A 7-center cooperative clinical study with a new formulation of epirubicin hydrochloride injectable solution (Epirubicin-RTU) was conducted in patients with superficial bladder carcinoma. Epirubicin-RTU at the dose of 60 mg/30 ml was administered by intravesical instillation once daily for three (3) consecutive days and a 4-day drug-free interval followed; then the above intravesical instillation of Epirubicin-RTU was repeated for three consecutive days. All 20 registered cases were eligible, and 18 cases completed the whole course of the study. In 18 completers, CR was observed in 12 cases and PR was observed in one (1) case, for an efficacy rate of 72.2%. The primary adverse reaction was bladder irritation including pollakiuria 85.0% (17/20), miction pain 85.0% (17/20), and hematuria 80.0% (16/20), which were all reversible and tolerable. In urinalysis, urinary sediment showed leukocytes and erythrocytes, and proteinuria was observed. All were reversible. From the above results, this new formulation of Epirubicin-RTU was considered useful for the treatment of superficial bladder carcinoma.

A combination of irinotecan hydrochloride (CPT-11; 160 mg/m2, intravenous infusion, day 1) and cisplatin (5-day continuous intravenous infusion; 20 mg/m2/day) was administrated to advanced non-small cell lung cancer patients. They were given Hangeshashin-to (TJ-14), a Kampo medicine, to prevent the occurrence of irinotecan-induced diarrhea. The authors studied the Kampo medicine's clinical usefulness in a randomised comparative trial. Subjects in the study comprised 41 non-resectable and untreated non-small cell lung cancer patients. A daily dosage of 7.5 g Hange shashin-to was divided into three portions, each of which was given to the subjects orally before each meal. The subjects began taking the medicine three or more days before the start of chemotherapy, and continued taking it more than 21 days after starting chemotherapy. A total of 18 patients received TJ-14, and 23 did not. Compared with the latter, those given the Kampo medicine reported a significant (p = 0.044) improvement in the grade of diarrhea, and had a lower incidence of diarrhea grade 3 and above (p = 0.018). However, no differences were seen among the two groups in terms of the frequency of diarrhea and the duration of the diarrhea. As side effects, two patients developed grade 1 constipation. These findings showed that TJ-14 was effective in preventing and alleviating the incidence of diarrhea induced by CPT-11.

In developing new anticancer agents, the most important thing is the balancing of antitumor activity and toxicity. To achieve high activity and low toxicity, S-1 was designed, in which tegafur, prodrug of 5-FU, was combined with two classes of modulators. CDHP, inhibitor of 5-FU degradation in liver and Oxo, inhibitor of 5-FU phosphoribosylation in digestive tract, respectively. This cooperative study with 15 nation-wide institutes was conducted to evaluate the antitumor activity and toxicity of S-1 in patients with advanced head and neck cancer from Jan. 1994 to March 1996 in Japan. Out of 26 patients, CR was achieved in 1 and PR in 11 with a response rate of 46.2%, while adverse events of grade 3 were as follows: hemoglobinemia (7.7%), leukocytopenia, neutropenia, stomatitis and anorexia (3.8%), each. Neither grade 4 adverse event nor treatment-related deaths were observed. Based on these findings, it was concluded that S-1 is a useful anticancer agent with the low grade toxicities for treatment of the patients with advanced head and neck cancer, and the effects of CDHP and Oxo found in preclinical studies might be also reflected in these results.

The efficacy of all chemotherapeutic agents is limited by the occurrence of drug resistance. To further understand resistance to topoisomerase (topo) II inhibitors, 50 sublines were isolated as single clones from parental cells by exposure to ETP or m-AMSA. Subsequently, a population of cells from each subline was exposed to three-fold higher drug concentrations allowing 16 stable sublines to be established at higher extracellular drug concentration. The frequency and nature of mutations in topo II in the drug selected cell lines have been evaluated. In order to screen a large number of cell lines, an RNase protection assay was developed. Fragments covering the entire coding sequence of topo II was isolated after PCR amplification and subcloned in pGEM3Z vector. Using this approach, mismatches was observed in 13.6% of resistant cell lines (12% of resistant cell lines exposed to lower drug concentrations and 18.8% of resistant cell lines exposed to higher drug concentrations). Our findings suggest that mutations of topo II gene seem to be an important and frequent mechanism of resistance to topo II inhibitors.

An early phase II clinical study of S-1 in patients with advanced or recurrent breast cancer was undertaken by a cooperative study group (Breast Cancer Working Group) of 14 institutes in Japan. S-1 was administered twice daily at 75 or 50 mg (dose FT)/body for 28 consecutive days with 14 days rest (one course). Twenty-eight patients were enrolled, 27 were eligible for the study, and 25 were evaluable for efficacy. Four complete responses and seven partial responses were obtained, and the response rate was 40.7% (11/27) [ninety percent confidence interval for this response was 26.7-56.4%]. The major adverse reactions observed were myelosuppression represented by leukopenia 44.4% (12/27), neutropenia 40.7% (11/27), RBC decreased 37.0% (10/27), hemoglobin decreased 29.6% (8/27), anorexia 55.6% (15/27), nausea/vomiting 48.1% (13/27), and fatigue 33.3% (13/27). The results suggested that the efficacy and safety of S-1 were effective against advanced or recurrent breast cancer. The objective of study judged should be investigated in a late phase II clinical study.

We performed a clinical phase II study of KRN8602, a new anthracycline derivative, for relapsed or recurrent malignant lymphoma. KRN8602 was given at doses of 12-15 mg/m2 for 3 consecutive days, repeating every 3-4 weeks. Among 44 patients entered into the study, 36 were evaluable for safety, and 35 were evaluable for efficacy. The response rate was 18.2% (6PR/33) for non-Hodgkin's lymphoma and 0% (0/2) for Hodgkin's disease. Major toxicities were bone marrow suppression and gastrointestinal toxicity. Leukopenia was observed in 77.8%, thrombocytopenia in 44.4%, hemoglobin decrease in 44.4%, nausea and vomiting in 94.4% and anorexia in 80.6%. However, all toxicities were clinically manageable.

A review concerning cancer chemotherapy in older patients from the aspect of clinical pharmacology was performed. Age-related physiological changes, comorbid disease, polypharmacy, and social issues are major problems in older patients with cancer. Pharmacokinetics of anticancer agents change according to physiological changes, and distribution, metabolism and excretion may change. Resistance to anticancer agents is more common. Side effects are more severe and frequent because of age-related physiological changes and comorbid disease. Since the interindividual difference is large in the elderly, the individual dose of anticancer agents must be determined especially for patients older than 75 years old.

Cytarabune ocfosfate (SPAC) is rapidly transformed into cytarabine (ara-C) when orally administered. The pharmacokinetics of SPAC was studied in six patients with acute non-lymphocytic leukemia (ANLL) and/or myelodysplastic syndromes (MDS) after oral administration of SPAC at 100 to 400 mg/day for 14 days. Plasma ara-C concentrations reached a plateau in 48 to 96 hours after initiation of SPAC administration, remained at this or a little higher level until one day after its termination and were less than 1 ng/ml 8 days after the termination. From all of pharmacokinetic data, the oral administration of SPAC at 150 to 300 mg/m2/day was pharmacokinetically concluded to be comparable to the continuous infusion of ara-C at 20 mg/m2/day. All of the patients could receive SPAC for 14 days. SPAC is considered to be useful for consolidation or maintenance chemotherapy of ANLL or MDS outpatients who are unable to undergo intensive chemotherapy.

Granisetron (G) is an effective antiemetic drug that is used to prevent cisplatin-induced emesis, although it is less effective for delayed emesis. To enhance the antiemetic effects of granisetron, corticosteroid analogues such as methylprednisolone (M) and dexamethasone (D) were employed in a study of patients treated with cisplatin (CDDP). We investigated the clinical response and urinary excretion of 5-hydroxyindole acetic acid (5-HIAA), the main metabolite of serotonin, in 31 patients with ovarian cancer or uterine endometrial cancer who received CAP therapy (CDDP 75 mg/m2) in a 3-day cross-over trial comparing G + M and G + D treated patients. Both regimens were and delayed emesis than G + D. We conclude that G + D is a more efficacious combination than G + D in protecting patients from CDDP-induced acute and delayed emesis.

A dose finding early phase II study of TAT-59, a new triphenylethylene derivative, was performed in patients with advanced or recurrent breast cancer. TAT-59 was given orally for over 8 weeks at a daily dose of 10 mg, 20 mg or 40 mg/day. Thirty-six, 38 and 35 patients were eligible in the group treated with 10, 20 and 40 mg of TAT-59, respectively. The proportion of patients obtaining a complete or partial response with 10 mg/day, 20 mg/day and 40 mg/day of TAT-59 was 28.6% (10/35), 28.6% (10/35) and 25.8% (8/31) in the evaluable cases, respectively. The median duration of initial response with TAT-59 was 38.5 days, 26.5 days and 25.6 days, respectively. The frequent adverse reactions observed in all dosing groups included hot flashes, anorexia, nausea and vomiting, sweating, and abnormal values in liver function tests. In these adverse reactions, the incidence of hot flashes, which might be caused by the pharmacologic function of TAT-59 was 0.0% (0 of 35), 2.9% (1 of 35) and 10.0% (3 of 30) in the evaluable cases receiving 10 mg, 20 mg and 40 mg of TAT-59, respectively. In conclusion, it was recommended that the optimal dose in terms of efficacy and adverse reactions should be 20 mg/day.

DP-TAT-59, an active metabolite of miproxifene phosphate (TAT-59), showed a strong anti-proliferating activity against ER-positive human mammary carcinoma cell lines, MCF-7 and T-47D, in the presence of 1 nM of estradiol. The ED50 value of DP-TAT-59 for each cell line was 30-fold lower than that of tamoxifen. TAT-59 suppressed the growth of mammary carcinoma, MCF-7 and Br-10, xenografted into nude mouse at a dose of 5 mg/kg/day, which is equivalent to 20 mg/body of daily dose to the patients. TAT-59 inhibited the growth of tamoxifen-resistant breast cancer cell lines, R-27 and FST-1, but not tamoxifen, suggesting the possible efficacy of TAT-59 for tamoxifen-refractory patients. DP-TAT-59 and DM-DP-TAT-59, major metabolites of TAT-59 detected in blood after oral administration in the patients, exhibited equal growth-inhibitory activity against human mammary tumor xenograft, meaning the antitumor activity of TAT-59 may equally depend on these two metabolites. In uterotrophic testing using both immature mice and ovariectomized rats, while the effective dose of TAT-59 was lower than that of tamoxifen, TAT-59 showed dose-dependent estrogenic activity against their uteri, similar to tamoxifen. These results suggested that TAT-59 had a stronger antagonistic activity against estrogen-dependent mammary tumor than tamoxifen. We expect that TAT-59 will become an effective therapeutic agent for patients with high estrogen levels in their blood, such as premenopausal women, and the patients with whom the tamoxifen modality failed.

Irinotecan has been approved in Japan, France and USA, however, its clinical usefulness seems to be differently understood. There is a strong opinion, especially in Japan, that the drug is too toxic since it may harm as many patients than it helps. On the contrary, irinotecan is well accepted to the US cancer chemotherapy practices. With irinotecan as a typical example of new chemotherapeutic agents, benefit and risk of cancer chemotherapy is discussed. Differences in cancer chemotherapy practices between Japan and USA are discussed as well.

Telomerase, a ribonucleoprotein that adds telomeric repeats onto chromosome ends, is involved in telomere length maintenance and permits unlimited cell proliferation. We examined the possibility that higher telomerase activity is associated with the replicative phase of the cell cycle using gastric cancer cell lines treated with anticancer drugs. Telomerase activity increased at the time point of S-phase accumulation in NUGC-3 cells (5 x 10(5) cells/ml) incubated with CDDP (0.5 microgram/ml), paclitaxel (0.01 microM), or VP-16 (1 microM) and in MKN-28 cells incubated with CDDP. When these cell lines were incubated with 5-fluorouracil (10 microM) or CPT (0.1 microM), the increase of telomerase activity preceded the S-phase accumulation. Our results suggest that telomerase activity be regulated by the cell cycle.

Telomerase, a ribonucleoprotein that maintains the ends of linear eukaryotic chromosomes, is expressed in the majority of malignant cells, while most normal somatic cells have no telomerase activity except germline and stem cells. Therefore, telomerase activity is considered one of important characteristics of tumors. In reviewing the possibility that conventional anticancer agents can partly perform their functions through modulation of telomerase. Several data including ours suggest that the down-modulation of telomerase activity along with inhibition by agents is the secondary event associated with cell death. Moreover, cells growth arrested at specific phase of cell cycle by agents still show the high level of telomerase activity. Since telomerase activity well correlates to the cell viability of treated cells, to study telomerase provides us a new implement to examine the sensitivity of cancer cells to agents.

Malignant melanoma cell possesses a unique metabolic pathway which consists of conversion of tyrosine, an essential amino acid, to dopa and subsequently to dopaquinone in the presence of tyrosinase to form melanin, the end product of the metabolic pathway. This tyrosinase-mediated melanin biosynthesis occurs within normal melanocyte and its transformed cell, malignant melanoma cell. It is in general highly elevated in malignant melanoma cells compared to normal melanocytes. The objective of our research is to develop targeted therapeutic approach for malignant melanoma by utilizing this unique metabolic pathway in the presence of tyrosinase. Specifically we have synthesized sulpher homologue of tyrosine, cysteinylphenol and its amine derivative, cysteaminylphenol (CAP) and subsequently its N-acetyl and N-propionyl derivatives (N-acetyl and N-propionyl-CAP). These synthetic compounds are good tyrosinase substrates and possess high lipophilicity and penetration through the plasma membrane into melanoma cells. Our in vivo and in vitro studies using these synthetic compounds revealed following findings: (1) CAP and its derivatives possess selective cytotoxicity to human neoplastic cells, in particular tyrosinase-positive melanoma cells; (2) N-Acetyl-CAP and N-propionyl-CAP possess both cytostatic and cytocidal effect; (3) These synthetic compounds provide irreversible DNA damage to melanoma cells with high tyrosinase activity; (4) However, there is no irreversible DNA damage to non-pigmented, tyrosinase negative cells; (5) Pharmacological effect of CAP appears to be related to oxidative stress; (6) Radio-labelled CAP derivatives showed selective incorporation into melanin-forming melanoma cells; (7) This selective cytotoxicity can occur in non-melanin forming cells after transfection of human tyrosinase cDNA, resulting cytocidal effect. All these findings clearly indicate that our synthetic compounds which are good substrates of human tyrosinase can provide basis for the development of targeted chemotherapy and/or chemoradiotherapy. In addition the transfection of human tyrosinase cDNA will provide the rational approach for developing the targeted gene therapy to non-melanoma cells.

The antitumor activity of adriamycin (ADR) was enhanced by combination with theobromine or pentoxifylline. Theobromine increased the concentration of ADR in the tumor without any effects on that in the heart and the liver. The influence of the combination of theobromine or pentoxifylline with ADR on the lipid peroxide level (indicating the ADR-induced side effect) and on DNA biosynthesis (indicating the side effect and antitumor activity) were examined. When ADR was administered into mice, the lipid peroxide level in the liver and the heart increased. However, the combination of theobromine or pentoxifylline did not enhance the ADR-induced increment of the lipid peroxide level in the liver, and moreover, it inhibited that in the heart. The decrease of DNA biosynthesis in the liver and the heart, induced by ADR, were not enhanced by combination with theobromine or pentoxifylline. On the other hand, the combination of theobromine with ADR significantly increased the inhibition of DNA biosynthesis in the tumor. These findings indicate that the combination of theobromine or pentoxifylline with ADR have no effect on the side effects of ADR in the liver and the heart, with the increase of antitumor activity of ADR in the tumor, and it is suggested that these drugs will be of value as a biochemical modulator of ADR.

A 48-year-old woman was admitted with chronic myelogenous leukemia in November, 1996 and was treated with hydroxyurea (HU), because of marked leukocytosis; WBC 404,000/microliter. On January 29, 1997, administration of HU was stopped, and treatment of alpha-interferon (IFN alpha) was started with 6x 10(6)U, every day. However, the WBC count rose from 19,600/microliter to 56,800/microliter, and the combination of IFN and 2,000 mg of HU was started on February 4. The dose of HU was reduced to 500 mg on February 27, and the IFN administration was reduced to 3 times a week from April 4, because the WBC count was less than 10,000/microliter. Pancytopenia was revealed in May. The bone marrow biopsy specimen demonstrated marked hypoplastic changes, and chromosome analysis of bone marrow cells showed Philadelphia chromosome in all 20 metaphases. Treatment was interrupted for 7 months, but hematologic parameters did not recover. There were 9 cases reported in detail with bone marrow hypoplasia induced by IFN. One patient received IFN alone and 8 patients received anti-cancer drugs before treatment of IFN. We concluded that great care must be taken for IFN treatment of CML.

A experimental study was reported here to clarify the chemosensitizing effect of Toremifene (Tor) on human breast cancer cell lines. MCF7, estrogen dependent adriamycin (ADM) resistant cell, and MDA-MB231, estrogen independent cell, were preincubated for 8 hours with Tor 0, 4 or 10 microM, then with ADM 0-10 micrograms/ml for one hour. After that, cells were cultured for 24 hours, and their cell cycle and growth were analyzed with flow-cytometry and MTT assay, respectively. Furthermore, the ADM concentrations of these cells were measured by high-performance liquid chromatographic assay (HPLC). Although flowcytometric analysis showed the enhancement of Gz block only in MCF7 at the ADM concentration with 5 micrograms/ml, the sensitizing effect was revealed by MTT assay, and the elevation of ADM concentration was found in HPLC assay in both cells. The chemosensitizing effect of Toremifene was observed in estrogen dependent and independent cell lines.

Cell death plays an essential role in cell homeostasis and the pathological process in cancer. Apoptosis has been identified by the internucleosomal DNA cleavage which appears to be associated with endonuclease activation. Proteolysis is considered to be an early event in apoptosis. We studied the effects of proteolysis on early apoptotic events, such as chromatin condensation, nuclear breakdown, DNA breakage and sensitivity to denaturation induced by anticancer drugs (camptothecin: CAM, 5-azacytidine: AZA) on HL-60 cells. CAM induced apoptosis on S phase and AZA on G1 phase. The internucleosomal DNA cleavage shown by both the presence of DNA fragments during gel electrophoresis and a large number of in situ DNA strands breaks (revealed in high intensity fluorescence FITC of cells in the TdT reaction) was prevented by the protease inhibitor, TPCK (N-tosyl-L-phenylalanine chlorometyl-ketone), as well as by an inhibitor of the apoptosis-associated endonuclease, ZnSO4. The protective effects were observed under conditions in which apoptosis was induced by agents with a different mechanism of action, such as the DNA damaging drug. CAM (topo-isomerase inhibitor), and an RNA antimetabolite, AZA. The protease inhibitor inhibits early events of apoptosis such as chromatin condensation, nuclear breakdown, DNA breakage and sensitivity to denaturation, which have different structures and a different mechanism of interaction with drugs. The results suggest that control of protease inhibitor may be a useful strategy to treat cancers.

We report a syndrome of inappropriate secretion of antidiuretic hormone (SIADH), neurotoxicity and facial erythema induced by several anti-cancer drugs in a case of malignant lymphoma of thyroid gland. A 68-year-old male was admitted, complaining of neck tumor and dyspnea. On admission, he was treated with vincristine (VCR) for bronchostenosis due to malignant lymphoma. Neck tumor and mediastinal lymph node swelling reduced. On the ninth day after chemotherapy of VCR, a consciousness disturbance was found and he was diagnosed as having SIADH. Following chemotherapy of cyclophosphamide, SIADH was also induced so he was treated with irradiation for neck and mediastinal field, instead of chemotherapy. During irradiation, however, enlargement of systemic lymph nodes appeared, and the chemotherapy was resumed. He achieved partial remission, but somnolence after ifosfamide and facial erythema after ranimustine were observed. In spite of the difference in the chemical structure of these anti-cancer drugs, several side effects occurred. It is suggested that the direct effects of drugs on the nervous system were SIADH and neurotoxicity.