Conversion to resection of liver metastases from colorectal cancer with hepatic artery infusion of combined chemotherapy and systemic cetuximab in multicenter trial OPTILIV.

BACKGROUND: Systemic chemotherapy typically converts previously unresectable liver metastases (LM) from colorectal cancer to curative intent resection in ∼15% of patients. This European multicenter phase II trial tested whether hepatic artery infusion (HAI) with triplet chemotherapy and systemic cetuximab could increase this rate to 30% in previously treated patients. PATIENTS AND METHODS: Participants had unresectable LM from wt KRAS colorectal cancer. Main non-inclusion criteria were advanced extra hepatic disease, prior HAI and grade 3 neuropathy. Irinotecan (180 mg/m(2)), oxaliplatin (85 mg/m(2)) and 5-fluorouracil (2800 mg/m(2)) were delivered via an implanted HAI access port and combined with i.v. cetuximab (500 mg/m(2)) every 14 days. Multidisciplinary decisions to resect LM were taken after every three courses. The rate of macroscopic complete resections (R0 + R1) of LM, progression-free survival (PFS) and overall survival (OS) were computed according to intent to treat. RESULTS: The patient population consisted of 42 men and 22 women, aged 33-76 years, with a median of 10 LM involving a median of six segments. Up to 3 extrahepatic lesions of <1 cm were found in 41% of the patients. A median of six courses was delivered. The primary end point was met, with R0-R1 hepatectomy for 19 of the 64 previously treated patients, 29.7% (95% confidence interval 18.5-40.9). Grade 3-4 neutropenia (42.6%), abdominal pain (26.2%), fatigue (18%) and diarrhea (16.4%) were frequent. Objective response rate was 40.6% (28.6-52.3). Median PFS and OS reached 9.3 (7.8-10.9) and 25.5 months (18.8-32.1) respectively. Those with R0-R1 hepatectomy had a median OS of 35.2 months (32.6-37.8), with 37.4% (23.6-51.2) alive at 4 years. CONCLUSION: The coordination of liver-specific intensive chemotherapy and surgery had a high curative intent potential that deserves upfront randomized testing. PROTOCOL NUMBERS: EUDRACT 2007-004632-24, NCT00852228.

Relationship between circadian rhythm of vinorelbine toxicity and efficacy in P388-bearing mice.

The relevance of chronopharmacology for improving tolerability and antitumor efficacy of the antimitotic drug vinorelbine was investigated in female B6D2F1 mice standardized with 12 h of light and 12 h of darkness. A single i.v. vinorelbine dose (26 mg/kg) was given to 279 mice at 7, 11, 19, or 23 hours after light onset (HALO). Bone marrow necrosis and leukopenia were nearly twice as large in the mice injected at 7 HALO as compared with those treated at 19 HALO (ANOVA: p <.001 and p = 0.004, respectively). The relevance of vinorelbine dosing time for antitumor efficacy was assessed in 672 P388 leukemia-bearing mice. Vinorelbine was injected as a single dose (20, 24, 26, or 30 mg/kg) or weekly (20, 24, 26, or 28 mg/kg/injection x 3) at one of six circadian times, 4 h apart. A significant correlation between single dose and median survival time was limited to vinorelbine administration at 19 or 23 HALO. An increase in the vinorelbine weekly dose shortened median survival time in the mice treated at 7 HALO (20 mg/kg: 29 days; 24 mg/kg: 17 days; and 26 mg/kg: 6 days) but significantly improved it in those treated at 19 HALO (20 mg/kg: 28.5 days; 24 mg/kg: 32 days; and 26 mg/kg: 36 days). The study demonstrates the circadian rhythm dependence of maximum tolerated dose and the need to deliver maximum tolerated dose at the least toxic time to achieve survival improvement through chronotherapy. This may be obtained with an evening administration of vinorelbine in cancer patients.

Chronomodulated versus fixed-infusion-rate delivery of ambulatory chemotherapy with oxaliplatin, fluorouracil, and folinic acid (leucovorin) in patients with colorectal cancer metastases: a randomized multi-institutional trial.

BACKGROUND: In a previous phase II trial, circadian (chronomodulated) delivery of fluorouracil (5-FU), folinic acid (FA; leucovorin), and oxaliplatin (1-OHP; a new platinum complex with no renal and minor hematologic toxic effects) produced an objective response rate of 58% in 93 patients with metastatic colorectal cancer. PURPOSE: To determine whether chronomodulated drug delivery affects therapeutic activity, we again tested this regimen in another trial in patients with previously untreated metastatic colorectal cancer, this time comparing chronomodulated with constant-rate drug delivery. METHODS: Seven European centers participated in this trial. Ninety-two patients with metastatic colorectal cancer were enrolled and assigned to a treatment schedule by central randomization. Treatment courses consisted of the daily administration of 5-FU (600 mg/m2 per day), FA (300 mg/m2 per day), and 1-OHP (20 mg/m2 per day) for 5 days and were repeated every 21 days (16-day intermission) in ambulatory patients with the use of a programmable in-time pump. Drug delivery was kept constant over a 5-day period in schedule A (47 patients). It was chronomodulated in schedule B (maximum delivery of 5-FU and FA infusions at 0400 hours and maximum delivery of 1-OHP at 1600 hours; 45 patients). A risk of partial chemical inactivation of 1-OHP by its 2-hour exposure to the basic pH of the 5-FU solution in the catheter was documented in schedule A. RESULTS: Severe stomatitis (grade 3 or 4, World Health Organization [WHO] grading system), the dose-limiting toxic effect of 5-FU, occurred in five times as many patients on schedule A than on schedule B (89% versus 18%; chi 2 = 46; P < .001). The cumulative dose-limiting toxicity of schedule B was peripheral sensitive neuropathy (WHO grade 2). This side effect was reversible following 1-OHP withdrawal. Higher doses of 5-FU were administered in schedule B (median: 700 mg/m2 per day) compared with schedule A (median: 500 mg/m2 per day) (P < .0001; Mann-Whitney U test). On schedule B, 24 of 45 patients (53%; 95% confidence interval [CI] = 38%-68%) exhibited an objective response compared with 15 of 47 patients (32%; 95% CI = 18%-46%) on schedule A (chi 2 = 4.3; P = .038). The median progression-free survival was, respectively, 11 and 8 months (P = .19; logrank). The median survival was 19 months (95% CI = 14.8-23.2) on schedule B and 14.9 months (95% CI = 12.1-17.8) on schedule A (P = .03; logrank). CONCLUSION: This ambulatory treatment modality was both more effective and less toxic if drug delivery was chronomodulated rather than constant over time. IMPLICATION: The respective roles of 1-OHP dose and schedule and circadian peak time of drug delivery are being investigated with regard to the high activity of this three-drug, chronomodulated chemotherapeutic regimen.

Circadian and estral changes in the hypothalamic prostaglandin e content and [h]prostaglandin e binding in female rats.

Abstract Prostaglandin E(2), (PGE(2)) is involved in the luteinizing hormone-releasing hormone-stimulated luteinizing hormone surge in female rats and may act via specific membrane receptors. The following studies were performed to determine whether there were any changes in the hypothalamic PGE(2) binding and/or PGE(2) content which were specific to proestrus and not to the rest of the estrous cycle. Groups of female Wistar rats were sacrificed at 3-h intervals throughout the estrous cycle to determine both the circadian and circaestral changes in the hypothalamic PGE(2) content and [(3)H]PGE(2) binding. The hypothalamic PGE(2) content was maximal at 1700 h on each of the 4 consecutive days of the estrous cycle but was independent of the stage of the cycle. [(3)H]PGE(2) binding also displayed a circadian rhythm; the lowest binding occurred near the circadian peak of PGE(2), suggesting that the PGE(2) binding sites were occupied by endogenous PGE(2). Since such circadian rhythms were not observed in the hypothalamus of male rats, they may be under the control of ovarian steroids. Also, since PGE(2) binding and the PGE(2) content both exhibit a diurnal pattern independent of the day of the cycle, there may be changes in the PGE(2) receptor-mediated process coupled to an adenylyl cyclase which could explain the luteinizing hormone surge in proestrus.

Circadian rhythms in circulating T lymphocyte subtypes and plasma testosterone, total and free cortisol in five healthy men.

Circadian variations of circulating T lymphocyte subtypes and their possible relations with those of endogenous cortisol or testosterone were investigated in five healthy young men. Venous blood (40 ml) was obtained every 4 h for 24 h from each subject in January, March, June, August and November. Leucocyte and differential counts were measured. Mononuclear cells were isolated on Ficoll-Paque gradient, and samples were incubated with OKT3, OKT4 or OKT8 monoclonal antibodies for characterizing all T, T helper and T suppressor-cytotoxic lymphocytes respectively. The proportion of labelled lymphocytes was determined under an epifluorescence microscope and the counts of circulating lymphocyte subsets (cells/mm3) computed. Total and free cortisol and testosterone were also determined in the corresponding plasma samples. Results from analysis of variance and cosinor indicated statistically significant differences (P less than 0.001) as a function of both individual subject and circadian sampling time for all variables. Circadian rhythms (with a period, tau = 24 h) were validated for total, T and T helper lymphocytes and for the T helper: T suppressor-cytotoxic ratio (P less than 0.001), with double amplitudes (2A, total extent of variation accounted for by the fitted cosine function) ranging from 25% up to 50% of the 24 h mean (M), and acrophases (phi, time of maximum) localized near 0100 h. A rhythm with tau = 12 h characterized circulating T suppressor-cytotoxic lymphocytes (P less than 0.001; 2A = 36% of M; phi = 0830 and 2030 h). Circadian rhythms were also found for plasma cortisol (either total or free) and testosterone (P less than 0.001). No correlation was found however between time-qualified data of these hormones and the immunological variables herein investigated (162 pairs of data) whether or not a 4 h or an 8 h lag time was considered to allow for hormonal actions to operate. This suggests that neither the circadian organization of the adrenal cortex nor that of the testis play a prominent role in the circadian time structure of the circulation of T lymphocytes.

Seasonal modulation of the circadian time structure of circulating T and natural killer lymphocyte subsets from healthy subjects.

A seasonal modulation of the circadian time structure of circulating T and natural killer (NK) lymphocyte subtypes was documented in five healthy men aged 24-36 yr. Venous blood was obtained every 4 h for 24 h from each subject in January, March, June, August, and November 1984. Three subjects were also studied in April and/or August and/or November 1983 for the T subsets only. Mononuclear cells were isolated on Ficoll-Paque gradient and aliquots were incubated with OKT3, OKT4, OKT8, or HNK-1 monoclonal antibodies for characterizing all, T, T helper, T suppressor-cytotoxic, and NK lymphocytes, respectively, under an epifluorescence microscope. An effect of both sampling time and study month was statistically validated (P less than 0.01) with both two-way analysis of variance and cosinor for the peripheral counts in total, pan-T, T helper, and NK lymphocytes (cells per cubic millimeter). Seasonal changes affected both the circadian patterns and the 24-h mean values. Thus the double amplitude (total extent of variation) of the circadian rhythm in circulating total, T and T helper lymphocytes varied between 0 in March (P greater than 0.30; no rhythm) and up to 46-68% of the 24-h-mean (M) in November, with acrophases (times of maximum, 0) localized in the first half of the night (P less than 0.001). Maximal values were found at 8:30 h for both T suppressor-cytotoxic and NK lymphocytes; a smaller second peak was also found at 20:30 h, and a 12-h rhythm was validated by cosinor (P less than 0.0001), with no patient change in waveform along the year scale. A circannual rhythm was statistically validated by cosinor for total (0 in November), pan-T (0 in March), T suppressor-cytotoxic (0 in December), and NK lymphocytes (0 in October). A rhythm with a period equal to 6 mo was found for circulating T helper cells with 0 occurring both in April and October. Seasonal variations in the incidence of several immunologically related diseases may correspond to an endogenous circannual time structure.

Circadian changes in anticoagulant effect of heparin infused at a constant rate.

Six patients with venous thromboembolism were treated with heparin, administered intravenously by a constant infusion pump. The initial daily dose of heparin was adjusted to keep the activated partial thromboplastin time, sampled at 0800, between 1.5 and 2.5 times the control level. Once that level was obtained, this dose was kept constant. Anticoagulation was thereafter measured, every four hours for 48 hours, by activated partial thromboplastin time, thrombin time, and coagulation factor Xa inhibition assay. The results of all three coagulation tests showed a circadian variation in the six patients. Maximum values were achieved at night and minimum values in the morning. These circadian variations were reproduced for two consecutive days. Differences between night and morning values reached almost 50% for activated partial thromboplastin time, 60% for thrombin time, and 40% for factor Xa inhibition assay. This circadian variation resulted from two rhythms, a circadian rhythm lasting 24 hours and an ultradian rhythm lasting 12 hours, which were detected by cosinor analysis for each coagulation test (p less than 0.01). A circadian rhythm was detected individually in most of the patients for each coagulation test (p less than 0.05). All patients had a nocturnal peak in activated partial thromboplastin time on both days. In four patients this peak exceeded the upper desired limit of activated partial thromboplastin time. These rhythms should be taken into account when evaluating the dosage of heparin to be administered.

Circadian and/or circahemidian rhythms in nine lymphocyte-related variables from peripheral blood of healthy subjects.

Circadian variations were investigated for nine lymphocyte-related variables in the peripheral blood of healthy subjects. Monoclonal antibodies targeted at membrane immunoglobulins (anti-Ig, anti-kappa, anti-lambda) or differentiation antigens (anti-IA and OKT3) were used to characterize respectively mature B cells (SIg+, kappa +, lambda +), cells expressing HLA-DR antigen (IA+), and T cells (OKT3+). Blood (33 ml) was drawn every 4 hr for 24 hr starting at 8.30 hr, on seven occasions in five apparently healthy male volunteers, recumbent from 23.00 hr to 07.00 hr. Leukocyte and differential counts were measured. Mononuclear cells were isolated on Ficoll-Hypaque before being incubated with monoclonal antibodies. The proportion of fluorescent cells per 100 microscopically determined cells was multiplied by the number of circulating lymphocytes per milliliter of venous blood. Temporal variations were validated by both paired t-test and cosinor. Rhythms with a period (tau) identical to 24 hr were validated with statistical significance (p less than 0.05) for total lymphocytes, OKT3+ cells and OKT3+:SIg+ ratio, and suggested (0.05 less than or equal to p less than or equal to 0.10) for lambda + and (kappa + + lambda +) cells. Rhythms with tau identical to 12 hr were also found (p less than 0.05) for OKT3+, SIg+, kappa +, and IA+ cells as well as for the OKT3+:SIg+ and the kappa +:lambda + ratios. Validated rhythms exhibited a large amplitude, e.g., peak-through differences were 40% of the 24-hr mean. This circadian and circahemidian temporal structure of immunologic variables constitutes a time-qualified reference system for investigating immune regulations and a tool for optimizing both diagnostic criteria and effectiveness of immunotherapeutic attempts.

A four-day subrenal capsule assay for testing the effectiveness of anticancer drugs against human tumors.

The subrenal capsule assay may predict to which anticancer drug a given patient's tumor is sensitive and may also be used to screen new anticancer drugs. The present study documents that the use of this model requires a histological assessment of both the exploitability of a subrenal capsule assay and the extent of drug-induced antitumor lesions. Thirty-five tumors from 34 patients with solid tumor were submitted to a subrenal capsule assay in a total of 1130 male B6D2F1 mice. After being biopsied, each tumor was dissected by a pathologist and cut into 50 pieces (1.5 X 1.5 X 1.5 cu mm), and one piece was implanted under the renal capsule of 35 mice; the mean tumor diameter was measured on Day 0. Mice were randomized into groups of 6 to 10 animals each. On Days 1, 2, and 3, mice were treated either with placebo (control group) or with various anticancer agents. On Days 4 or 6, mice were sacrificed, the mean tumor diameter measured, and the tumor-bearing kidney fixed in Bouin's picroformol solution and processed for histological analysis after staining with hematein -eosin. Seven histological parameters were blindly rated in a semiquantitative fashion yielding a compound score ( PAPAN ) which estimated the overall quality of each xenograft between -3 and +11. On Day 4, as opposed to Day 6, mean lymphocytic infiltration was 3-fold lower (p less than 0.01), and the rate of xenografts containing well-preserved cancer cells was 2-fold larger (p less than 0.01) in three different tumor specimens. Twenty-two of 31 (71%) assays were evaluable, as defined by a histological quality control test. In those, drug effects were demonstrable by statistically significant differences among groups in 2 assays (9%) by using the relative variation in tumor size as an index of drug effectiveness and in 12 assays (54%) by PAPAN histological score. This suggests the higher sensitivity of histological scoring over tumor size measurements. Moreover, no correlation between relative variation in tumor size and PAPAN was demonstrable with statistical significance indicating the poor reliability of tumor size measurements as an index of the antitumor effectiveness of cytostatic drugs.

Lethal nephrotoxicity and hematologic toxicity of cis-diamminedichloroplatinum ameliorated by optimal circadian timing and hydration.

Three hundred and forty-one female F344 (Fischer) rats were kept in light for 8 hr alternating with darkness for 16 hr; some were observed for survival for 21 days, while others were killed for blood sampling 4.5 days after a single intraperitoneal (i.p.) injection of 11 mg/kg cis-diamminedichloroplatinum (cis-DDP). cis-DDP was administered with or without concomitant i.p. saline load at one of six equispaced circadian stages. This high dose of cis-DDP resulted in marked lethal and renal toxicity, but in a moderate bone marrow suppression. Blood urea nitrogen (BUN), circulating total white blood cell counts (WBC) and survival times revealed statistically significant circadian rhythms of drug toxicity (P less than 0.03). Optimal tolerance for cis-DDP gauged by these three variables resulted from drug administration in the second half of the dark span. Renal tolerance for cis-DDP guaged by BUN was improved two-fold by appropriate drug timing. This benefit from drug timing alone was further improved two-fold if hydration and cis-DDP were given at the optimal circadian stage. Hydration-induced ameloriation of cis-DDP nephrotoxicity requires time qualification of both hydration and cis-DDP.

Reduction of cis-diamminedichloroplatinum nephrotoxicity in rats by optimal circadian drug timing.

A prominent circadian rhythm in the nephrotoxicity of a therapeutic dose of cis-diamminedichloroplatinum (cisplatin) is demonstrated in female Fischer rats. Rats were randomized to receive two doses of either cisplatin or 0.9% NaCl solution 14 days apart at the times of either high or low values in their circadian rhythm of urinary volume. Toxicity was assessed by measuring changes in body weight and changes in the 24-hr means of urinary volume, blood urea nitrogen, and urinary beta-N-acetylglucosaminidase (NAG) activity. Toxicity was least in rats which received the drug near the circadian maximum of urinary volume. Conversely, rats which received the same dose of drug near the circadian minimum of urinary volume lost more weight and exhibited a 2-fold increase in the 24-hr mean of urinary volume, a 3-fold rise in the 24-hr mean of blood urea nitrogen, and a 5-fold increase in the 24-hr mean of urinary NAG activity. A positive correlation between urinary NAG at the time of cisplatin administration and the extent of cisplatin nephrotoxicity was demonstrated (p less than 0.02). A correlation also was found between tissue NAG concentration and tissue uptake of cisplatin (p less than 0.001). A marked circadian rhythm of NAG activity in proximal tubular cells may contribute to the prominent circadian rhythm in murine renal tolerance for cisplatin.

Circadian stage dependence of cis-diamminedichloroplatinum lethal toxicity in rats.

Renal physiology is circadian rhythmic. The major toxicity of cis-diamminedichloroplatinum (cisplatin) is irreversible renal damage. A single dose of cisplatin (11 mg/kg) was given to groups of standardized female Fischer 344 rats at one of six equispaced circadian stages. A statistically significant effect of time of injection upon tolerance was found by chi 2 analysis. Differences of 3- to 8-fold in survival rate of 50% mortality and a nearly 3-fold difference in long-term survival depended on circadian timing of cisplatin administration. Cisplatin timing resulting in optimal tolerance was similar from study to study. Additional 0.9% NaCl solution was administered with cisplatin in three experiments and resulted in an increase in overall mean survival time. It also resulted in an amplification of the survival rhythm without changing its timing. The increase in survival resulting from 0.9% NaCl solution loading, when compared to controls receiving cisplatin alone, was also highly time dependent. A 52% improvement in mean survival time was achieved in those animals receiving cisplatin and 0.9% NaCl solution at the most favorable circadian stage, as compared to a 20% improvement when this regimen was administered at an inopportune circadian stage. The safest time for cisplatin administration is near the midactivity span, shortly after the maximum of the circadian rhythm in rectal temperature.