Use of Trastuzumab Beyond Disease Progression: Observations from a Retrospective Review of Case Histories

HER2 overexpression is associated with poor breast cancer prognosis and is the target for the humanized monoclonal antibody trastuzumab. This novel agent, when administered until disease progression in combination with chemotherapy, extends the survival of women with HER2-positive metastatic breast cancer (MBC). However, the optimal duration of trastuzumab therapy remains to be confirmed. We conducted a retrospective case review study of women with HER2-positive MBC who continued to receive trastuzumab beyond disease progression. Objectives were to assess whether treatment beyond disease progression shows any evidence of efficacy and to evaluate the feasibility of this approach. One hundred five patients (median age, 47 years; range, 24-77 years) were identified in 13 centers. Women had received </=6 chemotherapy regimens (median, 1) before trastuzumab therapy. Median survival from first trastuzumab dose was 29 months. The overall response rate to trastuzumab alone or with a taxane as the first regimen was 39%; a further 30% of patients had stable disease as the best response. These rates were 36% and 38% after a second regimen of trastuzumab alone or with paclitaxel or vinorelbine was administered. Some patients responded to both the first and second regimens; others responded to the second regimen after the first had failed. Twenty-two patients experienced cardiac events, of whom 18 received >/=1 more trastuzumab regimen. Trastuzumab treatment beyond progression appears to be of value, producing responses and clinical benefit, and is well tolerated without significant cardiac toxicity. The feasibility of this approach warrants examination in prospective trials.

Synthetic applications of planar chiral cationic η3-allylmolybdenum complexes

The synthesis of planar chiral η3-allylmolybdenum complexes is described together with some examples of the nucleophilic addition of organocopper(I) reagents.

New benchmarks from tokamak experiments for theoretical calculations of the dielectronic satellite spectra of heliumlike ions

Dielectronic satellite spectra of heliumlike argon, recorded with a high-resolution x-ray crystal spectrometer at the National Spherical Torus Experiment, were found to be inconsistent with existing predictions resulting in unacceptable values for the power balance and suggesting the unlikely existence of non-Maxwellian electron energy distributions. These problems were resolved with calculations from a new atomic code. It is now possible to perform reliable electron-temperature measurements and to eliminate the uncertainties associated with determinations of non-Maxwellian distributions.

Evaluation of the measurement of the fetal fat layer, interventricular septum and abdominal circumference percentile in the prediction of macrosomia in pregnancies affected by gestational diabetes

OBJECTIVES

To evaluate the measurement of the fetal abdominal fat layer (FFL), cardiac interventricular septum (IVS) and abdominal circumference (AC) percentile in the early third trimester as predictors of macrosomia at birth in the fetuses of women with gestational diabetes.

METHODS

Ninety patients attending the hospital's special diabetic clinic were recruited prospectively. FFL and IVS were measured in addition to the routine biometry in the early third trimester. AC was measured routinely and AC percentile was determined from established antenatal charts. These measurements were then assessed as predictors of macrosomia.

RESULTS

A fetal fat layer of >/=5 mm was the most useful predictor of macrosomia at term as assessed using the likelihood ratio. An AC >/=90th percentile, however, had a better sensitivity.

CONCLUSION

The usefulness of routine FFL measurement in the early third trimester in the management of diabetic pregnancies is worthy of further evaluation.

Psychometric properties of the Pain Attitudes Questionnaire (revised) in adult patients with chronic pain

Previous evidence supports the utility of the newly developed pain attitudes questionnaire (PAQ) for assessing pain-related stoicism and cautiousness in community-dwelling pain-free adults (Yong et al., 2001). A revised questionnaire (PAQ-R) was examined in the present study to determine the generalizability of psychometric properties when used with chronic pain patients. Results from both exploratory and confirmatory factor analyses suggest that the factor-structure of the revised questionnaire was best represented by a five- rather than a four-factor solution, thus, suggesting that chronic pain patients do not conceptualize the questionnaire items, in particular, with respect to the stoicism attitudes, in the same manner as the community-dwelling adults. A satisfactory internal consistency reliability of the PAQ-R was replicated in chronic pain patients. There was also evidence to suggest that chronic pain patients from different age cohorts do apply a similar frame of reference and calibration scale when responding to the items on the questionnaire. However, the cohorts of patients across the age spectrum show some differences in pain attitudes and possible reasons were discussed.

Multicenter phase 2 trial of thalidomide in relapsed/refractory multiple myeloma: adverse prognostic impact of advanced age

Relapsed or refractory multiple myeloma has a poor outlook. Some patients respond to thalidomide; however, criteria for predicting response have not been conclusively identified. We initiated a prospective multicenter phase 2 trial in patients with relapsed/refractory myeloma using thalidomide up to the maximum dose, 800 mg/d. Interferon-alpha-2B (1.5-3.0 x 10(6) U, subcutaneously, 3 times per week) was added at week 12 if disease was responsive or stable. Patients intolerant of interferon continued thalidomide alone. Thalidomide with or without interferon was continued until disease progression. Objectives were to determine toxicity, response rate (RR), progression-free survival (PFS), and overall survival (OS) and to elucidate relevant prognostic factors. We enrolled 75 patients, with median age 64 years (range, 36-83 years). Median individual maximum-tolerated dose of thalidomide was 600 mg/d; 41% reached 800 mg/d. Overall RR was 28%, and 55% stable disease (SD). The only predictor for response was age 65 years or younger (38% versus 17%; P =.043). At 18 months median follow-up, the actuarial median PFS and OS were 5.5 and 14.6 months, respectively. Multivariate analysis for OS demonstrated age exceeding 65 years (median, 9.2 months versus longer than 26 months; P =.011), raised serum lactate dehydrogenase (P =.002), and raised serum creatinine (P =.007) predicted inferior outcomes. Nineteen patients received interferon. Ten discontinued owing to toxicity. Four of 12 patients who received interferon for longer than 4 weeks were converted from SD to partial response. Our findings confirm substantial activity of thalidomide in relapsed/refractory myeloma. Interferon may improve response in selected patients, but is often not tolerated. The inferior outcome demonstrated in those with the identified prognostic factors is important in planning management for such patients.

Acute administration of conjugated equine oestrogen does not improve exercise-induced myocardial ischaemia in men with coronary artery disease

BACKGROUND

The parenteral administration of oestradiol acutely protects against exercise-induced myocardial ischaemia in women, but whether this effect is sex-specific is not known.

AIMS

The effects of acutely administered conjugated equine oestrogen on exercise-induced myocardial ischaemia in men with established coronary heart disease were investigated in a randomized, placebo-controlled, double-blind cross-over trial.

METHODS

Twenty men, aged 62 +/- 11.6 years, with reproducible exercise-induced myocardial ischaemia were treated with either intravenous conjugated equine oestrogen (25 mg) or saline prior to undergoing an exercise stress test. Primary end-points were total exercise time and time to 1 mm ST-segment depression.

RESULTS

All participants completed the protocol. Total exercise time exceeded the baseline value in 17 of the 20 men following saline, and in 17 of the 20 men following oestrogen pretreatment. Time to 1 mm ST-segment depression exceeded the baseline value in 14 of the 19 men following saline, and following oestrogen administration, exceeded baseline in 13 of the 19 men. There was no significant difference between the two treatments in either time to 1 mm ST-segment depression or total exercise time. A period effect was apparent for total exercise time (P = 0.05) but not for time to ST-segment depression.

CONCLUSION

Acute parenteral oestrogen therapy did not increase total exercise time or time to the onset of electrocardiographic changes of ischaemia in men with chronic stable coronary artery disease. These findings contrast the favourable effects of oestrogen in women in comparable studies and indicate a sex specificity for the acute cardiovascular effects of oestrogen.

What can we learn from Herceptin trials in metastatic breast cancer?

Herceptin (trastuzumab), an anti-HER2 monoclonal antibody, is the first oncogene-targeted therapy to be developed for the treatment of metastatic breast cancer. The Herceptin clinical trial program has demonstrated that treatment with Herceptin provides substantial clinical benefits when used either as monotherapy or in combination with a number of chemotherapeutic agents. Of note, accurate assessment of HER2 status is essential to ensure that the patients most likely to benefit from Herceptin are identified: patients with immunohistochemistry (IHC) 3+ or fluorescence in-situ hybridization (FISH)-positive disease gain the greatest clinical benefits. In addition, clinical benefits appear to be greater the earlier Herceptin is used, although there is currently no direct clinical evidence to indicate whether an initial strategy of combination therapy is better than monotherapy or vice versa. Herceptin has been shown to be generally well tolerated. The most severe adverse events are rare serious infusion-related reactions and cardiotoxicity. These adverse events can be managed by standard care and patients at risk can often be identified prior to the initiation of Herceptin treatment. Currently, Herceptin should be given until disease progression, but there could be benefit in continuing treatment beyond disease progression.

Ketamine as an adjuvant to opioids for cancer pain

BACKGROUND

Ketamine is a commonly used anaesthetic agent, and in subanaesthetic doses is also given as an adjuvant to opioids for the treatment of cancer pain, particularly when opioids alone prove to be ineffective. Ketamine is known to have hallucinogenic side effects. To date no systematic review of the benefits and harms of adjuvant ketamine for cancer pain has been undertaken.

OBJECTIVES

To determine the effectiveness and adverse effects of ketamine as an adjuvant to opioids in the treatment of cancer pain.

SEARCH STRATEGY

Studies were identified from MEDLINE (1966-2001), EMBASE (1980-2001), CancerLit (1966-2001), the Cochrane Library (Issue 1, 2001); by handsearching reference lists from review articles, trials, and chapters from standard textbooks on pain and palliative care. The manufacturer of ketamine (Pfizer Parke-Davis) provided search results from their in-house database, PARDLARS.

SELECTION CRITERIA

RCTs of adult patients with cancer and pain being treated with an opioid, and receiving either ketamine (any dose and any route of administration) or placebo or an active control.

DATA COLLECTION AND ANALYSIS

Two independent reviewers identified four RCTs for possible inclusion in the review, and 32 case studies/case series reports. Quality and validity assessment was performed by three independent reviewers, and two RCTs were excluded because of inappropriate study design. Patient reported pain intensity and pain relief was assessed using visual analog scales, verbal rating scales or other validated scales, and adverse effects data were collated.

MAIN RESULTS

Two trials were eligible for inclusion in the review and both concluded that ketamine improves the effectiveness of morphine in the treatment of cancer pain. However, pooling of the data was not appropriate because of the small total number of patients (30), and the presence of clinical heterogeneity. Some patients experienced hallucinations on both ketamine plus morphine and morphine alone and were treated successfully with diazepam. No other serious adverse effects were reported.

REVIEWER'S CONCLUSIONS

Current evidence is insufficient to assess the benefits and harms of ketamine as an adjuvant to opioids for the relief of cancer pain. More randomized controlled trials are needed.

Preliminary indication of a high prevalence of polycystic ovary syndrome in indigenous Australian women

We aimed to estimate the likely prevalence of polycystic ovary syndrome (PCOS) in indigenous Australian women in a cross-sectional survey based on structured interviews. In the Kimberley region of Western Australia and south-western Victoria, between February and June 1999, women over the age of 18 available for interview and willing to participate were included. Menstrual status, anthropometric measures, fasting blood biochemistry and hirsutism were assessed. A total of 38 premenopausal women completed the survey. Of these, 50% had regular menstrual cycles of normal duration and no hirsutism; seven had oligomenorrhea and hirsutism/hyperandrogenemia; and of the nine women with hirsutism and regular menses, three had hyperandrogenemia. Thus, possibly ten women fulfilled the criteria of PCOS. This unique data set suggests a high prevalence of PCOS in indigenous Australian women. Further research to document this formally is warranted, in view of the potential adverse effects of PCOS on reproduction and metabolism.

Characterization of film-coated aerosol canisters using electrochemical impedance spectroscopy

Drug adhesion to the walls of an aerosol canister can be prevented/reduced by coating the canister with a hydrophobic polymer (e.g., a fluoropolymer). In this study, three batches of fluoropolymer-coated canisters were investigated by electrochemical impedance spectroscopy (EIS) and scanning electron microscopy (SEM). The EIS technique showed that only one of the batches presented as a monolithic, non-porous film. The other two batches were either partially porous or highly porous. Scanning electron micrographs showed evidence of cracks, within the films, but could not alone establish the porous nature of these defects. For the non-porous and partly porous films it was possible to use the EIS data to determine the approximate film thickness. Estimates of 2-4 microm were obtained for the mean film thickness. These values compared favorably with micrometer estimates obtained following acid dissolution of the aluminum canister. It remains to be seen whether the properties of the films (i.e., the porosity and film thickness, determined by EIS) translate to differences in drug adhesion. Nevertheless, the EIS technique was shown to be a powerful, non-destructive method that lends itself to the rapid analysis of batch-to-batch variation in film-coated canisters.

Eosinophilic granuloma. A different behaviour in children than in adults

Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine. We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.

Eosinophilic granuloma

Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine.

We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients.

Analysis of the phenotypic abnormalities in lymphoedema-distichiasis syndrome in 74 patients with FOXC2 mutations or linkage to 16q24

INTRODUCTION

Lymphoedema-distichiasis syndrome (LD) (OMIM 153400) is a rare, primary lymphoedema of pubertal onset, associated with distichiasis. Causative mutations have now been described in FOXC2, a forkhead transcription factor gene. Numerous clinical associations have been reported with this condition, including congenital heart disease, ptosis, varicose veins, cleft palate, and spinal extradural cysts.

SUBJECTS

We report clinical findings in 74 affected subjects from 18 families and six isolated cases. All of them were shown to have mutations in FOXC2 with the exception of one family who had two affected subjects with lymphoedema and distichiasis and linkage consistent with the 16q24 locus.

RESULTS

The presence of lymphoedema was highly penetrant. Males had an earlier onset of lymphoedema and a significantly increased risk of complications. Lymphatic imaging confirmed the earlier suggestion that LD is associated with a normal or increased number of lymphatic vessels rather than the hypoplasia or aplasia seen in other forms of primary lymphoedema. Distichiasis was 94.2% penetrant, but not always symptomatic. Associated findings included ptosis (31%), congenital heart disease (6.8%), and cleft palate (4%). Other than distichiasis, the most commonly occurring anomaly was varicose veins of early onset (49%). This has not been previously reported and suggests a possible developmental role for FOXC2 in both venous and lymphatic systems. This is the first gene that has been implicated in the aetiology of varicose veins.

CONCLUSION

Unlike previous publications, the thorough clinical characterisation of our patients permits more accurate prediction of various phenotypic abnormalities likely to manifest in subjects with FOXC2 mutations.