Incorporation of high-dose 131I-metaiodobenzylguanidine treatment into tandem high-dose chemotherapy and autologous stem cell transplantation for high-risk neuroblastoma: results of the SMC NB-2009 study.

BACKGROUND: In our previous SMC NB-2004 study of patients with high-risk neuroblastomas, which incorporated total-body irradiation (TBI) with second high-dose chemotherapy and autologous stem cell transplantation (HDCT/auto-SCT), the survival rate was encouraging; however, short- and long-term toxicities were significant. In the present SMC NB-2009 study, only TBI was replaced with 131I-meta-iodobenzylguanidine (MIBG) treatment in order to reduce toxicities. METHODS: From January 2009 to December 2013, 54 consecutive patients were assigned to receive tandem HDCT/auto-SCT after nine cycles of induction chemotherapy. The CEC (carboplatin + etoposide + cyclophosphamide) regimen and the TM (thiotepa + melphalan) regimen with (for metastatic MIBG avid tumors) or without (for localized or MIBG non-avid tumors) 131I-MIBG treatment (18 or 12 mCi/kg) were used for tandem HDCT/auto-SCT. Local radiotherapy, differentiation therapy with 13-cis-retinoic acid, and immunotherapy with interleukin-2 were administered after tandem HDCT/auto-SCT. RESULTS: Fifty-two patients underwent the first HDCT/auto-SCT and 47 patients completed tandem HDCT/auto-SCT. There was no significant immediate toxicity during the 131I-MIBG infusion. Acute toxicities during the tandem HDCT/auto-SCT were less severe in the NB-2009 study than in the NB-2004 study. Late effects such as growth hormone deficiency, cataracts, and glomerulopathy evaluated at 3 years after the second HDCT/auto-SCT were also less significant in the NB-2009 study than in NB-2004 study. There was no difference in the 5-year event-free survival (EFS) between the two studies (67.5 ± 6.7% versus 58.3 ± 6.9%, P = 0.340). CONCLUSIONS: Incorporation of high-dose 131I-MIBG treatment into tandem HDCT/auto-SCT could reduce short- and long-term toxicities associated with TBI, without jeopardizing the survival rate. TRIAL REGISTRATION: ClinicalTrials.gov NCT03061656.

Mortality outcomes after busulfan-containing conditioning treatment and haemopoietic cell transplantation in patients with Gilbert's syndrome: a retrospective cohort study.

BACKGROUND: Gilbert's syndrome is a common inherited disorder of bilirubin metabolism, characterised by mild, unconjugated hyperbilirubinaemia. However, the effect of Gilbert's syndrome on the disposition of some drugs can lead to unexpected toxicity. We tested the hypothesis that patients undergoing myeloablative conditioning and haemopoietic cell transplantation would have different mortality outcomes depending on whether or not they had laboratory evidence of Gilbert's syndrome. METHODS: In this retrospective cohort study, we used clinical and laboratory data of patients who had haemopoietic cell transplantation from Jan 1, 1991, to Dec 31, 2011. Patients were included if they had received high-dose conditioning regimens of cyclophosphamide plus total body irradiation (CY/TBI), busulfan plus cyclophosphamide (BU/CY), busulfan plus melphalan plus thioTEPA (BUMELTT), or melphalan before transplant. Patients were excluded if their original consent forms to report transplant outcomes were not signed, if consent was withdrawn, or if they were a prisoner. Patients with Gilbert's syndrome were defined as having laboratory values before the start of conditioning therapy for unconjugated serum bilirubin concentrations of at least 17·1 µmol/L (≥1 mg/dL), normal conjugated serum bilirubin, and no evidence of hepatitis, cholestasis, or haemolysis. We assessed the association of Gilbert's syndrome with overall mortality and non-relapse mortality using adjusted Cox regression models at day 200 after transplantation. FINDINGS: Our study cohort was 3379 patients-1855 (55%) allograft and 1524 (45%) autograft recipients. 211 (6%) patients had Gilbert's syndrome and 3168 (94%) did not have this condition. Most patients were adults (median age 45·8 years [IQR 33·2-55·5]) with haematological malignancies. For overall mortality 664 (20%) patients had died by day 200 after transplant (47 [22%] of 211 who had Gilbert's syndrome vs 617 [19%] of 3168 who did not have Gilbert's syndrome), and for non-relapse mortality 499 (92%) patients had died before relapse was recorded (38 [18%] who had Gilbert's syndrome vs 461 [15%] who did not have Gilbert's syndrome). The effect of Gilbert's syndrome on the risk of overall mortality and non-relapse mortality by transplant day 200 varied between the conditioning regimens and donor groups. In patients conditioned with a myeloablative regimen that contained busulfan (n=1131), those with Gilbert's syndrome (n=60) were at a significantly increased risk of death and non-relapse mortality by day 200 compared with those without Gilbert's syndrome (n=1071; hazard ratio [HR] 2·30, 95% CI 1·47-3·61, p=0·00030; and 2·77, 1·71-4·49, p<0·0001). In patients who received CY/TBI or melphalan conditioning regimens, those with Gilbert's syndrome had similar outcomes to those without Gilbert's syndrome (overall mortality at day 200 HR 0·90, 95% CI 0·60-1·34, p=0·60; non-relapse mortality at day 200: 0·90, 0·56-1·45, p=0·65). Analyses of causes of death and busulfan disposition provided no mechanistic explanation for the differences in mortality. INTERPRETATION: Overall mortality and non-relapse mortality at day 200 after transplant were significantly worse in patients with Gilbert's syndrome who received busulfan-containing myeloablative conditioning regimens, compared with non-Gilbert's syndrome patients. Patients with Gilbert's syndrome should receive busulfan-containing myeloablative conditioning regimens with caution. FUNDING: US National Institutes of Health.

Genomic patterns resembling BRCA1- and BRCA2-mutated breast cancers predict benefit of intensified carboplatin-based chemotherapy.

INTRODUCTION: BRCA-mutated breast cancer cells lack the DNA-repair mechanism homologous recombination that is required for error-free DNA double-strand break (DSB) repair. Homologous recombination deficiency (HRD) may cause hypersensitivity to DNA DSB-inducing agents, such as bifunctional alkylating agents and platinum salts. HRD can be caused by BRCA mutations, and by other mechanisms. To identify HRD, studies have focused on triple-negative (TN) breast cancers as these resemble BRCA1-mutated breast cancer closely and might also share this hypersensitivity. However, ways to identify HRD in non-BRCA-mutated, estrogen receptor (ER)-positive breast cancers have remained elusive. The current study provides evidence that genomic patterns resembling BRCA1- or BRCA2-mutated breast cancers can identify breast cancer patients with TN as well as ER-positive, HER2-negative tumors that are sensitive to intensified, DSB-inducing chemotherapy. METHODS: Array comparative genomic hybridization (aCGH) was used to classify breast cancers. Patients with tumors with similar aCGH patterns as BRCA1- and/or BRCA2-mutated breast cancers were defined as having a BRCA-likeCGH status, others as non-BCRA-likeCGH. Stage-III patients (n = 249) had participated in a randomized controlled trial of adjuvant high-dose (HD) cyclophosphamide-thiotepa-carboplatin (CTC) versus 5-fluorouracil-epirubicin-cyclophosphamide (FE90C) chemotherapy. RESULTS: Among patients with BRCA-likeCGH tumors (81/249, 32%), a significant benefit of HD-CTC compared to FE90C was observed regarding overall survival (adjusted hazard ratio 0.19, 95% CI: 0.08 to 0.48) that was not seen for patients with non-BRCA-likeCGH tumors (adjusted hazard ratio 0.90, 95% CI: 0.53 to 1.54) (P = 0.004). Half of all BRCA-likeCGH tumors were ER-positive. CONCLUSIONS: Distinct aCGH patterns differentiated between HER2-negative patients with a markedly improved outcome after adjuvant treatment with an intensified DNA-DSB-inducing regimen (BRCA-likeCGH patients) and those without benefit (non-BRCA-likeCGH patients).

A chemosensitivity test for superficial bladder cancer based on three-dimensional culture of tumour spheroids.

OBJECTIVES: Three-dimensional (3D) spheroids are a good model for studying in vitro chemosensitivity because they reproduce unicellular and multicellular mechanisms of drug resistance. We aimed to develop a chemosensitivity test for intravesical drugs and to also verify the effects of verapamil (VPM) and ciprofloxacin (CIPRO). METHODS: Cold cup biopsies from 40 superficial bladder tumours were taken, fragmented, and left in culture. 3D-spheroids were obtained and transferred into a 24 multiwell dish containing (1) wells 1-3: 1 mg/ml epirubicin (EPI); (2) 4-6: 1 mg/ml EPI+0.5 mg/ml VPM; (3) 7-9: 1 mg/ml adriamycin (ADR); (4) 10-12: 1 mg/ml thiotepa (THIO); (5) 13-15: 1 mg/ml mitomycin C (MMC); (6) 16-18: 1mg/ml EPI+0.2 mg/ml CIPRO; (7) 19-21: 0.2 mg/ml CIPRO; (8) 22-24: controls. Sensitivity was calculated by using the trypan blue assay. RESULTS: Evaluability of clinically relevant tests (G1-G2 lesions) was 84% (21 of 25 patients). MMC was the best agent (p<0.001) with mean sensitivity being 50%, followed by THIO (37%), EPI (7%), and ADR (3%). We found no significant difference (p=0.370) between CIPRO and the control, or between EPI+CIPRO and EPI alone (p=0.550). VPM markedly enhanced sensitivity to EPI compared with EPI alone (97% vs. 7%, p<0.001). CONCLUSIONS: Our assay allows determining sensitivity to several drugs in superficial bladder tumours. It might be used in clinical practice to select the best drug for each patient. It also has experimental utility in investigating the effect of new drugs or combinations. VPM reverted resistance to EPI. CIPRO showed no effect on bladder tumour spheroids.

Enhanced antitumor activity of irofulven in combination with thiotepa or mitomycin C.

PURPOSE: Irofulven (6-hydroxymethylacylfulvene, MGI 114, NSC 683863) is a semisynthetic derivative of illudin S, a toxin present in the Omphalotus mushroom. Irofulven has demonstrated activity against a broad range of solid tumors in both xenograft models and human trials. The potential application of administering irofulven in combination with aziridine-containing chemotherapeutic agents was evaluated in this study. METHODS: Human lung carcinoma MV522 cells and BALB/c athymic mice bearing the human lung carcinoma MV522 xenograft were used to evaluate the activity of irofulven in combination with aziridine-containing drugs. RESULTS: Irofulven in combination with either thiotepa or mitomycin C demonstrated a strong synergistic (supraadditive) activity both in vitro and in vivo, that exceeded results obtained with monotherapy at the same or higher doses of these agents. The majority of xenograft-bearing animals that received subtoxic doses of irofulven, and either thiotepa or mitomycin C, demonstrated a complete cure. In contrast, there was no detectable synergistic activity between irofulven and other aziridine-containing drugs, including AZQ and thiotepa metabolites such as TEPA or AZD. CONCLUSIONS: These results indicate that the therapeutic activity of irofulven is enhanced when combined with mitomycin C or thiotepa, and further evaluation of these combinations is therefore warranted.

[Prevention of postoperative recurrence of bladder cancer: a clinical study].

OBJECTIVE: To lower postoperative recurrence rate of bladder cancer, the prophylactic effects of five kinds of method on bladder cancer were evaluated. METHODS: Between 1982 and 1997, 313 patients after TURBT or partial cystectomy were followed up for 2 to 15 years (average 7.6 years). These patients were divided into six groups: BCG, mitomycin C (MMC), thiotepa, Chinese herb medicine Zhuling (Grifola umbellata pilat), afterloading brachytherapy and control group. The prophylactic effects of them on postoperative recurrence of bladder cancer was evaluated. RESULTS: During the follow-up, the recurrence rates were 35.1% in BCG group, 34.9% in Zhuling group, 41.7% in MMC group, 52.6% in thiotepa group, 64.7% in control group, respectively. 25 high-risk patients with invading or multiple bladder cancer were treated by afterloading brachytherapy. They were followed up from 12 to 42 months, with a recurrence rate being 24.0%. CONCLUSIONS: The prophylactic effect of Zhuling and BCG on bladder cancer recurrence was better than MMC. The vale of thiotepa was not significant. The afterloading brachytherapy was of great vale to invading or recurrent, multiple bladder cancer.

Safe, compact and portable system for regional chemotherapeutic hyperthermic perfusion procedures.

Perfusion techniques utilizing hyperthermic chemotherapy have been established as a successful modality of therapy for isolated metastatic malignant melanoma. The combination of chemotherapeutic agents (Dactinomycin, thiotepa and Mechlorethamine HCl) given in high doses, not possible systemically, combined with hyperthermia (40-42 degrees C) in an isolated extremity has shown greater tumor regression compared with systemic medication only. Many of the isolated limb perfusion procedures are performed in non-cardiac centers, especially at specialized cancer institutions. This often presents new obstacles for the perfusionist including lack of adequate perfusion equipment and disposables. Other obstacles include unfamiliarity of the operating room staff with the heart-lung machine and inappropriate and/or unsafe handling of the perfusion circuit. In order to overcome these obstacles and enhance safety, portability and effectiveness, the authors have developed an isolated limb perfusion system. The purpose of this study was to compare the parameters of treatment and long term outcomes demonstrated by our system and method, to previously published data. The qualitative comparative analysis was performed between eight treatments with this type of perfusion system and outcome data previously published. It is the authors' conclusion that the portable isolated limb perfusion system achieved all of the required parameters to provide safe and effective treatment for this type of melanoma. No demonstrated variation of the long term clinical results in our patient population was seen when compared to previously published data.

New approaches to the chemotherapy of melanoma.

Several new investigational agents have shown some promise in the treatment of patients with disseminated melanoma. While earlier studies of combination chemotherapy led to increased toxicity without improved anti-tumor effect, more recent combination regimens have produced responses up to 50%. One of these is a dose-intensification regimen using high-dose cisplatin and the chemoprotective drug WR-2721. Other treatments under study include autologous bone marrow transplantation plus thiotepa, a combination regimen of chemotherapy and interferon, and newer agents such as taxol, tauromustine, and detrorubicin.

Application of traditional Chinese drugs in comprehensive treatment of primary liver cancer.

The present paper is a summary for treating 50 cases of Stage II primary liver cancer by the Integrated method of traditional Chinese and Western medicine. It was found by comparative observation that the average survival time of the Spleen-Deficiency (SD) type patients was markedly longer than that of Phlegm-Dampness-Stagnancy (PDS), Qi- and Blood-Stagnancy (QBS) and Liver-Kidney-Yin-Deficiency (LKYD) types, indicating that the SD type patients might have a better prognosis, and that the Chinese herbal medicine was an alternative for treating intermediate and late carcinoma.

Pharmacological modulation of photodynamic therapy with hematoporphyrin derivative and light.

The interactions between photodynamic therapy (PDT) with hemotoporphyrin derivative (HPD) and treatment with cytotoxic drugs have been examined using both an in vitro tissue culture assay and an in vivo transplantable mouse tumor assay. Adriamycin (0.5-4.0 mg/kg) administered with HPD and at the time of irradiation potentiated the photodynamic effect, doubling the duration of tumor control. Adriamycin administered after PDT was not as effective. Methotrexate (0.2 mg/kg) also potentiated the tumor response to PDT. The other cytotoxic agents tested, cyclophosphamide, thiotepa, vincristine, and 5-fluorouracil, did not result in significant increases in tumor responses at the doses tested. In contrast to the effects observed in vivo, Adriamycin inhibited the photodynamic destruction of Raji or Lewis lung carcinoma cells in vitro, in part by reducing the uptake of HPD. Methotrexate had no effect on either the uptake of HPD or the efficacy of photodynamic destruction of Raji cells in vitro. The discrepancy between the in vitro and in vivo results implies that the interaction between PDT and other pharmacological agents cannot be assessed in vitro.

In the search for new anticancer drugs XI. Anticancer activity of nitroxyl labeled phosphoric N,N;N',N';N",N"-tris[1,2-ethanediyl]triamide(TEPA) and phosphorothioic N,N;N',N';N",N"-tris[1,2-ethanediyl]triamide(thio-TEPA) derivatives.

In order to further evaluate the effect of the nitroxyl moiety on the anticancer activity of nitroxyl labeled analogues of phosphoric N,N;N',N';N",N"-tris[1,2-ethanediyl]triamide (TEPA) and phosphorothioic N,N;N',N';N",N"-tris[1,2-ethanediyl]triamide (thio-TEPA), the activity of these compounds was compared in vivo, using murine lymphoid leukemia L1210, with the reduced forms of the drugs, i.e. the hydroxylamines and amine congeners. At optimum dose, all compounds were active. However, the nitroxyl containing compounds were more active than the corresponding reduced forms. An admixture of 4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl had no effect on the activity of thio-TEPA. Consequently, the nitroxyl moiety must be an integral part of the anticancer drug's structure in order to influence that drug's performance.

[Cytotoxic action of thiophosphamide on human tumor cells]. / Tsitotoksicheskoe deistvie tiofosfamida na kletki opukholei cheloveka.

The cytotoxic action of thiophosphamide on the cells of 16 human tumor xenografts (lung, breast, colon and stomach carcinomas) was studied. The tumor xenografts placed into diffusion chambers were implanted into intact mice. It was demonstrated that thiophosphamide inhibits the progress of cancer cells to mitosis, reduces the rate of DNA synthesis and accumulation of the cells in mitosis and S-phase. The most pronounced and lasting alterations in cell proliferation were recorded in breast cancer, less significant in carcinoma of the stomach. These findings correlate with the data on the clinical efficacy of thiophosphamide applied to the treatment of these tumors.

Verapamil enhancement of chemotherapeutic efficacy in human bladder cancer cells.

The calcium influx blocker verapamil has been used to overcome drug resistance in several tumor systems. The possible in vitro enhancement of drug efficacy was assessed in bladder cancer cell line T24. Combination of thiotepa and doxorubicin hydrochloride with verapamil significantly reduced the survival and growth of T24 cells after as little as 1 hour of drug exposure. An increase in doxorubicin hydrochloride-induced inhibition of [3H]thymidine uptake resulted when verapamil was administered. However, this trend was not demonstrated when combined with thiotepa. It appears that verapamil enhances thiotepa-induced cytotoxicity while it potentiates the antimitotic nature of doxorubicin hydrochloride. The data presented is consistent with the postulate that verapamil alters active efflux of drug from malignant cells and suggests that verapamil has a role in the clinical management of bladder cancer.

The biology and treatment of superficial bladder cancer.

Management of the superficial bladder cancer patient consists of two complementary but separate therapeutic goals: treatment of the existing tumor(s) and prevention of tumor recurrence. At present, the stage, grade, and multicentricity are the major determinants in the natural and therapeutic history of the disease. Although intravesical instillation of chemotherapeutic agents has been used for greater than 20 years, neither its exact role nor the optimal dose or schedule of administration have been established. To date, no dramatic differences in efficacy between the agents commonly used for intravesical chemotherapy, either as definitive therapy or prophylaxis, have been appreciated. These agents do appear to lower the recurrence rate as well as extend the disease-free interval. Since the most thorough experience is with thiotepa, it is the drug against which other agents should be compared in terms of both efficacy and toxicologic evaluation. Different administration schedules and methodologies need further study, such as the utility of continuous bladder irrigation, the use of sequential chemotherapeutic agents to gain cell synchronization, and the use of multiple drug regimens. Because there are multiple factors that influence the occurrence and recurrence of bladder cancer, combined modality therapy deserves testing. Modes of therapy that could be used together because they act through different mechanisms are intravesical chemotherapy, radioactive needle implants, carcinogen modifiers such as pyridoxine, chemoprotective agents such as retinoic acid, and immune stimulants such as BCG. These studies should be performed in a randomized prospective controlled fashion, which may require cooperative multi-institutional involvement to accrue adequate numbers of patients. At this time there are a number of important questions that remain to be answered concerning the treatment of superficial bladder cancer: (1) does this mode of therapy affect overall survival, (2) does prophylactic intravesical chemotherapy alter the incidence of subsequent muscle invasive disease, (3) does intravesical chemotherapy alter the sites, incidence, or responsiveness to systemic chemotherapy of subsequent metastatic disease, and (4) and what is the optimal timing and duration of prophylactic therapy from a cost-effectiveness standpoint?

[Changes in the metastasis of experimental tumors and in the antimetastatic effect of cytostatics in their pharmacological action on adrenergic processes]. / Izmenenie metastazirovaniia éksperimental'nykh opukholei i antimetastaticheskogo éffekta tsitostatikov pri farmakologicheskikh vozdeistviiakh na adrenergicheskie protsessy.

Different pharmacologic drugs (isadrin, obsidan, phentolamine) changing adrenergic processes are shown to have different effect on the growth and development of lung metastases. An increase in the antimetastatic effect of some cytostatics is also observed in mice with Lewis carcinoma and melanoma B-16 under the influence of isadrin, a stimulator of beta-adrenoreceptors. In authors' opinion, isadrin changes microcirculation in lungs and prevents inhibition of the immune reactivity in animals with metastatic tumours, thus contributing to inhibition of the development and growth of metastases.