Oral Presentations
02 Novel Methods for Improving the Results Radiotherapy in localised Prostate Cancer. D.P. Dearnaley*, R.J. Shearer, L. Ellingham, D. Tait, A. Nahum, M. Chow, A. Horwich. Royal Marsden Hospital and Institute of Cancer Research Surrey. * Supported by the Bob Champion Cancer Trust and Cancer Research Campaign
GROWTH FACTOR INHIBITION AND CARCINOMA OF PROSTATE E O KEHINDE, T HORSBURGH, N MISTRY, T TERRY, P K DONNELLY
Leicester General Hospital, Leicester Prostate cancer cells no longer responsive to conventional hormonal manipulation provide their own fuel in the form of autocrine and paracrine growth factors which stimulate tumour growth in the absence of circulating androgens. Tumour progression may be influenced by growth factor regulators. In this study we evaluated the impact of the antiproliferative Somatostatin analogue (SMS 201-995) and Suramin (a synthetic poly-anionic compound capable of blocking the activity of basic fibroblast growth factor [bFGF] and epidermal growth factor (EGF]) on the in vitro growth of androgen dependent cancer of prostate cell line LNCaP and androgen independent cell lines PC3 and DU145. Tumour cells were adapted to growth in 2.5% FCS for LNCaP and serum free media containing RPMI 1640/ITS (Insulin, transferrin and selenous acid) for PC3 and DU145 cell lines. Cells were exposed to the following concentrations of SMS 201-995 in the range 0 - 200 mcg/ml and Suramin 0 - 810 mcg/ml after 24 hours of initiation of cell growth following plating. Cell counts using haemocytometer and MTT cell growth determination assay were carried out on day 0, 2, 4 and 6. Compared to Suramin-free control, Suramin produced inhibition of cell growth in a dose dependent mapner up to a maximum concentration of 270 mcg/ml. At 270 mcg/ml Suramin produced 50%, 49% and 68% inhibition of growth of LNCaP, PC3 and DU145 cell lines respectively on day 6. In all 3 cell lines at 810 mcg/ml Suramin produced cytolysis. Somatostatin produced inhibition of cell growth in a dose dependent manner in PC3 and LNCaP only. It produced 58% and 27% inhibition at 0.2 mcg/ml of SMS 201-995 on LNCaP and PC3 respectively. Suramin and Somatostatin play an inhibitory role in the growth of cancer of prostate in doses that are achievable in vivo and open new avenues of therapy.
External beam radiotherapy (RT) is effective in eradicating early localised prostate cancer. However as tumour size increases local control is less certain and requires higher irradiation doses and increased radiation target volumes, both of which are associated with an increased risk of treatment related morbidity. We have investigated two complimentary methods aimed at improving the 'therapeutic ratio' of radical radiotherapy using 1) LHRH analogues prior to RT (hormonal cytoreduction) and 2) conformal RT planning using 3-D reconstruction of CT images to build individualised blocks to shape or conform radiation fields. 23 patients were treated with initial LHRH analogues, response was assessed by monthly transrectal ultrasound (TRUS) measurement of prostate volume. Radical RT was given after volume stabilisation. 30 additional patients were evaluated using both conventional and conformal RT planning methods.
Prostate volume reduction after LHRH analogues measured by TRUS was 54% after a median treatment time of 13 weeks. CT Scans taken to simulate RT planning before and after LHRH treatment using 3-D reconstruction of prostate and radiotherapy target volumes showed a) close correlation with the volume measured by TRUS: TRUS mean 52cc, range 11-130 cc and CT mean 65cc, range 29-200cc r=0.78. b) Hormone pretreatment led to a decrease in RT volume (defined by 90% isodose) of 37%: pre-LHRH mean 508 cc, range 161-1093cc, and post LHRH mean 320cc, range 46-646cc. 2) Conformal RT planning reduced RT volumes by 45%: conventional RT volume mean 493cc, range 218-958cc, conformal RT volume mean 277cc, range 109-539cc.
The reduction of RT volume by these complimentary methods may be exploited to either reduce radiation sequelae or to increase the efficacy of treatment by using combined modality therapy or an escalation of radiation dose. Prospective studies are underway to optimise the benefit of these two novel therapeutic approaches.
1
03
04
What happens to patients with localised prostatic carcinoma treated with radiotherapy? - prognostic variables and patterns of relapse in 443 patients. Eeles R, Syndikus I, Gadd J, Davies J, Law M, Gellister J & Dearnaley DP. The Royal Marsden Hospital* & Institute of Cancer Research, Sutton, Surrey. From 1970-1988, 1846 patients with prostatic carcinoma have been treated at one institution.* Of these, 443 had disease localised to the pelvis which was treated by radiotherapy. Median follow-up is 4 years, 7 months (3 months -18.6 years). Presenting stages were TI in 13%, T2 in 24%, T3 in 33%, T4 in 30% and 21% presented with positive pelvic nodes on lymphangiogram or CT imaging. The median age was 67 (47-85 years), and 73% were diagnosed by TURP. All but 4% had adenocarcinomas: 20% grade 1, 52% grade 2, and 28% grade 3. Despite having no extrapelvic disease as assessed by chest X ray, bone scan and CT or lymphangiogram, 8% had a raised acid phoshatase, and this was associated with a higher disease stage (X2 test for trend: p=0.03). Radiotherapy was given to the pelvis in addition to the prostate in 38% and of these, 46% had pelvic nodal disease at presentation. Sixty-eight percent were CT planned, all after 1978. Severe late side effects were defined as those necessitating hospital intervention. No deaths occurred as a result of radiation treatment. Severe side effects, which included urinary catheterisation, were only seen in 8%. All were in the urinary tract; one patient also had a severe bowel complication. The 5 year survival was 55% and 10 year survival, 23%. Death was due to local disease in only 2%, whereas distant metastases caused 61% of deaths. Univariate prognostic factors for survival were T stage, nodal involvement, obstructive uropathy, grade, performance status, haemoglobin level, acid phosphatase and age (pl.OxlO9/litre and the platelet count >50 x 109/litre. If not, treatment was delayed for one week. 14 patients received scalp cooling using the Clinicool Scalp Cooling System. Three patients failed to complete the six weeks course of treatment due to progressive disease. All other patients derived symptomatic benefit from treatment. 14/18 (78%) patients achieved an objective partial response to treatment. The remaining patient died of a pulmonary embolism after two weeks treatment before response could be assessed. Bone marrow suppression was the only significant toxicity. However, there were no episodes of neutropenic sepsis or bleeding induced by the treatment. The median number of treatment delays was one (range 0-4). None of the patients using the Scalp Cooler throughout treatment required a wig. All patients who did not receive scalp cooling developed total alopecia. Complete or major control of emesis was achieved in all patients with simple antiemetics. The VEDEX regimen is effective and well tolerated with minimal gastrointestinal toxicity and, in conjunction with effective scalp cooling, appears to be a very attractive treatment package for
osteoradionecrosis, pathological fracture, or secondary malignancy. A high rate of both local control and long term survival, with minimal long term morbidity, can be achieved in patients presenting with primary lymphoma of bone treated
palliative therapy.
by chemotherapy combined with local radiotherapy. Radiotherapy alone cannot be considered adequate treatment for this condition as it is associated with a high rate of both local and distant failure.
10
040
039 LAMININ: A study of its role in the tumour biology of high grade non-Hodgkin's lymphoma Bailey, NP*., Gregory, Jt., Murphy, A*., Jones, ELt., Jack, An. *CRC Clinical Trials Unit, Birmingham, tDepartment of Pathology, University of Birmingham. aDepartment of Pathology, University of Leeds.
INFECTION, IMMUNE RESPONSES AND INTRAVENOUS IMMUNOGLOBULIN INFECTION PROPHYLAXIS IN MYELOMA R M HARGREAVES, J R LEA, J HOLT, C BUNCH, C REID, H GRIFFITHS, H CHAPEL. John Radcliffe Hospital, Oxford.
High grade (Kiel classification) non-Hodgkin's lymphoma (HGNHL) has a propensity for widespread heterogenous spread. In this study we examined the role of extracellular matrix laminin, a basement membrane glycoprotein, in the biological behaviour of this disease. Laminin increases the invasive metastatic activity of malignant cells (Kleinman, 1985) and is thought to play an active role
Bacterial infection is a well recognised complication of myeloma but its relationship to the almost universal polyclonal humoral immunosuppression characteristic of the disease remains obscure. 102 patients with myeloma were followed prospectively to assess infection rates and factors associated with infection; 41 patients were subsequently immunised and skin tested and 39 took part in a double blind placebo controlled trial of infusions of intravenous immunoglobulin as infection prophylaxis. The serious infection rate was 0.066 infections per patient-month. 45% first serious infections occurred within three months of diagnosis; the majority (50%) involved the respiratory tract. Male sex was associated with a significantly increased risk of serious infection. Severe polyclonal immunosuppression, reduced IgG subclass levels and specific antibody titres were demonstrated in patients with myeloma compared to age-matched controls. Immunisation responses to tetanus,diphtheria and Pneumovax II vaccines were poor in patients with myeloma. Low baseline antipneumococcal and E.Coli titres were associated with an increased risk of serious infection; poor response to
in tumour cell infiltration.
Using an IgG monoclonal antibody against laminin (Sera labs, Sussex, England) and an avidin-biotin complex (ABC) methwd of immunohistochemistry we assessed the laminin content in paraffin sections from 239 patients with histologically proven HGNHL. All sections were reviewed blind by one of us (JG) and laminin expression was assessed on a rating ±, 1+, 2+ or 3+. Tumour vascularity, macrophage infiltration and proliferative activity were similarly assessed by staining with Factor VIII, CD68 and PC1O respectively. The patients had been entered into a prospective multicentre randomised trial of two chemotherapeutic regimes. 4 patients were found to be ineligible for this study on subsequent histological review leaving 235 cases valid for analysis. The median follow-up for all patients was 36.5 months. There were no significant differences between the laminin content (±,1+,2+,3+)
(pj=0.81)
with respect to survival nor was there any trend in survival with respect to increased laminin expression (p=0.61). Comparing survival between laminin content ±_/+ and 2+13+ yields p=0.46 with 2 year survival of 55% and 51% respectively . Subsequent stratification of cases by T or B cell phenotype again showed no significant differences between laminin groups with respect to survival (p=0.62). We found no evidence of association between laminin expression and
Pneumovax correlated with an increased risk of septicaemia 39 patients received a total of 466 infusions (258 Gammagard, 208 placebo) without significant adverse effect These findings suggest a subgroup of patients with myeloma who are at increased risk of serious infection can be identified, and that they may benefit from regular replace -ment intravenous immunoglobulin as infection prophylaxis.
macrophage infiltration (Kendall's Tau-b, Tb = 0.09), proliferative activity (Tb = 0.07) or tumour vascularity (Ib=0.09).
In conclusion laminin content in HGNHL does not predict for subsequent survival. This confirms similar work in other tumours (Yavner, 1990). Laminin expression is also independant of macrophage infiltration, tumour vascularity and proliferative activity in HGNHL. The role of laminin in the biological behaviour of NHL remains unknown. Refs: Kleinman, H. et al (1985) J Cell Biochem 27 317-25. Yavner, D. et al (1990) Obstet Gynecol 76. 1014-19
041
042
CELL CYCLE DEPENDENT MODULATION OF TOPOISOMERASE II LEVELS IN SMALL CELL LUNG CANCER (SCLC) EXPOSED TO LOW DOSE ETOPOSIDE (VP-16).
AN
AUDIT
OF
CHZMOTHERAPY
IN
OF CYTOTOXIC THE EFFECTIVENESS ADVANCED BREAST CANCER.
KE Towlson, MS Leaning, RD Rubens. Clinical Oncology Unit, Guy's Hospital, London UK.
S. J. Falk; T. Gottleib; P.J.Smith. MRC Unit of Clinical Oncology and Radiotherapeutics, Cambridge, UK.
The precise value of cytotoxic chemotherapy in the palliative treatment of advanced breast cancer is For C-here to be bernefit frequently questioned. overall, the adverse effects (toxicity, psychological morbidity and social disruption) must be outweighed by the benefits (symptom relief, improved activity and reversal of life - threatening complications).
The DNA topoisomerase II poison etoposide (VP-16) is used increasingly in prolonged courses orally in SCLC. In model studies of novel clinical schedules incorporating VP-16, SCLC cells (NCI-H69) were exposed continuously to VP- 16 (concentrations < 24M). Quantitative flow cytometric analysis was used to define cell cycle delay, target enzyme expression (using an anti-rabbit topoisomerase II antibody), and DNA synthesis patterns (using bromodeoxyuridine labelling). Topoisomerase II trapping by VP-16 was assessed by measuring DNA-protein crosslinking using the K+-SDS precipitation method.
As part of a comprehensive audit of palliative cancer
chemotherapy
in
the
S
E
Thames
Region,
we
have
undertaken a preliminary analysis on a sub - set of the data relating to advanced breast cancer. Patients receiving first line chemotherapy for advanced disease were studied retrospectively. We have noted sites of disease, prior treatments, activity status and reporting of symptoms before start of treatment and have recorded what was deemed to have been the intention of treatment from information available. "Rules" to assess the utility of treatment have been devised. The data collected were rated independently by two observers with an initial 95% agreement on outcome judgements, rising to 100% at subsequent review.
Drug-induced cytostasis was seen within 48 h of drug exposure. Following a 24 h exposure, the major VP-16-induced cell cycle block occurred in G2 phase with a transient delay of cells in mid to late S phase being apparent at VP-16 concentrations 2 0.25p.M. Cells delayed in S phase showed up to 1.8-fold elevations in topoisomerase II levels compared with control cells in S phase. Following removal from drug, both those cells capable of returning to normal cell cycle distribution (given doses 0.25 gM) were capable of synthesizing DNA at apparently normal rates prior to entry into G2. Importantly, a 24 h pretreatment by 0.25-2tM VP-16 enhanced the ability of subsequent exposure to 4OtM VP-16 to induce cross-links in DNA, also suggesting an increase in target enzyme availability. The intrinsic sensitivity of actively proliferating tumour cells to topoisomerase II poisons is thought to be a function of the availability of the target enzyme. Chronic VP-16 exposure results in i) a scheduled delay of cells in cell cycle phases with elevated topoisomerase II levels. ii) an unscheduled increase in topoisomerase II in cells transiently trapped in S phase. VP- 16 pretreatment may allow enhanced responsiveness to further treatment with topoisomerase II poisons.
38% of patients had an objective response to first line chemotherapy during treatment, falling to 26% by the end of treatment. For second line treatment, the response rate fell to 16% on treatment and 3% by the end of treatment. we saw no objective responses to 34% of either third or fourth line treatments. treatments were judged worthwhile on first line, 11% on second line and none on subsequent treatments. Median durations of benefit to first and second line treatments were 6.0 and 6.5 months respectively. There was a strong correlation between objective response and utility
11
of
treatment
(ch,i2
16.5,
p
10 cm2, neurological symptoms, pathological fracture, disease free interval, consultant, age, performance status, mode of transport, lack of visceral disease, good response to previous RT, predicted survival.
The 13 Districts which participated were the more urban, centralised areas of the Region. These saw 82% of all eligible patients and 72% of general surgeons took part. Overall 31% of patients were entered with randomizations from individual Districts ranging from 6% to 71%. Examination of referral patterns over time indicates the importance of providing participants with adequate support to perform additional trial work. While all 13 centres became active within the first two years of accrual, the increase in the number of centres was offset by a gradual decline in the overall level of activity. Turnover of the trial's clinical support staff and the reporting of late toxicity were both shown to reduce randomizations.
Patients selected for multiple fractions lived significantly longer, but doctors were overoptimistic when real and predicted survivals were compared. Formal characterisation of the group considered unsuitable for single fractions may reduce bias in clinical trials, support formulation of consensus guidelines and provide a realistic basis for contracting arrangements.
Though the original target of 200 cases pa (100% of whole Region) was clearly over-optimistic, we have demonstrated the feasiblity of recruiting 50-70% of the available cases. If more, larger, centres had sustained this level, it would have been possible to reduce the time needed to complete recruitment by up to 24 months. The quality and extent of clinical collaboration shown by this study illustrates the value of encouraging wide participation in pragmatic clinical trials.
046
045
SEX STEROIDS MODULATE THE GROWTH OF TWO HUMAN PANCREATIC CANCER CELL LINES Robertson J.F.R, Watson S.A, Hardcastle J.D. Department of Surgery and Cancer Research Campaign Laboratory, University Hospital, Nottingham
TUMDUR CELL LOCALISATION IN COLONIC INJURY AND REPAIR D Reinbach, J R MbGregor & P J O'Dwyer Dept of Surgery, Western Infirmary, Glasgow.
The Tumour growth is enhanced by tissue injury. mechanism of this may be increased localisation of viable tumour cells at injury sites. The aim of this study was to compare adherence of viable intra-peritoneal tumour cells to normal and to injured colon and to injured colon repaired with different suture types. Under anaesthesia, F344 rats underwent laparotomy and a lcm colotomy in the descending colon. This was repaired with 4 interrupted 5/0 silk sutures (Group IS)., 4 interrupted prolene sutures (Group IP), or 4 interrupted silk or prolene sutures followed by suture remo4i once the anastomosis had sealed (Group IA). 10 Ii : IUDR labelled Mtln3 adenocarcinoma cells were then placed in the left paracolic gutter distant from the anastomosis and the laparotomy incision closed. After 1 hour animals were killed, anastomoses excised, radioactivity measured and cell counts calculated. A lcm length of non-injured left colon (control) was also taken from animals in the IA group. Results were as follows:-
*
Group
n
Control IA IP IS
16 16 7 10
Cell No (Median) 7002 8602 7449 21888
We have studied the effect of sex-hormones on the in-vitro growth of two human pancreatic cancers; MIA PA CA 2 is a well established cell line while PAN1 was derived in our own laboratories. Cells (10) were seeded into wells and thereafter treated with hormone; in all cases control wells were run omitting only the hormone tested. Growth was assessed by Selenomethionine uptake which has been shown to correlate with cell counts (r = 0.997; p < 0.001). The effect of each hormone on growth was expressed as a percentage of the control. All experiments contained 5 replicate wells and each experiment was repeated between 6-10 times. Resuft
Growth of MIA PA CA 2 was stimTlated by.gestradiol (10-6 1_0-lM; p < 0.01) and by progesterone (10 and 10-" M;p < 0.01). Growth was also stimulated by the synthetic progestogen, megestrol acetate (1000 ng/ml - 0.1 ng/ml). Tamoxifen (1000 ng/ml and 100 ng/mI) inhibited basal growth (p < 0.001). Danazol also inhibited basal growth at concentrations of 10 ug/mI (49% of control; p < 0.001) and 5 ug/mI (64% of control; p < 0.001). At 2.5 ug/mI and 1ug/ml Danazol had no effect. Glowth1f PAN1 was significantly stimulated by both,estrqgiol (10 10 M) (p < 0.05 - 0.002) and progesterone (10 - 10- M) (p < 0.001). Danazol inhibited basal growth at concentrations of 10 mg/ml (20% of control; p < 0.001), 5 mg/ml (44%; p < 0.001) and 2.5 mg/ml (74%; p < 0.001). Neither megestrol acetate nor tamoxifen affected the growth of PAN1. We have shown stimulation and inhibition of basal growth of two human pancreatic cancer cell lines by sex steroid hormones. Hormonal manipulation of pancreatic cancer appears to have therapeutic potential.
p Value
NS NS
02 Novel Methods for Improving the Results Radiotherapy in localised Prostate Cancer. D.P. Dearnaley*, R.J. Shearer, L. Ellingham, D. Tait, A. Nahum, M. Chow, A. Horwich. Royal Marsden Hospital and Institute of Cancer Research Surrey. * Supported by the Bob Champion Cancer Trust and Cancer Research Campaign
GROWTH FACTOR INHIBITION AND CARCINOMA OF PROSTATE E O KEHINDE, T HORSBURGH, N MISTRY, T TERRY, P K DONNELLY
Leicester General Hospital, Leicester Prostate cancer cells no longer responsive to conventional hormonal manipulation provide their own fuel in the form of autocrine and paracrine growth factors which stimulate tumour growth in the absence of circulating androgens. Tumour progression may be influenced by growth factor regulators. In this study we evaluated the impact of the antiproliferative Somatostatin analogue (SMS 201-995) and Suramin (a synthetic poly-anionic compound capable of blocking the activity of basic fibroblast growth factor [bFGF] and epidermal growth factor (EGF]) on the in vitro growth of androgen dependent cancer of prostate cell line LNCaP and androgen independent cell lines PC3 and DU145. Tumour cells were adapted to growth in 2.5% FCS for LNCaP and serum free media containing RPMI 1640/ITS (Insulin, transferrin and selenous acid) for PC3 and DU145 cell lines. Cells were exposed to the following concentrations of SMS 201-995 in the range 0 - 200 mcg/ml and Suramin 0 - 810 mcg/ml after 24 hours of initiation of cell growth following plating. Cell counts using haemocytometer and MTT cell growth determination assay were carried out on day 0, 2, 4 and 6. Compared to Suramin-free control, Suramin produced inhibition of cell growth in a dose dependent mapner up to a maximum concentration of 270 mcg/ml. At 270 mcg/ml Suramin produced 50%, 49% and 68% inhibition of growth of LNCaP, PC3 and DU145 cell lines respectively on day 6. In all 3 cell lines at 810 mcg/ml Suramin produced cytolysis. Somatostatin produced inhibition of cell growth in a dose dependent manner in PC3 and LNCaP only. It produced 58% and 27% inhibition at 0.2 mcg/ml of SMS 201-995 on LNCaP and PC3 respectively. Suramin and Somatostatin play an inhibitory role in the growth of cancer of prostate in doses that are achievable in vivo and open new avenues of therapy.
External beam radiotherapy (RT) is effective in eradicating early localised prostate cancer. However as tumour size increases local control is less certain and requires higher irradiation doses and increased radiation target volumes, both of which are associated with an increased risk of treatment related morbidity. We have investigated two complimentary methods aimed at improving the 'therapeutic ratio' of radical radiotherapy using 1) LHRH analogues prior to RT (hormonal cytoreduction) and 2) conformal RT planning using 3-D reconstruction of CT images to build individualised blocks to shape or conform radiation fields. 23 patients were treated with initial LHRH analogues, response was assessed by monthly transrectal ultrasound (TRUS) measurement of prostate volume. Radical RT was given after volume stabilisation. 30 additional patients were evaluated using both conventional and conformal RT planning methods.
Prostate volume reduction after LHRH analogues measured by TRUS was 54% after a median treatment time of 13 weeks. CT Scans taken to simulate RT planning before and after LHRH treatment using 3-D reconstruction of prostate and radiotherapy target volumes showed a) close correlation with the volume measured by TRUS: TRUS mean 52cc, range 11-130 cc and CT mean 65cc, range 29-200cc r=0.78. b) Hormone pretreatment led to a decrease in RT volume (defined by 90% isodose) of 37%: pre-LHRH mean 508 cc, range 161-1093cc, and post LHRH mean 320cc, range 46-646cc. 2) Conformal RT planning reduced RT volumes by 45%: conventional RT volume mean 493cc, range 218-958cc, conformal RT volume mean 277cc, range 109-539cc.
The reduction of RT volume by these complimentary methods may be exploited to either reduce radiation sequelae or to increase the efficacy of treatment by using combined modality therapy or an escalation of radiation dose. Prospective studies are underway to optimise the benefit of these two novel therapeutic approaches.
1
03
04
What happens to patients with localised prostatic carcinoma treated with radiotherapy? - prognostic variables and patterns of relapse in 443 patients. Eeles R, Syndikus I, Gadd J, Davies J, Law M, Gellister J & Dearnaley DP. The Royal Marsden Hospital* & Institute of Cancer Research, Sutton, Surrey. From 1970-1988, 1846 patients with prostatic carcinoma have been treated at one institution.* Of these, 443 had disease localised to the pelvis which was treated by radiotherapy. Median follow-up is 4 years, 7 months (3 months -18.6 years). Presenting stages were TI in 13%, T2 in 24%, T3 in 33%, T4 in 30% and 21% presented with positive pelvic nodes on lymphangiogram or CT imaging. The median age was 67 (47-85 years), and 73% were diagnosed by TURP. All but 4% had adenocarcinomas: 20% grade 1, 52% grade 2, and 28% grade 3. Despite having no extrapelvic disease as assessed by chest X ray, bone scan and CT or lymphangiogram, 8% had a raised acid phoshatase, and this was associated with a higher disease stage (X2 test for trend: p=0.03). Radiotherapy was given to the pelvis in addition to the prostate in 38% and of these, 46% had pelvic nodal disease at presentation. Sixty-eight percent were CT planned, all after 1978. Severe late side effects were defined as those necessitating hospital intervention. No deaths occurred as a result of radiation treatment. Severe side effects, which included urinary catheterisation, were only seen in 8%. All were in the urinary tract; one patient also had a severe bowel complication. The 5 year survival was 55% and 10 year survival, 23%. Death was due to local disease in only 2%, whereas distant metastases caused 61% of deaths. Univariate prognostic factors for survival were T stage, nodal involvement, obstructive uropathy, grade, performance status, haemoglobin level, acid phosphatase and age (pl.OxlO9/litre and the platelet count >50 x 109/litre. If not, treatment was delayed for one week. 14 patients received scalp cooling using the Clinicool Scalp Cooling System. Three patients failed to complete the six weeks course of treatment due to progressive disease. All other patients derived symptomatic benefit from treatment. 14/18 (78%) patients achieved an objective partial response to treatment. The remaining patient died of a pulmonary embolism after two weeks treatment before response could be assessed. Bone marrow suppression was the only significant toxicity. However, there were no episodes of neutropenic sepsis or bleeding induced by the treatment. The median number of treatment delays was one (range 0-4). None of the patients using the Scalp Cooler throughout treatment required a wig. All patients who did not receive scalp cooling developed total alopecia. Complete or major control of emesis was achieved in all patients with simple antiemetics. The VEDEX regimen is effective and well tolerated with minimal gastrointestinal toxicity and, in conjunction with effective scalp cooling, appears to be a very attractive treatment package for
osteoradionecrosis, pathological fracture, or secondary malignancy. A high rate of both local control and long term survival, with minimal long term morbidity, can be achieved in patients presenting with primary lymphoma of bone treated
palliative therapy.
by chemotherapy combined with local radiotherapy. Radiotherapy alone cannot be considered adequate treatment for this condition as it is associated with a high rate of both local and distant failure.
10
040
039 LAMININ: A study of its role in the tumour biology of high grade non-Hodgkin's lymphoma Bailey, NP*., Gregory, Jt., Murphy, A*., Jones, ELt., Jack, An. *CRC Clinical Trials Unit, Birmingham, tDepartment of Pathology, University of Birmingham. aDepartment of Pathology, University of Leeds.
INFECTION, IMMUNE RESPONSES AND INTRAVENOUS IMMUNOGLOBULIN INFECTION PROPHYLAXIS IN MYELOMA R M HARGREAVES, J R LEA, J HOLT, C BUNCH, C REID, H GRIFFITHS, H CHAPEL. John Radcliffe Hospital, Oxford.
High grade (Kiel classification) non-Hodgkin's lymphoma (HGNHL) has a propensity for widespread heterogenous spread. In this study we examined the role of extracellular matrix laminin, a basement membrane glycoprotein, in the biological behaviour of this disease. Laminin increases the invasive metastatic activity of malignant cells (Kleinman, 1985) and is thought to play an active role
Bacterial infection is a well recognised complication of myeloma but its relationship to the almost universal polyclonal humoral immunosuppression characteristic of the disease remains obscure. 102 patients with myeloma were followed prospectively to assess infection rates and factors associated with infection; 41 patients were subsequently immunised and skin tested and 39 took part in a double blind placebo controlled trial of infusions of intravenous immunoglobulin as infection prophylaxis. The serious infection rate was 0.066 infections per patient-month. 45% first serious infections occurred within three months of diagnosis; the majority (50%) involved the respiratory tract. Male sex was associated with a significantly increased risk of serious infection. Severe polyclonal immunosuppression, reduced IgG subclass levels and specific antibody titres were demonstrated in patients with myeloma compared to age-matched controls. Immunisation responses to tetanus,diphtheria and Pneumovax II vaccines were poor in patients with myeloma. Low baseline antipneumococcal and E.Coli titres were associated with an increased risk of serious infection; poor response to
in tumour cell infiltration.
Using an IgG monoclonal antibody against laminin (Sera labs, Sussex, England) and an avidin-biotin complex (ABC) methwd of immunohistochemistry we assessed the laminin content in paraffin sections from 239 patients with histologically proven HGNHL. All sections were reviewed blind by one of us (JG) and laminin expression was assessed on a rating ±, 1+, 2+ or 3+. Tumour vascularity, macrophage infiltration and proliferative activity were similarly assessed by staining with Factor VIII, CD68 and PC1O respectively. The patients had been entered into a prospective multicentre randomised trial of two chemotherapeutic regimes. 4 patients were found to be ineligible for this study on subsequent histological review leaving 235 cases valid for analysis. The median follow-up for all patients was 36.5 months. There were no significant differences between the laminin content (±,1+,2+,3+)
(pj=0.81)
with respect to survival nor was there any trend in survival with respect to increased laminin expression (p=0.61). Comparing survival between laminin content ±_/+ and 2+13+ yields p=0.46 with 2 year survival of 55% and 51% respectively . Subsequent stratification of cases by T or B cell phenotype again showed no significant differences between laminin groups with respect to survival (p=0.62). We found no evidence of association between laminin expression and
Pneumovax correlated with an increased risk of septicaemia 39 patients received a total of 466 infusions (258 Gammagard, 208 placebo) without significant adverse effect These findings suggest a subgroup of patients with myeloma who are at increased risk of serious infection can be identified, and that they may benefit from regular replace -ment intravenous immunoglobulin as infection prophylaxis.
macrophage infiltration (Kendall's Tau-b, Tb = 0.09), proliferative activity (Tb = 0.07) or tumour vascularity (Ib=0.09).
In conclusion laminin content in HGNHL does not predict for subsequent survival. This confirms similar work in other tumours (Yavner, 1990). Laminin expression is also independant of macrophage infiltration, tumour vascularity and proliferative activity in HGNHL. The role of laminin in the biological behaviour of NHL remains unknown. Refs: Kleinman, H. et al (1985) J Cell Biochem 27 317-25. Yavner, D. et al (1990) Obstet Gynecol 76. 1014-19
041
042
CELL CYCLE DEPENDENT MODULATION OF TOPOISOMERASE II LEVELS IN SMALL CELL LUNG CANCER (SCLC) EXPOSED TO LOW DOSE ETOPOSIDE (VP-16).
AN
AUDIT
OF
CHZMOTHERAPY
IN
OF CYTOTOXIC THE EFFECTIVENESS ADVANCED BREAST CANCER.
KE Towlson, MS Leaning, RD Rubens. Clinical Oncology Unit, Guy's Hospital, London UK.
S. J. Falk; T. Gottleib; P.J.Smith. MRC Unit of Clinical Oncology and Radiotherapeutics, Cambridge, UK.
The precise value of cytotoxic chemotherapy in the palliative treatment of advanced breast cancer is For C-here to be bernefit frequently questioned. overall, the adverse effects (toxicity, psychological morbidity and social disruption) must be outweighed by the benefits (symptom relief, improved activity and reversal of life - threatening complications).
The DNA topoisomerase II poison etoposide (VP-16) is used increasingly in prolonged courses orally in SCLC. In model studies of novel clinical schedules incorporating VP-16, SCLC cells (NCI-H69) were exposed continuously to VP- 16 (concentrations < 24M). Quantitative flow cytometric analysis was used to define cell cycle delay, target enzyme expression (using an anti-rabbit topoisomerase II antibody), and DNA synthesis patterns (using bromodeoxyuridine labelling). Topoisomerase II trapping by VP-16 was assessed by measuring DNA-protein crosslinking using the K+-SDS precipitation method.
As part of a comprehensive audit of palliative cancer
chemotherapy
in
the
S
E
Thames
Region,
we
have
undertaken a preliminary analysis on a sub - set of the data relating to advanced breast cancer. Patients receiving first line chemotherapy for advanced disease were studied retrospectively. We have noted sites of disease, prior treatments, activity status and reporting of symptoms before start of treatment and have recorded what was deemed to have been the intention of treatment from information available. "Rules" to assess the utility of treatment have been devised. The data collected were rated independently by two observers with an initial 95% agreement on outcome judgements, rising to 100% at subsequent review.
Drug-induced cytostasis was seen within 48 h of drug exposure. Following a 24 h exposure, the major VP-16-induced cell cycle block occurred in G2 phase with a transient delay of cells in mid to late S phase being apparent at VP-16 concentrations 2 0.25p.M. Cells delayed in S phase showed up to 1.8-fold elevations in topoisomerase II levels compared with control cells in S phase. Following removal from drug, both those cells capable of returning to normal cell cycle distribution (given doses 0.25 gM) were capable of synthesizing DNA at apparently normal rates prior to entry into G2. Importantly, a 24 h pretreatment by 0.25-2tM VP-16 enhanced the ability of subsequent exposure to 4OtM VP-16 to induce cross-links in DNA, also suggesting an increase in target enzyme availability. The intrinsic sensitivity of actively proliferating tumour cells to topoisomerase II poisons is thought to be a function of the availability of the target enzyme. Chronic VP-16 exposure results in i) a scheduled delay of cells in cell cycle phases with elevated topoisomerase II levels. ii) an unscheduled increase in topoisomerase II in cells transiently trapped in S phase. VP- 16 pretreatment may allow enhanced responsiveness to further treatment with topoisomerase II poisons.
38% of patients had an objective response to first line chemotherapy during treatment, falling to 26% by the end of treatment. For second line treatment, the response rate fell to 16% on treatment and 3% by the end of treatment. we saw no objective responses to 34% of either third or fourth line treatments. treatments were judged worthwhile on first line, 11% on second line and none on subsequent treatments. Median durations of benefit to first and second line treatments were 6.0 and 6.5 months respectively. There was a strong correlation between objective response and utility
11
of
treatment
(ch,i2
16.5,
p
10 cm2, neurological symptoms, pathological fracture, disease free interval, consultant, age, performance status, mode of transport, lack of visceral disease, good response to previous RT, predicted survival.
The 13 Districts which participated were the more urban, centralised areas of the Region. These saw 82% of all eligible patients and 72% of general surgeons took part. Overall 31% of patients were entered with randomizations from individual Districts ranging from 6% to 71%. Examination of referral patterns over time indicates the importance of providing participants with adequate support to perform additional trial work. While all 13 centres became active within the first two years of accrual, the increase in the number of centres was offset by a gradual decline in the overall level of activity. Turnover of the trial's clinical support staff and the reporting of late toxicity were both shown to reduce randomizations.
Patients selected for multiple fractions lived significantly longer, but doctors were overoptimistic when real and predicted survivals were compared. Formal characterisation of the group considered unsuitable for single fractions may reduce bias in clinical trials, support formulation of consensus guidelines and provide a realistic basis for contracting arrangements.
Though the original target of 200 cases pa (100% of whole Region) was clearly over-optimistic, we have demonstrated the feasiblity of recruiting 50-70% of the available cases. If more, larger, centres had sustained this level, it would have been possible to reduce the time needed to complete recruitment by up to 24 months. The quality and extent of clinical collaboration shown by this study illustrates the value of encouraging wide participation in pragmatic clinical trials.
046
045
SEX STEROIDS MODULATE THE GROWTH OF TWO HUMAN PANCREATIC CANCER CELL LINES Robertson J.F.R, Watson S.A, Hardcastle J.D. Department of Surgery and Cancer Research Campaign Laboratory, University Hospital, Nottingham
TUMDUR CELL LOCALISATION IN COLONIC INJURY AND REPAIR D Reinbach, J R MbGregor & P J O'Dwyer Dept of Surgery, Western Infirmary, Glasgow.
The Tumour growth is enhanced by tissue injury. mechanism of this may be increased localisation of viable tumour cells at injury sites. The aim of this study was to compare adherence of viable intra-peritoneal tumour cells to normal and to injured colon and to injured colon repaired with different suture types. Under anaesthesia, F344 rats underwent laparotomy and a lcm colotomy in the descending colon. This was repaired with 4 interrupted 5/0 silk sutures (Group IS)., 4 interrupted prolene sutures (Group IP), or 4 interrupted silk or prolene sutures followed by suture remo4i once the anastomosis had sealed (Group IA). 10 Ii : IUDR labelled Mtln3 adenocarcinoma cells were then placed in the left paracolic gutter distant from the anastomosis and the laparotomy incision closed. After 1 hour animals were killed, anastomoses excised, radioactivity measured and cell counts calculated. A lcm length of non-injured left colon (control) was also taken from animals in the IA group. Results were as follows:-
*
Group
n
Control IA IP IS
16 16 7 10
Cell No (Median) 7002 8602 7449 21888
We have studied the effect of sex-hormones on the in-vitro growth of two human pancreatic cancers; MIA PA CA 2 is a well established cell line while PAN1 was derived in our own laboratories. Cells (10) were seeded into wells and thereafter treated with hormone; in all cases control wells were run omitting only the hormone tested. Growth was assessed by Selenomethionine uptake which has been shown to correlate with cell counts (r = 0.997; p < 0.001). The effect of each hormone on growth was expressed as a percentage of the control. All experiments contained 5 replicate wells and each experiment was repeated between 6-10 times. Resuft
Growth of MIA PA CA 2 was stimTlated by.gestradiol (10-6 1_0-lM; p < 0.01) and by progesterone (10 and 10-" M;p < 0.01). Growth was also stimulated by the synthetic progestogen, megestrol acetate (1000 ng/ml - 0.1 ng/ml). Tamoxifen (1000 ng/ml and 100 ng/mI) inhibited basal growth (p < 0.001). Danazol also inhibited basal growth at concentrations of 10 ug/mI (49% of control; p < 0.001) and 5 ug/mI (64% of control; p < 0.001). At 2.5 ug/mI and 1ug/ml Danazol had no effect. Glowth1f PAN1 was significantly stimulated by both,estrqgiol (10 10 M) (p < 0.05 - 0.002) and progesterone (10 - 10- M) (p < 0.001). Danazol inhibited basal growth at concentrations of 10 mg/ml (20% of control; p < 0.001), 5 mg/ml (44%; p < 0.001) and 2.5 mg/ml (74%; p < 0.001). Neither megestrol acetate nor tamoxifen affected the growth of PAN1. We have shown stimulation and inhibition of basal growth of two human pancreatic cancer cell lines by sex steroid hormones. Hormonal manipulation of pancreatic cancer appears to have therapeutic potential.
p Value
NS NS
