Intravenous azidothymidine with fluorouracil and leucovorin: a phase I-II study in previously untreated metastatic colorectal cancer patients.

PURPOSE: To determine the plasma pharmacokinetics and the maximum-tolerated dose (MTD) of intravenous (IV) azidothymidine (AZT) administered 90 to 120 minutes after fluorouracil (5-FU) and leucovorin and to preliminarily evaluate the antitumor activity of this combination in metastatic colorectal cancer. PATIENTS AND METHODS: 5-FU 500 mg/m2 IV bolus was administered once a week in the middle of a 2-hour infusion of leucovorin; AZT was given as a 90 to 120-minute IV infusion 60 minutes after 5-FU. Initial AZT dose was 0.5 g/m2, and it was escalated in successive cohorts of three patients by 0.5 to 2 g/m2. RESULTS: Thirty-five chemotherapy-naive metastatic colorectal cancer patients were entered onto the study, and AZT doses ranged from 0.5 to 10 g/m2. The peak AZT plasma concentration increased from 21.9 to 995.6 micromol/L. The area under the concentration/time curve (AUC) also showed a progressive, but not linear increase from 40.34 to 3,108 h x micromol/L. The most relevant toxicity was diarrhea, which was severe in six patients (17%). Toxicities were not AZT-dose-related, except fpr hypotension, which occurred in patients treated at AZT doses > or = 7 g/m2 and became dose-limiting for AZT 10 g/m2. Among 34 assessable patients, 15 objective responses were observed (44%; 95% confidence interval 27 to 62), lasting a median of 44 weeks; five (15%) were complete. CONCLUSION: AZT doses > or = 6 g/m2 administered IV over 90 to 120 minutes produce maximum plasma concentration and AUC similar to those previously reached in murine tumor models. Dose-limiting toxicity is hypotension, which occurs at AZT 10 g/m2. The recommended AZT dose for further studies is 8 g/m2. The combination of 5-FU plus leucovorin plus AZT is feasible with acceptable toxicities, and has promising activity in metastatic colorectal cancer.

A phase II study of oral piritrexim in recurrent high-grade (III, IV) glioma.

Piritrexim is a lipid-soluble drug which is as effective an inhibitor of dihydrofolate reductase as methotrexate. Phase I and II studies have indicated activity in some tumour types. Because of its lipophilicity we have conducted a phase II study in recurrent high-grade malignant glioma (grades III and IV). Twenty-seven patients were treated with 25 mg p.o. three times daily for five consecutive days, repeated weekly, with provision for dose escalation or reduction according to toxicity. Five patients received less than 4 weeks' treatment because of disease progression or death. Twenty-two patients were evaluable for response. One complete and one partial response was seen (duration 262+ and 241+ weeks) and 13 patients had static disease for a median duration of 13 weeks (range 7-35). The major toxicity was myelosuppression. This response rate of 9% of evaluable patients is much lower than that seen for some conventionally used drugs and we conclude that piritrexim is unlikely to be of value in the management of high-grade gliomas.

In vitro and in vivo studies on the action of BW502U83, an arylmethylaminopropanediol.

BW502U83, an arylmethylaminopropanediol (AMAP), showed to be partially cross-resistant in a P-glycoprotein-positive and in a P-glycoprotein-negative, doxorubicin-resistant cell line, while no cross-resistance was noticed in a cisplatin-resistant cell line. Interstrand cross-links were not observed, but BW502U83 induced extensive DNA strand breaks. In a feasibility study the effect of intra-arterially BW502U83 was tested. One patient with a hepatocellular carcinoma showed partial remission and signs of a tumor lysis syndrome, another patient with a hepatocellular carcinoma improved clinically. A patient with soft tissue sarcoma had stable disease. Transient increase in SGOT, SGPT and LDH were observed, but no systemic side effects.

The effect of BW12C on the radiosensitivity and necrosis of murine tissues and tumours.

BW12C is a drug that has the potential to induce normal tissue and tumour hypoxia by binding to haemoglobin, increasing its affinity for oxygen and thereby reducing oxygen availability to tissues. Initial results suggested that BW12C administration caused significant radioprotection of normal tissues and induced tumour necrosis, but variable results have been reported subsequently. This work was carried to extend the range of observations concerning the ability of BW12C to radioprotect normal tissues and tumours and to induce necrosis of tumours of the mouse. BW12C was administered as 70 mg/kg i.v. 15 min before irradiation of jejunum in CBA mice and of foot skin in WHT mice with single doses of 240 kVp X-rays while mice breathed gases of varying oxygen tensions. The radiosensitivities of these tissues were assessed by the crypt survival assay and the acute skin reaction, respectively. The radiosensitivity of CaNT tumours to single fraction irradiation was assessed by the regrowth delay assay following administration of single or multiple doses of BW12C at varying times to air-breathing CBA mice. The radiation response was compared to the radiosensitivity of clamped tumours. The effect of BW12C alone on tumours was assessed by regrowth delay and histological examination for necrosis. BW12C did not change the radiosensitivity of jejunal crypts irradiated while mice breathed air or 10% O2, or of foot skin when mice breathed 12% O2. BW12C protected foot skin by a factory of 1.1 when mice breathed air. Single or multiple doses of BW12C did not influence the radiosensitivity of CaNT tumours, although marked radioprotection could be induced by clamping the tumours during irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical analysis of CDw52 antigen expression in non-Hodgkin's lymphomas.

AIM: To determine the antigen expression of CDw52 using Campath-1 antibodies in a series of non-Hodgkin's lymphomas (NHLs). METHODS: Tissue sections of lymphoma were stained immunohistochemically using rat Campath-1G and humanised Campath-1H with avidin-biotin-peroxidase complex techniques. Fifty-two fresh frozen lymphomas and a further 26 paraffin wax embedded sections were studied. RESULTS: Thirty-seven out of 41 B cell lymphomas were positive with Campath-1H in frozen sections (low grade, 24 of 24; high grade, 13 of 17) as were three out of five T cell lymphomas. Reed-Sternberg cells in six cases of Hodgkin's disease did not react. Eleven out of 16 high grade B cell lymphomas also stained positively with Campath-1G in paraffin wax sections as did five out of 10 T cell lymphomas. CONCLUSIONS: The Campath-1 antibodies showed that CDw52 antigen expression was present in all cases of low grade B cell NHL examined. Immunohistochemical staining in high grade B cell NHL and in T cell NHL was variable. These findings may be relevant to patient selection when considering treatment with Campath-1 antibodies.

Phase I study of BW12C in combination with mitomycin C in patients with advanced gastrointestinal cancer.

The effect of combining the oxyhemoglobin-modifying drug BW12C with mitomycin C was investigated in a Phase I study of 18 patients with advanced gastrointestinal cancer. The dose of BW12C was increased from 20 mg/kg to 50 mg/kg to modify the hemoglobin-oxygen saturation curve by up to 48%. The period of maximum modification was then prolonged for up to 3 hr by a maintenance infusion of 4-6 mg/kg/hr. Pharmacokinetics of BW12C and mitomycin C were performed in all patients. Peak levels of BW12C increased from 139 micrograms/ml to 378 micrograms/ml. Plasma half life was independent of dose, with an average of 3.3 hr. BW12C was well tolerated with no severe side effects. Three patients had objective tumour responses.

In vitro and in vivo studies using BW12C: toxicity, haemoglobin modification and effects on the radiosensitivity of normal marrow and RIF-1 tumours in mice.

BW12C binds to haemoglobin, shifting the oxygen saturation curve to the left, and is under investigation as an inducer of tumour hypoxia. The intrinsic cellular toxicity of the drug to RIF-1 and EMT6 cells in monolayer culture was studied, and IC50 values of 100 micrograms ml-1 for 24 h exposure and 10 micrograms ml-1 for 4-day exposure were measured. The LD50 (95% CL) in C3H mice was shown to be 124 (118-130) mg kg-1 for normal, rapid i.v. injection of the drug, and 173 (164-181) mg kg-1 for slow injection. The well-tolerated dose of 70 mg kg-1, used for all subsequent studies, was shown to produce a maximum haemoglobin modification of 70% 5 min after i.v. administration. This effect decayed with a half-life (+/- 2 se) of 76 +/- 8 min, giving 50% modification at 30 min and 22-25% modification at 2 h after administration. A dose of 70 mg kg-1 BW12C administered 30 min before irradiation protected animals against lethality, and increased the radiation LD50 (95% CL) from 7.16 (7.05-7.27) to 7.86 (7.70-8.02) Gy, representing a DMF of 1.1. In contrast the same drug dose and schedule did not alter normal marrow CFUs radiosensitivity at doses up to 6 Gy. The dose of 70 mg kg-1 did, however, cause marked radioprotection in RIF-1 intramuscular leg tumours. Four- to seven-fold increases in survival were measured by clonogenic cell survival immediately or 24 h after treatment. Protection was maximal 15 to 30 min after administration, and absent by 2 h. The drug did not protect RIF-1 cells in culture against radiation damage, indicating that the in vivo effect is indirect. BW12C is therefore an effective tumour radioprotector in this tumour model, in a manner consistent with an increase in tumour hypoxic fraction, although factors other than changes in blood chemistry may also be involved.

Protection of pig epidermis against radiation-induced damage by the infusion of BW12C.

BW12C, which was developed as an agent for the treatment of sickle cell anaemia, increases the binding of oxygen to haemoglobin and hence reduces the availability of oxygen to tissues. Due to these changes in oxygen availability BW12C could act as a protector against radiation-induced injury to normal tissues. In this study the potential value of BW12C, as a radioprotector, was studied in the irradiated epidermis of the pig. The infusion of BW12C caused an instant left shift of the oxygen dissociation curve, an effect that lasted for approximately 1.5 h. This left shift in the oxygen dissociation curves increased with increasing dose of the drug. There appeared to be no long-term systemic effects produced by doses of 20-100 mg/kg of BW12C. In the first 90 min after the infusion of BW12C skin fields were irradiated with single doses of beta-rays from strontium-90 plaques. The incidence of moist desquamation was used as an endpoint for assessing the severity of the radiation response. With animals breathing approximately 70% oxygen in the anaesthetic gas mixture, the ED50 values for moist desquamation were 30-31 Gy after a dose of 30 and 50 mg/kg, and 37-38 Gy for 75 and 100 mg/kg doses of BW12C. These ED50 values were significantly higher than the value of 27.3 Gy for radiation alone. This indicated dose modification factors (DMF) with mean values of approximately 1.13 and approximately 1.40 for irradiation following the infusion of low (30-50 mg/kg) and high (75-100 mg/kg) doses of the drug, respectively. With the animals breathing air (approximately 21% of oxygen) in the 2% halothane anaesthesia gas mixture, irradiation in the presence of 30 and 50 mg/kg of BW12C resulted in ED50 values of approximately 39 Gy for moist desquamation, which was significantly higher than the value of 31.2 Gy for radiation alone. Surprisingly, a higher dose of 75 mg/kg of BW12C resulted in a lower ED50 value for moist desquamation of 34.38 Gy. Irradiation in the presence of a dose of 100 mg/kg of BW12C produced an ED50 value which was not significantly different from that for radiation alone. In the situation where animals were breathing air (approximately 21% oxygen) during irradiation a DMF of 1.14 was obtained for irradiation alone, when the results were compared with those for irradiation alone with approximately 70% oxygen in the anaesthetic gas mixture.(ABSTRACT TRUNCATED AT 400 WORDS)

Biological modifiers and their role in cancer therapy.

Biological modification in cancer therapy involves many different strategies and substances. Bacterial products with established usefulness include BCG, C. parvum and L-Asparaginase. Immunotherapy with such agents has not, however, found general application, although revived interest in 'Coley's mixed toxins' (used earlier this century) paralleled the development of their presumed effector molecules, tumour necrosis factor and lymphotoxin. Many other Cytokines, both natural or recombinant, are now produced on a vast scale following the recent biotechnology revolution. Of these, Alpha Interferons have already proved useful in hairy cell leukaemia, carcinoid tumours, renal cell cancer, Kaposi's sarcoma, chronic granulocytic leukaemia and certain lymphomas, whilst their use as adjuvants or in combination is currently being investigated. More recently, Interleukin-2, which stimulates the clonal expansion of activated T-cells, has shown promise both as a single agent, and when used with lymphokine activated killer (LAK) cells or tumour infiltrating lymphocytes (TILS). A different approach involves the Colony Stimulating Factors such as G-CSF and GM-CSF which reduce the degree and duration of treatment-related myelosuppression, thereby allowing more intensive cytotoxic or radiation therapy, as well as facilitating early recovery following bone marrow transplantation. Monoclonal antibodies have not proved as specific for malignant cells as was originally hoped, but certain tumours, such as lymphoma, are now realistic targets for therapy. Increasingly sophisticated effector mechanisms (e.g. conjugated pro-drugs) and genetically engineered "humanised" monoclonal antibody hybrids present the brightest hopes for the future. Biotherapy, the "fourth modality of cancer treatment" has already assumed its place alongside surgery, radiotherapy and cytotoxic chemotherapy, and will grow in importance as our understanding of the molecular biology of cancer increases in the coming decades.

Induction of severe tumor hypoxia by modifiers of the oxygen affinity of hemoglobin.

Methods have been compared for inducing severe hypoxia in experimental tumors. Hypoxic fractions in the tumors were obtained from measurements of the displacement of cellular survival plots in vitro following tumor irradiation in vivo. Two compounds that displace to the left, oxygen-hemoglobin association curves greatly increase the hypoxic fractions in the tumors. The compound BW12C increases the hypoxic fractions in the KHT and Lewis-Lung tumors from about 10% to between 50-100%. The longer acting analogue BW589C increases hypoxic fraction in the KHT tumor to the same level achievable by treatment with the vaso-active drug hydralazine. The effect is also observed in the RIF-1 tumor even though the hypoxic fraction in this tumor is normally only about 1-3%. The kinetics for hypoxia induction by BW589C and its subsequent return to normal levels are comparable to those for the left-shifting of the oxy-hemoglobin association curve observable up to about 2 days post treatment.

Effect of the manipulation of oxyhemoglobin status by BW12C on tumor thermosensitivity and on blood flow in tumor and normal tissues in mice.

The effect of 70 mgkg-1 BW12C 30 min before heating on the thermosensitivity of RIF-1 leg tumors was studied. This schedule is known to increase the hypoxic fraction by a factor of 5. Heating, using a combined radio-frequency and saline bath technique, was for 30 min at 43, 43.5, and 44 degrees C and response was assayed by clonogenic cell survival immediately and 24 hr after treatment. BW12C did not alter RIF-1 thermosensitivity. The effects of heat up to 44 degrees C on the oxygen saturation curves of normal and BW12C-modified blood were compared and P50s were shown to rise from 36 to 52 mm Hg and 6.5 to 8.0 mm Hg respectively, showing the latter to be relatively resistant to right-shifting by heat. 86Rb extraction studies on BW12C-treated unheated animals showed that blood flow in leg and flank tumours 60 min after BW12C was reduced to 64% and 34% of control values respectively, indicating a further mechanism for induction of tumour hypoxia by BW12C. Blood flow in leg muscle, liver, and spleen was unchanged but in kidney and lung was increased to 127% and 119% of control respectively 60 min after BW12C.

Modification of the radiation response of pig skin by manipulation of tissue oxygen tension using anesthetics and administration of BW12C.

The importance of tissue oxygen tension on radiosensitivity was studied by examining modifications in the incidence of moist desquamation in pig skin after irradiation with strontium-90 plaques. The effects were analyzed using quantal dose-response data and comparisons were made using ED50 values for moist desquamation. Under standard anesthetic conditions of 2% halothane, approximately 70% oxygen, and approximately 30% nitrous oxide, the ED50 value (+/- SE) for moist desquamation was 27.32 +/- 0.52 Gy with no significant variation in radiosensitivity between dorsal, lateral, and ventral skin sites on the flank. Irradiation with 2% halothane and air increased the ED50 to 31.25 +/- 0.94 Gy, primarily due to an increased radioresistance of the dorsal sites. When combined with BW12C, a drug which binds oxygen selectively to hemoglobin and hence reduced the oxygen availability to tissues, a further increase in the ED50 values was observed. This was approximately 39 Gy with BW12C concentrations of 30 mg/kg and 50 mg/kg b.w. of BW12C, indicating a dose modification factor (DMF) of approximately 1.26. However, when animals were breathing the standard gas mixture, this DMF was reduced to 1.15 for 30 mg/kg of BW12C, indicating that a higher level of oxygen partly counteracted the effects of the drug in these studies with BW12C. The greatest variability in radiosensitivity was seen in the dorsal fields. This suggested complex physiological adaptation, a phenomenon that might also explain the absence of any modification of the radiation response when 100 mg/kg of BW12C was used.

Unexplained spontaneous regression and alpha-interferon as treatment for metastatic renal carcinoma.

A series of 73 patients with measurable metastatic disease referred to a tertiary referral centre for consideration for an experimental treatment protocol were entered into a surveillance protocol in order to establish the incidence of spontaneous regression. Initially, patients were taken off the study if metastases showed greater than 25% increase in products of bidimensional measurement but with increasing confidence patients went into therapy protocols only following the development of symptomatic progression. We observed 3 complete and 2 partial unexplained spontaneous regressions and a further 4 patients had prolonged stable disease for more than 12 months. A group of 21 patients on progression subsequently received treatment with alpha-interferon (Wellferon) as part of a multicentre study which included an additional 61 cases; 12 responded (3 surveillance relapse patients and 9 others). Patients with lung metastases only had the highest response rate (10/17 compared with 5 unexplained responses seen in 38 such patients on surveillance). These results confirm that alpha-interferon is active against metastatic renal carcinoma and that the responses are not totally explicable by spontaneous regression.

The beneficial effects of alpha IFN in CGL are probably not mediated by NK cells.

Natural killer (NK) cells in CGL were measured phenotypically (by Leu7 and CD16 Mab staining) and functionally (by a standard chromium-release cytotoxicity assay) in eight patients before and during alpha-IFN therapy. Before alpha IFN therapy, phenotypic NK cells were normal in relative and absolute numbers but were consistently defective functionally; this defect was partially corrected by in vitro exposure to alpha IFN. During alpha IFN therapy, there was no change in NK function in five patients and enhanced (two patients) or reduced (one patient) activity was observed in the other three. Cold-target inhibition experiments showed no evidence of NK binding to normal or CGL myeloid progenitors. It is concluded that alpha IFN-enhanced NK function, a known anti-tumour mechanism in animal models, is probably not the basis of the responsiveness of CGL to alpha IFN therapy.

Alpha-interferon in myelodysplasia; clinical observations and effects on NK cells.

A total of 15 patients with myelodysplastic states (MDS) were studied. Of the eight patients treated with alpha-interferon (alpha IFN) (3 megaunits/day for up to 6 months), one patient with refractory anaemia with excess blasts (RAEB) underwent an almost complete response while one case of chronic myelomonocytic leukaemia (CMML) showed a reduction in monocyte count; no improvement was observed in refractory anaemia (RA) or refractory anaemia with excess blasts in transformation (trRAEB). In all patients Leu7+ and Leu11a+ phenotypic natural killer (NK) cells were consistently normal in percentage numbers but functional NK activity was consistently reduced in all MDS subgroups. NK activity was enhanced by exposure to alpha IFN in vitro, but was very variable in patients being treated with the agent. There was no correlation between clinical response and changed NK activity in patients receiving alpha IFN. It is concluded that NK cells are unlikely to play a central role in the biology of myelodysplasia.

A CT based dosimetry system for intracavitary therapy in carcinoma of the cervix.

The physical dose distribution from intracavitary sources used in the treatment of carcinoma of the cervix can be accurately calculated in three dimensions. However, it is no simple matter to relate dose to critical tissues within the pelvis. We have studied 10 patients and have used CT scanning with dummy sources to determine the dose to lymph nodes, bladder and rectum. This technique may be superior to the use of orthogonal radiographs and highlights the limitations of the use of the flexible rectal dose meter. Further work will required to determine whether or not the morbidity of radical radiotherapy can be reduced using such detailed dosimetry to adjust therapy and eliminate small areas of high dose to critical normal tissues. In one case, CT showed a spontaneous and unexplained uterine perforation by the intrauterine tube one day after check films had shown a satisfactory position.

Natural IFN-alpha therapy in hairy-cell leukaemia (namalva-type IFN--Wellferon).

More than 50 patients with hairy-cell leukaemia have now been entered into the British Wellferon (IFN) study, at different centres under the coordination of the Wellcome Research Laboratories. While the treatment duration and dosage varied between patients, the initial dose was usually 3 megaunits daily by intramuscular or subcutaneous injection. Although flu-like symptoms and mild somnolence were commonly experienced side-effects; cessation of IFN treatment as a result of such effects was necessary in only three patients. All patients irrespective of previous treatment showed some response and a complete (less than 5% hairy cells, HCs) bone marrow response was observed in 17. The degree of response was related to the duration of therapy. Immunological markers showed that there was no apparent increase in natural killer (NK) cells and no return of normal B lymphocytes. Light-chain-restricted B cells became reduced in parallel with the disappearance of morphological HCs. Absolute numbers of T cells were reduced, Leu2a+ preferentially, resulting in an increase in helper/suppressor ratios. The ratios (saturation index, SI) of saturated to unsaturated 18 carbon fatty acids (C18FA) of erythrocyte or leukocyte membranes, while abnormal in untreated patients, approached normal levels during IFN therapy. It is concluded that prolonged alpha IFN therapy is highly effective in HCL. The mechanism of action of IFN remains unknown, but indirect surface-marker data favours a direct effect on HCs.