Unusual foreign bodies in ear, nose and throat practice

Ear, Nose and Throat practice presents the surgeons with an amazing variety of foreign bodies to deal with, some of them truly unusual. Presented here are two cases with foreign bodies unusual in nature, extracted by improvisation.

Progression-free survival as a primary endpoint in clinical trials of metastatic colorectal cancer

In recent years, significant advances have been made in the management of metastatic colorectal cancer. Traditionally, an improvement in overall survival has been considered the "gold standard"-the most convincing measure of efficacy. However, overall survival requires larger patient numbers and longer follow-up and may often be confounded by other factors, including subsequent therapies and crossover. Given the number of active therapies for potential investigation, demand for rapid evaluation and early availability of new therapies is growing. Progression-free survival is regarded as an important measure of treatment benefit and, compared with overall survival, can be evaluated earlier, with fewer patients and no confounding by subsequent lines of therapy. The present paper reviews the advantages, limitations, and relevance of progression-free survival as a primary endpoint in randomized trials of metastatic colorectal cancer.

Progression-Free Survival as a Primary Endpoint in Clinical Trials of Metastatic Colorectal Cancer

In recent years, significant advances have been made in the management of metastatic colorectal cancer. Traditionally, an improvement in overall survival has been considered the “gold standard”—the most convincing measure of efficacy. However, overall survival requires larger patient numbers and longer follow-up and may often be confounded by other factors, including subsequent therapies and crossover. Given the number of active therapies for potential investigation, demand for rapid evaluation and early availability of new therapies is growing. Progression-free survival is regarded as an important measure of treatment benefit and, compared with overall survival, can be evaluated earlier, with fewer patients and no confounding by subsequent lines of therapy. The present paper reviews the advantages, limitations, and relevance of progression-free survival as a primary endpoint in randomized trials of metastatic colorectal cancer.

Safety and efficacy of first-line bevacizumab with FOLFOX, XELOX, FOLFIRI and fluoropyrimidines in metastatic colorectal cancer: the BEAT study

BACKGROUND

Bevacizumab significantly improves survival when added to chemotherapy for metastatic colorectal cancer (mCRC). The Bevacizumab Expanded Access Trial (BEAT) evaluated the safety and efficacy of bevacizumab plus first-line chemotherapy in a general cohort of patients with mCRC.

PATIENTS AND METHODS

Patients with unresectable mCRC received chemotherapy (physician's choice) plus bevacizumab [5 mg/kg every 2 weeks (5-fluorouracil regimens) or 7.5 mg/kg every 3 weeks (capecitabine regimens)]. The primary end point was safety, including prospective data collection in patients receiving unanticipated surgery during the study. Secondary objectives were progression-free survival (PFS) and overall survival (OS).

RESULTS

The final analysis comprised 1914 assessable patients (male 58%; median age 59 years). Chemotherapy included 5-fluorouracil/leucovorin (5-FU/LV) + oxaliplatin (29%), irinotecan plus 5-FU/LV (26%), capecitabine plus oxaliplatin (18%) and monotherapy (16%). Serious/grade 3-5 adverse events of interest for bevacizumab included bleeding (3%), gastrointestinal perforation (2%), arterial thromboembolism (1%), hypertension (5.3%), proteinuria (1%) and wound-healing complications (1%). Sixty-day mortality was 3%. Median PFS was 10.8 months [95% confidence interval (CI) 10.4-11.3 months] and median OS reached 22.7 months (95% CI 21.7-23.8 months).

CONCLUSIONS

The BEAT study shows that the efficacy and safety profile of bevacizumab in routine clinical practice is consistent with results observed in prospective randomised clinical trials and another large observational study in the United States (BRiTE study).

QTL identification and microphenotype characterisation of the developmentally regulated yellow rust resistance in the UK wheat cultivar Guardian

Yellow rust (causal agent: Puccinia striiformis f.sp. tritici) resistance in the UK wheat cultivar Guardian is developmentally regulated, resistance increasing as the plant matures. Yellow rust resistance was assessed under field conditions on plants after ear emergence to ensure maximum expression of resistance. Three quantitative trait loci (QTL) for yellow rust resistance were identified, being located on chromosomes 1B (QPst.jic-1B), 2D (QPst.jic-2D) and 4B (QPst.jic-4B). The largest resistance effect, QPst.jic-1B located to the same position on the long arm of chromosome 1B as the known durable source of yellow rust resistance, Yr29. Microscopic studies were carried out to determine what effect the resistance in Guardian had on the development of P. striiformis f.sp. tritici. While the adult plant resistance in Guardian did not prevent germinated urediniospores from establishing an effective infection site, the growth of hyphae within flag leaf tissue was significantly inhibited, slowing the development of microcolonies. 3,3-diaminabenzadine (DAB) and trypan blue staining indicated that this inhibition of hyphal growth was not associated with hydrogen peroxide accumulation or extensive plant cell death.

Chondrosarcoma of larynx: review of literature and clinical experience

Laryngeal chondrosarcomas are rare, cartilaginous tumours, and around 300 cases have been reported in the literature. They are slow-growing tumours which present difficulties both in diagnosis and treatment. Most patients eventually require radical surgery. However, over the last 10 years, we have diagnosed two cases of laryngeal chondrosarcoma and managed them conservatively by endoscopic debulking and regular follow up. The objective of this article is to highlight the conservative approach in managing these patients, particularly in the presence of co-morbid conditions.

Common variable immunodeficiency syndrome: a difficult diagnostic problem

Objective:

We present a rare case of an adult male with undiagnosed common variable immunodeficiency syndrome who presented to the ENT department with refractory chronic sinusitis and otitis media with effusion.

Method:

Case report and a review of the international literature concerning common variable immunodeficiency syndrome in adults and upper respiratory tract involvement.

Results:

A 37-year-old male presented to the ENT department with refractory chronic sinusitis and otitis media with effusion. The diagnosis of common variable immunodeficiency syndrome was delayed, and difficult, primarily due to minimal symptoms with no lower respiratory tract involvement and negative past or family medical history.

Conclusion:

Early diagnosis helps to prevent morbidity and even mortality. This article highlights how difficult and important it is to make an early diagnosis of common variable immunodeficiency syndrome. Early diagnosis will only be made by increased awareness of this condition.

The use of the internet for medical information and a needs assessment for a web based educational resource: A survey of Canadian medical oncology trainees and training program directors

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Background: Medical Oncology trainees develop their skills and knowledge through formal educational sessions, independent learning and clinical rotations. The internet serves as a source of up to date information and a potential educatinal resource. Despite the existence of many websites with oncology related information, there has not been a comprehensive assessment of how medical oncology trainees and program directors use the internet to meet educational objectivs. Method: In the first phase of developing a new educational website (OncologyEducation.com), we surveyed medical oncology trainees and program directors from training programs across Canada to assess how they accessed the internet to determine the elements they considered essential for a trainee-oriented site. Results: 12 out of 13 Canadian medical oncology training programs participated in our survey. A total of 12 program directors and 23 trainees responsed to our survey for a 74.5% response rate. 71.4% of respondents spend up to 10 hours per week on the internet for work related reasons. Pubmed and UptoDate were the most frequently visited sites. Respondents reported using the internet for email (97.1%), answering clinical questions (88.6%), accessing practice guidelines (80%), and literature updates (71.4%). Respondents expressed a need for an educational website stressing the following content: (1) Key updates by disease sites (2) Access to pivotal journal articles (3) Access to upcoming conferences/information (4) Links to other medical sites/medical oncology sites (5) Fellowship Opportunities. Conclusion: The internet is an important resource for supplementing the training of medical oncology trainees. The development of an educational website based on the needs assessed in this survey is warranted. Upon development of the website it will be evaluated for effectiveness and impact on oncology training and clinical practice.

No significant financial relationships to disclose.

Preliminary efficacy of bevacizumab with first-line FOLFOX, XELOX, FOLFIRI and monotherapy for mCRC: First BEATrial

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Background: In a phase III pivotal trial in patients (pts) with metastatic colorectal cancer (mCRC), BEV (BEV, Avastin®) increased overall survival (OS) by 30% when added to first-line IFL chemotherapy (CT). Recently, a second trial reported a significant improvement in progression free survival (PFS) when BEV was added to FOLFOX/XELOX in a similar patient population. Although, First BEAT was opened to evaluate the safety profile of BEV in a broader pt population using a variety of CT regimens, efficacy endpoints were investigated. Methods: First BEAT enrolled 1,927 mCRC patients in 41 countries between June 2004 and February 2006. Eligible pts were treated with first-line CT (physician’s choice) in combination with BEV (5mg/kg q2w [5-FU-based CT] or 7.5mg/kg q3w [capecitabine [cap, Xeloda®]-based CT]) until disease progression. Secondary endpoints included OS, time to progression (TTP) and PFS. Disease progression was assessed by investigators. Results: By Nov 15th, 2006, 1,914/1,927 pts had data available for analysis (male 58%; median age 59 years, 33% =65 years; ECOG PS 0/1 65%/34%). Median follow-up was 15 months; 60-day mortality was 2.5%. Patients receiving 5-FU/cap CT appeared to have poorer prognosis with respect to age =65 years (41%), ECOG PS 0/1 (58%/42%) and 60-day mortality rate (6.6%), compared with those receiving doublet CT regimens. The most common first-line CT regimens used with BEV were FOLFOX (28%), FOLFIRI (26%), XELOX (18%) and 5-FU or cap CT (16%). Median PFS was 10.4 (95% CI: 10.1–10.9 months, based on 882 events), 10.5 (9.7 - 11.6) in FOLFOX, 10.3 (9.7 - 10.7) in XELOX, 11.1 (10.2–12.0) in FOLFIRI and 9.1 (8.1–10.3) in pts receiving 5-FU or cap CT, respectively. TTP was 10.8 (95% CI: 10.4–11.3 months, based on 805 events). Updated analyses will be presented. Conclusions: In this ongoing, large community-based study, the preliminary efficacy of first line BEV in mCRC pts receiving a variety of CT regimens appears consistent with that observed in large phase III randomised trials.

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Multicenter phase II study of combined neoadjuvant docetaxel and androgen ablation (ADT) prior to radical prostatectomy (RP) for patients (pts) with high risk localized prostate cancer (LCaP): Pathologic outcomes and 3-year follow-up analyses

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Background: Pts with high risk LCaP (cT3, Gleason score > 7 &/or PSA > 20) have an increased risk of relapse with a biochemical failure rate of >50% at 3 years after RP. Docetaxel is active in hormone refractory prostate cancer & potentially beneficial if combined with ADT for treatment naïve disease. The objectives of this trial were to assess the pathologic outcomes & feasibility of docetaxel + ADT in men with LCaP prior to RP. Methods: A phase II multi-center study of newly diagnosed previously untreated pts with clinically LCaP with high-risk features. All pts received ADT (buserelin acetate 6.3 mg q8 weeks x 3 and anti-androgen for 4 weeks) plus docetaxel (35 mg/m2 weekly for 6 out of 8 weeks for 3 cycles) prior to RP. Results: 72 men with a median age of 59 years (range 46–78) were enrolled at 6 sites. Baseline characteristics included: clinical stage T1C, T2 & T3 in 14%, 47% & 39%; and Gleason score <7, 7 & >7 in 10%, 30% & 60% of pts; respectively. Median baseline PSA was 10.8 μg/L (range 1.6–65.6) with PSA < 10 in 47%, 10–20 in 24% & >20 in 29% of pts. Eight pts did not complete protocol therapy because of toxicity (n=4), withdrawal of consent (n=1), or other reasons (n=3). 1 pt had myocardial infarction day 1 post-operatively & 1 pt had DVT 1.5 months after RP. No other major post-operative complications were reported. Of the 64 pts completing protocol therapy, 2 had a complete pathologic response and pathologic stage was T2 in 34 (53%) and T3 in 28 (44%) pts. Four pts had N1 disease & positive surgical margins were identified in 17 (27%). On multivariate Cox regression analysis only baseline Gleason score (=7 vs. >7) was associated with PSA recurrence-free survival (hazard ratio 4.58, 95% CI 1.32–15.93). At a median follow-up of 42.7 months (range 25.6–65.6), 19 (30%) pts have relapsed. Three pts have died at 32.0, 40.0 & 40.3 months, with all deaths attributed to prostate cancer. Conclusions: Combined ADT and docetaxel prior to RP was feasible and resulted in encouraging pathologic outcomes and PSA- recurrence free survival. These data further support the rationale for randomized trials determining the efficacy of chemo-hormonal therapy in pts with clinically LCaP.

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A survey of Canadian medical oncologists on internet use for medical information and a needs assessment for an oncology education website

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Background: The internet offers an innovative resource for medical oncologists to share and discuss important medical information and advances. Despite the existence of many websites with oncology related information, there has not been a comprehensive assessment of how Canadian medical oncologists use the internet to access this information. Purpose: In the first phase of developing a new educational website (OncologyEducation.com), we surveyed Canadian medical oncologists to determine how they used the internet to access information and to assess their needs for a web based educational resource. Method: A structured survey was developed and assessed for face and content validity by medical oncologists from our local institution. The survey had several domains including: comfort level with computers, description of internet use for work, and key features they would want in an educational website. The survey was sent to all medical oncologists in Canada via regular mail and e-mail. Results: 58 % (144/247) of medical oncologists responded to our survey. The number of years in practice varied from <5 yrs (31%) to 5–10 yrs (30%), and 11–20 years (15%) with 85% having an academic appointment. 90% of respondents were comfortable with using a computer. The most common reasons for internet use were email (91%), literature updates (78%), and answering clinical questions (72%). 27% of respondents used the internet for clinical questions daily, and 29% on a weekly basis. 49% accessed the internet for work-related information for 1–5 hours weekly, 26% for 6–10 hours weekly, and 20% for more than 11hrs weekly. Respondents expressed a need for an educational website stressing the following content: (1) Canadian Oncologists Database to improve opportunities for collaboration (2) Key updates by disease sites (3) Access to information about upcoming conferences. Conclusion: The internet plays a major role in the daily clinical activities of Canadian medical oncologists. The development of an education website based on the needs assessed in this survey is warranted. We are currently developing this site (OncologyEducation.com) and plan to evaluate on an ongoing basis.

No significant financial relationships to disclose.

Feasibility of metastasectomy in patients treated with bevacizumab in first-line mCRC - Preliminary results from the First Beat-study

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Background: In a phase III pivotal trial in patients (pts) with mCRC, bevacizumab (BEV) increased overall survival by 30% when added to first-line irinotecan, 5FU and leucovorin. The study reported 10% of pts having wound healing complications after major unplanned or elective surgery. The study had limited data on the feasibility and safety of metastastasectomies. First BEAT was opened to evaluate safety events of BEV in a broader pt population using a variety of chemotherapy (CT) regimens. Methods: First BEAT started in June 2004 and aims to enrol up to 2000 mCRC pts in 41 countries. Eligible patients starting with first-line CT are treated until progression with BEV (5mg/kg q2w (5FU based CT) or 7.5mg/kg q3w (Capecitabine (CAP) based CT). In case of major elective surgery, BEV should be stopped 6–8 weeks prior to the planned surgery and could be restarted 28 days after surgery and complete wound healing. At protocol visits, bleeding and wound healing data was collected according to CTC AE grading (v3.0). Results: By Dec 20th, 2005, 31 pts (13 male; median age 55 years; PS 0/1 90%/10%) had undergone metastasectomies. 27 were liver (1 pt had two operations), 3 lung, 1 peritoneal and 1 other resections. 27 were curative, 3 palliative and 2 other resections. 17 reported no residual disease, 5 had residual disease and for 8 resections the outcome was missing or unknown. Median time from first BEV treatment to surgery was 167 days and 54 days from last BEV administration to surgery, respectively. Median follow-up was 12.4 months. One pt died due to disease progression 5.5 months after surgery. CT regimens used with BEV included FOLFOX (N=9), CAPOX (N=9) and FOLFIRI (N=7). No wound healing or bleeding were reported. 21/31 pts reported no complications at all, for 3/31 data was currently missing and 7/31 pts reported the following complications: stomach perforation, right pleural effusion, surgical area infection, thrombosis portal vein/myocardial infarct, bowel-obstruction, ascites, ileus/cornea infection. Updated data will be available in June 06. Conclusions: Preliminary data suggest metastasectomies are feasible after treatment with BEV and CT. Stopping BEV 6–8 weeks before major surgery resulted in no bleeding or wound healing complications.

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Spatial orientation of the facial nerve in relation to parotid tumours

Objective: The aim of this study was to identify the distribution of parotid tumours within the gland in relation to the facial nerve branches. Documentation revealing such a relationship has not been reported previously.

Method: A prospective study involving 111 patients was carried out over a period of 18 years in a specialist otolaryngology unit within a district general hospital. The relationship of the facial nerve to the tumour was graded into six types. The grading system was then employed to categorize each case.

Results: More than two-thirds of the tumours were pleomorphic adenomas. The majority of these were located in the body and not in the tail of the parotid gland. In 50 per cent of these cases, the tumour was in close association with the two major divisions of the facial nerve. In the case of Warthin's tumours, 47 per cent were located in the tail, below the lower division of the facial nerve.