A phase I evaluation of the quinazoline antifolate thymidylate synthase inhibitor, N10-propargyl-5,8-dideazafolic acid, CB3717.

CB3717 is a quinazoline antifolate whose cytotoxic activity is mediated by inhibition of thymidylate synthase (TS). A phase I clinical trial commenced in September 1981 and 99 patients have received 296 treatments. Doses were dissolved in 0.15 mol/L NaHCO3 (pH 9.0) at a concentration of 4 mg/mL infused over one hour or in a total volume of 1 L infused over 12 hours. Doses were repeated every 3 weeks. The starting dose of 140 mg/m2 was escalated to 600 mg/m2. Renal toxicity, detected by a decrease in the 51Cr EDTA clearance, was dose-related and occurred in seven of ten patients receiving greater than 450 mg/m2. Reversible hepatic toxicity often associated with malaise occurred in 223 of 288 assessable courses (77%). Fifty-nine courses (20%) were associated with increases in alanine transaminase (ALT) levels to greater than 2.5 times the upper limit of the normal laboratory range. Increases in alkaline phosphatase levels also occurred, but were less marked. The severity and prevalence of these elevations were unaffected by the duration of the infusion. A self-limiting rash appeared in 12 patients and a radiation recall reaction was seen in two. Leukopenia developed in 17 patients (WBC less than 3 X 10(9)/L), and thrombocytopenia occurred in six patients (platelets less than 100 X 10(9)/L). The mean leucocyte nadir occurred on day 10 and was followed by recovery at 11 to 19 days. Neither the incidence nor the severity of any of these latter toxicities was dose related. The maximum tolerated dose was in the region of 600 mg/m2 with renal toxicity being dose limiting, although the inter-patient variation did not allow a precise definition. Seventy-six patients were evaluable for response. Responses occurred at doses greater than or equal to 200 mg/m2 and were ovary, one complete response (CR), one partial response (PR), seven minor responses (MR) in 30 cases; breast, two PRs and one MR in eight cases; adenocarcinoma of the lung, one MR in 5 cases; mesothelioma, one PR in five cases; and colon, two MRs in four cases. CB3717 has activity in heavily pretreated patients. The recommended phase II dose for good-risk patients is 400 mg/m2 using the one-hour infusion schedule of administration.

High dose melphalan and non-cryopreserved autologous bone marrow treatment of malignant melanoma and neuroblastoma.

Autologous non-cryopreserved bone marrow infused 8 hours after an intravenous injection of melphalan, 140 mg/m2, accelerates bone marrow recovery. This effect is most noticeable in the recovery of peripheral blood granulocytes. Twenty patients with disseminated malignant melanoma were treated with this regimen: there were 12 responses, two of them complete but the toxicity of the treatment was not sufficient to justify using this method of treatment routinely since survival was little influenced by treatment (4-11 months). In 8 patients with disseminated neuroblastoma, high dose melphalan/autograft was used in a program of combined modality treatment. Three of the patients are disease free at 16, 11 and 6 months and in one the disease is 'static', not having grown for 13 months. The treatment for this tumour deserves further exploration, and perhaps similar treatment ought to be explored for other tumours.

Colony-stimulating activity in the serum of patients with hemopoietic malignancies after intensive chemotherapy/radiotherapy: its augmentation by GM-CSF in vivo and interleukin 4 in vitro.

Colony-stimulating activity (CSA) in the serum of patients with hematological malignancies increased substantially after intensive therapy with cyclophosphamide/busulfan, cyclophosphamide/total body irradiation, or melphalan/total body irradiation. This was not dependent on patients receiving allogeneic bone marrow transplantation (ABMT) or autologous bone marrow rescue (ABMR). In 44 of 62 patients CSA was maximum approximately 7 days after chemotherapy/radiotherapy, whereas in 18 of 62 patients CSA was maximum between 9 and 20 days after therapy and decreased thereafter. The time course of CSA was not dependent on disease and was not affected by recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) given as a continuous infusion for 14 days after therapy; however, serum from patients receiving rhGM-CSF produced significantly more colonies from donor bone marrow than serum from patients who did not receive the cytokine (p = 0.013). Despite the early peak in CSA in the majority of patients, there was no correlation between the time at which CSA was maximum and the return of patients' neutrophils to 500/microliters. Recombinant human interleukin 4 (IL-4) increased the number of granulocyte-macrophage colony-forming unit colonies, principally granulocyte colony-forming unit colonies, from normal bone marrow exposed to patients' serum after intensive therapy and antibody to GM-CSF reduced colony numbers. The results suggest that after intensive therapy granulocyte colony-stimulating factor (G-CSF) as well as GM-CSF is released into the serum and, in addition to acting directly with G-CSF, IL-4 may stimulate mononuclear cells to produce and/or release G-CSF.

Quantitative study of radioiodinated metaiodobenzylguanidine uptake in children with neuroblastoma: correlation with tumor histopathology.

Six children with neuroblastoma and one with ganglioneuroma received [125I] metaiodobenzylguanidine (MIBG) before major surgery. Uptake of [125I]MIBG in the excised tissues was measured by scintillation counting, and the material was submitted for histopathology. The ranges of uptake of [125I]MIBG, expressed as percent of the injected dose per gram of tissue, were as follows: for neuroblastoma 0.0013-0.071, for ganglioneuroma 0.0017-0.0028, and for non-neoplastic control tissues 0.0002-0.011. The quantitative uptake of [125I]MIBG by neuroblastoma varied between different patients and between different parts of individual tumors. The more undifferentiated tumors took up more [125I]MIBG and may be more likely to respond to targeted radiotherapy with MIBG.

Stage III Hodgkin's disease--long-term results following chemotherapy, radiotherapy and combined modality therapy.

215 patients with stage III Hodgkin's disease (HD) were treated at the Royal Marsden Hospital between 1963 and 1985 (median follow-up 9 years). The actuarial 5- and 10-year survival was 77 and 65%, respectively with 55 and 48% 5 and 10 year disease-free survival. Of 13 variables tested, age was the only independent prognostic indicator for survival on multivariate analysis. Patients aged under 40, 40-59 and over 60 years had a 10-year survival of 76, 41 and 8%, respectively (p much less than 0.001). Ninety-one patients were initially treated with combined chemotherapy and radiotherapy (combined modality therapy, CMT), 73 patients with radiotherapy (RT) and 51 patients with chemotherapy (CT) alone. Patients under 40 years treated with CMT achieved the best disease-free survival (10 year disease-free survival: CMT 68%; RT 38%; CT 45%). The observed survival advantage for CMT was not statistically significant. In patients aged greater than 40 there was no survival or disease-free survival advantage following CMT. Analysis of recurrence pattern confirmed that CMT improves initial disease control both at previously involved and uninvolved sites. Recurrences at previously uninvolved sites continued up to 6 years following CT, up to 8 years following CMT and up to 14 years after RT alone. These results indicate that only long-term follow-up gives the true picture of stage III HD.

VAMP followed by high dose melphalan and autologous bone marrow transplantation for multiple myeloma.

Fifty previously untreated patients with myeloma were entered into a 2-phase treatment programme: vincristine, adriamycin and methyl prednisolone (VAMP) followed by high dose intravenous melphalan (HDM) with autologous bone marrow transplantation where possible. The complete remission rate of 50% was associated with very good quality of life and the reversal of humoral immunosuppression. Complete remission is important in younger patients with myeloma as it represents a first step in achieving long, symptom- free survival.

High dose melphalan and total body irradiation with autologous marrow rescue in childhood acute lymphoblastic leukaemia after relapse.

High dose melphalan (HDM 110-140 mg/m2) and total body irradiation (TBI, 10.5 Gy, single fraction) followed by infusion of autologous bone marrow (ABMT) was evaluated for toxicity and efficacy in 24 children with acute lymphoblastic leukaemia (ALL) in second (CR2) or third remission (CR3). Marrow was purged with Campath 1 in six children (four were children in CR3). All children had engraftment with a median of 30 days (range 18-70 days) to neutrophil count greater than 0.5 x 10(9)/l. Four children (16%) died from toxicity 1-4 months after autograft, two from pneumonitis, one from an intracerebral haemorrhage and one from sepsis. Apart from fever and mucositis the procedure was well tolerated. Nine of 17 children treated in CR2 remain in complete remission 6-72 months after ABMT (median 25 months). Seven of these have a follow-up of greater than 12 months. Three of the seven children treated in CR3 are alive 17, 22 and 29 months post ABMT. Seven children relapsed within 10 months (median 4 months) of the autograft. Only one relapse has occurred beyond 10 months. HDM and TBI followed by ABMT is a relatively well tolerated regimen and may contribute to survival in children with relapsed ALL.

Melphalan and total body irradiation (TBI) versus cyclophosphamide and TBI as conditioning for allogeneic matched sibling bone marrow transplants for acute myeloblastic leukaemia in first remission.

Between June 1981 and April 1986 63 patients with acute myeloid leukaemia (AML) in first remission and HLA-identical sibling donors were entered into a prospective study comparing cyclophosphamide (CY) + total body irradiation (TBI) with melphalan + TBI as conditioning therapy prior to transplantation. Thirty-six patients received CY/TBI and 27 received melphalan/TBI. The actuarial probability of remaining in remission for patients receiving melphalan/TBI was 94% compared with 66% following CY/TBI (p greater than 0.01). By including a comparable group of 41 patients with AML in first remission, conditioned with CY/TBI prior to the onset of the study, the greater anti-leukaemic effect of melphalan/TBI compared to CY/TBI was unchanged and statistically the chance of this being wrong is 1 in 10 (p less than 0.1). The overall survival in remission of both arms of the study was the same with 15/27 patients (55%) surviving in remission following melphalan/TBI compared with 19/36 patients (53%) following CY/TBI. The benefit obtained in reduced relapse was offset by the combined nephrotoxic effect of melphalan and cyclosporin which was not identified until the programme had been underway for a period of time. This shows that misinterpretation of 'no survival advantage' for the new treatment may occur due to unforeseen and preventable toxicities.

Cytogenetic studies in patients previously treated for Hodgkin's disease.

A cytogenetic study was made of bone marrow cells and lymphocytes from patients who had been successfully treated with various regimens for Hodgkin's disease. Most of the patients had been off treatment for at least 3 years before the study began. They were divided into three groups according to the intensity of the therapy received. The frequency of gaps and breaks in the chromosomes of lymphocytes was above normal limits and similar in the three treatment groups. In contrast, the frequency of both lymphocytes and bone marrow cells with rearranged karyotypes was correlated with the intensity of treatment. Clones of cells with an abnormal karyotype were found in only two patients, both of whom were in the group receiving the most intensive therapy, i.e., chemotherapy and total nodal irradiation.

Etoposide as a single agent in relapsed advanced lymphomas. A phase II study.

Twenty-three patients with relapsed lymphomas resistant to standard chemotherapy, 13 with Hodgkin's disease and 10 with non-Hodgkin's lymphomas, were treated with etoposide 120 mg/m2 i.v. daily for 5 days or orally for 7-10 days, repeated 3-weekly. This is a higher dose than has been used previously to treat these tumours. Objective responses were seen in eight of 13 (61%) patients with Hodgkin's disease (three CR, five PR) and in three of 10 (30%) patients with non-Hodgkin's lymphomas (three PR). The response rates for Hodgkin's disease are higher than those previously reported and are probably due to the greater dose of drug than has been previously employed. The dose-limiting toxicity was haematological, with gastro-intestinal toxicity occurring in the minority of patients only. It is concluded that etoposide has significant activity particularly in Hodgkin's disease. Its use in drug combinations should now be assessed.

Late intensification with high-dose melphalan and autologous bone marrow support in breast cancer patients responding to conventional chemotherapy.

Fifteen patients with advanced breast cancer who had achieved either a good partial or a complete response to conventional chemotherapy were selected to receive intensification treatment with high-dose melphalan 140-200 mg/m2 (HDM). All patients received autologous bone marrow rescue. All patients experienced marked haematological toxicity, and most experienced moderate or mild gastrointestinal side effects. There were three treatment-related deaths. Of twelve assessable patients eleven have relapsed; median time to relapse after HDM is 7 months. Nine of these eleven have died from recurrent breast cancer. Of the three patients remaining alive, only one is disease-free, at 18 months after HDM. Analysis of the pattern of metastatic relapse suggests that recurrence was due to failure of HDM to eradicate residual disease in the patient, rather than reinfusion of viable tumour cells. Treatment intensification with HDM has not succeeded in prolonging survival in patients already in good remission.

The combination of melphalan with prednisolone. Anti-tumor effect and normal tissue toxicity in laboratory systems.

The effect of prednisolone upon the therapeutic index of melphalan has been studied in a variety of laboratory systems. The anti-tumour action of melphalan was assessed for a human melanoma xenograft growing in immune-deprived mice, clonogenic cell survival and tumour growth delay being used as end-points. Normal tissue toxicity was assessed for human bone marrow colony-forming units, murine bone marrow colony-forming units, murine gastrointestinal crypt microcolony-forming cells, and mouse survival. Prednisolone had no anti-tumour effect when given alone, but increased the anti-tumour effect of melphalan significantly. No increase in the toxicity of melphalan to marrow or gut colony-forming cells could be demonstrated. However, mouse survival was significantly lower after treatment with the combination than with melphalan alone. This study supports the view that steroids may enhance the anti-tumour effect of some alkylating agents, but this may be at the expense of increased normal tissue toxicity in some circumstances.

Ondansetron--a new safe and effective antiemetic in patients receiving high-dose melphalan.

A total of 33 patients with myeloma receiving treatment with high-dose melphalan (140-200 mg/m2 i.v.) were given the 5HT3 antagonist Ondansetron (Glaxo) as an antiemetic. In 42% of patients, emetic episodes were either abolished (15%) or reduced to two or less (27%). Efficacy was not related to scheduling (two regimens) or total dose. No sedative or other significant side effects were seen. Ondansetron is a highly effective non-sedative antiemetic that justifies further assessment in combination with other antiemetics in patients receiving cytotoxic drugs associated with the production of severe nausea and vomiting.

Early clinical studies with cis-diammine-1,1-cyclobutane dicarboxylate platinum II.

cis-Diammine-1,1-cyclobutane dicarboxylate platinum II (CBDCA, JM8), an analogue of cisplatin showing reduced toxicity in preclinical studies, was evaluated in 60 patients. Doses were given initially every 3 weeks and escalated from 20 to 520 mg/m2. Following this, doses were given every 4 weeks and escalated from 300 to 500 mg/m2. The dose-limiting toxicity, thrombocytopoenia, occurred in four-fifths of patients treated at 520 mg/m2, with the nadir occurring 3 weeks after treatment. Leucopoenia and anaemia also occurred but were less severe. Vomiting occurred in all patients receiving over 120 mg/m2 but seldom persisted beyond 24 h. Serial measurements of 51Cr-EDTA clearances, urinary N-acetylglucosaminidase, urinary leucine aminopeptidase, and beta 2-microglobulin did not reveal significant evidence of nephrotoxicity. Detriment to the audiogram has not been seen in the first 13 patients studied. Pharmacological studies showed that most of the dose of platinum was excreted in the urine, and that impairment of renal function may be associated with drug retention and an increased risk of myelosuppression. The previous therapy and age of the patient also affected the tolerance of the drug. Clinical responses were seen in patients with ovarian carcinoma receiving greater than 120 mg/m2. A further dose escalation was performed on a 4-week schedule in patients under 65 with good renal function. The maximum dose it was possible to administer repeatedly without incurring myelosuppression was in the range 400-500 mg/m2. JM8 is not significantly nephrotoxic and is less emetic than cisplatin. It has antitumour activity in man and deserves wider evaluation, along with the other analogues under study in various centres, as an alternative to cisplatin.

Studies on the Clonogenicity of Human Myeloma Cells in vitro.

Myeloma is a disease of the B cell lineage which is characterized by the presence of excess numbers of isotypic plasma cells in the bone marrow and a serum paraprotein which is also isotypic for individual patients. These critieria may be accompanied by bone pain and often renal impairment. Until recently the median survival for patients treated with conventional chemotherapy was 2 years, however at the Royal Marsden Hospital (RMH) the use of VAMP (vincris-tine, 0.4 mg daily, days 1-4), adriamycin 9 mg/m(2) daily, days 1-4) and methylprednisolone (1 g/m(2) daily, days 1-5) followed by high-dose melphalan at 140 mg/m(2) or 200 mg/m(2) with autologous bone marrow transplantation has increased this survival time to 5 years in previously untreated patients(1,2). During the past 5 years the myeloma practice at the RMH has increased considerably and regular bone marrow aspirates from patients provide the material for in vitro studies. At present there: are approximately 160 patients whose disease is available for monitoring in vitro and approximately 15 myelomatous bone marrow are processed each week. The principal questions that need to be answered in myeloma is why do some patients fail to respond to chemotherapy and why does a further group become refractory to treatment at relapse. These problems encompass a need to examine drug-induced or endogenous drug resistance and to study the lineage of the disease. The development of an in vitro assay for myeloma colony formation by our group is enabling these questions to be investigated(3,4).

Misonidazole enhancement of the action of BCNU and melphalan against human melanoma xenografts.

We investigated the effects of combinations of BCNU and misonidazole, and melphalan and misonidazole on growth delay in two human malignant melanoma xenograft lines grown in immune-deprived mice. Misonidazole on its own had no effect on the growth of these tumors, but combinations of BCNU-misonidazole and melphalan-misonidazole produced greater tumor growth delays than those produced by the cytotoxic drugs alone. This was accompanied by increased weight loss. Misonidazole in combination with melphalan also increases hemopoietic stem cell toxicity, but in the case of BCNU there was no enhancement of bone marrow toxicity at the dose chosen for tumor experiments.

The modification of melphalan toxicity in tumor bearing mice by s-2-(3-aminopropylamino)- ethylphosphorothioic acid (WR 2721).

The toxicity of melphalan in mice was reduced by the injection of S-2-(3-aminopropylamino)-ethylphosphorothioic acid (WR2721). This was seen in terms of reduced toxicity to the stem cells of the bone marrow and intestinal epithelium as well as improved animal survival. Using human melanoma xenografts and growth delay as an end-point, it was demonstrated that WR2721 did not protect this tumor from melphalan. With radio-labelled WR2721, it was shown that WR2721 was rapidly cleared from the blood and actively accumulated by all normal tissues except the CNS. Intact human tumor xenografts and Lewis lung tumors were less able to accumulate WR2721 than normal tissues, but in vitro studies showed that tissue fragments or single cell suspensions of tumors were as efficient as liver fragments or bone marrow cells in accumulating the drug. The rapid clearance of WR2721 and poor vascularity of the intact tumors were thought to be responsible for the differential uptake and protection of normal tissues by WR2721.

The role of computed tomography in the management of children with advanced neuroblastoma.

Computed tomography (CT) was found to be a valuable method of assessing the extent of local disease in 36 patients with advanced neuroblastoma. Precise predictions on the operability of tumours can be made so that the timing of primary or "second look" surgery may be optimised. However, intraspinal extension of tumour is not detected on CT examinations without intrathecal contrast medium and plain radiographs are not a reliable guide to the presence of intraspinal disease; the examination should include intrathecal contrast medium (CT myelography) when patients undergo pre-operative staging by CT. The majority of neuroblastomas appear calcified on CT. During chemotherapy the most common change in tumour morphology is decrease in size and increase in calcification. There is however no correlation between tumour size or behaviour during chemotherapy and eventual survival but an increase in size during or after treatment is a serious prognostic sign.

Intravaginal iridium-192 in the management of embryonal rhabdomyosarcoma.

Three patients with vaginal rhabdomyosarcoma and residual vaginal disease following surgery and chemotherapy have been treated using high dose irradiation with vaginal moulds loaded with iridium-192. These patients remain well and disease-free seven years, 30 months and 18 months after their initial presentations. This paper describes a technique for local vaginal irradiation with individualized vaginal moulds made using a rapid-setting silastic foam impression and loaded with a single plane of iridium wires. Details of the dosimetry are also included.