Phase II feasibility of concurrent docetaxel and post mastectomy radiation after four cycles of AC chemotherapy in patients with high risk operable breast cancer: A trial of the Cancer Research Group Pakistan

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Background: Sequential use of docetaxel after four cycles of AC chemotherapy delays the postoperative radiation and can compromise loco-regional control. This delay can be avoided by starting radiotherapy concurrent with the docetaxel. We evaluated the feasibility of concurrent docetaxel and radiation therapy to chest wall and peripheral lymphatics after four cycles of AC chemotherapy. The preliminary results were reported in ASCO 2005 (Abstract 858). Methods: Females between 18–50 years, T2-T3 lesions, four or more positive nodes and hormone receptor negative tumors were eligible. Patients were enrolled after MRM. Four cycles of AC at 60/600 mg/m2 were followed by four cycles of docetaxel at 75mg/m2 every 21-days. Concurrent radiation to chest wall and peripheral lymphatics was started with the third cycle of docetaxel. A dose of 50 Gy in 5 weeks or equivalent was delivered. Successful completion of treatment in 18 out of 20 or 25 out of 30 patients was chosen as an index of feasibility. CTC version 2.0 of NCI and RTOG/EORTC Late Radiation Morbidity Scoring Scheme was used. Results: All the 30 enrolled patients successfully completed the planned treatment. Radiation was completed within 6 months of surgery in 27(90%) of the patients. Febrile neutropenia was seen in 5(16.7%). Grade-3 neutropenia and diarrhea in 8(26.7%) and 6(20%) respectively. Grade-3 dermatitis in the radiated area was seen in 2(6.7%) and grade-2 in 5(16.7%). Late toxicity included grade-2 skin atrophy and telangiectasia in radiated area in 6(20%) each. At a median follow up of 20 months (range 9–25 months) two local recurrences and two systemic relapses have been seen. Conclusion: This treatment schedule is feasible and safe in patients with high-risk operable breast cancer. It allows delivery of post mastectomy radiation within 6 months of surgery in patients undergoing sequential AC-docetaxel chemotherapy.

No significant financial relationships to disclose.

Determination of alpha-1 antitrypsin genetic deficiency in duodenal ulcer by polymerase chain reaction

OBJECTIVE

To confirm alpha-1-AT deficiency status in duodenal ulcer using a combination of PCR and restricted enzyme digestion.

METHODS

Fifty patients with endoscopically proven duodenal ulcer and hundred controls with no signs of the disease were included. Alpha-1-AT phenotypes were confirmed by polymerase chain reaction followed by restriction enzyme digestion.

RESULTS

Alpha-1-AT concentration in duodenal ulcer patients showed a mean value of 2.12 +/- 0.11 g/l (range: 0.52-3.95 g/l, p < 0.05). In controls this was 2.47 +/- 0.08 g/l (range: 0.52-5.0 g/l). Among the controls 70% had the MM phenotype, 28% M1 M2 and 2% FM. In duodenal ulcer, MM predominates (70%), followed by M1 M2 (18%), SS (4%), SZ (4%), ZZ (2%) and MZ (2%).

CONCLUSION

Alpha-1 AT deficiency was found in 10% of duodenal ulcer patients. DNA analysis more accurately resolved the phenotypes as S and Z mutations.

Phenotypes of alpha 1 antitrypsin in Karachi, Pakistan

OBJECTIVE

To determine serum level of the protease inhibitor, to identify phenotypes and determine their frequencies.

STUDY DESIGN

A prospective study.

SETTING

PMRC, Research Centre, JPMC and the Aga Khan University Hospital, Karachi.

SUBJECTS

Healthy adults without history of peptic ulcer disease and a normal endoscopy.

METHODOLOGY

Quantitative measurement of serum alpha 1 AT was carried out by radial immunodiffusion, phenotyping by iso-electric focusing and confirmation of phenotypes by immuno-fixation and DNA analysis technique.

RESULTS

Serum alpha 1 AT was low in 13.4% of the subjects. MM phenotype predominated followed by SZ, SS,MZ and ZZ. DNA diagnosis accurately resolved the phenotypes as S and Z.

CONCLUSION

Frequency of phenotype associated with total and intermediate deficiency is less in the population.

Exposer rate of hepatitis E (IgG) in a selected population of children and adults in Karachi

AIMS

To see exposure rate of hepatitis E (IgG) in 100 apparently healthy children and adults.

SUBJECTS AND METHODS

Sera from 100 healthy children aged 1 day to 10 years and 100 healthy adults aged 18-45 years were analysed for exposure to hepatitis E (IgG) using ELISA.

RESULTS

Two samples from children were excluded from the study due to improper storage leaving 98 samples for analysis. Of 98 sera from children 19.4% were positive for IgG indicating previous exposure to hepatitis E. The exposure rate increased with age and was 10% in children below 1 year of age, 14% at 2 years, 19% at 3 years and 28% at 10 years. In adults overall exposure was 16%. There was no predominance of either sex in both the groups and all individuals belonged to middle to lower socioeconomic strata.

CONCLUSION

An exposure of 19% in children and 16% in adults indicates high faecal contamination of drinking water and re-addressing of the issue of use of boiled water on individual level, supply of potable water on the government level and a need to produce a vaccine on international level.

Genetic markers and duodenal ulcer

Serum pepsinogen, alpha 1-antitrypsin (alpha 1-AT) and blood groups were studied as genetic markers in 32 patients with endoscopically proven duodenal ulcer and 44 control subjects with no family history of ulcer disease. Serum pepsinogen was determined by the modified method of Edward et al, alpha 1-AT by single radial immunodiffusion (RID) and phenotyping was carried out by isoelectric focusing (IEF). Duodenal ulcer patients with hyper- pepsinogenemia (28%) and low serum alpha 1-AT (35%) had a dominant blood group O, lower mean age, an early onset of disease, a higher frequency of gastrointestinal (GI) bleeding and ulcer perforation. These parameters were found considerably different in patients with normal serum pepsinogen and alpha 1-AT. Phenotype analysis of alpha 1-AT revealed that four duodenal ulcer patients had partial deficiency of the protease inhibitor and none of the normal exhibited the deficiency pattern. The etiology of the disease appears to be genetic anomaly in 28% of patients while the rest (72%) had ulcers as a result of neuroendocrinological or environmental factors.

Serum alpha 1 antitrypsin and pulmonary emphysema

Using isoelectric focusing (IEF) and radial immunodiffusion (RID) techniques, serum samples from 100 normal healthy adults and 21 patients with pulmonary emphysema were analysed to identify various alpha 1 antitrypsin phenotypes and the serum concentrations. Ten percent of the patients had low serum values. The normal or most common genetic form, MM, is the predominant phenotype in both controls and patients.

Genetic variants of serum alpha 1 antitrypsin

Complete absence of data on alpha 1 antitrypsin in this country prompted us to determine serum levels using radial immunodiffusion (RID) and phenotypes by isoelectric focusing (IEF) in 100 healthy adults (52 males and 48 females). Mean serum alpha 1 antitrypsin concentration in healthy subjects was 2.47 +/- 0.08 g/l and the main phenotypes MM (70%), M1 M2 (28%) and FM 3 (2%) are infrequent in our population.

Serum alpha 1-antitrypsin and duodenal ulcer

Evaluation of serum alpha 1-antitrypsin levels in the South Asian population and its possible involvement in disease conditions such as duodenal ulcer has not been given due consideration. This is mainly because reports from European and North American countries indicate that the genetic deficiency of this protease inhibitor is rare among Asians of the subcontinent. Using isoelectric focusing (IEF) and radial immunodiffusion (RID) techniques, we analysed serum samples from 100 normal, healthy adults and 50 patients with endoscopically proven duodenal ulcers to determine if there is a possible relationship between alpha 1-antitrypsin phenotype and this disease. Five duodenal ulcer patients had low alpha 1-antitrypsin levels as well as SZ and S phenotype. None of the controls showed presence of S or SZ phenotypes. The normal or most common genetic form, MM, is the predominant phenotype in both controls and patients.