Adjuvant chemotherapy in operable breast cancer: cyclophosphamide, methotrexate, and fluorouracil versus chlorambucil, methotrexate, and fluorouracil--11-year results of Swiss Group for Clinical Cancer Research trial SAKK 27/82.

PURPOSE: To compare two adjuvant combination chemotherapies, cyclophosphamide, methotrexate, and fluorouracil (CMF) and chlorambucil, methotrexate, and fluorouracil (LMF), for patients who had undergone potentially curative surgery for unilateral breast cancer, in terms of relapse, survival, and toxicity. PATIENTS AND METHODS: Selection criteria was as follows: stage pT1-3a, N+ or N-, M0, less than 72 years of age. Eligible patients were randomized to receive either CMF (cyclophosphamide 100 mg/m2 orally on days 1 to 14, methotrexate 40 mg/m2 intravenously (I.V.) on days 1 and 8, fluorouracil 600 mg/m2 I.V. on days 1 and 8) or LMF (Leukeran [Wellcome A.G., Bern, Switzerland] 5 mg/m2 orally on days 1 to 14 with the some I.V. cytostatic drugs). Follow-up examinations were performed every 3 months during the first 3 years after mastectomy, and every 6 months thereafter. RESULTS: A total of 246 patients were randomized, of whom 232 who were fully eligible and contribute to the analyses presented here. No statistically significant difference in favor of adjuvant CMF over LMF emerges after a median follow-up duration of 11.2 years, for either overall survival (P = .15) or disease-free survival (P = .14). A consistent trend suggestive of a possible relative benefit associated with CMF should be pointed out. However, CMF presents a significantly worse toxicity profile as concerns hematologic parameters as well as alopecia, nausea, and vomiting. CONCLUSION: This prospective trial has not identified a statistically significant difference in disease-free survival or overall survival between the two adjuvant regimens LMF and CMF. Although a trend in favor of CMF has been observed in premenopausal patients, this has to be weighted against its definitely more pronounced toxicity profile.

First isolated locoregional recurrence following mastectomy for breast cancer: results of a phase III multicenter study comparing systemic treatment with observation after excision and radiation. Swiss Group for Clinical Cancer Research.

PURPOSE: We performed a randomized phase III multicenter study to compare systemic treatment versus no treatment after complete excision and radiotherapy for isolated first locoregional recurrence in patients with breast cancer. PATIENTS AND METHODS: One hundred sixty-seven good-risk patients with an estrogen receptor (ER+) positive recurrence or, in case of unknown receptor status, a disease-free interval (DFI) of greater than 12 months and < or = three recurrent tumor nodules each < or = 3 cm in diameter were entered onto the study. They were randomized to observation subsequent to local treatment or to receive tamoxifen (TAM) until disease progression. Seventy-nine percent of the patients were postmenopausal. RESULTS: The median observation period for the entire study population was 6.3 years. The median disease-free survival (DFS) duration was 26 months for observation and 82 months for TAM patients (P = .007). This was mainly due to the reduction of further local recurrences, whereas the occurrence of early distant metastases was delayed. A multivariate analysis identified DFI and treatment with TAM as significant prognostic factors for DFS. The 5-year overall survival (OS) rates were 76% and 74%, respectively (P = .77). DFI was also a prognostic factor for OS. CONCLUSION: Systemic therapy with TAM after isolated locoregional recurrence of breast cancer significantly increased 5-year DFS rates from 36% to 59% compared with observation alone and prolonged median DFS by more than 4.5 years in patients with ER+ tumors or in the case of unknown ER status with a DFI of greater than 12 months and minimal tumor burden. Treatment with TAM currently has no significant impact on OS, but the median survival duration of the study population has not yet been reached.

Interferon-gamma and interleukin-4 down-regulate soluble CD14 release in human monocytes and macrophages.

CD14 is a 53-kd glycoprotein that is mainly expressed in myeloid cells and exists in two forms. The membrane-bound form represents the receptor for complexes of lipopolysaccharide (LPS) with LPS binding protein. The function and regulation of the soluble form are unknown. In the present study we investigated the release of soluble CD14 (sCD14) in cultures of human mononuclear leukocytes, elutriated monocytes, and monocyte-derived macrophages. The release of sCD14 into the medium of the cells cultured for 15 and 45 h was investigated in the absence or presence of selected cytokines. sCD14 release occurred constitutively and correlated with cell number. In monocytes differentiating into macrophages, cumulative release of sCD14 was linear from day 1 to day 7. Spontaneous sCD14 release after 15 h of culture (2 x 10(6) cells/ml) was higher in the supernatant from monocytes (314 +/- 58 ng/ml) than that from mononuclear leukocytes (68 +/- 10 ng/ml) and similar to that from macrophages (469 +/- 79 ng/ml). Cycloheximide and actinomycin D inhibited sCD14 release. Recombinant interferon-gamma (rIFN-gamma) and recombinant interleukin-4 (rIL-4) directly decreased sCD14 release in mononuclear leukocyte, monocyte, and macrophage cultures. rIL-2 and rIFN-alpha reduced sCD14 release into the supernatants of mononuclear leukocytes only. Use of anti-IFN-gamma antibodies indicated that the down-regulation of sCD14 release by rIL-2 and rIFN-alpha was partially due to induction of endogenous IFN-gamma. The down-regulation of sCD14 release by all four cytokines was both time and dose dependent. rIFN-gamma and rIL-4 added simultaneously had a synergistic effect on sCD14 down-regulation. In conclusion, sCD14 release may have an immunomodulatory role in circulating monocytes, is apparently not related to the process of macrophage differentiation, and is selectively down-regulated during an immune response when levels of IFN-gamma and IL-4 are high.

[Diagnostic problems in local recurrence after breast saving treatment]. / Diagnostische Probleme beim Lokalrezidiv nach brusterhaltender Behandlung.

353 patients with stages pTis, pT1-2, pN0-1, cM0 breast cancer have been treated consecutively by breast conserving therapy in a prospective, nonrandomized study at the University Hospital Basel and the Women's Clinic Rheinfelden/Baden/Germany. The median age was 47 years, the median follow-up time 67 months, and 4% only of this collective were lost to follow-up after a median time of 42 months. In 79% of the cases the tumor was excised totally, while in 19% the resection margins were positive and in 2% only the margins were not available for histological judgement. The rate of local failure reached 8% with a median time interval of 53 months. 116 patients showed postactinic induration in the primary tumor region. 73 of these were given additional diagnostic examination: The postactinic induration was judget clinically suspicious in 51 cases and clinically nonsuspicious of local failure in 22 cases. All 73 patients received additional examination by mammography and biopsy. By comparison with the histological results the clinical results were correct in 59% and false in 41%, while the mammographic results were correct in 82% and false in 18% of the cases.

Prolonged interferon-gamma application by subcutaneous infusion in cancer patients: differential response of serum CD14, neopterin, and monocyte HLA class I and II antigens.

This study reports on biological response modification induced by prolonged continuous subcutaneous (s.c.) infusion of recombinant interferon-gamma (rIFN-gamma) with particular attention to changes of soluble CD14. This glycoprotein with an unknown function is derived from myeloid cells carrying membrane CD14, which is the receptor for lipopolysaccharide (LPS)-LPS-binding protein (LBP) complexes. Fifteen metastatic cancer patients received weekly escalating doses of rIFN-gamma starting at either 50 or 100 micrograms/24 h and increasing up to 400 micrograms/24 h for a median duration of 6 weeks. The maximum tolerated dose was higher (200 micrograms/24 h) with the lower (50 micrograms/24 h) starting dose. Biological activity of rIFN-gamma was evaluated by weekly measurements of CD14, neopterin, and beta 2-microglobulin concentrations in serum as well as monocyte HLA class I and II antigen expression and tumor cytotoxicity. Serum IFN-gamma concentrations increased 20-fold within 4 weeks of therapy. The levels were correlated to the mean dose (r = 0.95, p less than 0.05). Among the biological markers, two patterns were observed. First, serum CD14 concentration and expression of monocyte HLA class II antigens increased significantly during the first week, and marker expression correlated with serum IFN-gamma levels (p less than 0.05); CD14 and HLA class II antigens thereafter returned to pretreatment levels within 4 weeks of therapy despite persistently elevated serum IFN-gamma concentrations. Second, serum neopterin and beta 2-microglobulin concentrations as well as monocyte HLA class I expression also increased significantly within the first week, but remained elevated thereafter without any further dose relationship.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of cytokines and lipopolysaccharide on CD14 antigen expression in human monocytes and macrophages.

The 52 kD myeloid membrane glycoprotein CD14 represents the receptor for complexes of lipopolysaccharide (LPS) and LPS binding protein (LBP); it is involved in LPS induced tumor necrosis factor-alpha production. Expression of CD14 increases in monocytes differentiating into macrophages, and it is reduced by rIFNg in monocytes in vitro. In the present study CD14 membrane antigen expression was investigated in cultures of human mononuclear leucocytes (PBL), in elutriated, purified monocytes, and in blood monocyte derived Teflon cultured macrophages. Cells were incubated for 15 or 45 h with rIL-1, rIL-2, rIL-3, rIL-5, rIL-6, rTNFa, rGM-CSF, rM-CSF, rTGFb1, rIFNa, lipopolysaccharide (LPS), and, as a control, rIFNg. The monoclonal antibodies Leu-M3 and MEM 18 were used for labelling of CD14 antigen by indirect immunofluorescence and FACS analysis of scatter gated monocytes or macrophages. IFNg concentrations were determined in PBL culture supernatants by ELISA. rIFNa and rIL-2 reduced CD14 in 15 and 45 h PBL cultures, an effect mediated by endogenous IFNg, since it was abolished by simultaneous addition of an anti-IFNg antibody. rIFNa and rIL-2 were ineffective in purified monocytes or macrophages. rIL-4 strongly reduced CD14 in PBL and purified monocytes after 45 h, whereas in macrophages the decrease was weak, although measurable after 15 h. The other cytokines investigated did not change CD14 antigen expression. Cycloheximide alone reduced CD14, but when added in combination with rIFNg the effect on CD14 downregulation was more pronounced. The effect of rIFNg on CD14 in PBL cultures was dose-dependently inhibited by rIL-4 and this inhibition is probably due to an IL-4 mediated blockade of IFNg secretion. LPS at a low dose increased CD14, at a high dose it produced a variable decrease of CD14 in PBL, which was probably due to LPS induced IFNg secretion. LPS strongly enhanced CD14 in 45 h cultures of purified monocytes. The results, showing that CD14 antigen expression is upregulated by LPS and downregulated by rIFNg and rIL-4, suggest that the LPS-LBP receptor is involved in the feedback response of IFNg and IL-4 to LPS stimulation.

Allelic loss on the short arm of chromosome 11 in non-small-cell lung cancer.

Forty-eight samples of primary non-small-cell lung cancer (NSCLC) and normal tissue from the same patients were analyzed for allelic deletions on chromosome 11p. Five polymorphic loci were assessed to determine the incidence of 11p sequence deletions and to define hot-spots of deletions. Information was obtained from all patients in at least one locus. Our data show that the deletions observed were not randomly scattered over the short arm of chromosome 11. Rather, 2 hot-spots of deletions were observed: one in the area of the genes for catalase and beta-FSH corresponding to band 11p13, the other close to the IGF-II locus corresponding to band 11p15. A high incidence of loss of heterozygosity (LOH) was found with the probe for catalase (21/29), a locus flanking the centromeric region of the Wilms' tumor locus. Most of the samples exhibiting LOH of one or more of the alleles analyzed remained heterozygous for at least one other chromosome 11p allele. Furthermore, duplication of the intensity of the remaining allele was rarely observed. Our results indicate that LOH on the short arm of chromosome 11 is a common event in NSCLC and that the chromosomal region containing the Wilms' tumor locus is most commonly involved.

[The oncologist and his patient]. / Der onkologische Arzt und sein Patient.

The motifs of medical practise, in particular by the oncologist and the basic experience of the patient notably the cancer patient are presented. They represent the prerequisite for an individually taylored, solid relationship between physician and patient founding on mutual trust. Medical practise is nowadays founded on a scientific rationale. In contrast to earlier times the ethos of compassion pertains the private sphere. It is the physicians individual choice to proffer the traditional compassion as interest in the fate of an individual patient or not. The fundamental experience of an individual that his destiny lies no longer in his own hands expresses itself in a paradigmatic way by the perception of his illness. The cancer patient experiences--as other patients do--the threats but also his healing as occurrences not caused by him. He therefore does not identify his disease with objective impairments or pathologic findings. On the contrary, he perceives it as a threat to himself, his existence and his personality. The patient experiences his fate, to depend on circumstances and particularly on other individuals, their benevolence, their acceptance, their help. Trust is the basis for relationship between the cancer patient and his physician. Trust is also acceptance of dependence. Dependence is only acceptable if the physician is trustworthy. Trustworthiness cannot be gained by scientific competence alone but requires personal affection by compassion with the patients fate. The physician needs ethical competence to fulfill his task. Information of the patient gains a particular importance in this context. It, as well as the divergent assessment of the disease by patient and physician--the anthropologic difference--and the "equilibrating systems" are exposed.

Cytokine regulation of the myeloid glycoprotein CD14.

Monocyte membrane CD14 (mCD14) antigen expression was measured in normal human monocytes and blood monocyte-derived macrophages. Seven-day culture of monocytes in serum-containing medium lead to an increase in mCD14. Addition of interferon-gamma (IFN gamma) or interleukin-4 (IL-4) to monocytes caused a dose-dependent reduction in mCD14 within 3 or 45 h respectively. These effects were strong in monocytes, weak in macrophages, and they were blocked by anti-IFN gamma and anti-IL-4 antibodies, respectively. Interleukin-2 and interferon-alpha produced a decrease in mCD14 in mononuclear leukocyte cultures but not in purified monocytes. Their effect was abolished in the presence of anti-IFN gamma. Other cytokines (TFN alpha, Ill beta, IL-6, IL-3, IL-5, GM-CSF, TGF beta 1) did not change mCD14. In conclusion, IFN gamma and IL-4 are revealed to be the only cytokines which directly affect monocyte CD14 expression.

Human B cells express membrane-bound and soluble forms of the CD14 myeloid antigen.

The expression of the myeloid differentiation antigen CD14 on the B lineage was analyzed. A CD14-specific monoclonal antibody was used to isolate the antigen from normal B, B-type chronic lymphocytic leukemia cells, and a representative Epstein-Barr virus-transformed B lymphoblastoid cell line (EBVLCL). A soluble form of this protein was detected in the culture supernatant of all the B cell types tested. The molecule expressed in the normal B and B-type chronic lymphocytic leukemia cells was identical in size to the 52,000 mol. wt monocyte-isolated CD14 glycoprotein. A 64,000 mol. wt antigen was isolated from the lymphoblastoid cell line. Similar 2-D gel electrophoretic patterns to that of the monocyte-derived CD14 were obtained from the normal B and B-type chronic lymphocytic leukemia cell-isolated molecules. These similarities were reflected in minor isoelectric point (pI) differences between the polypeptide spots (pI 4.8), in the first dimension, and identical molecular weight (52,000) in the second dimension. The EBVLCL-isolated polypeptide, when analyzed by 2-D gel electrophoresis, showed a pI identical to that of the myeloid antigen (pI 4.6). The isolated soluble form was of smaller (47,000 mol. wt, normal B and B-type chronic lymphocytic leukemia cells) or similar size (64,000 mol. wt, lymphoblastoid cell line) compared with their corresponding membrane-bound forms. Interestingly, two-colour immunofluorescence analysis showed that only two out of four CD14-specific mAb tested bound to the B cells. We conclude that the CD14 antigen is, in fact, expressed in the B lineage. Its cell surface expression and serum level in the prognosis of B-type chronic lymphocytic leukemia patients needs to be evaluated.

Acute and subacute toxicity of chemotactic conjugates between monoclonal antibody and fMet-Leu-Phe in humans: a phase I clinical trial.

Conjugates of the chemotactic peptide fMet-Leu-Phe (fMLP) to IgG retain chemotactic and antigen recognition function in vitro and enhance intra-tumour macrophage numbers in a guinea pig model. We report a study approved by the ethics committee on the acute toxicity of fMLP conjugates in ten consenting cancer patients with metastasizing melanoma and colon cancer. They were given increasing single doses (1-2500 micrograms) IgG-fMLP made with the anti-melanoma monoclonal antibody (mAb) 9.2.27. Clinical examinations and blood cell counts, urinalysis, electrolytes, and liver and kidney function tests before and after the infusion and weekly thereafter revealed no relevant toxicities. One patient had a herpes zooster exacerbation on day 1, which was judged to be coincidental. Peak post-infusion conjugate serum concentrations fell to unmeasurable levels within a few days. In no case was a human humoral anti-(mouse Ig) immune response detected.

Treatment of Cutaneous T-cell Lymphoma with Cyclosporin A: Case Report and Literature Review.

A 48 year old Caucasian man with cutaneous T-cell lymphoma, stage IVB is described. Initially he presented with an ichthyosis-like dermatosis and developed lymphadenopathy, hypercalcaemia, hepatosplenomegaly and lymphomatoid papulosis over a period of 7 years. Following splenectomy he developed a leukemic phase which was refractory to polychemotherapy. Therapy with cyclosporin A initially caused deterioration of the skin infiltrations and the peripheral blood T-helper lymphocytosis. However after 3 weeks an improvement of the patient's general condition was noted including decreased skin involvement, reduction of hepatomegaly and a sustained decrease of the absolute lymphocytosis, which lasted for ten months. Lymphomatoid papulosis was not significantly affected by cyclosporin A. In conclusion, this case and several case reports from the literature suggest that cyclosporin A may be valuable in the palliative treatment of selected patients with advanced cutaneous T-cell lymphoma.

Improved tolerance of interferon alpha-2a by continuous subcutaneous infusion.

Fifteen patients with progressing melanomas, hypernephromas or B-cell malignancies were treated in a phase I study with Interferon (IFN) alpha-2a by continuous subcutaneous infusion. With the help of a syringe driver pump daily doses of 12-15 MU resulting in median weekly doses of 90 MU could be safely given with little side effects. Flu-like symptoms and side effects from the gastrointestinal tract were mainly of grade 1 or 2 only. The major dose limiting but reversible toxicity was leukopenia. Five patients developed local inflammatory reactions at the infusion site. The pharmacokinetic data demonstrate that by this route of administration median serum levels of 54 IU/ml (range 9.6-192.0 IU/ml) (EIA-F-assay) can be achieved. Antibody formation was observed in 4 patients. - One out of 9 patients evaluable for tumor response demonstrated a partial tumor regression and 4 patients had a stabilisation of their disease. In comparison to intermittent i.m. or s.c. schedules, this novel route of administration by continuous subcutaneous infusion results in significant serum concentrations, biological activity and little clinical side effects. This may facilitate in the future the combination of IFN alpha-2a with other biological response modifiers like interleukin-2 or tumor necrosis factor.

[Attitude of ambulatory oncological patients to academic medicine, their physician and nurse. Results of an anonymous survey]. / Das Verhältnis ambulanter onkologischer Patienten zur Schulmedizin, zu ihrem Arzt und zur Krankenschwester. Ergebnisse einer anonymen Umfrage.

The attitude of ambulatory cancer patients at the Division of Oncology, Dept. of Internal Medicine, of the Basel University Hospital towards official medicine, its therapeutic modalities as well as doctors and nurses was analysed. 33% of the patients answered an anonymous questionnaire containing 55 questions, which was distributed at their first visit during 1987. Four fifths showed a positive attitude towards official medicine overall. Two thirds of the patients believed to have profited from surgery, radiotherapy and chemotherapy alike. Side effects of chemotherapy were classed as barely tolerable by one third, as tolerable by two thirds of the patients. Nearly 80% would accept another surgical, radiotherapeutical or cytostatic treatment. 44% of all patients used therapies of unknown efficacy, and these patients suffered more from side effects than non-users, but no differences existed in regard to other parameters. The medical oncologist was felt to be the closest person caring for the patient, followed by the partner, the family practitioner, the oncology nurse and the community nurse. Most important for the patients are firm technical skills--significantly more than emotional support. 97% of the patients asked for thorough information on all aspects of their disease, good or bad.

Effectiveness and low toxicity of hepatic artery infusion with fluorouracil and mitomycin for metastatic colorectal cancer confined to the liver. The Swiss Group for Clinical and Epidemiological Cancer Research (SAKK).

The usefulness of hepatic artery infusion (HAI) with floxuridine is limited by the severe biliary and hepatic toxicity of floxuridine. This prompted the SAKK to evaluate the effectiveness, toxicity and feasibility of HAI with fluorouracil (FU) and mitomycin (MMC) administered by an external portable pump. Of 28 patients treated, partial responses were obtained in 14 (50%, 95% confidence interval: 30% to 70%) and stabilization in 11 (39%, 21% to 60%), for a median duration of 12.6+ months. Median survival was 19.5+ months. Grade I-II toxicity (WHO) consisted of nausea (46%), leucopenia (32%) thrombocytopenia (21%) and abdominal discomfort (25%). Two patients developed gastro-duodenal ulcers and two others grade III leucopenia. No life-threatening side effects, especially no sclerosing cholangitis or chemical hepatitis, were observed. In conclusion, HAI with FU and MMC is a valid alternative to floxuridine HAI in metastatic colorectal cancer confined to the liver.