Adjuvant chemotherapy in node-negative breast cancer. NCI consensus conference.
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Antineoplastic Combined Chemotherapy Protocols↗
Biomedical subjects
G Bonadonna
Publications and source records attributed to G Bonadonna.
Influence of clinical trials on current treatment strategy for Hodgkin's disease.
This paper critically reviews the prospective randomized trials conducted over the past three decades in Hodgkin's disease of adults. On the basis of current findings, it is difficult to conclude which randomized trials were influential in defining widely accepted treatment strategies or treatment sequencies, as many studies were poorly conceived and/or executed. However, other reasons may have come into play. The treatment decision making of Hodgkin's disease involves a complex mosaic of prognostic factors and therefore of potentially successful treatment options. Although irradiation and chemotherapy are both effective in different stages, their optimal integration in a multi-disciplinary approach remains to be assessed. Over the years, different research philosophies were translated into different study designs for each stage or patient subset, and in some instances multiple treatment approaches represented a confounding factor in the search for true and reliable prognostic variables. Also, by the time a given trial became mature enough to provide meaningful results, other single arm or randomized studies were undertaken, often yielding premature data. Thus, the instability of treatment results from preliminary analyses can influence subsequent trial design and engender perplexity among physicians. Prospective randomized trials remain today the most reliable tool to assess in Hodgkin's disease the cost benefit ratio of given treatments in clearly identifiable prognostic subsets.
Adult↗
Does chemotherapy fulfill its expectations in cancer treatment?
In 1949, Cornelius P. Rhoads, director of the Memorial Sloan-Kettering Cancer Center, made his famous report on the practical value of nitrogen mustard before the Committee on Growth of the National Research Council, a quasi-governmental agency which had accepted the responsibility for the clinical trial of this drug at the end of the war. Doctor Rhoads assigned to David A. Karnofsky the job of receiving reports from individual physicians and analyzing the results in each type of cancer. The conclusions, based on 2500 case reports, indicated that nitrogen mustard did not cure any form of cancer, but it was temporarily useful in chronic leukemias, Hodgkin's disease, malignant lymphomas, and lung cancer. The most valuable outcome of this report was the beginning of massive and direct attack on cancer in humans. Since that time, in fact, there was enthusiasm and interest in studying cancer; physicians have been educated, interested and motivated to treat the disease; investigators became engaged in the search of new growth-inhibiting compounds and research clinicians in the formulation of new treatment strategies. The result was a progressively growing list of tumors responding to drug treatment with increased complete remission, prolonged disease free and even total survival rates particularly in the early stages of given malignancies; patient care, the most important achievement in cancer medicine, has been drastically improved. Clinical chemotherapy of cancer has a long history of controversies. Though never advocated as panacea, this form of treatment has continuously fluctuated between excessive optimism and detraction. Recently, harsh criticism has pointed to the magnitude of the overall results achieved in terms of decreased national mortality statistics for the various malignancies. An impatient group of clinicians, biostatisticians and epidemiologists began to question whether medical oncology has reached a plateau in its control of cancer or whether the entire treatment strategy for the control of cancer is wrong. Since sweeping generalization cannot be supported for the results of treatment in each tumor subset require separate analysis, let us review the biological principles of cancer treatment, the main strategies utilized, and the results achieved in the major groups of malignancies. The paper will also outline the contributions of chemotherapy to the medical sciences and to the care of the patients with cancer during the last 40 years.
Antineoplastic Combined Chemotherapy Protocols↗
Salvage chemotherapy in Hodgkin's disease. Results in patients relapsing more than twelve months after first complete remission.
Forty-nine patients with Hodgkin's disease who relapsed after a first complete remission of more than 12 months following primary chemotherapy were treated with salvage therapy regimens. A total of 41 patients (84%) achieved complete remission. In particular, complete response was documented in 17 of 19 patients re-treated with the same initial drug combination. The five-year freedom from progression, relapse-free and overall survivals were 51%, 57% and 65%, respectively. In our experience, consolidation radiotherapy following drug-induced remission failed to improve the five-year relapse-free survival. Present findings indicate that about half of patients relapsing after a disease-free interval exceeding 12 months can remain alive and disease-free 5 years after starting salvage chemotherapy.
Adult↗
Cisplatin and cyclophosphamide in advanced ovarian carcinoma: activity and toxicity of an ambulatory regimen.
Chemotherapy with cisplatin (CDDP, 90 mg/m2) and cyclophosphamide (CTX, 600 mg/m2) was administered to 54 consecutive patients with advanced epithelial ovarian cancer (37 stage III and 17 stage IV). In 51 patients, surgery was performed prior to chemotherapy. Of the 37 stage III patients, 13 had only minimal residual disease after surgical debulking. The overall response rate was 69%, with 44% patients achieving clinical (cCR; n = 2) or pathological (pCR; n = 20) complete response. Median follow-up and overall survival time was 26 months, and median CR duration was 30 months. CR was achieved in 6 of 14 patients (43%) who were partial responders after five cycles of chemotherapy and had continued treatment for three to five more cycles. Severe bone marrow toxicity or renal function impairment was never observed, but eight patients presented peripheral signs of dose-related neurotoxicity. These findings indicate that CDDP and CTX in combination are an effective treatment for patients with advanced ovarian carcinoma, and can be administered with tolerable toxicity. In selected cases, prolonged chemotherapy administration can result in durable complete remissions.
Adult↗
Recombinant human granulocyte-macrophage colony-stimulating factor reduces hematologic toxicity and widens clinical applicability of high-dose cyclophosphamide treatment in breast cancer and non-Hodgkin's lymphoma.
High-dose administration of anticancer agents is attractive both on theoretic and clinical grounds. Yet, high-dose regimens are usually used as salvage treatments, mainly as a consequence of their considerable hematologic toxicity. One pertinent example is represented by cyclophosphamide, an alkylating agent with a wide spectrum of marked antitumor activity. When used at doses up to 7 g/m2 (190 to 200 mg/kg) this drug does not cause myeloablation, but induces a severe, albeit transient, myelosuppression, which requires platelet transfusions in approximately 50% of treated patients, and is frequently complicated by infectious episodes, occasionally lethal. To accelerate hematopoietic recovery, we continuously infused for 14 consecutive days 5.5 micrograms/kg/d of the glycosylated human recombinant granulocyte-macrophage colony-stimulating factor (rhGM-CSF) into 15 patients with breast cancer and non-Hodgkin's lymphoma treated with 7 g/m2 cyclophosphamide. This schedule was chosen having obtained the fastest hematopoietic recovery among four different options during an initial schedule-finding phase on 12 overall patients. Twenty-one comparable subjects with solid tumors served as controls. We report here that this relatively low, well-tolerated dose of rhGM-CSF reduces from 20 to 14 (median) and from 24 to 14, the number of days required to recover circulating granulocyte counts over 1,000 and 2,500/microL, respectively. The stimulatory effect was associated with a remarkable clinical benefit. In fact, treated patients experienced less infectious complications (7% v 24%) were eligible to receive chemotherapy earlier (median, by day +14 v day +20 for controls), and fewer required prophylactic platelet transfusions (13% v 43%). Our results show that even very high doses of cyclophosphamide can be administered with improved hematologic toxicity, tolerable morbidity, and reduced supportive care requirements. The increase in the therapeutic index made possible by rhGM-CSF infusion prompts the use of high-dose cyclophosphamide, and possibly of other agents with similar myelotoxic activity, early in the clinical course of chemotherapy-sensitive tumors.
Adolescent↗
3H-thymidine-labeling index as a prognostic indicator in node-positive breast cancer.
The prognostic relevance of 3H-thymidine-labeling index (3H-TdR-LI) was retrospectively evaluated in 523 women with resectable node-positive breast cancer given adjuvant combination chemotherapy consisting of cyclophosphamide, methotrexate, and fluorouracil (CMF) +/- Adriamycin (doxorubicin; Farmitalia, Carlo Ezba, Italy). The 5-year relapse-free survival (RFS) and overall survival (OS) rates were significantly higher for patients with slowly proliferating tumors (3H-TdR-LI less than or equal to 2.8%) compared with rapidly proliferating tumors (RFS, 66% v 50%, P = .0007; OS, 85% v 73%, P = .0012). In the analysis of RFS, 3H-TdR-LI provided prognostic information independent of axillary node involvement, tumor size, and estrogen receptor (ER) status, with an estimated lower hazard ratio compared with the degree of nodal involvement, but equivalent to that of the other indicators. Conversely, nodal involvement was found to interact with 3H-TdR-LI and receptors on survival. Present findings confirm that tumor cell kinetics represents a prognostic indicator also in an adjuvant situation. 3H-TdR-LI can substantially contribute to a more precise definition of high-risk patients within subsets having the traditionally favorable prognostic characteristics.
Analysis of Variance↗
Durable and complete hematopoietic reconstitution after autografting of rhGM-CSF exposed peripheral blood progenitor cells.
Two patients with poor prognosis stage III multiple myeloma have been treated with myeloablative chemoradiotherapy, i.e. 10 Gy fractionated total body irradiation plus 120 mg/m2 intravenous melphalan, and then transplanted with autologous peripheral blood cells harvested by four leukaphereses during the phase of rapid hematopoietic recovery following induction therapy with high-dose (2 g/m2) etoposide and recombinant human glycosylated granulocyte macrophage-colony stimulating factor (rhGM-CSF). Following myeloablative therapy and autologous peripheral blood cell transplantation, both patients experienced brief pancytopenia followed by rapid hematopoietic recovery of leukocytes (time to greater than 500 x 10(6)/l = 12 days) and platelets (time to greater than 100 x 10(9)/l = 14 days). In particular, single donor platelet transfusion requirements were limited to one and two transfusions per patient, respectively. Reconstitution has so far been maintained throughout the follow-up period for the two patients (9 and 6 months, respectively). These two cases show that rhGM-CSF-exposed peripheral blood cells are capable of producing prompt and sustained hematopoietic reconstitution in patients treated with myeloablative chemoradiotherapy.
Adult↗
Selenium supplementation increases renal glomerular filtration rate.
Selenium (Se) is a trace element variously distributed in the human body and especially concentrated in certain organs, such as the renal cortex. We report results obtained during a ten weeks' oral Se supplementation. Experiments were devised to evaluate previous preliminary observations which suggested a possible effect of Se addition on the renal glomerular filtration rate. Eleven healthy volunteers have given increasing oral Se (as a sodium selenite solution) as follows: on the first week they have given 100 micrograms Se per day; this was progressively increased 100 micrograms per day for each of the following 6 weeks; the last dose (700 micrograms per day) was maintained for three further weeks. Serum and 24-hour urine were collected weekly for creatinine determination by kinetic Jaffé reaction and Se measurement by proton-induced X ray emission (PIXE). The final mean serum creatinine concentration was 13% lower than the initial mean value (p less than 0.01). Mean creatinine clearance increased significantly (p less than 0.05) and showed a direct correlation with mean Se clearance (r = 0.79; p less than 0.001). As the increase of creatinine clearance was concomitant with a reduction of serum creatinine levels, we excluded the possibility of toxic effects. Our results seem to suggest a positive influence of Se supplementation on the rate of glomerular filtration and we hypothesize that Se might be involved in the vascular regulatory mechanism of the kidney.
Adult↗
Soft tissue and bone sarcomas.
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Bone Neoplasms↗
Circulation of CD34+ hematopoietic stem cells in the peripheral blood of high-dose cyclophosphamide-treated patients: enhancement by intravenous recombinant human granulocyte-macrophage colony-stimulating factor.
We report that hematopoietic progenitor cells expressing the CD34 antigen (CD34+ cells) transiently circulate in the peripheral blood (PB) of cancer patients treated with 7 g/m2 cyclophosphamide (HD-CTX) with or without recombinant human granulocyte macrophage-colony stimulating factor (rHuGM-CSF). In adult humans, CD34+ cells represent a minor fraction (1% to 4%) of bone marrow (BM) cells, comprising virtually all hematopoietic colony-forming progenitors in vitro and probably also stem cells capable of restoring hematopoiesis of lethally irradiated hosts. We show that CD34+ cell circulation is fivefold enhanced by rHuGM-CSF 5.5 protein micrograms/kg/day by continuous intravenous infusion for 14 days after HD-CTX. During the third week after HD-CTX (ie, when CD34+ cells peak in the circulation), large-scale collection of PB leukocytes by three to four continuous-flow leukaphereses allows the yield of 2.19 to 2.73 x 10(9) or 0.45 to 0.56 x 10(9) CD34+ cells depending on whether or not patients receive rHuGM-CSF. The number of CD34+ cells retrieved from the circulation by leukaphereses exceeds the number that can be harvested by multiple BM aspirations under general anesthesia. Thus, after therapy with HD-CTX and rHuGM-CSF, PB represents a rich source of hematopoietic progenitors possibly usable for restoring hematopoiesis after myeloablative chemoradiotherapy. To determine whether CD34+ cells found in the PB are equivalent to their marrow counterpart, we evaluated their in vitro growth characteristics and immunological phenotype by colony assays and dual-color immunofluorescence, respectively. We show that PB CD34+ cells possess qualitatively normal hematopoietic colony growth and high cloning efficiency comparable to that observed with BM CD34+ cells. In addition, PB CD34+ cells display heterogeneous surface membrane differentiation antigens analogous to BM CD34+ cells. The availability of large quantities of CD34+ cells by leukapheresis is relevant to the field of stem cell transplantation and possibly to genetic manipulations of the hematopoietic system in humans.
Antigens, CD34↗
Granulocyte-macrophage colony-stimulating factor to harvest circulating haemopoietic stem cells for autotransplantation.
Granulocyte-macrophage colony-stimulating factor (GM-CSF), given to accelerate recovery from cytopenia induced by high-dose (7 g/m2) cyclophosphamide, reproducibly brought about a dramatic increase (up to 1000-fold) in the number of peripheral blood granulocyte-macrophage colony-forming units (CFU-GM). These circulating progenitors were harvested by leucapheresis and reinfused, together with autologous bone marrow cells, in seven patients with cancer after total body irradiation and melphalan. Complete haemopoietic recovery occurred in all seven transplanted patients in a very short time: mean (SD) 9.1 (0.9) days (range 8-11) to achieve more than 0.5 x 10(9)/l neutrophils, 9.9 (1.7) days (range 8-13) to over 1 x 10(9)/l neutrophils, 10.7 (2.6) days (range 9-16) to over 0.5 x 10(11)/l platelets, and 13.6 (4.2) days (range 13-21) to over 1.0 x 10(11)/l platelets. A reduction in the severity of mucositis was also observed. The rapid haematological recovery made possible by this approach promises to increase the therapeutic index of high-dose chemoradiotherapy regimens and to widen their role as treatment for chemoradiosensitive tumours.
Adult↗
Immunotoxin-mediated inhibition of chronic lymphocytic leukemia cell proliferation in humans.
We evaluated the cytotoxicity of the immunotoxin OKT1-SAP on fresh B-chronic lymphocytic leukemia (B-CLL) cells from 31 consecutive patients. OKT1-SAP comprised the OKT1 (CD5) monoclonal antibody disulfide linked to saporin-6 (SAP) ribosome-inactivating protein from the plant Saponaria officinalis. The effect of OKT1-SAP on target CD5-positive B-CLL cells was estimated using an in vitro proliferation inhibition assay in which control or OKT1-SAP-treated B-CLL cells were induced to proliferate by sequential stimulation with insolubilized anti-C3b receptor CB04 (CD35) antibody and low molecular weight B-cell growth factor. In 90% of patients, OKT1-SAP specifically suppressed B-CLL cell proliferation in a dose-related manner (50% inhibitory concentration, 4.0-6.8 nM). Taken together the findings reported in this article provide information relevant to the clinical development of immunotoxins because: (a) the in vitro conditions under which B-CLL cell proliferation is inhibited by OKT1-SAP are achievable in vivo without nonspecific toxicity according to our previous toxicology and pharmacokinetics studies in primates; and (b) the B-CLL cell proliferation inhibition assay described here provides a basis for future comparative studies.
Aged↗
Mitomycin C and vinblastine in advanced refractory breast cancer.
A combination of mitomycin C and vinblastine was administered as salvage treatment in 44 patients with heavily pretreated refractory breast cancer. Response rate was 23% (10 of 44) including one complete response of lung metastases. The highest response rate was seen in intrathoracic localizations (45%). Median duration of response was 6.5 months (range, 3+-17+). Treatment was generally well tolerated, and only 25% of patients developed nausea and vomiting. Neurologic toxicity was represented by paresthesia (8 patients) and constipation (one patient). Mild leukopenia was observed in 30 of 172 treatment cycles, but it exceeded grade 2 in only 5 patients. Considering the good compliance of this regimen and the poor prognosis of patients with advanced refractory disease, the combination of mitomycin C plus vinblastine appears to be useful as salvage treatment for metastatic breast cancer.
Adult↗
Mitoxantrone as first-salvage chemotherapy in relapsed breast cancer.
Mitoxantrone was administered at the dose of 14 mg/m2 i.v. every 3 weeks to 25 consecutive women with measurable progressive disease who relapsed after adjuvant CMF and endocrine therapy. The treatment plan consisted in the delivery of 6 cycles, unless disease progression or severe toxicity occurred. All patients were evaluable for drug response and toxicity. One patient achieved complete remission and 6 partial remission, for a total response rate of 28%. Objective tumor response was observed in all major sites of disease. The median time to achieve remission was 3 months. The median duration of response was 7 months (range, 5-39+), and the median survival for the entire group was 10 months (range, 3-39+). Results were influenced only by the duration of disease-free status from the end of adjuvant CMF chemotherapy. In fact, all tumor responses were documented in woman with free intervals exceeding 1 year (7 of 17 or 41%). Treatment was generally well tolerated, with 10 patients developing leukopenia at some time during treatment. Only 2 patients received less than 75% of the projected dose because of granulocytopenia. Complete alopecia occurred in only 2 cases. Three patients developed a fall greater than 15% in left ventricular ejection fraction, but no episode of congestive heart failure was observed. We conclude that mitoxantrone is an effective and safe drug which can be utilized in women relapsing after adjuvant CMF.
Adult↗
Pilot study with adriamycin and ifosfamide in small cell lung cancer.
Twenty-one patients with limited (12 cases) or extensive (9 cases) small cell lung cancer entered a pilot study with adriamycin (ADM) plus ifosfamide (IFX) as first line treatment for six planned cycles. ADM was administered at the dose of 60 mg/m2 iv push on day 1 and IFX at 3 g/m2/iv in 1-hour infusion on days 1 and 2. To prevent IFX-induced hemorrhagic cystitis, mercaptoethane sulfonate sodium (Mesna) was given after the administration of IFX at the dose of 500 mg/m2 by iv push four times (hour 0, 4, 8, 12) on days 1 and 2. In the absence of disease progression, chemotherapy was repeated every 3 weeks for 6 cycles. All patients were evaluable for analysis of response, toxicity and survival. The overall response rate clinically and radiologically assessed after four treatment cycles was 95.3% (CR 28.6%, PR 66.7%). However, by continuing the same drug treatment up to the sixth cycle, 7 of 14 partial responders showed tumor progression within the intrathoracic region. Therefore, at the end of the planned chemotherapy program the partial remission rate fell to 33.3%, for a total remission rate of 61.9% and a median total survival of 9 months (range 5 to 36+). The regimen was well tolerated with only one case presenting hemorrhagic cystitis. The results achieved with this drug combination appear comparable to those obtained with other conventional regimens. However, the high response rate achieved after four cycles and the low incidence of marrow toxicity suggest the use of this regimen for a short period with increased dose levels.
Adult↗
B-cell restricted saporin immunotoxins: activity against B-cell lines and chronic lymphocytic leukemia cells.
B cell-restricted immunotoxins were constructed by conjugating anti-B monoclonal antibodies to saporin, the major ribosome inactivating protein from the seeds of the plant Saponaria officinalis. HD37-SAP is directed against CD19, the broadest B cell-specific determinant. HD39-SAP and HD6-SAP recognize two different epitopes on the CD22 molecule, an antigen present on the cell surface of B cells at late stages of differentiation. All three immunotoxins inhibited DNA synthesis and protein synthesis in target B lymphoma cells with a dose-related effect, in short incubation times and in the absence of potentiators. A clonogenic assay demonstrated that all immunotoxins could eliminate more than two logs of clonogenic malignant B cells with a two-hour incubation at concentrations not toxic to cells not bearing target antigens. The immunotoxin activity was evaluated by DNA synthesis inhibition in fresh B-chronic lymphocytic leukemia cells (B-CLL) stimulated to proliferate by incubation with an antibody specific for the receptor of C3b complement component (CR1) plus B cell growth factor. B-CLL cell DNA synthesis was actively inhibited by treatment at low immunotoxin concentration without need of potentiators. Immunotoxins exerted their effect also in whole blood of CLL patients under conditions achievable in vivo. We conclude that B cell-restricted immunotoxins HD37-SAP, HD39-SAP, and HD6-SAP are good candidates for in vivo therapy of B-cell malignancies.
Antibodies, Monoclonal↗
Salvage treatments in relapsing resectable breast cancer.
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Antineoplastic Combined Chemotherapy Protocols↗