EVERSUN: a phase 2 trial of alternating sunitinib and everolimus as first-line therapy for advanced renal cell carcinoma.

BACKGROUND: We hypothesised that alternating inhibitors of the vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin pathways would delay the development of resistance in advanced renal cell carcinoma (aRCC). PATIENTS AND METHODS: A single-arm, two-stage, multicentre, phase 2 trial to determine the activity, feasibility, and safety of 12-week cycles of sunitinib 50 mg daily 4 weeks on / 2 weeks off, alternating with everolimus 10 mg daily for 5 weeks on / 1 week off, until disease progression or prohibitive toxicity in favourable or intermediate-risk aRCC. The primary end point was proportion alive and progression-free at 6 months (PFS6m). The secondary end points were feasibility, tumour response, overall survival (OS), and adverse events (AEs). The correlative objective was to assess biomarkers and correlate with clinical outcome. RESULTS: We recruited 55 eligible participants from September 2010 to August 2012. DEMOGRAPHICS: mean age 61, 71% male, favourable risk 16%, intermediate risk 84%. Cycle 2 commenced within 14 weeks for 80% of participants; 64% received ≥22 weeks of alternating therapy; 78% received ≥22 weeks of any treatment. PFS6m was 29/55 (53%; 95% confidence interval [CI] 40% to 66%). Tumour response rate was 7/55 (13%; 95% CI 4% to 22%, all partial responses). After median follow-up of 20 months, 47 of 55 (86%) had progressed with a median progression-free survival of 8 months (95% CI 5-10), and 30 of 55 (55%) had died with a median OS of 17 months (95% CI 12-undefined). AEs were consistent with those expected for each single agent. No convincing prognostic biomarkers were identified. CONCLUSIONS: The EVERSUN regimen was feasible and safe, but its activity did not meet pre-specified values to warrant further research. This supports the current approach of continuing anti-VEGF therapy until progression or prohibitive toxicity before changing treatment. AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12609000643279.

Multicentre phase I/II study of PI-88, a heparanase inhibitor in combination with docetaxel in patients with metastatic castrate-resistant prostate cancer.

BACKGROUND: Docetaxel (Taxotere) improve survival and prostate-specific antigen (PSA) response rates in patients with metastatic castrate-resistant prostate cancer (CRPC). We studied the combination of PI-88, an inhibitor of angiogenesis and heparanase activity, and docetaxel in chemotherapy-naive CRPC. PATIENTS AND METHODS: We conducted a multicentre open-label phase I/II trial of PI-88 in combination with docetaxel. The primary end point was PSA response. Secondary end points included toxicity, radiologic response and overall survival. Doses of PI-88 were escalated to the maximum tolerated dose; whereas docetaxel was given at a fixed 75 mg/m(2) dose every three weeks RESULTS: Twenty-one patients were enrolled in the dose-escalation component. A further 35 patients were randomly allocated to the study to evaluate the two schedules in phase II trial. The trial was stopped early by the Safety Data Review Board due to a higher-than-expected febrile neutropenia of 27%. In the pooled population, the PSA response (50% reduction) was 70%, median survival was 61 weeks (6-99 weeks) and 1-year survival was 71%. CONCLUSIONS: The regimen of docetaxel and PI-88 is active in CRPC but associated with significant haematologic toxicity. Further evaluation of different scheduling and dosing of PI-88 and docetaxel may be warranted to optimise efficacy with a more manageable safety profile.

Amplification and expression of the ABC transporters ARA and MRP in a series of multidrug-resistant leukaemia cell sublines.

E1000, the most drug-resistant subline from the E-series (CCRF-CEM/E16 to E1000), has been previously shown to express high mRNA levels from two ABC transporter genes associated with multidrug resistance, ARA and MRP. The expression and amplification of both genes has now been characterized for each member of the E-series of drug-resistant sublines and is reported here. Both ARA [detected by reverse transcriptase polymerase chain reaction (RT-PCR)] and MRP (detected by Northern blot analysis) were expressed at low levels in the sensitive parental CEM cell line. An equivalent level of MRP mRNA expression was detected throughout the CEM, E16, E25 and E50 sublines, and there was increasing expression in the E100, E200 and E1000 sublines. ARA expression was not detected in the E16, E25, E50 and E100 sublines but was detected by both RT-PCR and Northern blot analysis in the E200 and E1000 sublines. Southern blot analysis indicated the increased levels of MRP and ARA expression resulted from gene amplification and that MRP was first amplified in the E100 subline and ARA in the E200 subline, suggesting that the two genes were not initially co-amplified. Cytogenetic analysis of E1000 cells demonstrated a large addition to chromosome 16p, around the region where the ARA and MRP genes are located. Increased expression of ARA is associated with increased colchicine resistance in the E-series of sublines and combined with MRP may account for their resistance phenotype.

Increased MRP expression is associated with resistance to radiation, anthracyclines and etoposide in cells treated with fractionated gamma-radiation.

The failure of chemotherapy is often associated with the failure of radiotherapy in the treatment of cancer. To investigate this relationship, the CCRF-CEM (CEM) human T-cell leukaemia cell line was treated with fractionated gamma-radiation totalling 75 Gy (10 cycles of 1.5 Gy daily for 5 days). This produced the CEMRR subline which was 1.5-fold resistant to radiation compared with the parental CEM cells. The CEMRR subline was also resistant to daunorbicin, idarubicin and etoposide but not to paclitaxel, cis-platinum or chlorambucil. Treatment with 50 microM buthionine sulphoximine, an inhibitor of glutathione synthesis, reversed the daunorubicin resistance in the CEMRR subline. Multidrug resistance-associated protein (MRP) mRNA was 6-fold higher in the CEMRR subline than in the CEM cells, and there was no detectable expression of P-glycoprotein in either the CEM cells or the CEMRR subline. Treatment of the CEM cells with 2 Gy of gamma-radiation caused an increase in MRP-mRNA within 4 hr which, by 24 hr, was greater than 5-fold that of the untreated CEM cells. No change in MRP mRNA was observed in the CEMRR subline with similar treatment. We conclude that MRP is involved in the immediate response to radiation and it may account for the drug resistance that often develops following radiation treatment.

The potential of N-[2-(dimethylamino)ethyl]acridine-4-carboxamide to circumvent three multidrug-resistance phenotypes in vitro.

The effectiveness of N-[2-(dimethylamino)ethyl]acridine-4-carboxamide (DACA) relative to that of amsacrine, idarubicin, daunorubicin and paclitaxel against three different forms of multidrug resistance (MDR) was determined using two sublines of the CCRF-CEM human leukaemia cell line, the P-glyco-protein-expressing CEM/VLB100 subline and the MRP-expressing CEM/E1000 subline, and two extended-MDR sublines of the HL60 human leukaemia cell line, HL60/E8 and HL60/V8. DACA was effective against P-glycoprotein-mediated MDR and MRP-mediated MDR, whereas the extended-MDR phenotype showed only low levels of resistance (< 2-fold) to DACA. In comparison, idarubicin was ineffective against the MRP and extended-MDR phenotypes. Repeated exposure of the K562 human leukaemia cell line to DACA (55, 546 or 1092 nM for 3 days over 10 weeks) did not result in the development of any significant drug resistance. We conclude that DACA has the potential to treat refractory leukaemia.

The anthracycline resistance-associated (ara) gene, a novel gene associated with multidrug resistance in a human leukaemia cell line.

Multidrug resistance (MDR) in cancer cells is a major contributor to the failure of chemotherapy treatment. This paper describes a novel protein named the anthracycline resistance associated (ARA) protein. The ara gene is amplified in the MDR leukaemia line CCRF-CEM/E1000 and its mRNA is overexpressed. ARA belongs to the ATP binding cassette (ABC) family of proteins. Another ABC protein, the multidrug resistance-associated protein (MRP), has previously been reported to be overexpressed in the CEM/E1000 subline. The primary amino acid sequence of ARA indicates that it is 49.5 kDa without glycosylation, and that it has one potential glycosylation site. ARA has one ATP binding site and associated transmembrane regions. This is in contrast to MRP (190 kDa, 172 kDa deglycosylated) and most other higher eukaryote ABC proteins, which consist of two similar halves, each having one ATP binding site. In addition to ARA being coexpressed with MRP, comparison of amino acid sequences showed that, among known proteins, ARA is most similar to the C-terminal half of MRP.

Drug resistance mechanisms and MRP expression in response to epirubicin treatment in a human leukaemia cell line.

A drug resistant series of sublines were developed by treating the human leukaemia CCRF-CEM cell line with 16-1000 ng/ml of the anthracycline, epirubicin. The sublines developed resistance in two stages, neither involving detectable levels of P-glycoprotein. Treatment with up to 50 ng/ml epirubicin produced sublines with cross resistance limited to the anthracyclines and etoposide. Treatment with 100-1000 ng/ml epirubicin produced sublines with increased expression of the mrp gene, increased resistance to the anthracyclines and etoposide, additional cross resistance to vincristine and colchicine, decreased drug accumulation and reversal of resistance by verapamil and by buthionine sulphoximine (BSO; an inhibitor of glutathione synthesis). Our results indicate an interaction between MRP and glutathione metabolism as a mechanism for multidrug resistance.

Detection of mRNA by in situ hybridisation and in northern blot analysis using oligodeoxynucleotide probes labelled with alkaline phosphatase.

AIMS: To assess whether a reduction in intensity of signal observed using an alkaline phosphatase labelled oligodeoxynucleotide probe could be explained on the basis of procedural steps rather than reduced sensitivity. METHOD: Signal intensity was assessed on in situ hybridisation for pro-opiomelanocortin (POMC) mRNA in rat pituitary and for somatostatin mRNA in human pancreas and in northern blot analysis for POMC mRNA in the presence and absence of formamide. The direct effects of formamide on the alkaline phosphatase detection step were assessed using histochemical enzyme detection in rat kidney. RESULTS: All signals were reduced in systems containing formamide. CONCLUSIONS: In the absence of formamide clear, strong signals for specific mRNAs can be obtained by in situ hybridisation and northern blot analysis using oligodeoxynucleotide probes directly labelled with alkaline phosphatase. Formamide seems to inhibit the activity of alkaline phosphatase.

Detection of mRNA for ribosomal phosphoprotein P2 in normal colon and colonic tumours by in situ hybridization.

We have localized the mRNA for the ribosomal phosphoprotein P2, a putative metastasis-related sequence, in normal colon and colonic carcinomas by in situ hybridization, using an oligonucleotide probe end-labelled with digoxigenin. The mRNA was identified in normal colonic epithelial cells, the intensity of the signal being greater in cells at the base of the crypts compared with those on the surface. A strong positive signal was also seen in plasma cells, in fibroblasts in granulation tissue, in ganglion cells, and in hepatocytes. A positive signal was identified in all 16 primary colonic tumours studied and in 7 hepatic metastases. In contrast to previous studies based on Northern blot analysis, we were unable to demonstrate increased expression in metastases as compared with primary tumours, nor could we demonstrate any increased expression in primary tumours which were associated with distant metastases.

Detection of messenger RNA using a digoxigenin end labelled oligodeoxynucleotide probe.

A synthetic oligodeoxynucleotide sequence complementary to the mRNA for the adrenocorticotrophin (ACTH) precursor pro-opiomelanocortin (POMC) was end labelled using digoxigenin. The probe was used to detect POMC mRNA both on nitrocellulose filters and by non-isotopic in situ hybridisation (NISH) in tissue sections. Digoxigenin was identified using anti-digoxigenin alkaline phosphatase. The model system examined was the rat pituitary gland. Removal of both adrenal glands and dexamethasone administration were used to change the concentrations of POMC mRNA in the rat anterior lobe. The labelled probe reacted with a single band of appropriate molecular weight in Northern blot analysis. The distribution of signal in tissue sections and the changes induced by experimental manipulation were as predicted. The results indicate that this method of NISH will prove useful in the detection of specific messenger RNAs in tissue sections of buffered, formalin fixed, paraffin wax embedded material.

Serum galactosyltransferase as a prognostic marker in patients with solid tumors.

The serum level of galactosyltransferase was measured in a group of 218 patients with a variety of solid tumors and most with advanced disease. The pretreatment enzyme level showed little potential as a diagnostic tumor marker, and its change with treatment did not reflect the initial response. There was, however, a significant correlation between the length of survival and the pretreatment enzyme level. Patients with normal levels survived over twice as long as those with elevated levels. When Cox's proportional hazards regression analysis was used to compare the prognostic potential of galactosyltransferase with a number of known clinical indicators of prognosis, the variable most related to survival was performance status (P less than 10(-4) followed by galactosyltransferase (P = 0.01) and then the extent of disease (P = 0.03). The other variables, such as previous therapy, the type, site, and size of primary tumor, did not contribute significantly to the relationship with survival. The pretreatment level of galactosyltransferase is therefore a relatively independent prognosticator of survival and, as such, could be potentially useful in patient management by increasing the accuracy of the initial assessment of prognosis.

Serum galactosyltransferase isoenzyme patterns of cancer patients with liver involvement.

The level of galactosyltransferase activity was measured in the serum of 220 patients with a variety of solid tumours. There was a significantly greater proportion of patients with elevated galactosyltransferase in the group with metastatic disease (43%) than for the group with localised disease (16%). Galactosyltransferase was elevated in 69% of patients with liver metastasis compared to 32% of patients with metastatic disease at sites other than liver and this difference was also significant. High resolution agarose isoelectric-focusing was used to determine the 'isoenzyme' pattern of serum galactosyltransferase of 6 patients with liver metastasis and 2 patients with primary hepatoma and these were compared to those of 6 patients with similar primary tumours without liver involvement. There were no qualitative differences in the patterns from the two groups. The average peak height for each of the 19 peaks of activity identified was generally higher in the group with liver involvement, except for those peaks known to contain little or no attached sialic acid. Liver involvement appears not to contribute in any specific way to the altered pattern of serum galactosyltransferase often seen in patients with solid tumours. The tumour rather than the liver is therefore the most likely source of these alterations.

The heterogeneity and acceptor specificity of human serum galactosyltransferase.

Human serum was fractionated by high resolution agarose isoelectricfocusing and the galactosyltransferase activity profile was determined using the ovalbumin, mucin, glucose and N-acetylglucosamine acceptor assays. The four acceptors gave very similar activity profiles. There were minor quantitative differences in some of the 12 or more peaks of activity detected and the only qualitative difference between them was a minor peak at pH 3.90 (2% of the total activity) which reacted only with the mucin acceptor. This suggests that most of the isoenzymes of human serum galactosyltransferase have broad and similar acceptor specificities and that the heterogeneity seen in serum cannot be accounted for by acceptor-specific forms of the enzyme.

Serum galactosyltransferase isoenzymes as markers for solid tumours in humans.

High resolution agarose isoelectric focusing was used to compare the galactosyltransferase isoenzyme patterns of serum from 9 healthy controls with those from 38 patients with either breast, lung, ovarian, stomach or colonic cancer. At least 12 peaks of enzyme activity were found in every sample, the healthy controls having major forms with isoelectric points of 4.74, 4.87, 4.96, 5.16 and 5.23. Thirty patients (79%) had elevated levels of at least one isoenzyme and 23 (61%) had at least 3 isoenzymes elevated compared to only 10 (26%) patients who had elevated total serum galactosyltransferase activity. The isoenzymes which were most often elevated in the cancer patient group had isoelectric points of 4.93, 5.16 and 4.61. One isoenzyme with an isoelectric point of 4.43 was preferentially elevated in patients with ovarian cancer. Those isoenzymes containing little or no sialic acid were rarely elevated in cancer patients. Although no cancer-associated isoenzyme was detected the quantitative differences observed in the cancer patient group were striking.

Adverse effects of commonly used systemic drugs on the human eye. Part III.

Four tables are presented listing the adverse effects of commonly used drugs on the human eye. Both brand names and generic names of drugs are used. The optometrist using the tables can look up either the drug (to find the adverse effects) or the symptom (to find the drugs that might cause it).