John R. Durant

31P NMR spectroscopy of in vivo tumors

Abstract A probe, suitable for any wide-bore NMR spectrometer, was constructed for monitoring high-resolution spectra of in vivo subcutaneously implanted tumors in mice. Preliminary studies of a variety of murine tumors (MOPC 104E myeloma, Dunn osteosarcoma, colon-26, ovarian M5, and mammary adenocarcinoma as well as human colon, mammary, and lung tumors in athymic mice) indicate that the 31P NMR spectrum is a sensitive monitor of progressive metabolic changes that occur during untreated tumor growth and an early indicator of tumor response to chemotherapy, hyperthermia, and X radiation. Response to each of these therapeutic modalities is accompanied by distinctly different spectral changes.

Pulmonary Toxicity Associated with Bischloroethylnitrosourea (BCNU)

Ten patients developed pulmonary fibrosis after bischloroethylnitrosourea (BCNU) therapy for malignancy. This was lethal in seven patients, four of whom had no evidence of tumor at autopsy. Presenting symptoms were either the insidious onset of cough and dyspnea or the sudden onset of respiratory failure. Physical findings were unremarkable. Chest roentgenogram usually showed interstitial infiltrates. Pulmonary function studies showed resting hypoxia with diffusion and restrictive defects. This complication of therapy does not appear to be dose related and may be made more likely by the concomitant administration of cyclophosphamide. Prednisone therapy did not benefit most patients. The literature and the implications of the use of BCNU alone or in combination are reviewed.

The superiority of combination chemotherapy over single agent chemotherapy in small cell lung carcinoma.

From June 1974 to October 1976, 288 patients with small cell undifferentiated lung carcinoma were entered into a randomized, controlled study comparing the two noncycle‐active induction regimens of cyclophosphamide vs. the combination of cyclophosphamide, doxorubicin and imidazole carboximide (DTIC). Patients were stratified by extent of disease, previous radiotherapy and performance status. Responding patients and those who did not progress were then randomized to receive their initial regimen alone, or their initial regimen with added cycle‐active therapy (vincristine, hydroxyurea and methotrexate). While only 4/34 (12%) evaluable patients treated with cyclophosphamide achieved a response (<50% regression), a final total of 119/217 (57%) evaluable patients on the three drugs have responded (p = 0.005). The survival curve for all the combination‐treated patients was significantly better than for those treated with cyclophosphamide alone (p = 0.012). There was no demonstrable statistical superiority in length of remission or survival for patients on the combination who received in addition cycle‐active consolidation therapy. In the combination chemotherapy group, survival duration was longer for patients with limited disease than extensive disease (p = 0.035). There was a strong correlation between quality of remission produced by the combination and survival. Cancer 44:406‐413, 1979.

A practical system for clinical radiofrequency hyperthermia

Abstract This paper describes an apparatus for inducing local hyperthermis by passing high-frequency electrical currents through tissues between electrodes placed against the skin of the patient. The electrodes use a temperature-controlled saline solution contained by a thin rubber membrane to make contact. The resistivity of the saline solution is matched to that of body tissues. This yields a smooth transition from electrode to tissue, thereby greatly reducing the possibility of producing the skin burns which frequently appear along the edges of metallic electrodes. Use of the thin rubber membrane allows easy molding of a given set of electrodes to complex body contours for many different patients. The equipment has proven capable in clinical tests of heating bulky tumors in the head and neck and extremities without significant skin toxicity. Excessive beating of the subcutaneous fat, however, restricts the application of this heating method to tumors located in areas of the body with sparse adipose tissue.

Human tumors as examined by in vivo 31P NMR in athymic mice

Abstract Surface coils have been employed to monitor in vivo 31P NMR spectra of human breast (MX-1), lung (LX-1) and colon (CX-1) tumors subcutaneously implanted in athymic mice. Spectra of these NCI screening tumors were measured during various stages of untreated growth. A progressive decrease in phosphocreatine and ATP and an increase in inorganic phosphate were observed for the MX-1 tumor line. The lung and colon tumors also exhibited a growth associated increase in sugar phosphates. The spectral characteristics of these tumors were very similar to those of corresponding murine tumors: mammary 16 C adenocarcinoma, Lewis lung sarcoma and colon 26. These data provide a basis for development of NMR techniques for monitoring human tumors in situ or in athymic mice.

Evidence that estrogen‐receptor‐negative, progesterone‐receptor‐positive breast and ovarian carcinomas contain estrogen receptor

A small number of primary metastatic breast carcinomas are estrogen‐receptor‐negative and progesterone‐receptor‐positive (ER—, PGR+) under the normal ligand‐binding assay or sucrose density gradient conditions. Among more than 500 tumors analyzed in this laboratory over a year and a half, 28 cases fit this category, 18 of which were patients 51 years of age or younger (Group A) and 7 were patients over the age of 56 (Group B). The ages of three patients were unknown (Group C). By treatment of each of those tumor cytosols with dextran‐coated charcoal before the assay was done, 13 of group A became positive (ER range 10–87 fmol/mg protein); 1 was borderline (ER 3–9 fmol/mg protein); 1 became positive only on sucrose gradient determination, and 2 remained negative. In comparison, two patients in group B shifted from borderline ER to ER+ and only one ER– became ER+ at 10 fmol/mg protein. The data provide additional rationale for determining both ER and PGR in all patients, and have obvious implications for the need of standard methods of determining ER and PGR in the prognosis of women with breast cancer.

A randomized prospective clinical trial of adjuvant C. parvum immunotherapy in 260 patients with clinically localized melanoma (Stage I): Prognostic factors analysis and preliminary results of immunotherayp

A total of 260 patients with clinically localized melanoma (Stage I) from 18 medical institutions in the Southeastern Cancer Study Group were randomized to receive either surgical treatment alone, or surgery plus Corynebacterium parvum immunotherapy. A multivariant analysis (Cox regression model) of nine prognostic factors was performed on 110 patients with a minimum of two years follow‐up. The dominant prognostic variables were thickness (P = 0.0007) and anatomic location of the melanoma (trunk versus other, P = 0.015). Disease‐free survival curves were then calculated for 204 surgically evaluable patients. Overall, there was no significant difference in three‐year survival for the two‐treatment arms, which was 81% for the adjuvant immunotherapy group compared to 67% for the surgical control group (P = 0.10). The median follow‐up period was 24 months (range, 1‐60 months). However, when the data was subgrouped by tumor thickness, an apparent benefit of immunotherapy was observed in 49 patients with melanomas greater than 3 mm in thickness. Only five of 23 such patients relapsed after receiving C. parvum. Their three‐year disease‐free survival was 73%. In contrast, 13 of 26 patients who did not receive immunotherapy have relapsed so far and their three‐year disease‐free survival was only 33% (P = 0.01). In the 175 patients with melanomas less than 3 mm in thickness, both treatment arms had identical three‐year disease‐free survival rates of 83%. No significant differences between the treatment arms were observed using other prognostic variables, including the level of invasion. Toxicity to C. parvum injections was minimal in most patients. It is concluded that a prognostic factors analysis is critically important in adjunctive trials of melanoma to determine which dominant variables should be used for analyzing patient subgroups; that C. parvum immunotherapy appears to be associated with an improved disease‐free survival rate in the subgroup of patients with melanomas >3 mm thickness (this early encouraging data must still be confirmed with continued patients accrual and a longer observation period); and that patients with melanomas less than 3 mm thick have a relatively favorable prognosis after appropriate surgical treatment, and immunotherapy does not improve their survival rates.

Pathogenesis of hodgkin's disease: Separation and culture of different kinds of cells from hodgkin's disease in a sterile isokinetic gradient of ficoll in tissue culture medium

The pathogenesis of Hodgkins disease is controversial. Some view the lymphocyte in Hodgkins tumor as an integral part of the malignant proliferation; others interpret the lymphocyte as a manifestation of the hosts attempt to reject the neoplasm. In an effort to study interactions between individual kinds of cells from Hodgkins disease, we have developed a method for disaggregating Hodgkins tumor using collagenase. The disaggregated cells have been frozen in a viable state and, after storage over liquid nitrogen, two kinds of cells have been obtained consistently in tissue culture from all five patients whose cells have been studied. Prior to culture, one of these cell types—a very homogeneous population of mature‐appearing lymphoid cells—has been separated from the other kinds of cells in 98.4 ± O.4% purity. This separation was accomplished using centrifugation in a gradient of Ficoll (polysucrose) in tissue culture medium. In culture, these cells divide and produce only lymphoid cells. The other kind of cell which can be cultured from Hodgkins disease—a histiocytic cell—can be widely separated from the lymphoid cells and does not give rise to lymphocytes in tissue culture. Using purified populations of the individual kinds of cells, it will be possible to study the possible cytotoxicity of the lymphoid cells for the histiocytic cells. To our knowledge, this is the first reported separation of lymphocytes from solid tumors, and the method may be broadly applicable in the investigation of lymphocytes which infiltrate solid tumors.

Combination chemotherapy in small cell lung carcinoma: A randomized study of two intensive regimens

From April, 1979 to November, 1981, 293 patients with small cell lung carcinoma (SCLC) were entered on a randomized, controlled study comparing the two induction regimens of high‐dose CAV (HD‐CAV) (cyclophosphamide [CTX] 1200 mg/m2, doxorubicin [ADR] 70 mg/m2 and vincristine [VCR] 1 mg/m2 intravenously (IV) on days 1 and 21) versus, conventional‐dose CAV + VP‐16 (etoposide) (CAV‐VP) (CTX 1000 mg/m2, ADR 40 mg/m2, VCR 1 mg/m2 IV on days 1 and 21 with VP‐16 100 mg/m2 on days 1–3, and 21–23). Responding and stable patients were continued on conventional‐dose CAV for 5 consolidation courses. Prophylactic brain irradiation delivered after the first consolidation course in responders was optional. Patients were included in the study if they had extensive disease (i.e., beyond one hemithorax), no prior chemotherapy, or radiotherapy and performance status of 50 or above. After 2 induction courses, 215 cases are evaluable. Of these, 76 of 106 (72%) patients treated with HD‐CAV have responded (>50% regression), including 13 complete responders (CRs) versus 80 of 108 (74%) patients on CAV‐VP, including 15 CRs. Of the 130 evaluable patients who have completed consolidation (HD‐CAV, 65; CAV‐VP, 65), an additional 22 patients achieved CR (HD‐CAV, 12; CAV‐VP, 10) for an overall CR rate of 24%. Median duration of remission was 33.6 weeks for HD‐CAV and 35.6 weeks for CAV‐VP (P = 0.61). Median duration of complete response for HD‐CAV was 33.8 weeks and for CAV‐VP 36.7 weeks (P = 0.81). Survival curves were similar for the two regimens, with medians of 42.1 weeks for HD‐CAV and 42.3 weeks for CAV‐VP (P = 0.35). Survival correlated with performance status and quality of response. As anticipated, the major toxicity for both induction regimens was leukopenia. During induction, granulocyte nadirs of <500/mm3 occurred in 81% of patients on HD‐CAV and 77% of patients on CAV‐VP. Thus, dose intensification appears to produce high response rates and modest complete response rates in extensive SCLC, but it does not appear to improve materially survival compared to prior reports of conventional‐dose therapy.

BCNU, velban, cyclophosphamide, procarbazine, and prednisone (BVCPP) in advanced Hodgkin's disease.

Three hundred twenty‐four evaluable patients with advanced or recurrent Hodgkins disease were treated with BVCPP. After stratification according to amount of prior therapy, patients who achieved complete remission were randomized to no additional therapy, 6 monthly cycles of MOPP or 6 additional monthly cycles of BVCPP. Complete remission rates were comparable to other studies: 68–73% for those who had not received prior chemotherapy and 28% for those who had. Although curves of disease‐free survival suggested that BVCPP maintenance therapy significantly prolonged a complete remission in previously untreated patients, multivariate analysis did not demonstrate such therapy to be a significant prognostic factor. Rather, favorable prognostic indicators were shown to be related to host factors. Subsequent analysis demonstrated that the maintenance and no‐maintenance groups of previously untreated patients were not strictly comparable in that the maintained group had more patients with favorable histologies who were less than 40 years of age. Herpes Varicella Zoster was not found to affect prognosis adversely. It is concluded that maintenance chemotherapy with BVCPP or MOPP does not significantly improve duration of complete remission or survival and that further comparative or sequential studies should include stratification of the important factors influencing duration of response and survival. Further, even though second remissions may be induced in the previously treated, their subsequent prognosis is poorer. For all patient groups female sex and an initial lymphocyte count > 1,372 were favorable factors. For those with little or no prior therapy, age <40, Caucasian race, and having lymphocyte predominance or nodular sclerosis favorably influenced the outcome as well. For those with major prior therapy not having had prior chemotherapy, having IIIA disease, and not having nodular sclerosis were important additional determinants of remission or survival. Cancer 42:2101–2110, 1978.