Phase I clinical trial of irinotecan (CPT-11), 7-ethyl-10-[4-(1-piperidino)-1-piperidino]carbonyloxy-camptothecin, and cisplatin in combination with fixed dose of vindesine in advanced non-small cell lung cancer.

Irinotecan hydrochloride (CPT-11), a semisynthetic derivative of camptothecin, has been demonstrated to be active against solid tumors such as non-small cell lung cancer and colorectal cancer. Two combination phase I trials were undertaken to determine the maximum tolerated dose of CPT-11 in combination with cisplatin and vindesine in patients with advanced non-small cell lung cancer. All 46 patients (age 32-73 years) entered into these trials had a good performance status (Eastern Cooperative Oncology Group score, 0-1) and had received no prior chemotherapy or radiotherapy. In the first trial, 14 stage IV and 2 stage IIIb patients were studied; in the second trial 30 patients with stage IV disease were accrued. In the first trial, CPT-11 was given as a 90-min i.v. infusion on days 1 and 8 in combination with a fixed dose of cisplatin (100 mg/m2, i.v., on day 1) and vindesine (3 mg/m2, i.v., on days 1 and 8), every 4 weeks. The starting dose of CPT-11 was 25 mg/m2, and the dose was increased in increments of 25 mg/m2. In the second trial, the doses of either CPT-11 (days 1 and 8) or cisplatin (day 1) were escalated with a fixed dose of vindesine (same dose as the first study) given in a 4-week cycle. The starting doses of CPT-11 and cisplatin were 20 and 60 mg/m2, respectively, and the dose of either CPT-11 or cisplatin was increased in increments of 20 mg/m2. At least 3 patients were entered at each dose level in both trials. Use of granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor was not permitted in this trial. In the first trial, grade 4 granulocytopenia and grade > or = 3 diarrhea were dose limiting at 50 mg/m2 CPT-11, which represented the maximum tolerated dose. At the subsequent dose of CPT-11, 7 new patients were requited at the 50% reduced dose level of 37.5 mg/m2 on days 1 and 8. Nine patients were evaluated for response, and 4 of them achieved a partial response. In spite of a low dose of CPT-11 (25-37.5 mg/m2), the maximum concentration in plasma of CPT-11 (> 0.4 micrograms/ml) reached > 10-fold the in vitro concentration of CPT-11 required for 50% inhibition of growth. In the second trial, the dose-limiting toxicities were grade 4 granulocytopenia lasting for > or = 7 days and grade > or = 3 diarrhea.(ABSTRACT TRUNCATED AT 400 WORDS)

Phase I study of CPT-11 and etoposide in patients with refractory solid tumors.

PURPOSE: To determine the maximum-tolerated dose (MTD) and acceptable dose level of a cytotoxic regimen of CPT-11, a new camptothecin derivative, in combination with etoposide (VP-16) and to describe the principal toxicities associated with it. PATIENTS AND METHODS: Patients with refractory solid tumors received VP-16 and CPT-11 daily for 3 consecutive days (days 1 through 3) every 3 or 4 weeks. Groups entered the trial at escalating CPT-11/VP-16 dose levels of 40/60, 60/60, 60/80, and 80/60 mg/m2. Thirty-four patients entered this study, of whom 33 were assessable for toxicity and 22 for therapeutic efficacy. RESULTS: Granulocytopenia was so severe that this regimen required supportive therapy with recombinant human granulocyte colony-stimulating factor (G-CSF). The majority of the patients experienced a 5% weight loss and diarrhea was the dose-limiting toxicity. The MTDs were 60/80 and 80/60 mg/m2 administered on days 1 through 3. Five of seven previously untreated patients with non-small-cell lung cancer (NSCLC) achieved partial responses (PRs) to this therapy, as did two with NSCLC who had received prior chemotherapy, two with head and neck cancer, and one with an adenocarcinoma (primary tumor unknown). CONCLUSION: The recommended dose of CPT-11/VP-16 for this regimen with G-CSF is 60/60 mg/m2 on days 1 through 3 every 3 to 4 weeks. We suggest that the combination of topoisomerase I and II inhibitors is likely to be an effective treatment strategy. The activity of this regimen against NSCLC is particularly encouraging and should be evaluated in a phase II trial.

A cytotoxic monoclonal antibody (HU-39) that detects DRw8 + DRw12.

A monoclonal antibody, HU-39, was produced by immunizing BALB/c mice with a cultured human B lymphoblastoid cell line, Shi-C3 (HLA-A24, A31, B51, Bw52, DR2, DRw12, DQw1, DQw3). Utilizing the complement-dependent cytotoxicity test, HU-39 was found to detect a polymorphic determinant common to HLA-DRw8 and HLA-DRw12, a split antigen of HLA-DR5. Although HU-39 reacted with the cells from all of nine DRw12 positive individuals, the cells from only 18 out of 21 DRw8 positive individuals reacted with HU-39 and the remaining three were negative for HU-39. The cytotoxicity of the antibody was reduced after the surface HLA-DR molecules of two cell lines, GI and EBV-Sh, typed as DRw8 and DRw12, respectively, were masked with F(ab')2, of anti-HLA-DR monoclonal antibody. The results of the sequential coprecipitation test and the two-dimensional gel electrophoresis by using EBV-Sh also indicated that HU-39 preferentially recognizes an epitope borne on the DR molecules, but not on the DQ molecules. Thus, HU-39 appeared to be of great value as a tissue typing reagent to define DRw8 and DRw12, the latter of which had been difficult to assign because of the lack of monospecific alloantisera.

Phorbol ester-induced P-glycoprotein phosphorylation and functionality in the HTB-123 human breast cancer cell line.

The discordance between P-glycoprotein (P-gp) expression and functionality [as measured by the efflux of doxorubicin (DOX)] was analyzed in a DOX-sensitive human breast cancer cell line (HTB-123) with high reactivity against four P-gp specific monoclonal antibodies (C219, MRK-16, UIC2, and 4E3). Reverse transcription-polymerase chain reaction (RT-PCR) and Western blotting analyses confirmed the overexpression of MDR1 mRNA and P-gp in this cell line. However, incubation of cells with efflux blockers, verapamil (VPL) or dipyridamole (DPD), did not enhance cellular (DOX) accumulation or cytotoxicity. Upon incubation with 12-O-tetradecanoylphorbol-13-acetate (TPA), HTB-123 cells retained less DOX than control cells and were sensitive to the efflux blockers verapamil or dipyridamole. These observations suggest that 12-O-tetradecanoylphorbol-13-acetate-induced P-gp phosphorylation may be associated with induction of P-gp-mediated drug efflux in the HTB-123 cell line.

Association of HLA-DR with sarcoidosis. Correlation with clinical course.

HLA-DR typing was performed in 58 Japanese patients with sarcoidosis. We found a significantly increased frequency of HLA-DRw52 (p less than 0.0007; pc less than 0.009) and DR5J (p less than 0.004; pc less than 0.05). (Corrected probability value is given as pc.) In 34 of 58 patients the disease resolved spontaneously. There was no significant difference between the frequency of DRw52 and the resolution rate of disease. The frequency of DR5J was increased significantly in the unresolved cases. Our results also suggest that DRw52 is concerned with onset of sarcoidosis and DR5J antigen has an effect on the clinical course of this disease.

A randomized controlled trial of sulfamethoxazole/trimethoprim plus norfloxacin versus sulfamethoxazole/trimethoprim alone for the prophylaxis of bacteria infection during chemotherapy for lung cancer.

The efficacy of the prophylactic administration of sulfamethoxazole/trimethoprim (ST) plus norfloxacin (NFLX) versus ST alone to prevent the development of bacterial infection during chemotherapy-induced leukopenia was compared in patients with lung cancer. Patients who underwent systemic chemotherapy were randomized into one of the prophylactic regimens when grade 3 or 4 leukopenia occurred. Prophylactic treatment was performed on 133 courses of leukopenia in 75 patients and the efficacy was evaluated on 127 of those courses after excluding those patients who demonstrated a fever within 24 h from the start of the prophylaxis. The number of patients who had leukopenia associated fever was two out of 63 (3.2%) with the ST plus NFLX regimen and 10 out of 64 (15.6%) with ST alone; the difference was statistically significant. The prophylactic use of ST plus NFLX was thus found to be more useful than ST alone for the treatment of chemotherapy-induced leukopenia in patients with lung cancer.

Induction of apoptosis in cultured retinoblastoma cells by the protein phosphatase inhibitor, okadaic acid.

The induction of apoptosis in cultured retinoblastoma cells by diverse drugs was examined by analyzing DNA fragmentation, a hallmark of apoptosis. First, the ability of six retinoblastoma cell lines to undergo apoptosis was surveyed using etoposide (30 micrograms/ml, 20 h exposure). The NCC-RbC-60 cell line, established in this laboratory showed DNA fragmentation clearly, whereas the other cell lines tested, including the representative retinoblastoma cell line, Y-79, did not show distinct DNA fragmentation. Biochemical modulators, such as A23187, forskolin, retinoic acid, phorbol 12-myristate 13-acetate and okadaic acid, were examined to ascertain whether they could induce apoptosis in NCC-RbC-60 and Y-79 cells after exposure for 20 h. Only okadaic acid induced DNA fragmentation in all the retinoblastoma cell lines tested and it induced DNA fragmentation in Y-79 cells in a time- and concentration-dependent manner. Flow-cytometric analysis and microscopic examination revealed that Y-79 cells treated with okadaic acid for 24-48 h accumulated at the G2/M, especially M, phases, before undergoing DNA fragmentation. Other mitotic poisons, nocodazole, colcemid and taxol, also induced apoptosis in Y-79 cells. In the K1034 cell line, established from non-malignant retinal pigmented epithelium, okadaic acid failed to induce both G2/M arrest and DNA fragmentation. These findings suggest that okadaic-acid-induced apoptosis occurs as a result of metaphase arrest.

Prediction of carboplatin clearance calculated by patient characteristics or 24-hour creatinine clearance: a comparison of the performance of three formulae.

PURPOSE: Carboplatin doses can be individualized using the formula of Calvert et al. (Calvert formula) dose (mg) = area under the plasma concentration versus time curve (AUC) x [glomerular filtration rate (GFR) + 25]. Creatinine clearance (Ccr), either measured by the 24-h method or calculated by the formula of Cockcroft and Gault [Cockcroft-Gault (CG) formula], is often substituted for the GFR. The CG formula is based on patient weight, age and sex, and the serum creatinine (Cr) concentration. Another method for predicting carboplatin clearance (CL) using patient characteristics has also been proposed by Chatelut et al. (Chatelut formula). This study was undertaken to evaluate the performance of the three formulae in predicting standard- and low-dose carboplatin pharmacokinetics. METHODS: A total of 52 patients with advanced lung cancer were enrolled in this pharmacokinetic study; 37 received standard-dose carboplatin and 25 received low-dose carboplatin. The Cr concentration was measured using an enzymatic assay. The three formulae were used to predict carboplatin CL. The median absolute percent error (MAPE) for each formula was evaluated by comparing the calculated and observed CL. For comparison of AUCs, free platinum plasma concentrations were measured at intervals up to 24 h after carboplatin administration. AUCs were determined and compared with predicted values. RESULTS: In the standard-dose carboplatin group, the MAPEs for the prediction of carboplatin CL from the 24-h Calvert, CG-Calvert and Chatelut formulae were 13%, 12% and 23%, respectively. In the low-dose carboplatin group, the corresponding MAPEs were 27%, 18% and 44%, respectively. Observed standard-dose carboplatin AUCs after aiming for target AUCs of 5 and 6 mg x min/ml using the Calvert formula based upon the 24-h Ccr were 5.3+/-0.8 and 5.9+/-0.8, respectively, indicating a small and acceptable bias compared with that predicted from the dosing formula. CONCLUSIONS: The pharmacokinetics of standard-dose carboplatin were accurately predicted by the Calvert formula based upon either 24-h or CG-calculated Ccr, but not by the Chatelut formula. Either CG-calculated or 24-h Ccr can be substituted for the GFR in the Calvert formula for the determination of individual doses. The poor predictability of the Chatelut formula found in this study might be the result of a differences in either the Cr assay or the patient population. Therefore, formulae which attempt to estimate GFR are not necessarily valid if either the Cr assay or the patient population is changed.

Characterization of an etoposide-resistant human ovarian cancer cell line.

Etoposide (VP-16) is one of the most important anticancer agents available and is used in many chemotherapeutic regimens. To characterize resistance to this drug, we established a VP-16-resistant human ovarian cancer cell line, SKOV3/VP, by continuous stepwise exposure of SKOV3 cells to VP-16. The degree of resistance to VP-16 of SKOV3/VP was about 25 times that of the parent cell line (SKOV3), and SKOV3/VP showed cross-resistance to teniposide, adriamycin, CPT-11, and vincristine. The accumulation of [3H]-VP-16 observed in SKOV3/VP cells was about half that seen in SKOV3 cells, and the accumulation of Adriamycin by this resistant cell line was also lower than that of its parent. Overexpression of neither the multidrug resistance gene mdr-1, the multidrug-resistance-associated protein (mrp) gene, nor P-glycoprotein was detected using reverse transcriptase-polymerase chain reaction analysis and flow cytometry with MRK-16, a monoclonal antibody against P-glycoprotein. The topoisomerase II activity of nuclear extracts from SKOV3/VP cells was lower than that from the parental cells, as was the amount of DNA topoisomerase II, demonstrated by immunoblotting. These results suggest that the mechanism responsible for the multidrug resistance of this cell line may be attributable to changes on its DNA topoisomerase II and to its reduced accumulation of the drugs as compared with the parental line SKOV3.

Effect of taxol on vinblastine sulfate-induced crystallization of tubulin.

In human lung adenocarcinoma cells exposed to vinblastine (VLB) and stained with fast green, large tubulin crystals were seen in the cytoplasm. In contrast cells exposed to taxol had prominent bundles of stabilized microtubules. Pre- or co-incubation of cells with taxol before exposure to VLB prevented formation of the crystals. However, VLB did not prevent formation of stabilized microtubules by taxol if added at the same time. Under a fluorescent microscope, VLB induced crystals stained with secondary antibodies against anti-alpha- and anti-beta- tubulin antibodies. Neither of the drugs altered binding of the antibodies to these crystals.

Legionnaires' disease diagnosed by bronchoalveolar lavage.

A 51-year-old woman who had been on steroid therapy for systemic lupus erythematosus (SLE) developed a high fever 3 days after visiting a hot spring resort. Chest X-ray films revealed an interstitial, pneumonia-like shadow in the left lung field, which increased rapidly with a worsening of her symptoms. She died of multiple organ failure one week after the onset of the pneumonia. Although the serum antibody titer was negative, Legionella pneumophila was recovered from her bronchoalveolar lavage (BAL) fluid. BAL seems to be a useful method to diagnose Legionnaires' disease.

Response to combined modality treatment in a five-year survivor of extensive small cell lung cancer with severe complications.

We present a rare case of a five-year survivor of small cell lung cancer with severe complications who responded to combined modality treatment. Prior to initial chemotherapy, he experienced severe complications including sepsis, pneumonia, ileus, and a performance status of 4. He was treated with an ileus tube and IVH, and was managed by mechanical ventilation for four days. After his general condition improved, he received combination chemotherapy of carboplatin, with the target area under the plasma concentration versus the time curve (AUC) of 5 mg x min/ml day 1, and etoposide (80 mg/m2) on days 1, 2, 3 for four courses, and complete remission (CR) was obtained. Six months later, systemic relapse occurred, but he achieved complete remission again with nine courses of CODE (cisplatin, vincristine, adriamycin, and etoposide) chemotherapy and sequential chest radiotherapy. Five years after the initial chemotherapy, the patient is alive and disease free.

[A case of pulmonary cavernous hemangioma: immunohistological examination revealed its endothelial cell origin].

A 29-year-old woman was referred to our hospital for an abnormal shadow on chest roentgenogram. She had no symptom but its shadow was pointed out about 20 years ago. Chest CT scan showed a sharply demarcated homogenous mass measured 10 x 10 mm in the S4 segment. The tumor was resected with video-assisted thoracoscopic surgery under CT-guided marking wire inserted. Microscopic examination suspected cavernous hemangioma. Immunohistological staining demonstrated most lining cells of the cavernous structure stained positively for von Willebrand factor antibody, which suggests that this tumor was associated with endothelium. Then we decided that this tumor was pulmonary cavernous hemangioma.

[Regrowth of bullae around the staple-line is one of the causes of postoperative recurrence in thoracoscopic surgery for spontaneous pneumothorax].

Since August 1994, we have performed 65 thoracoscopic surgeries for spontaneous pneumothorax. Our operative method is partial resection of the lung with bullae using endoscopic autosuture. Three patients underwent reoperation because of persistent air leakage in one case and postoperative recurrences in two cases. In addition, we performed a second operation in one case that had undergone thoracoscopic surgery for spontaneous pneumothorax in another hospital. At the second operation, regrowth of bullae was found at the edge of staple-line in three of the 4 cases, and in one of these cases, such regrown bullae seemed to be a cause of recurrence of pneumothorax. The regrowth of the bullae was caused by incomplete resection at the initial surgery in one case. Such incomplete resection and oversight were not noticed in the review of the videotape of the initial surgeries in two cases. Reinforcement of the staple-line is necessary for prevention of recurrence of pneumothorax.

[Pulmonary histoplasmosis exhibiting solitary pulmonary nodule resected by thoracoscopic surgery: a case report and review of the Japanese literature].

We reported a case of pulmonary histoplasmosis showing solitary nodular shadow. A 43-year-old man was referred to our hospital because of an abnormal shadow on chest X-ray films during a routine checkup. He had traveled to Honduras for 7 days. Chest computed tomographic (CT) scans showed a 13 x 12 mm nodular shadow with unclear margin in the left upper lobe (S3). Both transbronchial lung biopsy and CT guided transcutaneous needle biopsy failed to yield a definitive diagnosis. Thoracoscopic resection of the nodule was performed due to suspicion of lung cancer. Pathologically, the nodule displayed central caseous necrosis with many round yeast-like fungi. The fungi measured 3 to 4 microns in diameter and were well-stained by Grocott stain. Immunohistochemical staining was positive for anti-Histoplasma capsulatum antibody, resulting in the final diagnosis of pulmonary histoplasmosis. The patient's postoperative course was uneventful, and no recurrence was observed. Histoplasmosis is a rare disease in Japan. However, it is important to keep imported infectious diseases in mind when examining and treating patients who have a history of travel abroad.

[Analysis of HLA-DQWa antigen ethnic polymorphism among a Japanese and Caucasian population and an association with Harada's disease].

A novel HLA-DQ antigen, DQWa was analysed with its serological, immunochemical, and molecular biological polymorphism. Furthermore, A disease association with DQWa was analysed by investigating HLA antigen frequencies of 24 patients with Harada's disease. DQWa was in linkage disequilibrium mainly with DR4-Dw15 in Japanese, and with DRw8 -Dw8 in Caucasians. The former haplotype was observed only in Japanese. A significant increase of DQWa was observed in the patients with Harada's disease (73.9% compared with 35.9% of the control, chi 2 = 9.77, P less than 0.005, Pc less than 0.05, Relative risk = 5.17). DQWa antigen molecules were different from each other between Japanese and in Caucasians, when they were analysed immunochemically by two dimensional electrophoresis, or molecular biologically by restriction fragment length polymorphism analysis. These results suggest that HLA-DQWa antigen may play a role in the pathogenesis of Harada's disease, which is seen only in Japanese.

Phase I/II pharmacokinetic and pharmacogenomic study of UGT1A1 polymorphism in elderly patients with advanced non-small cell lung cancer treated with irinotecan.

This phase II study investigated the recommended dose (RD) of irinotecan (CPT-11) by dose escalation in elderly (>or=70 years) chemotherapy-naive Japanese patients with advanced non-small cell lung cancer. UGT1A1*28 and *6 polymorphisms and pharmacokinetics were also investigated. Thirty-seven patients received the RD, 100 mg/m(2) of intravenous CPT-11, on days 1 and 8 of each 3-week cycle in phase II. The overall response rate was 8.1%. The median survival time was 441 days, and time to progression was 132 days. A significant correlation was observed between the incidence of grade 3/4 neutropenia and area under the time-concentration curve (AUC) values of SN-38. A reduction in AUC ratios (AUC(SN-38G)/AUC(SN-38)) and a rise in incidence of grade 3/4 neutropenia were observed with increase in polymorphism. The regimen was well tolerated and provided good disease control and promising survival effects. An analysis of the influence of UGT1A1*28 and *6 polymorphisms provides useful information for the prediction of CPT-11-related hematological toxicity.