Outpatient chemotherapy with gemcitabine and oxaliplatin in patients with biliary tract cancer.

This phase II study was conducted to determine the efficacy and toxicity of a gemcitabine (GEM) and oxaliplatin (OX) chemotherapy protocol in patients with unresectable biliary tract cancer (BTC). Patients were treated with GEM 1000 mg m-2 (30 min infusion) on days 1, 8, 15, and OX 100 mg m-2 (2 h infusion) on days 1 and 15 (gemcitabine and oxaliplatin (GEMOX-3 protocol), repeated every 28 days. The data were collected according to the Simon 2-stage design for a single centre phase II study (alpha=0.05; beta=0.2). Primary end point was response rate; secondary end points were time-to-progression (TTP), median survival, and safety profile. Thirty-one patients were enrolled in the study between July 2002 and April 2005. Therapeutic responses were as follows: partial response in eight patients (26%, 95% confidence interval (CI) 14-44), stable disease in 14 patients (45%, 95%CI 29-62), resulting in a disease control rate of 71%. Nine patients (29%, 95%CI 16-47) had progressive disease. Median TTP was 6.5 months. Median overall survival was 11 months. Common Toxicity Criteria (CTC) Grade 3-4 toxicities were transient thrombocytopenia (23%), peripheral sensory neuropathy (19%), leucopenia (16%), and anaemia (10%). In conclusion the GEMOX-3 protocol is active and well tolerated in patients with advanced BTC. It can be applied in an outpatient setting with three visits per month only.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]. / Gemcitabin/Cisplatin vs. MVAC. 5-Jahres-Ergebnisse der Phase-III-Studie zur Chemotherapie des fortgeschrittenen Urothelkarzinoms in Deutschland.

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

The clonogenic assay with human tumor xenografts: evaluation, predictive value and application for drug screening.

The feasibility, evaluation and predictive value of the colony-forming assay with human tumor xenografts for screening anticancer drugs have been studied. Using human tumors grown in serial passage in nude mice, adequate colony formation was observed in 215 of 251 (86%) different solid human tumors of various histologies. Based on in vitro growth characteristics, a quality-controlled assay protocol was developed. With the proposed criteria for standardized evaluation of individual experiments a substantial increase in assay reliability was achieved. The five clinically established agents, cisplatin, doxorubicin, etoposide, mitomycin-C and vindesine, were studied for anticancer activity in the clonogenic assay. Drugs were applied over a wide dose range by continuous exposure, yielding clear dose-response effects with coefficients of correlation between r = 0.946 and 0.995. Relevant dose levels predicting correctly for the clinical efficacy of the agents were determined by comparison of in vitro anticancer activity to in vitro toxicity on human bone marrow as follows: cisplatin 0.1 micrograms/ml, doxorubicin 0.01 micrograms/ml, etoposide 0.1 micrograms/ml, mitomycin-C 0.005 micrograms/ml, vindesine 0.01 micrograms/ml. At these concentrations, clinically sensitive tumor types showed inhibition of colony formation in 99 of 240 cases (41%), whereas 11% (19/176) of clinically resistant tumors were responsive. The relevant dose levels used equal between 0.3% and 4.0% of the achievable peak plasma concentrations in man. The predictive value of the clonogenic assay was determined by treatment of the same tumors in vitro and in vivo in tumor-bearing nude mice. In 174/220 comparisons (79%), in vitro data predicted correctly for the in vivo sensitivity of the xenografted malignancies.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of drug response in patients and in the clonogenic assay with solid human tumour xenografts.

The potential of evaluating the preclinical response of solid tumours was studied in human tumour xenografts in the clonogenic assay. Tumour specimens surgically removed from cancer patients were implanted subcutaneously into thymus-aplastic nude mice. Chemosensitivity of the mouse-grown tumours was tested with a modification of the double-layer soft-agar clonogenic assay. Tumour cells were tested against thirteen established cytostatic drugs at two dosages by continuous exposure. 62 retrospective in vivo/in vitro correlations were done. The clonogenic assay predicted correctly for clinical response in 16/27 (59%) and for resistance in 32/35 (91%). These correlation rates were similar to reported data for fresh solid human tumour specimens. The results support the clinical relevance of the nude mouse/clonogenic assay model.

Preclinical phase II study of ifosfamide in human tumour xenografts in vivo.

The in vivo effects of the oxazaphosphorine compound ifosfamide (IFO) on human tumour xenografts were assessed in thymus aplastic nude mice. The human origin of the tumours was confirmed by isoenzymatic and immunohistochemical methods. Tumour models were selected from a panel of 180 regularly growing, well-characterized xenografts. The maximum tolerated dose in tumour-bearing nude mice was determined to be 130 mg/kg per day given on days 1-3 and 15-17. After 21 days, lethality was 14% after i.p. and 6% after s.c. administration. A total of 43 human tumours were tested for antineoplastic activity, 15 of which (36%) showed regression: 4/5 breast cancer xenografts, 1/3 colon, 1/1 gastric, 2/7 non-small-cell lung cancers (NSCLC), 3/4 small-cell lung cancers (SCLC), 1/2 sarcomas and 3/3 testicular cancers. Two ovarian, two uterine and six renal cancer xenografts as well as three melanomas and five tumours of various histologies were resistant. In 30 human tumour xenografts, the antineoplastic efficacy of the two oxazaphosphorine derivatives cyclophosphamide and IFO was compared. The maximum tolerated dose of cyclophosphamide was 200 mg/kg per day given i.p. on days 1 and 15; it led to 17% lethality after 21 days. Cyclophosphamide induced tumour regression or remission in 10/30 xenografts (33%) and IFO in 13/30 (43%). In conclusion, the observed efficacy of IFO parallels the clinical situation. Breast, lung and testicular cancer and sarcomas proved to be responsive. The antitumoural activity of IFO shows similarities to that of cyclophosphamide; however, a higher response rate and lower toxicity were noted for the former. Preclinical phase II studies in nude mice seem to offer an effective way of identifying active drugs as well as sensitive tumour types for further clinical development.

[Prognostic factors in diffuse malignant mesothelioma of the pleura]. / Prognostische Faktoren beim diffusen malignen Mesotheliom der Pleura.

Diffuse malignant pleural mesothelioma (DMM) is associated with a very poor prognosis and is only partially accessible to treatment. On the basis of a retrospective analysis, we made an attempt to identify possible factors that influence the prognosis. Between 1964 and 1986, 84 evaluable patients were treated: the ratio of male to female patients was 4.3:1, their average age being 58.5 +/- 11.9 (range: 21-82 years). The tumour types included 50% epithelial, 38% biphasic, and 12% mesenchymal tumours. The classification in accordance with the suggestions of Butchart revealed: I 10%, II 89%, III 0%, IV 1%. In 32% of the patients, treatment was purely symptomatic, in 42% a palliative surgical procedure with decortication of the tumour and tumour-pleurectomy was performed, while in 26% the palliative procedure was followed by adjuvant chemotherapy using doxorubicin and cisplatin. The median survival for the patients overall was 253 days. Parameters that were found not to correlate with the prognosis were: age, sex, exposure to asbestos, use of tobacco, pleural effusion, and growth behaviour in the thymus aplastic nude mouse. A significant influence was found for the histological type of the tumour and therapy administered, epithelial and biphasic tumour forms, as also surgical and combined surgical/chemotherapeutic treatment resulting in a more prolonged survival. On the basis of these results, surgical therapy should always be employed, despite the fact that there is almost always no curative option; postoperative adjuvant therapy is capable of further improving the prognosis.

Phase-II study with the combination of cisplatin and doxorubicin in advanced malignant mesothelioma of the pleura.

The effectiveness of combination chemotherapy with doxorubicin and cisplatin was studied in patients with advanced malignant pleuramesothelioma. 19 patients were treated intravenously with cisplatin 60 mg/m2/day on days 1 and 2, and with adriamycin 40 mg/m2 on day 3 every 4 weeks. 8/19 patients (46%) responded to chemotherapy; 2 achieved complete remissions (CR), and 6 went into partial remissions (PR). Median duration of response was 222 days. Median survival time of all patients was 370 days compared to a median survival of 273 days in a historical control group consisting of 30 patients treated by surgery only. Substantial toxicity was observed, mainly gastrointestinal. We conclude that the combination of cisplatin and adriamycin is effective in malignant pleuramesothelioma. However, the duration of treatment is limited by gastrointestinal toxicity.

Colony assay with human tumor xenografts, murine tumors and human bone marrow. Potential for anticancer drug development.

The colony formation of human tumor xenografts from nude mice, of murine tumors, and of human bone marrow (CFU-C) has been investigated in vitro using a modification of the double-layer agar assay described by Hamburger and Salmon. Systematic modification of growth conditions and careful selection of viable tumor tissue enhanced the growth rate (at least 30 colonies per dish) of human tumor xenografts to 86% (98/114). The median plating efficiency was 0.07% which is comparable to the results observed by others using fresh human tumors. The growth of human bone marrow was stimulated with a placenta-conditioned medium, which allowed growth of granulocytic stem cell colonies (CFU-C). The median plating efficiency of the bone marrow was 0.08%. The murine tumors P388, L1210, B16 melanoma, Lewis lung carcinoma and colon carcinoma 38 grew very well in vitro. Excluding the Lewis lung carcinoma, the plating efficiency of these tumors was markedly higher than that of the human tumor xenografts and human bone marrow. The colony assay may have potential as a secondary screening system for identifying new active structures and also for indicating which tumor types are most responsive to a new antitumor agent. We test new structures in 20 well-selected human tumor xenografts and in the P388 mouse leukemia in dose-response relationships. The two most responsive xenograft tumors are subsequently studied in vivo in nude mice in order to determine if a new compound presents antitumor activity in an in vivo organism at a dose around the LD10 level. If a remission or at least no change is observed in the subcutaneously growing tumor, the new compound undergoes large disease-oriented testing usually in 60 xenografts. The in vivo studies are necessary in determining whether a compound has a more specific effect on tumor cells than on the dose-limiting normal tissue. The comparison of in vitro/in vivo activity allows an assessment of the relevant in vitro dose based on in vivo pharmacological behavior of a drug. It seems justifiable to apply the conclusions of this approach to the clinical setting because mouse toxicity data, e.g. the LD10, correspond well to the maximal tolerable doses in man. Moreover, for compounds whose dose-limiting toxicity is bone marrow suppression, the comparison of drug dosages effective in vitro on human bone marrow and tumor xenografts may prove helpful. The proposed testing strategy has been applied to TGU and Tiazofurin. At the relevant dosages TGU exhibited very limited activity in 67 human tumor xenografts studied.(ABSTRACT TRUNCATED AT 400 WORDS)

5-Fluorouracil, 4-epidoxorubicin, and mitomycin C (FEM) combination chemotherapy for advanced gastric carcinoma. A phase-II trial by the "chemotherapiegruppe gastrointestinaler tumoren (CGT)".

In a phase-II-trial 40 patients with advanced gastric cancer were treated with 5-fluorouracil, 4-epidoxorubicin, mitomycin C (FEM) combination therapy. Twenty-five out of 30 patients with measurable disease were evaluable for response after 8 weeks of treatment. Seven patients achieved a partial remission (PR), suggesting a response rate of 28%. Ten patients had no change (NC) and 8 patients showed progression (P). The median time to progression for patients with PR was 7.2 months and for patients with NC 6.3 months. Median survival time for all patients was 5.3 months, for patients with PR and NC 9.9 months. WHO grade 3 toxicity appeared in 3% (WBC and nausea/vomiting) and 15% (alopecia) of patients. The data suggest that this regimen is not more active, but is better tolerated than the original FAM schedule. Therefore it seems suitable for out-patient treatment, for elderly patients and for those who cannot be treated by more aggressive drugs.

Phase III study of 5-FU and carmustine versus 5-FU, carmustine, and doxorubicin in advanced gastric cancer.

Seventy-seven patients with advanced gastric carcinoma were prospectively randomized to receive 5-FU and carmustine (FB) with or without doxorubicin (FAB). Thirty-five patients were evaluable for response. Neither the response rates (partial remission, 11% for FB and 24% for FAB) nor survival times (median, 4.0 months for FB and 5.5 months for FAB) were statistically different. The median survival of patients with partial remission (7.8 months) and those with no change (7.4 months) was significantly prolonged compared to patients with progressive disease (4.5 months). The side effects of both regimens after the first treatment cycle (except alopecia in FAB) were low. After the second cycle more pronounced myelosuppression in the FAB arm was observed.

Development of three human small cell lung cancer models in nude mice.

The transplantation of seven human small cell lung cancers (SCLC) into athymic nude mice resulted in the development of three tumor lines that are suitable for study of biology and for tests of new drugs and combinations. They were characterized and the response to known drugs was determined. An identical tumor response was observed in the nude mouse system and in the patient in all four comparisons available.

[Phase II study of the water-soluble nitrosourea compound ACNU in advanced colorectal carcinomas]. / Phase-II-Studie des wasserlöslichen Nitrosoharnstoffes ACNU bei fortgeschrittenen kolorektalen Karzinomen.

In a phase-II study 46 patients with advanced colorectal cancer were treated with the new nitrosourea ACNU [1-(2-chloroethyl)-1-nitroso-3 (4-amino-2-methyl-5-pyrimidinyl)methyl-3-nitrosourea]. From 43 evaluable patients, 86% presented distant metastases and 14% an unresectable primary tumour or a recurrent tumour. 24 patients presented a colon and 19 a rectal cancer. Prior anticancer drug treatment was given to 34 patients (79%), 11 (26%) were pretreated with a nitrosourea. ACNU was administered every 4-6 weeks as a single intravenous push injection of 100 mg/m2. Most patients received 2-3 courses. From 43 evaluable patients, one patient achieved a complete and 3 a partial remission (CR + PR 9%). 5 patients reached a minimal regression (tumour regression of less than 50%) and 5 a no change for at least 2 months. The median duration (time from beginning of ACNU therapy until tumour progression) of the 14 responders was 132 days. The median survival time was significantly longer for responders in comparison to patients with progressive disease (9.8 versus 4.1 months). The dose limiting toxicity was delayed bone marrow suppression predominantly in the form of thrombocytopenia. 22/42 patients (52%) presented a thrombocytopenia of under 50.000/mm3 with a nadir after 27 days. Leucocytopenia under 2.000/mm3 were observed in 22/40 patients (30%). A fall of haemoglobin of more than 2 g/dl was seen in 71%. Nausea or vomiting over 1-2 days were found in 59% of the treatment courses. Other drug related side effects were not encountered. ACNU has a similar activity in colorectal cancer as BCNU and CCNU.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prospective randomized study in advanced stomach cancer. Comparison between combinations of 5-fluorouracil and carmustine without and with adriamycin]. / Prospektive randomisierte Studie beim fortgeschrittenen Magenkarzinom. Vergleich der Kombination von 5-Fluorouracil und Carmustin ohne und mit Adriamycin.

In a multi-center study of 77 patients with gastric carcinoma and metastases, the effects of combined 5-fluorouracil and carmustine with or without adriamycin (FB vs FAB) were compared. There was no significant difference between the two treatment groups as to rate of response or survival time, response to treatment was 20% (FB) and 24% (FAB), including "no change" 52% and 56%, respectively. But median survival time among the responders (partial remission and clinical improvement) and of the patients with unchanged findings was significantly longer (8.4 or 7.4 months, respectively) than that among patients with progression (4.5 months). Analysis of prognostic factors in terms of survival curves revealed no difference between patients with or without measurable tumor parameters, with or without local recurrences or liver metastases. However, there was a statistically significant worsening of prognosis for patients whose initial general state was reduced, who had lung metastases or increased WBC counts. Side effects were relatively mild with both therapy regimens, except for alopecia with FAB. After the second treatment cycle myelosuppression was more marked with FAB than FB.

Comparison of tumor response in nude mice and in the patients.

In 34 tumors of different origin 50 comparisons between the tumor response in the patients and in nude mice were performed. Combination chemotherapy was more successful than single agent chemotherapy. Out of the 25 combinations given, 9 (36%) effected a remission in comparison to 4 out of 25 (16%) after single agent chemotherapy. 13 patients got a remission which was found in 12 cases in the nude mouse, too. 37 patients did not respond to treatment and the same result was found in 36 cases in the nude mouse system. Xenografts gave a correct prediction for resistance in 97% and for tumor response in 92%. Despite great efforts to obtain a large number of comparisons, only 22 test results were available before the patients needed chemotherapy. In 13 cases chemotherapy was done simultaneously in the patient and in the nude mouse system. In 15 cases the patients were treated first. The xenograft system will not have practical significance in determining the treatment of the patients. Limitations are the duration of the testing, the testing rate of about 50% and the charges for nude mice. However, the highly correct prediction rates for tumor sensitivity and resistance validates human tumor xenografts as tumor models to test new drugs and combinations.

Clonal growth of human tumor xenografts. First experiences in drug testing.

Human tumors growing as nude mice xenografts were investigated for growth in a clonogenic assay. Colony formation of more than 30 colonies per plate was obtained in 47 of 63 tumors examined (74.6%). The growth rate was enhanced by raising the concentration of fetal calf serum in the culture medium. Plating efficiency ranged from 0.0003% to 5.5%. To study the applicability of this model for screening new anticancer drugs, preliminary studies in drug sensitivity were conducted with continuous incubation of different anticancer drugs in a dose range of 1/10 to 10 times the maximum achievable plasma level. The highest concentration almost always led to a complete suppression of colony growth. In our opinion the procedure described may be a useful combination of two methods in predictive drug testing, provided drug concentration and mode of drug incubation are adequately considered.

[Phase II study of AMSA in adults with acute therapy-refractory leukemias]. / Phase-II-Studie von AMSA bei Erwachsenen mit therapierefraktären akuten Leukämien.

The acridine derivative AMSA, Amsacrine, is a new anticancer drug which was effective in patients with advanced AML and ALL in studies performed in USA. In a multicenter phase II trial we treated 27 patients with acute resistant leukemia with AMSA. All presented progressive disease following several drug combination regimens. Out of the 25 evaluable patients 5 were resistant to primary therapies, 13 were in 2nd relapse, 6 in 3rd, and 1 in 4th relapse. Dosage was 75 mg/m2, iv, day 1-7, all 3-5 weeks. On an average, only 76% of the planned dose per cycle could be given, due to severe leucopenia. From 21 patients with ALL, 1 CR and 3 PR were observed; the 3 patients with ALL presented 1 CR and 1 PR. 1 AUL showed progressive disease. In all patients a marked cell reduction could be observed in the peripheral blood. The general tolerance was good. The most important side-effect was bone-marrow toxicity, 48% (12/25) presented leucopenia less than or equal to 600/mm3, 5 (20%) had fatal septic complications. All 5 early death presented high initial leucocyte counts of greater than or equal to 32.000 mm3 as a common risk factor. In conclusion, AMSA is an effective drug in heavily pretreated patients with AML and ALL.