Outcome of children with nodular lymphocyte predominant Hodgkin lymphoma - a Children's Cancer and Leukaemia Group report

This report describes the clinical outcomes and follow-up records of 42 children with nodular lymphocyte predominant Hodgkin lymphoma (LPHL) treated on United Kingdom Children's Cancer Study Group (UKCCSG) HD1 (1982-1992) and HD2 protocols (1992-2000). The clinical records of 42 children with LPHL treated between 1982 and 2000 were reviewed retrospectively. All 42 had histology reviewed centrally and confirmed as LPHL by an expert panel. In both trials, only patients with stage IA disease had the option of being treated with either involved field radiation alone or combination chemotherapy consisting of chlorambucil, vinblastine, procarbazine and prednisolone (ChlVPP). Patients with all other stages were treated with ChlVPP chemotherapy. Thirty-five patients (83%) presented with early stage disease (Stages I & II). All 42 patients achieved a complete remission (CR). Six children relapsed after primary therapy. The 5- and 10-year relapse-free survival rates were 87% and 82% respectively. Forty-one are currently alive in CR. In conclusion, children with low-stage LPHL treated between 1982 and 2000 according to the UK strategy for classical Hodgkin lymphoma (HL) had an excellent prognosis. There have been no second malignancies or transformations to B-cell non-Hodgkin lymphoma.

Hodgkin’s lymphoma in children aged 5 years or less – The United Kingdom experience

PURPOSE

The aim of this study is to describe the natural history of Hodgkin's Lymphoma (HL) in a large unselected group of children aged 5 years or below at diagnosis, who were treated on a standard treatment programme in the United Kingdom between 1982 and 2000.

METHODS

Eighty-one unselected children with HL aged 5 years or under at diagnosis, treated on the United Kingdom Children's Cancer Study Group (UKCCSG) Hodgkin's trials HD1 (1982-1992) and HD2 (1992-2000), were included in the study.

RESULTS

Sixty-one patients (81%) presented with early stage disease (n=66). Fifty-three patients (65%) received combination chemotherapy, 28 (34%) received involved field radiotherapy (IF-RT) and 4 patients were treated with combined modality therapy. Eighteen children relapsed after primary therapy.

CONCLUSIONS

Children treated with IF-RT had a higher rate of primary treatment failures as well as increased late treatment-related morbidity.

Descriptive Study Comparing Routine Hospital Administrative Data with the Vascular Society of Great Britain and Ireland's National Vascular Database

OBJECTIVE

To compare patient volume and outcomes in vascular surgery between an administrative data set (Hospital Episode Statistics) and a clinical database (National Vascular Database).

DESIGN

Descriptive study.

METHODS

Volume of cases determined by age, sex, year and procedure and in-hospital mortality by procedure for both datasets for patients undergoing either repair of abdominal aortic aneurysm, carotid endarterectomy or infrainguinal bypass over a three year period between 1st April 2001 and 31st March 2004.

RESULTS

There were 32,242 admissions with a mention of the three selected vascular procedures within the administrative data set compared to 8462 within the clinical database. For NHS trusts common to both datasets, there were twice as many procedures (16,923) recorded within the administrative dataset compared to the clinical database. Patient characteristics were similar across both databases. Further analysis limiting the administrative data to records attributed to consultants known to contribute to the clinical database showed much closer agreement with only 11% more repairs of abdominal aortic aneurysm recorded within the administrative dataset compared to the National Vascular Database.

CONCLUSIONS

There are significant differences in total numbers between HES and the NVD. If the National Vascular Database is to become a credible source of information on activity and outcomes for vascular surgery, there is a clear need to increase the number of contributing surgeons and to increase the completeness of data submitted. Further analysis at individual record level is needed to identify other reasons for discrepancies which could help to enhance data quality, both within Hospital Episode Statistics and within the National Vascular Database.

Predictive genetic testing for BRCA1/2 in a UK clinical cohort: three-year follow-up

This prospective multicentre study assesses long-term impact of genetic testing for breast/ovarian cancer predisposition in a clinical cohort. Areas evaluated include risk management, distress and insurance problems 3 years post-testing. Participants are adults unaffected with cancer from families with a known BRCA1/2 mutation. One hundred and ninety-three out of 285 (70% response) participants at nine UK clinical genetics centres completed assessments at 3 years: 80% female; 37% carriers of a BRCA1/2 mutation. In the 3 years, post-genetic testing carriers reported more risk management activities than non-carriers. Fifty-five per cent of female carriers opted for risk reducing surgery; 43% oophorectomy; and 34% mastectomy. Eighty-nine per cent had mammograms compared with 47% non-carriers. Thirty-six per cent non-carriers > or =50 years did not have a mammogram post-test. Twenty-two per cent male carriers had colorectal and 44% prostate screening compared with 5 and 19% non-carriers respectively. Seven per cent carriers and 1% non-carriers developed cancer. Distress levels did not differ in carriers and non-carriers at 3-year follow-up. Forty per cent of female carriers reported difficulties with life and/or health insurance. Given the return to pre-test levels of concern among female non-carriers at 3 years and a substantial minority not engaging in recommended screening, there appears to be a need to help some women understand the meaning of their genetic status.

Axillary staging in women with small invasive breast tumours

AIMS

To identify a group of women with small breast cancers of favourable histological grade for whom observation alone may be an acceptable approach for management of the axilla.

METHODS

In a retrospective analysis the incidence of nodal metastases was examined in a group of 355 consecutive patients over 55 years of age who underwent mastectomy or breast conserving surgery. All patients had either grade I (<20 mm) or grade II (<15 mm) oestrogen receptor positive tumours without lymphovascular invasion (LVI). In a related study on 173 clinically node negative patients, the rate of axillary recurrence was assessed in patients with small (<10 mm), non-high grade (I and II), ER-positive invasive ductal carcinomas without LVI. Axillary surgery was either omitted (135 patients) or delayed (38 patients) at the time of wide local excision or mastectomy.

RESULTS

The overall incidence of positive nodes in this good prognostic group of patients was 13% (95% confidence interval 9.5-16.5). When the analysis was confined to grade I (< or =20 mm) and grade II (< or =10 mm) the overall incidence of nodal metastases was 10%. Rates of axillary recurrence at a median follow up of 49 months were only 1% when axillary surgery was omitted according to patient choice/departmental policy with no cases of uncontrolled axillary recurrence.

CONCLUSION

The risk:benefit ratio for detection of node positive cases in a selected group of older patients does not justify any form of axillary procedure at the time of primary surgery.

Basal-like breast carcinomas: clinical outcome and response to chemotherapy

BACKGROUND

Grade-III invasive ductal carcinomas of no special type (IDCs-NST) constitute a heterogeneous group of tumours with different clinical behaviour and response to chemotherapy. As many as 25% of all grade-III IDCs-NST are known to harbour a basal-like phenotype, as defined by gene expression profiling or immunohistochemistry for basal cytokeratins. Patients with basal-like breast carcinomas (BLBC) are reported to have a shorter disease-free and overall survival.

MATERIAL AND METHODS

A retrospective analysis of 49 patients with BLBC (as defined by basal cytokeratin expression) and 49 controls matched for age, nodal status and grade was carried out. Histological features, immunohistochemical findings for oestrogen receptor (ER), progesterone receptor (PgR) and HER2, and clinical outcome and survival after adjuvant chemotherapy were compared between the two groups.

RESULTS

It was more likely for patients with BLBCs to be found negative for ER (p<0.0001), PgR (p<0.0001) and HER2 (p<0.01) than controls. Patients with BLBCs were found to have a significantly higher recurrence rate (p<0.05) and were associated with significantly shorter disease-free and overall survival (both p<0.05). In the group of patients who received anthracycline-based adjuvant chemotherapy (BLBC group, n = 47; controls, n = 49), both disease-free and overall survival were found to be significantly shorter in the BLBC group (p<0.05).

CONCLUSIONS

BLBCs are a distinct clinical and pathological entity, characterised by high nuclear grade, lack of hormone receptors and HER2 expression and a more aggressive clinical course. Standard adjuvant chemotherapy seems to be less effective in these tumours and new therapeutic approaches are indicated.

A study of factors determining outcome of patients receiving third line chemotherapy for metastatic breast cancer: The Royal Marsden Hospital experience

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Background: Metastatic breast cancer is increasingly treated with multiple lines of chemotherapy. We studied the factors determining the outcome of patients receiving third line chemotherapy for metastatic breast cancer Methods: This is retrospective study of 149 consecutive patients from the Royal Marsden Hospital chemotherapy database recorded to have received third line chemotherapy for metastatic breast cancer. The chemotherapy regimens and best response to chemotherapy for all three lines of chemotherapy were recorded. The time to progression (TTP) and survival after third line chemotherapy were also studied. Chi square and log rank tests were used to analyse differences in response rates (RR) and (TTP)/survival respectively. Results: 149 patients were studied with a median age of 52 (range 25 -80). The median TTP and survival was 4 months (range 1–25) and 8 months (range 1–52) respectively. Eighteen different chemotherapy regimens were used. The RR for third line chemotherapy was 30.2% (45/149). There was no significant difference in the TTP and survival of patients treated with different chemotherapy regimens (p= 0.82 and 0.44) respectively. We identified a subgroup of patients who had a poor outcome after third line chemotherapy. These patients did not respond to the first two lines of chemotherapy and had a response rate of 20.2% (10/49) compared to the rest of the cohort, 35% (35/100), p= 0.068. The TTP (3 Vs 4 months, p = 0.033) and survival, (6 Vs 9 months, p = 0.027) of this subgroup was significantly shorter than the rest of the cohort. The median time to death after progression in this subgroup was 2 months. Conclusions: The chemotherapy regimen used does not influence RR, TTP or survival in patients receiving third line chemotherapy for metastatic breast cancer. Patients not responding to the first two lines of chemotherapy have a significantly shorter TTP and survival. Best supportive care or experimental chemotherapy should be considered as options for these patients.

No significant financial relationships to disclose.

Role of palliative chemotherapy in advanced soft tissue sarcoma: Retrospective analysis of 488 patients

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Background: Advanced soft tissue sarcomas (aSTS) represent an incurable clinical entity of poor prognosis, in which chemotherapy is frequently viewed as relatively ineffective. We aimed to review the efficacy of palliative chemotherapy and investigate prognostic factors in a large group of patients treated on routine palliative protocols. Methods: Patients with STS who had first line chemotherapy for advanced and/or metastatic disease between 1991 and 2005 were identified from the Royal Marsden Hospital’s sarcoma database. Patients with Ewing’s sarcoma, rhabdomyosarcoma, desmoplastic small round cell tumour and GIST were excluded from the study. Patients who were treated elsewhere more than 1 year before they come to our hospital were also excluded. Results: 488 patients (242M/286F) fulfilled the criteria. Median age at the time of treatment was 50 years (range 19–79). The main tumour types were leiomyosarcomas (35%) synovial sarcoma (13%), liposarcoma (10%) and malignant fibrous histiocytoma (10%). The majority of patients (83%) received chemotherapy for metastatic disease. 71% of patients had single organ involvement and 29% had multiple disease sites. Lung was the most common site of metastasis (56%). 54% were treated with single agent chemotherapy. Response rate to chemotherapy was 33% (53% for synovial sarcoma); 22% achieved stable disease for a median duration of 8 months; 45% progressed through chemotherapy. Median time to progression was 3 months, duration of response 9 months and post treatment survival (OS) 12 months. In multivariate analysis, age <60, liposarcoma and synovial histology were found as positive and bone involvement as negative independent prognostic factors. Patients treated with combination chemotherapy experienced longer survival (11 vs 14 months OS; p=0.001). Conclusions: This retrospective study of standard palliative chemotherapy in unselected patients with aSTS shows that more than half of patients benefit from treatment, indicating that this is a worthwhile treatment option. Synovial sarcoma and liposarcoma represent the most chemosensitive sarcoma subtypes. Nevertheless, continuing search for new agents is strongly warranted to improve the survival of these patients.

No significant financial relationships to disclose.

Parainfluenza type 3 infection post stem cell transplant: high prevalence but low mortality

Parainfluenza type 3 (PIV 3) is a well-recognized cause of respiratory illness after stem cell transplantation (SCT), with an estimated incidence of 2-7% and a high mortality rate associated with lower respiratory tract infection (LRTI). A 12-month retrospective study was undertaken in which 23 positive cases of PIV 3 occurred in SCT recipients. The frequency of infection was 36.1% in matched unrelated donor SCT recipients, 23.8% in sibling allogeneic SCT recipients and 2.3% in autologous transplant recipients. Seventeen cases were outpatient or community acquired despite standard infection control measures. Eleven patients only developed upper respiratory tract symptoms. LRTI symptoms developed in 12 patients, of whom eight had a new infiltrate on chest X-ray. Overall mortality at 30 days from PIV 3 diagnosis was 4% (one patient). Four patients died within 100 days of PIV 3 diagnosis, but PIV 3 was not believed to be the primary cause of death in any of these patients. Early ribavirin was used in eight patients and only one patient who received ribavirin died. These results suggest a higher prevalence of PIV 3 but a lower mortality than documented previously, particularly in allogeneic transplant recipients. The authors propose that the high prevalence reflects the unit's policy of active surveillance for respiratory viruses and the difficulty in preventing transmission of PIV 3, especially in the outpatient setting during an outbreak period. Ribavirin treatment may improve outcome in patients with LRTI but is not required in all patients with PIV 3.

Fractionated stereotactic conformal radiotherapy for secreting and nonsecreting pituitary adenomas

OBJECTIVE

To assess the medium-term outcome in a cohort of patients with residual or recurrent pituitary adenoma treated with fractionated stereotactic conformal radiotherapy (SCRT).

PATIENTS AND METHODS

Ninety-two patients (median age 50 years) with a residual or recurrent nonfunctioning (67) or a secreting (25) pituitary adenoma were treated between 1995 and 2003. Eighteen patients had a GH-secreting, five PRL-secreting and two an ACTH-secreting pituitary adenoma. Vision was impaired in 39 patients, with visual field deficit (35) and/or reduced visual acuity (25). Sixty-four patients had partial or complete hypopituitarism before SCRT. The treatment was delivered stereotactically by four noncoplanar conformal fixed fields using a 6-MV linear accelerator to a dose of 45 Gy in 25 fractions.

RESULTS

At a median follow-up of 32 months (range 4-108) the 1, 3 and 5 years actuarial progression-free survival is 99%, 98% and 98%, and overall survival is 98%. Three patients recurred 5 months, 1 year and 9 years after SCRT requiring surgery. In secreting adenomas, hormone levels declined progressively, becoming normal in more than a third of patients with GH-secreting and PRL-secreting pituitary tumours. 50% of baseline GH level was achieved in just under 2 years. The treatment was well tolerated with minimal acute toxicity. Hypopituitarism was the most common long-term effect; 22% of patients had worsening of pituitary function. One patient developed unilateral quadrantopia without tumour progression.

CONCLUSION

SCRT as a high-precision technique of localized irradiation achieves tumour and hormone control of pituitary adenomas comparable with previously published data on the efficacy of conventional radiotherapy. Despite the potential advantage of reducing the volume of normal brain irradiated, the theoretical benefit over conventional radiotherapy in terms of the reduction in long-term morbidity has not yet been demonstrated and requires longer follow-up. Potential effect on long-term cognitive function has not been tested.

Pathological complete response and residual DCIS following neoadjuvant chemotherapy for breast carcinoma

Patients who have no residual invasive cancer following neoadjuvant chemotherapy for breast carcinoma have a better overall survival than those with residual disease. Many classification systems assessing pathological response to neoadjuvant chemotherapy include residual ductal carcinoma in situ (DCIS) only in the definition of pathological complete response. The purpose of this study was to investigate whether patients with residual DCIS only have the same prognosis as those with no residual invasive or in situ disease. A retrospective analysis of a prospectively maintained database identified 435 patients, who received neoadjuvant chemotherapy for operable breast cancer between February 1985 and February 2003. Of these, 30 (7%; 95% CI 5–9%) had no residual invasive disease or DCIS and 20 (5%; CI 3–7%) had residual DCIS only. With a median follow-up of 61 months, there was no statistical difference in disease-free survival, 80% (95% CI 60–90%) in those with no residual invasive or in situ disease and 61% (95% CI 35–80%) in those with DCIS only (P=0.4). No significant difference in 5-year overall survival was observed, 93% (95% CI 75–98%) in those with no residual invasive or in situ disease and 82% (95% CI 52–94%) in those with DCIS only (P=0.3). Due to the small number of patients and limited number of events in each group, it is not possible to draw definitive conclusions from this study. Further analyses of other databases are required to confirm our finding of no difference in disease-free and overall survival between patients with residual DCIS and those with no invasive or in situ disease following neoadjuvant chemotherapy for breast cancer.

Factors associated with emotional and behavioural problems among school age children of breast cancer patients

To identify factors linked with emotional and behavioural problems in school age (6- to 17-year-old) children of women with breast cancer. Reports of children's emotional and behavioural problems were obtained from patient mothers, their healthy partners, the children's teacher and adolescents using the Child Behaviour Checklist and Mental Health subscale of the Child Health Questionnaire. Parents reported on their own level of depression and, for patients only, their quality of life. Family functioning was assessed using the Family Assessment Device and Cohesion subscale of the Family Environment Scale. Using a cross-sectional within groups design, assessments were obtained (N=107 families) where the patients were 3-36 months postdiagnosis. Risk of problems in children were linked with low levels of family cohesion, low affective responsiveness and parental over-involvement as reported by both child and mother. Adolescents reported family communication issues, which were associated with externalising behaviour problems. Maternal depression was related to child internalising problems, particularly in girls. Whether the mother was currently on or off chemotherapy was not associated with child problems nor was time since cancer diagnosis. These findings held across child age. Where mothers have early stage breast cancer, a substantial minority of their school-aged children have emotional and behavioural problems. Such cases are characterised by the existence of maternal depression and poor family communication, rather than by the mother's treatment status or time since diagnosis. Targeted treatments, which focus on maternal depression and family communication may benefit the children and, through improved relationships, enhance the patients' quality of life.

Time and chemotherapy treatment trends in the treatment of elderly patients (age >/=70 years) with small cell lung cancer

Platinum-based treatment for small cell lung cancer (SCLC) has been established since 1995. This study investigates treatment outcome of elderly patients (age ⩾70 years) with SCLC over the past 20 years in a large UK cancer centre. Comparison of all-cause survival was assessed in patients presenting between two predefined time periods: 1982–1994 and 1995–2003. All the survival analysis were adjusted for stage and performance status and age if appropriate. Survival between different chemotherapy treatment regimens was compared. A total of 322 elderly patients (31% of all) registered between 1982–2003 received chemotherapy for SCLC. Patients presenting in 1995–2003 had an overall better median survival (43 vs 25 weeks) and a 1-year survival (37 vs 14%) than patients presenting in 1982–1994 (P<0.001). This applied to patients with both limited and extensive stage disease and all age groups. There was a trend towards the use of more platinum-based treatments in the later cohort but the use of radiotherapy remained constant. Patients who received platinum combinations (Carboplatin or Cisplatin) had significantly improved survival over those who received single agents or other combinations (P<0.001) and there was no significant difference between carboplatin and cisplatin (P=0.7). The analysis demonstrates that there has been a significant improvement in survival for elderly patients with lung cancer treated by chemotherapy in the past 20 years despite more very elderly patients being treated with a poorer performance status. This change is probably multifactorial and may be due to the increased use of platinum-based treatment and improved supportive care.

A randomised trial in malignant mesothelioma (M) of early (E) versus delayed (D) chemotherapy in symptomatically stable patients: the MED trial

BACKGROUND

Prior phase II trials have demonstrated the therapeutic activity of cytotoxic chemotherapy in mesothelioma. Currently there are few randomised data assessing the role of chemotherapy versus best supportive care (BSC) in the management of patients with stable symptoms after control of any pleural effusion. A policy of observation is often adopted over initial use of chemotherapy. In this prospective randomised trial we assess the use of early versus delayed cytotoxic therapy. The study opened in 1998, and closed in view of a competing national study (MSO 1) in 2003.

METHODS

Eligible patients had a performance status<or=2, life expectancy>3 months and had stable symptoms for at least 4 weeks prior to randomisation. Patients were randomised to receive immediate chemotherapy or initial BSC with the addition of chemotherapy at time of symptomatic progression. All patients received the same platinum-based chemotherapy regimen, MVP [mitomycin C 8 mg/m2 cycles 1, 2, 4 and 6, vinblastine 6 mg/m2, maximum 10 mg, and cisplatin 50 mg/m2 (or carboplatin AUC 5)], every 3 weeks for up to six cycles.

RESULTS

A total of 43 patients were recruited, of which 21 were randomised to the early treatment group and 22 to the delayed treatment group. The median ages were 59 years (range 50-78) and 67 years (range 48-75), respectively (P=0.1); other baseline parameters were well matched between the two groups. All 21 patients in the early group received chemotherapy versus 17 patients in the delayed group. Median time to symptomatic progression was 25 weeks in the early group compared with 11 weeks for the delayed group (P=0.1). Median survival was 14 months (1-year survival 66%) for the early group compared with 10 months (1-year survival 36%) for the delayed group (P=0.1). Quality of life was in general better maintained for early treatment and the health resources use was similar in both arms.

CONCLUSIONS

In this patient group, presenting with stable symptoms after control of pleural effusion, the early use of chemotherapy provided an extended period of symptom control, and in this small trial a trend to survival advantage.

A prospective randomised study to evaluate the effectiveness of standard 23 gauge fine needle, compared with a thinner 27 gauge needle for breast cytology

The aim of this study was to determine whether a 27 gauge needle could be used to obtain adequate cytology with less discomfort to the patient. Two types of needles were compared-23 gauge (blue) needle versus 27 gauge very fine needle. The cytology specimen was assessed for quality in terms of adequacy for diagnosis. Ninety samples were randomised into this study. The quality of samples was similar in both groups; there was no statistical difference in the quality of samples obtained. The 27 gauge needle produced two inadequate samples (4.4%), whereas there were no inadequate samples with the 23 gauge needle. There was no statistical difference in the amount of blood on the slide between the two groups. The pain scores were significantly better with the finer needle (P=0.004). This study provides evidence that the 27 gauge FNAC is suitable for obtaining cytology in palpable breast lumps.

Neoadjuvant phase II multicentre study of new agents in patients with malignant glioma after minimal surgery. Report of a cohort of 187 patients treated with temozolomide

BACKGROUND

The aim of this study was to assess the efficacy of new agents in patients with malignant glioma in a neoadjuvant setting not confounded by surgery. The first study of neoadjuvant temozolomide aimed to provide a benchmark for future evaluation of new treatments.

PATIENTS AND METHODS

This was a multicentre phase II study of chemotherapy in patients with histologically verified glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA) who had undergone biopsy alone. Patients were planned to receive two cycles of temozolomide at 200 mg/m(2) orally daily for 5 days at a 28-day interval prior to radiotherapy. Response was assessed by two central observers on pre- and post-chemotherapy enhanced scans using bi-dimensional criteria and as progression-free survival (PFS) at the time of second assessment prior to radiotherapy. Withdrawal from the study due to worsening clinical condition was, in the absence of second imaging, assessed as progressive disease. Survival and quality of life (QOL) were secondary endpoints.

RESULTS

Between August 1999 and June 2002, 188 patients from 15 UK and two Italian centres were entered into the study and 187 were analysed. Overall, 162 patients were assessable for response; seven had partial and 25 had minimal response. The objective response rate was 20% [95% confidence interval (CI) 14-26%] and PFS prior to commencing radiotherapy was 64% (95% CI 57-72%). The median survival was 10 months, and 1-year survival 41%. The median survival of responders was 16 months compared to 3 months in patients with progressive disease (P <0.001 on multivariate analysis).

CONCLUSION

The phase II study design of primary chemotherapy in patients with malignant glioma following biopsy alone is feasible and provides as objective a method of assessment of efficacy as is currently available. The baseline data on temozolomide provide a benchmark for assessment of efficacy of other agents and combinations.

Risk-adjusted predictive models of mortality after index arterial operations using a minimal data set

Background

Reducing the data required for a national vascular database (NVD) without compromising the statistical basis of comparative audit is an important goal. This work attempted to model outcomes (mortality and morbidity) from a small and simple subset of the NVD data items, specifically urea, sodium, potassium, haemoglobin, white cell count, age and mode of admission.

Methods

Logistic regression models of risk of adverse outcome were built from the 2001 submission to the NVD using all records that contained the complete data required by the models. These models were applied prospectively against the equivalent data from the 2002 submission to the NVD.

Results

As had previously been found using the P-POSSUM (Portsmouth POSSUM) approach, although elective abdominal aortic aneurysm (AAA) repair and infrainguinal bypass (IIB) operations could be described by the same model, separate models were required for carotid endarterectomy (CEA) and emergency AAA repair. For CEA there were insufficient adverse events recorded to allow prospective testing of the models. The overall mean predicted risk of death in 530 patients undergoing elective AAA repair or IIB operations was 5·6 per cent, predicting 30 deaths. There were 28 reported deaths (χ2 = 2·75, 4 d.f., P = 0·600; no evidence of lack of fit). Similarly, accurate predictions were obtained across a range of predicted risks as well as for patients undergoing repair of ruptured AAA and for morbidity.

Conclusion

A ‘data economic’ model for risk stratification of national data is feasible. The ability to use a minimal data set may facilitate the process of comparative audit within the NVD.

The palliative benefits of MVP (mitomycin C, vinblastine and cisplatin) chemotherapy in patients with malignant mesothelioma

BACKGROUND

With the rising incidence of malignant mesothelioma (MM), it is important to optimise treatment to control symptoms, maintain quality of life and, if possible, prolong life. We have analysed prospectively collected data to evaluate a frequently used palliative chemotherapy regimen.

PATIENTS AND METHODS

Between October 1986 and May 2002 all patients with inoperable pleural mesothelioma were considered for treatment with MVP (mitomycin C 8 mg/m2 every 6 weeks, vinblastine 6 mg/m2 every 3 weeks and cisplatin 50 mg/m2 every 3 weeks) chemotherapy. Symptoms were assessed by physician assessment at baseline and after each cycle of chemotherapy.

RESULTS

One hundred and fifty patients were treated with MVP for mesothelioma. Forty-three per cent had a performance status (PS) 2 or worse. The response rate was 15.3%, with 68.6% having stable disease. Sixty-nine per cent reported an improvement in symptoms; in particular there were good responses for pain (71%), cough (62%) and dyspnoea (50%). The most common grade 3/4 toxicity was neutropenia (22%). Median overall survival was 7 months, with 1-year survival 31% and 2-year survival 11%. Median survival for patients with PS 0/1 was 10 months, and was 6 months for patients with PS 2/3. Poor prognostic factors in univariate analysis included poor PS, weight loss, mixed or sarcomatoid histology, low haemoglobin and high white blood cell count. Excluding pathological subtype, the prognostic significance of poor PS and weight loss were retained in multivariate analysis.

CONCLUSIONS

Palliation of symptoms in MM is achievable with current cisplatin-based treatments.

Oestrogen receptor status, pathological complete response and prognosis in patients receiving neoadjuvant chemotherapy for early breast cancer

The aim of this study was to ascertain if oestrogen receptor (ER) status predicts for pathological complete response (pCR) to neoadjuvant chemotherapy in operable breast cancer, and the effects of pCR on survival. Using a single-institution database, 435 patients were identified, who received neoadjuvant chemotherapy for operable breast cancer and were eligible for the analysis. Patients whose tumours were ER negative were more likely to achieve a pCR than patients who were ER positive (21.6 vs 8.1%, P<0.001). Owing to a strong correlation between ER status and grade, these variables were not shown to be independent predictors of pCR. Overall survival (OS) was better in those patients who achieved a pCR compared to those who did not (5-year OS 91 vs 73%; P=0.02). This was still the case when only patients with ER-negative tumours were examined (5-year OS 90 vs 52%, P=0.005), but not in the subset of patients with ER-positive tumours (5-year OS 93 vs 79%; P=0.3). Therefore, patients with ER-negative tumours were found to be more likely to achieve a pCR to neoadjuvant chemotherapy than those with ER-positive tumours, and pathological response did not have prognostic significance in patients with ER-positive tumours.

Risk of second brain tumor after conservative surgery and radiotherapy for pituitary adenoma: update after an additional 10 years

We assessed the risk of second brain tumors in a cohort of patients with pituitary adenoma treated with conservative surgery and external beam radiotherapy. Four hundred and twenty-six patients (United Kingdom residents) with pituitary adenomas received radiotherapy at the Royal Marsden Hospital (RMH) between 1962 and 1994. They were followed up for 5749 person-years. The cumulative incidence of second intracranial tumors and systemic malignancy was compared with population incidence rates through the Thames Cancer Registry and the National Health Service Central Register (previously OPCS) to record death and the potential causes. Eleven patients developed a second brain tumor, including five meningiomas, four high grade astrocytomas, one meningeal sarcoma, and one primitive neuroectodermal tumor. The cumulative risk of second brain tumors was 2.0% [95% confidence interval (CI), 0.9-4.4%] at 10 yr and 2.4% (95% CI, 1.2-5.0%) at 20 yr, measured from the date of radiotherapy. The relative risk of second brain tumor compared with the incidence in the normal population was 10.5 (95% CI, 4.3-16.7). The relative risk was 7.0 for neuroepithelial and 24.3 for meningeal tumors. The relative risks were 24.2 (95% CI, 4.8-43.5), 2.9 (95% CI, 0-8.5), and 28.6 (95% CI, 0.6-56.6) during the intervals 5-9, 10-19, and more than 20 yr after radiotherapy (four cases occurred >20 yr after treatment). There was no evidence of excess risk of second systemic malignancy. An additional 10-yr update confirmed our previous report of an increased risk of second brain tumors in patients with pituitary adenoma treated with surgery and radiotherapy. The 2.4% risk at 20 yr remains low and should not preclude the use of radiotherapy as an effective treatment option. However, an increased risk of second brain tumors continues beyond 20 and 30 yr after treatment.

Psychosocial impact of breast/ovarian (BRCA1/2) cancer-predictive genetic testing in a UK multi-centre clinical cohort

This multi-centre UK study assesses the impact of predictive testing for breast and ovarian cancer predisposition genes (BRCA1/2) in the clinical context. In the year following predictive testing, 261 adults (59 male) from nine UK genetics centres participated; 91 gene mutation carriers and 170 noncarriers. Self-report questionnaires were completed at baseline (pre-genetic testing) and 1, 4 and 12 months following the genetic test result. Men were assessed for general mental health (by general health questionnaire (GHQ)) and women for general mental health, cancer-related worry, intrusive and avoidant thoughts, perception of risk and risk management behaviour. Main comparisons were between female carriers and noncarriers on all measures and men and women for general mental health. Female noncarriers benefited psychologically, with significant reductions in cancer-related worry following testing (P<0.001). However, younger female carriers (<50 years) showed a rise in cancer-related worry 1 month post-testing (P<0.05). This returned to pre-testing baseline levels 12 months later, but worry remained significantly higher than noncarriers throughout (P<0.01). There were no significant differences in GHQ scores between males and females (both carriers and noncarriers) at any time point. Female carriers engaged in significantly more risk management strategies than noncarriers in the year following testing (e.g. mammograms; 92% carriers vs 30% noncarriers). In the 12 months post-testing, 28% carriers had bilateral risk-reducing mastectomy and 31% oophorectomy. Oophorectomy was confined to older (mean 41 yrs) women who already had children. However, worry about cancer was not assuaged by surgery following genetic testing, and this requires further investigation. In all, 20% of female carriers reported insurance problems. The data show persistent worry in younger female gene carriers and confirm changes in risk management consistent with carrier status. Men were not adversely affected by genetic testing in terms of their general mental health.

Non-uptake of predictive genetic testing for BRCA1/2 among relatives of known carriers: attributes, cancer worry, and barriers to testing in a multicenter clinical cohort

BRCA1/2 test decliners/deferrers have received almost no attention in the literature and this is the first study of this population in the United Kingdom. The aim of this multicenter study is to examine the attributes of a group of individuals offered predictive genetic testing for breast/ovarian cancer predisposition who did not wish to proceed with testing at the time of entry into this study. This forms part of a larger study involving 9 U.K. centers investigating the psychosocial impact of predictive genetic testing for BRCA1/2. Cancer worry and reasons for declining or deferring BRCA1/2 predictive genetic testing were evaluated by questionnaire following genetic counseling. A total of 34 individuals declined the offer of predictive genetic testing. Compared to the national cohort of test acceptors, test decliners are significantly younger. Female test decliners have lower levels of cancer worry than female test acceptors. Barriers to testing include apprehension about the result, traveling to the genetics clinic, and taking time away from work/family. Women are more likely than men to worry about receiving less screening if found not to be a carrier. The findings do not indicate that healthy BRCA1/2 test decliners are a more vulnerable group in terms of cancer worry. However, barriers to testing need to be discussed in genetic counseling.

Do patients with weight loss have a worse outcome when undergoing chemotherapy for lung cancers?

To examine whether weight loss at presentation influences outcome in patients who received chemotherapy for lung cancer or mesothelioma. Multivariate analysis of prospectively collected data 1994–2001. Data were available for age, gender, performance status, histology, stage, response, toxicity, progression-free and overall survival. The outcomes of patients with or without weight loss treated with chemotherapy for small cell lung cancer (SCLC; n=290), stages III and IV non-small-cell lung cancer (NSCLC; n=418), or mesothelioma (n=72) were compared. Weight loss was reported by 59, 58 and 76% of patients with SCLC, NSCLC and mesothelioma, respectively. Patients with weight loss and NSCLC (P=0.003) or mesothelioma (P=0.05) more frequently failed to complete at least three cycles of chemotherapy. Anaemia as a toxicity occurred significantly more frequently in NSCLC patients with weight loss (P=0.0003). The incidence of other toxicities was not significantly affected by weight loss. NSCLC patients with weight loss had fewer symptomatic responses (P=0.001). Mesothelioma patients with weight loss had fewer symptomatic (P=0.03) and objective responses (P=0.05). Weight loss was an independent predictor of shorter overall survival for patients with SCLC (P=0.003, relative risk (RR)=1.5), NSCLC (P=0.009, RR=1.33) and mesothelioma (P=0.03, RR=1.92) and an independent predictor of progression-free survival in patients with SCLC (P=0.01, RR=1.43). In conclusion, weight loss as a symptom of lung cancer predicts for toxicity from treatment and shorter survival.

High incidence of HER-2 positivity in inflammatory breast cancer

HER-2 is over-expressed in around 25% of human breast cancers, and is associated with poor outcome. We examined the incidence of HER-2 status in inflammatory breast cancer (IBC). Forty-nine newly diagnosed IBCs were studied. Formalin-fixed paraffin-embedded pre-treatment tissue biopsies were examined immunohistochemically for the over-expression of the HER-2 protein and gene using the HercepTest and FISH assay. Clinical outcome was compared between the HER-2 positive (HercepTest score 3 + and FISH positive) and negative groups. Fifty-two per cent of the IBCs examined were HER-2 positive. The HER-2 positive group were demographically comparable to the HER-2 negative group. Ninety-six per cent of the HER-2 positive patients responded to primary chemotherapy compared to 76% of the HER-2 negative (P = 0.09). No significant differences in outcome emerged between the two groups. In conclusion, this study found the incidence of HER-2 protein over-expression in IBC is higher than previously reported in non-IBC. Early HER-2 directed therapy (such as the monoclonal antibody trastuzumab) as a part of multimodal treatment may improve outcome in this poor prognosis cancer.

Is Surgery Necessary After Complete Clinical Remission Following Neoadjuvant Chemotherapy for Early Breast Cancer?

Purpose: This retrospective analysis aimed to identify whether breast cancer patients receiving radiotherapy alone following a complete clinical remission (cCR) to neoadjuvant chemotherapy had a worse outcome than those treated with surgery.

Patients and Methods: One hundred thirty-six patients who had achieved a cCR to neoadjuvant chemotherapy for early breast cancer were identified from a prospectively maintained database of 453 patients. Of these, 67 patients had undergone surgery as their primary locoregional therapy, and 69 patients had radiotherapy alone. Outcome was assessed in relation to local recurrence-free survival, disease-free survival, and overall survival.

Results: Median follow-up was 63 months in the surgery group and 87 months in the no surgery group. Prognostic characteristics were well balanced between the two groups. For surgery and no surgery, respectively, there were no significant differences in disease-free survival or overall survival (5-year, 74% v 76%; 10-year, 60% v 70%, P = .9) between the two groups. There was a nonsignificant trend toward increased locoregional-only recurrence for the no surgery group (21% v 10% at 5 years; P = .09), but no long-term failures of local control. Patients in the no surgery group who also achieved an ultrasound complete remission had a 5-year local recurrence rate of only 8%.

Conclusion: In patients achieving a cCR to neoadjuvant chemotherapy, radiotherapy alone achieve survival rates as good as with surgery, but with higher local recurrence rates. Ultrasound may identify a low recurrence rate subgroup for assessing no surgery in a prospective trial.

The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway

The best chance of cure in non-small cell lung cancer (NSCLC) is surgical resection, but UK rates of 8% compare poorly to 25% in the USA and Europe. Delays in diagnosis in the current UK system may be one reason for such discrepancy. To address this problem we set up a rapid diagnostic system and compared it to the conventional method of investigations in a pilot randomised trial.

METHODS

Eighty-eight patients were prospectively enrolled from three District General Hospitals and randomised to either investigation locally or to the rapid system at The Royal Marsden Hospital. The pilot end-points were feasibility and audit of radical treatment rates to enable estimates for patient numbers for the full study.

RESULTS

Forty-five and 43 patients were in the central and conventional arms, respectively (65% male, median age 69 years). There was a 4-week improvement in time to first treatment in those in the central arm (P=0.0025) with 13/30 (43%) and 9/27 (33%) patients having radical treatment in the central and conventional arms, respectively. Patients in the conventional arm felt the diagnostic process was too slow (P=0.02) while those in the central arm seemed to have a better care experience (P=0.01). There were significantly less visits to the general practitioner (GP) in the central arm (P=0.02).

CONCLUSIONS

This pilot study demonstrates that the full study is feasible but would require the commitment and involvement of a large number of patients and physicians. The results show several advantages to investigations and diagnosis in the central arm, particularly in time to treatment initiation, patient satisfaction and rate of radical treatments. The improved rate of radical treatment could lead to an improved survival rate.

Phase II study of primary temozolomide chemotherapy in patients with WHO grade II gliomas

BACKGROUND

The aim of this study was to assess the efficacy of temozolomide in patients with World Health Organisation (WHO) grade II gliomas treated with surgery alone using imaging and clinical criteria.

PATIENTS AND METHODS

Thirty patients with histologically verified WHO grade II gliomas (17 astrocytoma, 11 oligodendroglioma, two mixed oligoastrocytoma) following surgery 2-104 months (median 23 months) after initial diagnosis received temozolomide 200 mg/m(2)/day for 5 days, on a 28-day cycle, for a maximum of 12 cycles or until tumour progression. Median age was 40 years (range 25-68 years). Median follow-up from entry into the study was 3 years [range 23-47 months (for patients alive)]. Objective response was assessed by 3-monthly magnetic resonance imaging and monthly health-related quality of life (HQoL) and clinical assessment. Tumour size was measured as the high signal intensity area on fluid attenuated inversion recovery sequences. Responses were assessed using change in the product of two perpendicular diameters as complete response (CR), partial response (PR), minimal response (MR), stable disease (SD) and progressive disease (PD).

RESULTS

Twenty-nine of 30 patients entered into the study were evaluable for response. Three patients had a PR, 14 MR, 11 SD and one PD. Twenty-four patients received 12 cycles of chemotherapy. Of 29 evaluable patients, three discontinued after four, five and six cycles and two after 10 cycles. Nine patients progressed (three during chemotherapy-one PD and two initial SD-and six after completion of chemotherapy); five had evidence of transformation. The 3-year progression-free survival was 66%. Five patients died; the actuarial 3-year survival was 82%. Ninety-six per cent of patients with impaired HQoL had improvement in at least one HQoL domain. There was improvement in 115 of the 207 domains (56%). Fifteen of 28 patients (54%) with epilepsy had reduction in seizure frequency, of whom six became seizure free. Six patients had transient grade III/IV haematological toxicity (11 episodes; 3.5%).

CONCLUSIONS

Temozolomide has single-agent activity in patients with WHO grade II cerebral glioma, with modest improvement in quality of life and improvement in epilepsy control. On present evidence, temozolomide cannot be considered as primary therapy without formal comparison with other treatment modalities.

Does Timing of Adjuvant Chemotherapy for Early Breast Cancer Influence Survival?

Purpose: Theoretically, patients with early breast cancer might benefit from starting adjuvant chemotherapy soon after surgery, and this would have important clinical implications. We have addressed this question from a large, single-center database in which the majority of patients received anthracyclines.

Patients and Methods: A total of 1,161 patients from a prospectively maintained database treated with adjuvant chemotherapy for early breast cancer at the Royal Marsden Hospital (London, United Kingdom), including 686 (59%) receiving anthracyclines, were retrospectively analyzed. The disease-free survival (DFS) and overall survival (OS) of the 368 patients starting chemotherapy within 21 days of surgery (group A) were compared with those of the 793 patients commencing chemotherapy ≥ 21 days after surgery (group B). Median follow-up time was 39 months (range, 12 to 147 months).

Results: No significant difference in 5-year DFS was found between the two groups overall (70% for group A v 72% for group B; P = .4) or in any subgroup. Likewise, there was no difference in 5-year OS (82% for group A v 84% for group B; P = .2) or when the interval to the start of chemotherapy was considered as a continuous variable (P = .4).

Conclusion: We have been unable to identify any significant survival benefit from starting adjuvant chemotherapy early after surgery, either overall or in any subset of patients.

Early changes in apoptosis and proliferation following primary chemotherapy for breast cancer

Patients undergoing primary chemotherapy for invasive breast cancer consented to a core biopsy of the invasive breast primary pre- and 24 h postchemotherapy. The resulting tissue was analysed for apoptosis, Ki67, ER and HER-2 using immunohistochemical techniques. These data were then used to evaluate the relationship between these biological markers and response to chemotherapy and overall survival. Response rate to chemotherapy in this group was 86%, 16 patients (25%) achieved a clinical complete response and 41 (63%) a partial response. Prechemotherapy there was a significant correlation between Ki67 and apoptotic index (AI), r=0.6, (P<0.001). A significant rise in AI (P<0.001), and fall in Ki67 (P=0.002) was seen 24 h following chemotherapy. No relationship was seen between pretreatment AI and clinical response, but higher Ki67 and growth index (Ki67/AI ratio, GI) did correlate with clinical response (both r=0.31, P<0.025). No correlation was seen between the change in AI or Ki67 at 24 h and clinical response or survival. Significant changes in apoptosis and proliferation can be demonstrated 24 h following chemotherapy, but these changes do not relate to clinical response or outcome in this study. Pretreatment proliferation and GI are however predictive of response to chemotherapy in breast cancer.

Hypofractionated radiotherapy for poor prognosis malignant glioma: matched pair survival analysis with MRC controls

PURPOSE

To assess the survival benefit of palliative hypofractionated radiotherapy in patients with poor prognosis high grade glioma by a matched comparison to conventionally treated controls.

METHOD

Ninety-two elderly and/or disabled patients with high grade glioma with poor prognostic features received palliative partial brain radiotherapy to a dose of 30Gy in six fractions over 2 weeks. Patients were matched for WHO histological grade, performance status and age from a cohort of patients treated with conventionally fractionated radiotherapy to a dose of 60Gy in 30 fractions in an Medical Research Council (MRC) BR05 trial.

RESULTS

Patients treated with hypofractionated radiotherapy had a median survival of 5 months with a 1-year survival rate of 12% from diagnosis. The median survival of case-matched controls was estimated to be 2.5-4.5 months longer. Following hypofractionated radiotherapy, Barthel score was improved or remained stable in 68% of patients.

CONCLUSION

Hypofractionated partial brain radiotherapy is a well-tolerated regimen with palliative benefit. Comparison with matched controls suggests lesser survival benefit than would be obtained with radical radiotherapy. However, this is compensated by lower intensity and duration of irradiation induced side effects. It is postulated that there may not be a significant difference in good quality survival or 'quality adjusted survival' between the two regimens and this requires testing in prospective trials.

An audit of the incidence of arm lymphoedema after prophylactic level I/II axillary dissection without division of the pectoralis minor muscle

Lymphoedema is reported to occur in approximately one in four women following curative treatment for breast cancer. Reported rates are almost exclusively for level 1,2,3 axillary clearance with few data for the current practice of level 1,2 dissections. Swelling can affect the whole upper limb but frequently will remain restricted to hand, forearm or upper arm. The aims of this study were to determine incidence after level 1,2 dissection, degree and site of swelling and risk factors which might determine such incidences. Results were available on 198 patients. The cumulative prevalence of lymphoedema after level 1,2 dissections was 14% in the arm, 12% in the forearm and 16% in the hand, assuming a circumference difference of more than 5% indicated lymphoedema. Moderate lymphoedema representing more than 10% circumference difference was found in 1% (arm), 3.5% (forearm) and 0.5% in the hand. Risk factors for lymphoedema were experience of the surgeon (upper arm only), dominant limb (forearm only) and right-sided cancer treatment (for hand only). When lymphoedema in any site was considered, right-sided treatment and nodal status were independently significant.

CONCLUSIONS

This study demonstrates that lymphoedema is a common complication following level 1,2 dissection. Whole limb volume is often considered the main outcome measure for detecting lymphoedema and determining success of treatment, yet swelling may be restricted to regions of the limb and site specific circumference measurements are therefore recommended. Pre- and postoperative circumference measurements are likely to be the most sensitive way of determining presence of lymphoedema following surgery for breast cancer.

Outcome after relapse in an unselected cohort of children and adolescents with Ewing sarcoma

BACKGROUND

Survival after relapse in patients with Ewing sarcoma is very poor and this retrospective study attempts to identify of prognostic factors predicting survival after relapse.

PROCEDURE

A total of 191 patients with localised Ewing sarcoma were registered in the ET-2 trial of the United Kingdom Children's Cancer Study Group (UKCCSG). All patients received standardised primary treatment with chemotherapy and surgery and or radiotherapy as local modality treatment. Sixty-four patients who relapsed are included in this report. Treatment at relapse was variable and included chemotherapy, surgery, radiotherapy and high dose therapy (HDT) or megatherapy with peripheral stem cell transplantation (PBSCT) or autologous bone marrow transplantation (ABMT) in various combinations. A subgroup of patients had only non-specific symptomatic treatment at relapse. Both univariate and multivariate methods were used to investigate variables affecting survival after relapse.

RESULTS

The overall actuarial median survival from relapse for all patients was 14 months (95% CI 11-16 months). Univariate analysis showed that males had a longer survival (median, 16 months vs. 11 months); patients who relapsed while on treatment did worse (median, 3 months vs. 16 months) and patients who had a longer disease-free interval (DFI) prior to relapse had a better outcome (DFI <1 year, median survival = 3 months; DFI 1-2 years, survival = 8 months; DFI > 2 years, median survival = 24 months, P < 0.001). Multivariate analysis confirmed that duration of first remission was the only factor associated with longer survival after relapse.

CONCLUSIONS

These data suggest that although aggressive therapy may delay disease progression after relapse for some children, the course of the disease after relapse is usually fatal. International co-operative studies are needed to evaluate new strategies.