P1-12-17: Fluorescent In Situ Hybridization Evaluation of HER2 Status in Tumors with Chromosome 17 Polysomy

Introduction: According to the American Society of Clinical Oncology-College of American Pathologists recommendations for HER2 testing, a positive fluorescent in situ hybridization (FISH) result is defined as >6 HER2 gene copies/nucleus (for test systems with no internal control probe [single-color]) or as HER2 gene/chromosome 17 centromere (CEP17) ratio > 2.2 (for systems with an internal control probe [dual-color]). Although an increase in CEP17 copy number (average ≥ 3.0 copies/nucleus) is commonly considered to represent polysomy of chromosome 17, it can also be a result of gains of 17q with centromere involvement, or amplification of the centromeric region. The classification of HER2−positive tumors according to the HER2/CEP17 ratio may therefore misclassify a fraction of truly amplified cases as polysomic. We prospectively evaluated tumors with chromosome 17 polysomy but no HER2 amplification to assess HER2 status using the above two FISH classifications and immunohistochemistry (IHC).

Materials and methods: Tumors were tested for gene amplification by FISH with probes to HER2/neu and CEP17 using the PathVysion HER-2 DNA Probe Kit (Vysis). Classification was based on the HER2/CEP17 ratio (amplified when > 2.2) and average HER2 gene copy number/nucleus (amplified when > 6 copies). Both polysomic and equivocal cases (HER2/CEP17 ratio 1.8 - 2.2) were further studied by IHC using the HercepTest (Dako) with 0–3 scoring system (overexpression when 3+).

Results: From March 2010 to May 2011 we evaluated 31 primary breast cancers showing chromosome 17 polysomy. Median HER2/CEP17 ratio was 1.3 (range 0.5−1.9), median HER2 copy number was 5.4 (range 2.6−13.8), and median CEP17 copy number was 4.2 (range 3.2−8.0). Thirteen (42%) had an average HER2 gene copy number > 6/nucleus (median 6.8, range 6.1−13.8) and would therefore be considered as amplified if classified according to the absolute HER2 gene copy number. Nine (75%) of these were 3+ at IHC and the remaining 4 were 2+, whereas among the 18 cases with an average HER2 gene copy number < 6/nucleus, one was 2+, ten were 1+, and 7 scored 0. Twenty-nine cases showed negative HER2/CEP17 ratios (< 1.8) and three cases equivocal HER2/CEP17 ratios (between 1.8 and 2.2). Using HER2/CEP17 ratio as first assessment and IHC only in equivocal cases, only one of the 31 “polysomic” cases would have been classified as HER2−positive. However, 8 polysomic cases with HER2/CEP17 ratio < 1.8 showed 3+ immunostaining (all with average HER2 gene copy number > 6/nucleus), while 3 other cases had an average HER2 gene copy number > 6/nucleus with 2+ immunostaining.

Conclusions: Our results show that both FISH evaluation criteria and IHC can modify the percentage of polysomic tumors classified as HER2−positive. However, the number of gene copies/nucleus appears more frequently associated with 3+ IHC than the HER2/CEP17 ratio. The predictive impact of the former method on response to anti-HER2 treatments warrants further investigation.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-12-17.

WEE1 inhibition sensitizes basal breast cancer cells to TRAIL-induced apoptosis

TRAIL is a member of the TNF super family and has been shown to induce apoptosis in many cancer cell lines but not in normal cells. Breast cancers can be divided into different subgroups on the basis of the expression of estrogen and progesterone receptors, HER-2 amplification, or the lack of these three markers (known as triple-negative or basal-type breast cancer). Our group and others have shown previously that triple-negative breast cancer cell lines are sensitive to TRAIL whereas others are relatively resistant. In an earlier study, we reported that inhibition of WEE1, a cell-cycle checkpoint regulator, causes increased cell death in breast cancer cell lines. In this study, we tested the effects of WEE1 inhibition on TRAIL-mediated apoptosis in breast cancer cell lines. Pretreatment with WEE1 inhibitor or knockdown of WEE1 increased the toxicity of TRAIL in the basal/triple-negative breast cancer cell lines compared with WEE1 inhibitor or TRAIL treatment alone. The enhanced cell death is attributed to increased surface expression of death receptors, increased caspase activation which could be blocked by the pan-caspase inhibitor, Z-VAD-FMK, thereby rescuing cells from caspase-mediated apoptosis. The cell death was initiated primarily by caspase-8 because knockdown of caspase-8 and not of any other initiator caspases (i.e., caspase-2, -9, or -10) rescued cells from WEE1 inhibitor-sensitized TRAIL-induced cell death. Taken together, the data suggest that the combination of WEE1 inhibitor and TRAIL could provide a novel combination for the treatment of basal/triple-negative breast cancer.

Abstract P6-05-02: Clinical-Pathological Features of All Nodules with the Same Histotype Affect Systemic Adjuvant Treatment Decision in Multifocal and Multicentric Breast Cancer

BACKGROUND

Decision criteria about systemic adjuvant treatment of patients affected by breast cancer include estrogen receptor (ER), progesterone receptor (PgR), HER2 status, histologic grading, and proliferative index. In case of multifocal or multicentric breast cancer, the College of American Pathologists (CAP) recommends to provide features for the largest invasive carcinoma. We evaluated the discordance of ER, PgR, HER2, grading, and proliferative index among all nodules with the same histotype of patients with multifocal or multicentric breast cancer and the impact on the choice of adjuvant treatment. METHODS

We retrospectively analyzed 113 consecutive patients operated for breast cancer between 2004 and 2009 in Forli (Italy). We performed histological examination of all nodules of each patient after surgery, at the same time. Immunohistochemical methods were used to detect ER/PgR status, and proliferative index (Ki67), whereas fluorescent in situ hybridization was used to determine HER2 status. ER/PgR < 10% was considered negative. Ki67 was considered high if ≥20%. Grading was determined according to Nottingham's score system. HER2 amplification was defined according to CAP guidelines or as the presence of a focal HER2 amplified clone ≥30% of tumor cells. We considered as “discordance” a difference in at least one nodule for any of the biologic features considered. In order to determine whether discordance among nodules affects systemic treatment approaches, we asked ten independent oncologists whether and how they would modify their prescribed adjuvant treatment. RESULTS

Discordance in ER or PgR status among different nodules was detected in 5 (4.4%) and 16 patients (14.1%), respectively. The majority of the oncologists (7 out of 10) decided to modify their prescribed systemic treatment in 3 patients (2.6%), in favor of a combined treatment (endocrine plus chemotherapy), instead of endocrine-or chemotherapy alone as if their decision was based on the receptor status only of the largest nodule. Discordance in HER2 status was detected in 10 (8.8%) patients. In 4 patients (3.5%), all clinicians found indication to an anti-HER2 treatment. Discordance in proliferative index occurred in 17 (15.0%) patients and discordance in grading was detected in 18 (17.8% over 101) patients. Five of ten oncologists decided to modify their prescribed systemic treatment by adding chemotherapy to endocrine-therapy alone in 5 patients (4.4%) based on Ki67 value, whereas there was no change based on grade. DISCUSSION

This study shows a discordance for all analyzed histological features among different nodules with the same histotype in multifocal and multicentric tumors. In a total of 8 patients (about 7%) this discordance affected the therapeutic decisions of oncologists, resulting in changes of the prescribed adjuvant systemic treatment, with respect to the prescriptions based on the clinicopathologic features only of the largest nodule. Therefore, we conclude that the analysis of all nodules in case of multifocality/multicentricity should be taken into consideration, in order to identify the best adjuvant treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-05-02.

Perioperative serum VEGF and extracellular domains of EGFR and HER2 in early breast cancer

BACKGROUND

The prognostic role of serum levels of molecular biomarkers during the perioperative period in patients with early breast cancer is not clear.

PATIENTS AND METHODS

Serum VEGF and extracellular domains (ECD) of EGFR and HER2 were prospectively determined in 119 consecutive patients with early breast cancer on the day before and after surgery.

RESULTS

After a median follow-up of 93 months, the preoperative value and the absolute change from pre- to postoperative serum levels of VEGF and HER2 ECD did not predict disease-free survival (DFS). A decrease after surgery of EGFR ECD correlated with a statistically significant lower DFS; each 1 ng/ml decrease in EGFR ECD serum level was associated with an increase of event risk of 15% on multivariable analysis (hazard ratio 1.15 95% confidence interval 1.04.-1.28, p=0.006).

CONCLUSION

The perioperative absolute change of EGFR ECD significantly correlated with disease outcome of patients with early breast cancer. No correlation was found between preoperative and perioperative absolute change of serum VEGF and HER2 ECD.

Randomized phase III trial of adjuvant epicirubicin (E) followed by cyclophosphamide, methotrexate, and fluorouracil (CMF) or CMF followed by E in patients with N- or ≤ 3 N+ rapidly proliferating breast cancer (RPBC)

560

Background: Antimetabolites are active in proliferating cells, and the adjuvant schedule CMF is highly effective in RPBC, whereas the sequential administration of doxorubicin (D) and CMF is superior to CMF–>D, especially in indolent tumors. In a phase III study, we evaluated whether adjuvant E followed by CMF is superior to the inverse sequence in RPBC. Methods: Patients with N-, T > 1 cm or ≤ 3 N+ and any T RPBC (defined by thymidine labeling index or grade or S-phase or Ki67/MIB1) were randomized to receive E (100 mg/m2 i.v. d 1, q 21 days for 4 cycles) followed by CMF (600, 40, 600 mg/m2 i.v. d 1 and 8, q 28 days for 4 cycles) (arm A) or CMF followed by E (arm B) or CMF (600, 40, 600 mg/m2 i.v. d 1 and 8, q 28 days for 6 cycles) (arm C). Arm C was closed after the EBCTCG 2000 meta-analysis (data not shown). The main endpoint was overall survival (OS), and the study had 80% power to detect a 7% absolute increase in 5-year OS with 400 patients per arm. Results: From November 1997 to December 2004, 1066 patients were enrolled (arms A/B/C: 440/438/188): N- 53%, estrogen receptor positive 63%, grade 3, 77%. At a median follow up of 69 months, 5-year disease-free survival was 80% in both arms (A and B) (p = 0.93, logrank test), with adjusted hazard ratio (AHR) 0.99 (95% CI 0.73–1.33, Cox model), and OS was 91% in arm A and 93% in arm B (p = 0.66, logrank), with AHR 0.88 (95% CI 0.58–1.35, Cox model). Adverse events were similar, apart from a small increase in grade 4 neutropenia in arm B. Conclusions: No relevant differences in clinical outcome were observed with the 2 different sequences. Further subgroup analyses are ongoing to verify the efficacy of each sequence as a function of biomolecular and hormonal profiles.

No significant financial relationships to disclose.

The dynamics of tumour-vasculature interaction suggests low-dose, time-dense anti-angiogenic schedulings

OBJECTIVES

The administration schedule appears to be a particularly relevant factor in determining the effectiveness of an antiangiogenic drug. A better quantitative knowledge of the interactions between tumour growth and the development of its vasculature could help to design effective therapies.

MATERIAL AND METHODS

Biological and clinical inferences were derived from the analysis of a mathematical model proposed by Hahnfeldt et al. (1999), and some of its variants. In particular, we compared the effect of constant continuous infusion of an anti-angiogenic drug that induces vascular loss, to the effect of periodic, bolus-based therapy.

RESULTS AND CONCLUSIONS

The role of drug elimination rate and of dose fractionation was investigated, and we show that different schedulings, guaranteeing the same mean value of drug concentration, may exhibit very different long-term responses according to their concentration vs. time profile. For a large class of tumour growth laws, the profiles that approach the constant one are the most effective. This behaviour appears to depend on the 'cooperativity' of the tumour-vasculature interaction and on the functional form of the relationship between tumour growth and vasculature extent. Moreover, we suggest that a therapy approaching constant drug infusion might be advantageous also in the case of cytostatic anti-angiogenic drugs.

Metronomic cyclophosphamide and capecitabine combined with bevacizumab in advanced breast cancer

PURPOSE

Metronomic chemotherapy has shown efficacy in patients with metastatic breast cancer. When used in association with targeted antiangiogenic drugs, it was more active than metronomic therapy alone in preclinical and clinical studies.

PATIENTS AND METHODS

Patients with advanced breast cancer were candidates to receive metronomic oral capecitabine (500 mg thrice daily) and cyclophosphamide (50 mg daily) plus bevacizumab (10 mg/kg every 2 weeks).

RESULTS

In 46 assessable patients, we observed one complete response (CR; 2%), 21 partial responses (PR; 46%), 19 patients (41%) with stable disease (SD), and five patients (11%) with progressive disease, for an overall response rate of 48% (95% CI, 33% to 63%). Additional long-term disease stabilization (SD > or = 24 weeks) occurred in eight patients, for an overall clinical benefit (CR + PR + SD > or = 24 weeks) of 68% (95% CI, 51% to 81%). Median time to progression was 42 weeks (95% CI, 26 to 72 weeks). Toxicity was generally mild. Grade 3 or 4 nonhematologic adverse effects included hypertension (n = 8), transaminitis (n = 2), and nausea/vomiting (n = 2). Higher baseline circulating endothelial cells (CECs) were correlated with overall response (P = .02), clinical benefit (P = .01), and improved progression-free survival (P = .04).

CONCLUSION

Treatment with metronomic capecitabine and cyclophosphamide in combination with bevacizumab was effective in advanced breast cancer and was minimally toxic. The number of baseline CECs significantly correlated with response and outcome, therefore supporting further studies on this surrogate marker for the selection of patients to be candidates for antiangiogenic treatments.

CT perfusion for the monitoring of neoadjuvant chemotherapy and radiation therapy in rectal carcinoma: initial experience

PURPOSE

To prospectively monitor changes in rectal cancer perfusion after combined neoadjuvant chemotherapy and radiation therapy with perfusion computed tomography (CT) and to evaluate whether perfusion CT findings correlate with response to therapy.

MATERIALS AND METHODS

The study was approved by the institutional ethics committee of the European Institute of Oncology; written informed consent was obtained from all participants before the study. Twenty-five patients with rectal adenocarcinoma (18 men, seven women; age range, 42-72 years; mean age, 61.3 years) underwent perfusion CT; all of them underwent neoadjuvant chemotherapy and radiation therapy, followed by surgery. In 19 patients, perfusion CT was repeated after chemotherapy and radiation therapy. Dynamic perfusion CT was performed for 50 seconds after intravenous injection of contrast medium (40 mL, 370 mg iodine per milliliter, 4 mL/sec). Blood flow (BF), blood volume (BV), mean transit time, and permeability-surface area product (PS) were computed in the tumor and in normal rectal wall by two independent blinded radiologists. Microvessel density was evaluated in pretreatment biopsy specimens in nine patients and in surgical specimens in seven patients. Wilcoxon signed-rank and rank sum tests were used for paired and independent comparisons, respectively.

RESULTS

BF, BV, and PS were significantly higher in rectal cancer than in normal rectal wall (P < .001). BF, BV, and PS significantly decreased after combined chemotherapy and radiation therapy (P < .009). No correlation was found between perfusion parameters and microvessel density, neither in baseline values nor in posttherapy changes. Baseline BF and BV in the seven patients who failed to respond to treatment were significantly lower than in the 17 responders (P = .02 for BF and < .001 for BV).

CONCLUSION

Perfusion CT has potential for monitoring the effects of combined neoadjuvant chemotherapy and radiation therapy and predicting the response of rectal cancer to such therapy.

Pathologic complete remission rate after cisplatin-based primary chemotherapy in breast cancer: correlation with p63 expression

PURPOSE

p63, a gene that shares structural and functional homologies with p53, codes for different isoforms, with (TA) and without (DeltaN) transactivating properties. The anti-apoptotic DeltaN isoform is often expressed in breast cancer (BC). DNA damaging drugs such as cisplatin (C) induce its degradation and stabilization of the TA, proapoptotic isoform. This supports the role of these drugs in the treatment of tumors expressing p63. The aim of the present study was to ascertain the predictive value of p63 immunoreactivity in patients treated preoperatively with regimens including cisplatin and/or anthracyclines.

METHODS

We reviewed the pretreatment biopsies of 189 patients with large or locally advanced BC (cT1-4d, N0-2, M0) treated with preoperative chemotherapy, performing p63 immunohistochemistry. The rate of pathological complete remission (pCR) at final surgery was assessed with respect to cisplatin administration and p63 immunoreaction.

RESULTS

pCR was identified in 20 patients (11%); 147 patients (78%) had an objective response, 39 (21%) stable disease, and 3 (1%) disease progression. One hundred forty seven patients (78%) received a cisplatin-containing regimen. Only regimens including cisplatin without anthracyclines yielded a higher rate of pCR in p63-positive compared with p63-negative tumors (23 vs. 0%, P=0.048). No significant difference in the pCR rate was observed for regimens containing anthracycline without cisplatin.

CONCLUSIONS

Administration of cisplatin without anthracyclines correlates with a high rate of pCR after primary chemotherapy in patients with p63-positive BC. The role of cisplatin-based chemotherapy should be further studied in these patients.

Antitumor activity and biological effects of primary endocrine therapy with GnRH analog and letrozole in premenopausal women with locally advanced operable ER and PgR positive breast cancer

21008

Background: Aromatase inhibitors (AIs) in combination with GnRH analog (A) were never systematically studied in premenopausal women with hormone receptor positive locally advanced operable breast cancer. Methods: We investigated in a two stage phase II trial, the activity of GnRH A plus letrozole (LT), added when E2 levels were in the postmenopausal range, in premenopausal women with T2-T4b N0-N2, endocrine responsive (ER and PgR ≥ 10% of the cells) breast cancer. We also investigated at baseline and at surgery the expression of ERβ, MAPkinases (MAPKs), ERa, EGFR, Her-2/neu, either normal or phosphorylated (p). Results: Thirty-nine patients (pts) were enrolled and 35 (ER >50%, 29 (90%) ; Ki 67 = 20%, 17 (53%); cT2/3, 24/5) are evaluable for response (3 of whom did not receive LT for refusal or failure of achievement of ovarian suppression). There were 16 objective responders (46%, 95% CI 29.5- 62.5), 1 of whom had pCR (3%). Nineteen pts (50%) were stable. Breast conserving surgery became possible for 42% of the patients. Side effects were mild. Endocrine therapy was correlated with grade 2 hot-flashes and arthralgia in 43% and 6% of the patients, respectively. Molecular analysis was performed in 27 pts (13 responders and 14 non responders). Treatment induced a significant decrease of pERa an upregulation of ER-β, which were independent of response. No overexpression of EGFR and HER-2 was registered at baseline and after treatment. Conclusions: The combination of LT and GnRH A is feasible and effective in premenopausal women with locally advanced endocrine responsive operable breast cancer. A biological response to estrogen suppression was observed. Tailored endocrine therapy of longer duration merits further investigations in the preoperative setting.

No significant financial relationships to disclose.

Preoperative concurrent chemo- and endocrine therapies for women with large operable breast cancer expressing steroid hormone receptors

21153

Background: Preoperative chemotherapy and endocrine therapy yielded low pathological complete remission (pCR) rates in patients with endocrine responsive breast cancer. Methods: Patients with large operable endocrine responsive (ER ≥ 10% of the cells) breast cancer (cT2-T3, N0–2, M0) were treated in 2 consecutive studies with preoperative chemotherapy (Study I: 6 courses of either fluorouracil, leucovorin, vinorelbine (FLN), or vinorelbine, cisplatin, and continuous infusion of fluorouracil (ViFuP), chosen at the discretion of the treating physician; Study II: an oral regimen with capecitabine and vinorelbine (CAVINO). In both studies concurrent endocrine therapies (letrozole, either alone or if premenopause, with triptorelin) were given. Results: Sixty-five (58 evaluable) and fifty-five (all evaluable) patients were enrolled to Studies I and II, (ER >50%, 51 and 50; Ki 67 = 20%, 42 and 39; cT2/3: 36 / 22 and 35 / 20; premenopausal 40 and 38) respectively. In Study I there were 43 objective responders (74%, 95% CI 63–85%), 4 of whom had pCR. In Study II 34 patients (62%, 95% CI 49–75%) had an objective response. Breast conserving surgery became possible for 64% and 62% of the patients in Study I and II, respectively. Conclusions: Intravenous, non anthracycline containing regimens together with tailored menopause status-adapted endocrine therapy, warrants further investigations in the preoperative setting.

No significant financial relationships to disclose.

Metronomic chemotherapy with capecitabine and oral cyclophosphamide in combination with bevacizumab in metastatic breast cancer (mbc): Evidence of activity of an antiangiogenic treatment

11501

Background: Metronomic chemotherapy has shown efficacy in patients (pts) with MBC. Laboratory and clinical studies suggest that the combination with a specific antiangiogenic drug may be particularly effective. Methods: We evaluated the activity and biological effects of low dose continuous oral Capecitabine (500 mg PO TID) and Cyclophosphamide (50 mg PO QD) plus Bevacizumab (10 mg/Kg Q 2 weeks) in a two stage phase II trial in MBC pts, who received =3 lines of chemotherapy for advanced disease. Planned sample size is 46 pts. Results: To date, 26 patients have been enrolled on the study and 23 are evaluable. Pts characteristics: 1/2/=3 sites of metastatic disease 6/9/11 pts; dominant sites of disease soft tissues/bone/viscera 1/11/22; previous treatment for MBC: endocrine/chemo/trastuzumab 13/21/1 pts (=2 lines 25). Results: there were 1 CRs (4.3%), 10 PRs (43.5%), 6 SD (26.1%), and 6 PD (26.1%), for an overall response rate of 48% (exact 95% CI 27–69%). Median progression free survival was 6 months (+). Grade 3 side effects: 6 hypertension , 1 leucopenia , 2 neutropenia , 2 transaminitis (both with liver metastases). No patient was withdrawn from the study due to side effects, and hypertension was manageable with adequate therapy. Data on median circulating endothelial cells (CECs) will be available. Conclusions: Metronomic chemotherapy with capecitabine and cyclophosphamide in combination with bevacizumab has clinical activity and low toxicity in advanced breast cancer.

No significant financial relationships to disclose.

Primary therapy with ECF in combination with a GnRH analog in premenopausal women with hormone receptor-positive T2–T4 breast cancer

Patients with hormone receptor-positive tumors less often show a pathological complete response (pCR) than do those with hormone receptor-negative tumors. The addition of endocrine therapies may improve the clinical benefits of primary therapies in these patients. We investigated the efficacy of the epirubicin+cisplatin+fluorouracil (ECF) as continuous infusion) regimen in association with a gonadotropin-releasing hormone (GnRH) analog in 36 premenopausal women with T2-T4a-d N0-2 M0 ER and/or PgR-positive breast cancer. Median age was 39.5 years (range 26-53). Clinical response (complete or partial) was observed in 27 out of 36 patients (75% 95% CI 57.8-87.9%) and a pCR was observed in four patients (11%). Nine (25%) patients had stable disease and no progression was observed. Twenty-one patients (58%) were submitted for breast-conserving surgery and 15 had a radical mastectomy. No baseline clinical and biological characteristics significantly correlated with response. Thirty out of 31 patients evaluable for endocrine assessment had documented ovarian suppression, which occurred after a median of 28 days (range 20-43). We conclude that the combination of ECF and a GnRH analog is associated with a high response rate in the primary treatment of breast cancer. Further studies combining chemotherapy and endocrine agents are warranted in patients with hormone receptor-positive tumors.

Serum EGFR and serum HER-2/neu are useful predictive and prognostic markers in metastatic breast cancer patients treated with metronomic chemotherapy

BACKGROUND

Metronomic chemotherapy has been demonstrated to be of value in patients with advanced breast cancer. No reliable markers of response are available. In breast tumor, HER-2/neu is a prognostic factor, whereas no definite data exist for EGFR. The aim of the study was to evaluate the prognostic and predictive role of serum HER-2/neu and serum EGFR in breast cancer patients treated with low-dose chemotherapy.

METHODS

Serum levels of HER-2/neu (n = 135) and of EGFR (n = 113) were prospectively determined before the start of chemotherapy, after 2 months of treatment, and when progressive disease was diagnosed.

RESULTS

Elevated (>15 ng/mL) serum HER-2/neu before the start of chemotherapy was not associated with response rate, whereas elevated serum HER-2/neu at 2 months was significantly associated with reduced long-term clinical benefit (24 weeks) (P < .001), as well as changes in HER-2/neu levels between baseline and 2 months (P < .0001). Multivariate analysis identified a >or=20% increase of serum HER-2/neu as an independent factor for progression-free survival (PFS). Kinetics of serum HER-2/neu were significantly associated with PFS (P < .0001) and overall survival (OS) (P = .015). Low baseline serum levels of EGFR (<45 ng/mL) were predictive of reduced response rate both at 2 months (P = .031) and after 24 weeks (P = .022). Moreover, they were significantly associated with reduced PFS (P = .016) and OS (P = .015).

CONCLUSIONS

Serum HER-2/neu and EGFR may represent useful markers for early prediction of probability of response, PFS, and OS in patients with advanced breast cancer treated with metronomic chemotherapy.

A randomized phase II trial comparing preoperative plus perioperative chemotherapy with preoperative chemotherapy in patients with locally advanced breast cancer

The aim of this study was to investigate in a randomized trial the activity of perioperative chemotherapy in patients treated with preoperative chemotherapy for locally advanced breast cancer and to compare it with the preoperative chemotherapy alone. Patients with cT2-3 N0-2 M0 histologically proven breast cancer, with estrogen receptors and progesterone receptors in less than 20% of cells, or with absence of progesterone receptors, received epirubicin 25 mg/m days 1 and 2, cisplatin 60 mg/m day 1, and fluorouracil 200 mg/m daily as continuous infusion. Responding patients were randomized to continue fluorouracil until 2 weeks after surgery (perioperative chemotherapy) or to stop fluorouracil 1 week before surgery. Fifty-eight patients completed six courses of epirubicin, cisplatin and fluorouracil, and were randomized to perioperative chemotherapy (29 patients) or to control (29 patients). The median Ki-67 index remained stable (32-27.5%) in the perioperative chemotherapy arm (P=0.3) and decreased from 55 to 22.5% in the control arm (P=0.01). The rate of pathological complete remission was 41% in both arms (P=1.0). No significant difference in terms of disease-free survival and overall survival was observed between the two arms. Perioperative chemotherapy failed to show an increase in the pathological complete remission rate. A biological effect on Ki-67 expression was demonstrated.

Role of endocrine responsiveness and adjuvant therapy in very young women (below 35 years) with operable breast cancer and node negative disease

BACKGROUND

There is limited knowledge about prognosis, and treatment effects in young women with node-negative disease.

PATIENTS AND METHODS

We evaluated biological features, treatment recommendations and prognosis for 841 premenopausal patients with pT1-3, pN0 and M0, operated from 1997 to 2001.

RESULTS

Patients below 35 years (101, 12%) were more likely to have tumors > 2 cm (35.6% versus 24.2%, P = 0.002), grade 3 (48.5% versus 31.9%, P = 0.009) and with elevated Ki-67 expression (62.4% versus 50.7%, P = 0.002). At the multivariate analysis a statistically significant difference in disease-free survival (DFS, HR 4.44; 95% CI 2.53 to 7.78, P < 0.0001), risk of distant metastases (DDFS) (HR 3.23; 95% CI 1.32 to 7.94, P = 0.011) and overall survival (OS) (HR 2.89; 95% CI 1.06 to 7.87, P = 0.038) was observed for younger versus older patients and in the subgroup with endocrine responsive tumors (DFS, HR 5.17, 95% CI 2.72-9.83, P = < 0.0001; DDFS, 3.76, 95% CI 1.33-10.6, P = 0.013; OS, 4.71, 95% CI 1.09-20.4, P = 0.039 ).

CONCLUSIONS

Compared with less young, very young patients with endocrine responsive and node-negative breast cancer have a worse prognosis. Tailored treatments should be explored in this cohort of patients.

Trastuzumab in combination with metronomic cyclophosphamide and methotrexate in patients with HER-2 positive metastatic breast cancer

Background

HER2/neu overexpression is linked to promotion of angiogenesis in breast cancer. We therefore tested the activity of the combination of Trastuzumab with metronomic, low dose chemotherapy with cyclophosphamide (CTX) and methotrexate (MTX) in metastatic breast cancer (MBC).

Methods

Between April 2002 and June 2005, twenty-two patients with metastatic breast cancer with the presence of overexpression or amplification of HER2-/neu, all pre-treated with trastuzumab plus other cytotoxics, were treated with trastuzumab (6 mg/kg every three weeks) in combination with metronomic chemotherapy (MTX 2.5 mg, bid on Day 1 and Day 4 every week) and CTX (50 mg daily) (CM).

Results

The 22 enrolled patients are evaluable: most had an ECOG performance status of 0 (17 pts), and all were pre-treated with chemotherapy for metastatic disease; 14 had progressive disease at study entry, and 11 had progressive disease during the last trastuzumab therapy. Metastatic sites included: lung (5 pts), liver (14 pts), bone (12 pts), lymph nodes (8 pts), central nervous system (CNS) (9 pts). We observed 4 partial remission (PR) (18%, 95% CI 5–40%), 10 stable disease (SD) (46%, 95% CI 24–68%), and 8 PD (36%, CI 17–59%). The clinical benefit (RP plus RC plus SD for ≥ 24 weeks) in all pts and in pts with disease resistant to previous trastuzumab therapy were 46% (95% CI, 24–68%) and 27% (95% CI, 6–61%), respectively. Median time to progression was 6 months and median duration of treatment was 5 months (range, 0,7 to 18.4 months and range, 1 to 18 months, respectively). Overall clinical toxicity was generally mild. Grade ≥2 reversible liver toxicity and leukopenia were reported in 5 and 3 pts, respectively.

Conclusion

The combination of trastuzumab and metronomic chemotherapy is effective and minimally toxic in advanced breast cancer patients. The efficacy observed in patients with disease resistant to trastuzumab supports the need of larger trial to confirm a role of this combination to delay acquired trastuzumab resistance.

Prolonged clinical benefit with metronomic chemotherapy in patients with metastatic breast cancer

The clinical efficacy and antiangiogenic effect of low-dose, metronomic administration of cyclophosphamide (CTX) and methotrexate (MTX) (CM) have been demonstrated. The authors report results and long-term follow-up for patients with metastatic breast carcinoma who obtained prolonged clinical benefit with CM. Prospectively collected data from two successive clinical trials were evaluated. From July 1997 to October 2003, patients with metastatic breast carcinoma were treated with low-dose oral chemotherapy (MTX 2.5 mg, twice daily on day 1 and day 2 or 4, and CTX 50 mg daily). Patients who achieved prolonged clinical benefit for a duration of 12 months or more (complete remission, partial remission or stabilization of disease) were considered for the analysis. Median follow-up was 23 months. A total of 153 patients were enrolled and are evaluable: Eastern Cooperative Oncology Group performance status 0-1 in 90 patients, two or more sites of metastatic disease in 97 patients, zero regimen for metastatic breast carcinoma in 48 patients. Among 153 patients, five demonstrated complete remission and 25 partial remission. The proportion of patients who achieved prolonged clinical benefit was 15.7% (95% confidence interval 9.9-21.4%). Median time to progression for patients with prolonged clinical benefit was 21 months (range 12-37+ months). One patient maintained complete remission 42 months after therapy discontinuation. At the multivariate analysis endocrine responsiveness and the achievement of an objective response significantly correlated with the achievement of prolonged clinical benefit. Metronomic chemotherapy can induce prolonged clinical benefit in metastatic breast cancer, supporting its role as an additional therapeutic tool in the treatment of patients with metastatic breast carcinoma.

A phase II study of primary dose-dense sequential doxorubicin plus cyclophosphamide and docetaxel in cT4 breast cancer

BACKGROUND

Dose-dense chemotherapy with anthracyclines and taxanes has improved either disease free survival or overall survival in high risk patients with early breast cancer.

PATIENTS AND METHODS

The activity and safety of a dose-dense schedule (q14 days) of adriamycin 60 mg/sqm and cyclophosphamide 600 mg/sqm (AC) x 4 cycles followed by docetaxel 75 mg/sqm for 4 cycles with hematopoietic support in patients with stage IIIB breast cancer was explored. Patients with ER > or =10% tumors received concomitant endocrine therapy with 3-month triptorelin and letrozole.

RESULTS

Fifteen patients with histologically proven cT4b (three patients) and cT4d (twelve patients) M0 breast cancer were enrolled. Median age was 48 years (range 25-66). Eight clinical responses including one pathological complete remission (pCR), three stable disease (including minor responses) and four progression of disease, one during AC and three during taxotere, were observed. Four patients had grade 3-4 non hematological toxicities and all except one discontinued treatment.

CONCLUSION

Due to the high rate of progressive disease, this schedule should not represent a standard option in cT4 breast cancer.

Safety and efficacy of the combination carboplatin and paclitaxel in patients (pts) with recurrent head and neck squamous cell carcinoma (HNSCC)

15534

Background: Pts with recurrent HNSCC have a dismal prognosis; treatment options are poorly effective and burdened with toxicity. In this clinical setting, cisplatin and paclitaxel have demonstrated activity despite relevant side effects. The purpose of this phase II trial was to investigate whether a combination of carboplatin and paclitaxel could offer a better toxicity profile without affecting efficacy. Methods: Pts with bi-dimensionally measurable disease, previously treated with induction chemotherapy (Cisplatin and 5-FU) followed by concomitant chemo-radiotherapy, were studied. Treatment consisted of Carboplatin AUC 5 and Paclitaxel 175 mg/m2 intravenously every 3 weeks. G-CSF and darbepoetin alpha were allowed in case of neutropenia (N < 1000/mm3) or anemia (Hb < 11 g/dL). Pts were evaluated for toxicity and response. Results: So far, 15 pts were enrolled. Median age was 53 yrs; ECOG P.S. was 0–1. Site of disease at relapse was head and neck excluding lips and sinus; 12 out of 15 pts had stage IV disease. All pts were evaluated for response and toxicity. After three cycles of chemotherapy, we observed 1 complete response (6.6%) and 7 partial responses (46.6%), with a 53.2 % overall response rate (95% CI 26.6–78.7%). Stable disease was seen in 2 patients (13.3%) and progressive disease was observed in 5 pts (33.3%). Toxicity was mild: we recorded 1 case of G3 toxicity (neutropenia) and no G4 side effects. Three pts experienced G1–2 neuropathy and 4 pts G1–2 hematologic toxicity (neutropenia and thrombocytopenia). Conclusions: The current regimen was feasible and effective. The combination of Carboplatin and Paclitaxel was well tolerated and could be safely administered to pts with recurrent HNSCC as second line treatment. Enrollment and data collection are still ongoing.

No significant financial relationships to disclose.

Hepatic intra-arterial chemotherapy in patients with metastatic breast cancer

10581

Background: Hepatic intra-arterial chemotherapy has been reported to produce higher response rate than systemic in patients (pts) with metastatic colorectal cancer. In breast cancer the liver is involved in up to 60% of cases and often conditions the prognosis. Nevertheless, only rare hepatic arterial infusion studies were published. Therefore, based on our previous experience in hepatic metastatic colorectal malignancies, we evaluated efficacy and toxicity of hepatic intra-arterial chemotherapy in pts with metastatic breast cancer. Methods: A three-day continuous arterial infusion (CAI) of fluorouracil 1000 mg/m2 q 24 hrs, with cisplatin 10 mg/m2 twice daily, and mitomycin-c 1 mg/m2 twice daily, was performed through a percutaneous radiological temporary trans-subclavicular catheter. Pts with responsive disease received up to four cycles every six weeks. Pts still responding could carry on with cisplatin and fluorouracil, without mitomycin-c. Pts were hospitalized and the catheter was removed upon end of infusion. Results: From 9.2000 to 6.2005, 25 pts with progressive liver metastases from breast cancer were treated. Nine had more than 50% of liver involvement. Fifteen had also extra-hepatic metastases. All had received antracyclines and 22/25 taxanes. Pts had a median of five previous chemotherapy lines. Median time from diagnosis of liver metastases to first CAI was 33 months (range: 7–110). Sixty-four total courses were administered, with a median of 2 (range: 1–7) per pts. Epigastric pain was the main clinical toxicity (54%) and iatrogenic gastro-duodenal ulcer, the main complication (28%). No relevant catheter-related complications occurred. Fifteen partial responses (60%) and eight stable diseases (32%) were observed. Response duration was 5.4 months (range: 2 - 27), time to progression 5.1 months (range: 2.5–29+), and median overall survival 13 months (range: 3.5+–32+). Conclusions: Hepatic arterial infusion of chemotherapy in heavily pre-treated pts with metastatic breast cancer is feasible and effective. A specific evaluation of quality of life should be performed to verify a real clinical benefit. An earlier timing during course of liver disease, and a shift to radiological implanted arterial port (allowing out-patient treatment), will be investigated.

No significant financial relationships to disclose.

Vinorelbine-based chemotherapy in hormone-refractory prostate cancer

BACKGROUND

No consensus exists regarding further therapy for the management of hormone-refractory prostate cancer. In this phase II study, the combination of Vinorelbine with 5-Fluorouracil and folinic acid (FLN regimen) was evaluated in patients with progressive or resistant disease after hormone therapy.

PATIENTS AND METHODS

Thirty-four patients were treated with Vinorelbine at a dose of 20 mg/m2 intravenously (i.v.) on days 1 and 3, folinic acid (FA), 100 mg/m2 i.v. and 5-Fluorouracil (5-FU), 350 mg/m2 i.v. as a short infusion on days 1 to 3. The therapy was given in an out-patient setting, every 3 weeks.

RESULTS

All of the 34 eligible patients were evaluable for toxicity and 30 for activity. A total of 127 cycles was administered (91% at full dose). Among thelS5 patients with measurable disease, four had a partial response (26.6%; C.I. 95%, 28.3% to 65.7%) and four achieved stable disease. In 14 patients (47%) a clinical benefit was documented. Six out of 15 patients with bone-only involvement had stable disease (40%). The median duration of stabilization and partial response was 16 weeks (range 4-24 weeks). The most common toxicity was hematological: Grade 4 (NCI-CTC scale) in five patients at re-cycle. Other toxicities were of low incidence and easy to manage.

CONCLUSION

The encouraging results obtained with the FLN regimen in terms of clinical benefit and its predictable and manageable toxicity support the palliative role of this chemotherapeutic strategy in hormone-refractory prostate patients.

Oxaliplatin combined with 5-fluorouracil and methotrexate in advanced colorectal cancer

BACKGROUND

A promising regimen including 5-Fluorouracil, methotrexate and oxaliplatin is reported.

PATIENTS AND METHODS

Patients with untreated measurable metastatic disease received bolus 5-Fluorouracil (600 mg/m2) on days 2 and 16, modulated by methotrexate (200 mg/m2) 24 h earlier, alternated with 4 weeks of continuous infusion of 5-Fluorouracil (200 mg/m2/daily) plus oxaliplatin (130 mg/m2) on days 29 and 56, followed by 2 weeks of rest. Serum vascular endothelial growth factor (VEGF) was analyzed at baseline and before every cycle.

RESULTS

Fifty-eight patients were enrolled. Objective remissions were reported in 45.6% (95% CI=34.3%, 57.3%). The median progression-free survival was 7.8 months and the median overall survival was 19.4 months. No grade 4 toxicity was reported, except for one case of diarrhea. The serum VEGF evaluated in 23 patients showed a decreasing trend during therapy.

CONCLUSION

The regimen was active, well tolerated and may be a possible option in patients not suitable for radical surgery.

Metronomic low-dose oral cyclophosphamide and methotrexate plus or minus thalidomide in metastatic breast cancer: antitumor activity and biological effects

BACKGROUND

We previously demonstrated efficacy and impact on serum vascular endothelial growth factor (VEGF) for metronomic cyclophosphamide (C) and methotrexate (M) in patients with breast cancer. New metronomic schedules were investigated.

PATIENTS AND METHODS

Patients with advanced breast cancer were randomized to receive oral C (50 mg daily) and M (2.5 mg twice daily on days 1 and 4) (arm A) or the same regimen plus thalidomide (200 mg daily) (arm B).

RESULTS

The mean VEGF level decreased from 378.9 (+/-274.4) pg/ml at baseline to 305.9 (+/-203.6) pg/ml at 2 months (P<0.001), with similar change with respect to baseline in both arms. In 171 evaluable patients we observed three complete remissions (CR) in both arms A and B, 15 partial remission (PR) in arm A and seven in arm B, for an overall response of 20.9% [95% confidence interval (CI) 12.9% to 31%] in arm A and 11.8% (95% CI 5.8% to 20.6%) in arm B. The clinical benefit (CR+PR+SD>or=24 weeks) was 41.5% for both arms. Toxicity was generally mild. Higher neurological toxicity (2% versus 60%; P<0.0001) and constipation (8% versus 51%; P<0.0001) was observed in arm B.

CONCLUSIONS

Metronomic low-dose CM induced a drop in VEGF, and was effective and minimally toxic. The addition of thalidomide did not improve results.

Capecitabine/Vinorelbine: An Effective and Well-Tolerated Regimen for Women with Pretreated Advanced-Stage Breast Cancer

BACKGROUND

The combination of capecitabine and vinorelbine is a potentially valuable treatment regimen for patients with advanced-stage breast cancer. The drugs are easy to administer and do not cause significant alopecia. In order to identify the spectrum of toxicity of a regimen containing 2 drugs, we conducted an extended phase I study aimed at defining maximum tolerated doses, recommended doses, safety, and efficacy in patients with pretreated advanced-stage breast cancer.

PATIENTS AND METHODS

Forty-nine patients with advanced-stage breast cancer were treated with escalating doses of oral capecitabine from 500 mg/m2 to 1375 mg/m2 twice daily on days 1-14 and escalating doses of vinorelbine from 12.5 mg/m2 to 25 mg/m2 intravenously (I.V.) on days 1 and 3 every 3 weeks. Almost all patients (90%) had received >or= 3 previous treatments for metastatic disease (anthracyclines, 76%; 5-flourouracil, 76%; taxanes, 29%).

RESULTS

Dose level 9 (capecitabine 1250 mg/m2 twice daily on days 1-14 and vinorelbine 22.5 mg/m2 I.V. on days 1 and 3) was identified as the maximum tolerated dose. The most frequent clinical adverse events were nausea (78%), asthenia (59%), constipation (51%), mucositis (47%), and hand-foot syndrome (41%). The majority of events were mild to moderate; the only grade 4 clinical adverse events were diarrhea, fever, and thromboembolism, each of which occurred in 1 patient (2%) at dose level 8. Objective confirmed responses were observed in 18 patients (37%), including 1 complete response (2%) and 17 partial responses (35%). Disease was stable in an additional 10 patients (20%), with a median duration of 6.3 months (range, 4-24 months).

CONCLUSION

The combination of the 2 drugs is very well tolerated and effective, especially considering the previous exposure to chemotherapy. The recommended dose for further phase II studies should be capecitabine 1250 mg/m2 twice daily on days 1-14 and vinorelbine 22.5 mg/m2 I.V. on days 1 and 3.

Perception that oral anticancer treatments are less efficacious: development of a questionnaire to assess the possible prejudices of patients with cancer

We developed and pilot tested a 12-item questionnaire, to approach the issue of patients' perception on efficacy of oral chemotherapy. An additional question was on 'trade-off' between treatment efficacy and the ease of oral administration. The motivating underlying hypothesis was that oral drugs might be perceived by patients as less effective than when drugs were delivered by injection. The questionnaire was given to 59 patients with advanced breast cancer who received oral chemotherapy. Ninety-percent of patients considered clear and completed the questionnaire. Oral chemotherapy was positively viewed by most patients, perceiving it as advantageous (58%), able to help them feel less ill (77%) and to reduce the effort in coping with the disease (67%). The most important feeling elicited was the sense of freedom. Younger patients (<45 years) required bigger effort to face their illness and expected the most from oral chemotherapy. The questionnaire was shown to be robust, reliable and reproducible instrument in assessing patients' prejudices towards oral anticancer treatments.

[Hexadactylism of the four limbs: a case report]

An unusual case of postaxial hexadactylism of the hands and feet in one female Caucasian neonate is described. The clinical picture was characterized by symmetrical duplication of the 5th finger in both hands and of the 4th finger in both feet. Malformations of the extremities both in the paternal and in the maternal family were reported. No other associated malformations have been found in the baby and her karyotype was normal. The performed analysis of the literature confirmed the peculiarity of the associated features of this case.

Reverting estrogen-receptor-negative phenotype in HER-2-overexpressing advanced breast cancer patients exposed to trastuzumab plus chemotherapy

Introduction

The amounts of estrogen receptor (ER) and progesterone receptor (PgR) in a primary tumor are predictive of the response to endocrine therapies of breast cancer. Several patients with ER-positive primary tumors relapse after adjuvant endocrine therapy with no ER expression in the recurrent tissue; much fewer with a recurrent disease after an ER-negative primary tumor may become endocrine responsive. These sequences of events indicate that a phenotype based on ER expression may not be a permanent feature of breast cancer.

Methods

Ten patients with advanced breast cancer whose tumors overexpressed HER-2, but not ER or PgR, were treated with weekly trastuzumab at standard doses with or without chemotherapy.

Results

Three out of 10 patients showed overexpression of ERs first appearing after 9, 12 and 37 weeks, respectively, from the initiation of trastuzumab. Two of these patients were subsequently treated with endocrine therapy alone: one of them received letrozole for 3 years without evidence of progression.

Conclusion

Therapeutic targets enabling the appearance of an endocrine responsive disease may increase treatment options for patients with breast cancer. Furthermore, these clinical data suggest that an ER-negative phenotype is a multi-step process with a reversible repression modality, and that some ER-negative tumors may either revert to an ER-positive phenotype, allowing an endocrine treatment to be effective.

Breast cancer vaccines: a clinical reality or fairy tale?

The characterization of tumor antigens recognized by immune effector cells has opened the perspective of developing therapeutic vaccines in the field of breast cancer. The potential advantages of the vaccines are: (i) the induction of a robust immune response against tumors that are spontaneously weekly immunogenic; (ii) the tumor specificity for some antigens; (iii) the good tolerance and safety profile and (iv) the long-term immune memory, critical to prevent efficiently tumor recurrence. Most trials evaluating breast cancer vaccines have been carried out in patients with extended metastatic breast cancer, characterized by aggressive tumors, resistant to standard cytotoxic treatments, so that clinical efficacy was difficult to achieve. However, some significant immune responses against tumor antigens induced upon vaccinations were recorded. The aim of this review is to analyze the activity of vaccination strategies in current clinical trials. Data of clinical activity have been observed by using vaccines targeting HER2/neu protein, human telomerase reverse transcriptase, carcinoembryonic antigen and carbohydrate antigen given after stem cell rescue. The review discusses possible future directions for vaccine development and applications in the adjuvant setting.

Update: current management issues in malignant melanoma

The incidence of melanoma has increased continuously during the last decade. Surgery is the mainstay of therapy but, for patients with thick lesions or regional metastatic lymph nodes, there is a high risk of relapse. For this group of patients, there is no standard therapy or general agreement amongst oncologists. In this article, we review the current management of melanoma with regard to past completed adjuvant trials and open trials. Moreover, we discuss the role of chemotherapy in metastatic melanoma, in particular with attention to the use of fotemustine.

A Retrospective Analysis of the Outcome of Patients with Recurrent and/or Metastatic Squamous Cell Carcinoma of the Head and Neck Refractory to a Platinum-based Chemotherapy

AIMS

Recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) develops in around 72,000 people in Europe every year. Treatment options are limited, mainly consisting of platinum-based palliative chemotherapy, with median overall survival times of only 6-8 months. No standard second-line treatment after progression on platinum-based chemotherapy is available. Few data have reported the efficacy of these treatments and the outcome of the patients. In an effort to generate such data, this retrospective study analysed clinical records from 151 patients with SCCHN refractory to platinum-based chemotherapy treated between 1990 and 2000 at seven different centres around Europe.

MATERIALS AND METHODS

Most patients (45%) received only best supportive care (BSC), and had a median survival of 56 days. A total of 28.5% of the patients received second-line chemotherapies: 16.6% radiotherapy and 9.9% chemoradiotherapy.

RESULTS

No objective response was observed with the various second-line chemotherapies. The overall median survival was 103 days (95% confidence interval [CI]: 77-126 days) for the whole cohort. The overall objective response rate (ORR) to second-line treatment in this population was calculated to be 2.6%.

CONCLUSION

These results highlight the need for additional treatment options for this disease. Similar, if not superior, response rates have already been observed in initial clinical studies of novel, targeted anti-cancer agents.

Are all high-grade breast cancers with no steroid receptor hormone expression alike? The special case of the medullary phenotype

BACKGROUND

Medullary carcinoma (MC) of the breast is associated with favorable prognosis compared with other histological types, despite high nuclear grade, fast proliferation and lack of steroid hormone receptor expression. We retrospectively evaluated the clinical relevance of selected immunohistochemical features of tumors in three cohorts of patients with typical medullary (MC), 'atypical' medullary (AMC) or ductal (DC) breast carcinoma.

PATIENTS AND METHODS

Evaluation was performed on node-negative tumor specimens from 40 patients who had either MC (12 patients), AMC (nine patients) or DC (19 patients), treated in a single institution. All had no hormonal receptor, Ki-67 > or =30%, G3, expansive pattern of growth and peritumoral lymphocytic infiltration. In addition, p27, p21 and HER2/neu overexpression, p53, cyclin E and E-cadherin expression, presence of apoptotic cells, stromal tenascin (TN), and type of immune cell infiltration (CD3- and CD68-positive cells) were assessed.

RESULTS

No difference in expression of HER2/neu, p21, p27, p53, number of apoptotic cells and CD68-positive cells was detected. Lower levels of stromal TN expression were found in MC compared with DC (P=0.0007), but differences between MC and AMC were not significant (P=0.27). A higher proportion of intratumoral CD3-positive cells was seen in MC than in AMC (P=0.046). No differences were seen between MC and DC (P=0.73). With a median follow-up of 67 months, three patients with DC had relapsed in distant sites, while one patient with AMC had a second primary. Two patients with MC had reappearance of DC in the breast.

CONCLUSIONS

The three distinct disease types, selected by having similar high proliferation, had similar expression of cell cycle regulators. The lower expression of TN and massive infiltration of T lymphocytes might both indicate a special interaction between tumor cells and microenvironment, important features for conferring improved prognosis through negligible invasive and metastatic potential to MC. In our series, however, patients with a previous MC are not free from the risk of developing a subsequent DC. Finally, defining AMC as a distinct entity from DC is not justified.

Hyperfractionated radiotherapy in locally advanced nasopharyngeal cancer. An analysis of 43 consecutive patients

BACKGROUND

Despite numerous randomized trials suggesting a benefit of unconventional fractionation in locally advanced head and neck cancer, the role of this approach in nasopharyngeal carcinoma is debatable. Based on the current clinical experience, the authors introduced hyperfractionated irradiation in the treatment of locally advanced head and neck cancer, including nasopharyngeal tumors. The preliminary results of this treatment approach in nasopharyngeal cancer patients are presented, with special focus on the pattern of failure and toxicity.

PATIENTS AND METHODS

43 patients with nasopharyngeal cancer (stage II-IV, TNM 1997) underwent hyperfractionated irradiation. In 34 cases, radiotherapy was preceded by a median of three cycles of cisplatin-based induction chemotherapy. Irradiation was delivered using a shrinking-field technique up to a total dose of 74.4 Gy in 62 fractions of 1.2 Gy twice daily (minimum 6-h interval)/5 days/week.

RESULTS

Acute toxicity of hyperfractionated radiotherapy was significant but tolerable. Mucositis proved the most common side effect (grade 3: 24 patients, grade 4: three patients). Severe late toxicity was not observed. 30 of 34 patients (88%) responded to induction chemotherapy. At 6 weeks after completion of radiotherapy, complete response was seen in 35 patients (81%), partial response in five (12%), stable disease in one, and progressive disease in two. After a median follow-up of 32 months, 18 patients (41%) developed progressive disease. Primary tumor progression was observed in three patients, and seven patients each showed regional lymph node progression and distant metastases. In one case both regional lymph node progression and distant metastases were diagnosed. The 2-year progression-free survival and overall survival rates were 58% and 84%, respectively.

CONCLUSION

Hyperfractionated radiotherapy seems a feasible and active regimen in locally advanced nasopharyngeal carcinoma. Accompanying acute and late toxicity is acceptable and does not compromise delivery of the planned irradiation dose. This regimen is associated with a high local control rate; relatively high nodal and distant failure, however, call for further treatment modifications, e. g., optimization of irradiation technique and/or dose escalation as well as improved systemic therapies.

Diagnosis and management of neck metastases from an unknown primary

Neck lymph node metastases from occult primary constitute about 5%-10% of all patients with carcinoma of unknown primary site. Metastases in the upper and middle neck (levels I-II-III-V) are generally attributed to head and neck cancers, whereas the lower neck (level IV) involvement is often associated with primaries below the clavicles. Diagnostic procedures include a careful clinical evaluation and a fiberoptic endoscopic examination of the head and neck mucosa, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computerized tomography scan, and magnetic resonance. The most frequent histological finding is Squamous Cell Carcinoma, particularly when the upper neck is involved. In these cases, a systematic tonsillectomy in the absence of suspicious lesions is discussed since up to 25% of primary tumours can be detected in this site. Thoracic, and abdominal primaries (especially from lung, oesophagus, stomach, ovary or pancreas) should be sought in the case of adenocarcinoma and involvement of the lower neck. Positron emission tomography with fluoro-2-deoxy-D-glucose allows detection of primary tumour in about 25% of cases, but this procedure is still considered investigational. Therapeutic approaches include surgery (neck dissection), with or without post-operative radiotherapy, radiotherapy alone and radiotherapy followed by surgery as reported by several guide-lines. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) require combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighed against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined.

Midazolam for acute emesis refractory to dexamethasone and granisetron after highly emetogenic chemotherapy: a phase II study

GOALS OF THE WORK

To assess whether the addition of midazolam to dexamethasone and granisetron could ameliorate the refractory acute nausea and/or vomiting caused by a highly emetogenic platinum-based chemotherapy.

PATIENTS AND METHODS

Enrolled in the study were 30 consecutive adult patients with refractory acute emesis. Nausea and vomiting were assessed by physicians and graded according to the NCI common toxicity criteria. Nausea was further self-assessed by patients using a visual analogue scale. Statistical analysis was performed by nonparametric tests.

RESULTS

With the introduction of midazolam, 73% of patients had a reduction of at least one grade in nausea and vomiting intensity in comparison with the previous cycle of chemotherapy. From the second cycle, six patients (23%) had complete control of acute vomiting, a benefit that usually persisted in the subsequent cycles. Five more patients achieved complete control of acute vomiting during the third course; this effect persisted in the subsequent courses as well. The average relative reduction in acute nausea and vomiting grade from the first to the second course was 48% (95% CI 34-62%) and 48% (95% CI 31-65%), respectively. A significant difference in acute nausea and vomiting over all the six courses of chemotherapy administered was recorded (Friedman ANOVA, P <0.0001). Comparing each course with any subsequent course, a significant reduction in acute nausea and vomiting was observed between the first and second course, the first and third course, and the first and fourth course.

CONCLUSIONS

Our results suggest that midazolam may be a useful adjunct to standard antiemetic drugs for patients receiving highly emetogenic cisplatin-based chemotherapy. A randomized trial is warranted to confirm these results.