Biomarker testing and time to treatment decision in patients with advanced nonsmall-cell lung cancer.

BACKGROUND: Testing for EGFR mutations and ALK rearrangement has become standard in managing advanced nonsmall-cell lung cancer (NSCLC). However, many institutions in Europe, North America and other world regions continue to face a common challenge of facilitating timely molecular testing with rapid result turnaround time. We assessed the prevalence of biomarker testing for advanced NSCLC patients and whether testing affected the timeliness of treatment decisions. METHODS: We conducted a retrospective chart review of a random sample of one-quarter of all patients with advanced NSCLC referred to the Princess Margaret Cancer Centre from 1 April 2010 to 31 March 2013. RESULTS: Of 300 patients reviewed, 175 seen by medical oncology had nonsquamous NSCLC, 72% of whom had biomarker testing carried out. Patients tested for biomarkers were more likely to be female (47% versus 21%, P = 0.002), Asian (27% versus 6%, P = 0.005) and never smokers (42% versus 8%, P < 0.0001). Only 21% of patients with biomarker testing had results available at their initial oncology consultation. This group had a shorter median time from consultation to treatment decision (0 versus 22 days, P = 0.0008) and time to treatment start (16 versus 29, P = 0.004). Thirteen percent underwent repeat biopsy for molecular testing after the initial consultation. Of those with positive EGFR or ALK results, 19% started chemotherapy before biomarker results became available. CONCLUSIONS: Awaiting biomarker testing results can delay treatment decisions and treatment initiation for patients with advanced NSCLC. This may be avoided by incorporating reflex biomarker testing into diagnostic algorithms for NSCLC at the level of the pathologist, and further education of specialists involved in obtaining diagnostic cancer specimens to ensure they are sufficient for molecular testing.

Overall survival should be the primary endpoint in clinical trials for advanced non-small-cell lung cancer.

An article in a recent edition of Current Oncology explored the validation of progression-free survival (pfs) as an endpoint in clinical trials of antineoplastic agents for metastatic colorectal cancer, metastatic renal cell carcinoma, and ovarian cancer. The support for pfs as a surrogate endpoint for overall survival (os) was elucidated. As with the aforementioned tumour types, advanced non-small-cell lung cancer (nsclc) has seen a rise in active agents since the year 2000. Those agents range from improved cytotoxics such as pemetrexed, to targeted therapies such as tyrosine kinase inhibitors of the epidermal growth factor receptor and agents that target the EML4-ALK gene mutation. More recently, it has also become apparent that histology plays an important role in the response to and outcomes of treatment. With the therapeutic options for patients with advanced nsclc increasing, concerns are being raised that the efficacy of drugs measured by os may be diluted in clinical trials, thereby underestimating their true clinical benefit. That possibility, together with the need to have efficacious drugs available to patients earlier, has resulted in the search for a surrogate to the os endpoint in advanced nsclc. The present article follows up the recent article on pfs as a surrogate. Although advances in identifying pfs as a valid surrogate endpoint for os have been made in other tumour types, in advanced nsclc, such surrogacy has not been formally validated. Until it has, os should remain the primary endpoint of clinical trials in advanced nsclc.

Association of hypomagnesemia with inferior survival in a phase III, randomized study of cetuximab plus best supportive care versus best supportive care alone: NCIC CTG/AGITG CO.17.

BACKGROUND: Cetuximab-induced hypomagnesemia has been associated with improved clinical outcomes in advanced colorectal cancer (CRC). We explored this relationship from a randomized clinical trial of cetuximab plus best supportive care (BSC) versus BSC alone in patients with pretreated advanced CRC. PATIENTS AND METHODS: Day 28 hypomagnesemia grade (0 versus ≥1) and percent reduction (<20% versus ≥20%) of Mg from baseline was correlated with outcome. RESULTS: The median percentage Mg reduction at day 28 was 10% (-42.4% to 63.0%) for cetuximab (N = 260) versus 0% (-21.1% to 25%) for BSC (N = 251) [P < 0.0001]. Grade ≥1 hypomagnesemia and ≥20% reduction from baseline at day 28 were associated with worse overall survival (OS) [hazard ratio, HR 1.61 (95% CI 1.12-2.33), P = 0.01 and 2.08 (95% CI 1.32-3.29), P = 0.002, respectively] in multivariate analysis including grade of rash (0-1 versus 2+). Dyspnea (grade ≥3) was more common in patients with ≥20% versus < 20% Mg reduction (68% versus 45%; P = 0.02) and grade 3/4 anorexia were higher in patients with grade ≥1 hypomagnesemia (81% versus 63%; P = 0.02). CONCLUSIONS: In contrast to prior reports, cetuximab-induced hypomagnesemia was associated with poor OS, even after adjustment for grade of rash.

Enhancing treatment decision-making: pilot study of a treatment decision aid in stage IV non-small cell lung cancer.

We developed a decision aid (DA) for patients with metastatic non-small cell lung cancer (NSCLC), to better inform patients of their prognosis and treatment options, and facilitate involvement in decision-making. In a pilot study, 20 patients with metastatic NSCLC attending outpatient clinics at a major cancer centre, who had already made a treatment decision, reviewed acceptability of the DA. The median age of the patients was 61 years (range 37-77 years), 35% were male, 20% had a university education, and most (75%) had English as a first language. Most had received chemotherapy, with 65% currently on treatment. Patients were not anxious at baseline and had clear understanding of the goals and toxicity of chemotherapy in advanced NSCLC. After reviewing the DA, patients' anxiety decreased slightly (P=0.04) and knowledge scores improved by 25% (P<0.001). Most improvements in understanding were of prognosis with and without chemotherapy, although patients still believed advanced NSCLC to be curable. Patients rated the DA highly with respect to information clarity, usefulness and were positive about its use in practice, although 40% found the prognostic information slightly upsetting. The DA for advanced NSCLC is feasible, acceptable to patients and improves understanding of advanced NSCLC without increasing patient anxiety.

Phase II study of pegylated liposomal doxorubicin HCl (Caelyx) in combination with cyclophosphamide and vincristine as second-line treatment of patients with small cell lung cancer.

BACKGROUND: Despite chemotherapy and radiotherapy for small cell lung cancer (SCLC), most patients die within 2 years. Response rates for second-line chemotherapy are 15-25%, with a median survival of 5 months. Caelyx, a pegylated liposomal formulation of doxorubicin, may be better tolerated and has activity in SCLC. PATIENTS AND METHODS: Thirty-two patients were enrolled in a phase II study of intravenous Caelyx (35 mg/m2), cyclophosphamide (750 mg/m2) and vincristine (1.2 mg/m2) every 21 days as second-line therapy in SCLC for up to six cycles. RESULTS: Thirty patients were evaluable for response, with a response rate of 10%. Another two had an unconfirmed response. Stable disease (SD) for >or=2 cycles was seen in an additional 53%. Grade 3 or 4 non-hematologic toxicity was seen in 17 (55%) patients (26 [22%] cycles) and included fatigue, mucositis, plantar-palmar erythrodysesthesia, rash and neuropathy. Twelve patients required transfusions. All patients on study have now expired, with a median survival of 28 weeks (7 months). For patients with SD or partial response, median time to progression was 15 weeks. CONCLUSION: The combination of Caelyx, cyclophosphamide and vincristine, despite cyclophosphamide and Caelyx dose reductions, has modest activity in relapsed SCLC with acceptable toxicity.

Acute spontaneous tumor lysis syndrome in adenocarcinoma of the lung: a case report.

Acute tumor lysis syndrome (ATLS) is a constellation of metabolic complications that typically occurs in the setting of treatment of hematologic malignancies. On occasion, it has been reported to occur after therapy for solid tumors associated with large tumor burdens and aggressive therapy. We herein report the occurrence of spontaneous acute tumor lysis syndrome in a man with untreated metastatic adenocarcinoma of the lung, and briefly discuss the literature.

Primary non-Hodgkin's lymphoma of bone.

Primary non-Hodgkin's lymphoma of bone (PLB) constitutes approximately 5% of all extranodal non-Hodgkin's lymphoma (NHL) and 7% of primary bone tumors. The peak incidence for PLB is in the fifth decade, with a slight preponderance of males over females. The presenting symptoms usually consist of localized bone pain and occasionally a palpable mass. Most patients with PLB have B-cell tumors with a diffuse mixed-cell or diffuse large cell histology. While most patients present with early-stage disease, it is not clear whether such patients benefit from combined-modality therapy (CMT) consisting of radiation therapy (RT) and chemotherapy (CT) compared with either RT or CT alone. However, there is strong evidence that CMT is beneficial in the treatment of localized NHL, and these results might be applicable to the therapy for PLB. Nevertheless, only a phase III randomized, controlled clinical trial will determine whether CMT is superior to either CT or RT alone.

Epiphora in patients receiving systemic 5-fluorouracil therapy.

OBJECTIVE: To determine the prevalence of tearing and canalicular fibrosis in patients receiving systemic 5-fluorouracil (5-FU) therapy and the reversibility of the symptoms when treatment is stopped. DESIGN: Prospective study. SETTING: University-affiliated tertiary care hospital in Toronto. PATIENTS: Thirty patients (17 men and 13 women aged 38 to 81 years) with advanced gastrointestinal carcinoma receiving intravenous 5-FU therapy as palliative (weekly) treatment (20 patients) or adjunctive (cycle) treatment (10 patients). OUTCOME MEASURES: Tearing, eyelid changes and canalicular fibrosis during and after treatment. Patients who experienced tearing were advised to massage and wipe the lower eyelids in an upward direction. RESULTS: Tearing and canalicular fibrosis developed in 10 patients (50%) and 3 patients (15%) respectively in the palliative treatment group; no patient in the adjunctive treatment group experienced these side effects. In the palliative treatment group, the patients who experienced tearing received double the dose of 5-FU (p = 0.03) and received treatment for twice as long (p = 0.042) as those who did not experience tearing. Of the patients with tearing, those in whom canalicular fibrosis developed received treatment for three times as long as those without fibrosis and received 2.6 times the total dose (p < 0.000). Of the seven patients with tearing in whom canalicular fibrosis did not develop, four stopped 5-FU treatment, and 2 to 4 weeks later the epiphora disappeared. CONCLUSIONS: Our findings suggest that the prevalence of tearing and canalicular fibrosis in patients receiving systemic 5-FU therapy as palliative treatment is related to the total dose and duration of treatment. Such side effects are less likely in those receiving adjunctive therapy. The epiphora is often reversible on stopping therapy if canalicular fibrosis has not yet developed.

[A phase II multicenter study of gemcitabine in non small cell lung cancers]. / Etude multicentrique de phase II de la gemcitabine dans les cancers bronchiques non à petites cellules (CBNPC).

Gemcitabine is a novel pyrimidine nucleoside whose activity has been demonstrated on solid tumors. We report here the results of a multicentre phase II trial of gemcitabine in chemonaive patients with inoperable non small cell lung cancer (NSCLC). Gemcitabine was given weekly at a dose of 1,250 mg/m2 administered as a 30 min intravenous infusion, for 3 weeks followed by 1 week of rest (1 cycle). All the 161 patients included were evaluable for toxicity and 151 of them were evaluable for efficacy. The majority of patients had a stage IIIb (31.1%) or stage IV (64.6%) disease; 10.6%, 83.2% and 6.2% of patients had a WHO performance status (PS) 0, 1, and 2, respectively. Adenocarcinoma accounted for 52.2% of cases and squamous cell carcinoma for 43.5% of cases. Three complete responses and 30 partial responses gave an objective response (OR) rate of 21.8% (95% confidence interval; 15.5-29.3%). All responses were validated by an independent Oncology Review Board. Median duration of response was 7.6 months. Median time to progression was 4.6 months (3.3 months in non responders and 7.6 months in responders). Median survival was 7.3 months in non responders and 13.4 months in responders (p < 0.001), which gave an overall median survival of 8.9 months (95% CI: 0.1-21.9 months) in the entire study population. An improvement of symptoms and personal state was also observed. Treatment was well tolerated. Neutropenia was the only dose limiting toxicity. WHO grade 3 or 4 neutropenia occurred in 19.6% and 5.7% of patients, respectively. With a 21.8% OR rate, this multicentre study confirms the activity of gemcitabine as a single agent in patients with inoperable NSCLC. Its good tolerance and original mode of action make gemcitabine a drug of choice in the therapeutic strategy of these tumors.

Final results of the Canadian phase I dose escalation trial of gemcitabine and cisplatin for advanced non-small cell lung cancer.

When given at doses of > or = 1,250 mg2 weekly x 3 with a 1-week break, single-agent gemcitabine induces responses in more than 20% of previously untreated patients with non-small cell lung cancer (NSCLC). This study was undertaken to determine the maximum tolerated doses for a 4-week cycle of gemcitabine and cisplatin given in combination weekly x 3 with a 1-week rest. Patients younger than 75 years were eligible if they had stage III/IV NSCLC, life expectancy > or = 12 weeks, hemoglobin > or = 10 g/dL, absolute granulocyte count > or = 2 x 10(9)/L, platelets > or = 100 x 10(9)/L, hepatic enzymes < or = 3 times the upper limit of normal, and serum creatinine < or = 130 mumol/L. The starting doses for gemcitabine and cisplatin were 1,000 mg/m2 and 25 mg/m2 per week x 3, respectively. At dose level 2 cisplatin was increased to 30 mg/m2/week x 3. Thereafter only the gemcitabine was increased, by 250 mg/m2/wk at each dose level, to a maximum of 2,250 mg/m2/wk at dose level 7. The median nadir granulocyte and platelet counts decreased with each dose level, but dose-limiting toxicity in two or more patients was not encountered in the first treatment cycle, even at dose level 7. Cumulative bone marrow toxicity was seen at all dose levels, and this resulted in frequent dose reductions or omissions. Dose delivery was well maintained over time only at dose level 1. Grade 3-4 nonhematologic toxicity was infrequent and rarely dose limiting. An assessment of all toxicities seen during the treatment cycles was undertaken using continual reassessment methodology. This model suggested that dose level 4 (cisplatin 30 mg/m2/wk and gemcitabine 1,500 mg/m2/wk) would be the maximum dose at which grade 4 toxicity would be expected in up to 33% of patients at any time over four treatment cycles. Of 47 patients evaluable for response, partial remission was seen in 14, with an overall response rate of 30% (confidence interval, 17% to 43%). The median duration of response was 16 weeks and the median survival time was 24 weeks (range, 3.5 to 64+ weeks). A phase II trial is planned in which dose level 4 will be evaluated in a larger cohort of patients with NSCLC.

Activity of gemcitabine in patients with non-small cell lung cancer: a multicentre, extended phase II study.

Gemcitabine is a novel nucleoside analogue with activity in solid tumours. This study assessed the objective response rate to gemcitabine given weekly intravenously at a dose of 1250 mg/m2 for 3 weeks followed by 1 week of rest (one cycle) in chemonaive patients with inoperable non-small cell lung cancer (NSCLC). 161 patients with NSCLC were recruited from 10 sites in nine countries. Most patients had stage IIIb (31.3%) or IV (64.6%) disease, and 93.8% had a performance status of 0 or 1 according to the WHO scale. Of 151 evaluable patients, there were 3 complete responses and 30 partial responses lasting at least 4 weeks for an objective response rate of 21.8% (95% CI 15.5-29.3%). All responses were validated by an extramural Oncology Review Board. The mean duration of response was 8.8 months. The mean survival for all patients (16.1% of patients still alive 26 months after last patient started treatment) was 11.5 months. Improvements were also observed in secondary efficacy parameters such as performance status, weight, analgesic requirement, pain, and other disease-related symptoms including cough, dyspnoea, haemoptysis, anorexia, somnolence and hoarseness. Haematological and non-haematological toxicity was mild given the biological activity of gemcitabine. This study confirms gemcitabine as one of the most active agents in NSCLC with the added benefit of a modest toxicity profile and ease of administration on an out-patient basis. Gemcitabine is a suitable candidate for combination chemotherapy in patients with NSCLC.

Gemcitabine in the treatment of non-small-cell lung cancer.

Gemcitabine is a nucleoside analogue with activity in non-small-cell lung cancer (NSCLC). Phase I trials have determined the best tolerated dose of gemcitabine in chemotherapy-naive patients to be 1250 mg/m2 given as a 30-minute infusion weekly x 3 every 4 weeks. The single-agent efficacy of gemcitabine has been assessed in 4 phase II trials (361 patients) at dose of 800-1250 mg/m2/weekly x 3 every 4 weeks. Single-agent response rates (externally verified by Oncology Review Board) were > 20%, with duration of response 7.6-12.7 months and median survival 8-9 months. Dose-limiting toxicity was neutropenia, but this was rare, even at the highest dose levels. In 3 Japanese studies, response rates of 16.3%, 26% and 20.9% were seen in untreated patients. Pooled data from all NSCLC studies shows that responses were seen in stages IIIA, IIIB and IV disease, and were similar in adeno and squamous cell types. Gemcitabine has also been studied in combination with other drugs active in NSCLC. In one study 50 patients were treated with gemcitabine and cisplatin given weekly x 3 every 4 weeks, cisplatin at a dosage of 25-30 mg/m2 and gemcitabine at doses escalating from 1000 mg/m2 in steps of 250 mg/m2 per cycle, 38 of 50 patients have been evaluated to date, with an overall response rate of 31.6%. Dose limiting toxicity was rare, but there was evidence of cumulative haematological toxicity with grade 4 granulocytopenia and thrombocytopenia becoming more frequent with repeated administration. Similar activity was seen when gemcitabine (1000 mg/m2) was combined with monthly cisplatin (60, 75, 100 mg/m2). Other studies have shown that gemcitabine can enhance radiosensitivity in NSCLC and other solid tumour types such as pancreas/breast and colorectal cancer cell lines.

Current management of mediastinal tumors.

The incidence of mediastinal tumors is increasing throughout North America. The benign variants are usually managed by relatively simple surgical procedures. Malignant mediastinal tumors can be among the most challenging of medical and surgical conditions and may require the expertise of medical, radiation, and surgical oncologists. Thymomas, germ-cell tumors, and lymphomas comprise the majority of the malignant mediastinal neoplasms. Some variants are managed entirely medically while others are extirpated initially. Many require multimodality therapies, either according to an accepted protocol or, more challengingly, off protocol.

Malignant lymphoma of bone.

OBJECTIVE: To evaluate the diagnosis and management of patients with malignant lymphoma of bone. DESIGN: A case series review in which the minimum follow-up was 24 months and the mean follow-up was 49 months. SETTING: All patients were managed at a tertiary care centre, although initial biopsies were often done in community centres. PATIENTS: Selected for review were 15 of 18 consecutive patients who were referred to the Musculoskeletal Oncology Unit at the Mount Sinai Hospital, Toronto, between 1984 and 1989, with a bone lesion as the presenting symptom of lymphoma. The three excluded patients included two with diffuse nodal disease at presentation and one who had a second, unrelated malignant tumour. INTERVENTIONS: Staging studies (hematologic investigations, radiography, technetium bone scanning and computed tomography), surgical biopsies of the lesion, chemotherapy, radiotherapy and in some cases surgical resection of the lesion. MAIN OUTCOME MEASURES: The number of biopsies required for diagnosis and the incidence of complications that required operative intervention. RESULTS: Seven of the 15 patients required more than one biopsy to establish the diagnosis. Five patients required surgical procedures for late complications that included pathologic fractures, wound infection and osteonecrosis. At 24 months' follow-up, 13 patients were disease free and 2 had died. CONCLUSIONS: Proper biopsy and pathological evaluation are crucial in the diagnosis of lymphoma of bone. These measures will decrease the necessity for repeat biopsies. Lymphoma is best managed medically. Surgery should be reserved for biopsy and for treatment of the complications of therapy.

Primary non-Hodgkin's lymphoma of bone. A clinicopathologic study.

BACKGROUND: This study relates our experience in the diagnosis and treatment of a rare clinical entity, non-Hodgkin's primary lymphoma of bone. METHODS: Seventeen cases of patients with primary lymphoma of bone diagnosed and treated at a single institution between 1975 and 1992 are reviewed. Ten patients received combined-modality therapy, consisting of an anthracycline-containing combination chemotherapy (CT) regimen, followed by adjuvant radiotherapy (RT) to the primary site of disease. Five patients were treated with CT alone; one patient received RT alone; and one patient was treated with CT after emergency RT for spinal cord compression. RESULTS: Thirteen patients presented with Stage I disease, two with Stage II; and two with Stage IV disease (multiple bony sites only). Thirteen patients had an intermediate-grade diffuse large cell lymphoma; two had an intermediate-grade mixed small and large cell lymphoma; and two had a high-grade lymphoma (one immunoblastic and one small non-cleaved cell lymphoma). The overall response rate was 94% (18% complete response, 58% partial response 1, and 18% partial response 2). Thirteen patients are alive and disease-free at a median of 29 months; 10 of these received CT+RT, and 3 received CT alone. Three patients have died; one of these received CT+RT and one CT alone, and one relapsed immediately after CT. One patient, who was initially treated with RT and then with CT+RT after relapse, was lost to follow-up 40 months from the start of treatment. CONCLUSIONS: Because experience in the literature suggests a 50% distant relapse rate in primary lymphoma of bone treated with RT alone, our policy is to treat all patients with combined-modality therapy (CT+RT). However, only a Phase III randomized, controlled clinical trial will determine whether CT+RT is superior to either modality alone.

Induction chemotherapy for stage IIIA unresectable non-small cell lung cancer: the Toronto experience and an overview.

Thirty-nine patients with mediastinoscopy stage IIIA, N2 non-small cell lung cancer received two cycles of MVP (mitomycin C, vindesine, cisplatin). Responders underwent thoracotomy for resection and two further courses of MVP. Overall response rate was 64% (25/39) with three complete and 22 partial responses. Twenty-two patients were resected, which included radical mediastinal node dissection. Eighteen resections were complete and four were incomplete. Pathologically, three patients (7.7%) had no remaining tumor. Toxicity included two postoperative deaths with B-P fistula, mitomycin pulmonary toxicity in two patients, and four septic deaths. Twenty-eight patients have died, 20 with recurrent or progressive disease. Of the 18 patients completely resected, eight have recurred with a median time to recurrence of 20.6 months. Sites of recurrence include two locoregional, five distant (two in brain) and one in both. Median survival of the entire 39 patients is 18.6 months, with a three year survival of 26%. The median survival for those patients completely resected was 29.7 months with a 3-year survival of 40%.

Treatment of AIDS-related non-Hodgkin's lymphoma with a twelve week chemotherapy program.

Current treatment options for acquired-immunodeficiency syndrome (AIDS)-related non-Hodgkin's lymphoma (NHL) are unsatisfactory because of excessive toxicity rates and frequent recurrence of lymphoma. In this phase II study, we evaluated a novel 12 week chemotherapy program with respect to feasibility, toxicity and therapeutic results. Thirty HIV-seropositive patients with intermediate grade or small non-cleaved cell NHL received a 12 week program of weekly intravenous and oral chemotherapy consisting of etoposide, adriamycin, cyclophosphamide, bleomycin, vincristine, methotrexate and prednisone as well as biweekly intrathecal cytosine arabinoside. Prophylaxis against Pneumocystis carinii pneumonia (PCP) and candida were given routinely. The overall objective response rate was 73% with 33% complete responders. The time to progression for those stable or responding was 9.4 months. Five of 10 complete responders are well and free of disease 13.2 to 24.5 months from diagnosis. Median survival for the 30 patients was 8.1 months. NHL was the most common cause of death (13/22); opportunistic infection caused only one death (cryptococcal meningitis). Only 1 case of PCP occurred. The major toxicity was neutropenia. In conclusion this regimen resulted in response rates similar to other reports with acceptable toxicity and a very low incidence of PCP. Relapse of NHL remains a major challenge, however, and further studies are needed. Routine PCP prophylaxis should be incorporated into new trials of therapy for AIDS-related NHL.

Induction chemotherapy with mitomycin, vindesine, and cisplatin for stage III unresectable non-small-cell lung cancer: results of the Toronto Phase II Trial.

PURPOSE: The 5-year survival rates with surgical resection for preoperatively identified stage IIIA N2 non-small-cell lung cancer (NSCLC) are less than 10%. A pilot study of mitomycin, vindesine, and cisplatin (MVP) induction chemotherapy was undertaken in an attempt to improve the curative potential of surgery in this group of patients. PATIENTS AND METHODS: Thirty-nine patients with mediastinoscopy stage IIIA N2 NSCLC received two cycles of MVP. Responding patients underwent thoracotomy for resection and two further courses of MVP. RESULTS: The overall response rate was 64% (25 of 39) with three complete and 22 partial responses. Twenty-two patients were resected, which included a radical mediastinal node dissection. Eighteen resections were complete and four were incomplete. Pathologically, three patients (7.7%) had no tumor remaining. Toxicity included two postoperative deaths secondary to a bronchopleural (BP) fistula, mitomycin pulmonary toxicity in two patients, and septic deaths in four patients. Twenty-eight patients have died; 20 have recurrent or progressive disease. Eight of the 18 patients completely resected have recurred, with a median time to recurrence of 20.6 months. Sites of recurrence include two locoregional, five distant (two in brain), and one in both. Median survival of all 39 patients is 18.6 months, with a 3-year survival of 26%. The median survival for those patients completely resected was 29.7 months with a 3-year survival of 40%. CONCLUSIONS: We conclude (1) that MVP is an effective but toxic chemotherapeutic regimen for limited NSCLC; (2) the median survival seems to be prolonged; and (3) the role of induction chemotherapy followed by surgery in stage IIIA N2 NSCLC requires a phase III randomized trial to compare it with other treatment modalities.

A phase II study of 4'-epirubicin in the treatment of poor-risk Kaposi's sarcoma and AIDS.

Twenty-six patients with poor-risk Kaposi's sarcoma and AIDS were treated with epirubicin 90 mg/m2 intravenously every 3 weeks. One patient achieved complete response and 10 achieved partial response (overall response rate 42.3%). The median time to treatment failure was 22 weeks. The dose-limiting toxicity was neutropenia.