Posaconazole liquid vs tablet formulation in lung transplant recipients.

Posaconazole is an extended-spectrum triazole antifungal used in the treatment and prophylaxis of Aspergillus infections. It is available as oral suspension (POS-Liq) and delayed-release tablets (POS-Tab). The aim of this longitudinal, retrospective study was to compare the clinical effectiveness, toxicity and pharmacokinetics of POS-Liq vs POS-Tab in lung transplant recipients (LTx-recipients), who were treated with both formulations subsequently. Twenty-four consecutive LTx-recipients with 191 documented posaconazole trough levels (PTLs) for POS-Liq or POS-Tab were included. The administered daily doses were 300 mg for POS-Tab and 600 mg (prophylaxis) or 800 mg (therapy) for POS-Liq. Target PTLs were ≥700 ng/mL (prophylaxis) and ≥1250 ng/mL (therapy). The overall prophylactic and therapeutic response rates were 78% and 67%, respectively. No cases of hepatotoxicity or QT-prolongation were observed with either formulation. The achieved target PTLs were tripled under POS-Tab compared to POS-Liq with fewer risk factors for sub-therapeutic PTLs. Concomitant administration of POS-Tab significantly reduced the tacrolimus concentration-to-dose ratio (P = .001). We suggest the use of POS-Tab is appropriate for prophylaxis and therapy of Aspergillus infections in LTx-recipients, since POS-Tab displayed more reliable PTLs with no added adverse events. However, we recommend regular drug monitoring for POS-Liq and for therapy with POS-Tab and that immunosuppressant levels are monitored closely when the posaconazole formulation is switched.

Identification of high-risk patients with clear cell renal cell carcinoma based on interphase-FISH.

BACKGROUND: The aim of this study was to examine the prognostic value of four significant aberrations based on our previous studies by array-CGH to develop a prognostic Fluorescence-in situ-hybridisation (FISH) assay for clear cell renal cell carcinomas (ccRCC). METHODS: Fluorescence-in situ-hybridisation experiments were performed on 100 ccRCCs (52 metastasised out of 48 non-metastasised). The mean/median follow up of patients was 59/54 months. Commercially available FISH probes were used for each critical chromosomal region (1q21.3, 7q36.3, 9p21.3p24.1 and 20q11.21q13.32). The total number of specific aberrations (TNSA) was calculated for each tumour based on the specific genomic alterations. RESULTS: Total number of specific aberrations was the best predictor of metastasis (area under the curve (AUC)=0.814) compared with single aberrations (AUC: 0.619-0.708) and to 11 different combinations of these 4 aberrations in the receiver operating characteristic curve analysis. Total number of specific aberrations, tumour grade and tumour size were independent predictors of metastasis in the multivariate analysis (P<0.001) for the whole cohort as well as for organ-confined tumours. Total number of specific aberrations and grade could also independently predict cancer-specific mortality (CSM). Total number of specific aberrations demonstrated the highest significance in COX proportional hazard models of overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS). CONCLUSIONS: We identified TNSA as an independent prognostic factor which is associated with metastasis occurrence, CSM, OS, CSS and PFS in patients with ccRCCs.

Exaggerated aggression and decreased anxiety in mice deficient in brain serotonin.

Serotonin is a major neurotransmitter in the central nervous system (CNS). Dysregulation of serotonin transmission in the CNS is reported to be related to different psychiatric disorders in humans including depression, impulsive aggression and anxiety disorders. The most frequently prescribed antidepressants and anxiolytics target the serotonergic system. However, these drugs are not effective in 20-30% of cases. The causes of this failure as well as the molecular mechanisms involved in the origin of psychological disorders are poorly understood. Biosynthesis of serotonin in the CNS is initiated by tryptophan hydroxylase 2 (TPH2). In this study, we used Tph2-deficient (Tph2(-/-)) mice to evaluate the impact of serotonin depletion in the brain on mouse behavior. Tph2(-/-) mice exhibited increased depression-like behavior in the forced swim test but not in the tail suspension test. In addition, they showed decreased anxiety-like behavior in three different paradigms: elevated plus maze, marble burying and novelty-suppressed feeding tests. These phenotypes were accompanied by strong aggressiveness observed in the resident-intruder paradigm. Despite carrying only one copy of the gene, heterozygous Tph2(+/-) mice showed only 10% reduction in brain serotonin, which was not sufficient to modulate behavior in the tested paradigms. Our findings provide unequivocal evidence on the pivotal role of central serotonin in anxiety and aggression.

On the interactions between Fusarium toxin-contaminated wheat and non-starch-polysaccharide hydrolysing enzymes in turkey diets on performance, health and carry-over of deoxynivalenol and zearalenone.

1. Diets with increasing proportions of Fusarium toxin-contaminated wheat (0, 170, 340 and 510 g CW/kg) were fed to male turkeys (BUT Big 6) from d 21 to d 56 of age. Each diet was tested with or without a non-starch-polysaccharide (NSP) hydrolysing enzyme preparation. Dietary deoxynivalenol (DON) and zearalenone (ZON) concentrations were successively increased up to approximately 5.4 and 0.04 mg/kg, respectively. 2. Weight gain decreased slightly with increasing proportions of CW, by 1.6, 0.7 and 3.6%, whereas other performance parameters remained unaffected. NSP enzyme supplements to the diets had no influence. 3. The weight of the emptied jejunum plus ileum, relative to live weight, decreased in a dose-related fashion whereby the NSP enzyme exerted an additional weight-decreasing effect. A similar weight-decreasing NSP enzyme effect was noted for heart weights. Activity of glutamate dehydrogenase in serum was significantly increased in groups fed the diets with the highest CW proportion, whereas gamma-glutamyl-transferase remained unaltered. 4. Viscosity in the small intestine was significantly reduced by supplementing the diets with the NSP enzyme. This effect successively decreased with increasing proportions of the CW. 5. Concentrations of DON and of its de-epoxidised metabolite de-epoxy-DON in plasma, liver and breast meat were lower than the detection limits of 2 ng/ml (plasma) and 4 ng/g, respectively, of the applied HPLC method. DON concentration in bile reached up to 13 to 23 ng/ml whereas de-epoxy-DON concentration was lower than 4 ng/ml. 6. ZON or its metabolites were not detectable in plasma, liver or breast meat (detection limits of the HPLC method were 1, 0.5 and 5 ng/g for ZON, alpha-zearalenol (ZOL) and beta-ZOL, respectively). Concentrations of ZON and alpha-ZOL in bile increased with dietary ZON concentration. The mean proportions of ZON, alpha-ZOL and beta-ZOL of the sum of all three metabolites were 19, 77 and 4%, respectively.

On the interactions between Fusarium toxin-contaminated wheat and nonstarch polysaccharide hydrolyzing enzymes in diets of broilers on performance, intestinal viscosity, and carryover of deoxynivalenol.

Wheat was inoculated with Fusarium culmorum. Broiler diets were formulated to contain this Fusarium-infected wheat (FIW) or control wheat (CW) at a proportion of 60% and were prepared without and with an exogenous nonstarch polysaccharide (NSP) hydrolyzing enzyme preparation [endo-1,4-beta-xylanase (EC 3.2.1.8) 1,000 FXU/g; ZY68, Lohmann Animal Health GmbH & Co. KG, Cuxhaven, Germany] to test the hypothesis that Fusarium infection-related increases in NSP hydrolyzing enzyme activities could compensate for the deleterious effects of the fungal-origin mycotoxins such as deoxynivalenol (DON). Deoxynivalenol concentration of CW and FIW amounted to 0.045 and 2.5 mg/kg of DM, respectively. After 35 d, the level of feed intake was generally lower in broilers fed the diets containing the FIW. Feed intake was stimulated by the addition of the NSP enzyme to both diet types. Similar relationships were observed for live weight gain, although the enzyme effect was much more pronounced for the CW-fed broilers, who performed even worse than the broilers fed the unsupplemented FIW. Viscosity was significantly reduced in the jejunum and the ileum by supplemental exogenous NSP hydrolyzing enzyme. However, this effect was more pronounced when the enzyme was added to the control diet, as indicated by the significant interactions between wheat and NSP enzyme. Concentrations of DON and its metabolite deepoxy-DON in plasma, bile, liver, and breast meat were lower than the detection limits of the applied HPLC-method. Overall, it can be concluded that feeding FIW might positively influence broiler performance and nutritional physiology, as indicated by the reduced intestinal viscosity and the less pronounced effects of addition of an exogenous NSP hydrolyzing enzyme preparation.

Effects of graded levels of Fusarium-toxin-contaminated wheat in Pekin duck diets on performance, health and metabolism of deoxynivalenol and zearalenone.

1. Diets with increasing proportions of Fusarium-toxin-contaminated wheat were fed to Pekin ducks for 49 d in order to titrate the lowest effect level. Dietary deoxynivalenol (DON) and zearalenone (ZON) concentrations were successively increased up to 6 to 7 mg/kg and 0.05 to 0.06 mg/kg, respectively. 2. Feed intake, live weight gain and feed to gain ratio were not influenced by dietary treatment. 3. Gross macroscopic inspection of the upper digestive tract did not reveal any signs of irritation, inflammation or other pathological changes. The weight of the bursa of Fabricius, relative to live weight, decreased in a dose-related fashion. Activities of glutamate dehydrogenase and gamma-glutamyl-transferase in serum were either unaffected or inconsistently affected by dietary treatments. 4. Concentrations of DON and of its de-epoxydised metabolite in plasma and bile were lower than the detection limits of 6 and 16 ng/ml, respectively, of the applied high performance liquid chromatography (HPLC) method. 5. ZON or its metabolites were not detectable in plasma and livers (detection limits of the HPLC method were 1, 0.5 and 5 ng/g for ZON, alpha-zearalenol (alpha-ZOL) and beta-zearalenol (beta-ZOL), respectively). Concentrations of ZON, alpha-ZOL and beta-ZOL in bile increased linearly with dietary ZON concentration. The mean proportions of ZON, alpha-ZOL and beta-ZOL of the sum of all three metabolites were 80, 16 and 4%, respectively. 6. Taken together, it can be concluded that dietary DON and ZON concentrations up to 6 and 0.06 mg/kg, respectively, did not adversely affect performance and health of growing Pekin ducks.

Dose-response feeding study of chlorinated paraffins in broiler chickens: effects on growth rate and tissue distribution.

Even with the highest additions of 100mg kg(-1) short-chain (C10-C13) chlorinated paraffins (CP) to feed, the health of broilers was not adversely affected during a 31-day feeding experiment. In addition, 1 and 3 weeks after the experiment started, growth rate and feed consumption of the young animals were not impaired. No significant influence on mortality, organ weight relative to live weight or performance (weight gain, feed consumption) was noted. The CP concentrations in abdominal fat, meat, liver and kidneys were related linearly to the CP concentration of the feed. The highest contents were analysed in fat and the faeces, and the lowest concentrations were found in blood, meat and bile fluid. Less than 5% of the CP amount consumed was incorporated into the body, without taking the head, gut, feet and feathers into account.

Effects of graded levels of Fusarium toxin-contaminated wheat and of a detoxifying agent in broiler diets on performance, nutrient digestibility and blood chemical parameters.

1. A growth experiment was carried out with male broilers from d 1 to d 35 of age in order to evaluate the effects of the addition of a detoxifying agent (Mycofix Plus, Biomin GmbH, Herzogenburg, Austria) at different dietary proportions of wheat (0, 16.5, 33, 49.5 and 66%) contaminated with Fusarium mycotoxins (21.2 mg of deoxynivalenol and 406 microg of zearalenone, ZON, per kg of wheat) on growth performance, nutrient and zearalenone balance and clinical-chemical parameters. 2. An increase in dietary mycotoxin concentration resulted in a linearly related decrease in feed intake, a slight decrease in weight gain and an improvement in feed to gain ratio. 3. Apparent protein digestibility and net protein utilisation were higher in diets containing exclusively Fusarium toxin-contaminated wheat than control diets. 4. The proportions of beta-zearalenol, alpha-zearalenol and ZON of total ZON metabolites in excreta of broilers fed on the diets containing the Fusarium toxin-contaminated wheat were approximately 3, 21 and 76%. 5. Serum antibody titres to Newcastle disease virus decreased in a linear fashion with increasing mycotoxin concentration in the diets, whereas other clinical-chemical serum parameters (liver cell and muscle cell necrosis indicating enzymes, haemoglobin, haematocrit, magnesium, inorganic phosphate) were not influenced by increasing Fusarium toxin concentrations. 6. Supplementation of the diets with Mycofix Plus decreased performance in a manner independent of mycotoxin concentration. Moreover, some clinical-chemical serum parameters were significantly altered due to Mycofix Plus but also independently of the dietary mycotoxin concentration.

[Influence of ergot feeding on piglets and chicken]. / Zum Einfluss von Mutterkorn im Futter auf Absetzferkel und Masthähnchen.

Two preliminary tests were conducted with piglets and chicken to study the influence of feeding ergot, which was specified concerning alkaloid content and pattern, on growth performance and health parameters. Treatments were 5 ergot concentrations in the diets (0; 0.05; 0.1; 0.2; 0.4%) which were fed to 5×16 piglets for 35 days and 5×28 chicken for 21 days. A content of 0.4% ergot in the diet decreased feed intake and growth performance of piglets significantly. Contents of 0.1% and 0.2% ergot in the diet showed a tendency towards improved weight gain as compared to controls. Feed to gain ratio was found to be the lowest in the group with 0.2% ergot in the diet. In the study conducted with chicken significant effects of ergot feeding on growth performance were not detected. With increased ergot concentrations in the diet the weight of hearts decreased, which proved to be significant only at a level of 0.2 % ergot in the diet. Moderate to severe inflammations were found in the proximal duodenum of the ergot fed groups, which, however, were not dosedependent. Further studies with ergot from other sources differing in alkaloid content and pattern are necessary to evaluate toxic alkaloid levels for the various animal species or categories.

Effect of addition of a detoxifying agent to laying hen diets containing uncontaminated or Fusarium toxin-contaminated maize on performance of hens and on carryover of zearalenone.

16-wk experiment with laying hens was carried out to examine the effects of feeding of mycotoxin-contaminated maize (CM) on performance, nutrient digestibility, weight of organs, serum chemical parameters, and antibody titers to Newcastle disease virus (NDV) in serum. Also tested were fimbrien antigen K88 in egg yolk and zearalenone (ZON) residues in eggs and tissues. The Fusarium-toxin-contaminated maize contained 17,630 microg deoxynivalenol and 1,580 microg ZON/kg. Moreover, Mycofix Plus (MP), a so-called detoxifying agent, was added to both the uncontaminated control (UCM) and to the CM diet (70% dietary maize inclusion). Each of the four resulting diets (UCM, UCM-MP, CM, CM-MP) was tested on 25 laying hybrids (Lohmann Brown). Feeding of the CM diets significantly depressed feed intake compared to the control groups by approximately 5%. This was mainly due to the effects observed at the beginning of the experiment. Daily egg mass production/hen was 56.6, 58.4, 53.9, and 55.2 g in groups UCM, UCM-MP, CM and CM-MP, respectively. Nutrient digestibility and metabolizability of gross energy were slightly depressed by feeding the CM diets and improved by MP addition. Feeding of the CM diets resulted in a significant decrease in serum titers to NDV and to an increase in yolk titers to antigen K88. No residues of ZON or of its metabolites were found in yolk, albumen, abdominal fat, breast meat, follicles greater than 1 cm in diameter, ovaries including follicles smaller than 1 cm in diameter, magnum, and serum. ZON and alpha-zearalenol (alpha-ZOL) were detected in livers of hens fed the CM diets at mean concentrations of 2.1 and 3.7 microg/kg, respectively. It was concluded that feeding maize which was highly contaminated with Fusarium mycotoxins adversely influenced performance of hens and modulated immune response. At the given level of zearalenone and at the indicated detection limits, no residues of ZON and its metabolites were found in eggs. The effects of the tested detoxifying agent were quite mycotoxin-independent.

Resistance to Marek's disease virus in White Leghorn chickens: effects of avian leukosis virus infection genotype, reciprocal mating, and major histocompatibility complex.

Genetic improvement for resistance to Marek's Disease (MD) in chickens continues to be of interest to the poultry industry. The aims of this study were to identify effects of the MHC on the molecular level and of avian leukosis virus (ALV) resistance status on MD mortality in two noninbred White Leghorn chicken lines that differ in B blood group type. Previously, within each of the chicken lines, sublines had been selected for resistance or susceptibility to ALV infection with Subgroups A and B. In this study, F2 offspring, obtained by crossing the two ALV-resistant or the two ALV-susceptible sublines, were tested for MD mortality after contact exposure at 1 d of age. Reciprocal matings were made in the grandparental generation. The MD mortality percentages, in an observation period of 17 wk, of F2 offspring from two hatches were 82.63 and 92.35%, respectively. Survival analysis (Cox model) was applied to assess the risk of dying from MD. No differences in MD mortality risk profiles were found between ALV-resistant and ALV-susceptible F2 offspring. Within ALV-susceptible F2 offspring, however, a reciprocal mating effect was observed in both hatches. The MHC Class I, II, and IV restriction fragment length polymorphism (RFLP) analyses were carried out on birds of the first hatch. Although two of 11 MHC class IV RFLP bands displayed a significant effect, in general, a strong association of MHC and MD mortality was not detectable.

On the effects of Fusarium toxin contaminated maize in laying hen feeding.

The effects of feeding a Fusarium toxin contaminated maize (CM) to laying hens were studied in a 16-week lasting experiment. The CM contained 17630 µg deoxynivalenol (DON) and 1580 µg zearalenone (ZON) per kg.Animal performance, serum chemical parameters, antibody titers to Newcastle disease virus (NDV) in serum, antibody titers to fimbrien antigen K88 in egg yolk, and ZON residues in eggs and tissues were investigated.Moreover, Mycofix® Plus (MP), a so-called detoxifying agent, was added both the non-contaminated control (M) and to the CM diet. Each of the four resulting diets (M, M-MP, CM, CM-MP) was tested on 25 laying hybrids (Lohmann Brown).Hens fed the CM- and the CM-MP diet had a significantly depressed feed intake compared to the control groups of about 5 percent, mainly due to the effects observed at the beginning of the experiment.Daily egg mass production per hen was 56.6 g, 58.4 g, 53.9 g and 55.2 g in groups M, M-MP, CM and CM-MP, respectively. The main factors (maize contamination, MP-addition) were significant, whereas interactions were insignificant, suggesting a mycotoxin-independent effect of MP.Feeding of the CM-diets resulted in a significant decrease in serum titers to NDV and to an increase in yolk titers to antigen K88.No residues of ZON or of its metabolites were found in yolk, albumen, abdominal fat, breast meat, follicles greater than one cm in diameter, ovaries including follicles smaller than one cm in diameter, magnum or serum. ZON and α-zearalenol (α-ZOL) were detected in the livers of hens fed the CM-diets at mean concentrations of 2.1 µg/kg and 3.7 µg/kg, respectively.It was concluded that the feeding of maize highly contaminated with Fusarium mycotoxins adversely influenced performance of the hens and modulated immune response. At the given level of zearalenone and at the detection limits (0.5-2 µg/kg), no residues of ZON or its metabolites were found in eggs. The effects of the tested detoxifying agent were found to be independent of mycotoxins.

Cardiac toxicity following high-dose cyclophosphamide, cisplatin, and BCNU (STAMP-I) for breast cancer.

We retrospectively evaluated 443 breast cancer patients treated with high-dose cyclophosphamide, cisplatin, and BCNU (STAMP-I) with autologous stem cell support to characterize the cardiac toxicity of this regimen. Patients had stage II-III (n = 243) or stage IV (n = 200) breast cancer. We observed an overall 5.1% incidence of cardiac complications, both clinical and subclinical, in the whole group: 4.9% in stage II-III and 5.5% in stage IV patients. Clinical cardiomyopathy (CMP) was observed in 1.6% of stage II-III patients (1 case of fatal grade 5 toxicity and 3 cases of grade 3 CMP) and in 3.5% of patients with stage IV disease (1 case of grade 4 and 6 cases of grade 3). The incidence of cardiac toxicity did not differ significantly between the groups. Prior radiation therapy to the mediastinum or left chest wall (P = .001) and advanced age (P = .01) were independent predictors of an increased risk of the appearance of this complication. No pharmacodynamic correlation was observed between any of the 3 drugs and cardiac toxicity.

Selection of CD34-Positive Blood Cells for Allogeneic Transplantation: Approaches to Optimize D34-Cell Recovery, Purity, Viability, and T-cell Depletion.

BACKGROUND: Methods for clinical-scale selection of CD34-positive hematopoietic stem and progenitor cells have facilitated allogeneic transplants using HLA-mismatched healthy donors. We examined different approaches to purify mobilized CD34+ cells, focusing on yield, purity, and viability of the selected cells and T-cell depletion levels. METHODS: Sixty-seven CD34-positive selections were performed for a total of 37 allogeneic transplantations, 23 of which from HLA-haploidentical donors. The selection devices were the Isolex((R)) 300i (v. 1.12) used alone (n =13) or with the SuperMACS (n = 29); the CliniMACS (n = 3); and the Isolex 300i (v. 2.0b1). The latter was used for CD34-positive selection (n = 7) and combined CD34+/CD4 8 19-negative selections (n =15). DNAse was included to reduce cell clumping. RESULTS: With the Isolex 300i (v. 1.12), the median CD34+-cell recovery increased from 51% (without DNAse) to 61% (15 mg DNAse) and 70% (7.5 mg). DNAse (5 mg) was used for 22 selections with the Isolex (v. 2.0b1) without cell clumping. CD34-positive cell purity, yield, and viability, as well as the degree of CD3 depletion varied with the selection device and procedure used. CONCLUSION: With regard to all of the above-mentioned parameters, the best results were obtained with the Isolex 300i (v. 2.0b1). Values achieved for CD34-positive cells were 98% for purity, 50-60% for yield, and > 96% for cell viability; T-cell depletion was 4.5 to > 5 log. The automated and closed system provides target cells that are free of both magnetic particles and murine monoclonal antibody. Copyright 2000 S. Karger GmbH, Freiburg

Kinetics of chimerism during the early post-transplant period in pediatric patients with malignant and non-malignant hematologic disorders: implications for timely detection of engraftment, graft failure and rejection.

The monitoring of chimerism by PCR has become a routine diagnostic approach in patients after allogeneic bone marrow or peripheral blood stem cell transplantation. Nevertheless, a temporal correlation between molecular and hematologic assessment of engraftment has not been clearly established. To address this issue, and to determine the potential clinical implications of early kinetics of mixed chimerism, we have investigated 66 allogeneic stem cell transplantations (SCTs) in 58 pediatric patients suffering from different types of leukemia (n = 44) or non-malignant hematologic disorders (n = 14) by close molecular monitoring during the first days and weeks after transplantation. Patient- and donor-derived hematopoiesis were assessed at 1- to 3-day intervals in peripheral blood samples by PCR analysis of highly polymorphic microsatellite loci (STR-PCR). Detection of an increasing, and ultimately dominant donor-specific allelic pattern, which we defined as molecular engraftment, preceded hematologic engraftment by a median of 7 days (range 1-17 days) in all patients investigated. PCR analyses during the first days after transplantation facilitated detection of molecular engraftment according to the above definition by day +14 (range day +2 to day +14), thus permitting prediction of successful engraftment (upper limit of the two-sided confidence interval po = 6%) while the peripheral leukocyte counts were mostly below 200/microl. In three cases, however, the criteria for molecular engraftment were not fulfilled by day +14. These patients also failed to show hematologic engraftment, and required a second transplantation. Close monitoring by STR-PCR showed that graft rejection and autologous recovery can occur early and with very rapid dynamics. Molecular analysis of specific leukocyte subsets isolated by flow-sorting enabled sensitive assessment of changes in the pattern of chimerism which had escaped detection in assays using whole white blood cell (WBC) samples. This approach facilitated the identification of expanding or decreasing recipient cells, and permitted early detection of impending rejection or relapse. Moreover, monitoring of the dynamics of chimerism allowed rapid assessment of the response to therapy. Our observations provide support for the concept of initiating genotype analyses early after SCT and monitoring at rather short intervals to permit timely evaluation of clinically relevant processes, and to provide a basis for early implementation of treatment.

Phase II trial of high-dose chemotherapy with autologous stem cell transplant for stage IV breast cancer with minimal metastatic disease.

The purpose of this study was to assess the efficacy of high-dose chemotherapy (HDC) with autologous stem cell transplant in stage IV breast cancer patients with minimal metastases. Eligible patients had (a) disease that could be resected en bloc and/or irradiated with curative intent using a single field and could, thus, be rendered as having no evidence of disease (NED); and/or (b) <5% bone marrow involvement. From September 1991 to August 1997, 40 consecutive patients were prospectively entered on the study. Pre-HDC local treatment consisted of surgery (n = 31) and radiotherapy (XRT; n = 3). All patients received HDC with cyclophosphamide, cisplatin, and 1,3-bis(2-chloroethyl)-1-nitrosourea and autologous stem cell transplant, with or without CD34 selection. Following HDC, 22 patients received XRT. Four patients died of treatment-related complications. Eighteen patients developed grade 3 nonhematological toxicities (15 lung, 2 cardiomyopathy, and 1 optic neuritis), which resolved with therapy. Within a median follow-up of 49 (15-91) months, 14 patients had relapsed. Twenty-five patients (62.5%) were alive, and 22 patients (55%) were alive and free of disease. Median event-free and overall survivals were 43 and 77 months, respectively. In the subset of patients with one metastatic site, 17 of 24 (68%) remained relapse free. Grade 2 tumors, a single metastatic site, and delivery of XRT were favorable predictors of relapse-free survival in univariate but not multivariate analyses. Inclusion of HDC, as described, in the multimodal treatment of stage IV breast cancer patients with minimal metastases is promising. These results warrant prospective randomized trials with a HDC-containing arm in this patient population.

Modification of the pharmacokinetics of high-dose cyclophosphamide and cisplatin by antiemetics.

Interpatient variability in exposure to certain chemotherapy agents can influence patient outcome, particularly with high-dose chemotherapy. We evaluated the possibility of a pharmacokinetic (PK) drug-drug interaction between the antiemetic agents and high-dose cyclophosphamide, cisplatin and BCNU (CPA/cDDP/BCNU). Twenty-three self-selected patients treated with high-dose CPA/cDDP/BCNU followed by autologous hematopoietic progenitor cell support (AHPCS) received ondansetron, lorazepam and diphenhydramine as antiemetics. PK parameters for each chemotherapeutic drug in the regimen were compared with those of 129 patients who received exactly the same chemotherapy but an antiemetic regimen substituting prochlorperazine for ondansetron. In addition, we performed a review of the English literature for reported drug-drug interactions between antiemetics and chemotherapy agents that led to modifications in any PK parameters of the chemotherapy agent. Our retrospective study showed that the mean area under the curve (AUC) for both cyclophosphamide (76,600 vs 90,600 microg/ml/min, P=0.001) and cisplatin (525 vs 648 microg/ml/min, P = 0.01) were significantly lower in the ondansetron group when compared with the prochlorperazine group. The AUC for BCNU was not significantly different in both groups (544 vs 677, P = 0.43). We found only one report of modifications of the PK parameters of high-dose chemotherapy agents due to drug-drug interactions with the most commonly used antiemetics in a review of the English literature between 1966 and 1995. We concluded that the AUC of high-dose cyclophosphamide and cisplatin are significantly lower when ondansetron, as opposed to prochlorperazine, is used as the antiemetic. The small sample size and heterogeneity of this group of patients precludes any outcome analysis of pharmacodynamic endpoints such as toxicity or antitumor effect. Nevertheless, the potential for interactions between antiemetics and chemotherapy agents should be taken into account when using different high-dose chemotherapy regimens.

Nonpredictable pharmacokinetic behavior of high-dose cyclophosphamide in combination with cisplatin and 1,3-bis(2-chloroethyl)-1-nitrosourea.

Our objective was to assess whether the total area under the curve (AUC) of high-dose cyclophosphamide (CPA), combined with cisplatin and 1,3-bis(2-chloroethyl)-1-nitrosourea, could be predicted from its AUC on the first day of treatment. We reviewed the AUC of CPA in 470 patients who underwent pharmacokinetic monitoring of the drug. All patients received the same high-dose regimen of CPA, cisplatin, and 1,3-bis(2-chloroethyl)-1-nitrosourea (STAMP-I) with identical antiemetic support. Subsequently, patients who experienced a toxic death, relapsed after high-dose chemotherapy, or remained relapse-free at a minimum follow-up of 1 year after high-dose chemotherapy were analyzed for a correlation between the total AUC of CPA and both relapse-free survival and toxic death. The AUC of CPA decreased from day 1 to day 2 in most patients. However, its changes from day 2 to day 3 varied significantly. Neither the value of AUC on day 1 nor its decreasing trend from day 2 to day 3 could predict the AUC on day 3 and the total AUC. Our pharmacodynamic analysis in 335 patients failed to show a correlation between the total AUC of CPA and either toxic death or relapse-free survival. The significant intersubject variability in the AUC of CPA makes the final AUC of the drug unpredictable from an initial measurement on day 1. Thus, in this combination, measurement of levels of parent CPA, with the objective of real-time therapeutic monitoring of this drug, is not informative.

Acute encephalopathy: a new toxicity associated with high-dose paclitaxel.

The purpose of this study was to describe acute encephalopathy as a new toxicity associated with paclitaxel, when it is delivered at high doses (> or =600 mg/m2) with stem cell support. A total of 129 patients, included in clinical trials of paclitaxel-containing high-dose chemotherapy, were analyzed. A total of 114 patients received paclitaxel at a dose of > or =600 mg/m2. Six patients presented acute encephalopathy starting between 7 and 23 days after paclitaxel treatment; two of them had received prior whole-brain irradiation. Paclitaxel was given alone (one patient), with cyclophosphamide and cisplatin (two patients), and with cyclophosphamide and cisplatin plus 1,3-bis(2-chloroethyl)-1-nitrosourea (three patients). Central nervous system toxicity consisted of rapid obtundation and coma (five patients) and severe confusional picture with paranoid ideations (one patient). Brain magnetic resonance imaging showed diffuse white matter atrophy (one patient) or multiple small infarcts (one patient), or it was normal (four patients). Other complementary tests, including cerebrospinal fluid analysis and electroencephalography, were nondiagnostic. An effect from concomitant psychotropic medications or from other organ toxicities was excluded in all patients. Three patients recovered after 8-15 days, either spontaneously (two patients) or after high-dose steroids (one patient). Three patients died of irreversible coma. Necropsy, performed in two patients, showed generalized white matter atrophy and multiple brain parenchymal infarcts, respectively. No pharmacodynamic correlation between the occurrence of encephalopathy and a pharmacokinetic parameter of paclitaxel could be identified. Paclitaxel-containing high-dose chemotherapy can cause severe acute encephalopathy. An aggravating effect from prior brain irradiation or concurrent 1,3-bis(2-chloroethyl)-1-nitrosourea seems possible.

Flow cytometric monitoring of hematopoietic reconstitution in myeloablated patients following allogeneic transplantation.

BACKGROUND: We report a routine flow cytometric (FACS) approach to quantify circulating leukocytes (NC) in myeloablated patients before and during regeneration after allogeneic transplantation of either whole bone marrow (BM) or of highly purified (> 99%) blood-derived CD34(+) cells (PBSC). METHODS: Blood samples were analyzed daily between infusion of the transplant and hematopoietic reconstitution. Significant differences in the composition of NC types and CD34(+) cells were observed between the two CD34 sources. The detection threshold for NC was roughly 1 cell per w L blood. RESULTS: The cell nadir of < 100 NC/ microL was reached on Day +4 (BM) and on day 0 (PBSC), when unusual CD34(+) cells of recipient genotype were detected in all patients. They were not clonogenic, showed high CD34 expression, but were negative for CD45, CD38, CD33, CD50, HLA-DR and Stro-1. Between Days +5 and +16, the onset of hematopoietic reconstitution was clearly detectable in multi-parameter evaluation of the FACS data. This was a median of 3.5 days before NC increased above 200/ w L blood and 4-10 days before granulocyte counts were > 500/ microL. It was marked by the appearance of monocytes, immature (CD38(+)) granulocytes, and clonogenic donor CD34(+) cells exhibited normal size and phenotype. DISCUSSION: We conclude that dynamic FACS analyses can reliably detect hematopoietic reconstitution, but also graft rejection, before a visible increase NC numbers. This may have considerable impact on clinical management strategies.