Cystic fibrosis hetero- and homozygosity is associated with inhibition of breast cancer growth.

Cystic fibrosis (CF) is the most common lethal recessive genetic disease of the Caucasian population. Although reports of cancer frequency in CF have emphasized an elevated observed-to-expected ratio of 6.5 for digestive tract cancers, these studies also show a significantly decreased observed-to-expected ratio for other malignancies including breast cancer. The cystic fibrosis transmembrane conductance regulator (CFTR) functions as an ATP channel. We found that heterozygous and homozygous CFTR knockout mice had elevated blood ATP concentrations. Elevated extracellular ATP is known to inhibit tumor growth in vivo and in vitro. Using double mutant mice created by F2 generation crosses of CFTR knockout and nude mice, we observed reduced breast tumor implantability in CFTR homozygous nude animals. Decreased tumor growth rate was observed in both CFTR heterozygous and homozygous nude animals. Extracellular ATP reduced human breast tumor cell growth rate in vitro, and a breast tumor transfected with human CFTR that had high extracellular ATP concentrations in vitro correspondingly had a slower growth rate in vivo. The results suggest that both CFTR heterozygosity and homozygosity suppress breast cancer growth and that elevated extracellular ATP can account for this phenomenon.

Toxicity, radiation sensitivity modification, and combined drug effects of ascorbic acid with misonidazole in vivo on FSaII murine fibrosarcomas.

Ascorbic acid (ASC) has been shown to radioprotect nonmalignant tissue and to enhance the effects of misonidazole (MISO) on hypoxic cells in vitro. Since ASC is minimally toxic, it is an interesting candidate for improving the radiotherapeutic gain factor in vivo. The in vivo radiomodifying effects of ASC on a C3H/fSed murine fibrosarcoma (FSaII), on normal skin, and on bone marrow were determined with the use of the tumor growth delay and TCD50 (i.e., radiation dose required to control 50% of treated tumors for a minimum of 120 days) assays and the RD50 (i.e., dose required to cause a peak skin reaction of 2 in 50% of treated hind limbs) and LD50 (i.e., whole-body radiation lethal dose) assays, respectively. ASC was buffered to pH 7.35 and delivered ip at a dose of 4.5 mg g-1 body weight. ASC did not modify tumor growth delay induced by radiation or the TCD50 [87.1 Gy (control) vs. 85.6 Gy (ASC)]. Normal tissues, however, were radioprotected by ASC. RD50 values for 2+ acute skin reactions were 46.4 and 55.7 Gy for control and ASC-treated subjects, respectively; LD50 (30 days) values were 7.2 and 8.5 Gy. The enhancement ratios for skin and bone marrow were 1.20 and 1.18, and 95% confidence limits were (1.07 ... 1.34) and (1.14 ... 1.23), respectively. The therapeutic gain factor was 1.22 calculated as the ratio of the TCD50 and the reference normal tissue (RD50 or LD50). When ASC and MISO were combined, ASC reduced the in vivo radiosensitizing effects of MISO.

Effects of hydralazine-induced vasodilation on the energy metabolism of murine tumors studied by in vivo 31P-nuclear magnetic resonance spectroscopy.

The effects of hydralazine on tumor energy metabolism and on some cardiovascular parameters were measured. Tumor energy metabolism was studied in C3Hf/Sed mice with isotransplants of a spontaneous murine fibrosarcoma (FSaII, congruent to 100 mm3 in volume) and 31P-NMR. Cardiovascular parameters were measured in anesthetized C3Hf/Sed mice via intracarotid catheter. Hydralazine doses of 0.25 mg/kg given ip caused an increase of the phosphocreatine to inorganic phosphate ratio (PCr: Pi) in 5 of 6 animals. These doses had minimal effects on mean arterial blood pressure, though there may have been an increased cardiac output due to a decreased afterload. Hydralazine doses greater than or equal to 2.0 mg/kg given ip were associated with a decrease in PCr, nucleotide triphosphate, and pH, and an increase in Pi (P less than .01 for control vs. 10 mg hydralazine/kg). This substantial decrease in high-energy phosphates was associated with a pronounced decrement in mean arterial blood pressure. These findings provide a rational basis for the study in experimental systems of hydralazine-induced enhancement of cell killing by hyperthermia and by agents toxic to hypoxic cells. Further, these results can be taken as a sign that hydralazine should be used with care in patients undergoing radiation treatment.

Tumor growth and tumor radiosensitivity in mice given myeloprotective doses of fibroblast growth factors.

BACKGROUND: Radiation at doses high enough to cure cancer also frequently destroys normal tissue. Development of agents that protect normal tissue without also protecting diseased tissue has been difficult. In vivo radioprotection of bone marrow by acidic and basic fibroblast growth factors (FGF1 and FGF2, respectively) has recently been demonstrated after whole-body irradiation of C3H/HeN mice. PURPOSE: Our purpose was to determine whether myeloprotective doses of those growth factors also protect malignant tumors. METHODS: First, we investigated the effects of exogenous FGF1 or FGF2 (FGF1/2) administration (treatment group receiving two intravenous injections of 3 micrograms FGF1/2 per mouse 24 hours and 4 hours before local irradiation of right hind leg and control group receiving two intravenous injections of 0.1 mL of saline) on growth and radiosensitivity of three transplantable murine tumors (one squamous cell carcinoma [SCC-VII] and two sarcomas [KHT and Rif-1]), all of which were grown in C3H/HeN mice. We then evaluated the effect of FGF1/2 on tumor cell proliferation, cell cycle distribution, and pulmonary metastatic frequency in the mice. Specifically, survival studies were performed in mice treated with 0, 6, 6.5, 7.5, 8.5, 9, or 10 Gy whole-body irradiation with or without FGF2 (n = 250). Rif-1 (n = 40), KHT (n = 40), and SCC-VII (n = 40) tumors were implanted in the hind leg of mice, and mice were treated with FGF2 or saline when their tumor-bearing thighs were 9 mm in diameter. In separate experiments (treatment group receiving two injections of 3 micrograms each of FGF2 [6 micrograms total] either intravenously or intratumorally 24 hours and 4 hours before local tumor irradiation and control group receiving 0.1 mL saline), tumor growth was followed, and mice were killed to count lung metastases and measure tumor proliferating cell nuclear antigen (PCNA) and bromodeoxyuridine labeling at various times thereafter (three to eight mice per group). Tumor growth curves of untreated and irradiated tumors were determined with and without intravenous or intratumoral FGF1/2 in SCC-VII tumors (n = 120). Radiation doses to the tumor-bearing leg were 15 and 30 Gy for SCC-VII, 30 Gy for Rif-1, and 15 Gy for KHT. From each experiment, the mean (+/- 1 standard error) was calculated from data obtained from three to 20 mice. Statistical tests used included two-tailed Student's t test, the chi-squared test, and Fisher's exact test. All P values represent two-tailed tests of statistical significance. RESULTS: There was no statistically significant difference in tumor growth rate between FGF2-treated and saline-treated mice when FGF2 was administered intravenously at doses and schedules found to be optimally myeloprotective in whole-body irradiation experiments. Intravenous administration of FGF2 did not induce lung metastases, and it did not augment the S-phase fraction of tumor cells. Likewise, there was no evidence of enhanced cell proliferation as measured by PCNA-labeling index. Intratumoral injection of FGF1/2 did increase the size of SCC-VII tumors (P < .05 [Student's t test] at 3 days after treatment); however, the radiation response after intratumoral injection of growth factor was not compromised. CONCLUSION: Low intravenous doses of FGF1 or FGF2 appear to protect bone marrow from the toxic effects of radiation without increasing the rates of tumor growth or metastases or decreasing the radiosensitivity of tumors.

Treatment of locally advanced cancer of the head and neck with 5'-iododeoxyuridine and hyperfractionated radiation therapy: measurement of cell labeling and thymidine replacement.

BACKGROUND: The halogenated pyrimidines 5'-iododeoxyuridine (IdUrd) and 5'-bromodeoxyuridine (BrdUrd) are under active study as radiation sensitizers for a variety of malignancies. Head and neck neoplasms may also be suitable for halogenated pyrimidine-mediated sensitization; previous regimens using intra-arterial BrdUrd delivery, however, were poorly tolerated. PURPOSE: A pilot study was undertaken with the use of intravenous IdUrd with hyperfractionated radiotherapy to assess tolerance. In addition, serial tumor biopsy specimens were obtained to determine the kinetics of IdUrd labeling and incorporation. METHODS: Twelve patients with squamous cell carcinomas of the head and neck (one patient had stage II cancer, one had stage III, and 10 had stage IV) were treated with hyperfractionated radiation therapy at a dose of 1.2 or 1.5 Gy twice a day, to a total dose in the range of 70-76 Gy. IdUrd (1000 mg/m2 per day) was infused for a maximum of 14 days at the beginning and then again during the middle of the radiotherapy. A tumor biopsy specimen was obtained from 11 patients following initiation of treatment with IdUrd. Eight patients consented to serial biopsy to allow the study of IdUrd-labeling indices and thymidine replacement over time. Incorporation of IdUrd into tumor DNA was determined by high-performance liquid chromatography, and cell labeling was determined with the use of an anti-BrdUrd/IdUrd monoclonal antibody in conjunction with flow cytometry. Patients continue to be followed to assess local control. RESULTS: A plot of corrected IdUrd replacement as a function of infusion time suggests the possibility of a plateau after 5-7 days of infusion at 7.5%-8%. The average rate of replacement from days 1 to 5 was 1.3% per day and was determined by linear regression analysis. Acute toxic effects, especially mucositis, were severe enough to require delays in the radiation therapy. Eleven of 12 patients treated had complete clinical remissions. Seven of these patients remain clinically free of local disease at the time of death or most recent follow-up. CONCLUSIONS: The level of IdUrd incorporation and cell labeling should be adequate to produce sensitization. However, the treatment as prescribed in this study (two 14-day infusions of IdUrd during radical radiotherapy with only one planned split) was not completed in a single patient because of either dose-limiting hematologic toxicity or severe mucositis necessitating treatment break. Since this particular regimen is not tolerable, future protocols will have shorter exposures to IdUrd. IMPLICATIONS: Previous regimens using halogenated pyrimidine radiosensitizers have generally used protracted drug delivery schedules. In this study, a high level of IdUrd labeling was measured after 5-7 days of drug infusion. The halogenated pyrimidines deserve further study with the use of repetitive short courses to reduce toxicity and possibly improve efficacy.

Role of hypovolemic hemoconcentration in dose-dependent flow decline observed in murine tumors after intraperitoneal administration of glucose or mannitol.

Responses of tumor microcirculation (RBC flux) to i.p. glucose or mannitol injections were studied in early generation isotransplants of a spontaneous C3Hf/Sed mouse fibrosarcoma (FSaII). RBC flux in superficial tumor microregions was assessed using laser Doppler flowmetry. After administration of glucose or mannitol (a nonmetabolized sugar alcohol), a dose-dependent reduction in laser Doppler flow, and a dose-dependent increase in systemic hematocrit occurred concurrently. Maximum flow reductions induced by i.p. glucose or mannitol were statistically indistinguishable for equal osmotic load. Maximum decreases in RBC flux for glucose or mannitol were 20 and 25% (1.25 mg/g i.p.), 42 and 48% (2.5 mg/g i.p.), 72 and 60% (5 mg/g i.p.), and 80 and 75% (10 mg/g i.p.), respectively. Maximum increases in systemic hematocrit ranged from 18% (1.25 mg/g glucose i.p.) to 33% (10 mg/g glucose i.p.). Examination of RBC count, blood hemoglobin concentration, and fluid accumulation in the abdominal cavity after glucose or mannitol administration were all compatible with a significant shift of intravascular/extracellular water into the abdominal cavity with resultant systemic hypovolemic hemoconcentration. RBC volume and mean hemoglobin content of RBC remained unchanged with glucose loading. The data suggest that reductions in laser Doppler flow are predominantly caused by hypovolemic hemoconcentration following i.p. administration of hyperosmolar sugar solutions. Changes in laser Doppler flow due to specific glucose-mediated or glucose-related phenomena are probably of minor importance in the murine tumor system investigated. Future studies on murine tumors, examining for specific effects of glucose on metabolism and/or therapy, should not use i.p. administration of hyperosmolar solutions.

Effect of intraperitoneal versus intravenous glucose administration on laser Doppler flow in murine FSaII tumors and normal skin.

The effects of i.p. versus i.v. glucose administration on laser Doppler flow (LDF) were studied in peripheral tissue areas of murine FSaII tumors implanted s.c. in the hind foot dorsum and in normal skin of conscious C3Hf/Sed mice. LDF was monitored prior to and continuously for 90 min following the administration of glucose, galactose, or mannitol at doses of 5 or 10 mg/g. Results showed that i.p. administration of hyperosmolar solutions was followed by a substantial, dose-dependent flow reduction which was indistinguishable for the various agents at equal osmotic load, and similar in tumor tissue and normal skin. Reductions in LDF are, therefore, primarily caused by hypovolemic hemoconcentration following i.p. administration of hyperosmolar sugar solutions. In contrast, i.v. administration of these solutions at 5 mg/g caused an initial flow increase (most probably due to a transient hypervolemic hemodilution), with a return to baseline readings within 5-10 min. At 10 mg/g i.v., a biphasic change in LDF occurred with an initial, temporary increase and a significant decline thereafter with no recovery within the observation period. This drop in LDF most probably is due to a decrease in cardiac output and an increase in viscous resistance to flow. Since comparable changes were observed with all agents and in both tissues investigated, it is concluded that the alterations in flow pattern following injection of hyperosmolar solutions are neither glucose nor tissue specific. Glucose- or tumor-specific effects, if present at all, must be of secondary importance in the animal model chosen.

Blood flow, oxygen and nutrient supply, and metabolic microenvironment of human tumors: a review.

The objective of this review article is to summarize current knowledge of blood flow and perfusion-related parameters, which usually go hand in hand and in turn define the cellular metabolic microenvironment of human malignancies. A compilation of available data from the literature on blood flow, oxygen and nutrient supply, and tissue oxygen and pH distribution in human tumors is presented. Whenever possible, data obtained for human tumors are compared with the respective parameters in normal tissues, isotransplanted or spontaneous rodent tumors, and xenografted human tumors. Although data on human tumors in situ are scarce and there may be significant errors associated with the techniques used for measurements, experimental evidence is provided for the existence of a compromised and anisotropic blood supply to many tumors. As a result, O2-depleted areas develop in human malignancies which coincide with nutrient and energy deprivation and with a hostile metabolic microenvironment (e.g., existence of severe tissue acidosis). Significant variations in these relevant parameters must be expected between different locations within the same tumor, at the same location at different times, and between individual tumors of the same grading and staging. Furthermore, this synopsis will attempt to identify relevant pathophysiological parameters and other related areas future research of which might be most beneficial for designing individually tailored treatment protocols with the goal of predicting the acute and/or long-term response of tumors to therapy.

Dose-dependent effects of hydralazine on microcirculatory function and hyperthermic response of murine FSall tumors.

The effects of the vasodilator hydralazine (HYD) on microcirculatory function and hyperthermic response were studied in early generation isotransplants of a spontaneous C3Hf/Sed mouse fibrosarcoma (FSall). Red blood cell flux (RBC flux) in superficial tumor regions was assessed using laser Doppler flowmetry. A differential microcirculatory response was seen between tumor and normal skin after 0.25 micrograms/g i.p. HYD, the tumor showing a transient increase in flow and the skin remaining almost stable. At 1.0 micrograms/g i.p., the differential response continued, this time with a transient fall in tumor blood flow but again no change in skin flow. High dose hydralazine (10.0 micrograms/g i.p.) was associated with a dramatic and prolonged decrease in tumor blood flow but a lesser and only transient decline in skin flow. Identical doses of hydralazine were given 30 min prior to heat treatment (43.5 degrees C for 15, 30, or 60 min). Tumor growth was measured daily and compared to controls (HT without hydralazine). Hydralazine at 0.25 micrograms/g i.p. did not affect heat induced growth delay. At 1.0 micrograms/g i.p., it significantly increased growth delay upon heat exposures of 15 min, but not after 30 or 60 min HT. Hydralazine at 10 micrograms/g i.p. increased growth delay for all heat doses (P less than 0.05). Hydralazine alone had no influence on growth delay of sham-heated tumors. The results obtained clearly indicate that tumor and normal tissues have microcirculatory differences in the time-course, degree and/or direction of response after hydralazine, and that hydralazine has potential for increasing the response of tumor to HT.

Mammalian DNA topoisomerase I mediates the enhancement of radiation cytotoxicity by camptothecin derivatives.

The role of DNA topoisomerase I as a biochemical mediator of radiosensitization in cultured mammalian cells by camptothecin derivatives was studied. We found that, in Chinese hamster DC3F cells, camptothecin enhanced the cytotoxicity of radiation in a schedule-dependent manner. At 4 microM, a sensitizer enhancement ratio of 1.45 was observed when radiation was used concurrently with or immediately after drug treatment. By comparison, no enhancement was obtained if radiation preceded camptothecin treatment. Consistently, in human breast cancer MCF-7 cells, sensitizer enhancement ratios of 1.43, 1.38, and 1.05 were observed when radiation was used concurrently with, immediately after, or prior to treatment with 20(S)-10,11-methylenedioxycamptothecin (MDCamp). Three studies indicated that an intact stereospecific interaction between camptothecin derivatives and DNA topoisomerase I is essential in the induction of radiosensitization: (a) higher concentrations of camptothecin were required to radiosensitize the camptothecin-resistant DC3F/C-10 cells; (b) a newly identified topoisomerase 1-targeting Hoechst 33342 also radiosensitized DC3F cells; and (c) 20(S)-methylenedioxycamptothecin, but not its noncytotoxic 20(R)-stereoisomer, radiosensitized MCF-7 cells by obliterating the "shoulder" of the radiation survival curve. The mechanism of radiosensitization was investigated in DC3F cells. We found that camptothecin only minimally enhanced the cytoxic effect of radiation in G1-phase cells obtained by a mitotic shake-off technique as well as in plateau-phase cells arrested by growing to confluency. Our data suggest a potential development of topoisomerase I drugs as radiosensitizers in treating human malignancies.

Intratumoral administration of endostatin plasmid inhibits vascular growth and perfusion in MCa-4 murine mammary carcinomas.

Endostatin, a fragment of the COOH-terminal domain of mouse collagen XVIII is a recently demonstrated endogenous inhibitor of tumor angiogenesis and endothelial cell growth. Antiangiogenic therapy with endostatin in animals requires multiple and prolonged administration of the protein. Gene therapy could provide an alternative approach to continuous local delivery of this antiangiogenic factor in vivo. Established MCa-4 murine mammary carcinomas, grown in immunodeficient mice, were treated with intratumoral injection of endostatin plasmid at 7-day intervals. At the time of sacrifice, 14 days after the first injection, endostatin-treated tumor weights were 51% of controls (P < 0.01). Tumor growth inhibition was accompanied by a marked reduction in total vascular density. Specifically, computerized image analysis showed a 18-21% increase in the median distances between tumor cells and both the nearest anatomical (CD31-stained) vessel [48.1 +/- 3.8 versus 38.3 +/- 1.6 microm (P < 0.05)] and the nearest tumor-specific (CD105-stained) vessel [48.5 +/- 1.5 versus 39.8 +/- 1.5 microm (P < 0.01)]. An increased apoptotic index of tumor cells in endostatin-treated tumors [3.2 +/- 0.5% versus 1.9 +/- 0.3% (P < 0.05)] was observed in conjunction with a significant decrease in tumor perfused vessels (DiOC7 staining), and an increase in tumor cell hypoxia (EF5 staining). Hypoxia resulting from endostatin therapy most likely caused a compensatory increase of in situ vascular endothelial growth factor (VEGF) and VEGF receptor mRNA expression. Increased immunoreactivity of endostatin staining in endostatin-treated tumors was also associated with an increased thrombospondin-1 staining [1.12 +/- 0.16 versus 2.44 +/- 0.35]. Our data suggest that intratumoral delivery of the endostatin gene efficiently suppresses murine mammary carcinoma growth and support the potential utility of the endostatin gene for cancer therapy.

Angiogenesis determines blood flow, metabolism, growth rate, and ATPase kinetics of tumors growing in an irradiated bed: 31P and 2H nuclear magnetic resonance studies.

Experimental tumors growing in irradiated tissue have been used to study the biological differences characteristic of locally recurrent tumors. Since the hypoxic cell fraction of tumors growing in irradiated tissue is increased and growth rate is slowed, these tumors are assumed to be metabolically deprived with hypoperfusion. In this study, we directly measured the effect of tumor bed irradiation on blood flow, growth rate, rate of nucleoside triphosphate (NTP) turnover, and metabolic state using 31P and 2H nuclear magnetic resonance, and an intradermal assay for angiogenesis. (NTP turnover refers to ATP-synthetase mediated NTP turnover that is visible to 31P nuclear magnetic resonance using the technique of saturation transfer.) A decrease in the number of small blood vessels perfusing tumors in a preirradiated bed was found. Most of the decrease was due to a loss of vessels with diameters less than 0.04 mm. When tumors growing in preirradiated tissue reached approximately 100 mm3 in volume, a high frequency of gross and microscopic necrosis and hemorrhage was already observed in most tumors. Consistent with these observations, the phosphocreatine/inorganic phosphate and nucleoside triphosphate/inorganic phosphate ratios were significantly lower in the tumors growing in a preirradiated bed compared with tumors in a nonirradiated bed. The blood flow rate was similar to control for tumors less than 100 mm3 (45.8 versus 40.5 ml/100 g/min, P = not significant), but was significantly lower than control for tumors greater than 100 mm3 (40.4 versus 12.2 ml/100 g/min, P less than 0.01). The NTP turnover rates correlated (P less than 0.005, r = 0.66) with the volume doubling rate (1/tumor volume doubling time), but for tumors approximately 100 mm3 in size neither the volume doubling rate nor the NTP turnover rate of tumors growing in an irradiated bed was statistically lower than control [NTP turnover: 14 +/- 3%/s versus 9 +/- 2%/s; volume doubling rate: 0.47 +/- 0.07/day versus 0.33 +/- 0.04/day (mean +/- SE)]. A large intertumor variability of all metabolic parameters was observed.

Blood flow, metabolism, cellular microenvironment, and growth rate of human tumor xenografts.

Better understanding of the micromilieu of human tumors in situ is mandatory for further improvement of diagnostic and therapeutic interventions. Since investigations of untreated tumors of a wide size range are precluded in humans for ethical reasons, size-dependent changes in the pathophysiology of primary and metastatic human tumors were studied using "tissue-isolated" xenografts in nude rats. Tumor types included lung and breast cancers, ovarian and thyroid carcinomas, uterus tumors, and melanomas. A 10-fold variation in weight-adjusted tumor perfusion indicated large variations in angiogenesis which were unrelated to tumor type. Flow values obtained were consistent with data from clinical observations and were comparable to that in isografted rodent tumors. Using actual consumption and supply rates, maximum oxygen and glucose uptake rates were calculated for each tumor type. The capacity to consume oxygen and glucose varied 9-fold and 4-fold, respectively. However, considering actual consumption rates, blood flow was the principal modulator of substrate supply and tumor metabolism in these human tumor xenografts. Consequently, therapeutically relevant parameters of the metabolic micromilieu largely depended on the efficacy of the tumor circulation. Hereby, high metabolic rates concomitant with high flow values coincided with rapid tumor growth. Thus, in order to design the best individualized therapy, flow-related data should supplement histological classification and clinical staging and grading. Further development of relatively noninvasive technologies (magnetic resonance imaging, magnetic resonance spectroscopy, or positron emission tomography) might permit such monitoring.

Failure of 1H nuclear magnetic resonance spectroscopy of blood plasma to detect malignancy.

Water-suppressed proton nuclear magnetic resonance (NMR) of plasma was proposed as a technique for detecting malignant tumors. In that analysis, bloods drawn from cancer patients at the Beth Israel Hospital (BIH; Boston, MA), were easily distinguished from normal subjects by measuring and averaging the proton NMR methyl and methylene line widths of plasma lipoproteins. We collected blood at the Massachusetts General Hospital (MGH), including from normal controls, patients with untreated and treated malignant tumors, and patients with nontumor diseases. The plasma NMR analyses were carried out blind. The code was not broken until all patient charts and pathology records were reviewed, plasma analyses were completed, and patients had been divided into appropriate clinical groups. Analysis of these data showed no differences between the means of the study groups (false-positive and false-negative frequencies 46% and 57%, respectively). An inverse correlation of methyl/methylene line widths with age (P less than .01), and a correlation with nitrate-requiring cardiovascular disease (P less than .05) was, however, evident. This test cannot be validly used to detect malignancy.

Risk of second aerodigestive cancers increases in patients who survive free of small-cell lung cancer for more than 2 years.

PURPOSE: Patients who survived small-cell lung cancer (SCLC) for more than 2 years were evaluated to determine the frequency and anatomic pattern of redevelopment of small-cell cancer and development of non-small-cell lung cancer (NSCLC) and aerodigestive cancers with the passage of time. PATIENTS AND METHODS: From April 1973 through December 1991, 578 patients with previously untreated SCLC were entered onto prospective therapeutic trials at the National Cancer Institute (NCI), Bethesda, MD. Sixty-two (11%) were cancer-free 2 years after initiation of therapy and were assessable for redevelopment of SCLC and development of NSCLC, and aerodigestive cancers. RESULTS: Twenty patients redeveloped SCLC 2.0 to 12.2 years after initiation of chemotherapy, of whom two patients were deemed to have a second primary small-cell cancer that involved the aerodigestive tract. Fifteen patients developed 16 cancers in the lung other than SCLC 3.4 to 14.9 years after initiation of therapy. Two developed other aerodigestive cancers that involved the larynx and lip. The risk of a NSCLC and aerodigestive cancer in these patients increased more than sixfold from 2% per patient per year during years 2 to 4 to 12.6% and 14.4%, respectively, after more than 10 years. The cumulative actuarial risk of a second primary NSCLC or aerodigestive cancer at 16 years is 69% and 72%, respectively. CONCLUSION: The increasing risk of second aerodigestive cancers with the passage of time is a mounting problem for patients cured of SCLC. Chemoprevention trials for these patients should be considered.

Loss of p16 expression is of prognostic significance in locally advanced prostate cancer: an analysis from the Radiation Therapy Oncology Group protocol 86-10.

PURPOSE: The retinoblastoma (RB) cell cycle regulatory pathway is known to be deregulated in virtually all known human tumors. The protein product of the RB gene, pRB, and its upstream regulator, p16, are among the most commonly affected members of this pathway. We investigated the prognostic significance of both pRB and p16 expression in locally advanced prostate cancers, from patients treated on the Radiation Therapy Oncology Group (RTOG) protocol 86-10. MATERIALS AND METHODS: Sixty-seven cases from RTOG 86-10 had immunohistochemically stained slides, judged interpretable for both p16 and pRB, available for analysis. Median follow-up was 8.9 years (range, 6.0 to 11.8 years) for surviving patients. Staining for each marker was then correlated with overall survival, local progression, distant metastasis, and disease-specific survival. RESULTS: Loss of p16 expression, as defined by expression was significantly associated with reduced overall survival (P =.039), disease-specific survival (P =.006), and higher risk of local progression (P =.0007) and distant metastasis (P =.026) in the univariate analysis. In the multivariate analysis, loss of p16 was significantly associated with reduced disease-specific survival (P =.0078) and increased risk of local failure (P =.0035) and distant metastasis (P =.026). A borderline association with reduced overall survival (P =.07) was also evident. Loss of pRB was associated with improved disease-specific survival on univariate (P =.028) and multivariate analysis (P =.043), but carried no other significant outcome associations. CONCLUSION: Loss of p16 is significantly associated with adverse clinical outcome in cases of locally advanced prostate cancer.

Interactions between ascorbic acid and the radiation of bone marrow, skin, and tumor.

In studies of isotransplants of a murine fibrosarcoma, FSaII, ascorbic acid administered 50 min before whole-body radiation significantly increased the dose of radiation required to cause a fatal radiation syndrome and the dose of radiation required to obtain skin desquamation. A single intraperitoneal dose of 4.5 g/kg body wt was not cytotoxic and did not affect the radiation dose required to control 50% of tumors or to achieve remissions. The mechanism of this differential radiomodification of normal tissue sensitivity and tumor tissue response is unclear. The data suggest that after high-dose ascorbic acid the radiation dose given to cancer patients could be increased without increasing acute complications but with an expected increase in tumor-control probability. However, only acute radiation reaction endpoints have been studied. Application of these findings to humans must therefore await further studies confirming that late reacting tissues are similarly protected by ascorbic acid.

The life shortening effects of treatment with doxorubicin and/or local irradiation on a cohort of young C3Hf/Sed mice.

The long-term consequences of treating a cohort of C3Hf/Sed mice in early life with either local-field single dose radiation, systemic doxorubicin, or both, are reported in this study. Significant life shortening was observed in all treatment groups. Median survival times (days) from time of treatment were: control, 690; 35 Gy, 560; 70 Gy, 460; 5 mg/kg doxorubicin, 580; 10 mg/kg doxorubicin, 350; 35 Gy + 5 mg/kg doxorubicin, 510; 70 Gy + 10 mg/kg doxorubicin, 310. Mice receiving hind limb irradiation died principally from induced sarcomas in a dose dependent fashion (80% after 70 Gy and 55% after 35 Gy). Those treated with doxorubicin alone showed an increase in the actuarial incidence of spontaneous malignancies but died mainly from non-malignant causes. Histological examination did not reveal any characteristic cardiac, renal or pulmonary lesions. Doxorubicin did not increase the rate of development of radiation induced sarcomas in mice treated with combined modality.

Extremity preservation by combined modality treatment of sarcomas of the hand and wrist.

Soft tissue sarcomas are uncommon malignancies, less than 10% of which arise on the distal upper extremities. Consequently, experience with treatments which preserve both the limb and its function is lacking for tumors in this region. Sixteen patients with sarcomas arising in the hand and wrist and one with an aggressive desmoid tumor were treated by combined modality therapy at the Massachusetts General Hospital. Two patients had wide resections for multiple recurrent lesions, 5 had excisional biopsies, and 9 had incomplete excisions to preserve anatomic structures of the hand. One patient refused an amputation and had no surgery. Sarcoma patients were given postoperative radiation with a dose range of 50.2 to 69 Gy (median 68 Gy). The desmoid tumor received 44 Gy. A shrinking field technique with customized castings and cerrobend blocks was used to assure precision and minimize treatment volumes. Chemotherapy was reserved for metastatic disease. Local control was achieved in 14 patients who received combined modality treatment (87%), with a follow-up 1-12 years (median 33 months). Two of the three patients with local failures subsequently obtained a local control after salvage surgery and radiation. Four patients developed metastases, one with epitrochlear lymph node metastases was salvaged by amputation, the others died with lung disease 17, 37, and 111 months after treatment. Functional integrity of the limb was primarily dependent on the extent of surgical resection required. Among 12 patients with local and distant control, one patient (who had multiple wide resections of an extensive desmoid tumor preceding irradiation) lost over 50% use of her limb, but no patients required amputation for edema or pain control. Ten of the 12 patients with local and distant control had less than a 25% decrement in limb function and had no pain or edema associated with normal use of their hand. We conclude that for selected patients with sarcomas of the distal upper extremity, combined modality therapy consisting of conservative resection and careful radiation therapy is a viable alternative to amputation.

An approach to dose measurement for total body irradiation.

PURPOSE: An approach is proposed to allow the interpretation of diode measurements on patients receiving total body irradiation (TBI) in opposed lateral fields as midplane dose measurements. METHODS AND MATERIALS: This technique consists of making measurements on both entrance and exit sides of any ray path along which the midplane dose is desired. The diode on the entrance side is calibrated so that its output is indicative of the dose delivered at the depth of maximum dose along the ray. The diode on the exit side is calibrated so that its output represents the dose that would have been delivered to that depth had the medium (the patient) been semi-infinite. Because these two measurements lie along the same ray, they are related by a simple depth-dose equation from which the effective absorption coefficient (mueff) can be determined. The dose at the midplane is calculated using this mueff in a similar equation. RESULTS: The validity of this approach was checked with measurements at isocenter and at the TBI distance using a polystyrene phantom. In both cases, the calculated midplane dose was within reasonable experimental error (range approximately +/- 2% on average) of the measured dose. Measurements on eight patients showed the excellent reproducibility of entrance surface measurements (standard deviation [SD] approximately +/- 1%), compared to that of midplane measurements (SD approximately +/- 4%) and exit surface measurements (SD approximately < or = 8%). Midplane doses determined from these equations confirmed that dose inhomogeneity using this opposed lateral technique is on the order of +/- 10% with highest doses delivered to the calves and lowest to the lungs. CONCLUSION: Recent measurements made on TBI patients have shown that a commercial eight-diode system can be used successfully to measure the dose delivered to the midplane within an accuracy of approximately +/- 4%. The reproducibility of entrance surface measurements (approximately +/- 1%) shows that such measurements provide the accuracy required for quality assurance purposes.