and cisplatin + paclitaxel, respectively, followed by G-CSF (n=24) or GM-CSF (n=1) for stem cell mobilization. Results: A mean of 7.2 ± 6.1 × 10⁶ CD34+ cells per kg bw were collected. Thirteen patients received double transplants and one patient received a triple transplant. The median age was 47 years (range 24–61 years) and the mean number of prior regimens was three (range 1–8). Engraftment occurred on time in all patients and there was one treatment-related death resulting in an overall mortality rate of 4.8% among the 21 patients treated with HDC. The response rate was 72% (48% CR, 24% PR) and the mean time to progression and overall survival after HDC were 7 and 32 months, respectively. Conclusion: HDC could be performed safely in patients with advanced ovarian cancer. However, even with a high response rate, the duration of response is short, warranting new treatment approaches to further improve the outcome of this population of patients with unfavorable prognosis. Received: 19 July 2000 / Accepted: 25 August 2000     

Palliative cytoreduction in refractory acute leukemia: a retrospective study of 57 adult patients

 The efficiency and toxicity of treatment regimens for nonintensive cytoreduction in 57 outpatients with refractory acute leukemia (mean age 56 years, 51 AML, six ALL/AUL) were retrospectively studied. Seventeen patients received one treatment regimen, 19 patients two treatment regimens, and 21 patients three or more treatment regimens. The treatment regimens analyzed were 6-thioguanine p.o. (daily) (T), 6-thioguanine p.o. (4–7 days/week) + cytarabine s.c./i.v. (once a week) (T+C), 6-mercaptopurine p.o. (daily) (MP), 6-mercaptopurine p.o. (daily) + methotrexate p.o./i.v. (once a week) (MP+MTX), etoposide p.o. (daily) (E), and mitoxantrone i.v. (M). The median leukocyte count was higher for M (73×10⁹/l) than for the other treatment regimens (T: 27×10⁹/l, T+C: 37×10⁹/l, MP: 24×10⁹/l, MP+MTX: 30×10⁹/l, E: 31×10⁹/l). A cytoreduction >50% in the peripheral blood was achieved by T in 11/19, by T+C in 7/11, by MP in 5/8, by MP+MTX in 3/6, by E in 3/4, and by M in 16/22 patients. The period of cytoreduction was regarded as the duration of response – T: median 53 days, range 5–98; T+C: median 61 days, range 14–226; MP: median 37 days, range 4–192; MP+MTX: median 58 days, range 36–59; E: median 121 days, range 26–159; M: median 39 days, range 8–78. T and T+C were well tolerated by all but three patients (stomatitis, diarrhea, WHO grade 2). MP was accompanied by a rise of transaminases (WHO 1–3) in 5/6 patients. E led to stomatitis (WHO 1,2) in 4/5 and M to nausea/vomiting (WHO 1,2) in 5/22 and to stomatitis (WHO 2) in 4/22 cases. The mean survival time after start of palliative cytoreduction was 16 weeks (2–65). In summary, 6-thioguanine ± cytarabine was best tolerated with effective but – in oral monotherapy – often protracted cytoreduction in 60% of patients. Mitoxantrone showed tolerable side effects and potent cytoreduction in 73% of patients even after ineffective palliative pretreatment. Palliative cytoreductive therapy does not reduce the quality of life and can prevent complications of significant leukocytosis in refractory acute leukemia. Received: April 8, 1999 / Accepted: August 9, 1999     

Idarubicin and intermediate-dose cytarabine for myeloid blast crisis of chronic myelogenous leukemia – results of a phase-II trial

 Sixteen patients with Philadelphia chromosome-positive chronic myelogenous leukemia (CML) in myeloid blast crisis were treated with cytarabine (AraC) 600 mg/m² two times daily for 5 days and idarubicin 12 mg/m² for 3 days. Patients achieving a second chronic phase received interferon (IFN) alpha 2b 5 mio units/day daily and AraC 20 mg/day subcutaneously 14 days every month. Study end points were remission rate and survival. Four patients (25%) entered a second chronic phase and had a median survival of 31.1 weeks (range 16.1–111 weeks). Nine patients (56%) experienced blast crisis again and had a median survival of 12.9 weeks (range 5.1–59.3 weeks). Three patients (18.8%) died of septic complications during marrow aplasia. The median overall survival was 16.1 weeks (range 2.6–111 weeks) with no significant difference between responders and nonresponding patients. We conclude that AraC/idarubicin is as effective as other intensive regimens in inducing second chronic phase in patients with myeloid blast crisis of CML. Remission duration and survival are comparable to previous results. Further studies to improve survival are required. Received: May 7, 1998 / Accepted: August 7, 1998     

Local host response in osteosarcoma after chemotherapy referred to radiographs, CT, tumour necrosis and patient survival

The necrotic effect of chemotherapy on primary osteosarcoma has been shown to be predictive of the final outcome. Little attention has been paid to the local response of the host (LHR), which reflects the tumour–host relationship. Design: A four-step grading system was developed based on distinct histological patterns of the LHR around the lesion. These responses were correlated with the chemotherapy-induced necrosis or chemosensitivity and analysed in an attempt to ascertain their influence on the patient prognosis. The ability of conventional radiographs and computed tomography to measure LHR was studied. Methods: The grading system was applied to macroslides of specimens obtained from 72 patients with stage II B primary osteosarcoma in various limbs after wide resection and complete courses of pre- and postoperative chemotherapy who were treated between 1985 and 1991 with a median follow-up of 5 years and 9 months. The histological specimens were blindly reviewed by two pathologists and two experienced musculoskeletal oncologists to assign a grade of response. The results were correlated with tumour necrosis, patient survival and response features on conventional radiographs and CT images. Results: Significant correlation was found between LHR and tumour necrosis or chemosensitivity (r = 0.55) and between LHR and CT response (r = 0.56). There was no correlation between LHR and the findings on conventional radiographs. A grade 4 LHR was predictive of long-term survival. Conclusions: The LHR to preoperative chemotherapy has a prognostic influence on patient survival and can be predicted by CT. Received: 30 March 1998 / Accepted: 20 July 1998     

Microvessel density of hepatocellular carcinoma: its relationship with prognosis

Purpose: To elucidate the relationship between angiogenesis and prognosis after curative resection of hepatocellular carcinoma (HCC). Methods: An immunohistochemical study using anti-CD34 monoclonal antibody was carried out on surgical specimens from 78 HCC patients who had undergone curative resection; microvessel density (MVD) was counted and the overall survival and disease-free survival were analyzed retrospectively. Results: Blood vessels in the tumor were strongly stained by anti-CD34 antibody, but not those in the surrounding liver parenchyma. There were three types of tumor vessels: capillary-like (n = 59), sinusoid-like (n = 16) and mixed-type (n = 3). The median MVD count was 100 per field. The HCC were designated as hypovascular (n = 36) with an MVD count below 100, and hypervascular (n = 42) with an MVD count of 100 or more per field. The 5-year survival and disease-free survival rates were 49.7% and 42.8% respectively, and statistical analysis showed that the MVD level was not correlated with tumor size, capsule status, Edmondson's grade, α-fetoprotein level, associated cirrhosis, γ-glutamyltransferase, and serum HBsAg status. The sinusoid-like tumor vessels appeared more frequently in the more differentiated tumors (P < 0.05). No statistical difference in overall and disease-free survival between different MVD levels and microvessel types was found. Tumor size was the only predicting factor in the entire series. In patients with small HCC (≤ 5 cm, n = 40), 5-year survival and disease-free survival rates were 58.9% and 52.7% respectively, higher than the values in large HCC (39.8% and 32.0% respectively, P < 0.05). The MVD level was an independent predicting factor of disease-free survival, 5-year disease-free survival in the hypovascular group (74.6%) being better than that in the hypervascular group (34.7%, P < 0.05). Conclusions: The MVD level was not related to tumor size, capsule statuo, Edmondson's grade, α-fetoprotein level, associated cirrhosis, γ-glutamyltransferase and serum HBsAg status. In the entire series, tumor size was the only factor influencing survival after curative resection. However, in patients with small HCC, the MVD level was an independent factor of disease-free survival. The pathological and clinical implications of different types of tumor vessels in HCC remain to be studied. Received: 27 November 1998 / Accepted: 5 January 1999     

Phase I / II trial of human recombinant granulocyte-colony-stimulating factor (filgrastim) and escalating doses of cyclophosphamide, mitoxantrone, and 5-FU in the treatment of advanced breast cancer

Purpose: We performed a phase I/II dose-escalation trial of cyclophosphamide, mitoxantrone, and 5-fluorouracil (CNF) in combination with human recombinant granulocyte-colony-stimulating factor (G-CSF, filgrastim) in patients with advanced breast cancer. The objectives of this trial were (1) to gain experience with filgrastim given to patients with advanced breast cancer and receiving standard-dose CNF, and (2) to determine the maximum tolerated dose of CNF that could be given with filgrastim support by incremental dose escalation of two components of the CNF regimen, cyclophosphamide and mitoxantrone. Methods: Four patients who had received prior therapy for advanced disease received standard-dose CNF with filgrastim support. Sequentially enrolled patients who had received no prior chemotherapy for advanced disease were treated with standard-dose CNF without filgrastim (5 patients), standard-dose CNF with filgrastim (15 patients), or were entered into sequential cohorts of 3–6 patients to be treated with increasing doses of CNF with filgrastim support (29 patients). Results: The maximum tolerated doses that could be given with filgrastim support were 1500 mg/m² cyclophosphamide, 20 mg/m² mitoxantrone, and 500 mg/m² 5-FU. Overall, 7 complete (14%) and 13 partial responses (26%) were observed. Despite the use of filgrastim, repeated cycles of CNF at doses of 2000 mg/m² cyclophosphamide, 25 mg/m² mitoxantrone, and 500 mg/m² 5-FU could not be given because of neutropenia and thrombopenia. Among 18 patients with bidimensionally measurable disease there were 3 complete (17%) and 5 partial (28%) responses. The median progression-free survival of all patients was 236 days (34 weeks). Conclusion: The use of filgrastim allows CNF to be given at approximately twice the dose intensity of “standard”-dose CNF. Because non-hematopoietic toxicity was not dose-limiting, further dose escalation of this regimen might be possible with more effective hematopoietic support. The response rate and survival of patients treated in this study were within the range expected with standard-dose chemotherapy. Received: 10 December 1998 / Accepted: 3 February 1999     

Intestinal permeability in patients with chemotherapy-induced stomatitis

Purpose: Mucositis represents one of the most common side effects of chemotherapy, and may affect any part of the gastrointestinal tract, resulting in stomatitis, dysphagia, dyspepsia, or diarrhea. The aim of the present study was to evaluate intestinal permeability in patients with stomatitis during treatment with oral granulocyte-monocyte colony-stimulating factor (GM-CSF, Leucomax). Methods: Ten patients with chemotherapy-induced stomatitis and 21 control cancer patients were included in the study. Intestinal permeability in patients with stomatitis was evaluated before and after the treatment with oral GM-CSF (200 μg for 4 consecutive days) by measuring urinary lactulose, D-xylose, and mannitol after oral challenge in collected urine using capillary gas chromatography. Results: Mean grade of stomatitis (3, range 2–3) improved during treatment by a mean of 1 grade (range 0–2, sign test P < 0.05) with an improvement observed in eight of ten patients. Lactulose excretion, lactulose/mannitol, and lactulose/xylose ratios were markedly elevated in the patients with mucositis compared with 21 control cancer patients (1.60 ± 1.04%, 0.2446 ± 0.2937, and 0.3877 ± 0.6808 vs 0.35 ± 0.20%, 0.0332 ± 0.0148, and 0.0255 ± 0.0086, respectively, Mann Whitney U-test, P < 0.001). After treatment, lactulose excretion, lactulose/mannitol, and lactulose/xylose ratio decreased significantly (1.60 ± 1.04 vs 0.63 ± 0.42%; 0.2446 ± 0.2937 vs 0.1303 ± 0.1149; and 0.3877 ± 0.6808 vs 0.1126 ± 0.1146, respectively, P < 0.05). Conclusions: Lactulose excretion after oral challenge, lactulose/mannitol, or lactulose/xylose ratio may be useful markers for intestinal involvement in chemotherapy-induced mucositis. Improvement of oral mucositis was associated with a significant decrease of intestinal permeability to lactulose. Testing of intestinal permeability by the present method may be useful to evaluate the effect of therapeutic interventions in patients with chemotherapy-induced mucositis. Received: 13 July 2000 / Accepted: 29 August 2000     

Advanced non-small-cell lung cancer: adjunctive interferon γ in induction and maintenance therapy

To evaluate the feasibility of interferon γ (IFNγ) as an adjunct to chemotherapy in advanced non-small-cell lung cancer (NSCLC). Methods: A total of 32 patients were recruited and received 25 mg/m² cisplatin and 100 mg/m² etoposide on days 8, 10 and 12 every 3 weeks for a total of three cycles. A dose of 100 μg IFNγ was given subcutaneously three times weekly from days 1 to 8 and between days 15 and 29. After induction, all patients except those with progressive disease were offered IFNγ maintenance therapy: 100 μg three times weekly. Results: The following responses were obtained: partial response, 5 (16%); minor response, 12 (37%); stable disease, 4 (13%); progressive disease, 11 (34%). The survival rates after 1 and 2 years were 47% and 25% respectively. Patients receiving maintenance IFNγ had a 2-year survival rate of 58%. Toxic side-effects were rare and included grade III/IV fever (7%/1%) and grade III/IV leucopenia (4%/1%). Conclusions: In patients with advanced NSCLC, an adjunctive dose of 100 μg IFNγ, given three times weekly in the induction and maintenance phase, is feasible. Survival data seem favourable so this regimen may warrant further investigation in a phase III study. Received: 21 April 1998 / Accepted: 21 September 1998     

Prognostic significance of DNA cytometry in thymoma

 Purpose: The aim of this work was to evaluate the prognostic significance of DNA image cytometry in thymoma. Patients and methods: Image cytometric studies with an automatic video-based analysis system (LEYTAS) were carried out on 47 archival specimens from 36 patients with thymomas who underwent operation at a single institution from 1954 to 1992. The significance of aneuploidy DNA-content (5c-exceeding events), and nuclear size on stage and survival were evaluated. The median follow-up was 52.7 (6–164) months. Results: Masaoka's stage was predictive of aneuploidy (P < 0.01) and disease-free survival (P < 0.015). In stage I 18% of the tumors were aneuploid, in stage II 78%, in stage III 85% and in stage IV 100%. The occurrence of 5c-exceeding events was associated with both decreased disease-free survival (P < 0.01) and overall survival (P = 0.013). Nuclear size was not significantly correlated to stage. Under multivariate analysis, aneuploidy and DNA content failed to attain independent significance for stage, performance status, and histology. Conclusion: DNA image cytometry may provide additional information about the prognosis of resected thymoma. Received: 25 August 1999 / Accepted: 2 December 1999     

Additive cytotoxic effect of cisplatin and X-irradiation on human glioma cell cultures derived from biopsy-tissue

Purpose: Investigation of the in vitro cytotoxic effect of X-rays, either alone or combined with cisplatin on early passage cell cultures derived from human glioblastoma multiforme biopsy tissue. Materials and methods: Fresh tumour specimens from four patients were processed to cell cultures. The U373 glioma cell line was used as a reference. Early passage cell cultures were X-irradiated (0–8 Gy) either alone or in combination with cisplatin (0.5–1 μg/ml). Cell survival was determined by either clonogenic assay or the colorimetric MTT assay. Survival curves were generated and mathematically analysed using the linear quadratic model, to obtain the radiosensitivity parameters α, β, and SF2, i.e., the Surviving Fraction after 2 Gy. Results: Two patient-derived glioma cell cultures and the U373 cell line showed rather high SF2 values of 0.61–0.72 in the clonogenic assay, indicating relative high radiation resistance. Cisplatin alone (1 μg/ml) reduced cell survival by 10–30% (n=4). When combined with irradiation, a clear additive cytotoxic effect of cisplatin was demonstrated by the unaltered value of the α-parameter for reproductive cell death. Conclusion: Cisplatin exerted an additive rather than radiosensitising cytotoxic effect in uncharacterised patient derived glioma cell cultures. Received: 5 November 1999 / Accepted: 10 May 2000     

Effectiveness of colorectal laparoscopic surgery on patients at high anesthetic risk: an intervention cohort study

Aims The aim of the study was to assess the effectiveness of laparoscopic colorectal surgery in patients at high preoperative anesthetic risk because of associated pathologies. Materials and methods From January 2003 until January 2005, 116 patients were systematically assigned at a ratio of 1:1 to one of two groups: laparoscopy surgery (n = 59, of which 31 were American Society of Anesthesiologists score [ASA] I–II [L1] and 28 ASA III–IV [L2]) or open surgery (n = 57, of which 30 were ASA I–II [O1] and 27 ASA III–IV [O2]). Data on patient demographics and clinical and anesthetic variables were collected prospectively. Informed consent was obtained from the patients, and approval was obtained from the designated review board of the institution involved. Results The number of minor anesthetic complications during surgery was higher in L2 patients. No differences were observed in blood gas parameters studied during surgery (pCO₂, pH, and pO₂/FiO₂). Transfusion rates in the laparoscopy group at greater anesthetic risk (L2) were lower than those of the high-risk conventional surgery group (O2; 21.4 vs 63%, P < 0.02). Duration of stay in the surgical recovery room and the inpatient ward were also shorter in the L2 group than in the O2 group (8.7 ± 4.5 vs 12.2 ± 6 days, P = 0.02). There was no difference in perioperative clinical variables between laparoscopy groups (L1, L2). Conclusion Postoperative recovery of ASA III–IV patients is better after laparoscopic surgery for colorectal cancer, at the expense of a higher rate of minor anesthetic occurrences during surgery.