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`Annals of Oncology7: 643-645, 1996.
`
`Letters to the editor
`
`Low-dose prednisone and increased
`risk of development of bone metastases
`
`Marini et al. report that low-dose continuous prednisone (7.5
`mg/day) added to adjuvant CMF chemotherapy is associated
`with an increased risk of development of bone metastases [1].
`As suggested by the authors, this puzzling observation could
`be due to the effects of corticosteroids on bone metabolism.
`This is even more disturbing that corticosteroids are more
`and more used in oncology, notably for the control of emesis
`[2]. The authors suggest that inhibition of cytokines in bone
`by steroids could impair the organ specific natural anti-neo-
`plastic activity.
`More specifically, there are data to suggest that this pos-
`sible relationship could be due to increased bone resorption
`induced by the corticosteroids. It has been demonstrated that
`the administration of comparable doses of corticosteroids
`enhances bone resorption and induces a significant bone loss
`[3, 4] and a stimulation of bone resorption could well be
`important for the development of bone metastases and the
`pathophysiology of tumor-induced osteolysis [5].
`The propensity of breast cancer cells to metastasize and
`proliferate in bone could be due to the rich supply of relevant
`growth factors present in the skeletal microenvironment. This
`'seed and soil' concept has been recently reviewed [6]. Breast
`cancer cells (the 'seed') appear to secrete factors such as para-
`thyroid hormone-related protein (PTHrP) potentiating the
`development of metastases in the skeleton which constitutes a
`fertile 'soil' rich in cytokines and growth factors that can stimu-
`late breast cancer cell, growth. Local production of PTHrP
`and of other osteolytic factors such as transforming growth fac-
`tors (TGFs) by cancer cells in bone would stimulate osteoclas-
`tic bone resorption by inducing osteoclast differentiation from
`hematopoietic stem cells and/or by activating mature osteo-
`clasts already present in bone. Increased osteoclast activity
`would then cause local foci of osteolysis, which could further
`stimulate cancer cells proliferation since products of bone re-
`sorption can enhance tumor cell growth [5-7]. This reasoning
`actually forms the basis for the use of bisphosphonates in can-
`cer patients to target bone-resorbing cells for the treatment
`and the prevention of tumor-induced osteolysis [8].
`The data of Marini et al. indicate that it is appropriate to
`investigate the deleterious effects of the use of corticosteroids
`on bone metabolism in cancer patients, especially concerning
`a possible increase in the incidence of bone metastases. If
`these data are confirmed, they would have obvious important
`clinical implications, especially since the introduction of
`potent bisphosphonates in our therapeutic armamentarium
`that can prevent glucocorticoid-induced osteolysis [9-10].
`
`J J. Body
`Supportive Care Clinic, Institute Jules Bordet, 1000
`Bruxelles, Belgium
`
`References
`
`1. Marini G, Murray S, Goldhirsch A et al. The effect of adjuvant
`prednisone combined with CMF on patterns of relapse and
`
`occurrence of second malignancies in patients with breast
`cancer. Ann Oncol 1996; 7: 245-50.
`2. Koo WH, Ang PT. Role of maintenance oral dexamethasone in
`prophylaxis of delayed emesis caused by moderately emeto-
`genic chemotherapy. Ann Oncol 1996; 7: 71-4.
`3. Lukert BP, Raisz LG. Glucocorticoid-induced osteoporosis:
`Pathogenesis and management. Ann Intern Med 1990; 112:
`352-64.
`4. Saito JK, Davis JW, Wasnich RD, Ross PD. Users of low-dose
`glucocorticoids have increased bone loss rates: A longitudinal
`study. Calcif Tissue Intern 1995; 57:115-9.
`5. Body JJ. Bone metastases and tumor-induced hypercalcemia.
`Curr Opin Oncol 1992; 4: 624-31.
`6. Guise TA, Mundy GR. Breast cancer and bone. Curr Opin
`Endo 1995; 2: 548-55.
`7. Kostenuik PJ, Singh G, Suyama KL, Orr FW. Stimulation of
`bone resorption results in a selective increase in the growth rate
`of spontaneously metastatic Walker 256 cancer cells in bone.
`Clin Exp Metastasis 1992; 10:411-8.
`8. Body JJ, Dumon JC. Treatment of tumor-induced hypercalca-
`emia with the bisphosphonate pamidronate: Dose-response re-
`lationship and influence of the tumour type. Ann Oncol 1994;
`5:359-63.
`9. Gallacher SJ, Fenner JAK, Anderson K et al. Intravenous
`pamidronate in the treatment of osteoporosis associated with
`corticosteroid dependent lung disease: An open pilot study.
`Thorax 1992; 47: 932-6.
`10. Eastell R. Management of corticosteroid-induced osteoporosis.
`J Intern Med 1995; 237:439-47.
`
`Ifosfamide encephalopathy and
`methylene-blue: A case report
`
`Ifosfamide is one of the most widely used alkylating agents.
`Before mesna was introduced, its dose-limiting toxicity was
`haemorrhagic cystitis, but at present, neurotoxicity is one of
`its most worrisome side effects. Ifosfamide-induced encep-
`halopathy (HE) is a dose-dependent condition reported to
`have been fatal in a number of patients [1, 2], HE is more fre-
`quently seen in patients with renal and liver dysfunction, low
`levels of serum albumin, pelvic disease, poor performance
`status, prior central nervous system alterations (metastases,
`radiotherapy) and previous treatment with cisplatinum. It
`also seems to be more common in female and elderly
`patients. Kiipfer et al. have suggested the use of methylene-
`blue (MB) for both the treatment and prophylaxis of this
`toxicity. They found excessive urinary excretion of glutaric
`acid and sarcosine in a patient with IIE [3]. These can be
`detected in type II glutaricaciduria, an intrinsic flaw probably
`due to a deficiency in electron-transferring flavoprotein or in
`its dehydrogenase. Acyl-CoA dehydrogenases cannot trans-
`fer their electrons to the respiratory chain and become in-
`effective, leading to the accumulation of toxic metabolites.
`MB might oxidize the reduced dehydrogenases and allow
`further oxidation of the enzyme substrates [4J. We report a
`case of ifosfamide-induced encephalopathy successfully
`treated with methylene-blue.
`The patient was a 46-year-old woman with stage IV ovar-
`ian carcinoma (pleura! effusion with malignant cytology), and
`bulky pelvic and peritoneal disease. She had previously re-
`ceived four cycles of a carboplatin-cyclophosphamide regi-
`men, with disease progression, followed by four cycles of
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