- Email: [email protected]
Dose response relationship of methotrexate in combination with cisplatin in murine bladder cancer
INVESTIGATIVE UROLOGY
DOSE RESPONSE RELATIONSHIP OF METHOTREXATE IN COMBINATION WITH CISPLATIN IN MURINE BLADDER CANCER* MAURIZIO BRAUSI, M.D. ANTONY BLATNIK, B.S. MARK S. SOLOWAY, M.D. From the Department of Urology, University of Tennessee, Memphis, Tennessee
B-TRACT--Methotrexate (MTX) has activity in transitional cell carcinoma (TCC) in man and ~ e have suggested an advantage o] high-dose methotrexate versus the standard dose in control~g:tUmor growth and prolonging survival. MBT-2, a poorly differentiated TCC induced by the ~ci'nogen FANFT, is" both grossly and histologically similar to human TCC and has been used as ~ n i m a l model. One hundred twenty C3H/HE female mice were injected in the hind limb with ~ × 104 MBT-2 tumor cells. When palpable tumors developed in all animals, therapy was initia L Animals' were randomized into a control group and nine treallment groups as Jol!ows: cisplatin ~ ) P ) , MTX 32 mg, M T X 50 mg, MTX 80 mg, DDP + MTX 32, M T X 50 + Leucovorin, MTX 80 rin, DDP + MTX 50 + Leucovorin, DDP + M T X 80 + Leucovorin. The combination STX 50 mg with Leucovorin + DDP and DDP alone were the two most effective regimens in ~ trolling tumor growth and prolonging s°urvival. No statistically significant difference was ob~lecl between the group treated by high-dose MTX alone and those treated by low-dose MTX. No ~:city was observed even when high doses' o] MTX were m'ed.
~Leucovo
thotrexate (MTX) is a folinic acid antagonist eh inhibits the conversion of folinic acid to ahydrofolate. It is cell-cycle dependent, aetI~speeifieallv during DNA synthesis. In 1966, ~ ] d i n et al: ~ established that intermittent ~ e s of MTX are more effective than daily dose ~ t m e n t in the early phases of growth of the ~ i d l y growing L1210 murine leukemia. The ~ o t h e s i z e d advantage of higher doses would ~!r~creased cell kill and prevention or delay in ~41develoDment of resistance In ex erimental ~ . ~i~or models, in fact, both in vitro and in vivo ~ s t a n c e to MTX occurs more rapidly when ~ I I doses of the drug are administered contin~4tlsIY .2-4 Resistance eventually occurs despite use o; high-dose MTX plus folinie acid res-
~
~
•
.
p
~!
~ a p p o r t e d by PHS Grant GA 186643 by National Ganeer In.~_:~!e and grant bv Veterans Administra(ion Medical Research
Io'''OCY ,
MARCH 1990 ,
VOI,UME XXXV, NUMBER 3
cue. In that ease, it may be due to accumulation of reduced folates as a consequence of Leueovorin (LV) administration. 2-4 Another advantage of high-dose MTX plus LV is reduced marrow toxicity. Methotrexate has demonstrated activity in advanced bladder cancer, s-9 There are no randomized trials comparing high-dose to standard-dose MTX. Since the MBT-2 transitional cell carcinoma has provided insight into the relative efficiency of antitumor drugs in human bladder cancer, varying doses of MTX were compared using this model. Material and Methods Tumor cell preparation Tumor tissue was aseptically excised from carrier mice, minced with scissors, and placed in a trypsinizing flask where enzymatic dissociation was carried out with Hank's Balanced
253
Salt solution (Gibeo, Grand Island, New York) containing 0.175 percent trypsin. An antibiotieantimycotic solution (Gibco, Grand Island, New York) was added to the Hank's solution, 1 mg/!00 mL, prior to the trypsinization. The mixture was agitated at 37°C using a magnetic stirrer for twenty-five minutes, at which point the supernatant was discarded. Fresh trypsinizing solution was added and stirred for an additional twenty minutes at 37°C. This solution was poured through a fine nylon mesh and centrifuged at 1,100 rpm for twelve minutes• The pellet was resuspended in a Hank's solution containing antibiotic-antimycotic solution and glutamine. The viable cell count was determined by trypan blue exelusion. The final concentration of cells desired was adjusted by dilution with RPMI 1640 with fetal calf serum.
In vivo drug testing One hundred and twenty C3H/HE female mice (Harlan Breeding Labs) were injected in the right hind limb with 7.5 x 104 MBT-2 tumor cells. MBT-2 is a FANFT-induced, poorly differentiated transitional cell carcinoma that was initially transplanted from the bladder of a mouse that ingested the carcinogen FANFT for forty weeks. The MBT-2 tumor used in this experiment was in its sixty-first transplant generation. The hind limbs of the animals were palpated daily until tumors were positively identified. Therapy was initiated on the day that 100 percent of the animals had tumor. On day 11 (post inoculation) the animals were randomized and therapy was initiated (Table I). All drugs were given in a volume of 0.1 cc intraperitoneally except the Leucovorin rescue which was administered subcutaneously. Therapy was administered weekly for a total of three doses. Tumors were measured biweekly with a Vernier caliper. The percent tumor reduction was calculated. The percent inerease in life span (% ILS) was calculated by subtracting the median survival time (MST) of the control group from the treated group divided by the MST of the control x 100. Statistical analysis of drug effectiveness on tumor control was done using the Levene, and the Dunnet and Dunkin tests for independent events. Results In evaluating the response to chemotherapy at days 28 and 34, mean tumor diameter, percent of tumor reduction, and survival were analyzed (Table II). Animals receiving cisplatin 254
Post-inoculation therapy oj animalsJl
TABLE I.
Group (dosesin mg/kg)
N0!]
Anin~:~
1. C o n t r o l (no t r e a t m e n t )
12~!
2. DDP 6.0
19Jj:,:,i
3. MTX 32
4. 5. 6. 7. 8. 9. 10.
MTX 50 MTX 80 DDP 6.0 MTX 50 MTX 80 DDP 6.0 DDP 6.0
+ MTX 32 + Leueovorin 200 + Leucovorin 200 + MTX 50 + Leueovorin 200 + MTX 80 + Leueovorin 200
~" i2ii~ 12,:~!~i 12~!~ 121:!:~i~ iP,!~! 121~:
(DDP) alone or in combination with MTXi!~ mg followed by Leucovorm showed tumor~:r~ duction of 34 percent and 32 percent, r e ~ tively, with ILS of 9.9 percent. This is a si~! I c a n t difference w h e n c o m p a r e d wittii~ eontrol group (p = 0.05). Methotrexate aI:0 with or without Leucovorin, did not alter:'~!~ mor growth. Despite a prolonged ILS of 53~{~i cent in the mice receiving DDP plus, hig:h:a~{ ..... MTX (80 mg) and Leueovorin, the percenf;{N tumor reduction was only 15 percent. Alth~)i~~ the survival in this group of animals was t ~ than the survival observed m" mice" reeel~'~, ~;::~ DDP alone or reeewmg low-dose MTX ( o 0 , ~ with DDP and Leucovorin, this difference ~ not statistically significant. ~"~; •
,,
Comment MTX is probably the see tumor drug in the treamer tional cell cancer. 5-9 At the pital, 61 patients with ] metastatic bladder eaneei MTX at different doses. ' rate was 13 percent in pal 50 rag, 56 percent in the 11 percent for those who re Leueovorin rescue. The m sponse was six months. 6 This experience was , Yagoda 7 who reported a rate in 28 patients who ha vious treatment with eis] MTX was 250 mg/M 2 witl Soequet s reported 90 perec years in 33 patients with "I treated by partial or total by 1-3 g MTX and folinie Oliver et al. 9 reported { MTX and observed a respo:
UROI.OGY
,
MARCH 1990 ,' VOLUME xXXV, NuMt(!~. ~:
TABLE II. i
Evaluation o] cell line MBT-2 rasponse to chemotherapy at days 28 and 34
Therapy (mg/k__g)
Total No. Mice
No. of Tumors (%)
Mean Tumor Diameter
Std. Dev.
P
12 12 12 12 12 12 12 12
12 (100)
12 (lOO)
13.89 9.94 13.19 13.04 12.33 12.12 13.73 12.79
2.0 2.5 2.3 2.4 1.9 3.3 1.5 3.5
. . 0.05" n.s. n.s. n.s. n.s. n.s. n.s.
12
12 (100)
10.47
2.1
0.05*
12
12 (100)
12.18
3.0
n.s.
12
12 12 12
12 12 12 12 12 12 12 12
(100) (100) (100) (100) (100) (100) (100) (100)
16.48 12.34 16.25 15.65 14.86 14.29 17.24 15.10
2.3 3.5 2.9 2.4 2.1 3.4 1.4 4.3
. . 0.05* n.s. n.s. n.s. n.s. n.s. n.s.
12
12 (100)
12.44
2.9
0.05*
12
12 (100)
14.29
2.7
n.s.
i Control ODe 6 •~ T × 32 i 'MT : X 50
i iavx 80 :'iMTX 32 + DDP 6 I~TX 50 + LCV res. ,MTX 80 + LCV res. ;MTX 50 + DDP 6 i~~,i,LCV res. MTX80 + D D P 6 ~ :~LCV res. ~6itS day 34 ~bntrol fiDe 6 ~TX 32
~
12 12
: tx 50 80
12 12
32 + DDP 50 + LCV 80 + LCV 50 + DDP 3V res. 80 + DDP ~V res.
6 res. res. 6
12 (I00) 12 (100) 12 (100) 12 (100) 12 (100) 12 (m0)
% Tumor tledx. .
.
.
.
% ILS
MST (Days)
29 16 5 21 37 -5 11
38 49 44 40 46 52 36 42
33
29
49
14
53
58
29 16 5 21 37 - 5 11
38 49 44 40 46 52 36 42
32
29
49
15
53
58
. . 40 5 7 13 15 1 9
. . 34 1 5 11 15 - 5 9
6
es compared with control. There are significant differences between treatment groups.
ili:i~:4
i{!atients with measurable metastases and 28 ~6nt with recurrent p r i m a r y tumors. T h e ~'~d~inistered doses w e r e 1,000 m g / M 2 with ~ei}h0vorin and 50-100 m g / M ~ w i t h o u t rescue. • et al.'° published a series of 57 pT2, p T 3 a , and p T 3 b transitional a of the b l a d d e r treated b y T U R ight courses of M T X 2 g IV every vith Leueovorin rescue (12 mg 6 twelve to forty-eight hours. The ase-free survival rate was 52 per~-year disease-free survival was 46 :Nevertheless, none of these studies was ranthe n u m b e r of patients was small, L~/shrgieal treatments varied T h e relative ef ~rC~Cy ~::i,..... of hi g h - dose M T X versus low dose MTX -~s~hot been answered. , , ,!~:Our study, MTX, with or w i t h o u t tolinie ~cid ~¢ J : .rescue . ' was tested in mice to corn P are the "!f~hveness of high-dose to low-dose in con:rOlling tumor g r o w t h and prolonging survival
I0 ed,
~S:!~dtOcy i~
/
MARCH 1990
/
VOLUMF XXXV, NUMBER 3
in mice with established tumors. The combination of low-dose M T X w i t h Leueovorin and eisplatin and eisplatin alone resulted in the most effective regimens against the MBT-2 tumor. M T X alone, even at high doses, was not as effective as eisplatin. This is consistent with our previous studies. 11-13 T h e group of mice receiving high-dose M T X in c o m b i n a t i o n with eisplatin and Leucovorin had the longest median survival (ILS = 53%) although t u m o r reduction was only modest. T h e i m p r o v e m e n t in the ILS was not statistically better than the c o m b i n a t i o n of M T X and D D P w i t h o u t rescue. O u r results are consistent with the KaplanMeier survival curves of successive studies perf o r m e d by the E O R T C 14,t5 in which they demonstrated t h a t M T X a n d e i s p l a t i n in c o m b i n a t i o n did not significantly improve survival in patients with a d v a n c e d bladder cancer. I m p o r t a n t side effects in h u m a n s after administration of high-dose M T X with folinie acid
255
rescue are reported in the literature. The most f r e q u e n t s y m p t o m s are mucositis, conjuneti~4tis, nausea, and vomiting and are usually diminished or treated by Leueovorin. Nevertheless, some cases of liver failure and bone m a r r o w depression have been seen even after folinie acid rescue. ~° In our study, no i m p o r t a n t toxicity was observed, even after administration of high-dose MTX. Before embarking on extensive clinical trims with high-dose MTX in transitional cell carcinoma of the bladder, these animal studies suggest that a r a n d o m i z e d trial between convent i o n a l a n d h i g h - d o s e M T X s h o u l d be performed. T h e additional cost and potential toxicity of the high-dose regimen m a y not be warranted. 956 Court Avenue, Box 10
Memphis, Tennessee 38163 (DR. SOLOWAY) References 1. Goldin A, et al: Eradication of leukemia ceils (L1210) by methotrexatc and methotrexate plus eitrovorum factor, Nature 212:1548 (1966). 2. Bertinn JR: Clinical use of methotrexate--with emphasis on use of high doses, Cancer Treat Rep (Suppl) 65:131 (1981). 3. Bertino JR: Toward improved selectivity in cancer chemotherapy, Cancer Res 39:293 (1979). 4. Shrecker AW, et al: Dihydrofolate reductase activity of
256
leukemia Lt210 during development of methotrexate resistan~ Biochcm Pharmacol 20- 716 (1971). i 5. Yagoda A: Chemotherapy for advanced urothelial eh~'~ Semin Urol 7:60 (1983). ~,~ 6. Turner A: Methotrexate, in Oliver RTD, ttendry "WE~i Bloom HJG (Eds): Bladder Cancer: Principles of Combiria~, Therapy, London, Butterworth Publishing, Inc., chap 23;:iI~ pp 219-229. 7-:..~ 7. Yagoda A: Phase II trials of single agents and combin~i~ regimens in the treatment of urothelial tract tumors. Me~:~ Hospital experience, in Ohver et a~. B chap 20 pp 193-206: ~ 8. Socquet Y: Combined surgery and adjuvant chemotli~i~ with high-dose methotrexate and folinie acid rescue (HI3~[~ CF) for infiltrating tumours, of the bladder, Br J Urol 531:;~ ~*~ (1981). ~-~ 9. Oliver BTD, et ah Methotrexate in the treatment of Ni static and recurrent primary transitional cell eareinoma~iji~ 131:483 (1984). 2"; 10. Hall RR, et ah Treatment of invasive bladder cai~ local resection and high-dose methotrexate, Br J Urol Nli (1984). ",;i ll. Soloway MS: lntravesieal and systemic ehemotheriii murine bladder cancer, Cancer Res 37:2918 (1977). ~ 12. Soloway MS, and Cox CE: The effect of platinum a~ and combination chemotherapy on murine blad Am Assoe Genitourin Surg 71:8 (1979). 13. Hiekey DR Brausi M, Blatnik AE and So' parison of single agent cisplatin and eisplatin binations in the treatment of murine bladder ca~ 484 (1987). 14. 8toter G, et al: Combination chemothera and methotrexate in advanced transitional cell c~ der, J Urol 137:663 (1987). 15. Splinter TAW: Neoadjuvant chemotherap cinoma of the bladder, preliminary resulL~ of presented at International Symposium on Pr( t r o v e r s i e s in Oneologieal Urology II, Ar~ Netherlands, March 19-21, 1987. •
•
7
•
UROLOGY ;
MARCH I990
,.
"
/
'
r/ll~
• Cq~
VOLUME XXXV, N ::?i~,~
DOSE RESPONSE RELATIONSHIP OF METHOTREXATE IN COMBINATION WITH CISPLATIN IN MURINE BLADDER CANCER* MAURIZIO BRAUSI, M.D. ANTONY BLATNIK, B.S. MARK S. SOLOWAY, M.D. From the Department of Urology, University of Tennessee, Memphis, Tennessee
B-TRACT--Methotrexate (MTX) has activity in transitional cell carcinoma (TCC) in man and ~ e have suggested an advantage o] high-dose methotrexate versus the standard dose in control~g:tUmor growth and prolonging survival. MBT-2, a poorly differentiated TCC induced by the ~ci'nogen FANFT, is" both grossly and histologically similar to human TCC and has been used as ~ n i m a l model. One hundred twenty C3H/HE female mice were injected in the hind limb with ~ × 104 MBT-2 tumor cells. When palpable tumors developed in all animals, therapy was initia L Animals' were randomized into a control group and nine treallment groups as Jol!ows: cisplatin ~ ) P ) , MTX 32 mg, M T X 50 mg, MTX 80 mg, DDP + MTX 32, M T X 50 + Leucovorin, MTX 80 rin, DDP + MTX 50 + Leucovorin, DDP + M T X 80 + Leucovorin. The combination STX 50 mg with Leucovorin + DDP and DDP alone were the two most effective regimens in ~ trolling tumor growth and prolonging s°urvival. No statistically significant difference was ob~lecl between the group treated by high-dose MTX alone and those treated by low-dose MTX. No ~:city was observed even when high doses' o] MTX were m'ed.
~Leucovo
thotrexate (MTX) is a folinic acid antagonist eh inhibits the conversion of folinic acid to ahydrofolate. It is cell-cycle dependent, aetI~speeifieallv during DNA synthesis. In 1966, ~ ] d i n et al: ~ established that intermittent ~ e s of MTX are more effective than daily dose ~ t m e n t in the early phases of growth of the ~ i d l y growing L1210 murine leukemia. The ~ o t h e s i z e d advantage of higher doses would ~!r~creased cell kill and prevention or delay in ~41develoDment of resistance In ex erimental ~ . ~i~or models, in fact, both in vitro and in vivo ~ s t a n c e to MTX occurs more rapidly when ~ I I doses of the drug are administered contin~4tlsIY .2-4 Resistance eventually occurs despite use o; high-dose MTX plus folinie acid res-
~
~
•
.
p
~!
~ a p p o r t e d by PHS Grant GA 186643 by National Ganeer In.~_:~!e and grant bv Veterans Administra(ion Medical Research
Io'''OCY ,
MARCH 1990 ,
VOI,UME XXXV, NUMBER 3
cue. In that ease, it may be due to accumulation of reduced folates as a consequence of Leueovorin (LV) administration. 2-4 Another advantage of high-dose MTX plus LV is reduced marrow toxicity. Methotrexate has demonstrated activity in advanced bladder cancer, s-9 There are no randomized trials comparing high-dose to standard-dose MTX. Since the MBT-2 transitional cell carcinoma has provided insight into the relative efficiency of antitumor drugs in human bladder cancer, varying doses of MTX were compared using this model. Material and Methods Tumor cell preparation Tumor tissue was aseptically excised from carrier mice, minced with scissors, and placed in a trypsinizing flask where enzymatic dissociation was carried out with Hank's Balanced
253
Salt solution (Gibeo, Grand Island, New York) containing 0.175 percent trypsin. An antibiotieantimycotic solution (Gibco, Grand Island, New York) was added to the Hank's solution, 1 mg/!00 mL, prior to the trypsinization. The mixture was agitated at 37°C using a magnetic stirrer for twenty-five minutes, at which point the supernatant was discarded. Fresh trypsinizing solution was added and stirred for an additional twenty minutes at 37°C. This solution was poured through a fine nylon mesh and centrifuged at 1,100 rpm for twelve minutes• The pellet was resuspended in a Hank's solution containing antibiotic-antimycotic solution and glutamine. The viable cell count was determined by trypan blue exelusion. The final concentration of cells desired was adjusted by dilution with RPMI 1640 with fetal calf serum.
In vivo drug testing One hundred and twenty C3H/HE female mice (Harlan Breeding Labs) were injected in the right hind limb with 7.5 x 104 MBT-2 tumor cells. MBT-2 is a FANFT-induced, poorly differentiated transitional cell carcinoma that was initially transplanted from the bladder of a mouse that ingested the carcinogen FANFT for forty weeks. The MBT-2 tumor used in this experiment was in its sixty-first transplant generation. The hind limbs of the animals were palpated daily until tumors were positively identified. Therapy was initiated on the day that 100 percent of the animals had tumor. On day 11 (post inoculation) the animals were randomized and therapy was initiated (Table I). All drugs were given in a volume of 0.1 cc intraperitoneally except the Leucovorin rescue which was administered subcutaneously. Therapy was administered weekly for a total of three doses. Tumors were measured biweekly with a Vernier caliper. The percent tumor reduction was calculated. The percent inerease in life span (% ILS) was calculated by subtracting the median survival time (MST) of the control group from the treated group divided by the MST of the control x 100. Statistical analysis of drug effectiveness on tumor control was done using the Levene, and the Dunnet and Dunkin tests for independent events. Results In evaluating the response to chemotherapy at days 28 and 34, mean tumor diameter, percent of tumor reduction, and survival were analyzed (Table II). Animals receiving cisplatin 254
Post-inoculation therapy oj animalsJl
TABLE I.
Group (dosesin mg/kg)
N0!]
Anin~:~
1. C o n t r o l (no t r e a t m e n t )
12~!
2. DDP 6.0
19Jj:,:,i
3. MTX 32
4. 5. 6. 7. 8. 9. 10.
MTX 50 MTX 80 DDP 6.0 MTX 50 MTX 80 DDP 6.0 DDP 6.0
+ MTX 32 + Leueovorin 200 + Leucovorin 200 + MTX 50 + Leueovorin 200 + MTX 80 + Leueovorin 200
~" i2ii~ 12,:~!~i 12~!~ 121:!:~i~ iP,!~! 121~:
(DDP) alone or in combination with MTXi!~ mg followed by Leucovorm showed tumor~:r~ duction of 34 percent and 32 percent, r e ~ tively, with ILS of 9.9 percent. This is a si~! I c a n t difference w h e n c o m p a r e d wittii~ eontrol group (p = 0.05). Methotrexate aI:0 with or without Leucovorin, did not alter:'~!~ mor growth. Despite a prolonged ILS of 53~{~i cent in the mice receiving DDP plus, hig:h:a~{ ..... MTX (80 mg) and Leueovorin, the percenf;{N tumor reduction was only 15 percent. Alth~)i~~ the survival in this group of animals was t ~ than the survival observed m" mice" reeel~'~, ~;::~ DDP alone or reeewmg low-dose MTX ( o 0 , ~ with DDP and Leucovorin, this difference ~ not statistically significant. ~"~; •
,,
Comment MTX is probably the see tumor drug in the treamer tional cell cancer. 5-9 At the pital, 61 patients with ] metastatic bladder eaneei MTX at different doses. ' rate was 13 percent in pal 50 rag, 56 percent in the 11 percent for those who re Leueovorin rescue. The m sponse was six months. 6 This experience was , Yagoda 7 who reported a rate in 28 patients who ha vious treatment with eis] MTX was 250 mg/M 2 witl Soequet s reported 90 perec years in 33 patients with "I treated by partial or total by 1-3 g MTX and folinie Oliver et al. 9 reported { MTX and observed a respo:
UROI.OGY
,
MARCH 1990 ,' VOLUME xXXV, NuMt(!~. ~:
TABLE II. i
Evaluation o] cell line MBT-2 rasponse to chemotherapy at days 28 and 34
Therapy (mg/k__g)
Total No. Mice
No. of Tumors (%)
Mean Tumor Diameter
Std. Dev.
P
12 12 12 12 12 12 12 12
12 (100)
12 (lOO)
13.89 9.94 13.19 13.04 12.33 12.12 13.73 12.79
2.0 2.5 2.3 2.4 1.9 3.3 1.5 3.5
. . 0.05" n.s. n.s. n.s. n.s. n.s. n.s.
12
12 (100)
10.47
2.1
0.05*
12
12 (100)
12.18
3.0
n.s.
12
12 12 12
12 12 12 12 12 12 12 12
(100) (100) (100) (100) (100) (100) (100) (100)
16.48 12.34 16.25 15.65 14.86 14.29 17.24 15.10
2.3 3.5 2.9 2.4 2.1 3.4 1.4 4.3
. . 0.05* n.s. n.s. n.s. n.s. n.s. n.s.
12
12 (100)
12.44
2.9
0.05*
12
12 (100)
14.29
2.7
n.s.
i Control ODe 6 •~ T × 32 i 'MT : X 50
i iavx 80 :'iMTX 32 + DDP 6 I~TX 50 + LCV res. ,MTX 80 + LCV res. ;MTX 50 + DDP 6 i~~,i,LCV res. MTX80 + D D P 6 ~ :~LCV res. ~6itS day 34 ~bntrol fiDe 6 ~TX 32
~
12 12
: tx 50 80
12 12
32 + DDP 50 + LCV 80 + LCV 50 + DDP 3V res. 80 + DDP ~V res.
6 res. res. 6
12 (I00) 12 (100) 12 (100) 12 (100) 12 (100) 12 (m0)
% Tumor tledx. .
.
.
.
% ILS
MST (Days)
29 16 5 21 37 -5 11
38 49 44 40 46 52 36 42
33
29
49
14
53
58
29 16 5 21 37 - 5 11
38 49 44 40 46 52 36 42
32
29
49
15
53
58
. . 40 5 7 13 15 1 9
. . 34 1 5 11 15 - 5 9
6
es compared with control. There are significant differences between treatment groups.
ili:i~:4
i{!atients with measurable metastases and 28 ~6nt with recurrent p r i m a r y tumors. T h e ~'~d~inistered doses w e r e 1,000 m g / M 2 with ~ei}h0vorin and 50-100 m g / M ~ w i t h o u t rescue. • et al.'° published a series of 57 pT2, p T 3 a , and p T 3 b transitional a of the b l a d d e r treated b y T U R ight courses of M T X 2 g IV every vith Leueovorin rescue (12 mg 6 twelve to forty-eight hours. The ase-free survival rate was 52 per~-year disease-free survival was 46 :Nevertheless, none of these studies was ranthe n u m b e r of patients was small, L~/shrgieal treatments varied T h e relative ef ~rC~Cy ~::i,..... of hi g h - dose M T X versus low dose MTX -~s~hot been answered. , , ,!~:Our study, MTX, with or w i t h o u t tolinie ~cid ~¢ J : .rescue . ' was tested in mice to corn P are the "!f~hveness of high-dose to low-dose in con:rOlling tumor g r o w t h and prolonging survival
I0 ed,
~S:!~dtOcy i~
/
MARCH 1990
/
VOLUMF XXXV, NUMBER 3
in mice with established tumors. The combination of low-dose M T X w i t h Leueovorin and eisplatin and eisplatin alone resulted in the most effective regimens against the MBT-2 tumor. M T X alone, even at high doses, was not as effective as eisplatin. This is consistent with our previous studies. 11-13 T h e group of mice receiving high-dose M T X in c o m b i n a t i o n with eisplatin and Leucovorin had the longest median survival (ILS = 53%) although t u m o r reduction was only modest. T h e i m p r o v e m e n t in the ILS was not statistically better than the c o m b i n a t i o n of M T X and D D P w i t h o u t rescue. O u r results are consistent with the KaplanMeier survival curves of successive studies perf o r m e d by the E O R T C 14,t5 in which they demonstrated t h a t M T X a n d e i s p l a t i n in c o m b i n a t i o n did not significantly improve survival in patients with a d v a n c e d bladder cancer. I m p o r t a n t side effects in h u m a n s after administration of high-dose M T X with folinie acid
255
rescue are reported in the literature. The most f r e q u e n t s y m p t o m s are mucositis, conjuneti~4tis, nausea, and vomiting and are usually diminished or treated by Leueovorin. Nevertheless, some cases of liver failure and bone m a r r o w depression have been seen even after folinie acid rescue. ~° In our study, no i m p o r t a n t toxicity was observed, even after administration of high-dose MTX. Before embarking on extensive clinical trims with high-dose MTX in transitional cell carcinoma of the bladder, these animal studies suggest that a r a n d o m i z e d trial between convent i o n a l a n d h i g h - d o s e M T X s h o u l d be performed. T h e additional cost and potential toxicity of the high-dose regimen m a y not be warranted. 956 Court Avenue, Box 10
Memphis, Tennessee 38163 (DR. SOLOWAY) References 1. Goldin A, et al: Eradication of leukemia ceils (L1210) by methotrexatc and methotrexate plus eitrovorum factor, Nature 212:1548 (1966). 2. Bertinn JR: Clinical use of methotrexate--with emphasis on use of high doses, Cancer Treat Rep (Suppl) 65:131 (1981). 3. Bertino JR: Toward improved selectivity in cancer chemotherapy, Cancer Res 39:293 (1979). 4. Shrecker AW, et al: Dihydrofolate reductase activity of
256
leukemia Lt210 during development of methotrexate resistan~ Biochcm Pharmacol 20- 716 (1971). i 5. Yagoda A: Chemotherapy for advanced urothelial eh~'~ Semin Urol 7:60 (1983). ~,~ 6. Turner A: Methotrexate, in Oliver RTD, ttendry "WE~i Bloom HJG (Eds): Bladder Cancer: Principles of Combiria~, Therapy, London, Butterworth Publishing, Inc., chap 23;:iI~ pp 219-229. 7-:..~ 7. Yagoda A: Phase II trials of single agents and combin~i~ regimens in the treatment of urothelial tract tumors. Me~:~ Hospital experience, in Ohver et a~. B chap 20 pp 193-206: ~ 8. Socquet Y: Combined surgery and adjuvant chemotli~i~ with high-dose methotrexate and folinie acid rescue (HI3~[~ CF) for infiltrating tumours, of the bladder, Br J Urol 531:;~ ~*~ (1981). ~-~ 9. Oliver BTD, et ah Methotrexate in the treatment of Ni static and recurrent primary transitional cell eareinoma~iji~ 131:483 (1984). 2"; 10. Hall RR, et ah Treatment of invasive bladder cai~ local resection and high-dose methotrexate, Br J Urol Nli (1984). ",;i ll. Soloway MS: lntravesieal and systemic ehemotheriii murine bladder cancer, Cancer Res 37:2918 (1977). ~ 12. Soloway MS, and Cox CE: The effect of platinum a~ and combination chemotherapy on murine blad Am Assoe Genitourin Surg 71:8 (1979). 13. Hiekey DR Brausi M, Blatnik AE and So' parison of single agent cisplatin and eisplatin binations in the treatment of murine bladder ca~ 484 (1987). 14. 8toter G, et al: Combination chemothera and methotrexate in advanced transitional cell c~ der, J Urol 137:663 (1987). 15. Splinter TAW: Neoadjuvant chemotherap cinoma of the bladder, preliminary resulL~ of presented at International Symposium on Pr( t r o v e r s i e s in Oneologieal Urology II, Ar~ Netherlands, March 19-21, 1987. •
•
7
•
UROLOGY ;
MARCH I990
,.
"
/
'
r/ll~
• Cq~
VOLUME XXXV, N ::?i~,~