Purification and characterisation of an acid phosphatase with phytase activity from Mucor hiemalis Wehmer

An acid phosphatase with phytase activity, produced by Mucor hiemalis Wehmer, was purified to homogeneity by a combination of anion exchange, gel filtration and hydrophobic interaction chromatography. The monomeric, glycosylated enzyme displayed maximum activity at 55 degrees C and pH 5.0-5.5. When compared to commercialised products, the enzyme is more thermostable (80 degrees C, 5min), displays a broader pH versus activity profile and greater stability under simulated digestive tract conditions. Unlike commercial phytases, the Mucor enzyme should retain some activity in the small intestine as well as in the stomach, facilitating a longer duration of action and hence more extensive substrate hydrolysis. Substrate specificity studies and protein database similarity searching using mass spectrometry-derived sequence data indicate that the enzyme is an acid phosphatase with activity on phytate. Cocktails containing acid phosphatases in combination with true phytases have been shown to promote more extensive phytate degradation than do true phytases alone. This, coupled to the enzyme's functionally relevant physicochemical characteristics, suggests its likely suitability for inclusion in second generation phytase cocktails for application in animal feed.

Production, purification and application-relevant characterisation of an endo-1,3(4)-β-glucanase from Rhizomucor miehei

Growth on a wheat bran media induced production of an extracellular beta-glucanase by Rhizomucor miehei (DSM 1330). The enzyme was purified to homogeneity. Substrate specificity studies coupled with protein database similarity searching using mass spectrometry-derived sequence data indicate it to be an endo-1,3(4)-beta-glucanase (EC 3.2.1.6). The enzyme was characterised in terms of potential suitability for use in animal (poultry) feed. Significant activity was observed over the entire pH range typical of the avian upper digestive tract (pH 2.6-6.5). The enzyme was also found to be more thermostable than current commercialized beta-glucanases, particularly when heated at a high enzyme concentration, and retained twice as much residual activity as the latter upon exposure to simulated avian digestive tract conditions. There are no previous reports of the production, purification or characterization of a beta-glucanase from a Rhizomucor, and the enzyme's application-relevant physicochemical characteristics render it potentially suited for use in animal feed.

Purification and properties of a β-galactosidase with potential application as a digestive supplement

Functional-based screening of crude beta-galactosidase activities from 42 yeast strains resulted in the selection of a single enzyme of potential interest as a digestive supplement. beta-Galactosidase produced by Kluyveromyces marxianus DSM5418 was purified to homogeneity by a combination of gel filtration, ion-exchange, and hydroxylapatite chromatographies. The denatured (123 kDa) and native molecular masses (251 kDa) suggest that the enzyme is a homodimer. The optimum pH and temperature of the purified enzyme were 6.8 and 37 degrees C, respectively. The unpurified beta-galactosidase in particular displayed a high level of stability when exposed to simulated intestinal conditions in vitro for 4 h. Matrix-assisted laser desorption ionization mass sectrometry analysis revealed that the enzyme's trypsin-generated peptide mass fingerprint shares several peptide fragment hits with beta-galactosidases from Kluyveromyces lactis. This confirms the enzyme's identity and indicates that significant sequence homology exists between these enzymes.

Clinical efficacy of capecitabine as first-line chemotherapy in metastatic breast cancer--how low can you go?

Sixty-three patients received capecitabine at 1000 mg/m2 twice daily every 2 out of 3 weeks as first-line treatment for advanced disease at our institution. Forty-five patients (71%) had previously received adjuvant or neoadjuvant chemotherapy. The median number of capecitabine cycles administered was 5(1-40). Forty-eight patients had measurable disease with response rate (RR) of 29%. The median time to progression (TTP) was 18(2-122) weeks. Seven patients (11%) had TTP of >1 yr, four of whom received more than 10(24-40) cycles of capecitabine. Thirty-seven percent of patients still needed dose reductions. Our retrospective audit is consistent with a previously published study which used a higher starting dose of capecitabine as first-line chemotherapy. For a subgroup of patients, capecitabine can result in a long TTP with minimal toxicity. The benefit of continuing capecitabine beyond a fixed number of cycles should be investigated further. Schedules using even lower doses of capecitabine for longer periods may also be of interest.

Treatment outcomes of patients (pts) with primary mediastinal germ cell tumors (PMGCT): The M. D. Anderson Cancer Center (MDACC) experience

14538

Background: PMGCT are uncommon germ cell malignancies. Mediastinal nonseminomatous germ cell tumors (NSGCT) have a poor prognosis, whereas pure seminoma (Sem) has a good or intermediate prognosis irrespective of mediastinal presentation. Methods: We retrospectively identified 19 male pts with PMGCT seen at MDACC between October 1998 and September 2004 from a clinical database. Pts with resectable NSGCT were offered surgery upon plateau of their chemotherapy response. Prior to referral, 1 pt had primary surgical resection without preoperative (preop) chemotherapy. Results: There were 14 pts with NSGCT and 5 with good prognosis Sem. The median age was 29.5 (20–60). Seven pts with NSGCT had mixed or undifferentiated histology, and the remainder had pure yolk sac (5 pts) or choriocarcinoma (2 pts). The estimated median survival (Kaplan-Meier) for all patients (Sem + NSGCT) was 21 months. All pts with Sem were alive and disease-free at last follow-up (median 12 months, range 7–34). All pts with Sem received 4 courses of etoposide and cisplatin (EP); one also received bleomycin (BEP); one received radiotherapy consolidation; none received surgery. Of the pts with NSGCT, 9 (64%) have died, including 1 who refused surgery. Five pts with NSGCT were alive at last follow-up and 3 (21%) were disease-free (15+, 27+ and 35+ months). Four pts with NSGCT (29%) reached beyond 2 years survival (27+, 28, 35+, and 63+ months) including 3 with lung metastases and one with elevated preop alpha-fetoprotein (28,022 ng/ml). Each of these pts received 6–10 courses of multiple-regimen preop chemotherapy, and 2 received initially 4 courses of BEP without marker normalization. Conclusions: Mediastinal Sem treated with 4 courses EP had an excellent outcome without surgery. Pts with mediastinal NSGCT had a 64% mortality rate despite aggressive treatment. Several pts with mediastinal NSGCT did achieve long-term survival following aggressive chemotherapy and surgery, even with lung metastases and failure to normalize markers. A phase III trial of BEP versus dose-dense chemotherapy for poor-prognosis NSGCT is now in progress at MDACC.

No significant financial relationships to disclose.

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

657

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.

Clinical efficacy of capecitabine as first-line chemotherapy in metastatic breast cancer

10727

Background: Capecitabine is commonly used in metastatic breast cancer (MBC), but there are limited data on its efficacy in the first-line setting. The clinical efficacy of capecitabine monotherapy was evaluated in our institution. Methods: Patients who received capecitabine monotherapy (starting dose 1 g/m2 twice daily every 2 out of 3 weeks) between April 2001 and April 2005 as first-line treatment for advanced disease were retrospectively identified from our prospectively maintained database. Endpoints included response rate (RR), response duration, time to progression (TTP) and overall survival (OS). Results: 63 patients were evaluated. The median age was 57 (30–79) years. The sites of disease were soft tissue and/or bone only in 24 (38%) patients, and involved visceral sites in 39 (62%) patients. 45 (71%) patients had previously received adjuvant or neoadjuvant chemotherapy. The median number of cycles administered was 5 (1–40). 48 (76%) had measurable disease with a RR of 29% (14/48). Chemotherapy-naive patients with measurable disease had a RR of 33% (5/15), while patients previously exposed to neoadjuvant or adjuvant chemotherapy had a RR of 27% (9/33). The median response duration was 24(9–68) weeks. The median TTP was 18 (range 2–122) weeks. However 12(19%) had a TTP of 9 months or more, including 7 (11%) with a TTP of >1 year (14–28 months). Of these, 6/7 were oestrogen receptor +ve and 5/7 had bone and/or soft tissue disease only. 21 (33%) patients developed disease progression on treatment, and response was not evaluable in 4 (6%) patients who stopped capecitabine after 2 or fewer cycles due to medical co-morbidities. Conclusions: These audit results on first line capecitabine monotherapy in MBC are consistent with a previously published study(1). The overall RR may be less than for anthracyclines and taxanes (generally 30–50%) in this setting, but for a subgroup of patients with predominantly soft tissue/bone disease capecitabine can result in prolonged TTP with minimal toxicity. This should be evaluated further in a randomized clinical trial. References 1. O’Shaughnessey JA et al. Ann Oncol 2001 Sept; 12 (9): 1247–54.

[Table: see text]

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.

Physicochemical Characteristics of Commercial Lactases Relevant to Their Application in the Alleviation of Lactose Intolerance

Selected microbial lactases are used to treat lactose intolerance. A series of experiments were carried out in vitro in order to determine the likely relative suitability of four major commercial lactase products used in this regard. The lactases displayed between 55 and 61% of maximum activity at 37 degrees C and significant activity between pH 3.0 and 6.5. They retained between 0 and 65% of original activities after exposure to full simulated digestive tract conditions for 6 h. All four enzymes proved to be particularly acid sensitive and only two products were enteric coated. The products demonstrated varying ability to hydrolyze lactose under simulated digestive tract conditions. The most effective product hydrolyzed 2.7 g lactose per capsule, suggesting that consumption of several capsules, as opposed to the usually recommended one or two, would be required to hydrolyze the entire 12 g lactose load characteristic of a dairy-based meal. All enzymes were substantially pure and displayed similar kinetic properties and molecular weights. None appeared ideally suited for use in the alleviation of lactose intolerance. The findings may in part explain the variability and often disappointing results previously reported for lactase-based clinical trials and will provide comparative baseline data against which candidate second-generation lactases may be assessed.

Comparison of selected physicochemical characteristics of commercial phytases relevant to their application in phosphate pollution abatement

The enzyme phytase catalyses the dephosphorylation of phytic acid and it's salts, phytates. Supplementation of monogastric animal feed with microbial-derived phytase increases the bioavailability of phytic acid bound phosphate. This facilitates a reduction in the addition of inorganic phosphate to the feed and reduces phosphorus excretion. To achieve maximum efficacy in terms of phosphate pollution abatement, supplemental phytases added to animal feed must survive thermal processing of the feed, resist inactivation by the proteolytic enzymes encountered in the animal's digestive tract and display high activity at physiological temperature and pH. A series of in vitro experiments were carried out to determine the relative suitability of four major commercial phytase products for use in animal feed. The enzymes assessed lost between 14% and 72% of their original activities after heating to 80 degrees C for 5 minutes. After exposure to simulated upper digestive tract conditions, the phytases assessed retained between 0 and 28% of their original activities. The commercial phytases displayed between 98% and 67% of their maximum activities at 39 degrees C and all phytases assessed had an optimum pH between pH 4 and pH 5. None of the phytases assessed satisfied all of the criteria of an ideal phytase for use in animal feed.

Mitomycin C, vinblastine and cisplatin (MVP): an active and well-tolerated salvage regimen for advanced breast cancer

This phase II study assessed the clinical efficacy and tolerability of a combination of mitomycin C, vinblastine and cisplatin in patients with metastatic breast cancer (MBC) previously treated with chemotherapy. A total of 87 patients with MBC, most of whom had been exposed to anthracyclines (92%) and/or taxanes (29%) in the adjuvant and/or metastatic setting, were treated with mitomycin C (8 mg m⁻² day 1 cycles 1, 2, 4 and 6), vinblastine (6 mg m⁻² day 1) and cisplatin (50 mg m⁻² day 1) repeated each 21 days for a maximum of six cycles. The overall response rate (ORR) was 32% (95% CI: 22–42%) with 31% partial response (PR) and one complete response (CR). Stable disease (SD) rate was 21% (95% CI: 12–29%). There was no statistically significant difference in the ORR when MVP was given as the first-line treatment for MBC vs second or subsequent line (38 vs 30%, P=0.6), or between patients with an early (<6 months) vs late (>6 months) relapse post-anthracyclines (30 vs 52%, P=0.3). Toxicity profile was mild. This platinum-based chemotherapy is an effective, well-tolerated and low-cost regimen for patients with MBC, including those pretreated with anthracyclines.

Hypodermoclysis

The hypodermoclysis technique of subcutaneous infusion has many benefits for long-term care patients and staff. Minor complications associated with the procedure are easily remedied, and studies have proved its effectiveness. Hypodermoclysis provides an easy-to-use, safe, and cost-effective alternative to intravenous hydration for the elderly long-term care patient.

Quantification of supplemental enzymes in animal feedingstuffs by radial enzyme diffusion

Methods are described which facilitate quantification of supplemental cellulase, protease and alpha-amylase when added to animal feedingstuffs at normal industrial inclusion levels. The methods entail extraction of the enzymes from the feedingstuffs by agitation in buffer followed by quantification of extract activity using radial diffusion techniques. A linear relationship between the diameter of the zone of hydrolyzed substrate and the log of the enzyme activity applied is observed over a broad activity range. Assay of a feedingstuff supplemented with 1 kg t(-1) cellulase, protease and alpha-amylase yielded net supplemental activity recoveries of 104+/-11.7%, 91.3+/-6.74% and 126+/-29.5%, respectively. A similar assay method did not prove sufficiently sensitive to facilitate detection of xylanase at typical in-feed inclusion levels. The levels of endogenous cellulase, protease and alpha-amylase activity detected in the unsupplemented feedingstuffs were equivalent to 6.4+/-0.47%, 6.6+/-0.82% and 29.0+/-14.1%, respectively, of a 1 kg t(-1) supplement. The methods are technically straightforward and will facilitate determination of enzyme stabilities during processes such as high-temperature pelleting of feedingstuffs, as well as allowing more rigorous quality control related to enzyme-supplemented animal feedingstuffs.

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.

Postoperative radiotherapy increases locoregional control of patients with stage IIIA non-small-cell lung cancer treated with induction chemotherapy followed by surgery

PURPOSE

To determine the effectiveness of postoperative radiotherapy (RT) in patients with Stage IIB and Stage IIIA non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgery.

METHODS AND MATERIALS

We retrospectively reviewed the treatment records of 98 patients (58 men and 40 women; median age 61 years, range 31-91) with Stage IIB and Stage IIIA NSCLC who were treated with induction chemotherapy followed by surgery at our institution between January 1990 and December 2000. Patients were grouped by treatment (chemotherapy/surgery alone vs. chemotherapy/surgery/RT), by disease stage and nodal classification. The rates of local control (LC), disease-specific survival, disease-free survival, and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS

Of the 98 patients, 40 had Stage IIB and 58 had Stage IIIA. The clinical disease stage and N stage were significantly greater in those patients who underwent RT than in those who did not; however, no statistically significant differences were identified in the additional characteristics between those receiving and not receiving RT within each stage or nodal group. The overall 5-year actuarial LC rate was 81% in the RT group and 54% in the chemotherapy/surgery-alone group (p = 0.07). Postoperative RT significantly improved the 5-year LC rate in patients with Stage IIIA disease (from 35% to 82%, p = 0.01). Postoperative RT did not significantly improve the 5-year OS rate (30% with RT vs. 49% without) for all patients or for patients with Stage IIIA disease. The disease-specific survival and disease-free survival rates did not differ between the treatment groups. Patients who responded to induction chemotherapy had a significantly greater 5-year OS rate (49%) than did those with stable or progressive disease (22%, p = 0.003).

CONCLUSION

Postoperative RT in patients with Stage IIIA NSCLC treated with induction chemotherapy followed by surgery significantly improved LC without improving OS. Significantly improved survival was observed in all patients who responded to induction chemotherapy compared with those with stable or progressive disease.

A collaborative evidence-based approach to making healthcare a healthier place to work

It is increasingly well documented that a collaborative problem-solving approach is more effective in addressing workplace health concerns than an adversarial approach. Combining this with strategies based on good evidence is key to success. On this premise, a trial was conducted in British Columbia, beginning in July 1999, based on a collaborative approach in which healthcare workers and managers work together to identify and implement evidence-based initiatives to improve the health and working conditions of healthcare workers.

A randomised phase II study of conventional versus accelerated infusional chemotherapy with granulocyte colony-stimulating factor support in advanced breast cancer

BACKGROUND

Granulocyte colony-stimulating factor (G-CSF) allows cycles of conventional bolus chemotherapy to be accelerated with reduction in treatment time and a boost in dose intensity. Theoretically, this approach could be hazardous with infusional 5-fluorouracil (5-FU) chemotherapy, since G-CSF-stimulated neutrophil proliferation would be occurring in the face of continuous S-phase active 5-FU. We performed this phase II randomised study to compare the safety, tolerability and efficacy of conventional 3-weekly epirubicin, cyclophosphamide and continuous infusional 5-FU (infusional ECF) to an accelerated 2-weekly schedule with G-CSF support, in patients with advanced breast cancer.

PATIENTS AND METHODS

Twenty-seven patients were randomised. with 14 in the accelerated arm. Patients received bolus epirubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 every 3 weeks (conventional arm) or every 2 weeks (accelerated arm) and 5-FU 200 mg/m2/day continuous infusion throughout. G-CSF 300 microg/day s.c. on days 10-12 was given each accelerated cycle.

RESULTS

There were no treatment delays secondary to inadequate neutrophil or platelet recovery in either arm, with higher median day 1 neutrophil counts for each cycle in the accelerated arm compared with the conventional arm. Eighty-six per cent of the planned conventional chemotherapy cycles and 82% of the planned accelerated cycles were given. There were no major differences in toxicity between the arms, with the most common grade 3 toxicities being alopecia and stomatitis. Eight patients developed neutropenic sepsis (five in the accelerated arm and three in the conventional arm). Ten patients (77%) responded in the conventional arm and nine (64%) in the accelerated arm.

CONCLUSIONS

Accelerated infusional ECF with limited G-CSF support is a feasible and well-tolerated regimen with rapid haematological recovery. A 50% increase in relative dose intensity of epirubicin and cyclophosphamide is achieved, while overall treatment time is reduced by 33%.

Free surface nickel in CE-marked and non-CE-marked spectacle frames

Three hundred and ninety-five new frames were tested for evidence of nickel release using dimethylglyoxime and ammonia. For areas of CE-marked frames in direct contact with the skin a considerable improvement was found over the previous such survey by the authors, carried out before the widespread introduction of CE marking. However, free nickel was found in 6.5% of CE-marked metal frames (excluding titanium and titanium alloy) in such areas and a majority of half joints. Some titanium alloy frames also tested positive for nickel in areas in contact with the skin.

The incidence of breast cancer from screening women according to predicted family history risk: Does annual clinical examination add to mammography?

In breast cancer, mutations of predisposition genes such as BRCA-1/2 and other genes as yet uncharacterised are manifest in up to 10% of cases. Although the prior probability of the presence of a breast cancer predisposing gene can be calculated for individual women, there is no published evidence to justify predicted risk as a selection criteria for screening. This study aims to define which patient groups with a significant family history should be screened, and whether clinical examination is necessary in addition to mammography. The Claus model was used to predict breast cancer risk in women with a family history. Women were divided into two groups according to their predicted risk: group I consisted of women at standard risk (lifetime risk less than 1:6) and group II with moderate/high risk (lifetime risk greater than or equal to 1:6). Women were cancer-free at the point of entry, and screening consisted of annual clinical examination and mammography from the age of 35 years. This study consisted of 1500 women in group I and 1078 in group II. The period of observation was 5902.0 and 4327.8 women years, respectively. A total of 31 cancers were detected, 12 in group I and 19 in group II. The median age at diagnosis in group II was 45 years (range 26-66 years) compared with 54.5 years (range 38-63 years) in group I (P=0.03). The relative risk of developing breast cancer in group II was 2.6 (95% confidence interval (CI) 1.2-5.8). When compared with breast cancer incidence in the normal population, the standardised incidence ratio in group II was significantly higher at 2.8 (95% CI: 1.7-4.2). The standardised incidence ratio of women in group I was similar to that of the general population (1.1 (95% CI: 0.6-1.8)). A total of 26/31 (84%) cancers detected were palpable, of which 14 (54%) were not visible on mammography. Approximately one-third of all palpable cancers were detected at routine follow-up. Mammography correctly identified 17/31 cancers (55%), but 29% of these were not palpable. Family history screening programmes are effective and women should be selected for screening according to predicted risk. The younger age of diagnosis in group II justifies screening from an earlier age using both annual clinical examination and mammography.

A three-step strategy of induction chemotherapy then chemoradiation followed by surgery in patients with potentially resectable carcinoma of the esophagus or gastroesophageal junction

BACKGROUND

Patients with locoregional carcinoma of the esophagus or gastroesophageal junction have a poor survival rate after surgery. Preoperative chemotherapy or chemoradiotherapy has not improved the outcome for these patients. Our study was designed to assess the feasibility of preoperative induction combination chemotherapy in addition to chemoradiotherapy to improve the curative resection rate, local control, and survival. PATIENTS AND METHODS Patients having histologic proof of localized carcinoma (either squamous cell carcinoma or adenocarcinoma) of the esophagus or gastroesophageal junction underwent full classification including endoscopic ultrasonography (EUS). Patients first received up to two courses of induction chemotherapy consisting of 5-fluorouracil at 750 mg/m(2)/day as continuous infusion on Days 1--5, cisplatin at 15 mg/m(2)/day as an intravenous bolus on Days 1--5, and paclitaxel at 200 mg/m(2) as a 24-hour intravenous infusion on Day 1. The second course was repeated on Day 29. This was followed by radiotherapy (45 grays in 25 fractions) and concurrent admission of 5-fluorouracil (300 mg/m(2)/day as a continuous infusion 5 days/week) and cisplatin (20 mg/m(2) on Days 1--5 of radiotherapy). After chemoradiotherapy, patients underwent surgery. The feasibility of this approach, curative resection rates, patient survival, and patterns of failure were assessed.

RESULTS

Thirty-seven of 38 patients enrolled were evaluable for toxicity and survival. Adenocarcinoma and distal esophageal location of carcinoma were observed frequently. Thirty-five (95%) of the 37 patients underwent surgery, all of whom had an R0 (curative) resection. A pathologic complete response was noted in 11 (30%) of the 37 total patients. In addition, 5 patients (14%) had only microscopic carcinoma. According to EUS classification, 31 (89%) of the 35 patients who underwent surgery had a T3 carcinoma whereas according to pathologic classification only 3 (9%) had a T3 carcinoma (P </= 0.01). Similarly, according to EUS classification, 23 patients (66%) had an N1 carcinoma, whereas according to pathologic classification only 7 patients (20%) had an N1 carcinoma (P < or = 0.01). At a median follow-up of 20 months (minimum follow-up, 13+ months; maximum follow-up, 36+ months), the median survival duration for the 37 patients had not yet been reached. In addition, there were two deaths related to surgery.

CONCLUSIONS

These data show that the three-step strategy of preoperative paclitaxel-based induction chemotherapy then chemoradiotherapy followed by surgery is feasible and appears quite active in patients having locoregional carcinoma of the esophagus or gastroesophageal junction. Future investigations should focus on substituting cisplatin with less toxic agents and including more systemic therapy with newer classes of agents.