Secondary drug resistance in breast cancer: failure to reverse with oral nifedipine.

We tested the efficacy of nifedipine to reverse acquired resistance to chemotherapy regimens containing doxorubicin or vinblastine or both in 12 patients with metastatic breast cancer. All patients had been receiving one or both of these drugs, had had a prior partial response (median duration 5 months, range 2-10) and subsequently progressed. Immediately after drug resistance was documented by tumor progression, eligible patients with measurable or evaluable disease were treated with nifedipine beginning 3 days before restarting the same chemotherapy. The initial dose of nifedipine was 20 mg TID, escalating daily to 40 mg TID on day 3 if the patient had no serious side effects. Nifedipine was continued at the highest tolerable dose during and for 2 days after completion of the chemotherapy. Most patients had < or = 2 prior chemotherapy regimens and a median Zubrod performance status of 1. Twelve patients received a total of 23 courses preceded by nifedipine. No objective tumor responses were observed. The expected toxic effects attributable to nifedipine occurred, but nifedipine did not increase the toxicity caused by the chemotherapy. Nifedipine, given in this dose and schedule, did not reverse acquired drug resistance in patients with breast cancer.

A phase I study of TNP-470 administered to patients with advanced squamous cell cancer of the cervix.

A Phase I study of the novel angiogenesis inhibitor TNP-470 was performed. Patients with inoperable recurring or metastatic squamous cell cancer of the cervix with evaluable disease, no coagulopathy, and adequate renal, hepatic, and hematological function were eligible. One course of treatment consisted of an i.v. infusion of TNP-470 over 60 min every other day for 28 days, followed by a 14-day rest period. The starting dose was 9.3 mg/m2. Eighteen evaluable patients were treated, with a median age of 48 years (range 27-55) and performance status Zubrod 1 (range 0-2). Grade 3 neurotoxicities consisting of weakness, nystagmus, diplopia, and ataxia were encountered in two patients receiving the 71.2 mg/m2 dose. An intermediate dose level of 60 mg/m2 was evaluated and found to be well tolerated by three patients. Only one patient experienced grade 3 nausea on the 60 mg/m2 dose level. No myelosuppression, retinal hemorrhage, weight loss, or significant alopecia were observed. One patient had a complete response, which continues for 26 months, and three patients with initially progressive disease stage had stable disease for 5, 7.7, and 19+ months. Other Phase I studies, including over 200 patients, were performed concurrently with this study. Based on this experience, the dose of TNP-470 recommended for further studies is 60 mg/m2 as a 60-min i.v. infusion every Monday, Wednesday, and Friday. Neurotoxicity was dose limiting, but appears to be reversible. Otherwise, the treatment was well tolerated. The drug may be active in squamous cell cancer of the cervix. Further studies of TNP-470 in squamous cell cancer of the cervix are warranted.

Gastrointestinal leiomyosarcoma metastatic to the liver. Durable tumor regression by hepatic chemoembolization infusion with cisplatin and vinblastine.

BACKGROUND: Gastrointestinal leiomyosarcoma metastatic to the liver is considered most resistant to any combination of systemic chemotherapy containing doxorubicin and/or ifosphamide. METHODS: Fourteen patients with gastrointestinal leiomyosarcoma metastatic to the liver were treated with hepatic chemoembolization infusion consisting of polyvinyl alcohol sponge particles mixed with cisplatin powder (150 mg) followed by an intrahepatic arterial infusion of vinblastine (10 mg/m2). RESULTS: Ten major (> 50% regression) tumor responses were observed (70%) in patients lasting from 8 to 31+ months (median, 12 months) after an average of two hepatic chemoembolization procedures, usually 4 weeks apart. Transient side effects included right upper quadrant pain requiring narcotics, significant hepatic enzyme elevation, particularly of lactic dehydrogenase with a minimal increase in bilirubin, paralytic ileus requiring nasogastric suction up to 72 hours, urinary electrolyte losses (potassium+, magnesium++, sodium+) requiring supplements, and occasionally mild but transient leukopenia and thrombocytopenia. CONCLUSIONS: Hepatic chemoembolization infusion appears to induce a high rate of durable tumor response in patients with notoriously chemoresistant gastrointestinal leiomyosarcoma metastatic to the liver.

Severe, symptomatic, dose-limiting hypophosphatemia induced by hepatic arterial infusion of recombinant tumor necrosis factor in patients with liver metastases.

Twenty-two patients with liver metastases received 45 courses of recombinant tumor necrosis factor (rTNF) by hepatic arterial infusion in doses ranging from 12.5 to 175 micrograms/m2/d for 5 days by continuous infusion. The induction of statistically significant, dose-related, severe, albeit transient, hypophosphatemia (less than 1.0 mg/dl) associated with clinically significant, right-sided myocardial dysfunction and severe lassitude was observed. These side effects were promptly reversed after rTNF was stopped and intravenous phosphate supplementation was started. As no significant or consistent increase in urinary phosphate excretion was detected, the rTNF-induced hypophosphatemia probably resulted from an intracellular shift of phosphate. Since tumor regression was clearly associated with the lowest levels of serum phosphate, hypophosphatemia may be important in the antitumor effects of rTNF.

[F3, a fractionated extract of Astragalus membranaceus, potentiates lymphokine-activated killer cell cytotoxicity generated by low-dose recombinant interleukin-2].

Success with rIL-2 immunotherapy of human cancer appears to depend on the administration of high doses which are frequently associated with excessive toxicity. Future use of rIL-2 will require certain modifications based on the use of lower doses of rIL-2 without significant loss of antitumor efficacy. The authors tested in vitro the possibility of potentiating the activity of rIL-2 in terms of LAK cell generation. The authors hypothesized that co-incubation of LAK cell precursors with a Chinese herbal extract (F3) of Astragalus membranaceus (an immune modulator currently under study in the authors' laboratory), along with a low concentration of rIL-2 would generate levels of LAK cell activity equivalent to those generated by high concentrations of rIL-2 alone. The authors found: (1) a 10-fold potentiation of rIL-2 activity manifested by tumor cell killing activity of 80% resulting from LAK cell generation with F3 plus 100 u/ml of rIL-2 versus 76% generated by 1000 u/ml of rIL-2 alone; (2) a significant reduction in the number of effector LAK cells required for equicytotoxic reaction following LAK cell generation with F3 plus rIL-2 compared to rIL-2 alone. The authors conclude that potentiation of antitumor activity mediated by rIL-2 in low concentrations is possible by the concomitant use of another immune modulator such as Astragalus membranaceus.

Fractionated extract of Astragalus membranaceus, a Chinese medicinal herb, potentiates LAK cell cytotoxicity generated by a low dose of recombinant interleukin-2.

Success with rIL-2 immunotherapy of human cancer appears to depend on the administration of high doses which are frequently associated with excessive toxicity. Future use of rIL-2 will require certain modifications based on the use of lower doses of rIL-2 without significant loss of antitumor efficacy. We tested in vitro the possibility of potentiating the activity of rIL-2 in terms of LAK cell generation. We hypothesized that co-incubation of LAK cell precursors with a Chinese herbal extract (F3) of Astragalus membranaceus, (an immune modulator currently under study in our laboratory), along with a low concentration of rIL-2, would generate levels of LAK cell activity equivalent to those generated by high concentrations of rIL-2 alone. We found (1) a 10-fold potentiation of rIL-2 activity manifested by tumor cell-killing activity of 80% resulting from LAK cell generation with F3 plus 100 u/ml of rIL-2 versus 76% generated by 1,000 u/ml of rIL-2 alone; (2) a significant reduction in the number of effector LAK cells required for equicytotoxic reaction following LAK cell generation with F3 plus rIL-2 compared to rIL-2 alone. We conclude that potentiation of antitumor activity mediated by rIL-2 in low concentrations is possible by the concomitant use of another immune modulator such as Astragalus membranaceus.

Immunotherapy with Chinese medicinal herbs. II. Reversal of cyclophosphamide-induced immune suppression by administration of fractionated Astragalus membranaceus in vivo.

A partially purified fraction (F3) with an estimated molecular weight of 20,000 to 25,000 derived from the traditional Chinese medicinal herb Astragalus membranaceus, was found to possess a potent immunorestorative activity in vitro. Its capacity to aborogate the local xenogeneic graft versus host reaction (XGVHR) following injection in vivo was further studied in a newly developed animal model designed for preclinical evaluation of various biological response modifiers. F3 was injected intravenously into cyclophosphamide-primed rats at varied concentrations and schedules prior to grafting of mononuclear cells from healthy normal donors. Maximal abrogation of the local XGVHR mounted by the mononuclear cells, was observed following injection of 5.55 mg of F3 daily for eight days. This abrogation of XGVHR indicates a reversal of the immunosuppressive effect of cyclophosphamide as manifested by a significant decline in the local XGVHR volume from 99.42 +/- 9.2 mm3 (positive control) to 39.78 +/- 8.3 mm3 (p less than 0.001). This reversal of cyclophosphamide-induced immunosuppression by the administration of F3 was complete, since the volume of the abrogated local XGVHR (39.78 +/- 8.3 mm3) was comparable to 34.79 +/- 5.69 mm3 (p greater than 0.1) in the negative control group (no cyclophosphamide-priming; saline injection only). These data indicate that F3 administration markedly enhances the rats' ability to reject the xenogeneic graft and therefore possesses a strong immune potentiating activity in vivo. These preclinical data also provide the rational basis for the use of extracts of Astragalus membranaceus in phase I clinical trials among patients suffering from iatrogenic or inherent immune deficiency states.

Immunotherapy with Chinese medicinal herbs. I. Immune restoration of local xenogeneic graft-versus-host reaction in cancer patients by fractionated Astragalus membranaceus in vitro.

The in vitro immunomodulatory activity of fractions derived from Astragalus membranaceus, an herb commonly used in the practice of traditional Chinese medicine, was first screened by studying their individual effects on mononuclear cells (MNC) derived from healthy normal donors using the local xenogeneic graft-versus-host reaction (XGVHR). Sephacryl S-200 column-separated Fraction 3 (MW 20,000-25,000) along with its crude extract precursor, Fraction 7, and another crude extract derivative, Fraction 8, were equally augmentative (p less than 0.05) in their effect on MNC from normal donors. These three active fractions were further studied on MNC derived from 13 cancer patients. Using again the local XGVHR as a model assay for T-cell function, preincubation of MNC derived from cancer patients with Fraction 3 induced a significant increase in local XGVHR (compared to untreated cells) with a mean +/- SD of 151.34 +/- 46.02 mm3 vs 57.80 +/- 16.44 mm3; p less than 0.001. Fractions 7 and 8 likewise induced significant increases in local XGVHR (109.14 +/- 19.32 mm3 versus 50.91 +/- 17.39 mm3; p less than 0.001 and 119.74 +/- 18.33 mm3 versus 48.77 +/- 16.17 mm3; p less than 0.001, respectively). The augmented immune reactions which were induced by either Fraction 3 or Fraction 8 (but not by Fraction 7) in MNC derived from cancer patients, each significantly exceeded the local XGVHR observed in the untreated MNC derived from normal donor controls with a relative reference index (ratio) of 1.60 +/- 0.48 and 1.23 +/- 0.17 respectively; p less than 0.005.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity and resistance to chemotherapy in acute leukemia: correlation with in vitro drug uptake and lack of potentiation by verapamil.

The calcium channel blocker verapamil has been reported to circumvent acquired resistance to different antitumor agents in tumor cell lines in vitro. We studied its effect on in vitro uptake of m-AMSA and adriamycin in fresh leukemic cells from 11 leukemia patients. Six previously untreated patients were sensitive to m-AMSA (obtained remission). Four were clinically resistant to m-AMSA, and two of these also to adriamycin. Leukemic cells were incubated in pharmacological doses of 14C-adriamycin and 14C-m-AMSA for up to 2 h. Samples were supplemented with verapamil (750 ng ml-1) 30 min prior to the addition of m-AMSA or adriamycin. Drug uptake was measured at 15 min intervals up to 2 h and drug retention was measured during 30 min after the end of incubation, following washing and resuspension in fresh medium without cytotoxic drugs. Adriamycin uptake was the same irrespective of verapamil in all four cell samples, two of which were derived from patients resistant to adriamycin. The cellular m-AMSA uptake was higher in cells from clinically sensitive than from resistant patients (510 +/- 155 fg cell-1 vs 275 +/- 125 fg cell-1; P less than 0.01). Retention of m-AMSA 30 min after incubation was higher in cells from sensitive compared to resistant patients (187 +/- 78 vs 25 +/- 7; P less than 0.05). Our data suggest: (1) in vitro uptake greater than or equal to 350 fg cell-1 and subsequent retention greater than 75 fg cell-1 correlate to clinical sensitivity to the drug; and (2) neither m-AMSA nor adriamycin uptake could be significantly increased by verapamil.

Immune restoration and/or augmentation of local graft versus host reaction by traditional Chinese medicinal herbs.

The in vitro restorative effect of aqueous extracts from two traditional Chinese medicinal herbs were studied in 19 cancer patients and in 15 normal healthy donors. Using the local graft versus host (GVH) reaction as a test assay for T-cell function, the extract from astragalus membranaceus (10 microgram/ml) induced a restored reaction in nine of ten patients with an increase in local GVH reaction from 18.2 plus/minus 15.8 mm3 to 112.9 plus/minus 94.2 mm3 (P less than 0.01). The extract from ligustrum lucidum, likewise effected an immune restoration in nine of 13 cancer patients with an increase in local GVH reaction from 32.3 plus/minus 36.1 mm3 to 118 plus/minus 104.9 mm3 (P less than 0.01). This degree of immune restoration appears to be complete as it equals the local GVH reaction observed among untreated mononuclear cells from normal healthy donors (82.8 plus/minus 41.1 mm3, P greater than 0.1). These results suggest that both extracts of the traditional Chinese medicinal herbs contain potent immune stimulants which may provide the rational basis for their therapeutic use as biological response modifiers.

Preliminary observations on the effects of the Chinese medicinal herbs Astragalus membranaceus and Ligustrum lucidum on lymphocyte blastogenic responses.

The biological effects of extracts of two Chinese medicinal herbs, Astragalus membranaceus and Ligustrum lucidum, on in vitro lymphocyte blastogenesis were assessed. Aqueous extracts augmented the spontaneous [3H]thymidine incorporation in the mononuclear cells (MNC) of 14 normal subjects from 273.0 to 609.3 counts per minute (cpm) and 252.9 to 656.9 cpm for the two herbs, respectively. The stimulation indices were 2.4 and 3.1, respectively (p less than 0.001). They also augmented the proliferation of normal subjects' lymphocytes induced by suboptimal concentrations of phytohemagglutinin (PHA) from 5084.6 to 23,398.3 and 221.7 to 24,132.8 cpm, of concanavalin A (con A) from 4046.5 to 15,661.5 and 677.6 to 14,644.6 cpm, and of pokeweed mitogen (PWM) from 4377.9 to 24,405.6 and 322.7 to 11,730.0 cpm, respectively (p less than 0.00). Herb extracts augmented the PHA responses of the MNC from 14 cancer patients significantly (p less than 0.01 and p less than 0.05, respectively). Extracts of L. lucidum also augmented the con A response of patients (p less than 0.05). The augmenting effect of the herbs on the PHA, con A, and PWM responses was dose dependent, and proliferation was inhibited at higher concentrations. The optimal concentration for stimulating the MNC of cancer patients was 100 micrograms/ml, compared to 10 micrograms/ml for the MNC of normal donors. MNC of seven patients depressed the mitogen responses of normal cells in a co-culture system. This was partially abrogated in five by preincubating the patients' cells in herb extracts for 45 min or by irradiation of the patients' cells. These results suggest that the herb extracts contain immunomodulatory components which may be useful in the immunotherapy of disease.

Adjuvant immunotherapy and chemoimmunotherapy in colorectal cancer (Dukes' class C): prolongation of disease-free interval and survival.

The poor postsurgical prognosis in patients with colorectal cancer of the Dukes' C classification has prompted a clinical trial of adjuvant immunotherapy versus chemoimmunotherapy intended to prolong either the disease-free interval or the overall survival or both. One hundred and twenty-one patients have been entered on this study. Fifty-two patients received BCG alone and 69 patients received the combination of 5-FU and BCG. The disease-free interval and the overall survival were compared with similar parameters in a group of historical controls with similar prognostic characteristics who were operated on in our institution prior to the initiation of the current study. There was no difference as yet between BCG alone and the combination of 5-FU + BCG in terms of both the disease-free interval and the survival. Both treatments, however, had significantly better results than the surgical controls. Adjuvant therapy, especially with BCG is advocated for patients with colorectal carcinoma, Dukes' C class, following potentially curative surgery.

Prolongation of postoperative disease-free interval and survival in human colorectal cancer by B.C.G. or B.C.G. plus 5-fluorouracil.

83 patients with colorectal carcinoma of the Dukes' C class were randomised to receive postoperative adjuvant therapy with B.C.G. alone or in combination with oral doses of 5-fluorouracil (5-F.U.), and have been followed for up to thirty months. Results were compared with carefully selected historical controls who were treated by surgery alone. A statistically significant prolongation of both disease-free interval and overall survival was observed in 50 patients receiving the combination of B.C.G. and 5-F.U. (P=0.03, P=0.01 respectively) as well as in 33 patients receiving B.C.G. alone (P=0.03, P=0.05 respectively). The efficacy of B.C.G.+5-F.U. was independent of the number of tumour-involved lymph-nodes in the surgical specimen. In contrast, B.C.G. given alone appears to be highly effective among 10 patients with 6 or more positive lymph-nodes (P less than 0.04) and ineffective (as yet) among 23 patients with 5 or less positive lymph-nodes. These results suggest that adjuvant immunotherapy, with or without chemotherapy, can improve the prognosis of surgically treated patients with colorectal carcinoma of the Dukes' C class.

Adjuvant immunotherapy and chemoimmunotherapy in colorectal cancer of the Dukes' C classification. Preliminary clinical results.

Fifty-eight patients with Dukes' C classification of carcinoma of the large bowel were placed on adjuvant immuno- or chemoimmunotherapy with Bacillus calmette guerin (BCG) or combination of 5-fluorouracil (5-FU) plus BCG following primary and definitive surgery, and were followed for up to 21 months. Of twenty-six patients receiving BCG alone by scarification, five have relapsed with 75% of freedom from disease estimated at 15.1 months compared with 10.1 months in a group of carefully selected historical controls who had surgery alone (p = 0.12). The survival of all patients receiving BCG alone has not reached the 75 percentile yet, and the difference from controls is currently estimated at the 18% level. The combination of 5-FU plus BCG (studied in 32 patients) may be superior to BCG alone at this time, in that it appears to more effectively protect against tumor recurrence (75 percentile not yet reached compared to control, (p = 0.08). The survival of patients on 5-FU plus BCG also appears to be improved (p = 0.09). No patients have expired compared to a 75 percentile survival of 16.6 months in the control. Serial determination of plasma CEA was crucial in the clinical follow-up of these patients. Frequent CEA detetminations have led to early detection of clinical relapse. In the elevation of CEA suggests tumor recurrence with a high degree of probability in patients with past history of cancer of the large bowel.