Breast Cancer Survivors

Chemo Secrets From a Breast Cancer Survivor

Undergoing chemotherapy can be one of the most terrifying things that you go through in your life. One of the most frightening things about chemotherapy is the lack of real information that most people have about it, and the unknown makes it so much more frightening as a result. This eBook, written by a young cancer survivor gives you the real story about what chemo is all about. The most valuable information you can get about chemotherapy is from someone that has already experienced it. This PDF eBook allows you to download and read it as soon as your order it. You can begin your journey of reassurance as soon as you want! Because that's what this is about: chemo does not have to be a terrifying unknown! Other people have gone through it before, and want to help you through it as well! This eBook is the guide through chemo that many people wish they could have had, and now you can have it yourself! Read more...

Chemo Secrets From a Breast Cancer Survivor Overview

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Clinical Pharmacology of Brain Tumor Chemotherapy

ABSTRACT Chemotherapy has become a more common adjunctive treatment for most patients with malignant brain tumors and for selected patients with benign neoplasms. In general, the most effective chemotherapeutic drugs are alkylating agents, such as the nitrosoureas, procarbazine, temozolomide, cisplatin, carboplatin, and cyclophosphamide. Other agents that have been applied to brain tumors include methotrexate, vincristine, etoposide, irinotecan, hydroxyurea, and paclitaxel. Molecular therapeutic strategies are also under development, such as tyrosine kinase inhibitors and angiogenesis inhibitors. Overall, the efficacy of chemotherapy for brain tumors remains modest in the majority of patients. This chapter will review the detailed pharmacology and clinical application of chemotherapy in brain tumor patients.

What Is Hereditary Breast Cancer

It is worth stating at the outset that the term hereditary breast cancer, while in widespread usage, is somewhat problematic. Hereditary implies that the propensity to disease in that individual has been inherited. Thus, the implication is that breast cancer can be dichotomized into those cases where susceptibility is inherited and those where it is not. This concept arose from consideration of cancers with a simpler genetic basis such as retinoblastoma and Wilm's tumor, which can be usefully categorized in this way (2,3). As we shall see, the situation is much more complex for breast cancer. There are many different susceptibility genes for breast cancer, and a substantial fraction (in fact the majority) of breast cancer cases occur in women who are predisposed in some way. It is also worth emphasizing here that there is no known pathologically distinct type of breast cancer that is hereditary (although certain pathological features are more common in BRCA1 carriers), so it is not...

Chemotherapy and Anti Epileptic Drug Interactions

ABSTRACT Patients with primary or metastatic brain tumors are often on medications that alter the pharmacokinetics of chemotherapeutic agents (CTAs). The most common drugs administered to neuro-oncology patients that can affect their chemotherapy are anti-epileptic drugs (AEDs). Oncology patients who require chemotherapy may also be on AEDs for pre-existing epilepsy, neuropathic pain or headaches. These enzyme-inducing anti-epiletic drugs (EIAEDs) induce the production and activity of hepatic enzymes that are responsible for the metabolism of many drugs. The most common mechanism for this effect is induction of the cytochrome p450 (CYP) system. The induction of CYP by EIAEDs can affect the metabolism and effectiveness of CTAs. When patients require chemotherapy, it is important to know, how their concomitant medications affect the pharamacokinetics of the chosen CTA, because significant under or overdosing can occur. It is also important that these interactions be taken into account...

Adjuvant Chemotherapy Preoperative Chemotherapy

There have been 11 trials that have tested the benefit of neoadjuvant chemotherapy followed by surgery with surgery alone (1-11). Most have used cisplatin and 5-fluorouracil (5-FU)-based regimens but are otherwise heterogeneous in design and outcome (Table 1). A systematic review of 11 of these studies, randomizing a total of 2051 patients, has been published in the Cochrane Library (12) (evidence level 1a). This meta-analysis found a survival advantage for neoadjuvant chemotherapy which becomes apparent from the third year 21 increase in three-year survival TABLE 1 Trails of Neoadjuvant Chemotherapy for Esophageal Cancer TABLE 1 Trails of Neoadjuvant Chemotherapy for Esophageal Cancer

Epidemiological Studies Of Familial Breast Cancer

Much of the impetus for breast cancer genetics has come from observations of families with extraordinary numbers of cases of the disease (5). These families have often been critical to the identification of the high-risk susceptibility genes. They are, however, less useful for evaluating the risks associated with a family history of breast cancer or with any particular gene, because they are not collected in a systematic fashion. To provide useful information for genetic counseling, risk estimates from epidemiological studies are required. Fortunately, many such studies have been conducted. Most are case-control studies that compare the family history of breast cancer in cases with the family history in controls. Other studies are cohort studies of relatives of breast cancer patients. These latter studies include those based on record linkage with national records, notably those done in Sweden, Iceland, and Utah, and they provide estimates that are free from any potential recall bias...

Postoperative Chemotherapy

The potential advantage of using postoperative therapy is that one can be relatively selective, based on pathological factors, in the patients who receive treatment, and there is no delay in definitive surgical therapy. However, the selection of only fit postoperative patients for clinical studies of postoperative treatment should lead one to be cautious in interpreting the applicability of such treatment to the general population, for example, excluding patients with R1 or R2 resections (microscopic and macroscopic residual disease, respectively) or those with prolonged postoperative complications. This potential bias is not present in trials of pre- or perioperative therapy. Indeed, patients randomized to receive chemotherapy before and after surgery show that less than 50 of the patients are able to receive full doses of chemotherapy following major upper GI surgery (1,15). The results of three Japanese randomized control trials have failed to show a benefit for postoperative...

Twin Studies and Bilateral Breast Cancer

In principle, the familial aggregation of breast cancer may be due either to genetic factors or to lifestyle or environmental factors that are shared among relatives. The latter possibility is unlikely in that no lifestyle risk factors that are sufficiently strong to materially affect familial aggregation of the disease have been identified. More formal evidence that familial aggregation has a genetic basis comes from twin studies. Based on an analysis of population-based twin registers from the Nordic studies, Lichtenstein et al. (23) found that the risk of breast cancer in the monozygotic (MZ) twins of cases was about twice as great as the risk in the dizygotic (DZ) twins. Using a particular multifactorial model, this study estimated that about 27 of the variation in breast cancer risk was genetic. This particular estimate should be viewed cautiously since it does depend on the model used and on how one defines the variation in breast cancer risk, but it does point to a substantial...

Practical Effects Of Aedchemotherapy Interactions

The potential for subtherapeutic chemotherapy dosing in patients on EIAEDs has affected clinical trial design for patients with malignant gliomas, and should also be taken into account in trials for patients with central nervous system metastases as well. Clinical trials for patients with brain tumors must stratify patients by the use or non-use of EIAEDs, and seek separate maximum tolerated doses for any CTA that might be metabolized by the CYP system 49,51,54 . In effect, there has to be a separate Phase I clinical trial in patients on EIAEDs, because the dose determined in Phase II trials done in patients who are not taking such agents is an inadequate estimate of the dose that will produce toxicity or effectiveness in patients on EIAEDs. This leads to a complicated accrual process for clinical trials for brain tumor patients. To find the proper dose in patients on EIAEDs, there must be one arm that dose escalates to find the MTD in patients on EIAEDs. At the same time, another arm...

Breast Cancer Susceptibility And Other Risk Factors

An important and largely unresolved question is the relationship between genetic and lifestyle risk factors for breast cancer. The combined analysis by the Collaborative Group examined the effect of several important risk factors on the familial risk of breast cancer, including parity, age at first full-term pregnancy, and ages at menarche and menopause. In each case, they found that the relative risks conferred by these risk factors were similar in women with and without a family history (1). These results imply that such risk factors can be assumed to multiply the familial risks of breast cancer (an assumption made in the Tyrer et al. and Gail models). It also suggests that such risk factors are largely independent of genotype. Whether this is true for specific susceptibility genes, in particular BRCA1 and BRCA2, is less clear however. Several studies have examined the effects of these risk factors in BRCA1 2 carriers but many of the results are contradictory, perhaps reflecting...

Models Of Breast Cancer Susceptibility

Several models have been developed to derive estimates of risk to women with a family history of breast cancer or to estimate the probability of carrying a mutation in the BRCA1 or BRCA2 gene. These models can be broadly categorized as empirical models and genetic models. Empirical models are based summarily on measures of family history, such as the number of affected relatives and other risk factors. Perhaps the most widely used model of this kind is the Gail model, which incorporates a variety of breast cancer risk factors in addition to the number of affected relatives (31). Such a model is useful in the general population context, for example, in selecting women for prevention trials but is less useful in high-risk families where the nuances of the family history cannot be captured well. Genetic models seek to model the familial aggregation of the disease in terms of the effects of specific genes or other familial risk factors. These models are developed from population-based...

Association of 16aHydroxylated Estrogens with Breast Cancer Risk

Mation of 16a-hydroxylated estrogen metabolites might be associated with increased risk of developing breast cancer. Their initial studies showed that 2- and 16-hydroxylation of estradiol was minimally affected by age and did not differ between premenopausal and post-menopausal women.129 However, when these enzymatic activities were compared between breast cancer patients (n 33) and matched controls (n 10), 16-hydroxylation was associated with increased risk of breast cancer, whereas the competing 2-hydroxylation pathway was either neutral or associated with decreased risk.135 The investigators suggested that the breast cancer patients had an increased extent of 16a-hydroxylation prior to the onset of the disease, unless the increase was a consequence of the cancer itself. In a subsequent study, using a murine mammary tumor model, Bradlow and associates136 reported a close correlation between the extent of tumor incidence and 16a-hydroxylation, but not 2-hydroxylation, of estra-diol....

Other Breast Cancer Genes High Risk Breast Cancer Genes

Breast cancer is involved in two other hereditary syndromes, for which causative genes have been identified. The Li-Fraumeni syndrome is characterized by childhood sarcoma and early-onset breast cancer, brain tumors, and a variety of other cancers. Most families with Li-Fraumeni syndrome appear to be due to germline mutations in the TP53 gene. TP53 mutations confer a very high risk of breast cancer (approaching 100 by age 50) but are much rarer than BRCA1 or BRCA2 mutations (45,46). Cowden's syndrome is a rare syndrome characterized by hamartomas, multiple hamartomas, thyroid cancer, and mucocutaneous lesions and is due to germline mutations in PTEN (61). The risk of breast cancer associated with Cowden's syndrome has not been well estimated, but it is of the order of 30 to 50 lifetime (47).

Low Risk Breast Cancer Genes

A growing list of genes is associated with more moderate risks of breast cancer. The first such gene to be identified was ATM. Mutations in this gene cause the recessive condition Ataxia-Telangiectasia (A-T) (62). Studies dating back over 30 years have suggested that relatives of A-T patients were at increased risk of breast (and perhaps other) cancer (63). This was long regarded as controversial because the studies were small. However, more recent national cohort studies, and direct studies of ATM mutations in breast cancer families and controls, have confirmed that ATM mutations confer an approximately twofold risk of breast cancer (with perhaps a higher relative risk at young ages) (64-67). Another important low-risk susceptibility gene is CHEK2, another DNA repair gene that acts downstream of ATM. Mutations in this gene were first identified in patients with a family history reminiscent of Li-Fraumeni syndrome, and it was therefore suspected that this was another high-risk...

Contribution Of Known Genes To Breast Cancer Incidence

The frequency of BRCA1 and BRCA2 mutations in breast cancer cases has been estimated by a number of studies. By pooling data from a number of population-based studies, Thompson and Easton (78) estimated that the prevalences of BRCA1 and BRCA2 mutations among breast cancer patients diagnosed below their mid-30s were approximately 4.6 and 3.5 , respectively. In contrast, the Anglian Breast Cancer Study (the largest population-based study to date) found the prevalences among cases diagnosed between 45 and 54 years of age to be just 0.3 and 1.0 , respectively (79). These studies underestimate the true prevalence of mutations because studies use methods that are not fully sensitive. Indeed, the fraction of mutations that are detected by such studies is somewhat uncertain because some variants in BRCA1 and BRCA2 are of uncertain significance and may or may not be associated with risk. Nevertheless, overall fraction of breast cancer patients in outbred populations carrying BRCA1 and BRCA2...

Chemotherapy Resistance

As described in Chapter 8 of this book, the molecular changes that occur during the formation and progression of malignant gliomas vary, leading to the phenotypic and genotypic heterogeneity demonstrated by numerous investigators 1-7 . Chemotherapy resistance can come about in a number of ways. The process by which a tumor cell becomes resistant to a particular chemotherapeutic agent is a function of the type of therapy and the phenotype of the particular tumor cell. The fact that some tumors do not respond to chemotherapy, and others rapidly recur and are often refractory to further therapy with the same or similar agents suggests that within the heterogeneous primary tumor there are cells that are intrinsically resistant to therapy. This has been demonstrated by Shapiro and coworkers who showed that glioma cells selected for resistance to clinically achievable concentrations (blood plasma levels) of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) in vitro, or in vivo through the use of...

Adjuvant Chemotherapy

Adjuvant cytotoxic chemotherapy for gastric cancer has been studied over the last 40 years. This approach has demonstrated its usefulness in other diseases such as colon and breast cancers. Gastric cancer would seem to be a natural disease to test adjuvant chemotherapy, as there are a number of significantly active advanced disease chemotherapy programs that demonstrated activity in the treatment of disseminated stomach cancer. A variety of combination chemotherapy regimens have been widely used in the palliative management of patients with gastric cancer (11-19). Over the last decade, there has been interest in the use of prolonged infusion of 5-fluorouracil (FU) as a part of the combination chemotherapy treatment for stomach cancer. Cookes et al. (12) used continuous infusion 5-FU as a major component of a neoadjuvant program and Webb et al. (17) reported important results with a combination regimen designated combination of epirubicin, cisplatin, and 5-fluorouracil

Tyrercuzick International Breast Cancer Intervention Study

This is the most recently developed of the breast cancer risk assessment models (32). It was developed using published data regarding BRCA1 and BRCA2 mutation carrier frequencies from a study of mother-daughter pairs (33) and penetrance estimates from the Breast Cancer Linkage Consortium (34) rather than one specific dataset. There are two parts to the model's calculations a genetic part and a personal risk factors part. Like the BRCAPRO model, International Breast Cancer Intervention Study (IBIS) uses Bayesian calculations as a basis for the genetic part of the model. The Bayesian variables used are BRCA1 mutation, BRCA2 mutation, and other genetic risk factor, an as yet unknown low-penetrance gene that is assumed to follow an autosomal-dominant inheritance pattern. Like BOADICEA, IBIS can incorporate exact family relationships and is not restricted to a certain number of first- and second-degree relatives in order to make its assessment. It is also capable of dealing with bilateral...

Reducing Chemotherapy Sideeffects

Results from a small, open, prospective study of subjects with advanced gastric cancer suggests that intravenous administration of a polysaccharide fraction isolated from E. purpurea may be effective in reducing chemotherapy-induced leucopenia (Melchart et al 2002). Test subjects had advanced gastric cancer and were undergoing palliative chemotherapy with etoposide, leucovorin and 5-fluorouracil. The median number of leukocytes 14-16 days after chemotherapy was 3630 microL (range 1470-5770) in the patients receiving herbal treatment compared with 2370 microL (870-3950) in the patients of the historical control group (P 0.01 5).

Molecular Chemotherapy With rAAV

Although a majority of both preclinical and clinical gene therapy studies using molecular chemotherapy approaches have been conducted with recombinant adenoviral Consideration of molecular chemotherapy strategies for selective killing of tumor cells suggests that long-term expression of transgenes is not an imminent requirement hence, AAV-based vectors are less preferred over adenoviral vectors. Further, the efficacy of adenoviral infection in different tumor cells has been reported to be significantly higher than many other available gene therapy vectors. However, it has recently been reported that the efficiency of rAAV transduction of primary tumor material, derived from malignant melanoma and ovarian carcinoma, is significantly higher (> 90 ) than that seen in established tumor cells of the same derivation in culture (86). This observation suggests that it is possible to utilize rAAV in direct targeting of tumor cells for an effective killing by approaches such as molecular...

Apoptosis Pathways and Chemotherapy

ABSTRACT Tumor cell death is the ultimate goal of chemotherapy. In particular, the induction of apoptosis has been suggested as a strategy for efficient and selective elimination of tumor cells. However, in malignant gliomas, the most common malignant intrinsic brain tumors, there is little evidence that the currently available chemotherapeu-tic drugs mediate their effects via induction of apoptosis, with the possible exception of anaplastic oligodendrogliomas which often show striking tumor regression on neuroimaging. Nevertheless, the induction of apoptosis plays a major conceptual role in the majority of novel experimental approaches to brain tumors.

Estrogens Aromatase and Risk of Breast Cancer

These observations provide the rationale for the use of endocrine therapy as preventative measures against BC in women with high risk ofthe disease. Four trials using tamoxifen have been published (55-57), as has a fifth trial using raloxifene (58). Although there are differences among studies, a recent metaanalysis of the tamoxifen trials indicated that results were compatible with a 42 reduction in short term incidence of breast cancer with tamoxifen use (59).

Modifications Of Technique For Postchemotherapy Dissection

The technique for RPLND for postchemotherapy tumor is an extension of the same techniques used for primary RPLND (see also Chapter 11). The subtraction concept holds in postchemotherapy disease, and the operation remains essentially a vascular procedure. The great vessels are mobilized from the tumor and posterior body wall by dividing lumbar arteries and veins. The ureters and renal vascular structures are similarly dissected away from the retroperitoneal lymphatics. After chemotherapy, residual tumor is frequently adherent to retroperi-toneal structures such as the aorta and the vena cava. Hence, surgeons embarking upon postchemotherapy RPLND should have at their disposal a full array of vascular techniques and capabilities (Figure 10-21). It is interesting that the therapeutic capability of RPLND is retained in cases of disease after chemotherapy. The surgical removal of tumor after chemotherapy is curative in 30 to 80 of cases, depending on the clinical situation and the pathology...

Postchemotherapy Histology

The histology of a residual mass after initial chemotherapy varies substantially in different series. Steyerberg and colleagues5 reviewed 996 postchemo-therapy resections from 19 studies published between 1983 and 1990. Residual cancer was present in an average of 16 of cases, mature teratoma was in 36 of cases, and fibrotic and or necrotic tissue was in 48 . In resected lung lesions, necrosis was found more often (57 of cases) and teratoma was found less frequently (27 of cases). The same author6 reviewed six studies published between 1986 and 1993 that included a total of 556 patients undergoing postchemotherapy retroperitoneal lymph node dissection (RPLND) 13 of patients had residual cancer, 42 had mature teratoma, and 45 had fibrosis-necrosis. Steyerberg and colleagues7 also found a higher frequency of residual necrosis in patients treated with regimens containing etoposide (as I and my colleagues had predicted in 1985).8 Last, but not least, about 50 of patients undergoing...

Chemotherapy In Practice

From chemotherapy has emerged in terms of disease progression, overall survival, and quality of life. Several randomized trials have revealed chemotherapy to be valuable when compared to best supportive care (BSC) or delayed chemotherapy (4,5). In 2000, the Colorectal Cancer Collaborative Group (6) reported on a meta-analysis examining individual patient data (866 patients) and published summary statistics from 13 randomized controlled trials comparing palliative chemotherapy with supportive care reported between 1983 and 1998 (total patients 1365). They examined survival, disease progression, quality of life, and toxicity. They found that palliative chemotherapy was associated with a 35 reduction in the risk of death (95 Confidence Intervals (CIs) 24-44 ) translating into an absolute survival benefit of 16 at 6 and 12 months, and an improvement in median survival of 3.7 months. Similarly, a systematic review of results of chemotherapy in colorectal cancer was performed by the Swedish...

Breast Cancer Risk In Males

Familial clustering of female breast cancer was demonstrated as early as 1926 (81), and epidemiological studies have shown that although both men and women with breast cancer are more likely to have family histories in first-degree relatives than unaffected individuals, men with breast cancer were even more likely to have a first-degree relative with ovarian cancer than affected women (82,83). It is noteworthy that initial linkage studies of BRCA1 did not reveal an association with male breast cancer (14,84). Linkage studies for BRCA2, on the other hand, did contain male breast cancer cases (16). Germline analyses of 50 men affected with breast cancer unselected for family history revealed that 14 of these men carried a BRCA2 mutation (85). Easton et al. (52), in a study of two large kindreds linked to BRCA2, estimated the cumulative risk of breast cancer in male carriers to be 6.3 by the age of 70 years. In an analysis of 164 BRCA2 kindreds, a similar estimate for cumulative risk...

Further Chemotherapy For Radically Resected Residual Cancer

The presence of viable cancer cells in completely resected residual masses carries the worst prognosis when compared with the presence of mature teratoma or necrosis alone (see also Chapter 16).26,33 Since the study by Einhorn and colleagues,37 which reported a dismal outcome for all 18 patients with residual cancer at postchemotherapy surgery who received no further therapy, many investigators have opted for the routine use of postoperative adjuvant chemotherapy.2,5,9,11,12,24,26,33 No compelling evidence has existed to confirm whether adjuvant chemotherapy for consolidation is justified in this setting. Thus, my colleagues and I recently challenged this approach as we found no difference in the 5-year survival in a retrospective study of 49 evaluable patients who were treated (24 patients) or not treated (25 patients) with adjuvant chemotherapy following complete resection of residual cancer after first-line (30 patients) or salvage (19 patients) chemotherapy.38,39 An international...

Modifiers Of Penetrance And Breast Cancer Genes Other Than Brca

Several studies have noted an increased penetrance for BRCA1 2 in more recent birth cohorts. The NYBCS (9) confirmed Narod's earlier observation of a significant increase in breast cancer risk by the age of 50 years in birth cohorts after 1940 (67 after 1940, 24 before 1940) (39). Ovarian cancer risk did not differ by birth cohort. This increase in incidence for BRCA1 2 mutation carriers parallels an increase in breast cancer in the general U.S. population over that period (37). Antoniou et al. (61) analyzed the results of 22 studies in which cases were unselected for family history. The RR for breast cancer among BRCA1 2 mutation carriers in the post-1960 birth cohorts was two to three times the RR in the preceding four decades. A study of Austrian BRCA1 mutation-positive women found that those from birth cohorts after 1958 had a significantly higher incidence of breast cancer by 40 years of age than those from earlier birth cohorts 46 versus 27 , respectively (89). Finally,...

Neoadjuvant Chemotherapy

Disease that is felt to be inoperable initially may still be rendered potentially operable by the use of the newer chemotherapy agents with their improved rates of response. One of the first reports (38) investigated chronomodulated chemotherapy in unresectable liver metastases. They reported a trial in which 53 of 330 patients initially deemed to have unresectable liver disease (due to location, large size, multinodular lesions, or extrahepatic disease) were downstaged with systemic, chronomodulated chemotherapy using 5-flurorouracil, folinic acid, and oxaliplatin to the point at which operation could be performed. The cumulative three- and five-year survival rates were 54 and 40 . In 15 cases, hepatic recurrence amenable to repeat surgery occurred. A larger series reported by the same group (37) revealed a 13.5 rate of conversion from inoperable to operable with a potential for cure by the use of neoadjuvant therapy. Adam and coworkers treated 701 patients with unresectable...

Intrahepatic Chemotherapy

The rationale for administering intrahepatic arterial chemotherapy is that by delivering chemotherapy directly to the target organ, high levels of drug will reach the metastatic lesions. As 5-FU undergoes arterial extraction at first pass the concentrations will be far greater (up to 100 times) than that obtained with intravenous administration. This will be of particular benefit due to the steep dose-response curve seen with cytotoxic drugs. However, the procedure is complex and potentially dangerous, requiring insertion of an intra-arterial catheter. The meta-analysis Group in Cancer carried out a meta-analysis of early trials of intrahe-patic arterial (IHA) chemotherapy, using data from individual patients, reviewing response rates and survival rates (39). Their report revealed that IHA treatment gave improved objective tumor response rates when compared to intravenous therapy (IHA 41 vs. 14 IV or 0.25, 95 CI 0.16-0.40, p < 0.0001) but a statistically significant survival...

Recommendations For Chemotherapy

The chemotherapy regimen developed at Indiana University should be considered the standard of care for patients with good-prognosis NSGCT. This recommendation is based on successful results with this program in a number of randomized clinical trials comparing it to other treatment programs.7,64,66,70,77,81 The regimen has been used successfully in centers Table 13-4. PATIENT GROUPS WITH NONSEMINOMA ELIGIBLE FOR GOOD-PROGNOSIS CHEMOTHERAPY REGIMENS 2. Patients with low-bulk stage II disease managed in centers (generally outside North America) that select primary chemotherapy rather than retroperitoneal lymph node dissection for this group. These patients should also fulfill the IGCCC criteria for good prognosis. The recent MRC EORTC trial demonstrated that the same doses of chemotherapy could be delivered over 3 days without compromising efficacy.66 Toxicity and quality-of-life data indicate little difference between the 3- and 5-day schedule, with increased nausea and vomiting...

Management of Nonseminomatous Testicular Cancer Chemotherapy for Poor Risk Patients Standard Dose Therapy

And actinomycin D, cyclophosphamide, and etopo-side (ACE) was devised in 1977.4 The concept behind this essentially alternating schedule of chemotherapy was to alternate the POMB schedule, which was less myelosuppressive than the ACE schedule, and to increase the dose intensity by having a schedule of every two weeks rather than the more commonly used schedule of every three weeks of chemotherapy. Although the POMB ACE schedule contains seven drugs, the total cumulative dose of each individual drug is less than that in schedules such as PVB and such as bleomycin, etoposide, and cisplatin (BEP)5 because the component schedules essentially alternate. The experience of the past 25 years of treating these patients is that durable remissions are maximized if the chemotherapy contains a minimum of 300 mg m2 of cisplatin and that the proportion of remissions probably increases with the total dose of etoposide administered.*

Commonly Used Chemotherapy Regimens For Metastatic Germ Cell Tumor

We try for normalization of the main two serum tumor markers hCG and AFP and continue alternating POMB and ACE until the patient has been in tumor marker remission for approximately 4 weeks (Figure 14-1). In common with other centers, as confidence in the stability of the complete remissions obtained with chemotherapy has increased, we have shortened the total duration of treatment. It should be noted that we have modified our current approach to this regimen, shortening the duration of treatment by omitting the second 24-hour infusion of bleomycin. two courses usually are sufficient to reduce the organ failure so that the full POMB ACE schedule can be started as described above. This approach allows chemotherapy to be delivered to patients who would otherwise get major toxicity if they received either BEP in full dose or POMB in full dose. In our last analysis of the patients treated with POMB ACE chemotherapy for metastatic NSGCT between 1977 and 1995,16...

PTEN and Cowden Syndrome Prevention Of Breast Cancer In Cs

Some women with CS consider prophylactic mastectomy, especially if breast tissue is dense, making surveillance difficult, or if repeated breast biopsies have been necessary. Prophylactic mastectomy reduces the risk of breast cancer by 90 in women at high risk (63), although no studies have specifically addressed this intervention in patients with CS. There is no direct evidence to support the routine use of agents such as tamoxifen or raloxifene in individuals with CS to reduce the risk of developing breast cancer. Physicians should discuss the limitations of the evidence and the risks and benefits of chemoprophylaxis with each individual. In addition, the clinician must discuss the increased risk of endometrial cancer associated with tamoxifen use in this population that is already at increased risk for this malignancy.

Evidence For Inherited Predisposition To Breast Cancer

Mutations in BRCA1 or BRCA2 account for the majority of families with multiple cases of either breast cancer alone or breast and ovarian Figure 7.1 Familial breast cancer. Individuals were diagnosed with primary breast cancer at the ages shown. A familial pattern such as this is strongly suggestive of autosomal dominant predisposition by a single predisposing gene. These cases proved to be due to mutation in BRCA1. Figure 7.1 Familial breast cancer. Individuals were diagnosed with primary breast cancer at the ages shown. A familial pattern such as this is strongly suggestive of autosomal dominant predisposition by a single predisposing gene. These cases proved to be due to mutation in BRCA1. cancer. It is perhaps surprising that they account for only a small part of the excess familial clustering of these cancers in the population as a whole. The overall extent of familial clustering can be measured by ascertaining a large series of breast cancer cases from the population and...

Intra Arterial Chemotherapy

ABSTRACT Intra-arterial (IA) chemotherapy is a form of regional delivery to brain tumors, designed to enhance the intra-tumoral concentrations of a given drug, in comparison to the intravenous route. Drugs that are likely to be benefit from IA delivery have a rapid systemic clearance and include carmustine and other nitrosoureas, cisplatin, carboplatin, etopo-side, and methotrexate. Clinical studies have demonstrated activity of IA chemotherapy approaches for low- and high-grade gliomas, cerebral lymphoma, and brain metastases. However, a survival benefit for IA drug delivery, in comparison to intravenous administration, has not been proven in phase III trials. The technique is limited by the potential for significant vascular and neurological toxicity, including visual loss, stroke, and leukoencephalopathy. More recent studies suggest that toxicity can be reduced by the use of carboplatin- and methotrex-ate-based regimens. Further clinical studies will be needed to determine the...

Singleagent Ia Chemotherapy Of Newly Diagnosed Gliomas

The experience with IA chemotherapy has been extensive in patients with gliomas, both at initial diagnosis and at recurrence 4-7 . In patients with newly diagnosed tumors, IA chemotherapy has usually been administered just prior to, or in combination with, external beam irradiation. Single agents that have been used in this context include carmustine, nimustine, HeCNU, cisplatin, and 5-fluorouracil (see Table 17.1). The median time to progression (TTP) of newly diagnosed patients receiving single-agent IA chemotherapy has ranged from 12 to 32 weeks, with a median survival of approximately 1 year (range of 32-73 weeks). The nitrosourea class of drugs, especially carmustine, have been used most often in this group of patients. Initial experience began with single-agent carmustine in the 1980s, with doses ranging from 150 to 300 mg m2 IA every 6-8 weeks 31-34 . Greenberg and colleagues treated twelve patients using an intra-carotid approach and noted a 75 per cent response rate, with a...

Combination Ia Chemotherapy Of Newly Diagnosed Gliomas

Combination chemotherapy has also been attempted in patients with newly diagnosed gliomas, in which one or more drugs are administered via the IA route (see Table 17.2) 4-7 . The median TTP of combination IA regimens has ranged from 33 weeks to greater than 50 weeks in several studies. Similar to the reports of single-agent IA chemotherapy, the median survival for combination regimens is approximately one year, with a range of 40-228 weeks. The initial experience with combination IA treatment involved carmustine and was reported in the early 1980s by West and colleagues 46 . They administered intra-carotid carmustine (100 mg m2) in combination with PCV (procarbazine, lomustine, vincristine) over four cycles to a cohort of 15 patients, before the onset of irradiation. There was a 75 per cent overall response rate however, the median survival was only 50 weeks. Seizure activity was documented in 7 per cent of the cohort in association with IA carmustine. Similar results were noted in a...

Rationale For Hepatic Arterial Infusion Chemotherapy

Until recently, the pyrimidine analog 5-fluorouracil (5-FU) had been the palliative standard for patients with metastatic colorectal cancer. It resulted in response rates of approximately 20 (12). The addition of leucovorin (LV) to 5-FU results in a higher response rate without significant improvement in survival (13). Changing the method of administration of 5-FU from bolus to continuous infusion can modestly improve response rates, without significant impact on survival (12). Thus, the poor response to 5-FU-based system chemotherapy provided the initial impetus for developing alternative approaches to the management of metastatic colorectal cancer. Regional chemotherapy by HAI is based on sound physiological and pharmacological grounds. First, liver metastases that grow beyond 2 to 3 mm are dependent on the hepatic artery for vascularization, whereas normal liver tissues are perfused by the portal vein (14,15). Second, HAI therapy allows delivery of increased local concentration of...

Technical Aspects Of Hepatic Arterial Infusion Chemotherapy The Totally Implantable Pump

Early experience with regional chemotherapy involves the use of a percutaneously placed catheter attached to an external infusion device. Treatment required hospitalization and was often associated with a high incidence of complications such as catheter dislodgement, bleeding, thrombosis, and infection (19). Another approach is the implanted port which allows repeated access to the arterial system as well as attachment to an external portable pump for ambulatory treatment. However, these ports still had a high failure rate, particularly with regard to hepatic arterial thrombosis (20). The development of a totally implantable arterial-infusion pump in the late 1970s marked the modern era of HAI therapy (21). Slightly larger than a pacemaker, these pumps can provide a constant slow infusion of chemotherapy at infusion volumes of 30 to 50 mL. The constant flow of fluid is driven by the pressure generated from a self-charging system of fluorocarbon liquid present in the sealed chamber of...

Principles Of Chemotherapy For Central Nervous System Malignancies

Treatment of high-grade gliomas (HGG) with systemic chemotherapy poses challenges unique to brain tumors. Foremost is the blood-brain barrier (BBB) which impairs delivery of adequate concentrations of most chemotherapeutic agents to the tumor. The BBB is maintained by interaction between astrocytes and endothelial cells that protect the brain from the foreign and undesirable molecules. This membrane lacks intercellular fenestrations, has high-electrical resistance and low-ionic permeability rendering it relatively impermeable to many water-soluble compounds (1). Most cytotoxic drugs traverse the BBB by passive diffusion while some use specific endothelial cell transport mechanisms to gain access to the central nervous system (CNS). Gadolinium enhancement, however, most likely signifies disruption of the BBB that may allow access of chemotherapeutic agents although the degree of penetration is unknown. To cross the BBB, chemotherapy agents administered systemically must be less than...

Combination Ia Chemotherapy Of Recurrent Gliomas

IA chemotherapy approaches utilizing multiple IA agents or the combination of an IA agent with an oral or intravenous drug have also been extensively reported in the literature (see Table 17.4). The majority of regimens have focused on the use of IA carmustine in combination with other drugs. The initial experience was reported by West and colleagues, when they utilized a regimen of IA carmustine (100 mg m2) plus PCV for nine patients with recurrent malignant gliomas 46 . The objective response rate was 22 per cent, with a median survival of 20 weeks. Neurotoxicity was similar to that reported above for IA carmustine. Another report combined IA carmustine (100-125 mg m2), IA cisplatin (60 mg m2), and IA teniposide (VM-26 150-175 mg m2) in a series of 19 patients 68 . The response rate was 68 per cent, with another 6 per cent stabilizing while on treatment. However, the overall median TTP was only 15 weeks. The regimen was limited by retinal toxicity (19 per cent), hearing loss (5 per...

Ia Chemotherapy For Primary Cns Lymphoma

Primary CNS lymphoma (PCNSL) has been shown to be a chemosensitive tumor, and can respond well to multi-agent chemotherapy, including methotrexate-based or carboplatin-based IA regimens 5,6,78,79 . In the majority of cases, IA chemotherapy for PCNSL is used in combination with IA mannitol and blood-brain barrier disruption, to further improve delivery of chemotherapy drugs to tumor cells 5,79,80 . Many patients are also treated ''up-front'', before any form of irradiation. The median survival with this approach ranges from 42 to 48 months, with an acceptable level of systemic and neurological toxicity. For an in-depth review of this topic, see Chapter 18.

Use in Increasing Chemotherapy Dose Intensity

The guidelines note that there is an apparent steep dose-response curve in preclinical studies but that retrospective analyses of dose-delivered intensity in the clinic suggest that bias may have been introduced. Some of the randomized trials compared lower than standard-dose chemotherapy with standard-dose chemotherapy. In the late 1990s, trials increasing dose intensity above standard levels were not shown to improve survival. The recommendation was that outside the setting of clinical trials, the use of CSFs to increase dose intensity was not justified.

Genetic models of breast cancer susceptibility

It is likely that the inheritance of most common cancers is polygenic. Breast cancer, like other common cancers, exhibits some degree of familial clustering, with disease being approximately twice as common in first-degree relatives of cases (Amundadottir et al., 2004 Collaborative Group on Hormonal Factors in Breast Cancer, 2001). The higher rate of most cancers in the monozygotic twins of cases than in dizygotic twins or siblings suggests that most of the familial clustering is the result of genetic variation rather than lifestyle or environmental factors (Lichtenstein et al., 2000 Peto and Mack, 2000). Further evidence for the relative importance of genetic factors comes from the observation that more distant relatives of a case (i.e. those beyond the nuclear family) are also at increased risk of disease even though they would be expected to share environmental or lifestyle factors to a lesser degree (Amundadottir et al., 2004). Furthermore, the magnitude of the risks in distant...

Results Of Randomized Trials Comparing Hepatic Arterial Infusion With Systemic Chemotherapy In Patients With

Early phase II trials employing HAI FUDR given mainly by an external pump have reported encouraging response rates of 29 to 83 (27-31). This sets the stage for prospective, randomized phase III comparison between HAI therapy and systemic chemotherapy or best supportive care. Seven randomized studies were reported between 1987 and 1994 (Table 1) (32-38). One major conclusion that one can draw from these studies is that HAI therapy has resulted in higher tumor response rates than systemic chemotherapy. Since most individual trials are small and therefore not adequately powered to detect a small difference in overall survival (OS), two meta-analyses have been performed in order to determine whether HAI therapy confers a survival benefit over systemic chemotherapy (Table 1) (39,40). The Meta-analysis Group in Cancer included individual patient data from six of seven randomized studies (39). The Northern California Oncology Group (NCOG) trial (34) (representing 143 patients) was excluded...

Toxicity Of Ia Chemotherapy

The most common toxicity of patients receiving IA chemotherapy is ipsilateral periorbital erythralgia and visual loss, which in many cases can be dose-limiting 4-7,85,86 . Ophthalmological examination of affected patients suggests a toxic retinal vasculitis, with retinal arteriolar narrowing, hemorrhages, nerve fiber layer infarctions, and arterial phase leaks 31 . An anterior ischemic optic neuropathy may also occur in some patients 58 . The incidence of visual loss among the cases cited in this review was approximately 10-12 per cent for patients receiving a nitrosurea-based regimen and 5-8 per cent for those receiving a cisplatin-based regimen. Intra-arterial PCNU and HeCNU appear to have a higher incidence of visual loss than carmustine. Overall, the potential for visual loss appears to be greater for patients receiving IA carmustine and other nitrosoureas than for patients receiving cisplatin, carboplatin, or methotrexate. Visual loss is less likely when patients Hearing loss is...

Blood Brain Barrier Disruption Chemotherapy

ABSTRACT The goal of chemotherapy administered in conjunction with blood-brain barrier disruption (BBBD) is maximizing drug delivery to the brain, while preserving neurocognitive function and minimizing systemic toxicity. Translational blood-brain barrier (BBB) pre-clinical and clinical studies at Oregon Health & Science University (OHSU) evaluate the toxicity and antitumor efficacy of chemothera-peutics, chemoprotectants, and monoclonal antibodies (mAbs) as well as novel therapeutics and imaging agents. A current program focus is thiol chemo-protection against the hearing and bone marrow toxicity that is caused by platinum chemotherapy. Thiols may permit increased dose intensity of agents administered in conjunction with BBBD. In the clinic, BBBD has shown promising results in chemo-sensitive brain tumors such as primary central nervous system lymphoma (PCNSL) and offers a new strategy for global delivery of chemotherapy to tumors, such as anaplastic oligodendroglioma and central...

Preirradiation Or Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy refers to treatment given at diagnosis before other modalities such as radiation. It has several potential advantages. First, neoadjuvant chemotherapy allows early treatment of the infiltrating tumor cells that may be at or beyond the border of the radiation field. Second, neoadjuvant chemotherapy allows true assessment of the efficacy of the chemotherapy. Such information is important at the time of tumor progression in deciding whether treatment with the same regimen might be helpful. Finally, new agents are most effectively screened for activity in this setting (51). If a given agent has no efficacy in newly diagnosed patients, it will not help patients with recurrent tumors, and further testing in these patients can be avoided. The risk of tumor progression during chemotherapy, however, is significant, particularly for patients with GBM. The neoadjuvant trial design for patients with HGG requires very close monitoring. Most such trials appropriately...

Finding lowpenetrance breast cancer alleles

And gene-environment interactions in the etiology of cancer with more than 20 cohorts participating (www.epi.grants.cancer.gov Consortia cohort.html). Advances in our understanding of the nature of human genetic variation coupled to new genotyping technologies raise the hope that empirical whole-genome approaches will bring similar successes to those achieved by empirical family-based linkage studies. Empirical association studies to scan 60 of the genome for breast cancer susceptibility genes are currently in progress, and similar studies of other cancers are likely in the near future. The association studies design relies on the ''common disease common variant'' hypothesis. It is, however, equally possible that much of the variation in cancer risk is due to rarer alleles. Indeed, virtually all susceptibility alleles identified to date have frequencies of less than 1 . These include both high-penetrance mutations, but also low-penetrance variants in ATM and CHEK2 that predispose to...

Expression in Breast Cancer

Situation analogous to the regulation of promoter II by FSH in the ovary. Indeed, it appears that in breast cancer cell lines an additional CRE, located within promoter 1.3 ( 66 59), contributes to cAMP-induced transcription from promoters II and I.3.59 This CRE-like sequence overlaps a binding site for the zinc-finger tran-scriptional factor Snail (SnaH), which was identified by yeast one-hybrid screen using the CRE as a probe.60 SnaH acts as a repressor of promoter 1.3 activity and was expressed at higher levels in normal breast epithelial cell and stro-mal fibroblast cell lines than in breast cancer cell lines.60 Thus, downregulation of SnaH in stro-mal cells adjacent to malignant breast epithelial cells might contribute to induction of aromatase through promoter I.3. Figure 8.5 Proposed regulation of aromatase gene expression in breast adipose tissue from cancer-free individuals and from those with breast cancer. In the former case, expression is stimulated primarily by class I...

Frequency Of Germ Line P53 Mutations In Breast Cancer

The earliest publications on LFS focused on childhood soft tissue sarcoma and breast cancer (1,2), with most ascertainment through the less common childhood sarcomas. However, with the opportunity to test for a specific gene, focus shifted to the far more common, and often familial, breast cancer. The question was, what fraction of breast cancer, young, familial, bilateral, or associated with other cancers, might be attributable to germ line p53 mutations A flurry of papers appeared in the literature from the early 1990s, studying different clinical groups of breast cancer and using various techniques to identify mutations. However, few p53 germ line mutations were observed using criteria of familial breast cancer (40-46), bilateral breast cancer (47), age at breast cancer diagnosis less than 31, 35, or 40 years (48-50), breast cancer associated with a personal or family history of multiple primary tumors (51), or breast cancer associated with no more than one sarcoma in the index...

Combining Hepatic Arterial Infusion Therapy With Contemporary Systemic Chemotherapy

The combination of HAI FUDR with systemic oxaliplatin has also been evaluated in a phase I study where patients were assigned to receive two different oxaliplatin-containing systemic regimens (Table 4) (74). In Group A, patients receive HAI FUDR in combination with escalating doses of systemic oxaliplatin and irinotecan. In group B, patients receive HAI FUDR plus systemic oxaliplatin at 100 mg m2, LV at 400 mg m2, and escalating doses of continuous infusion of 5-FU. Systemic treatment was given every two weeks. Sixty-nine percent of the 36 patients were previously treated with irinotecan. An impressive 90 (Group A) and 89 (Group B) response rates were obtained (74). In Group A, seven of 21 patients were able to undergo liver resection, and two patients had no remaining tumor. The MTD for Group A was oxaliplatin 100 mg m2 and irinotecan 150 mg m2, not dissimilar to the recommended dose of oxaliplatin 85 mg m2 and irinotecan 200 mg m2 when given without HAI therapy. The MTD of 5-FU in...

Penetrance For Breast Cancer In P53 Mutation Carriers

Overall data from the IARC TP53 Database (14) confirm findings of smaller series that breast cancer is the most common cancer in LFS, accounting for about 25 to 30 of all cancers. For p53 mutation carriers the median age of breast cancer onset is 33 years, significantly earlier than for non-p53 LFS at 42.5 years. To date no genotype-phenotype correlation, that is, no association of specific p53 mutations by structural or functional domain, or by mutation type, has been observed for breast cancer overall however, breast cancer median age of onset was significantly younger in those with mutations in the DNA-binding domain (average age 32 years) as compared with missense mutations not in the DNA-binding domain (average age 42 years) age of onset for those with inactivating or likely null mutations was similar to that for mutations in the DNA-binding domain (median age 33 years) (14). This is in contrast to previous findings (57) of a higher incidence and earlier onset of breast cancer in...

Risk Factors for Chemotherapy Induced Febrile Neutropenia

Cytokines reset the thermoregulatory center in the hypothalamus to retain heat and allow the core temperature of the body to increase. Mononuclear phagocytes are the principle producers of the endogenous cytokines that cause fever and are much less affected by chemotherapy than neutrophils. Therefore, fever is reliable as a marker of infection in patients receiving chemotherapy, including neutropenic patients. In a review of the risk of FN among patients with intermediate-grade NHL receiving cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy, Lyman and coworkers (5,6) identified several factors associated with an increased risk of neu-tropenia-related complications. Data for this study came from 577 patients and 224 occurrences of FN in 12 community and academic oncology practices. Age > 65 yr (p 0.001), significant cardiovascular or renal disease (p 0.02), baseline hemoglobin concentration < 12 g dL (p 0.018), and administration of > 80 planned dose...

Treatment Of Chemotherapyinduced Febrile Neutropenia

The treatment of patients with chemotherapy-induced FN is multifactorial and includes not only antibiotic and CSF therapy but also supportive measures. Observational vigilance is an important aspect in the care of patients with chemotherapy-induced neutropenia there is no substitute for frequent observation and examination, particularly of the oropharynx, chest, and abdominal and perirectal areas. Frequent blood cell counts, blood cultures, and culture and examination of exudates and other bodily fluids in patients with fever remain the mainstay of good medical care. In addition to good skin care and oral hygiene, every effort should be made to maintain good functional status through nutritional support and exercise. Patients with cancer should be encouraged to decrease or eliminate smoking and maintain their immunization status, including influenza immunizations. Education of the patient and family, as observers of health status, is also important, particularly to recognize the...

Breast Cancer As A First Or Subsequent Cancer In

Not only is breast cancer the most common cancer observed in LFS, it plays a major role in subsequent cancers. In the Hisada et al. (71) series, 200 LFS patients had at least one cancer, including 104 females and 96 males among 30 patients who developed one or more additional cancers, 19 (63 ) were in females. The 19 females who had multiple primary tumors experienced a total of 46 cancers (original plus subsequent), with breast cancer accounting for 26. Forty-five of the original tumors were female breast, and 10 of those patients developed at least one additional tumor, including eight with an additional breast cancer. Breast cancer also accounted for 5 6 (83 ) of second cancers in those with an initial sarcoma (the other common original tumor). These data overall suggest an extremely high probability of breast cancer in LFS females, most of which occur before age 45, with a remarkably high probability of a second breast cancer. In Hwang et al. (58), the cumulative risk of female...

Radiation And Chemotherapy Risks

Most series of LFS families, as well as case reports, have noted not only the high risk of multiple primary tumors but the frequent occurrence of new cancers in radiation-treated sites (48,53,58,60,71-73). Hisada et al. (71) observed only one of 14 subsequent breast cancers arising in a previously irradiated area however most of the subsequent sarcomas arose in previously irradiated areas, and studies of childhood cancer survivors, especially young soft tissue patients (67,74), have noted a significant excess of female breast cancer, both within and in the absence of radiation therapy. It seems clear that there is an extremely high risk of multiple primary tumors in LFS patients, occurring both spontaneously and in irradiated sites. This is consistent with observations in heterozygous p53 knockout mice in which radiation significantly accelerates tumor development (75). Many authors have suggested that radiation not be used for cancer treatment in p53 mutation carriers if feasible,...

Standard Dose Salvage Chemotherapy Summary

Approximately 50 of recurrent testicular cancer patients will achieve a disease-free status when VeIP is administered as second-line therapy.72,73 Half of the patients who achieve complete remission on VeIP eventually relapse therefore, approximately 25 of patients with recurrent germ cell tumors can have the expectation of long-term disease-free survival with standard salvage chemotherapy. The substitution of paclitaxel for vinblastine has yielded impressive results in a patient population with favorable prognostic features. However, a direct comparison to VeIP is needed to determine its true worth in this setting.

Highdose Chemotherapy At First Relapse

High-dose chemotherapy as the first salvage treatment of relapsed germ cell tumors has been less extensively investigated.115 Unlike patients with multiply recurrent germ cell cancer, patients in first relapse can expect a 50 likelihood of complete remission and a 25 chance of long-term freedom from disease with conventional-dose salvage chemotherapy. The goal, therefore, is not the salvage of otherwise doomed patients but improvement in the efficacy of salvage therapy. Demonstrating efficacy in this setting is thus more challenging. The typical approach employed to date has included one or two cycles of conventional-dose chemotherapy followed by one or two courses of high-dose chemotherapy with carboplatin etoposide, with or without an alkylating agent.116119 Less commonly, high-dose therapy has been administered alone, without a prior conventional-dose salvage regimen.120,121 Investigators at Indiana University Table 16-2. PROGNOSTIC SCORING FOR OVERALL SURVIVAL AND FAILURE-FREE...

Efficacy of Chemotherapy Regimens

A sizable number of patients with locally advanced anal tumors receiving chemoradio-therapy will still ultimately require salvage APR. In an attempt to improve outcome and reduce toxicity, several investigators have examined the role of cisplatin, a potentially more effective chemotherapy agent and radiosensitizer, as a substitute for MMC. In a retrospective analysis, Hung et al. reported their experience with 92 patients treated with protracted daily infusion of cisplatin (4 mg m2 day) and 5-FU (250 mg m2 day) during radiation therapy (55 Gy in six weeks without a planned break) (31). The five-year survival rate was 85 , and colostomy-free survival was 82 with no patient requiring colostomy for symptom control. Local control was achieved in 83 of patients (T1 T2 90 and T3 T4 72 ). The regimen was well-tolerated with < 5 grade 4 acute toxicity. In another retrospective series, 95 patients were treated with cisplatin (25-mg m2 day bolus) and 5-FU (1000 mg m2 day) on days 1-4 of...

Breast Cancer Prognosis In

Many studies have indicated that a p53 somatic mutation is an independent poor prognostic indicator for breast cancer (86), with some data suggesting that the prognosis may be influenced by the nature of the mutation (87). Miller et al. (30) have shown that an expression signature for p53 functional status in breast cancer is more predictive of outcome than p53 sequence analysis, and suggest that p53 may be functionally attenuated in the absence of DNA sequence variants. From those data one might assume that the breast cancer in germ line p53 mutation carriers would also carry a poor prognosis surprisingly little data are available to support that expectation, and the absence of data perhaps speaks loudly. Given that there are no published survival data for breast cancer in p53 mutation carriers, the frequent reports of multiple primary tumors occurring over 10 to 30 years (71) suggest that many of these patients do not succumb to their breast cancer. Unlike BRCA1,2 mutation carriers...

Gene transfer and its implications for chemotherapy

Traditionally, drug and vaccine design often targets parasite-specific pathways or structures that are essential for the survival and growth of the parasites (Fairlamb 2002 Agbo et al. 2003). The fact that apicoplasts provide essential functions (e.g. fatty acid and isoprenoid synthesis) and the fact that humans and other mammals to do not have apicoplasts, makes this organelle and its associated biochemical processes excellent antiapicomplexan drug targets (McFadden and Roos 1999 Ralph et al. 2004). Additionally, many of the laterally transferred genes also bear implications for chemotherapy. For example nucleotide biosynthesis is essential to parasite growth. Because Cryptospor-idium lost both de novo purine and pyrimidine biosynthetic abilities, their dependence entirely on salvage pathways that assembled with several prokaryotic genes can be explored for antic-ryptosporidial drugs. Antagonists of IMPDH have already proven to affect C. parvum viability

Marrow Ablative Chemotherapy with Hematopoietic Stem Cell Rescue

ABSTRACT Marrow ablative chemotherapy with hematopoietic stem cell rescue (also referred to as hematopoietic stem cell transplantation) is a therapeutic strategy used to treat children and young adults with brain tumors whose conventional therapy is either too toxic (e.g., radiotherapy in infants) or ineffective (e.g., rhabdoid tumors or progressive malignant tumors). In this strategy, highdose chemotherapy (typically including alkylating agents and or other radiomimetic drugs) is given to patients after initial conventional therapy, including surgery and irradiation, if possible, and conventional-dose chemotherapy. The success of marrow ablative chemotherapy with hematopoietic stem cell rescue depends on several variables, including the histological type of tumor, extent of disease and of surgical resection, and response to prior chemotherapy. In this chapter, we shall review results of marrow ablative chemotherapy with hematopoietic stem cell rescue in brain tumors of differing...

QOL in Long Term Survivors of Breast Cancer

In total, 16 studies met our search criteria for breast cancer, all published after 1998. The studies are described in Table 1 and include our study,32 which will be discussed in greater detail following the general review. Quality of life was a primary outcome in all studies. Of the 16, five studies compared the QOL between breast cancer survivors and healthy or normal controls.4,41-44 Two of five also compared QOL outcomes between survivors who have experienced a cancer recurrence to those who have not.4,43 Three of the 16 studies compared QOL between breast cancer survivors receiving different types of treatment.2,45,46 Two of the 16 investigated the QOL between breast cancer survivors diagnosed at different ages47,48 another two studies compared QOL at time of diagnosis and follow-up32,49 and two more examined the impact of treatment on QOL.50,51 One study looked specifically at the role of ethnicity in QOL outcomes,52 while the final study examined the...

Newer Chemotherapy Agents

The results of the numerous clinical trials of adjuvant therapy for pancreatic cancer leave many questions unanswered with no definitive answer as to the optimal treatment for these patients. In addition, newer chemotherapy agents such as gemcitabine and molecularly targeted agents have emerged, and the possible benefit of their addition to adjuvant therapy has yet to be reported in larger trials. Based on the results of a prospective randomized trial, gemcitabine has become the standard first line agent in patients with advanced pancreatic cancer. Burris and colleagues randomized 160 previously untreated patients with advanced and metastatic pancreatic cancer to receive either gemcitabine or 5-FU. Patients who received gemcitabine had a statistically improved median survival, one-year survival rate, and clinical benefit compared to patients who received 5-FU (19). In radiobiologic models, gemcitabine has also been observed to be a potent radiosensitizer. Although the mechanism of...

More Intensive Chemotherapy as Standard CHOP

After earlier studies showed that intensive chemotherapy led to a disproportionately high risk of infection and toxic complications (Kaplan 1997), the tendency for a long time was to withhold HIV patients from therapy and often to treat them with reduced-dose regimens. This seems to be changing in the age of HAART. Several prospective studies have shown that the tolerability of chemotherapy is improved through HAART (Powles 2002, Sparano 2004). In the past few years, small pilot studies have been repeatedly published in which HIV patients have been treated with CHOP regimens. There are also studies in which doxorubicin has been given as liposomal Caelyx (Levine 2004) or where the dose of cyclophosphamide was increased (Costello 2004). In addition, CDE, a regimen which, when given for several days as infusions is supposed to overcome the potential chemotherapy resistance of lymphoma cells, is propagated again and again (Sparano 2004). The CR rates in these studies were between 50 and...

Dose Intensity in Breast Cancer Preclinical and Retrospective Clinical Data

Preclinical in vivo and in vitro data suggest that increasing the dose of chemotherapy increases tumor cell kill, but with significant myelosuppression (4). Hryniuk and Bush (5), in a literature review of regimens for metastatic breast cancer, calculated the dose of CMF chemotherapy given over a unit of time and concluded that a relationship was apparent with dose intensity and response rate in the setting of metastatic breast cancer. For the adjuvant setting, Hryniuk and Levine (6) evaluated chemotherapy trials for women with stage II breast cancer treated with CMF-like regimens. In this retrospective study, the authors concluded in both univariate and multivariate analyses that dose intensity was a significant predictor of relapse-free survival (6). These initial observations of dose intensity, although suggestive, were retrospective.

Prospective Dose Intensity Trials for Breast Cancer

Tannock et al. (7) evaluated the dose-intensity concept in a prospective setting for patients with metastatic breast cancer. Patients were randomly assigned to receive two dose levels of CMF chemotherapy every 3 wk standard (cyclophosphamide 600 At the M.D. Anderson Cancer Center, Hortobagyi and colleagues (8) evaluated the impact of higher dose anthracycline therapy in metastatic breast cancer. Patients were randomly assigned to receive either standard 5-fluorouracil (F), doxorubicin (A), and cyclophosphamide (C) or 260 higher FAC. The median response durations and overall survival rates were not significantly different. Furthermore, hematologic, infection-related, and gastrointestinal complications were increased in the high-dose FAC group (8). The studies by Tannock et al. (7) and Hortobagyi et al. (8) seemed to indicate that a threshold dose existed for the treatment of breast cancer, but a large confirmatory trial was needed.

Threshold Dose in the Treatment of Breast Cancer

The Cancer and Leukemia Group B (CALGB) did a randomized trial evaluating different doses and dose intensities of adjuvant chemotherapy in patients with node-positive breast cancer 1572 patients were randomized to receive CAF at three dose levels low-dose (5-flurouracil 300 mg mL, doxorubicin 30 mg mL, cyclophosphamide 300 mg mL), moderate dose (5-fluorouracil 400 mg mL, doxorubicin 40 mg mL, cyclophosphamide 400 mg mL), and high dose (5-fluorouracil 600 mg mL, doxorubicin 60 mg mL, cyclophosphamide 600 mg mL). Women treated in the moderate- and high-dose-intensity groups had significantly longer disease-free and overall survival than those in the low-dose group. Survival was not different between the moderate- and high-dose groups (9). This study validated the idea of a threshold dose in the treatment of breast cancer.

Biological Basis For Tamoxifen As A Breast Cancer Preventive

Tamoxifen was selected for testing as a preventive based on (1) animal studies that demonstrated it could prevent carcinogenesis,49-52,103 (2) extensive clinical experience that showed few serious side effects, and (3) a beneficial profile of estrogen-like action in maintaining bone density and reducing circulating cholesterol. Ta-moxifen was already known to reduce the incidence of contralateral breast cancer47 and to have a favorable toxicity profile, making the drug the primary agent to test in high-risk women. Sporadic reports19,104 and placebo-controlled randomized trials20,105 demonstrated that ta-moxifen can increase bone density in the lumbar spine, forearm, and neck of the femur by 1 -2 . Although the increases are modest compared to the results obtained with estrogen or biphosphonates (5 increase in bone density), tamoxifen produced a marginal decrease in hip and wrist fractures as a secondary end point in the breast cancer prevention trial.106 Tamoxifen reduces circulating...

Risk Factors For Breast Cancer

Identification of women at risk for definitive clinical trials. Family history is probably the best-recognized risk factor for breast cancer. An inherited gene mutation is thought to account for 5 -10 of breast cancer cases.116,117 Although infrequent, these mutations are significant since they are associated with a lifetime risk of breast cancer of 50 -80 ,118,119 beginning at a young age. At present, two predisposition genes, BRCA1, located on chromosome 17q21,120 and BRCA2, located on chromosome 13q12-13,121 have been identified, both of which are inherited in an autosomal dominant pattern. Most women with a family history of breast cancer do not have the genetically transmitted form of the disease, and their risk is much less than that seen in women who have inherited a predisposing gene. The cumulative probability that a 30-year-old woman with a mother and sister with breast cancer will develop breast cancer by the age of 70 is between 7 and 18 .122,123 While this risk increases...

Granulocyte Colonystimulating Factor And Granulocytemacrophage Colonystimulating Factor For Chemotherapyinduced

Granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are endogenous glycoproteins that participate in the differentiation and proliferation of granulocytes, monocyte-macrophages, and other cells for hematopoeisis (17). Myelosuppresion is the major toxicity of chemotherapy for solid organ tumors, and prolonged myelosuppression and neutropenia lead to a reduction in chemotherapy dose intensity. Therefore, with the discovery, cloning, and production of recombinant human forms of G-CSF and GM-CSF (rHuG-CSF and Fig. 1. The relationship between absolute neutrophil count (ANC) and neutropenic fever after salvage chemotherapy is shown for patients with metastatic breast carcinoma. When the ANC decreases to a level below the threshold of 500 mL, the incidence of neutropenic fever increases in a linear trend (p < 0.01). *, Number of courses with fever number of courses with nadir ANC in the same range. Fig. 1. The relationship between...

Prevention Of Breast Cancer With Tamoxifen

In 1986, Cuzick et al.156 outlined a prevention trial with tamoxifen in women at high risk of breast cancer. The previous year, Cuzick and Baum157 documented a marginally significant reduction in the risk of a second primary cancer in the contralateral breast of breast cancer patients after 2 years of tamoxifen. This initial observation was confirmed in larger randomized clinical trials. Fornander et al.158 recruited 1846 postmenopausal patients for the Stockholm Adjuvant Tamoxifen Trial and randomized them to a trial of adjuvant tamoxifen or nothing for early breast cancers. In the tamoxifen patients, new primary breast cancers occurred less often (RR 0.55). Similar results were obtained by the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-14.159 These results led to the obvious interest in tamoxifen as a possible preventive for primary disease. Carefully controlled clinical chemoprevention trials continue to establish the activity and toxicity of specific agents and...

Filgrastim In The Treatment Of Breast Cancer

Although filgrastim was known to have an effect on hematopoetic cell lines, it was not clear whether it stimulated nonhematopoetic cells or tumor cells. Several studies were done to elucidate the effect, if any, on human breast cancer cells. Emerman and Eaves (22) evaluated human breast epithelial cells from normal and malignant tissues and evaluated the effects of eight cytokines G-CSF, GM-CSF, Steel factor, interleukin (IL)-2, IL-3, IL-6, transforming growth factor-P (TGF-P), and macrophage inflammatory protein 1-a. The authors found no effect of the cytokines on the growth of normal or malignant breast epithelial cells. Filgrastim appears to be safe in the treatment of breast cancer, but when in the course of chemotherapy is the best time for it to be given

Regional Intraarterial Chemotherapy

In patients with HCC, uncontrolled tumor in the liver is the most significant cause of morbidity and mortality, although extrahepatic metastases are apparent in up to 25 of patients at the time of diagnosis and up to 90 on autopsy. Thus, effective local chemotherapy would have a significant clinical effect. Administration of the drug into the hepatic artery could theoretically increase local drug delivery to the tumor tissue and possibly lower systemic toxicity. An ideal pharmacologic profile would be a high degree of hepatic extraction, high systemic clearance, rapid biotransformation to less toxic metabolites, and a steep dose-response relationship with respect to tumor cell kill.

Biological Basis For Raloxifene As A Breast Cancer Preventive

Raloxifene, originally named keoxifene or LY156758,170 was discovered in the breast cancer program at the laboratories of Eli Lilly (Indianapolis, IN). The drug has a high binding affinity for the ER,171,172 primarily because it has strategically located phenolic groups (Fig. 12.1). Raloxifene and an analogue, LY117018,59,173-175 are short-acting compounds with poor bioavailability due to rapid phase II metabolism.176 Indeed, a concern in the early clinical trials was an inability to monitor blood levels. Although numerous assays are available to monitor ta-moxifen and its metabolites,177 the structure of raloxifene does not permit the use of similar chemical methods of detection. The analytical technique used to monitor raloxifene has not been published therefore, there has been limited clinical experience for the treatment of breast cancer. The initial study, conducted at the M.D. Anderson Cancer Center in Houston, showed no responses in heavily pretreated patients with stage IV...

Indications For Chemotherapy

It is now generally accepted that patients with bulky abdominal nodal metastases from testicular semi-noma, patients with supradiaphragmatic metastases, and patients with extranodal metastases should be treated with chemotherapy. There is some controversy over the treatment of patients with small-volume retroperitoneal node metastases since in the past, these patients have been treated with radiotherapy, reserving chemotherapy for those 10 to 20 who experience recurrence. However, with abdominal node metastases that are greater than about 5 cm in diameter (see Figure 20-1), there is a risk of renal damage from the radiation fields, and the risk of recurrence after radiotherapy becomes higher.6 Also, in most centers, abdominal node metastases > 5 cm in cross-sectional diameter would provide an indication for chemotherapy rather than radiotherapy. The efficacy of chemotherapy is such that many centers would administer chemotherapy for abdominal node metastases of smaller volume. There...

Comparisons Of Longterm Effects Of Diagnosis And Treatment By Cancer Site Breast Cancer And Hodgkins Disease

Was expected that type and frequency of the physical dimension of QOL would be explained by type of treatment, age at the time of treatment and time since diagnosis. It was also expected that social and psychological dimensions of QOL would be explained by differences in educational attainment. The sample was composed of 141 individuals (55 male) who participated in two different surveys conducted at Stanford University Medical Center. The initial interviews were conducted in-person while the 12-year follow-up interviews were self-administered both surveys were conducted when the individual came to the clinic for a routine check-up. The second study was a 5-year follow-up of a population-based cohort of 185 women who were younger 50 years of age at diagnosis of breast cancer and were cancer-free 5 years later. The initial survey was in-person, often in the women's home, and the 5-year follow-up was a telephone survey.32 Comparative findings are organized according to Ferrell and...

Prognosis After Chemotherapy

In a prognostic factor analysis of chemotherapy results in germ cell tumors, the International Germ Cell Cancer Collaborative Group (IGCCCG) reviewed 637 patients treated for advanced seminoma. The 3-year survival rate was 82 .9 However, the majority of patients were in a good prognostic subgroup, with metastasis confined to either lymph nodes or lung fields, and in this group, the 5-year survival rate was 86 . Those with nonpulmonary visceral metastases had a 5-year survival rate of 72 . In an analysis of a subset of 236 of these patients treated with cisplatin-based chemotherapy at 1 of 10 European oncology units, a very-good-prognosis group was identified this group comprised patients who had not had previous radiotherapy and who either had abdominal node metastases with any level of serum lactate dehydrogenase (LDH) or were stage C patients without nonpulmonary visceral metastases and whose serum LDH was less than twice the upper limit of normal. These patients had a 94 3-year...

Cell Molecular Biology Breast Cancer

Bi-directional Regulation of Human Progesterone Receptors and the Mitogen Activated Protein Kinase Pathway in Breast Cancer Cell Models Abnormal Properties of Mutants in the Hinge Region of ErV Implications in Breast Cancer Microarray Analysis of Estrogen-Induced Protection Against Breast Cancer

Residual Masses And Postchemotherapy Radiation

Especially with cases of large-volume seminoma, it is common to find a residual mass on scanning the patient after a course of chemotherapy. However, approximately 90 of these masses do not contain residual malignancies and appear to be fibrotic remnants (Figure 20-3).30,31 Attempted resection can be hazardous because of extensive dense scar tissue involving the great vessels and retroperitoneal tissues. The analysis from the Memorial Sloan-Ketter-ing Cancer Center suggested that there was a higher risk of residual malignancy if the residual mass was > 3 cm in diameter.32 This suggestion has led, at some centers, to a policy of particularly close surveillance or adjuvant radiotherapy for this subset of patients.33 However, other investigators have not found that recurrence was more likely when the residual mass was 3 cm in diameter.34 Furthermore, retrospective data from 302 patients treated in 10 European centers with chemotherapy for metastatic seminoma indicated that 174 of those...

Chemotherapy of High Grade Astrocytomas

ABSTRACT High-grade astrocytomas, including anaplastic astrocytoma (AA) and glioblastoma multiforme (GBM), are frequently diagnosed tumors that continue to have a poor prognosis and protracted survival. Chemotherapy has recently been demonstrated to provide a survival benefit in patients with AA and GBM, in addition to surgical resection and irradiation, by several meta-analyses. The improvement in survival has been modest and mainly associated with the use of nitrosourea drugs such as BCNU and CCNU, as well as platinum compounds. Recent clinical trial data also suggests that the alkylating agent, temozolomide (TZM), has activity against AA and GBM in the neoadjuvant, adjuvant, and recurrent settings. In addition, TZM has been shown in phase II and III clinical trials to improve survival of patients with GBM in combination with radiation therapy. Further drug discovery and clinical trial testing will be needed to make more substantial improvements in the survival of patients with...

Concurrent Use With Chemotherapy

In 1994, Livingston et al. (43) began a series of studies exploring the concept of dose density, namely, multifractioned doses of chemotherapy given at shorter intervals than standard regimens. To prevent dose-limiting myelosuppression, they began intermittent and then continuous neutrophil support with daily filgrastim. In the first study, vinorelbine 35 mg m2 was given weekly with continuous filgrastim 5 mg kg to 40 patients previously treated with anthracyclines and resistant to paclitaxel. They observed that continuous filgrastim allowed a nearly twofold increase in the delivered dose intensity, from 46 to 73 , compared with similar historical series without filgrastim. The increase in delivered dose intensity was suggested as the basis for the observed 25 objective response rate. Use of continuous filgrastim with an alkylating agent, cyclophosphamide 60 mg m2 d, continously with doxorubicin 24 mg m2 wk was tested preoperatively in 122 patients with locally advanced breast cancer...

Chemotherapy Of Aa And Gbmhistorical Overview

In the 1960s and 1970s, surgical resection and postoperative external beam radiation therapy were established as the standard treatment approach for patients with AA and GBM 5,14 . However, in the late 1970s, investigators began to evaluate chemotherapy as a potential treatment modality when it became obvious that surgical resection and radiation therapy were not curative in the vast majority of patients, and that other forms of treatment were desperately needed to improve survival 20-24 . Over the next fifteen years numerous chemotherapy agents were tested, alone and in combination, for efficacy against newly diagnosed and recurrent high-grade gliomas. Single-agent nitrosoureas (i.e., BCNU) and nitrosourea-based combination regimens (i.e., PCV procarbazine, CCNU, vincristine) were most effective (outlined in more detail below), although only to a modest degree. However, much of the literature regarding chemotherapy for patients with AA and GBM have methodological deficiencies that...

Concomitant Chemotherapy And Irradiation Approaches

A potent radiosensitizing effect, independent activity against tumor cells, non-cell-cycle specific, and amenable to dose-intensive or prolonged administration schedules. The three most common mechanisms for radiosensitization are inhibition of radiation damage repair (e.g., purine and pyrimidine analogs), perturbation of the cell cycle in order to increase the fraction of tumor cells in the G2 M phase (e.g., vinca alkaloids, paclitaxel), and alteration of hypoxic cell populations (e.g., RSR 13). Although numerous compounds have been tested for a radiation sensitizing effect, chemotherapy drugs have been most effective and form the basis for the evolving discipline of chemoradiation 42-45 . Chemoradiation has been applied to high-grade astrocytomas, initially with alkylating agents such as BCNU and methyl-CCNU, and halogenated pyrimidines (e.g., iododeox-yuridine) 45-49 . Other chemotherapy agents that have been used in chemoradiation regimens include cisplatin, fluorouracil,...

Neoadjuvant Chemotherapy Approaches

In addition to BCNU and PCV (as outlined above), numerous other chemotherapy drugs, alone and in combination, have been used for neoadjuvant treatment of high-grade astrocytomas (see Tables 24.1 and 24.2) 20-24 . Dropcho and colleagues attempted neoadjuvant intra-arterial (IA see Chapter 17) cisplatin (75 mg m2 every 4 weeks) in a series of 22 assessable patients with newly diagnosed high-grade astrocytomas (GBM 13, AA 9) 72 . There were five patients (23 per cent) with partial responses (PR) and five patients (23 per cent) with minor responses (MR) after IA therapy. The time to progression (TTP) ranged from 22 to 115 weeks, with a median of 39.8 weeks overall and 56.3 weeks in responders. Although hematologic, renal, and otic toxicity were mild, there were several patients with significant neurological toxicity. Other investigators have used high-dose intravenous cyclophosphamide (2 g m2 day for 2 doses every 28 days) as neoadjuvant treatment for 14 patients with newly diagnosed GBM...

Chemotherapy For Recurrent Highgrade Astrocytomas

Similar to the experience with adjuvant treatment, chemotherapy for the majority of patients with recurrent high-grade astrocytomas has been disappointing. Over the past 25 years, numerous drugs have been tested, typically with minimal efficacy and no survival advantage over a nitrosourea-based regimen 20-24 . The use of BCNU, CCNU, or PCV at the time of recurrence has been associated with a 25 to 30 per cent response rate, with a survival benefit that is similar to that obtained when the treatment is used immediately after the completion of irradiation 22,24 . Among the nitrosourea-based approaches, single-agent BCNU appears to be the most active agent. Other drugs with activity against recurrent high-grade astrocytomas include single-agent procar-bazine, an oral alkylating agent commonly used as part of the PCV regimen (see Tables 24.1 and 24.2). When used at the time of recurrence after BCNU failure, procarbazine (150 mg m2 day x 28 days every 8 weeks) is capable of inducing...

Chemotherapy of Low Grade Astrocytomas

ABSTRACT Rational decisions regarding the appropriate use of chemotherapy in patients with low-grade astrocytoma (LGA) will require further data from prospective randomized trials. Until such data becomes available, chemotherapy should probably still be used only as a salvage option in patients with recurrent or progressive LGA who have previously received radiation therapy (RT). Increasingly, due primarily to its low toxicity and possibly due to its modest efficacy, temozolomide has become the most popular chemotherapeutic agent in this setting. However, chemotherapy cannot yet be considered standard of care in patients with newly diagnosed tumors. When faced with an adult with a LGA, either at initial diagnosis or at recurrence, referral to an academic medical center with open clinical trials should be seriously considered.

Other Chemotherapy Regimens

18 patients, and grade 4 in 4 patients. Soffieti et al. studied the effectiveness of Carboplatin as second-line chemotherapy for recurrent or progressive oligoden-droglial tumors after PCV 60 . Eight of the twenty-three patients had oligoastrocytoma (five grade II and three grade III). There were no responders in the oli-goastrocytoma group in comparison to three partial responders in the oligodendroglioma group. In a study of Carboplatin and teniposide as third-line chemotherapy in 23 patients with recurrent oligodendroglial tumors (two low-grade and four anaplastic oligoas-trocytomas), 33 per cent of the patients with oligoas-trocytomas remained progression-free during treatment 61 . This was in comparison to 70 per cent of the patients with oligodendrogliomas. Median TTP of the entire study group was 19 weeks. The median survival of the entire 23 patients was 60.7 weeks. Oligoastrocytoma histology was a significant negative prognostic factor with a median TTP of 6 weeks and a MST...

Chemotherapy for Primary Central Nervous System Lymphoma

ABSTRACT Methotrexate-based chemotherapy has significantly improved the treatment of primary CNS lymphoma. At the present time, several effective single-agent and multiagent methotrexate-based regimens have been reported as well as attempts to enhance delivery using blood-brain barrier disruption, maintenance chemotherapy, and myeloab-lative regimens requiring stem cell support. As no one approach is clearly superior to the others, the relative risks and benefits as well as newer agents and approaches to therapy will be discussed.

Intrathecal Chemotherapy

Although the experience from systemic lymphoma and leukemia clearly supports the use of intrathecal chemotherapy to prevent or treat leptomeningeal disease, its role in the treatment of PCNSL remains controversial. Most therapeutic regimens for PCNSL rely on high-dose MTX and high-dose ARA-C, both of which, when administered as a rapid infusion, can achieve tumoricidal CSF levels, thus obviating the need for IT chemotherapy 41,46 . Furthermore, at least two retrospective studies have failed to demonstrate any advantage in terms of disease control or survival for patients treated with intrathecal chemotherapy 41,46,47 .

Does Chemotherapy Or Chemoradiotherapy Improve Qualityoflife In Patients With Unresectable Cholangiocarcinoma

Systemic chemotherapy has not been clearly proven to prolong survival significantly in patients with unresectable biliary tract neoplasms (1). However, one small randomized study (22) has indicated that 5-FU, when compared to best supportive care, can add to both quantity and quality-of-life in advanced pancreatic and biliary cancer. Ninety-three patients were included in the study, but only 37 had biliary tract disease. In this subgroup of patients, overall survival was clearly superior in the treated group (six months vs. 2.5 months evidence level 1b) this was significant in the study as a whole, but not in the biliary subgroup, probably because of lack of power due to small numbers. Many different chemotherapeutic regimens have been investigated in small, mostly uncontrolled studies, with generally poor results. Reported response rates for most single-agent regimens (e.g., 5-FU, mitomycin C, cisplatin, nitrosoureas, etopo-side, methotrexate, adriamycin, irinotecan, and paclitaxel)...

Chemotherapy of Medulloblastoma

ABSTRACT Medulloblastoma is the most common primary brain tumor in children and accounts for 25 per cent of newly diagnosed cases. Recent advances in treatment have extended 5-year survival rates from 3 to over 70 per cent during the past 50 years. These improvements in survival have resulted from a multi-modality approach that includes surgical resection, posterior fossa and craniospinal irradiation (RT), and chemotherapy for selected, high-risk patients. The literature regarding chemotherapy of adult and pediatric patients is reviewed in depth. The most active agents include cisplatin, CCNU, cyclophosphamide, vincristine, and carboplatin. Although patients are living longer with their disease, neuro-cognitive function and quality of life are often impaired after RT to the developing brain. To safely allow reductions in the dose of RT, the specificity and efficacy of chemotherapy must be improved. Recent advances in the molecular genetics of medulloblas-toma transformation (e.g.,...

Chemotherapy Of Infants And Very Young Children

Sensitive to the effects of irradiation 12,14,29-31 . More than 60 per cent of surviving brain tumor patients will develop significant cognitive impairment after exposure to cranial RT. In this group of medulloblastoma patients (roughly 20 per cent of all pediatric cases, which also have the poorest prognosis for survival), chemotherapy has a very prominent role, because it is often applied ''up front'' to delay the use of RT until the patient matures beyond 2.5 to 3 years of age (see Tables 29.1 and 29.2) 3-5 . Initial reports by van Eys and colleagues have suggested that MOPP chemotherapy, using nitrogen mustard (6 mg m2), vincristine (1.4 mg m2), procarbazine (100 mg m2), and prednisone (40 mg m2) was effective against pediatric brain tumors, including medulloblastoma in infants 32-34 . They were able to demonstrate durable responses in 30-40 per cent of their infant cohort. In a subsequent report from the same group, follow-up data was available for 12 infants with medulloblastoma...

Chemotherapy Of Children And Adolescents

The application of chemotherapy to medulloblas-toma patients in this age range is an extensive topic several excellent review articles have been published 3,4,14-16,19,20,46,47 . Several important randomized, multicenter, clinical trials have been conducted by CCG, POG, and other groups in newly diagnosed patients to determine the efficacy of chemotherapy after craniospinal RT (see Tables 29.1 and 29.2). In 1990, the CCG-942 trial was reported, in which 179 newly diagnosed patients were randomized to receive either RT alone (3500-4000 cGy to craniospinal axis, 5000 to 5500 cGy to posterior fossa) or RT plus adjuvant chemotherapy (CCNU 100 mg m2 vincristine 1.5 mg m2, during RT and with each cycle prednisone 40 mg m2 in 6-week cycles for 1 year) 48 . The 5-year survival rate was 65 per cent in both groups. Chemotherapy was not beneficial for patients with low-risk disease. However, in patients with high-risk disease (i.e., large residual tumors after resection, brainstem infiltration,...

Chemotherapy Of Adult Patients

Medulloblastoma is uncommon in adults, occurring in less than 20 per cent of all patients diagnosed after 20 years of age 3,6,7,15 . Survival in adults, like that of pediatric patients, has improved with the advent of microsurgical techniques, mega-voltage RT, and the use of craniospinal radiotherapy. Recent estimates of event-free and overall survival at 5-years are approaching 60 and 75 per cent, respectively, in most series 3,6,7,65-69 . The application of chemotherapy to adult patients has been derived from the pediatric experience. Thus far, no randomized, comparative, multi-center trials have been reported in adults. Many of the above-mentioned reports of survival trends in adults have included patients treated with chemotherapy, either up-front or at relapse (see Table 29.2) 6,7,15,65-71 . The efficacy of chemotherapy was variable, with some studies noting a survival benefit, while others were unable to demonstrate any effect on survival. A recent prospective phase II trial by...

Chemotherapy With Bone Marrow Transplantation

In an attempt to improve dose intensity, several investigators have used myeloablative, high-dose chemotherapy followed by bone marrow transplant or rescue (BMT) 3,40,48,74-80 . Preliminary results suggest that durable responses can be achieved in a sub-group of selected patients with high risk or recurrent disease. Chemotherapeutic agents appropriate for high-dose protocols require bone marrow suppression as the dose-limiting toxicity. The most commonly used drugs are busulfan, thiotepa, cyclo-phosphamide, etoposide, melphalan, and carboplatin. The previously mentioned study by Dupuis-Girod used this approach with a regimen of busulfan and thiotepa in infants and young children 40 . They noted 6 CR, 6 PR, and 3 SD in 15 evaluable patients with progressive disease. The event-free survival at 31 months follow-up was 50 per cent. A similar study of young patients with recurrent brain tumors by Gururangan and co-workers included five with medulloblastoma 77 . High-dose chemotherapy...

Chemotherapy for Glioneuronal Tumors

ABSTRACT Glioneuronal tumors are rare primary brain tumors. They are composed of both glial and neuronal elements. In most cases, they are benign tumors that are often cured with surgery. Radiation therapy is sometimes used to treat residual or aggressive tumors. The role of chemotherapy for these tumors is not well defined or not indicated. This chapter reviews the available literature on the use of chemotherapy to treat these tumors and when it may be indicated. A framework for which agents may be of benefit should assist physicians when chemotherapy is needed.

Chemotherapy of Pineal Parenchymal Tumors

ABSTRACT Pineal region tumors encompass a large group of neoplasms, including germ cell tumors, meningiomas, neuroectodermal tumors, and pineal parenchymal tumors (pineocytoma, pineoblastoma). They have an incidence of 0.3-0.7 per cent and usually affect patients between the ages of 20 and 35 years. Common presenting signs and symptoms include headache, Parinaud's syndrome, hydrocephalus, papilledema, and ataxia. Pineal tumors and hydro-cephalus are clearly delineated on enhanced magnetic resonance imaging. The main form of treatment for pineocytoma is surgical resection, which may be curative in some cases. For patients with pineoblas-toma, surgical resection and radiation therapy are usually required. The role of chemotherapy continues to be defined, but should be considered for all the patients with malignant tumors, as well as for patients with lower grade tumors that recur or become disseminated. Platinum-based regimens appear to be most effective, usually in combination with...

Systemic Chemotherapy

Systemic chemotherapy is not used routinely for advanced HCC. There are factors related to the tumors. HCC is relatively chemoresistant, partly due to the presence of drug-resistant genes, including p-glycoprotein, glutathione-S-transferase, heat shock proteins and mutations in p53. There are also factors related to the patients. Patients often do not tolerate chemotherapy well because of the underlying liver dysfunction and liver cirrhosis. Several chemotherapy agents, including doxorubicin, epirubicin, 5-fluorouracil and leucovorin, gemcitabine, thalidomide, and capecitabine, have been studied in the treatment of advanced HCC either as single agents (41-46) or in combination (47-49). The response rates vary from 20 to 50 , but no improvement in overall survival has been reported. A number of small uncontrolled studies report an overall response to doxorubicin monotherapy to be less than 20 . The only controlled trial involving 104 patients showed a modest improvement in median...

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