Combination chemotherapy with cis-diamminedichloroplatinum and vinblastine in advanced non-small cell lung cancer.

Twenty-seven patients (25 males and 2 females) with histologically confirmed, unresectable, or metastatic non-small cell lung cancer were entered on a combination chemotherapy protocol including cisplatinum and vinblastine sulfate (DDP)(VLB). Patients had to have measurable disease as defined by the presence of two clearly measurable perpendicular diameters, be untreated with either chemotherapy or radiation therapy, and give informed consent to be eligible for study entry. The median age was 57 yr and the median performance status was 70 (Karnofsky scale); 10 patients had epidermoid carcinoma, 9 adenocarcinoma, 4 large cell carcinoma, and 4 undifferentiated carcinoma. All patients had intrathoracic disease, 12 also had extrathoracic lymph node involvement, 8 bone involvement, 2 liver metastasis, and 2 central nervous system metastasis prior to beginning chemotherapy; 9 patients had involvement of one site, 12 of two sites, 5 of three sites, and 1 of four sites. Cisplatinum was given as a short intravenous infusion of 120 mg/m2 on days 1 and 28, and then every 6 wk. Vinblastine was administered as an intravenous injection of 8 mg/m2 on days 1, 14, and 28, and then every 3 wk. Patients were evaluated prior to each course of cisplatinum. If progression occurred, therapy was discontinued. If stabilization or response was noted, then therapy was continued until intolerable toxicity or progression supervened. Every patient entered is considered evaluable for toxicity and response. There were no complete remissions; 14 patients achieved a partial response, 3 had a minimal response, 5 had stabilization of their disease, 1 had disease progression, and 4 are considered to have had drug deaths. Responses were seen after the first cisplatinum course in 13 patients and after the second in 1. Toxicities seen were universal nausea and vomiting; elevation of creatinine occurred in 6 patients, ranging from 2.1 to 14.6 mg/dl, and was clinically significant in 2 patients. Myelosuppression, with a leukocyte nadir of less than 3.0 X 10(9)l in 10 cases and platelet nadir of less than 100.0 X 10(9)l was seen in 5 cases and partial hearing deficit occurred in 2 patients. Median survival was 22 wk for the whole group (24 wk for the whole group if the 4 early drug deaths are excluded). Median survival was 26 wk for responding patients and 13 wk for nonresponding patients (remains the same if the early deaths are excluded from the latter group).(ABSTRACT TRUNCATED AT 400 WORDS)

High-dose cisplatin and vinblastine infusion with or without radiation therapy in patients with advanced non-small-cell lung cancer.

Non-small-cell lung cancer (NSCLC) patients with locally advanced or metastatic measurable disease were given a combination of cisplatin, 200 mg/m2 divided in five daily doses, and simultaneously, vinblastine, 7.5 mg/m2 as a continuous intravenous (IV) infusion over five days. Five courses of chemotherapy were planned. Afterwards or on progression, patients were randomized to receive maximally tolerated radiation to all sites of disease v observation only. Forty males and seven females were entered. Median age was 60 years (range, 37 to 74), median Karnofsky performance status was 70 (range, 30 to 90). Five patients had previous brain radiation therapy for metastatic disease, all others were previously untreated. Side effects in the 87 courses of chemotherapy administered included leukopenia (WBC less than 1,000/microL following nine courses) and thrombocytopenia (platelets less than 20,000/microL following four courses). Ten patients became septic, nine of them while leukopenic. Elevations of serum creatinine followed eight courses; in all cases the level was less than 3.0 mg/dL. Nausea and vomiting were mild to moderate. Five patients experienced mild hypoacusis and six had sensory polyneuropathy. The deaths of three patients were considered drug-related. The response rate was 28%. The median survival for the group was 22 weeks, 63.2 weeks for responders and 17.9 weeks for nonresponders. Twenty-six patients received radiation therapy, 16 randomized to this arm as planned, ten to palliate symptoms. Median survival of all irradiated patients was 24.8 weeks. Seven responders to chemotherapy were randomized to receive radiotherapy; their median survival was 25 weeks. In six responders randomized not to receive radiation, the median survival was 77.8 weeks (P greater than .3). Among nonresponding patients, the median survival of those radiated was 22.2 weeks, while that of nonradiated patients was 11 weeks. This regimen is cumbersome and toxic. It has offered no major survival benefits, or improvement in response rates, therefore, we do not recommend it for the standard treatment of NSCLC.

In vivo modulation of myelopoiesis by prostaglandin E2. II. Inhibition of granulocyte-monocyte progenitor cell (CFU-GM) cell-cycle rate.

The effects of in vivo administration of native prostaglandin E2 (PGE) on the cycling status of the granulocyte-monocyte progenitor cell (CFU-GM) were examined in a mouse model. In mice hematopoietically rebounding from a sublethal dose of cyclophosphamide, intravenous injection of PGE in doses ranging from 100 to 10(-4) micrograms/mouse/day over three days, significantly decreased the absolute number of CFU-GM per femur and the percentage of CFU-GM in the S-phase of the cell cycle. Administration of PGE2, 10 micrograms/mouse/day, over three days to steady-state mice resulted in significant suppression of the absolute number of CFU-GM per femur, but was without effect on CFU-GM cycling. However, when an additional PGE2 injection was included on day 4 and mice killed 6 h later, inhibition of both parameters was observed. Single bolus injection of PGE2 into steady-state mice was found to have the identical effect. Inhibition of the absolute number of CFU-GM per femur and percentage of CFU-GM in S-phase were apparent 6 h after injection of a single dose of 10 micrograms PGE, with a loss of effect on CFU-GM cycling status 12-14 h after injection. The inhibitory effect of PGE2 on the absolute number of CFU-GM per femur persisted for two days after injection. These studies confirmed the cell-cycle effects of PGE, heretofore demonstrated only in vitro; illustrated the importance of timing and dose analysis when examining the effects of hematopoietic inhibitors in vivo; and suggested that PGE2 may be useful as an adjunct to chemotherapy in ameliorating myelotoxicity. Furthermore, dose-response analysis revealed an enhanced in vivo sensitivity of macrophage progenitor cells (M-CFC) to the inhibitory effects of injected PGE2. Inhibition of in vivo incorporation of tritiated thymidine (3HTdr) into bone marrow CFU-GM by PGE could also be demonstrated.

A phase II trial of vinblastine, bleomycin, and cisplatin induction followed by dacarbazine and dibromodulcitol maintenance in the treatment of metastatic melanoma. A follow-up study of twenty-two patients.

Twenty-two patients with metastatic melanoma were treated with a chemotherapy regimen consisting of two cycles of induction therapy with vinblastine, bleomycin, and cisplatin, followed by maintenance therapy with dacarbazine and dibromodulcitol. A 17% response rate was noted in this patient group, with a median survival of 40 weeks. Objective responses were limited to cutaneous, nodal, pulmonary, and one adrenal site of metastatic disease. Toxicity was acceptable and was limited to myelosuppression and nausea with emesis. Further study appears warranted to define the optimal treatment plan for metastatic melanoma.

A phase II trial of chlorambucil in non-small cell lung cancer.

A Phase II trial of high-dose chlorambucil at 108 mg/m2 was undertaken in non-small cell lung cancer. No complete or partial objective responses were observed, and significant toxicity, including nausea, vomiting, and seizures, was noted. Chlorambucil at this dose and schedule of administration is not recommended for the treatment of non-small cell lung cancer.

In vivo modulation of myelopoiesis by prostaglandin E2. IV. Prostaglandin E2 induction of myelopoietic inhibitory activity.

Conditioned medium (CM) prepared from bone marrow (BM) or spleen (SPL) cells from mice injected with PGE2 in doses ranging from 0.0001 to 10 micrograms was found to contain an activity inhibitory to the proliferation of granulocyte-monocyte progenitor cells (CFU-GM). This activity was found in medium conditioned for 24 to 48 h, but was not present in medium conditioned for longer time intervals. BM cells from PGE2-treated mice incubated over a concentration range of 0.1 to 1.0 x 10(6) cells/ml and SPL cells over a range of 1.0 to 10 x 10(6) cells/ml produced CM with equivalent degrees of inhibition for CFU-GM proliferation. Titration of this activity revealed a significant inhibitory effect still present at a 1/256 dilution. Inhibitory activity was similar whether or not CM was prepared in the presence or absence of FCS. Inhibition of CFU-GM development was approximately equal in the presence of either PWM SPL CM or L cell CM as sources of CSF activity. Morphologic analysis of CFU-GM revealed an equivalent inhibition of monocyte, monocyte-neutrophil, and neutrophil CFU-GM by the PGE2-stimulated inhibitory activity. Equivalent picogram amounts of PGE were measured in CM derived from BM or SPL cells from either control or PGE2-treated mice, indicating a low probability that injected PGE2 was carried over in the CM and contributed to CFU-GM inhibition. Protease digestion of BM or SPL cell CM from PGE2-treated mice revealed a loss of inhibitory activity after trypsin, chymotrypsin, pronase, and neuraminidase treatment. Inhibitory activity was also ablated by heat treatment at 56 degrees C for 30 min and 100 degrees C for 5 min. Acrylamide-agarose gel filtration of BM CM revealed an active inhibitory fraction in the Mr range of 5.5 to 8.0 kDa. The results of the present study suggest that one of the mechanisms by which PGE2 exerts its in vivo myelopoietic inhibitory action may be by stimulating the production of an inhibitory factor or factors from BM and SPL cells.

In vivo modulation of myelopoiesis by prostaglandin E2. III. Induction of suppressor cells in marrow and spleen capable of mediating inhibition of CFU-GM proliferation.

Intravenous (IV) injection of 0.1 to 10 micrograms of authentic prostaglandin E2 (PGE2) in intact steady-state mice induces a population of bone marrow and spleen cells having the capacity to suppress CFU-GM proliferation when admixed with normal bone marrow cells. Equivalent suppression of CFU-GM committed to monocytic as well as granulocytic differentiation was observed using colony-stimulating factors (CSFs) differing in their lineage specificities and by direct morphological analysis of proliferating clones. Kinetic analysis indicates that suppressive bone marrow cells appear within 2 hours after PGE2 injection, are maximal at 6 hours, and are no longer observed by 24 hours postinjection. Positive and negative selection studies using monoclonal antibodies indicate that the PGE2-induced suppressor cells react positively with anti-GMA 1.2, MAC1, and F4/80 monoclonal antibodies, suggesting a myeloid/monocytic origin. As few as 1,000 positively selected bone marrow or spleen cells were able to inhibit maximally normal CFU-GM proliferation by 50,000 control bone marrow cells. Suppression of normal CFU-GM can be substituted for by 24-hour cell-free supernates from unseparated bone marrow cells or GMA 1.2 or F4/80 positively selected marrow or spleen cells from PGE2-treated but not control mice. These supernates also inhibited BFU-E proliferation. Injection of as few as 2 million bone marrow cells from PGE2-treated mice into steady-state mice or animals hematopoietically rebounding following a sublethal injection of cyclophosphamide significantly suppressed total CFU-GM proliferation in recipient mice within 6 hours. In summary, these studies describe the detection of a novel hematopoietic control network induced by PGE2 in intact mice.

Hemopoietic inhibition in hairy cell leukemia.

Leukopenia, thrombocytopenia, and anemia are important features of hairy cell leukemia (HCL). They are generally considered to be due to hypersplenism and to inadequate production by bone marrow which is heavily infiltrated by the neoplastic hairy cells (HC). However, the cytopenias may also be caused by hemopoietic inhibition by cytokines derived from the mononuclear cells (MNC) of HCL. We studied the MNC of HCL with an in vitro assay for granulocyte-macrophage progenitors (CFU-GM) to search for this hemopoietic inhibitor(s) and to determine the cell source and mechanism of its production/release. We found that MNC conditioned media from 7 of 9 HCL cases exerted substantial inhibitory effect (23% to 66%) on normal marrow cells. Peak inhibitory activity was obtained in media conditioned with 10(6) MNC/ml for 90 minutes to 24 hours. Both HC and lymphocytes could release inhibitor(s) through mutually synergistic cell interactions. HC alone were inactive and lymphocytes alone were only weakly active. Mixtures of conditioned media of HC and of lymphocytes were not synergistic. The lymphocytes responsible for the inhibition were present in preparations depleted of cells bearing the cluster designation 4 antigen (CD4+) and B cells and were most likely the CD8+ T-cells. In one patient so examined, a partial reversal of inhibition was achieved by treating MNC-CM with antibodies to tumor necrosis factor (TNF)-alpha suggesting that TNF-alpha was at least partly involved in the inhibition of CFU-GM. This mechanism of cytokine release may be operative in vivo to account for the cytopenias in HCL and, if so, could alter the concept of hypersplenism in this disease.

Bone marrow failure after hemorrhagic shock.

The proliferation of white blood cells is an important and necessary response to bacterial infection. The effect of hemorrhagic shock and LPS administration on myelopoiesis was investigated. Rats subjected to hemorrhagic shock and resuscitation were injected IP with 100 micrograms E. coli LPS or saline 24 hr following shock. Twenty-four hours later, myelopoiesis was assessed by the growth of granulocyte-macrophage progenitor cells (CFU-GM) in both bone marrow (BM) and spleen (SPL). CFU-GM were cultured in the presence of no additional serum or normal rat serum or shock serum obtained 6 hr after hemorrhage. Shock resulted in a peripheral leukocytosis although BM and SPL cellularity was unaffected by either shock or LPS. BM and SPL CFU-GM from unshocked rats significantly increased after LPS administration (BM 47 +/- 6 vs. 70 +/- 8; SPL 40 +/- 4 vs. 72 +/- 14; both P less than 0.05). Shock had no effect on BM or SPL CFU-GM. In contrast, LPS given to shocked rats decreased BM CFU-GM compared to saline-treated rats (50 +/- 3 vs. 34 +/- 4 P less than 0.05). The addition of normal serum to the culture system had no effect on BM CFU-GM but the addition of shock serum reduced CFU-GM by 50% in all groups (P less than 0.05). These data demonstrate that shock markedly alters the myelopoietic response to LPS and may also result in the production or release of inhibitors of CFU-GM growth.

The relationship of hair zinc concentrations to height, weight, age, and sex in the normal population.

Hair samples from forty-nine normal individuals (both children and adults) were assessed for concentrations of zinc. Pearson correlation coefficients were computed between zinc values and the variables: height, weight, and age (see Table 3). In children (under 240 months), all these relationships were linear, positive, and statistically significant. A linear regression equation using all these variables was found to account for 47.7% of the variance in hair zinc concentrations. In adults (over 240 months), the correlation coefficients between hair zinc and height, weight, and age were not found to be significant, with the exception of the negative correlation between hair zinc and weight (r = -0.464; P less than 0.047). Nevertheless, a multivariate linear regression equation accounted for about 24.6% of the variability of hair zinc values. In both children and adults, tests for sex differences in means and standard deviations using both raw score and residual values failed to reveal any significant differences. Similarly, no significant sex differences were observed between corresponding correlation coefficients. Results indicate that future studies utilizing hair must systematically or mathematically control for individual variation in zinc concentrations due to differences in age, weight, and height.

Disseminated prostatic carcinoma simulating primary lung cancer. Indications for immunodiagnostic studies.

Recognition of disseminated adenocarcinomas potentially responsive to current treatment programs is an important objective in the management of cancer patients. Metastatic adenocarcinoma of the prostate gland is a malignant entity which often can be palliated effectively by hormonally based therapeutic strategies. In cases of metastatic prostate cancer presenting with typical clinical features, the correct diagnosis can be readily achieved, but in patients with less obvious presentations the diagnosis of prostatic carcinoma may be overlooked. In the current report, a group of elderly men presenting with a clinical syndrome resembling either metastatic primary adenocarcinoma of the lung or primary adenocarcinoma of the lung coexisting with prostate cancer were found in fact to have metastatic prostatic carcinoma as their sole disease process. In each case, cytologic characterization of clinically involved tissue specimens by the prostate specific antigen and prostatic acid phosphatase immunohistochemical markers enabled clinical investigators to arrive at the correct diagnosis. Other clinical features, such as a positive bone scan and an enlarged prostate gland on physical exam and/or radiographic studies were noted to be present in these patients. All the patients in the current series responded to hormonal treatment regimens once the diagnosis of metastatic prostate cancer had been established. In elderly male patients presenting with what appears to be primary adenocarcinoma of the lung, the diagnosis of metastatic prostate cancer should be considered and when necessary evaluated by the use of appropriate clinical and immunohistochemical studies.

High-dose cisplatin in patients with advanced malignancies.

A study was conducted to determine if cisplatin (CDDP) can be given at higher doses than usual, utilizing aggressive supportive measures. Twelve patients were entered into three dose levels of CDDP: level I, 180 mg/m2 given as a short infusion; level II, 220 mg/m2 also given as a short infusion; level III, 200 mg/m2 divided in five daily doses, each infused over 6 hours. In all cases, CDDP was dissolved and given in 250 ml of a 5% saline solution. For levels I and II, intravenous hydration with 200 to 250 ml/hour D5 1/2NS with potassium and magnesium supplements, was started 24 hours before therapy and continued for 3 to 4 days after, longer if nausea persisted. Mannitol was given before (25% solution, 50 ml bolus) and after (20% solution, 500 ml over 3 hours) CDDP. At level III hydration with the same intravenous (IV) fluids was begun the day before therapy and continued without interruption at 200 to 250 ml/hour for a minimum of 24 hours after the completion of the 5 days of chemotherapy. Each daily dose of CDDP was preceded by injection of mannitol (25% solution, 50 ml bolus) and accompanied by a 6-hour infusion of 1000 ml 20% mannitol. Three patients received five CDDP courses at level I; 4 patients, seven courses at level II; and 5 patients, seven courses at level III. Ototoxicity was dose-limiting in three patients at level II. Transient elevation of serum creatinine was seen following two courses at level I and two courses at level II. The renal impairment was asymptomatic in all cases; dialysis was not needed. At level II, leukocyte nadir counts between 1.0 and 2.0 X 10(3)/mm3 were seen following two courses and between 2.0 and 3.0 X 10(3)/mm3 following three courses. Platelet nadir counts below 50 X 10(3)/mm3 were recorded after four courses and between 50 and 100 X 10(3)/mm3 after one course. Nausea and vomiting occurred frequently, but were tolerable. At level III, myelosuppression was dose-limiting. Nadir leukocyte counts between 1.0 and 2.0 X 10(3)/mm3 followed four courses and between 2.0 and 3.0 followed one course. Nadir platelet counts below 50 X 10(3)/mm3 were seen after three courses; two patients required prophylactic platelet transfusions. Nadirs between 50 and 100 X 10(3) platelets/mm3 followed three further courses. Ototoxicity and nephrotoxicity did not occur at level III.(ABSTRACT TRUNCATED AT 400 WORDS)

A phase I trial of chlorambucil administered in short pulses in patients with advanced malignancies.

We carried out a phase I trial with chlorambucil. Thirty patients with advanced cancer were entered in six dose levels: 36, 48, 60, 84, 108, and 144 mg/m2. The drug was given in six divided oral doses every 6 hours and the regimen was repeated every 3 weeks. The median age was 62 years (31-84), median Karnofsky performance status (KPS) 60 (40-90). All patients but one had received prior radiation therapy, chemotherapy, or both. Central nervous system toxicity was dose limiting, occurring in 5 of 6 patients at 144 mg/m2. It was characterized by transient seizures, hallucinations, lethargy, stupor, and coma. Metoclopramide was successful in controlling nausea and vomiting, which was severe if the antiemetic was not used. Leukopenia (3 patients) and thrombocytopenia (2 patients) were mild. One patient with colorectal carcinoma had a minor response, and two patients with non-small cell lung cancer had stable disease. A safe dose for phase II trials is 108 mg/m2 in six 6-hourly oral doses.

A phase I trial of dactinomycin intravenous infusion in patients with advanced malignancies.

Eighteen patients with advanced malignancies refractory to other forms of treatment were given dactinomycin (Act D) as continuous intravenous infusions. Their median age was 51 years (range, 36-67); their median performance status was 50 (range, 40-90) on the Karnofsky scale. Act D was administered continuously for 5 days, utilizing a central venous line and a perfusion pump. The starting dose was 0.1 mg/m2/24 hours X 5 days (total dose, 0.5 mg/m2) and was escalated according to a modified Fibonacci scale to 0.2, 0.33, and 0.5 mg/m2/24 hours X 5 days, respectively. Three, three, four, and eight patients were entered, respectively, in each dose level. Toxicities observed were: leukopenia in four patients (nadir leukocyte count less than 1000 cells/nm3 in one patient and 2000-3000 cells/mm3 in 3 patients); thrombocytopenia, with nadir platelet counts between 50,000 and 100,000 platelets/mm3 in 2 patients; stomatitis in four patients; and nausea in three patients. Vomiting was not observed during the infusions. Two patients may have had a radiation recall phenomenon. Blood count depression, nausea, and mucositis were transient, resolving after a few days. One patient at level IV died of sepsis, which was diagnosed on the fourth day of the infusion, before leukopenia intervened. No objective responses were seen. It was concluded that a higher dose of Act D can be given by continuous infusion than by a bolus injection; the authors recommended 0.5 mg/m2/day X 5 days (total dose, 2.5 mg/m2) for further studies.

Long-term intravenous hydroxyurea infusions in patients with advanced cancer. A phase I trial.

BACKGROUND: Hydroxyurea is an S-phase specific drug. Constant exposure of tumor cells with a low S-phase fraction to the agent may result in improved cell kill. Because of its short half-life, a continuous intravenous infusion may result in better tumor exposure than intake by mouth. The goal of this trial was to find the longest tolerable duration of a continued intravenous infusion of hydroxyurea (HU) given at escalating doses. METHODS: Eligible patients had histologically confirmed cancer without effective alternate therapy, normal blood counts, liver and kidney function. After giving informed consent, the infusion began via a permanent indwelling catheter utilizing a portable pump. Dose levels (in g/m2/d) were 0.5 for level I, 1.0 for level II, 1.66 for level III, and 2.5 for level IV. RESULTS: Fourteen patients were entered. Five were men. Median age was 56 years of age (range: 32-67), median performance status 1 (range: 0-2). Diagnoses were as follows: colorectal cancer, seven; unknown primary site, three; breast cancer, two; melanoma, one; and adenoid-cystic carcinoma, one. Nine patients were pretreated with chemotherapy. Three patients were entered per dose level, except on level I, were five were entered. The mean duration of infusion was 12 weeks on level I, 5 weeks on II, 3 on III, 1 on IV. Toxicity included leukopenia below 2.0 K/mm3 in one patient each on levels III and IV, thrombocytopenia below 100 K/mm3 in one patient each on levels II and IV, and stomatitis in three patients (one on level II and two on IV). This toxicity was dose limiting. One patient on level III, with an unknown primary, had an objective response. HU levels were measured by a modification of the Fabricius-Rajewsky method. Mean plasma levels in micrograms per milliliter (SEM) were as follows: level I, 3.6 (0.23); level II, 5.1 (0.57); level III, 10.1 (1.55); and level IV, 16.7 (one point). Fetal hemoglobin rose two-fold and five-fold in two patients on level I after 9 and 16 weeks on therapy, respectively. CONCLUSIONS: HU as a continuous intravenous infusion is well tolerated; the maximum duration of therapy is related inversely with the dose given. No major antitumor activity was seen. The greatest interest in the drug rests in its future use as a modulator and radiation potentiator. The increase in hemoglobin F was of interest and may be important in the treatment of sickle cell disease.