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Background: As a single agent, 100 mg/m(2) of docetaxel every 3 weeks remains the standard schedule in the first-line treatment for metastatic disease. At this dose level, the major limiting toxicity is neutropenia. The current study was conducted to assess the feasibility of reducing time intervals between cycles while delivering standard doses of docetaxel with granulocyte-colony-stimulating factor (G-CSF; lenograstim)., Methods: In the first part of the study, 24 patients were randomized to receive 1 of 4 schedules: 100 mg/m(2) of docetaxel every 21 days without lenograstim; 100 mg/m(2) of docetaxel every 18 days with lenograstim; 100 mg/m(2) of docetaxel every 14 days with lenograstim; or 100 mg/m(2) of docetaxel every 10 days with lenograstim. In the second part of the study, 15 additional patients were included to confirm the feasibility of the recommended interval between cycles., Results: Of the 39 patients treated, 14 patients (36%) withdrew from therapy because of Grade 3 (according to standard World Health Organization criteria) nonhematologic limiting toxicities. Only 3 patients were treated in the 10-day interval arm and were withdrawn because of toxicity--1 patient had Grade 3 asthenia after the second cycle and 2 patients had Grade 3 dermatitis after 4 cycles. Of the 24 patients treated in the 14-day intervals, Grade 3 limiting toxicities occurred in 8 patients (33%), including dermatitis in 3 patients; diarrhea, myalgia/arthralgia, or asthenia in 4 patients; and ungual toxicity in 1 patient., Conclusions: Introduction of G-CSF (lenograstim) as primary prophylaxis allowed the administration of docetaxel every 14 days with manageable toxicities. Further studies are now required to assess the impact in terms of response rates and survival in patients with cancer., (Copyright 2004 American Cancer Society.)

Previous studies have shown that glutathione S-transferases (GSTs) can operate in synergy with efflux transporters, multi-drug resistance proteins (MRPs), to confer resistance to several carcinogens, mutagens and anticancer drugs. To address the poorly documented role of the GSTM1 in cancer chemoresistance, we used CAL1 human melanoma cells expressing no endogenous GSTM1 and a high level of MRP1. Cells were transfected with an expression vector containing the GSTM1 cDNA, and different clones were selected expressing different levels of GSTM1 (RT-PCR, Western blot, and enzyme activity). Cells overexpressing GSTM1 displayed a 3- to 4-fold increase in resistance to anticancer drugs vincristine (VCR) and chlorambucil (CHB) in proliferation, cytotoxic, and clonogenic survival assays. Inhibitors of MRP1 (sulfinpyrazone, verapamil) and GST (dicumarol, curcumin) completely reversed the GSTM1-associated resistance to VCR, indicating that a MRP efflux function is necessary to potentiate GSTM1-mediated resistance to VCR. Conversely, MRP1 inhibitors had no effect on the sensitivity to CHB. Using immunofluorescence assay, GSTM1 was also shown to protect microtubule network integrity from VCR-induced inhibition of microtubule polymerization. In conclusion, these results show that GSTM1 alone is involved in melanoma resistance to CHB, whereas it can act in synergy with MRP1 to protect cells from toxic effects of VCR.

Background: The current study was performed to evaluate the efficacy and toxicity of a noncisplatin-based chemotherapy regimen combining gemcitabine and docetaxel as front-line chemotherapy for patients with carcinoma of an unknown primary site., Methods: Patients were to receive intravenous gemcitabine at a dose of 1000 mg/m2 over 30 minutes on Days 1 and 8 and docetaxel at a dose of 75 mg/m2 over 1 hour on Day 8 in an outpatient setting. The schedule was repeated every 3 weeks for a maximum of 6 cycles., Results: Thirty-five patients were assessable for response and survival. One complete and 13 partial responses were observed. The overall response rate was 40% (95% confidence interval, 28-52%). The median time to disease progression was 2 months (range, 1-4 months). The median overall survival time was 10 months (range, 0-32 months). Toxicity was reported to be manageable., Conclusions: The combination of gemcitabine and docetaxel was found to be active in patients with carcinomas of an unknown primary site. However, the overall outcome of these patients remains poor and novel treatment approaches are required., (Copyright 2004 American Cancer Society.)

Fotemustine is a third generation chloroethylnitrosourea that has demonstrated significant antitumoral effects in malignant melanoma. However, its use is somewhat limited by its toxic side effects and chemoresistance caused by direct repair of O6-alkyl groups by the enzyme O6-methylguanine DNA-methyltransferase (MGMT). The aim of this work was to determine to what extent the expression of MGMT influences cytotoxicity, DNA damage, and apoptosis induced by new nitrososulfamide analogs of fotemustine (compounds 4 and 8), which have previously demonstrated interesting antiproliferative properties. We carried out complementary strategies that consisted of MGMT cDNA transfection in CAL77 Mer- melanoma cells and of MGMT inhibition with O6-benzylguanine (BG) in A375 Mer+ melanoma cells. MGMT-transfected cells were 7 to 9 times less sensitive to fotemustine than parent cells, whereas no difference between the transfected and parent cells was observed for nitrososulfamide analogs. The cytotoxicity of these analogs vis à vis a MGMT-proficient A375 melanoma cell line was approximately 3 times greater than that of fotemustine. Coincubation of these cells with O6-benzylguanine significantly increased the cytotoxicity of fotemustine and compound 8, whereas BG had little effect on the cytotoxicity of compound 4. Furthermore, DNA fragmentation determined by a comet assay was greater with nitrososulfamide analogs than with fotemustine. O6-benzylguanine increased DNA fragmentation for fotemustine and compound 8, but not for compound 4, which induced comets with a typical apoptotic appearance. The ability of this compound to induce apoptosis in the absence of BG was confirmed by a specific enzyme-linked immunosorbent assay apoptotic assay using a single-stranded DNA monoclonal antibody.

Background: The prognosis of patients with carcinoma of unknown primary remains poor with an expected median survival of 6 to 12 months. We evaluated the activity of a chemotherapy regimen combining gemcitabine and docetaxel in patients who primarily failed cisplatin-based chemotherapy., Patients and Methods: Fifteen patients received cycles of gemcitabine 1,000 mg/m2 on days 1 and 8 and docetaxel 75 mg/m2 on day 8 every 3 weeks., Results: The median number of cycles per patient was 3. Overall toxicity was moderate. Four partial responses were observed among 14 patients with measurable disease. The median survival was 8 months from start of therapy and 23 months from diagnosis., Conclusion: These results were obtained in a small series of selected patients and require further confirmation in the front-line management of the disease.

Background: The purpose of this study was to carry out two randomised phase II trials of S16020, a new olivacine derivative, tested as a single agent in patients with recurrent head and neck cancer, using methotrexate as the control arm to validate the results., Patients and Methods: S16020 at either 80 or 100 mg/m2 was administered as a 3-h infusion every 3 weeks. Methotrexate, 40 or 50 mg/m2, was given by bolus injection, weekly for a minimum of 6 weeks. In total, 36 patients were entered in the randomised studies (25 in an initial study, 11 in a confirmatory study) of whom 24 received S16020 and 12 received methotrexate., Results: A scheduled interim analysis showed one patient having a non-confirmed objective response with S16020 and three patients having a confirmed objective response with methotrexate. In the methotrexate group, there were no patients with severe non-haematological toxicity. With S16020, there was a high incidence of severe non-haematological toxicities, including asthenia, oedema of the face, oedema and pain at the tumour sites and erythematous rash; consequently, both studies were stopped., Conclusions: Both studies were stopped due to the poor anticipated benefit/risk ratio for S16020, although time to progression and overall survival time were similar in both treatment arms.

Twenty-seven patients with recurrent soft-tissue sarcoma (STS) entered a multicenter study to determine the efficacy of the combination paclitaxel 200 mg/m and epirubicin 75 mg/m administered every 21 days. Patient characteristics included the following: 14 women and 13 men, median age of 52 years, 12 patients had local recurrence and 20 had metastasis. Eighteen patients had previously received chemotherapy for recurrent disease. The main grade III to IV hematologic toxicities were neutropenia (70%), anemia (3.7%), and thrombocytopenia (7.4%). Febrile neutropenia occurred in 5 patients (18.5%). Severe nonhematologic toxicities were rare. Two patients had a partial response (7.4%; 95% CI: 2.6-12.2%), with a median response duration of 3 and 5 months. Six patients had stable disease (22.2%), and 19 had progressive disease (70.5%). The median overall survival from study inclusion was 8 months. This study suggests the association paclitaxel-epirubicin does not increase the known activity of anthracycline in recurrent STS.

Background: Because carcinomas of unknown primary origin are highly malignant tumors with a bad prognosis (median survival, 6-12 months) and no current optimal therapy, the authors designed a prospective dose-dense chemotherapy regimen with the objective of improving the results observed in patients who receive conventional treatment., Methods: Eighty-two patients received alternative bimonthly cycles of doxorubicin 50 mg/m(2) with cyclophosphamide 1000 mg/m(2) (AC) and etoposide 300 mg/m(2) with cisplatin 100 mg/m(2) (EP). Cycles were given at 2-week intervals with granulocyte-macrophage-stimulating factor support (5 microg/kg per day) from Day 4 to Day 10. Patients without measurable lesions were included, because the major end point was survival., Results: The median number of alternative cycles of AC and EP was 4 cycles (range, 1-12 cycles). An objective response was observed in 24 of 62 patients (39%; 95% confidence interval, 30-48%) with measurable lesions, including 6 patients who achieved a complete response. Among 20 patients with nonmeasurable disease, 9 patients (45%) had no evidence of progressive disease at the end of chemotherapy. The overall median survival of 82 patients was 10 months, with 5 patients surviving clinically disease free at 17 months, 29 months, 45 months, 64 months, and 70 months after the end of treatment. Myelosuppression was the most common toxicity. Two toxic deaths occurred., Conclusions: Using these doses and schedules, a dose-dense chemotherapy regimen did not appear to improve the outcome of patients with carcinoma of unknown primary site. Alternative studies dealing with news drugs will be required., (Copyright 2002 American Cancer Society. DOI 10.1002/cncr.10264)

Purpose: As vinorelbine is 78% bound to platelets, it seems interesting to investigate the pharmacokinetic profile of this drug from blood and to compare it to that determined from plasma. Thus, in this study, the comparative blood/plasma pharmacokinetics of vinorelbine were investigated in 15 elderly patients with advanced metastatic cancer., Methods: The drug was given as a short (10 min) peripheral intravenous infusion; the administered dose ranged from 20 to 30 mg/m2 depending on the patient. Chemotherapy was repeated weekly. During the first and the fifth courses, each patient underwent pharmacokinetic evaluation. Toxicity evaluation was performed after each course of chemotherapy; a total of 109 courses was studied. Plasma and blood vinorelbine determinations were performed by high-performance liquid chromatography with spectrofluorimetric detection. Individual pharmacokinetic parameters were estimated with an empirical Bayes methodology. An open three-compartment pharmacokinetic model was used to describe the kinetics of vinorelbine., Results: The half-lives of the terminal part of the curves, determined from blood and plasma data, were of the same order of magnitude: 31-35 h. Mean total clearances were about 0.71 l/h/kg from plasma and 0.45 l/h/kg from blood. Except during the first 15-20 min following the end of infusion, vinorelbine concentrations were 1.9 times higher in blood than in plasma. The ratio AUC(B)/AUC(P) (AUC(B) and AUC(P) are the area under the concentration-time curve from blood and plasma data, respectively) averaged 1.7; it was comparable to the blood/plasma ratio of 1.6 that remained constant over the 72 h of the study. There was substantial intra- and interpatient variability in vinorelbine pharmacokinetic parameters. This variability is similar within and between patients, and between pharmacokinetic parameters computed from blood and plasma. The elimination half-life is the parameter with the lowest intra- and interindividual variability (10-14%), while the AUC is the parameter presenting the highest variability (20-65%). The main haematological toxicity was anaemia (12 patients) and neutropenia (10 patients). Thrombocytopenia occurred in only one patient. At the first cycle, significant correlations were found between AUC(B) and AUC(P) and the decrease in neutrophil count (P < 0.05). The highest haematological toxicities encountered in this study occurred in patients presenting the lowest platelet count. AUC computed from plasma data decreased significantly with the increase of platelet count (P = 0.03)., Conclusion: From the results of this study, blood did not appear to be a better predictor of haematological toxicity than plasma, but the decrease of platelet count seems to be a good predictor of this toxicity. Indeed, changes in platelet count are likely to produce strong variations in the unbound fraction of vinorelbine; this exposes the patient to a high risk of toxicity.

The comparative saliva/plasma pharmacokinetics of topotecan were investigated in 13 patients with metastatic epithelial ovarian cancer receiving topotecan (30-min intravenous (i.v.) infusion) on a five consecutive day schedule every 3 weeks. During the first and the second courses of treatment, each patient underwent pharmacokinetic evaluation. Quantitation of the total topotecan (lactone plus carboxylate form) was assessed by a highly specific high-performance liquid chromatographic (HPLC) method. Large patient-to-patient variations in the plasma and saliva concentrations were observed. Plasma and saliva pharmacokinetics could be described using a biexponential pattern. From the saliva data, the half-life of the terminal part of the curve was 2.64 h, it was of the same order of magnitude as the topotecan elimination half-life determined from the plasma data, 3.18 h. Topotecan concentrations were higher in the saliva than in the plasma, the saliva/plasma concentration ratio averaged 2.31 and the ratio area under the parotid saliva (AUC(s)) over plasma (AUC(p)) concentration-time curve (AUC(s)/AUC(p)) averaged 2.11. For each individual, a significant relationship was found between topotecan concentrations in the saliva and in the plasma, the coefficients of correlation ranged from 0.75 to 0.92 according to the patient. Myelosuppression, especially granulocytopenia was the most frequent toxicity encountered during the trial. The percent decrease in the leucocyte count, absolute neutrophil count and platelet count were related to the AUCp/day using sigmoidal E(max) models. The high values of the Hill constant found reflect the very steep AUC-haematoxicity relationship observed. In most cases, abdominal pain occurred in patients presenting high saliva concentrations. One patient with high salivary concentrations (mean S/P ratio=4.60) had grade 1 mucositis. In conclusion, the concentration of topotecan in saliva appeared to be useful as an indirect, non-invasive estimation of the levels of topotecan in the plasma; thus, saliva concentrations could be a good predictor of the behaviour of topotecan in the body.

Objective: Twenty-seven patients with recurrent squamous cell carcinoma of the head and neck were entered in a multicenter study to determine the efficacy of the paclitaxel-carboplatin association., Methods: Standard eligibility criteria applied, i.e. measurable disease, and chemotherapy given as induction treatment or concomitant chemoradiotherapy was allowed if completed more than 6 months prior to the study. Every 21 days, paclitaxel 175 mg/m(2) and carboplatin AUC 6 were administered. The patient group included 3 females and 24 males with a median age of 61 years (range 39-75 years)., Results: All patients were assessable for toxicity and 24 for responses. Main grade 3-4 toxicities were: neutropenia (62.9%), febrile neutropenia (18.5%), anemia (11.1%), thrombocytopenia (14.8%), mucositis (7.4%) and vomiting (7.4%). Among the intent-to-treat population, 29.6% of patients had an objective response, with a median response duration of 4.2 months (range 1-5.7 months). Stable and progressive disease were observed in 11.1 and 48.1% of patients, respectively. The median overall survival was 7.2 months (range 0.5-10.9 months)., Conclusion: From these data, paclitaxel-carboplatin seems to have an activity in recurrent squamous cell carcinoma of the head and neck, but the high level of toxicity highlights the need to search for a safer chemotherapy combination.

Context: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature systematic review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery., Objectives: To develop clinical practice guidelines according to the definitions of Standards, Options and Recommendations for the management of patients with cutaneous melanoma., Methods: Data have been identified by literature search using Medline - until December 1998 - and the personal reference lists of the expert group. Once the guidelines were defined, the document was submitted for review to national and international independent reviewers and to the medical committees of the 20 French Cancer Centres., Results: The main recommendations for the management of cutaneous melanoma (CM) are: 1) The primary prevention of melanoma is based on a reduction in exposure to ultraviolet rays (solar or artificial). 2) The diagnosis of CM requires the surgical removal and histological examination of the lesion (standard). 3) The pathological report must include the diagnosis of primary malignant melanoma, the maximum thickness of the tumour in millimeters (Breslow), the clearance of surgical margins, the level of invasion (Clark), the presence and extension of regression and the presence of any ulceration (standard). 4) The standard treatment of a primary melanoma without lymph node involvement is based on surgery that must ensure adequate margins depending on the thickness of the tumour (standard, level of evidence B). 5) After surgery of a stage I melanoma, there is no indication for additional treatment outside a prospective therapeutic study (standard, level of evidence B, French Consensus Conference). 6) For a local recurrence without node involvement, in the absence of other metastases, surgical excision is the standard treatment. 7) In the case of metastatic regional lymph nodes, a complete regional lymphadenectomy is required. There is no indication for additional treatment outside a prospective therapeutic study (standard, level of evidence B). The inclusion of these patients in controlled studies of immunotherapy is recommended. 8) There is no standard therapeutic strategy for metastatic melanoma. Conventional palliative treatment is chemotherapy with dacarbazine (level of evidence B). 9) Follow-up is based on physical examination (standard). Patient information must encourage self-surveillance. Clinical surveillance and self-detection are indicated in all cases throughout life (standard).

Purpose: The pharmacokinetics (PK) of platinum was investigated and compared in patients with normal (NRF) and impaired renal function (IRF), after they had received oxaliplatin at the recommended dose and delivery modality., Methods: Oxaliplatin was administered at 130 mg/m(2) as a 2-h infusion without hydration. Patients were recruited and classified according to their creatinine clearance (CrCl > or < 60 ml/min), calculated using the Cockcroft and Gault formula. Blood was taken for PK analysis during and after the infusion. Twenty-three patients were included in the PK analysis (13 NRF and 10 IRF). At inclusion, the median CrCls were 70.5 ml/min (range 63-136) for the NRF group and 42 ml/min (range 27-57) for the IRF group. Three patients underwent a second course of treatment and additional blood sampling for analysis. Platinum levels in the plasma, ultrafiltrate and red blood cells (RBCs) were measured using flameless atomic absorption spectrophotometry (FAAS)., Results: Following the administration of oxaliplatin, platinum binding to plasma proteins and RBCs was rapid and extensive; at the end of the 2-h infusion, 27% of the platinum in the plasma remained free (40% bound to RBCs, 33% bound to plasma proteins). Neither the mean maximal concentration (C(max)) of total platinum in the plasma, the mean C(max) of ultrafilterable platinum in the plasma, nor the maximal platinum content in the RBCs differed significantly between the two groups (2.59 vs 2.58 microg/ml, 1.09 vs 1.28 microg/ml and 2. 06 vs 2.17 microg/ml, respectively, for patients with NRF vs IRF). After the end of the infusion, levels of total and free (ultrafilterable) platinum in the plasma declined biexponentially. The plasma clearance of both total and free platinum as well as the area under the curve (AUC) of the free platinum fraction correlate with the calculated CrCl (P=9 x 10(-3), P=3.1 x 10(-5) and P=9 x 10(-6), respectively). After a single course of oxaliplatin, toxicities reported in the two groups of patients were similar., Conclusions: Our results are in agreement with the in vitro data concerning the extensive binding of oxaliplatin to plasma proteins and RBCs. They also reveal a strong negative correlation between free drug plasma availability and renal function, with a corresponding positive correlation between clearance of the plasmatic platinum and renal function. Thus, renal impairment entails a greater overall exposure to platinum in the plasma. However, this study failed to elicit any relationship between moderate renal impairment and the acute toxicity associated with oxaliplatin.

Background: Unknown primary tumors are highly malignant diseases which portend a dire prognosis. We designed a prospective high dose-intensity policy with the aim of improving the results obtained with conventional chemotherapy., Patients and Methods: Chemotherapy regimens were determined according to clinical features. In patients younger than 61 years with an ECOG performance status of 0 or 1, poorly differentiated adenocarcinoma or poorly differentiated carcinoma, and no evidence of brain or bone marrow involvement (group A), the treatment plan included four sequential high-dose courses with hematopoietic progenitor cell and growth factor support. Peripheral blood progenitor cells were collected by apheresis as the leukocyte counts recovered from the nadir induced by the first cycle of chemotherapy (doxorubicin 75 mg/m2, cyclophosphamide 6000 mg/m2). Patients then received two cycles of etoposide (800 mg/m2) and carboplatin (900 mg/m2) separated by one cycle of doxorubicin (75 mg/m2) and cyclophosphamide (3000 mg/m2). G-CSF (5 micrograms/kg/d) was given until engraftment. It was planned that cycles would be delivered every three weeks. The remaining patients (group B) received alternative cycles of AC (doxorubicin 50 mg/m2, cyclophosphamide 1000 mg/m2) and EP (etoposide 300 mg/m2, cisplatin 100 mg/m2). Cycles were given at two-week intervals with GM-CSF support (5 micrograms/kg/d) from day 4 to day 10. Patients without measurable lesions were included, since the major endpoint was survival., Results: Sixty patients entered the study. Twenty patients were assigned to group A and 40 patients to group B. In group A, 5 of 12 patients with measurable lesions (42%; 95% confidence interval (95% CI): 22%-62%) achieved major responses to chemotherapy, including one complete response. The duration of the overall median survival was 11 months. In group B, a major response was observed in 12 (39%; 95% CI: 28%-50%) of 31 patients with measurable lesions, including three complete responses. The overall median survival was 8 months. Hematological toxicities were noteworthy in both groups. Two toxic deaths occurred in group B., Conclusion: Using these doses and schedules of chemotherapy, a high-dose intensity policy does not appear to improve the outcome of patients with carcinoma of unknown primary site. Alternative studies dealing with new drugs are required.

The aim of this study was to demonstrate the value of the level of platinum in lymphocytes, plasma and saliva, in order to predict neutropenia during the same cycle after cisplatin chemotherapy. Plasma and lymphocytes samples were obtained from 14 patients receiving 100 mg/m2 cisplatin in different combination. Saliva samples were obtained from 3 other patients. We found that platinum plasma concentration at the Cmax and 1 hour after the end of the infusion were significantly higher in the grade 4 neutropenia cycles (respectively 2.60 vs 2.05 and 2.55 vs 2.00 mg/l p < 0.05). Platinum DNA-adduct were not detectable by ICPMS. Maximum concentrations in saliva ranged between 0.05 to 0.08 mg/l at the end of the infusion. The ratio of platinum levels in plasma and saliva varied between 2 and 3%. Saliva seems to be useful for therapeutic drug monitoring of cisplatin because it can be obtained by non invasive and patient-friendly-means. However, new studies are required to demonstrate the relationship between these two biological fluids.

Objective: To determine the applicability and safety of an ifosfamide, cisplatin, and etoposide (VIP) regimen as a neoadjuvant chemotherapy to a concomitant thoracic radiotherapy and cisplatin continuous infusion in locally advanced non-small cell lung cancer (NSCLC)., Patients and Methods: Forty-four patients (stage IIIb in 43 and stage IIIa in 1) entered a study of VIP, followed by concomitant thoracic radiotherapy and cisplatin continuous infusion. Chemotherapy consisted of three courses of cisplatin 25 mg/m2, ifosfamide 1.5 g/m2 (with uroprotection), and etoposide 100 mg/m2 given on days 1 to 4 of a 21-day cycle with hematopoietic support using recombinant human methionyl granulocyte colony stimulating factor. Patients who achieved a response or a stabilization were planned to receive a split-course normofractionated thoracic radiotherapy (first course: 30 Gy/10; 4-week rest period; second course: 25 Gy/10). A continuous cisplatin infusion of 6 mg/m2 daily was administered using an autonomous chemotherapy delivery device. Total plasma platinum titration was performed daily during the two courses in five of the patients. Analyses were done on an intent-to-treat basis., Results: Thirty-nine of the 44 patients received the three-cycle chemotherapy program. Received dose intensity was 82%. Thirty-eight patients received the radiotherapy and, among them, 35 received the complete concomitant continuous cisplatin infusion. Objective (complete) response rates were 48% (7%) at the end of chemotherapy and increased up to 61% (16%) by the end of radiotherapy. At the end of the first radiotherapy cycle, the mean total plasma platinum concentration was twice as high as that of the residual postinduction chemotherapy concentration. During induction chemotherapy, myelosuppression was the limiting toxicity requiring hospital readmission in 23 patients. During radiotherapy, the main toxicity was acute esophagitis. A relatively high rate of pulmonary fibrosis was observed using the subjective objective management analytic--late effects of normal tissue score without life-threatening pulmonary function impairment. None of the patients died from toxic reactions. Probability of survival at 1, 2, and 3 years was 49%, 19%, and 5%, respectively. Primary cause of failure was a local relapse in 63% of the patients, brain metastases in 24%, and hematogeneous metastases to other sites in 13%., Conclusion: Neoadjuvant VIP followed by concomitant radiotherapy-chemotherapy is feasible, but the split-course radiotherapy did not prevent a high rate of local recurrences. The high rate of toxic reactions requiring hospital readmission limits further development of such an aggressive regimen in NSCLC.

Purpose: Carcinomas of unknown primary site are frequent neoplasms which raise diagnostic and therapeutic problems in clinical practice., Methods: Clinical records of 100 patients with carcinoma of unknown primary site whose clinical management took place at the Centre Regional de Lutte Contre le Cancer de Montpellier were retrospectively reviewed. Initial clinical and biological characteristics, pre-treatment evaluation, therapies and outcome were recorded., Results: Three main histological types were observed: adenocarcinoma (66 patients), poorly differentiated carcinoma (19 patients), epidermoid carcinoma (11 patients). Bone, lung, lymph nodes and liver were the most frequently involved metastatic sites. Analysis of the investigations aimed at identifying the primary site (none of which being positive) showed 68 different combinations in 100 patients. Anemia (< 100 g/L) was observed in 10 patients, while serum alkaline phosphatase was increased in 42 patients. Seven patients died before any therapy. Chemotherapy or radiotherapy was advocated in 70 and 59 patients, respectively. Thirty-six patients had concomitant chemoradiotherapy. Chemotherapy included a platinum derivative in 53 patients. The median number of cycles was four. Nine objective responses were observed, six of which occurred in patients who were receiving platinum-based chemotherapy. Ninety-six deaths were encountered, 95 due to the disease progress and one due to an intercurrent cause. The median survival was 9 months. Univariate analysis identified two prognostic factors: the number of metastatic sites and the serum alkaline phosphatase., Conclusions: This retrospective study confirms the difficulties in the management of patients with carcinomas of unknown primary site. A literature review suggests limited diagnostic investigations in clinical practice with the aim of identifying tumors of potential prognostic (breast and ovary) or therapeutic (prostate) value. Apart from specific subgroups of patients for whom specific therapy is recommended, there is no current standard chemotherapy.

A multicenter, open-label, compassionate-use trial studied the antiemetic efficacy and tolerability of granisetron in patients who had failed other antiemetic therapies in previous cycles of cytostatic chemotherapy. The antiemetics that had been used previously included metoclopramide, dexamethasone and ondansetron. A total of 517 patients, 456 of whom had failed other antiemetics, were treated in up to 15 successive cycles of chemotherapy. The numbers of patients treated in the first six of these cycles were large enough to allow the drawing of meaningful conclusions from the results. During that period, a complete response was achieved in 53-60% of patients. In addition, antiemetic efficacy was sustained throughout these six repeated treatment cycles. Granisetron was less effective against high-dose cisplatin chemotherapy than against other cytostatic regimens. The treatment was well tolerated--the main adverse events reported were headache and constipation; no serious adverse events were considered to be attributable to the drug. It is concluded that granisetron treatment was effective and well tolerated in patients who had previously failed other antiemetic therapies, including treatment with 5-hydroxytryptamine3 antagonists.

The anti-tumoral activity of interleukin-2 (IL-2) is well-documented. Although the response rate with this cytokine is low, it appears to be improved when associated with interferon-alpha (INF-alpha) and/or cytotoxic drugs. Aim of this work was to study the efficacy and tolerance of an ambulatory treatment using subcutaneous, low-dose IL-2 with subcutaneous INF-alpha and chemotherapy. We report a multicenter study of ambulatory treatment combining subcutaneous (SC) low-dose IL-2 (9 x 10(6) IU) with SC INF-alpha-2a (3 x 10(6) IU) and cisplatin (100 mg/m2) in 33 patients (13 women and 20 men, 22 to 66 years of age) with metastatic malignant melanoma. Metastases were mainly nodal (54.5%) and pulmonary (51.5%). For 81.8% of patients, this therapy constituted the firstline treatment. The overall response rate at the end of the first maintenance course was 30.3% (3 complete responses and 7 partial responses). Adverse effects were observed in 28 patients (84.8%), but were most often minor (grade 1 or 2 on the WHO toxicity scale). The results confirmed the good tolerance to SC IL-2 and its suitability for ambulatory therapy, as well as the potential benefit of associating IL-2 with cisplatin in the treatment of metastatic melanoma (a possibility considered in two previous studies).

Adaptive dosing of cisplatin (CDDP) results in reduced haematological and renal toxicity but it has never been clearly shown that it affects the tumoral response rate. Before undertaking a clinical randomized study of CDDP monitoring versus standard dose, a comparative study was performed between a new software dedicated to the interactive adjustments--the AJI software--and the APIS software for clinical pharmacokinetics which incorporates a bayesian procedure and a population information computed according to a three compartment model. CDDP was administered by continuous infusion at variable rates with a controlled flow pump during four days in order to reach the target of 1.3 mg/L at the end of the first day, and to maintain this level during the whole treatment. This study was carried out on two groups of patients. Group 1 (12 patients; 27 courses) received CDDP with sequential flow rates in order to obtain a population information to be used with AJI. For patients in group 2 (14 patients; 26 courses), doses (flows) were adapted in a prospective study using the AJI software two to three times the first day, then daily. They could have been adapted (retrospective study) after platin pharmacokinetic parameters identification by APIS. The dosage recommendations proposed by APIS the first day, from 12 hours to 24 hours, to reach the target of 1.3 mg/L at 24 hours, and then daily up to D4 (AAPT at Di) to maintain this level were compared to those which were really administered during the interactive treatment (DA at Di). There were no statistically significant difference for D2, D4 and for the total dose (118.7 +/- 20.1 mg and 118.5 +/- 45.1 mg). The difference was statistically significant for D1 and D3 (P < 0.05). The inter-individual variability was less important with AJI (CV = 16.9% for DA total) than with APIS (CV = 38.0% for ADAPT total). The platin pharmacokinetic parameters identified the first day by APIS were not statistically different from those identified from the whole treatment for clearance (5.92 and 5.63 l/d) and Vtotal 87.8 and 93.1 L); the difference was statistically significant for Vinitial (34.7 and 42.5 L; P < 0.05) and the terminal half-life (13.1 and 15.5 days; P < 0.05).

This multicentre, double-blind, double-dummy, randomised trial was designed to compare the efficacy and safety of single intravenous doses of dolasetron mesilate and granisetron in the prevention of acute emesis and nausea due to high-dose (> or = 80 mg/m2) cisplatin. Single intravenous doses of 1.8 or 2.4 mg/kg of dolasetron mesilate or 3 mg of granisetron hydrochloride were administered in a volume of 50 ml over a 5-min period, beginning 30 min prior to cisplatin (> or = 80 mg/m2) administration. The number and timing of emetic episodes, time to administration of escape anti-emetic medication, severity of nausea by visual analogue scale (VAS), and safety were monitored for 24 h after the start of cisplatin-containing chemotherapy. Investigators' evaluations of overall efficacy and patients' satisfaction with therapy were recorded at the end of the 24-h study period. Of the 474 patients evaluable for efficacy, complete responses were achieved by 54, 47 and 48% of patients given dolasetron mesilate 1.8 mg/kg, dolasetron mesilate 2.4 mg/kg and granisetron, respectively. Statistically, treatment groups had comparable complete and complete plus major responses, times to first emesis, and use of escape medication; patient maximum nausea severity and treatment satisfaction ratings; and physician nausea severity and overall efficacy assessments. For the majority of efficacy endpoints, 1.8 mg/kg dolasetron mesilate produced numerically superior responses compared with the 2.4 mg/kg dose. Gender and prior chemotherapy were significant predictors of complete response; males and chemotherapy-naive patients had higher responses. The overall incidences of adverse events were comparable among the treatment groups; headache and diarrhoea were most common. In conclusion, 1.8 and 2.4 mg/kg of dolasetron mesilate and granisetron (3 mg) were equally effective in preventing nausea and vomiting induced by highly emetogenic cisplatin-containing chemotherapy. In addition, because no additional benefit was observed with 2.4 mg/kg of dolasetron mesilate and numerically greater responses were observed with the 1.8 mg/kg dose, the lower dose of 1.8 mg/kg is optimal for further clinical development.

Granisetron is a novel, highly specific 5-hydroxytryptamine receptor antagonist given prophylactically to patients undergoing chemotherapy. An open, randomized, crossover trial was performed with 37 patients (24 females and 13 males) undergoing cytotoxic chemotherapy for malignant disease to compare an oral tablet (1-mg tablet given twice daily) with a clinical-trial capsule (1-mg capsule given twice daily). Complete pharmacokinetic data were determined for 24 patients (14 females and 10 males). The concentration of granisetron in plasma was measured by HPLC; the limit of quantitation was 0.2 ng/mL. The bioavailability evaluation was based mainly on the area under the curve (AUC) (mean values: 52.1 ng.h/mL for the capsule and 54.2 ng.h/mL for the tablet) and the maximum concentration (Cmax) (mean values: 7.42 ng/mL for the capsule and 8.18 ng/mL for the tablet) measured at the steady state after 7 days of continuous therapy. Wide interpatient variability in plasma granisetron levels after oral administration was observed. The 90% standard confidence interval for the geometric mean ratio overlapped the critical range, 0.8-1.25. Point estimates for AUC and Cmax based on two one-sided t tests and log-transformed data showed that the upper limit of the confidence interval was not within 20% of the mean for the capsule; the corresponding power analysis values for AUC and Cmax were 0.89 and 0.81, respectively. Despite bioequivalence not being proven, any differences that exist between the two formulations are likely to be small. There was no difference in efficacy or safety between the two formulations assessed.

The aim of this study consisted in underlining the concentrations' evolution in time of two cytokines: IL-1 beta and IFN-gamma, as well as that of RIL-2 (soluble receptor for IL-2), in healthy volunteers. Under normal physiological conditions, these molecules are secreted in small amounts, according to a sequential chronology. Thus, 25 blood samples were carried out from each of the four subjects included in the study, one every 20 minutes, during 8 hours. Concentrations were determined with the ELISA method. Spectral analysis was carried out using the Frequencies Spectrum method (Fourier Transform of a temporal series). This method allows a rhythm search over a milited number of values, in a short interval of time, provided having enough samples. Important variabilities have been observed between all subjects sera, particularly for IL-1 beta (Range (mean +/- SD): 132 +/- 34.6 pg/ml to 250 +/- 17.5 pg/ml, one subject had low values: 2.34 +/- 0.53 pg/ml) and RIL-2 (Range: 677 +/- 175 pg/ml to 1,187 +/- 46.2 pg/ml). Furthermore, ultradian serum variations, characterized by the relation ((Cmax-Cmin)/Cmax) x 100, have been assessed for each subject and each molecule: IL-1 beta (Range: 18.9 to 92.2%), IFN-gamma (Range: 66.3 to 74.2%) and RIL-2 (Range: 11.6 to 86.3%); they might be the manifestation of a periodicity; this hypothesis has been confirmed by the spectral analysis. Thus, the concentrations' variation with time showed a periodicity (Range: 80 mn to 240 mn, the most frequent period was 160 mn (2 h 40 mn)).

119 patients with metastatic melanoma received fotemustine 100 mg/m2 on days 1 and 8 and dacarbazine 250 mg/m2 on days 15-18. After a 5-week rest, fotemustine 100 mg/m2 on day 1 and dacarbazine 250 mg/m2 on days 2-5 was given every 3-4 weeks. 12 complete responses (11.6%) and 16 partial responses were observed in 103 evaluable patients (response rate 27.2%). The median duration of response was 21.5+ weeks (8+ to 53+). The response rate was 26.3% in CNS, 18.2% in visceral sites and 37.5% in non-visceral sites. The toxicity was mainly haematological: grade III-IV leukopenia in 27.4% and thrombocytopenia in 23.4%. The response rate was lower than that in 63 patients previously reported. The present series had a higher median age (54 vs. 40 years) without any differences in other population variables. However, activity on CNS metastases and on non-visceral sites was confirmed. Haematological toxicity was about 50% lower than that with fotemustine alone. Hence, this is an active outpatient regimen for metastatic melanoma, especially against cerebral and non-visceral metastases.

A single-centre, double-blind, placebo-controlled study was carried out in 28 patients with malignant disease, naive to chemotherapy, receiving cisplatin at a mean dose in excess of 80 mg/m2. Patients were randomized into two groups, receiving either granisetron (40 micrograms/kg) or placebo. Patients in both groups who experienced symptoms of vomiting and nausea were given up to a further three 40 micrograms/kg doses of granisetron on an open-label basis, allowing the assessment of granisetron as an intervention anti-emetic in the placebo group. Following granisetron administration, 13 (93%) patients had no vomiting or nausea in the first 24 h, a significant difference compared with the one patient in the placebo group who remained free from vomiting and had only mild nausea in the same period (P less than 0.001). As a single intervention agent, granisetron achieved control or improvement of existing symptoms in the remaining members of the placebo group.

A total of 70 patients presenting with a disseminated malignant melanoma were entered into a multicentric study of combination chemotherapy using dacarbazine and fotemustine. In all, 63 patients were evaluable, 31.8% of whom had previously received cytotoxic chemotherapy. The protocol consisted of induction treatment with a weekly infusion of 100 mg/m2 fotemustine on days 1 and 8 and a daily infusion of 250 mg/m2 dacarbazine on days 15/18 followed by a 4- to 5-week rest period. Responding and stabilized patients were given maintenance treatment comprising fotemustine (100 mg/m2, day 1) and dacarbazine (250 mg/m2, days 2/5) every 3 weeks. The response rate was 33.3% (9 complete responses (CRs) and 12 partial responses (PRs)) and was outstanding among pretreated patients (34.9%). Responses were also documented in cerebral (28.6%), visceral (23.1%) and nonvisceral (43.3%) metastatic sites. Toxicity was mainly hematologic (22.2%, grade III/IV leukopenia; 20.3%, grade III/IV thrombocytopenia) and was acceptable. These results are encouraging in terms of the antitumor activity against nonvisceral metastases (43.3%) and the percentage of CRs obtained (23.3%), and they confirm the activity of fotemustine in cerebral metastatic sites.

Modulation of suppressor cell activity by thymosin was evaluated in vivo in a murine tumor system, and in vitro on human lymphocytes. We showed that splenocytes from tumor bearing mice were able to enhance tumor growth in a syngeneic system. This enhancement was T dependent and disappeared by Thymosin treatment. A decrease of Tumor size associated with injection of bone marrow cells treated by thymosin was observed. In the human system we showed that ConA stimulated lymphocytes were able to suppress the response of normal lymphocytes to PHA, PWM and ConA, and in MLC. This effect was significantly blocked in presence of thymosin fraction 5.

A randomized trial was initiated to compare the effects of PIVN-associated chemotherapy (adriamycin, vincristine, VP16-213 and cyclophosphamide) versus as chemotherapy control group in patients with small-cell lung neoplasias. The results obtained are preliminary. The test group included ten patients whereas nine were followed in the control group. PIVN was scheduled each day the patient underwent chemotherapy. Each patient received 1550 kcal/day, which included 10% glucose, 20% lipids, and amino acids which may or may not be mixed in the same infusion bottle. The results show three PIVN patients presently in complete remission at the end of three courses of treatment compared to two over the same time period in the chemotherapy control group. Of all patients who can be evaluated at this time, five out of six PIVN patients are in complete remission compared to four out of five in the control group. There was no significant difference in either general health or side effects, such as nausea and vomiting. The median length of time for which a low white cell or platelet count was noted was the same for both groups.

The immune status of the tumor-bearing patient remains poorly defined. In various solid-tumor-bearing patients, we demonstrated the absence of ADCC modifications in the patient in relapse or in evolution. These same patients presented a significant increase in immune complexes when compared with patients in remission. Furthermore, we noted a decreased NK activity, a decreased number of ARFC, corresponding to a helper T cell subpopulation, and a corollary increase in T-dependent suppressor activity. These results, on the whole, suggest an immune imbalance and that the helper cell-suppressor cell ratio should be investigated in greater depth within the context of the immune response in the cancer patient.

We have demonstrated that splenic lymphocytes from normal syngeneic animals can stimulate tumor growth. This effect is T-cell dependent. Preincubation of these lymphocytes with thymosin not only blocks facilitated tumor growth but can induce a significant reduction of local tumor growth and number of pulmonary metastases. Furthermore, thymosin can also block the expression of suppressor activity of lymphocytes either stimulated by Con A or originating from various advanced solid tumor bearing patients. These results therefore suggest that thymosin is able to modulate, directly or indirectly, functional expression of suppressor cells.

C57BL/6 mice were injected subcutaneously with Lewis-tumor cells and syngeneic spleen lymphocytes. When these lymphocytes had been preincubated with a thymic extract, tumor development was impaired: the tumor weight and volume were significantly decreased and the number and size of lung metastases were strikingly diminished. In addition, the increase in weight of adrenals and spleen, common in tumor-bearing animals, was not observed. Lymphocytes incubated with a thymic factor preparation can therefore enhance the defense against this tumor.

The antiemetic effect of alizapride was evaluated in 50 patients with advanced cancer undergoing chemotherapy with cis-platinum. Our results suggest that alizapride, in a dose of 800 or 900 mg, significantly alleviates nausea and emesis. In a preliminary study, we had established that, without antiemetic therapy, the same patients all suffered from emesis. On the whole, alizapride was well tolerated ; no major side-effects were recorded.

In vitro cloning of human tumor cells were carried out for 19 patients: 13 breast cancers (4 metastatic effusions and 9 primary tumors), 3 ovarian cancers, 2 glioblastomas and 1 meningioma. Cloning efficiency varied from 1 X 10(-5) to 2.8 X 10(-3). Tumor cells with the highest cloning rates were provided by patients with rapidly evolving tumors. 7 drug assays were performed: in vitro-in vivo correlation was observed in all cases (drug resistance in 5 cases: drug sensitivity in 2).

The treatment of epithelial carcinoma of the ovary (90% of malignant ovarian tumours) has largely benefited from chemotherapy, notably since the advent of cisplatinum. Radiotherapy may be an important adjuvant treatment to sterilize the pelvis. Both chemo- and radiotherapy are effective mainly on small residual diseases, hence the importance of initial surgery with maximal cell reduction, notably in carcinomas classified as stage III according to the International Gynaecology and Obstetrics Federation system. Regional surgery of the ovary must be pelvic and abdominal: from Douglas' pouch to the diaphragmatic domes. This therapeutic approach requires the resolution of two problems: intensive care and post-operative feeding. It has 2 major advantages: it avoids second-look operations or reduces their number, and it increases the survival rate at 5 years.

The nutritional state of the cancer patient is still a poorly defined parameter that most probably presents specific differences when compared with other states of denutrition. By definition, the immune response is altered in the denutritive condition. Factors such as amino acids, lipids, insulin, vitamin A, vitamin C and, zinc should be studied in more depth since existing studies have already shown that changes in plasma levels of these factors can modulate the immune response. Present information on hypernutrition is clearly inadequate and often difficult to evaluate, since it is based on nonrandomized trials in cancer patients, and for whom the relationship between nutritional state and the associated immune response was not clearly established. In addition, the effects on lymphocyte subpopulation functions within this context have not been adequately studied. These and other factors employed, is of limited interest and also expensive. We propose a more specific approach to nutritional therapy that would lead to a more specific modulation of the overall immune response.

The effect of iv injection in C57BL/6 mice of 3X10(7) bone marrow cells preincubated in either thymosin fraction V or thymosin alpha-1 was evaluated on the growth of a 3-methylcholanthrene-induced transplantable tumor in a syngeneic system. The effect was then compared to that elicited by theophylline or levamisole, which both demonstrated thymosin-like action in vitro. The results showed significantly retarded tumor growth (P less than 0.001) and prolonged survival time (P less than 0.001) when thymosin fraction V was used. The same results were obtained with thymosin alpha-1 with use of the same protocol but only one-twentieth of the concentration of fraction V. Theophylline and levamisole demonstrated no antitumor effect.

The infiltration by inflammatory cells of dacron mesh tissue containing live BCG, implanted under the skin of male and female guinea-pigs treated with normal control and cancer patients' plasmas, was investigated. These cells migrated from the blood vessels to the peri-implant region under the influence of local chemotactic mechanisms generated by the bacilli. Animals given normal or cancer patients' plasmas were unable to produce normal levels of cellular infiltration. This was more markedly reduced with plasma from patients with malignant disease. Cell counts in treated animals have shown significant reduction in while-cell counts but the more marked effect was seen on the polymorphonuclear neutrophil level. Ketoprofen restored normal infiltration responses to animals simultaneously given plasma from cancer patients. These observations further underline the importance of prostaglandins in both inflammation and malignant disease.

A randomized trial was initiated to compare the effects of peripheral i.v. nutrition (PIVN)-associated chemotherapy (adriamycin, vincristine, VP-16-213, and cyclophosphamide) versus a chemotherapy control group in patients with oat cell lung carcinoma. Thirty-nine evaluable patients were randomized. The test group included 19 patients, whereas 20 were followed in the control group. PIVN was scheduled each day the patient underwent chemotherapy. Each patient received 1,550 kcal day which included 10% glucose, 20% lipids, and amino acids which may or may not have been mixed in the same infusion bottle. The results show ten PIVN patients presently in complete remission at the end of three courses of treatment, compared to nine over the same time period in the chemotherapy control group. Thirty-three percent of patients are still alive after 15 months after the beginning of treatment. There was no significant difference in either general health or side effects, frequency or duration of complete remission, or survival time. After 1 year of treatment, 8 of 19 PIVN patients are still in complete remission, compared to 7 of 20 patients in the control groups.

Platinum and its derivates are particularly efficient in treatment of ovarian and testis carcinomas. Nevertheless, the high nephrotoxicity of these drugs limits their use. It is known that nephrotoxicity appears when platinum plasmatic concentrations are higher than 1.5 mg/l. Moreover, the wide variability between patients and between cures, emphasizes the difficulties of utilization. Using a computerized pump and a program for individual dosage regimen, an efficient prevention of plasmatic overdosages have been realised and nephrotoxicity accidents have been avoided.