Determination of the optimal dose of 5-fluorouracil when combined with low dose D,L-leucovorin and irradiation in rectal cancer: results of three consecutive phase II studies. EORTC Radiotherapy Group.

In three consecutive phase II trials, 5-fluorouracil (5FU)-low dose leucovorin (20 mg/m2/day) was delivered in two 5-day courses during the first (d1 to d5) and the last (d29 to d33) week of a limited pelvic irradiation (45 Gy, 5 weeks, 25 fractions) in patients with locally extended rectal cancer. The three trials differed only by the 5FU dose in the chemotherapy (CT) schemes. In trial 1 (first CT course 5FU dose 425 mg/m2/day, second CT course 370 mg/m2/day), 16 patients were included. 5 patients suffered a grade 3+ toxicity and the compliance was 63%. In trial 2 (first and second CT course 5FU dose 370 mg/m2/day), 53 patients were included. 5 patients suffered a grade 3+ toxicity. The compliance was 94%. In the trial 3 (first and second CT course 5FU dose 350 mg/m2/day), 16 patients were included. 1 patient suffered a grade 3 toxicity and the compliance was 100%. The overall response rate (complete and partial responses) of local disease and distant metastasis were 87 and 7%, respectively. 43 patients were operated on after a mean delay of 8 weeks. Among the 41 macroscopic complete resections, 6 (14.6%) were sterilised and 12 (29.3%) were classified Asler-Coller A/B1. Regression curve analysis using either grade 3+ toxicity or incomplete treatment as an end point against the 5FU dose indicates that a 350 mg/m2/day 5FU dose is advisable for a phase III adjuvant multicentre trial.

Evidence that a transient enhancement of endogenous hematopoiesis contributes significantly to the favorable outcome following interleukin 1 pretreatment and allogeneic bone marrow transplantation.

The administration of IL-1, a potent radioprotective cytokine, before allogeneic BMT is associated with an early transient increase of circulating granulocytes, successful engraftment, and accelerated multilineage hematopoietic recovery. We have examined the effects of IL-1 alpha pretreatment on the engraftment of an allogeneic BMT unable to sustain survival by itself after a lethal irradiation: (1) transplantation of a limited amount of marrow cells and (2) transplantation several days after irradiation. IL-1 was unable to allow the engraftment of an early quantitatively inadequate BMT. However, delayed BMT with limited amounts of marrow cells was associated with engraftment in IL-1 pretreated recipients. Engraftment of a late (day 12) BMT in these IL-1-pretreated mice was comparable to the engraftment of a similar day 12 allogeneic BMT in non-IL-1-pretreated mice rescued from the lethal irradiation by an early (day 1) syngeneic graft. These findings demonstrate that IL-1 pretreatment can result in a dissociation between BMT-induced survival and engraftment and suggest that the favorable effects of IL-1 pretreatment in an allogeneic BMT setting are mainly mediated through a transient enhancement of endogenous hematopoiesis and not through a direct effect on the allogeneic stem cells present in the marrow graft.

In vivo alloreactive potential of ex vivo-expanded primary T lymphocytes.

BACKGROUND: We are presently investigating the therapeutic potential of herpes simplex-thymidine kinase-expressing donor T cells in the setting of a T cell-depleted allogeneic bone marrow transplantation. The generation, expansion, and selection of the gene-modified T cells require a 12-day ex vivo culture period in high-dose interleukin (IL)-2 that could significantly alter their in vivo alloreactivity. METHODS: We evaluated the alloreactive potential of such cultured cells in a murine allogeneic bone marrow transplantation model. RESULTS: The present studies demonstrate that ex vivo-expanded cultured T cells are capable of strong alloreactivity as evidenced by the occurrence of lethal acute graft-versus-host disease (GVHD). However, GVHD mortality after administration of the cultured T cells occurred later than after the administration of a same number of fresh T cells. Similar kinetics of GVHD-induced mortality between cultured and fresh T cells required a 10-fold increase in the number of cultured T cells, indicating a reduced alloreactive potential of these cells. The addition of a 2-day "resting" period in low-dose IL-2 resulted in T cells with enhanced alloreactive potential identical to the alloreactivity observed with fresh T cells. CONCLUSION: Ex vivo IL-2-expanded T cells are capable of significant in vivo alloreactivity. However, an increase in the number of cultured T cells administered or the introduction of a short resting culture period prior to infusion is necessary in order to achieve in vivo alloreactivity identical to the alloreactivity observed with fresh T cells.

Conventional external irradiation alone as adjuvant treatment in resectable pancreatic cancer: results of a prospective study.

Between 1/85 and 1/90, 14 consecutive patients were entered into a prospective study of conventional adjuvant post-operative external beam radiotherapy after complete resection for a pancreatic adenocarcinoma. The surgical procedure was a Whipple resection in nine patients, a distal pancreatectomy in four patients and a total pancreatectomy in one patient. There were three T1b, eight T2 and three T3 tumours (UICC 1987); nodal involvement was present in five cases. The radiotherapy was delivered using a four-field box technique with a 23 x MV photon beam. All patients received a total dose of 54 Gy to the tumour bed. The mean treated volume was 900 cm3. Acute toxicities consisted mainly of weight loss (mean: 2 kg). Two patients had a grade 2 diarrhoea and two patients a grade 2 gastritis. Late effects were minimal and only observed in two patients. The overall locoregional recurrence (LR) rate was 50%. The median disease-free survival was 12 months, and the median survival was 23 months. This post-operative conventional radiotherapy treatment gives results that are comparable to the results of the GITSG-adjuvant study using a combination of split-course radiotherapy and 5-fluorouracil (5-FU).

Differential effects of cyclosporin A on the alloreactivity of fresh and ex vivo-expanded T lymphocytes.

GVHD remains a major source of morbidity and mortality after non-T cell-depleted BMT. The use of donor T lymphocytes expressing a suicide gene could lead to specific immunomodulation after BMT. We are currently evaluating such an approach in a phase I clinical study. A 12-day ex vivo expansion is required to generate gene-modified donor T lymphocytes. CsA is commonly used for GVHD prophylaxis. We analyzed, in a murine GVHD model, the effects of CsA administration on the alloreactivity of fresh or ex vivo-expanded T cells. Variable amounts of fresh or ex vivo-expanded T cells were administered in conjunction with a marrow graft to lethally irradiated allogeneic mice. As expected, a protective effect of CsA with a delayed GVHD-related mortality (P < 0.01 vs saline treatment) was observed in mice receiving fresh splenocytes. However, CsA treatment had no effect (P = NS) in mice experiencing lethal GVHD induced by ex vivo-expanded T cells whether or not the T cells had been 'rested' in low-dose IL-2 prior to in vivo administration. In agreement with the in vivo findings, CsA also inhibited the in vitro proliferation of alloreactive fresh T cells while having no significant inhibitory effect on the alloreactivity of ex vivo-expanded T lymphocytes. Overall, we demonstrate that the alloreactivity of ex vivo-expanded T lymphocytes is not sensitive to CsA and that this differential effect of CsA is not related to the alloreactive potential of the infused T cells. These findings could be highly relevant when considering allogeneic T cell therapy approaches.

Graft failure after T cell depleted HLA identical allogeneic bone marrow transplantation: risk factors in leukemic patients.

In a retrospective analysis of T cell depleted bone marrow transplantation, we have looked at different parameters in order to determine risk-factors of graft-failure after allogeneic bone marrow transplantation for leukemia. Fifty-one patients with acute leukemia or chronic myeloid leukemia have been analysed. For 33 of them, the pretransplant conditioning regimen consisted of fractionated total body irradiation (TBI) at 12 Gy prior to cyclophosphamide (120 mg/kg). The other patients received various reinforced preparative regimens. T-cell depletion consisted of treating marrow cells with pan-T monoclonal antibodies (CD2+CD3 or CD2-CD5-CD7) followed by complement mediated cytolysis. No post-transplant immunosuppressive prophylaxis was administered except for the first nine patients who received Methotrexate alone. In this group of 51 patients, 12 died within 3 months from graft-related complications and 10 developed graft failure (no engraftment or rejection). Among the possible risk factors associated with this failure, two graft-related parameters appeared significant: the number of CFU-GM progenitors and the number of viable T cells injected with the marrow inoculum. No correlation with graft failure was found with other parameters including diagnosis, disease status at transplant, conditioning regimen, age, sex, and CMV status of donor/host pairs. However, the interpretation must remain cautious because of the relatively small samples in each group.

Human breast cancer: correlation study between HER-2/neu amplification and prognostic factors in an unselected population.

In 199 breast cancers, HER-2/neu amplification was analyzed by Southern blotting (149 cases) and by slot blotting (149 cases), with 99 cases studied using both techniques. There were 18.8% amplified tumors (> or = 2 copies) by Southern blotting and 15.4% by slot blotting. The difference in the percentages of amplified tumors was not statistically significant (p = 0.44). There was a correlation between HER-2/neu amplification and the SBR grade (p = 0.046): this correlation relied on the absence of amplification in the GI tumors. In a subset study, the negativity of the progesterone receptor content was correlated with HER-2/neu amplification in the node positive (p = 0.02), the pre-menopausal (p = 0.04) and the pre-menopausal node positive (p = 0.002) patients. In the literature as in our results, amplification appears to be correlated with poor prognostic factors. However, in a subgroup with most of the favorable prognostic factors: positive estrogen and progesterone receptor contents and node negativity, the frequency of amplified tumors (19.4%, n = 67) was the same as that observed in the whole group (16.6%, n = 199). This result may suggest that the HER-2/neu amplification could act as an independent prognostic factor.

Screening of five specific cell cycle inhibitors using a T cell lymphoma cell line synchrony/release assay.

To obtain different cell populations at specific cell cycle stages, we used a cell culture synchronization protocol. Effects of five different cell cycle inhibitors acting throughout the cell cycle were examined by DNA flow cytometric analysis of a synchrony/release lymphoma cell line (CEM). The screening synchronized protocol showed that staurosporine, mimosine and aphidicolin are reversible G1 phase inhibitors that act at different times. Staurosporine acted in early G1, exhibited the strongest cytotoxic effect, and induced apoptosis. Mimosine and aphidicolin acted in late G1 and at the G1/S boundary, respectively. Hydroxyurea arrested CEM cells in early S phase, but later than the aphidicolin arrest point. Nocodazole synchronized CEM cells in M phase. All the inhibitors examined in this study can be used to synchronize cells at different phases of the cell cycle and were reversible with little toxicity except for staurosporine which is highly toxic. Because the regulatory mechanism of the cell cycle is disrupted by their effects on protein synthesis, however, these drugs must be used with caution.

[Late effects of radiations on the esophagus]. / Effets tardifs des radiations sur l'oesophage.

Radiation-induced late effects of oesophagus are observed after treatment for various cancers. Acute reactions, mainly oesophagitis, are well known and accurately described; late effects share, for most of these, a common consequence: alteration of the main oesophageal function, namely to conduct the food bolus; clinically they are impaired in terms of mobility and stenosis. More rarely, ulcerations and pseudodiverticulae can be observed. Chemotherapy further increases the risk of late effects, especially in case of concomitant chemo-radiotherapy. All numbers and statistical data on oesophagus late effects should be regarded with caution due to recent changes in the therapeutic attitudes (more and more combined chemotherapy-radiotherapy) and some progress in given cancer locations. A common scale like the LENT-SOMA should enable the clinician to better know these late effects on oesophagus which is required to initiate effective prevention measures and adapted treatments.

[Late intestinal complications of adjuvant radiotherapy of rectal cancers]. / Les complications intestinales tardives de la radiothérapie adjuvante des cancers rectaux.

Pre or postoperative pelvic irradiation has demonstrated a definitive efficacy in reducing the local failure rate of rectal cancer treated with surgery alone. However it can induce late small bowel morbidity that could alter the therapeutic ratio. The clinical pictures of radiation enteritis include obstruction and diarrhea/malabsorption. Prognostic factors that increase the risk of late small bowel complications include extended fields out of the pelvis, irradiation dose, inappropriate irradiation technique, and increased small bowel irradiated volumes. The addition of chemotherapy increases acute but not late toxicity. Recommendations concerning the clinical practice are described. Radiotherapy may also alter the residual sphincter function and we recommend to assess correctly these complications.

[Scoring system of late effects of radiations on normal tissues: the SOMA-LENT scale]. / Système d'évaluation des effets tardifs des radiations sur les tissus normaux: l'échelle SOMA-LENT. Groupe de travail des effets tardifs de l'EORTC.

Radiation tolerance of normal tissues remains the limiting factor for delivering tumoricidal dose. The late toxicity of normal tissues is the most critical element of an irradiation: somatic, functional and structural alterations occur during the actual treatment itself, but late effects manifest months to years after acute effects heal, and may progress with time. The optimal therapeutic ratio ultimately requires not only complete tumor clearance, but also minimal residual injury to surrounding vital normal tissues. The disparity between the intensity of acute and late effects and the inability to predict the eventual manifestations of late normal tissue injury has made radiation oncologists recognize the importance of careful patient follow-up. There is so far no uniform toxicity scoring system to compare several clinical studies in the absence of a "common toxicity language". This justifies the need to establish a precise evaluation system for the analysis of late effects of radiation on normal tissues. The SOMA/LENT scoring system results from an international collaboration. European Organization Treatment of Cancer (EORTC) and Radiation Therapy Oncology Group (RTOG) have created subcommittees with the aim of addressing the question of standardized toxic effects criteria. This effort appeared as a necessity to standardize and improve the data recording, to then describe and evaluate uniform toxicity at regular time intervals. The current proposed scale is not yet validated, and should be used cautiously.

[Predictive tests of response to radiotherapy. Assessment and perspectives in 1997]. / Les tests prédictifs de la réponse à la radiothérapie: bilan et perspectives en 1997.

The potential tailoring of radiotherapy modalities to the biological characteristics of individual tumours and normal tissues appears to be an exciting way to improve the therapeutic, ratio in radiation therapy patients. Numerous assays have been proposed to provide the clinician with the biological information necessary to predict the outcome after irradiation and to guide the treatment prescription, but none of them has made its way to daily practice. Major difficulties are due to the technical burden of the procedures, the poor characterization of the assayed cells, and, moreover, the high complexity of tumour and normal tissues biology. The present paper reviews the present status of the assessment of tumour cells radiosensitivity, proliferation and oxygenation. Research remains extremely active in the field of biological predictors of response to irradiation. Future steps forwards are expected from progress in the available technologies, (re-)discovery of apoptosis and investigation of normal tissue tolerance.

[Concomitant preoperative radiochemotherapy for rectal cancers]. / Radio-chimiothérapie concomitante pré-opératoire des cancers rectaux.

In December 1994, The French Consensus Conference on the Treatment of Rectal Cancer stated that: "Preoperative irradiation improves local control in T3 and T4 resectable rectal cancer patients and is recommended". Recent data indicate that this approach not only reduces local failure but also increases overall survival. The therapeutic ratio depends on the total dose delivered and technical parameters. Inadequate radiotherapy techniques leeds to increased toxicity and masks the potential benefits of the treatment. Combined preoperative chemo-radiotherapy, a promising issue in rectal cancer patients, is now under evaluation in a large European phase III trial (EORTC 22921).

[Cancer of the breast in men. 106 cases]. / Cancer du sein chez l'homme. 106 observations.

In a retrospective and multicentre study 106 cases treated from 1970 to 1985 were analysed. The patients' median age was 64 years. TNM classification showed 20 T1, 48 T2, 2 T3, 32 T4 and 4 Tx. Twenty one patients had clinical gynaecomastia; 99 underwent surgery and 85 radiotherapy; 32 received adjuvant chemotherapy or hormonal therapy. The main histological type was ductal infiltrating carcinoma; 82 axillary dissections were performed, and positive lymph nodes were found in 67 percent of the cases. Hormone receptors were positive in 15 out of 20 measured cases. Five and 10 years overall survival rates (Kaplan-Meier) were 57 and 37 percent, and corrected survival rates 68 and 55 percent respectively. The main prognostic factor remains the clinical size of the tumour (T) and histologically axillary node status (pN). Eleven patients developed a second metachronous cancer. The aetiology of male breast cancer is a poorly known as that of female breast cancer. Nevertheless, imbalance among oestrogens and androgens due to metabolic, infectious or pharmacological causes is probably responsible, at least in part, for this cancer. An on-going multicentre prospective national trial tries to address this question.

[Radiotherapy and symptomatic treatments of advanced colorectal cancers]. / Radiothérapie et traitements symptomatiques des cancers colo-rectaux évolués.

Treatments of colorectal cancers can still be curative up to fairly advanced stage. Clinical situations vary greatly depending on the primary: local recurrence is a major event in rectal cancer whereas metastases are the main problem in colon cancer. Therefore, rectal cancer benefit from locoregional combined treatments, chemotherapy, radiotherapy and surgery, to control the pelvic disease. In the metastatic setting, it is important to offer potentially curative treatment as often as possible. Radiotherapy for bone or brain metastasis is well known and frequently used; irradiation of painful liver metastasis is less regularly discussed despite its efficacy. Symptomatic treatments like analgesics narcotic or not, non steroidal anti-inflammatory, anxiolytics, etc. are useful. All these treatments must be evaluated, not only in term of anti-tumoural but also from the quality of life point of view.

[Radiotherapy of cancer of the rectum]. / Radiothérapie du cancer du rectum.

As soon as there is a tumor extension into the perirectal fibro fatty tissue (T3 stage) the chance to cure the rectal cancer is no more than 65%. The aim of adjuvant treatment is to reduce the risk of local recurrence and metastasis. Postoperative irradiation does not have a definitive effect on local control, and its tolerance is poor; it may not be recommended. The efficacy of combined postoperative irradiation and chemotherapy has not been definitively proved. Moreover, this approach leads to high toxicities and may not be recommended routinely. On the contrary, preoperative irradiation definitely improves the local control, reducing the risk of recurrence up to 50%. It is commonly indicated as soon as the rectal cancer is at the T3 stage. The efficacy of combined preoperative irradiation and chemotherapy is under evaluation. Irradiation is also indicated for patients with rectal cancer at the first stage or as palliative treatment.