A phase II study on the efficacy and safety of procedural analgesia with fentanyl buccal tablet in cancer patients for the placement of indwelling central venous access systems.

BACKGROUND: Pain in cancer patients is often related to oncologic therapies and diagnostic procedures. The placement of fully implantable venous access systems is a very common procedure in oncology patients. Local anaesthesia is the method most commonly used to overcome pain related to this surgical procedure, but the local anaesthetic may be unable to completely eradicate all pain. This study investigates the effectiveness and safety of fentanyl buccal tablet (FBT), administered by OraVescent® technology, in reducing procedural pain related to the placement of indwelling central venous access systems (Ports) in opioid-naïve cancer patients. METHODS: Inpatients who required an indwelling vascular access (Port) were preoperatively assessed with a self-assessment questionnaire on anxiety and pain. A 100 µg FBT was administered 10 min before preparation of the operating field. A self-assessment scale for pain experienced during the procedure was administered at the end of the procedure. Vital signs and the presence of any side effects or bothersome symptoms were monitored during the procedure, at the end, and 4 h later. RESULTS: From October 2012 to June 2014, 65 patients were enrolled in the study. A total of 61 (93.9 %) patients perceived no or a little pain during the procedure. Four patients (6.2 %) reported a lot of pain. No patient reported very severe pain. This data is significant in terms of the lower than expected presence of pain (Fisher test p = 0.0018) as assessed in our previous experience without procedural analgesia. The most common side effects of FBT was drowsiness, experienced by 28 patients at the end of the procedure (43.1 %), significantly reduced (p < 0.01) to 8 patients after 4 h (12.5 %). Nausea was present in 6 cases at the end of the procedure (9.2 %) and in 7 cases 4 h later (10.9 %). Vomiting was present in 3 cases at the end (4.7 %) and in 2 other patients after 4 h (7.8 %). No significant change of vital parameters was observed between the baseline and the subsequent measurements in all patients studied. CONCLUSIONS: The significant improvement in the number of patients experiencing little or no pain, accompanied by a lower number of non-severe side effects, suggests that FBT is a valid, practical and safe method of procedural analgesia. It will be necessary to perform further studies, taking into account the need for standard antiemetic pre-medication to minimise the incidence of nausea and vomiting.

MUC1 oncogene amplification correlates with protein overexpression in invasive breast carcinoma cells.

The MUC1 gene is aberrantly overexpressed in approximately 90% of human breast cancers. Several studies have shown that MUC1 overexpression is due to transcriptional regulatory events. However, the importance of gene amplification as a mechanism leading to the increase of MUC1 expression in breast cancer has been poorly characterized. The aim of this study was to evaluate the role of MUC1 gene amplification and protein expression in human breast cancer development. By means of real-time quantitative polymerase chain reaction and immunohistochemical methods, 83 breast tissue samples were analyzed for MUC1 gene amplification and protein expression. This analysis showed MUC1 genomic amplification and a positive association with the histopathological group in 12% (1 out of 8) of benign lesions and 38% (23 out of 60) of primary invasive breast carcinoma samples (P = 0.004). Array-comparative genomic hybridization meta-analysis of 886 primary invasive breast carcinomas obtained from 22 studies showed MUC1 genomic gain in 43.7% (387 out of 886) of the samples. Moreover, we identified a highly statistical significant association between MUC1 gene amplification and MUC1 protein expression assessed by immunohistochemistry and Western blot test (P < 0.0001). In conclusion, this study demonstrated that MUC1 copy number increases from normal breast tissue to primary invasive breast carcinomas in correlation with MUC1 protein expression.

Molecular control of reactive gas uptake "on water".

Reactive gas uptake on environmentally realistic aqueous surfaces is expected to be affected by a combination of multiple interactions. This issue is herein explored in experiments where the formation of Me(3)NH(+) on neat and doped water microjets exposed to Me(3)N(g) is monitored within <1 ms by online electrospray ionization mass spectrometry as a function of pH of the bulk liquid (pH(BLK)). Notably, Me(3)N(g) is protonated on the surface of neat water microjets below pH(BLK) approximately 4, rather than at pH(BLK) less than or approximately pK(A)(Me(3)NH(+)) = 9.8 as in bulk water. Me(3)N(g) uptake is significantly enhanced by anionic surfactants and fulvic acid (a surrogate of complex natural organic matter) above pH(BLK) approximately 4, uniformly depressed by cationics (which otherwise counteract FA effects), and unaffected by n-octanol. The direct hydrogen isotope effects associated with enhanced uptake of Me(3)N(g) on H(2)O/D(2)O microjets implicate a process controlled by proton transfer from interfacial donors whose coverage is electrostatically modulated by ionic headgroups. The finding that the combined effect of fulvic acid and tetrabutylammonium bromide closely matches the geometric mean of their separate effects on TMA uptake is evidence of strong dopant interactions.

Rhomboid domain containing 2 (RHBDD2): a novel cancer-related gene over-expressed in breast cancer.

In the course of breast cancer global gene expression studies, we identified an uncharacterized gene known as RHBDD2 (Rhomboid domain containing 2) to be markedly over-expressed in primary tumors from patients with recurrent disease. In this study, we identified RHBDD2 mRNA and protein expression significantly elevated in breast carcinomas compared with normal breast samples as analyzed by SAGE (n=46) and immunohistochemistry (n=213). Interestingly, specimens displaying RHBDD2 over-expression were predominantly advanced stage III breast carcinomas (p=0.001). Western-blot, RT-PCR and cDNA sequencing analyses allowed us to identify two RHBDD2 alternatively spliced mRNA isoforms expressed in breast cancer cell lines. We further investigated the occurrence and frequency of gene amplification and over-expression affecting RHBDD2 in 131 breast samples. RHBDD2 gene amplification was detected in 21% of 98 invasive breast carcinomas analyzed. However, no RHBDD2 amplification was detected in normal breast tissues (n=17) or breast benign lesions (n=16) (p=0.014). Interestingly, siRNA-mediated silencing of RHBDD2 expression results in a decrease of MCF7 breast cancer cells proliferation compared with the corresponding controls (p=0.001). In addition, analysis of publicly available gene expression data showed a strong association between high RHBDD2 expression and decreased overall survival (p=0.0023), relapse-free survival (p=0.0013), and metastasis-free interval (p=0.006) in patients with primary ER-negative breast carcinomas. In conclusion, our findings suggest that RHBDD2 over-expression behaves as an indicator of poor prognosis and may play a role facilitating breast cancer progression.

Simultaneous detection of cysteine sulfenate, sulfinate, and sulfonate during cysteine interfacial ozonolysis.

Sulfenic acids (RSOH) are reactive intermediates in the oxidation of protein cysteines. Among cysteine oxoforms, RSOH represent redox-reversible species that can thus participate in regulation and signaling mechanisms and play key roles in enzyme catalysis and antioxidant activity. How the cysteine (CyS) thiol groups of the human surfactant protein that lines the lung epithelium react with inhaled ozone is deemed critical in preserving structural integrity and immune functions. Here we report the simultaneous detection, by online thermospray ionization mass spectrometry, of cysteine sulfenate (CySO(-)) and the overoxidized cysteine sulfinate (CySO(2)(-)) and cysteine sulfonate (CySO(3)(-)) species on the surface of aqueous CyS microdroplets exposed to O(3)(g) for <1 ms. These species are produced by rapid, sequential O-atom additions whose relative rates are herein quantified for the first time. From the pH-dependence of ozonation rates, we derive pK(a)(CySOH) = 7.6 +/- 0.3 < pK(a)(CyS) = 8.3.

How phenol and alpha-tocopherol react with ambient ozone at gas/liquid interfaces.

The exceptional ability of alpha-tocopherol (alpha-TOH) for scavenging free radicals is believed to also underlie its protective functions in respiratory epithelia. Phenols, however, can scavenge other reactive species. Herein, we report that alpha-TOH/alpha-TO(-) reacts with closed-shell O(3)(g) on the surface of inert solvent microdroplets in < 1 ms to produce persistent alpha-TO-O(n)(-)(n = 1-4) adducts detectable by online thermospray ionization mass spectrometry. The prototype phenolate PhO(-), in contrast, undergoes electron transfer under identical conditions. These reactions are deemed to occur at the gas/liquid interface because their rates: (1) depend on pH, (2) are several orders of magnitude faster than within microdroplets saturated with O(3)(g). They also fail to incorporate solvent into the products: the same alpha-TO-O(n)(-) species are formed on acetonitrile or nucleophilic methanol microdroplets. alpha-TO-O(n = 1-3)(-) signals initially evolve with [O(3)(g)] as expected from first-generation species, but alpha-TO-O(-) reacts further with O(3)(g) and undergoes collisionally induced dissociation into a C(19)H(40) fragment (vs C(19)H(38) from alpha-TO(-)) carrying the phytyl side chain, whereas the higher alpha-TO-O(n > or = 2)(-) homologues are unreactive toward O(3)(g) and split CO(2) instead. On this basis, alpha-TO-O(-) is assigned to a chroman-6-ol (4a, 8a)-ene oxide, alpha-TO-O(2)(-) to an endoperoxide, and alpha-TO-O(3)(-) to a secondary ozonide. The atmospheric degradation of the substituted phenols detected in combustion emissions is therefore expected to produce related oxidants on the aerosol particles present in the air we breathe.

Ozone oxidizes glutathione to a sulfonic acid.

Biosurfaces are universally covered with fluid microfilms containing reduced glutathione (GSH) and other antioxidants whose putative roles include the detoxification of ambient ozone (O(3)). It is generally believed that O(3) accepts an electron from the thiolate GS(2-) function [pK(a)(GS(-)) = 8.8] of GSH to produce thiyl GS(*-) radicals en route to the disulfide GSSG. Here, we report novel electrospray mass spectrometry experiments showing that sulfonates (GSO(3)(-)/GSO(3)(2-)), not GSSG, are the exclusive final products on the surface of aqueous GSH microdroplets exposed to dilute O(3)(g) for approximately 1 ms. The higher reactivity of the thiolate GS(2-) toward O(3)(g) over the thiol GS(-) is kinetically resolved in this time frame due to slow GS(-) acid dissociation. However, our experiments also show that O(3) will be largely scavenged by the more reactive ascorbate coantioxidant in typical interfacial biofilms. The presence of GSSG and the absence of GSO(3)(-)/GSO(3)(2-) in extracellular lining fluids are therefore evidence of GSH oxidation by species other than O(3).

Acidity enhances the formation of a persistent ozonide at aqueous ascorbate/ozone gas interfaces.

The pulmonary epithelium, like most aerial biosurfaces, is naturally protected against atmospheric ozone (O(3)) by fluid films that contain ascorbic acid (AH(2)) and related scavengers. This mechanism of protection will fail, however, if specific copollutants redirect AH(2) and O(3)(g) to produce species that can transduce oxidative damage to underlying tissues. Here, the possibility that the synergistic adverse health effects of atmospheric O(3)(g) and acidic particulate matter revealed by epidemiological studies could be mediated by hitherto unidentified species is investigated by electrospray mass spectrometry of aqueous AH(2) droplets exposed to O(3)(g). The products of AH(2) ozonolysis at the relevant air-water interface shift from the innocuous dehydroascorbic acid at biological pH to a C(4)-hydroxy acid plus a previously unreported ascorbate ozonide (m/z = 223) below pH approximately 5. The structure of this ozonide is confirmed by tandem mass spectrometry and its mechanism of formation delineated by kinetic studies. Present results imply enhanced production of a persistent ozonide in airway-lining fluids acidified by preexisting pathologies or inhaled particulate matter. Ozonides are known to generate cytotoxic free radicals in vivo and can, therefore, transduce oxidative damage.

Electrospray mass spectrometric detection of products and short-lived intermediates in aqueous aerosol microdroplets exposed to a reactive gas.

The intermediates ISO3- (m/z=207) and IS2O3- (m/z=239) generated in aqueous (NaI/Na2S2O3) microdroplets traversing dilute O3 gas plumes are detected via online electrospray mass spectrometry within approximately 1 ms, and their stabilities gauged by collisionally induced dissociation. The simultaneous detection of anionic reactants and the S2O62-, HSO4-, IO3-, and I3- products as a function of experimental conditions provides evidence of genuinely interfacial reaction kinetics. Although O3(aq) reacts about 3 times faster with I- than with S2O32- in bulk solution, only S2O32- is significantly depleted in the interfacial layers of [I-]/[S2O32-]=10 microdroplets below [O3(g)] approximately 50 ppm.

Oral etoposide in elderly patients with advanced non small cell lung cancer: a clinical and pharmacological study.

Seventeen elderly patients with advanced progressive non small cell lung cancer (NSCLC) were treated with oral etoposide at the daily dose of 100 mg for 14 days every 3-4 weeks with pharmacokinetic monitoring. One partial response and 6 stabilizations were documented with a median overall duration of 13 weeks (range 8-32). The median survival was 24 weeks with an apparent advantage for non-progressive patients (40 weeks vs. 18 weeks). The treatment was well tolerated especially by those patients without concomitant illness, suggesting the crucial role of a careful selection of the geriatric population. Toxicity was not related to the etoposide plasma level, but was clearly dependent on comorbidity. A geriatric assessment rather than chronological age therefore appears to be more reliable in the selection of elderly patients for clinical trials. The easy self-management, favorable toxicity profile and synergy with other compounds makes oral etoposide suitable for further clinical-pharmacological studies in elderly patients.

MUC1 cytoplasmic tail detection using CT33 polyclonal and CT2 monoclonal antibodies in breast and colorectal tissue.

UNLABELLED: The immunohistochemical detection (IHC) of MUC1-CT employing a polyclonal antibody (CT33) in relation to CT2 monoclonal antibody (MAb) was analyzed. Western blot (WB) was used to determine the molecular mass of CT. MATERIALS AND METHODS: We studied 163 breast and 89 colorectal cancer specimens, 10 breast and 14 colorectal benign conditions, and 12 breast and 20 colorectal normal samples. From each tumor sample, subcellular fractions were obtained and analyzed by SDS-PAGE and WB. A nonparametric statistical analysis was employed; data were standardized and a Kendall-Tau correlation was applied. RESULTS: By IHC, 146/163 (90%) and 151/163 (93%) of breast cancer were positive with CT33 and CT2, respectively; a statistically significant correlation was obtained (t=0.5199). Seven out of ten (70%) benign breast specimens were positive with CT33 while all samples stained with CT2; in normal breast sample tissues, all were positive with both Abs. In colorectal cancer samples, both antibodies stained 47/89 (53%) samples; CT2 reacted in 13/14 (93%) of benign samples while CT33 showed a positive reaction in 9/14 (64%) of benign specimens. In normal samples, CT2 showed staining in 17/20 (85%) of samples and CT33 was reactive in 12/20 (60%). By WB, in breast and colorectal cancer samples, similar results were obtained with both antibodies: a main band at about 30kDa which represents the smaller subunit. CONCLUSION: CT33 polyclonal antibody has demonstrated its efficacy to detect MUC1 in breast and colorectal cancer tissues with similar reactivity to CT2. It is worthwhile to affirm that CT33 is a good indicator of MUC1 expression.

The EORTC clinical research coordinators group. European Organisation for Research and Treatment of Cancer.

The Clinical Research Coordinators Group (CRCG) is an umbrella organisation, compiled from four existing groups, namely the Oncology Nurses Group, the Data Management Group, the Radiation Technologists Group and the Early Clinical Studies Group Research Nurses. From the existing steering committees, a new board was formed and consists of two members per group. The CRCG will function as an independent group within the EORTC. The CRCG will create conditions and standards for implementing and conducting clinical protocols according to Good Clinical Practice.

Population pharmacokinetics and pharmacodynamics of oral etoposide.

AIMS: To study the population pharmacokinetics and pharmacodynamics of oral etoposide in patients with solid tumours. METHODS: A prospective, open label, cross-over, bioavailability study was performed in 50 adult patients with miscellaneous, advanced stage solid tumours, who were receiving oral (100 mg capsules) etoposide for 14 days and i.v. (50 mg) etoposide on day 1 or day 7 in randomised order during the first cycle treatment. Total and unbound etoposide concentration were assayed by h.p.l.c. Population PK parameters estimation was done by using the P-Pharm software (Simed). Haematological toxicity and tumour response were the main pharmacodynamic endpoints. RESULTS: Mean clearance was 1.14 l h(-1) (CV 25%). Creatinine clearance was the only covariable to significantly reduce clearance variability (residual CV 18%). (CL = 0.74 + 0.0057 CLCR; r(2) = 0.32). Mean bioavailability was 45% (CV 22%) and mean protein binding 91.5% (CV 5%). Exposure to free, pharmacologically active etoposide (free AUC p.o.) was highly variable (mean value 2.8 mg l(-1) h; CV 64%; range 0.4-9.5). It decreased with increased creatinine clearance and increased with age which accounted for 9% of the CV. Mean free AUC p.o. was the best predictor of neutropenia. Free AUC50 (exposure producing a 50% reduction in absolute neutrophil count) was 1.80 mg l(-1) h. In patients with lung cancer, the free AUC p.o. was higher in the two patients with responsive tumour (5.9 mg l(-1) h) than in patients with stable (2.1 mg l-1 h) or progressive disease (2.3 mg l-1 h) (P = 0.01). CONCLUSIONS: Exposure to free etoposide during prolonged oral treatment is highly variable and is the main determinant of pharmacodynamic effects. The population PK model based on creatinine clearance is poorly predictive of exposure. Therapeutic drug monitoring would be necessary for dose individualization or to study the relationship between exposure and antitumour effect.

The elderly cancer patient: a nursing perspective.

Since cancer incidence tends to increase with age, health professionals will encounter ever-greater numbers of older people with cancer. Elderly cancer patients present complex problems that need comprehensive physical and psychosocial support. In order to give specialised care to this segment of the population, a multidisciplinary approach must be used; only in this way can an individualised treatment program be provided. Oncology nurses are an important component of this team and can contribute significantly to the panorama of needs of this segment of the population, which include the prevention and early detection of cancer, the use of state-of-the-art treatments, patient education, care during and after hospitalisation and quality of life (QOL) issues. In this way, the older person with cancer can be treated in an optimal manner and survival can hopefully be improved in a meaningful way.

Establishment and characterization of a cell line (T201) derived from a human larynx squamous cell carcinoma.

The purpose of this report was the initiation and further maintenance of tumor cells from a primary larynx squamous cell carcinoma. A tumor fragment was mechanically dissociated, the cells were grown in RPMI medium, being the primary culture dependent on the presence of epidermal growth factor and insulin; during subsequent passages the adaptation to conventional growth conditions was obtained. Cells grew in monolayer with an epitheliod shape, showing a pavement-like arrangement; at confluence, cells piled up without contact inhibition maintaining the same morphology. Population doubling time was about 48 h with a colony-forming efficiency of 10%. Immunocytochemical characterization was performed with a panel of monoclonal antibodies reactive against tumor associated antigens, including mucin glycoproteins and related carbohydrate antigens, carcinoembryonic antigen (CEA), p53 as well as cytokeratins, vimentin and desmin. T201 expressed CEA, sialyl Lewis x, Lewis x, Lewis y, MUC1 mucin, Tn hapten, p53, vimentin and cytokeratins. On the other hand, a modal chromosome diploid number of 46 occurring in 74% of cells was detected. Present data confirmed that the methodology employed was adequate for the establishment and characterization of a new cell line which can provide a useful model to study biological and immunological aspects of larynx squamous cell carcinoma.

Dose-finding and pharmacologic study of chronic oral idarubicin therapy in metastatic breast cancer patients.

Oral idarubicin (IDA) is an active drug in metastatic breast cancer, but its role in the management of this tumor is yet not established completely. To investigate a new modality of IDA administration, a dose-finding study was designed with hyperfractionated doses. The purpose was to determine the maximum tolerated dose (MTD), the dose-limiting toxicity (DLT), and the pharmacokinetics of this schedule. IDA was administered twice daily as outpatient therapy in cycles of 3 weeks followed by a 1-week rest. Thirty-one patients with progressive metastatic breast cancer and pretreated with chemotherapy (including epirubicin and doxorubicin) were enrolled. DLT was defined as G4 hematological toxicity or any other toxicity G3 or higher (Bloom and Richardson grading). Inter- and intrapatient dose increases were studied. Pharmacokinetics of IDA and its metabolite idarubicinol (IDOL) were evaluated. IDA dose was increased from 2 mg/day to 10 mg/day, by steps of 1 mg/day, with the larger dose given in the evening. MTD was reached at 10 mg/day. Overall, the therapy cycles were 69 (median/patient, 2; range, 1-6). DLTs were G4 neutropenia associated with leukopenia and thrombocytopenia in one patient and G3 diarrhea in another of the 5 patients in the 10 mg/day cohort. The two patients developing DLT at the daily dose of 10 mg received a dose normalized for body surface of 6.85 and 5.65 mg/m2/day, respectively. We considered 5.5 mg/m2/day to be the MTD. Other toxicities were nausea, vomiting, neutropenia, and diarrhea, grades G1 to G2. By univariate analysis, significant correlations were observed between absolute neutrophil count at nadir and IDA area under the curve (P = 0.022; r = -0.33), IDA Cmax (P = 0.0067; r = -0.38), IDOL area under the curve (P = 0.0009; r = -0.43), and IDOL Cmax (P = 0.0016; r = -0.41), respectively. By multivariate analysis, IDA Cmax was the strongest determinant for neutropenia (R2 = 0.14; P = 0.01). Among the 21 patients evaluable for response, 3 (14.3%) had partial response (lasting 3, 6, and 8 months, respectively), and 6 (28.6%) had a complete arrest of disease progression (lasting 2-6 months). In conclusion, the MTD of this schedule is 10 mg/day and the DLTs are neutropenia and diarrhea. Tolerance was good, and the treatment is feasible as home therapy. Some objective measurable responses were documented in this group of anthracycline-pretreated patients. IDOL could have a role for the pharmacological effect. Further evaluation of this schedule is warranted to assess the activity and toxicity of prolonged oral IDA administration.

Efficacy of total androgen blockade in metastatic prostatic carcinoma with transient hypogonadotropic hypogonadism: a case report.

A patient affected by metastatic prostatic carcinoma and hypogonadotropic hypogonadism (HH) was treated with flutamide 750 mg/day plus an LH-RH analog. After confirmation of basal castration during treatment, he continued with antiandrogens alone. Following the normalization of gonadic function and subjective mild bone flare-up, the patient resumed the initial treatment and obtained a partial response. When flutamide was interrupted because of liver toxicity, the patient showed progressive disease in the bone, which was unresponsive to both flutamide resumption and salvage hormone therapy (bicalutamide). The patient is currently receiving chemotherapy with VP16 and estramustine phosphate and is showing both serologic (PSA) and symptomatic response. The interest of this case lies in the incidental detection of HH during therapy and in the responsiveness to treatment.

Pharmacokinetic interaction between etoposide and tamoxifen in patients with hepatocellular carcinoma.

The effect of tamoxifen (TAM) on the pharmacokinetics of oral administration of etoposide (VP-16) in patients with nonoperable hepatocellular carcinoma was investigated. The pharmacokinetics of VP-16 was studied by using a validated limited sampling strategy. The pharmacokinetic parameters of VP-16, such as area under curve (AUC), free AUC and protein binding, were determined from drug plasma concentrations at 1 and 4 h after VP-16 administration on the first day (day -1) and at the end of the chemotherapy cycle (day -21) for VP-16 alone and VP-16+TAM, respectively. When VP-16 was administered in association with TAM, the median total systemic exposure was not significantly (p = NS) different from that observed when VP-16 was administered alone [33.74 (range 11.19-56.58) versus 32.97 (range 20.23-119.28) mg/l/h]. Moreover, TAM did not affect significantly (p = NS) the levels of protein binding of VP-16 [median 94.6 (range 87.7-98.2) versus median 94.9 (range 91.6-98.0)% for VP-16+TAM and VP-16 alone, respectively] and the systemic exposure of the free drug (free AUC) [1.86 (range 0.21-4.57) versus median 1.78 (range 0.59-3.73) mg/l/h for VP-16+TAM and VP = 16 alone, respectively]. These results indicate a lack of pharmacokinetic interaction between VP-16 and TAM, and suggest that the increased hematological toxicity observed when TAM is given in combination with VP-16 could be related to pharmacodynamic interactions.

Identification and characterization of different subpopulations in a human lung adenocarcinoma cell line (A549).

The morphology, cell growth, antigenic expression and tumorigenicity of cell subpopulations from the A549 lung adenocarcinoma isolated by Percoll gradient separation have been analysed. Four subpopulations were obtained (subpopulations A, B, C and D). Immunocytochemical analysis of several antigens was performed with monoclonal antibodies (MAbs): MUC1 mucin (C595, HMFG1 and HMFG2), MUC5B (PANH2); gp230 (PANH4); carbohydrate antigens including sialyl Lewis x (KM93), Tn antigen (83D4), Lewis y (C14); 5, 6, 8, 17 and 19 cytokeratins and p53. The cell population D tended to form cell aggregates that piled up on the monolayer similar to overgrowth cultures of the A549 parental cell line, whereas A, B and C cell subpopulations formed well spread monolayers. Both parental A549 and subpopulation D secreted abundant mucus. The topographic distribution and secretion production were correlated with tumorigenic assays since only subpopulation D grew in nude mice exhibiting reduced latency period; these characteristics correlated with the fast growth of the subpopulation D in vitro. Immunocytochemical analysis demonstrated that subpopulation D showed greater expression of MUC1 mucin and carbohydrate antigens such as Tn antigen, sialyl Lewis x and Lewis y and less expression of cytokeratins, p53, MUC5B and gp230; conversely, subpopulations A, B and C showed the opposite antigenic profile. Our results illustrate heterogeneity in the A549 cell line; subpopulations A, B and C retained characteristics of more differentiated adenocarcinoma while subpopulation D displayed features of a less differentiated tumor line.

Pharmacokinetics of oral etoposide in patients with hepatocellular carcinoma.

Etoposide dosage in patients with liver dysfunction remains controversial. Since etoposide has a hepatic component to its clearance (CL) and shows a high degree of protein binding, hepatic impairment could affect etoposide disposition. However, the empiric recommendation that the dose of etoposide be decreased in such patients may reduce systemic exposure and be detrimental to its antitumor activity. To address these issues we studied the pharmacokinetics (PK) of etoposide in patients with hepatocellular carcinoma (HCC) and underlying cirrhosis (n = 17) treated with daily oral etoposide. Unbound etoposide was obtained by ultrafiltration. Etoposide concentrations (total and free drug) were measured by high-performance liquid chromatography (HPLC) and analyzed by noncompartmental equations. The patients had mild or moderate liver dysfunction. Albuminemia was in the normal range for all the patients. Creatininemia was normal in all but two patients. PK results (mean and range) showed that etoposide disposition was unchanged in patients with liver dysfunction. We found slightly high etoposide bioavailability [F, 61% (17-95%)] and clearance [CL, 1.1 (0.7-2.3)l h(-1) m(-2)] resulting in a normal degree of systemic exposure (AUC(oral) 27 microg h ml(-1)). Normal protein binding [PB 93.2% (84.4-98.1%)] contributed to a normal level of exposure to free drug (AUC(f, oral) 1.9 microg h ml(-1)). The distribution volume [V(SS) 8.4 (6.1-13.2) l/m2] and the effective half-life [t1/2eff, 5.1 (3.0-9.6) h] were normal. Median CL and protein binding did not differ in the seven patients with total bilirubin value of > 1.2 mg/dl as compared with the ten patients with total bilirubin levels of < or = 1.2 mg/dl (1.3 versus 1.01 h(-1) m(-2) and 92.5% versus 93.4%, respectively). In agreement with this PK finding, we observed no clinical evidence of increased toxicity in patients with hyperbilirubinemia as compared with patients with normal bilirubinemia (mean WBC decrease 38% versus 47%). The only case of severe (grade 4) hematological toxicity was observed in one patient with reduced glomerular filtration. Since the pharmacological effects of etoposide correlate with the level of systemic exposure to the free drug, our data suggest that no dose reduction is needed in patients with HCC. It is even possible to increase the dose intensity in patients with favorable PK parameters under appropriate hematological and therapeutic drug monitoring.