Induction cisplatin-gemcitabine-paclitaxel plus concurrent radiotherapy and gemcitabine in the multimodality treatment of unresectable stage IIIB non-small cell lung cancer

BACKGROUND

To evaluate feasibility and safety of induction three-drugs combination chemotherapy and concurrent radio-chemotherapy in stage IIIB NSCLC.

PATIENTS AND METHODS

Patients with stage IIIB NSCLC were treated with three courses of induction chemotherapy, cisplatin 50 mg/m(2), paclitaxel 125 mg/m(2) and gemcitabine 1000 mg/m(2) on days 1,8 of every 21 day cycle. Patients without distant progressive disease were then treated with radiotherapy and concurrent weekly gemcitabine (250 mg/m(2)). Toxicity and response of radio-chemotherapy treatment have been assessed.

RESULTS

Between Jan 01 and Nov 02, 46 patients were enrolled. Grade 3+ hematological and non-hematological toxicity during the induction phase were 41.3% and 13.1%, respectively. In 38 patients a Clinical Response or Stable Disease was recorded and these patients underwent to concurrent radio-chemotherapy. Grade 3+ hematological and non-hematological toxicities were 8.2% in this group. Further response was observed in 66% of patients. Overall median survival time was 17.8 months, with a 3-year survival rates of 23%.

CONCLUSION

Three-drugs induction chemotherapy and concurrent radio-chemotherapy with weekly gemcitabine in locally advanced stage IIIB NSCLC is feasible and safe.

Developing a paradigm of drug innovation: an evaluation algorithm

Assessment of drug innovation is a burning issue because it involves so many different perspectives, mainly those of patients, decision- and policy-makers, regulatory authorities and pharmaceutical companies. Moreover, the innovative value of a new medicine is usually an intrinsic property of the compound, but it also depends on the specific context in which the medicine is introduced and the availability of other medicines for treating the same clinical condition. Thus, a model designed to assess drug innovation should be able to capture the intrinsic properties of a compound (which usually emerge during R&D) and/or modification of its innovative value with time. Here we describe the innovation assessment algorithm (IAA), a simulation model for assessing drug innovation. IAA provides a score of drug innovation by assessing information generated during both the pre-marketing and the post-marketing authorization phase.

Italian Multiple Sclerosis Database Network

The Multiple Sclerosis Database Network (MSDN) is the first Italian multiple sclerosis (MS) registry. The preliminary results on the MSDN cohort demonstrated that the risk of disability progression, in a sample of 2090 MS patients, was reduced by about four- to five-fold in patients exposed to IFNbeta for more than 4 years compared with patients exposed for up to 2 years. More recent results showed, in a subset of 1170 relapsing-remitting MS patients, of whom 918 were treated with IFNbeta and 252 were untreated, that IFNbeta-treated patients had a differential reduction in EDSS score change of -0.055 for each year of follow-up in comparison with the untreated group. These results provide significant information on the effectiveness of IFNbeta treatment on long-term disability progression in MS.

Detection of ovine lentivirus in the cumulus cells, but not in the oocytes or follicular fluid, of naturally infected sheep

The aim of this study was to examine the Maedi-Visna virus (MVV) infection status of oocytes, cumulus cells, and follicular fluid taken from 140 ewes from breeding flocks. MVV proviral-DNA and MVV RNA were detected using nested-PCR and RT-PCR MVV gene amplification, respectively in the gag gene. Nested-PCR analysis for MVV proviral-DNA was positive in peripheral blood mononuclear cells in 37.1% (52/140) of ewes and in 44.6% (125/280) of ovarian cortex samples. The examination of samples taken from ovarian follicles demonstrated that 8/280 batches of cumulus cells contained MVV proviral-DNA, whereas none of the 280 batches of oocytes taken from the same ovaries and whose cumulus cells has been removed, was found to be PCR positive. This was confirmed by RT-PCR analysis showing no MVV-viral RNA detection in all batches of oocytes without cumulus cells (0/280) and follicular fluid samples taken from the last 88 ovaries (0/88). The purity of the oocyte fraction and the efficacy of cumulus cell removal from oocytes was proved by absence of granulosa cell-specific mRNA in all batches of oocytes lacking the cumulus cells, using RT-PCR. This is the first demonstration that ewe cumulus cells harbor MVV genome and despite being in contact with these infected-cumulus cells, the oocytes and follicular fluid remain free from infection. In addition, the enzymatic and mechanical procedures we used to remove infected-cumulus cells surrounding the oocytes, are effective to generate MVV free-oocytes from MVV-infected ewes.

An evaluation of acid-base changes following aortic cross-clamping using transcutaneous carbon dioxide monitoring

To investigate the cause of acidosis following release of an aortic cross-clamp, we measured tissue PCO2 using a transcutaneous (TC) CO2 monitor placed below the level of the cross-clamp in 10 patients undergoing aortic arch surgery. Following placement of the aortic cross-clamp, the TC CO2 value from the lower extremity increased from 41 +/- 4 to 92 +/- 41, whereas there was no change in the TC CO2 value from the upper extremity. With release of the cross-clamp, end-tidal CO2 increased by 6.2 +/- 1.9 mmHg, the upper TC CO2 increased by 8.4 +/- 4.8 mmHg, and the lower extremity TC CO2 value returned to baseline. During cross-clamping, there was an increase in the base deficit of 4.3 +/- 2.9 when comparing the baseline arterial blood gas value with the one obtained after cross-clamp release (p = 0.0004). These data demonstrate that the acidosis occurring during aortic cross-clamping is a mixed metabolic and hypercarbic acidosis. Appropriate treatment includes the provision of adequate minute ventilation to ensure CO2 removal and the use of sodium bicarbonate based on the degree of metabolic acidosis demonstrated by arterial blood gas analysis.

Prospective trial of ifosfamide, paclitaxel, and cisplatin (ITP) in patients with advanced non-transitional cell (non-TCC) carcinomas of the urothelial tract

4542

Background: Non-TCC’s account for 5–10% of urothelial tract tumors and are each characterized by unique demographics, risk factors, and patterns of spread. A unifying feature of these malignancies is their aggressive course and poor outcomes with standard chemotherapeutic regimens. Given the rarity of these tumors, no prospective data are available to guide management. Methods: Patients with unresectable/metastatic adenocarcinoma, squamous cell, small cell, sarcomatoid, and poorly differentiated carcinomas of the urothelial tract were eligible. Treatment consisted of: Paclitaxel 200 mg/m2 IV on day 1, cisplatin 70 mg/m2 IV on day 1, ifosfamide 1500 mg/m2 IV on days 1–3 + mesna. GCSF was administered with each cycle. Treatment was recycled every 3 weeks for a maximum of 6 cycles. The primary endpoint was the response rate. Results: Twenty patients (pts) were enrolled with the following histologic types: adenocarcinoma 11/20, squamous cell carcinoma 8/20, small cell carcinoma 1/20. Pts received a median of 4 cycles (range, 1–6). The grade 3–4 toxicities included neutropenia (6/20), anemia (9/20), thrombocytopenia (4/20), confusion (1/20), seizure (1/20), neuropathy (1/20), renal insufficiency (2/20), fatigue (2/20), and hyponatremia (1/20). Thirteen of the 20 pts have died. The median survival for pts with adenocarcinoma is 24 months (95% CI 9.6–32.4) and with squamous cell carcinoma is 8.4 months (95% CI 5.3-NR). Five pts achieved durable disease-free survival (1+, 2+, 4+, 6+, and 8+ years) after ITP ± surgical consolidation. Conclusions: ITP is an active regimen in pts with advanced non-TCC’s of the urothelial tract. To our knowledge, this is the first prospective study of a chemotherapeutic regimen in this patient population.

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Tumor location does not impact return of renal function following partial nephrectomy

14511

Background: To study the impact of tumor location on the glomerular filtration rate (GFR) changes following partial nephrectomy. Methods: We reviewed our institutional database to identify patients who underwent partial nephrectomy between 1/1995 and 7/2005. Preoperative CT and/or MRI studies were reviewed to characterize tumors as either central or peripheral. Central tumors were defined as those involving the collecting system or renal sinus; all others were categorized as peripheral. We used the Abbreviated Modification of Diet in Renal Disease study equation to estimate GFR preoperatively, in the early postoperative hospital stay, and at 1 and 12 months after surgery. Multivariate models were fit to determine the association of tumor location with changes in GFR at each time period after controlling for age, sex, tumor size, American Society of Anesthesia Score, ischemic time, operative time, and blood loss. Results: A total of 616 patients (265 central and 351 peripheral tumors) were available for analysis. Patients with central tumors were younger compared to those with peripheral tumors (62 vs. 59, p = 0.014), had longer intraoperative renal ischemia (40 vs. 30 min, respectively, p < 0.001), and had longer operations (201 vs. 184 min, respectively, p = 0.01). Although baseline GFR did not differ between the groups, a significantly larger decrease in GFR was found in patients with central compared to peripheral tumors in the early postoperative period (−16 vs. −11 cc/min/1.73 m2, p = 0.013) and 1-month follow-up (−10 vs. −6 cc/min/1.73 m2, p = 0.017). The GFR change was similar at 1-year follow-up, −10 and −11 cc/min/1.73m2 (p = 0.586) for central and peripheral tumors, respectively. On multivariate analysis, tumor location was not significantly associated with the change in GFR at any of the time intervals after adjusting for size, ischemic time, operative time, age, sex and comorbidity. Conclusions: Patients with centrally located tumors have a more pronounced short-term decrease in GFR, which reflects a longer operative time and ischemia duration. Tumor location does not appear to impact the long-term renal function. This suggests that renal sparing surgery should not be withheld from this subset of patients.

No significant financial relationships to disclose.

Predicting the histology of renal masses using pre-operative Doppler ultrasonography

4598

Background: Traditional imaging techniques cannot differentiate between benign, indolent and malignant renal neoplasms. Since conventional clear cell carcinomas are highly vascular, we evaluated the association between vascular flow within a renal mass on pre-operative color and/or power Doppler ultrasonography (CDUS) and surgical pathology. Methods: Nephrectomies performed at our institution between 1/2001 and 12/2004 were retrospectively evaluated. Detection of flow within the renal mass on CDUS was defined as vascular flow. A prospective validation study was performed from 1/2005 to 10/2005, and a nomogram predicting clear cell histology created using vascular flow along with clinical and radiologic parameters. Results: Of 299 renal lesions in the retrospective cohort, 210 (70%) had evidence of vascular flow, including 156 of 169 (92%) conventional clear cell carcinomas (p < 0.0001). On logistic regression analyses, vascular flow was associated with conventional clear cell histology with an odds ratio of 16.9, CI: 8.7–32.8, p < 0.0001. These findings were validated prospectively in 97 patients; CDUS detected vascular flow in 54 of 65 (83%) renal masses with conventional clear cell histology (p < 0.0001) and was associated with an odds ratio of 10.8 (95% CI 4.0–29.0; p < 0.0001). On multivariable analyses, vascular flow was still a statistically significant predictor of conventional clear cell histology. A nomogram incorporating vascular flow along with clinical and radiologic variables (clinical size, patient gender and age) to predict conventional clear cell histology was constructed on the retrospective cohort and validated on the prospective data set (concordance index 0.82 and 0.76 respectively). Conclusions: Vascular flow within a renal mass detected by CDUS is strongly associated with conventional clear cell histology with an odds ratio of 10.8–16.9. A nomogram incorporating vascular flow on CDUS and clinical and radiographic parameters may aid in the non-invasive characterization of renal lesions.

[Table: see text]

No significant financial relationships to disclose.

Successful recovery of acute hemosiderotic heart failure in beta-thalassemia major treated with a combined regimen of desferrioxamine and deferiprone

We report the case of a 25-years-old male with beta-thalassemia major who developed acute heart failure, with severe systolic dysfunction, resulting from iron overload. Combined iron chelation with desferrioxamine and deferiprone together with standard cardiological treatment induced prompt and complete restoration of the cardiac function.

Total fat, fat distribution and blood pressure according to eating frequency in children living in southern Italy: the ARCA project

The relationships between eating frequency and adiposity and cardiovascular risk factors have been poorly investigated in children. To evaluate this issue, anthropometric indices and blood pressure (BP) were measured in 3668 children, aged 6-11 years. Meals/snack frequency, assessed by a questionnaire, was 'Low' in 332 (<or=3 meals/day), 'Intermediate' in 1334 (4/day) and 'High' in 2002 (>or=5/day) children. Body mass index (BMI) and waist circumference significantly decreased going up across meals/snacks categories (BMI=20.5+/-0.2, 19.7+/-0.1 and 18.8+/-0.1 kg/m2; waist=68.0+/-0.6, 66.6+/-0.3, 63.9+/-0.2 cm, for Low, Intermediate and High groups, respectively; M+/-s.e.; P<0.001 by ANCOVA trend analysis adjusted by age, sex, birth weight, physical activity, parental overweight and education level). BP decreased from Low to High group but differences were no longer significant after adjustment for BMI. In our sample of school children, the daily eating frequency was inversely associated with the degree of both total adiposity and central fat deposition.

Brain atrophy and lesion load in a large population of patients with multiple sclerosis

OBJECTIVE

To measure white matter (WM) and gray matter (GM) atrophy and lesion load in a large population of patients with multiple sclerosis (MS) using a fully automated, operator-independent, multiparametric segmentation method.

METHODS

The study population consisted of 597 patients with MS and 104 control subjects. The MRI parameters were abnormal WM fraction (AWM-f), global WM-f (gWM-f), and GM fraction (GM-f).

RESULTS

Significant differences between patients with MS and control subjects included higher AWM-f and reduced gWM-f and GM-f. MRI data showed significant differences between patients with relapsing-remitting and secondary progressive forms of MS. Significant correlations between MRI parameters and between MRI and clinical data were found.

CONCLUSIONS

Patients with multiple sclerosis have significant atrophy of both white matter (WM) and gray matter (GM); secondary progressive patients have significantly more atrophy of both WM and GM than do relapsing-remitting patients and a significantly higher lesion load (abnormal WM fraction); lesion load is related to both WM and even more to GM atrophy; lesion load and WM and GM atrophy are significantly related to Expanded Disability Status Scale score and age at onset (suggesting that the younger the age at disease onset, the worse the lesion load and brain atrophy); and GM atrophy is the most significant MRI variable in determining the final disability.

Predictors of long–term clinical response to interferon beta therapy in relapsing multiple sclerosis

OBJECTIVES

The aim of this study was to identify clinical, magnetic resonance imaging (MRI) and biological markers predictive of long-term clinical response to interferon beta (IFN beta) therapy in patients with relapsing-remitting multiple sclerosis (RRMS).

METHODS

Sixty-eight patients treated with IFN beta were followed over a 6-year period. Relapse rate and disability progression were evaluated throughout the study. We considered suboptimal clinical response to be either the presence of sustained disability progression, or more than two relapses. Baseline and 12-month demographic, clinical and MRI findings, as well as the development of neutralizing antibodies (NAbs) against IFN beta during the first year of therapy were analyzed as predictors of long-term clinical outcome.

RESULTS

"Black holes" on MRI were the best baseline predictor of disability progression (odds ratio [OR] 6.8; p < 0.001). At 1 year, both male gender (OR 4.9; p = 0.009) and NAbs (OR 7.3; p = 0.003) were independently associated with a high risk of developing subsequent disability. The presence of gadolinium enhancement, both at baseline (OR 4.7; p = 0.005) and on the 1-year MRI scan (OR 7.9; p = 0.002), was the unique variable associated with the number of relapses over the study period.

CONCLUSIONS

Variables assessable within the first year of treatment significantly influence relapse rate and disability progression in patients with RRMS treated with IFN beta. These findings may help clinicians to make decisions regarding therapy regimen over time, and highlight the need for a prognostic algorithm.

Topical nonsteroidal anti-inflammatory drugs in uncomplicated cataract surgery: effect of sodium naproxen

PURPOSE

To investigate whether topical nonsteroidal antiinflammatory drugs (NSAIDs) are useful, in the absence of concomitant corticosteroid therapy, in limiting postoperative inflammation after uncomplicated cataract surgery.

METHODS

A total of 328 patients were enrolled in a prospective, randomized, double-masked, parallel-group, active-controlled study. Anterior chamber inflammation (ACI) was evaluated as the primary efficacy parameter. Only patients with moderate inflammation (ACI score of < or =4) the day after surgery were randomized and treated with NSAIDs. A novel topical formulation containing 0.2% sodium naproxen was compared with 0.1% diclofenac. Both were administered three times a day for 14 consecutive days. Ocular inflammation was measured after 7 and 14 days by using slit-lamp biomicroscopy. Safety parameters were also evaluated at the same time.

RESULTS

Both treatments were equally effective in controlling postsurgical inflammation. No statistically significant differences between treatment groups were observed for the safety variables. No serious adverse events (AEs) occurred during the course of the study. The most frequent AE reported with naproxen was eye redness.

CONCLUSIONS

NSAIDs can effectively be used without concurrent administration of corticosteroids to control postoperative inflammation after uncomplicated cataract surgery. In addition, naproxen ophthalmic solution may be considered a suitable alternative to the currently available NSAIDs.