A multicenter, randomized trial of flat dosing versus intrapatient dose escalation of single-agent carboplatin as first-line chemotherapy for advanced ovarian cancer: an SGCTG (SCOTROC 4) and ANZGOG study on behalf of GCIG.

BACKGROUND: The aim of the study is to demonstrate that intrapatient dose escalation of carboplatin would improve the outcome in ovarian cancer compared with flat dosing. PATIENTS AND METHODS: Patients with untreated stage IC-IV ovarian cancer received six cycles of carboplatin area under the curve 6 (AUC 6) 3 weekly either with no dose modification except for toxicity (Arm A) or with dose escalations in cycles 2-6 based on nadir neutrophil and platelet counts (Arm B). The primary end-point was progression-free survival (PFS). RESULTS: Nine hundred and sixty-four patients were recruited from 71 centers. Dose escalation was achieved in 77% of patients who had ≥1 cycle. The median AUCs (cycle 2-6) received were 6.0 (Arm A) and 7.2 (Arm B) (P < 0.001). Grade 3/4 non-hematological toxicity was higher in Arm B (31% versus 22% P = 0.001). The median PFS was 12.1 months in Arm A and B [hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.85-1.15; P = 0.93]. The median overall survival (OS) was 34.1 and 30.7 months in Arms A and B, respectively (HR 0.98; 95% CI 0.81-1.18, P = 0.82). In multivariate analysis, baseline neutrophil (P < 0.001), baseline platelet counts (P < 0.001) and the difference between white blood cell (WBC) and neutrophil count (P = 0.009) had a significant adverse prognostic value. CONCLUSIONS: Intrapatient dose escalation of carboplatin based on nadir blood counts is feasible and safe. However, it provided no improvement in PFS or OS compared with flat dosing. Baseline neutrophils over-ride nadir counts in prognostic significance. These data may have wider implications particularly in respect of the management of chemotherapy-induced neutropenia.

Pharmacokinetics of 2,5-diaziridinyl-3,6-bis(2-hydroxyethylamino)-1,4-benzoquinone (BZG, NSC 224070) during a phase I clinical trial.

Plasma levels of 2,5-diaziridinyl-3,6-bis(2-hydroxyethylamino)-1,4-benzoquinone (BZQ, NSC 224070) were measured in nine patients after i.v. administration of the drug during a Phase I trial. Our own isocratic high performance liquid chromatographic (HPLC) method with a sensitivity of 3 ng/ml was used to quantify BZQ. Patients receiving 18-60 mg BZQ i.v. showed alpha and beta plasma decays with half-lives of 6.2 +/- 1.5 (mean +/- S.D.) and 24 +/- 4 min respectively. The apparent volume of the central compartment was 12.2 +/- 4.6 l, and the total volume of distribution was 33.6 +/- 11.3 l. The calculated plasma AUCs were linearly related to dose. A marked similarity in kinetic parameters was found for BZQ and diaziquone (AZQ, NSC 182986), another diaziridinylbenzoquinone that has recently completed phase II clinical trials.

The effect of alkylating agents and other drugs on the accumulation of melphalan by murine L1210 leukaemia cells in vitro.

The effect of cytotoxic and other drugs on the accumulation of melphalan by L1210 murine leukaemia cells was studied. We have confirmed that uptake is an active process competitively inhibited by L-leucine. In 36 experiments in amino acid-free medium the mean concentration of melphalan taken up was 225 pmoles/10(6) cells. High pressure liquid chromatographic analysis showed that the majority of the drug is present as free native melphalan. 1,3-Bis(2-chloroethyl)-1-nitrosourea (BCNU) was the only drug that stimulated accumulation, but without significant effect on influx or efflux rates. Busulphan, chlorambucil, cyclophosphamide, interferon, methotrexate and prednisolone had no effect on accumulation after 30 min melphalan transport. Adriamycin, CCNU, methyl CCNU, mustine and vincristine all impaired melphalan accumulation as did the non-cytotoxic drugs aminophylline, chlorpromazine and ouabain. Adriamycin, aminophylline, chloropromazine, indomethacin and ouabain all reduced melphalan influx.

Semi-micro adaptation of a 4-day differential staining cytotoxicity (DiSC) assay for determining the in-vitro chemosensitivity of haematological malignancies.

A semi-micro differential staining cytotoxicity (micro-DiSC) assay has been developed to determine the in-vitro chemosensitivity of haematological cancers. The method comprised isolation of leukocytes from blood or bone marrow, drug exposure and culture for 4 days in 1 ml tubes arranged in the microtitre format. Drug-induced tumour cell kill was determined by differential staining of live and dead cells, such that the former could be morphologically identified. Tumour cell viability was calculated by reference to an internal standard of fixed duck red blood cells. Up to 15 drugs at 5-6 concentrations each could be set up at a time in the assay within one hour of receipt of a sample, using only 10(7) viable cells. A result was obtained in 38 of 40 samples received. The assay is of potential use for the routine prediction of clinical response to cytotoxic drugs in haematological cancers and warrants wider investigation.

Comparison of the fed and fasting states on the absorption of melphalan in multiple myeloma.

Melphalan absorption was studied over three consecutive days in five patients with multiple myeloma. On 1 day melphalan (approximately 7 mg/m2 = 10-12 mg) was administered IV, on 1 day PO fasting, and on 1 day PO after a standard breakfast. The order was different for each patient to minimise trends that might affect absorption. Melphalan concentrations were determined by high-pressure liquid chromatography and fitted to biexponential equations by computer. The parameters of these equations were in broad agreement with previously published data, and melphalan absorption varied between patients. Considerable differences were observed in the melphalan concentration curves between the 'PO fed' and 'PO fasting' days: on the PO fed days the delay before absorption started was longer (1.1 +/- 0.5 h as against 0.3 +/- 0.1 h); peak plasma levels were one-third the value (65 +/- 15 ng/ml; 195 +/- 80 ng/ml) and occurred at twice the time after administration (2.8 +/- 0.8 h; 1.3 +/- 0.3 h); and areas under the curve were smaller 10.8 +/- 4.7 min X micrograms/ml; 23.8 +/- 13.8 min X micrograms/ml). There was a significant difference between the fraction of the dose of melphalan absorbed on the PO fed day (0.49 +/- 0.20) and on the PO fasting day (0.93 +/- 0.22), with P less than 0.005. This work suggests that melphalan should be taken first thing in the morning to obtain greatest absorption.

The quantitation of cyclophosphamide in human blood and urine by mass spectrometry-stable isotope dilution.

The levels of cyclophosphamide in the blood and the urine of patients have been monitored by direct insertion, electron impact mass spectrometry using the principle of stable isotope dilution. When a tetradeuterated analogue of the drug was added to a sample of blood or urine the concentration of cyclophosphamide could be determined from the ratio of the intensities of the signals (M-CH2 C1) characteristic for cyclophosphamide and the tetradeuterated analogue present in the mass spectrum of a chloroform extract. The procedure is highly specific for cyclophosphamide and obviates the need to use radioactively labelled cyclophosphamide for quantitation of the drug in man.

Pectoral myoplasty for recurrent pneumothorax: an extrathoracic solution to an intrathoracic problem.

The recurrence rate of spontaneous pneumothorax in patients with underlying lung disease can be as high as 50%. We present a novel method of treatment for recurrent pneumothorax based on the intrathoracic transfer of an extrathoracic muscle flap.

Endocrine function in small cell undifferentiated carcinoma of the lung.

The endocrine status of 106 patients with undifferentiated small cell carcinoma of the lung was evaluated before treatment was begun. Almost one half of the patients had evidence of abnormal control of the secretion of adrenal cortical steroids, manifested by loss of diurnal rhythmicity or dexamethasone suppressibility. Only two had the clinical syndrome of ectopic ACTH secretion. Evidence of inappropriate secretion of vasopressin was found in 38% of the patients, most of whom also had abnormalities of corticosteroid secretory pattern. About one half of the patients had evidence of abnormal glucose tolerance, and many also had a paradoxical rise of plasma growth hormone concentration after glucose administration. The levels of the other hormones studies were normal. The pattern of hormone abnormality observed in these patients appears to be relatively specific for small cell undifferentiated carcinoma, and is different from that observed in other pulmonary tumors. Patients with abnormal control of plasma cortisol had a worse prognosis than those with normal adrenal function, largely because of decreased response rates to chemotherapy. Other endocrine abnormalities were of no prognostic significance.

Ultrasound monitoring of hepatic metastases during chemotherapy.

Grey-scale ultrasonography has been found to be the most sensitive method of detecting metastatic disease of the liver. In two cases the results of chemotherapy were monitored by ultrasound; the response to treatment could be distinguished from non-response and ultrasonography gave useful information when chemotherapy made radioisotope examination unreliable.

Measurement of plasma melphalan at therapeutic concentrations using isocratic high-performance liquid chromatography.

A sensitive isocratic high-performance liquid chromatographic (HPLC) method for the measurement of melphalan in plasma is presented. It requires an extraction step using columns of XAD-2 resin before injecting the clarified methanol eluate directly into the HPLC system. The HPLC system uses an isocratic mobile phase containing an ion-pair reagent, and a sensitive fixed-wavelength (254 nm) monitor with a noise specification of less than 2 . 10(-5) absorbance units peak to peak. The concentration of melphalan was followed in a patient with multiple myeloma on day 1 and day 4 of a four-day course of the drug. Little difference was detected between the two curves with terminal half-lives of 71 and 68 min respectively and areas under the curve of 1.08 and 1.15 min . microgram/ml . (mg dose)-1.

Pharmacokinetics of oral and intravenous melphalan during routine treatment of multiple myeloma.

Plasma melphalan levels have been measured in nine (mostly stage IIIA) multiple myeloma patients after therapeutic doses of drug had been given p.o. and i.v. A new isocratic high-pressure liquid chromatographic (HPLC) method with a sensitivity limit o 5 ng/ml was used to quantify the melphalan. Patients receiving 8-28.5 mg melphalan i.v. showed alpha and beta plasma decays with half-lives of 7.7 +/- 3.3 (mean +/- S.D.) and 83 +/- 14 min respectively. The apparent volume of the central compartment was 12.8 +/- 4.3 1, and the total volume of distribution was 0.62 +/- 0.21 l/kg. Very variable absorption was seen in the same patients after receiving 5-12 mg melphalan p.o. The half-life of the absorption phase varied from 2.1 to 62.1 min (22.8 +/- 18.1 min) with delays (before absorption started) of 0-113 min. The fraction of dose absorbed varied from 0.32 to 1.03 (0.72 +/- 0.23), and the half-life of the beta phase was 92 +/- 27 min. The type of breakfast eaten before p.o. melphalan was found to correlate with the fraction of drug absorbed.

In vitro determination of tumour chemosensitivity in haematological malignancies.

A four-day tumour chemosensitivity assay of potential use in predicting tumour response to cytotoxic drugs has been developed for haematological cancers. The method comprised isolation of white cells from peripheral blood or bone marrow aspirates, drug exposure and incubation for 4 days. Drug-induced tumour cell kill was assessed by differential staining of live and dead cells such that the former could be morphologically identified. Tumour cell viability was subsequently calculated by reference to an internal standard of fixed duck red blood cells. Over 30 drugs have been tested in vitro, all of which have shown a dose response relationship in vitro and given a good scatter of sensitivities from patient to patient within the concentration ranges tested. In 27 cases where the in vitro chemosensitivity could be compared with the in vivo response, there were 7 true positive comparisons (sensitive in vitro and in vivo), 17 true negative comparisons (resistant both in vitro and in vivo) and 3 false positive comparisons (sensitive in vitro, resistant in vivo). A result was obtained in 38 of 50 samples received, comprising 16 of 18 chronic lymphocytic leukaemias, 11 of 20 acute lymphoblastic leukaemias, 5 of 5 acute myeloid leukaemias and 6 of 7 myelomas. The assay appears to show considerable promise as a tumour chemosensitivity test and warrants wider investigations.

Meeting National Service Framework goals for patients presenting with acute myocardial infarction.

BACKGROUND: The National Service Framework for coronary heart disease established clear standards for the management of patients with acute myocardial infarction in March 2000. This study evaluates an emergency department's thrombolysis performance in light of these standards. SETTING: Inner city teaching hospital emergency department. METHODS: The data were prospectively collected using a formal clinical pathway for all patients receiving thrombolysis in the emergency department between February 2000 and January 2001. Cases were reviewed at monthly multidisciplinary audit meetings. Regular feedback complemented routine teaching for both nursing and medical staff. RESULTS: 127 patients were thrombolysed, of whom 92 (72%) were immediately eligible. Some 77% of these had a door to needle time of less than 30 minutes and 38% less than 20 minutes. Twenty per cent of patients had a call to door time of less than 30 minutes. Some 84% of patients managed by the emergency department team had a door to needle time of less than 30 minutes compared with 53% of those patients seen by duty physicians. CONCLUSIONS: The thrombolysis target set by the National Service Framework for April 2002 is achievable. The target set for April 2003 remains an ambitious goal. Overall call to needle times are undermined by call to door times. Emergency department teams may be more efficient than duty physicians in processing patients needing thrombolysis.

Long-term comparison of results of a drug sensitivity assay in vitro with patient response in lymphatic neoplasms.

A short-term differential staining cytotoxicity (DiSC) assay was used to assess the sensitivity of tumor cells in vitro from patients with chronic lymphocytic leukemia (CLL) and non-Hodgkin's lymphoma to various cytotoxic drugs. The results have been correlated with drug sensitivities of the tumors in vivo. The chemosensitivity in vitro of eight patients with CLL was observed for 12 to 42 months. In 44 cases the assay correctly predicted seven sensitive and 30 resistant tumors (84% positive correlations). There were six false predictions of sensitivity and one false prediction of resistance. Repeated testing of patients receiving treatment revealed significant and progressive development of drug resistance, while serial tests on untreated patients with CLL gave unaltered results. The development of cross-resistance to structurally related drugs was observed after treatment and many samples showed a high level of cross-resistance. However, teniposide showed greater activity than etoposide, and mitoxantrone showed greater activity than the anthracyclines. The high level of agreement between laboratory and clinical results suggests that the DiSC assay may have a useful place (1) in guiding the clinician in the selection of drugs for chemotherapy and (2) in giving an added indication of prognosis for an individual with a lymphatic neoplasm.

The influence of sample source and cell concentration on the in vitro chemosensitivity of haematological tumours.

The Differential Staining Cytotoxicity (DiSC) assay has been used to study the effects of sample source and cell concentration on the in vitro chemosensitivity of haematological malignancies. The chemosensitivity of blood and bone marrow samples was significantly associated (P less than 0.001) in 12 cases where both were tested simultaneously. In 8 of the cases, where the in vitro result could be compared with clinical response, the in vitro and in vivo chemosensitivity was in agreement in 7, for both blood and bone marrow samples. The in vitro chemosensitivity of chronic lymphocytic leukaemia blood lymphocytes was dependent on the cell concentration for 4 out of 5 drugs tested. A five fold reduction in cell number resulted in a significantly greater cell kill with 4-hydroperoxycyclophosphamide, a greater cell kill (not significant) with chlorambucil and adriamycin, and a significantly lower cell kill with prednisolone. The cell concentration did not affect vincristine cytotoxicity. These results suggest that sample source is not an important consideration for the in vitro chemosensitivity of leukaemias, but that the cell concentration tested should not be varied from assay to assay if the results are to be used for comparative purposes.

An assessment of a short-term tumour chemosensitivity assay in chronic lymphocytic leukaemia.

A 4-day tumour sensitivity assay of potential use in predicting tumour response to cytotoxic drugs has been investigated in patients with chronic lymphocytic leukaemia. The method comprised isolation of white cells from peripheral blood, drug exposure and incubation for 4 days. Drug-induced tumour cell kill was assessed by differential staining of dead and live cells such that the latter could be morphologically identified, with subsequent calculation of tumour cell viability. Concentrations of drug for use in the assay were chosen for chlorambucil (2 micrograms ml-1), 4-hydroperoxy-cyclophosphamide (2 micrograms ml-1)--which was used in vitro in place of cyclophosphamide--prednisolone (0.5 microgram ml-1) and vincristine (0.1 microgram ml-1), to give a scatter of values which was in good agreement with clinical expectations. In 21 cases where the in vitro result could be compared with the in vivo response, there were 4 true positive comparisons (sensitive in vitro, sensitive in vivo), 15 true negative comparisons (resistant both in vitro and in vivo) and 2 false positive comparisons (sensitive in vitro, resistant in vivo). A result was obtained in 86% (65/76) of samples received. The assay appears to show considerable promise as a tumour chemosensitivity test and warrants wider investigation, including prospective in vivo/in vitro correlations that could be based on the results presented here.