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Cuzick J, Powles T, Veronesi U, Forbes J, Edwards R, Ashley S, Boyle P. Overview of the main outcomes in breast-cancer prevention trials. Lancet 2003; 361:296-300. [PMID: 12559863 DOI: 10.1016/s0140-6736(03)12342-2] [Citation(s) in RCA: 727] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early findings on the use of tamoxifen or raloxifene as prophylaxis against breast cancer have been mixed; we update available data and overview the combined results. METHODS All five randomised prevention trials comparing tamoxifen or raloxifene with placebo were included. Relevant data on contralateral breast tumours and side-effects were included from an overview of adjuvant trials of tamoxifen versus control. FINDINGS The tamoxifen prevention trials showed a 38% (95% CI 28-46; p<0.0001) reduction in breast-cancer incidence. There was no effect for breast cancers negative for oestrogen receptor (ER; hazard ratio 1.22 [0.89-1.67]; p=0.21), but ER-positive cancers were decreased by 48% (36-58; p<0.0001) in the tamoxifen prevention trials. Age had no apparent effect. Rates of endometrial cancer were increased in all tamoxifen prevention trials (consensus relative risk 2.4 [1.5-4.0]; p=0.0005) and the adjuvant trials (relative risk 3.4 [1.8-6.4]; p=0.0002); no increase has been seen so far with raloxifene. Venous thromboembolic events were increased in all tamoxifen studies (relative risk 1.9 [1.4-2.6] in the prevention trials; p<0.0001) and with raloxifene. Overall, there was no effect on non-breast-cancer mortality; the only cause showing a mortality increase was pulmonary embolism (six vs two). INTERPRETATION The evidence now clearly shows that tamoxifen can reduce the risk of ER-positive breast cancer. New approaches are needed to prevent ER-negative breast cancer and to reduce the side-effects of tamoxifen. Newer agents such as raloxifene and the aromatase inhibitors need to be evaluated. Although tamoxifen cannot yet be recommended as a preventive agent (except possibly in women at very high risk with a low risk of side-effects), continued follow-up of the current trials is essential for identification of a subgroup of high-risk, healthy women for whom the risk-benefit ratio is sufficiently positive.
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Lambert AW, Dashfield A, Cosgrove C, Wilkins DC, Walker AJ, Ashley S. Randomized prospective study comparing pre-emptive epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2000.01420-62.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
The reported incidence of phantom limb pain (PLP) following amputation is up to 85 per cent. This study was designed to compare the efficacy of two perioperative analgesic techniques with respect to postoperative stump pain (POSP) and PLP.
Methods
Patients were randomized prospectively. Group 1 received a pre-emptive epidural for a minimum of 24 h before surgery which was continued after operation. Group 2 had intraoperative placement of a perineural catheter for the administration of local anaesthetic by infusion after operation. All amputations were performed under general anaesthesia. POSP was assessed by visual analogue score (VAS), ranging from 0 to 10. The presence of PLP was assessed 6 and 12 months after operation.
Results
A total of 30 patients were recruited, 12 men and 18 women, of median age 74 (range 47–93) years. Each group was well matched for concurrent cardiovascular disease and the level of amputation. VAS at 6 h, 1, 2 and 3 days after operation was significantly less in group 1 than group 2 (P < 0·05, two-sample t test). Six patients died in each group and one was lost to follow-up. The overall incidence of PLP was 75 per cent at 6 months and 44 per cent at 12 months, with no significant difference between the two groups.
Conclusion
In this series, pre-emptive epidural analgesia significantly reduced the severity of POSP. The incidence of PLP remains disappointingly high regardless of the analgesic technique used.
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Brada M, Ashley S, Ford D, Traish D, Burchell L, Rajan B. Cerebrovascular mortality in patients with pituitary adenoma. Clin Endocrinol (Oxf) 2002; 57:713-7. [PMID: 12460319 DOI: 10.1046/j.1365-2265.2002.01570.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess cerebrovascular mortality in a UK cohort of patients with pituitary adenoma known to have increased incidence of cerebrovascular accidents (CVA). METHODS A total of 334 patients treated at the Royal Marsden Hospital (RMH) between 1962 and 1986 with surgery and postoperative radiotherapy were followed up via the NHS Central Register (NHSCR) to identify deaths and emigrations. The causes of death were assessed by NHSCR-based death certificates and coded according to the 9th revision of ICD. Follow-up was censored at age 85, on emigration or cancellation of NHSCR. Thirteen patients could not be traced. A total of 4982 person-years was accumulated in the cohort. Expected numbers of deaths were computed from the national age-, sex- and period-specific mortality rates for England and Wales. RESULTS In the pituitary adenoma cohort, 128 deaths were observed compared to 80.9 expected [relative risk (RR) of death 1.58 (95% CI: 1.32-1.90)]. There were 33 cerebrovascular deaths compared with 8.04 expected (RR 4.11, 95% CI 2.84-5.75). Three deaths were from subarachnoid haemorrhage compared to 0.54 expected (RR 5.51, 95% CI 1.14-16.09). There was an increased cerebrovascular mortality in women (RR 6.93, 95% CI 4.29-10.60) compared to men (RR 2.4, 95% CI 1.24-4.20; P = 0.002) and in patients having debulking surgery (RR 5.19, 95% CI 3.50-7.42) compared to biopsy/no surgery (RR 1.33, 95% CI 0.27-3.88; P = 0.02). The RR in patients with nonsecretory tumours was 3.65 (95% CI 2.26-5.58), compared with 5.23 (95% CI 2.25-10.30) in secretory tumours (P = 0.4). The effect of age at radiotherapy was not significant (P = 0.4). CONCLUSION Patients with pituitary adenoma treated with surgery and radiotherapy have an increased risk of cerebrovascular mortality compared to the general population, which mirrors the increased incidence of CVA. The possible risk factors include hypopituitarism, radiotherapy and extent of surgery but none are at present proven causes. The evaluation of new treatment strategies should not only assess intermediate end-points of tumour and endocrine control but should concentrate on long-term survival with particular emphasis on CVA incidence and mortality.
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Cosgrove CM, Thornberry DJ, Wilkins DC, Ashley S. Surgical experience and supervision may influence the quality of lower limb amputation. Ann R Coll Surg Engl 2002; 84:344-7. [PMID: 12398130 PMCID: PMC2504180 DOI: 10.1308/003588402760452691] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AIM Only half of those patients undergoing major lower limb amputations for peripheral vascular disease (PVD) are likely to mobilise on a prosthesis. This study aimed to determine whether a surgeon's experience influenced the quality of the residual limb and thus the likelihood of the stump being suitable for a prosthesis. METHODS All patients undergoing major lower limb amputations for PVD were recruited prospectively, between August 1992 and July 1996. Following surgery, patients were categorised, by a consultant in rehabilitation medicine, as potentially suitable (group 1) or unsuitable (group II) for rehabilitation. Patients in group I were further assessed by prosthetists for limb fitting. RESULTS A total of 217 patients underwent 260 amputations for PVD between 1992 and 1996: transfemoral (TFA) 131, trans-tibial (TTA) 127, and through-knee (TKA) in 2. The 30-day mortality was 12% (n = 27). Following surgery, 109 patients were assigned to group I (51%), and 81 patients to group II (37%). The proportion of junior surgeons performing surgery was similar for patients in both groups. Twenty-three amputation stumps (9%) required revision or conversion to a higher level within 30 days. Revisions or conversions were significantly more frequent where the original operation had been performed by an unsupervised junior surgeon rather than a senior surgeon (P = 0.009). The rate of defective amputations compromising limb fitting also reached significance when unsupervised junior and senior surgeons were compared (P = 0.04). CONCLUSIONS Rehabilitation of the relatively few amputees who reach the stage of limb fitting is hindered by poor surgical technique in a large proportion of cases. Patients operated on by a more experienced surgeon had a better chance of mobilising without revision or conversion surgery.
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Gregory RK, Smith IE, Norton A, Ashley S, O'Brien ME. Mitomycin C, vinblastine and carboplatin: effective outpatient chemotherapy for advanced non-small cell carcinoma of the lung (NSCLC). Clin Oncol (R Coll Radiol) 2002; 13:483-7. [PMID: 11824893 DOI: 10.1053/clon.2001.9320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The majority of patients diagnosed with non-small cell lung carcinoma (NSCLC) present with advanced disease and, as such, are treated with palliative intent. Platinum-based combination chemotherapy plays an important role in the management of these patients, with response rates to most regimens being in the range of 30%-40%. with symptom relief in up to 60%. One of the most commonly utilized combinations is mitomycin C, vinblastine and cisplatin (MVP). Owing to the hydration regimen, and to the age and performance status of many of these patients, in reality this combination often necessitates an overnight stay in hospital. A combination of drugs that could be administered as an outpatient would be beneficial to patients and could result in substantial economic benefits. Forty-three patients with Stage IlIb and IV NSCLC were treated with the MVCarbo regimen, in which the cisplatin in the MVP regimen was replaced with carboplatin. All treatment was administered on an outpatient basis. The overall objective response rate was 30%; the symptomatic response rate was 60%, which was exactly equivalent to the response rate seen in a comparable group of patients treated with MVP in a trial on duration of chemotherapy at the Royal Marsden Hospital. There was no difference in progression-free or overall survival between patients treated with the two regimens. The MVCarbo regimen resulted in response rates and survival rates equivalent to those seen with standard MVP and, as such, provides an acceptable outpatient alternative to this treatment.
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De Boer RH, Eisen TG, Ellis PA, Johnston SRD, Walsh G, Ashley S, Smith IE. A randomised phase II study of conventional versus accelerated infusional chemotherapy with granulocyte colony-stimulating factor support in advanced breast cancer. Ann Oncol 2002; 13:889-94. [PMID: 12123334 DOI: 10.1093/annonc/mdf150] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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%.
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Trent S, Kong A, Short SC, Traish D, Ashley S, Dowe A, Hines F, Brada M. Temozolomide as second-line chemotherapy for relapsed gliomas. J Neurooncol 2002; 57:247-51. [PMID: 12125988 DOI: 10.1023/a:1015788814667] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Temozolomide, an imidazotetrazine prodrug has shown activity in phase II studies in patients with high-grade glioma at first recurrence. We assessed the efficacy of temozolomide as second-line therapy following failure of PCV chemotherapy in patients with recurrent/progressive gliomas. PATIENTS AND METHODS Between September 1994 and November 2000, 32 patients with high-grade gliomas at second recurrence/progression received temozolomide as salvage therapy and results were reviewed retrospectively. RESULTS Of 32 assessable patients 7 had clinical improvement; there were no imaging responses. Median survival of the cohort was 4 months, with 28% alive at 6 months. Age, performance status, histology and previous response to PCV chemotherapy did not predict for clinical response to temozolomide. CONCLUSION In the small cohort of patients with recurrent malignant glioma who failed PCV chemotherapy temozolomide demonstrated limited activity as second-line treatment although this remains within the confidence intervals of response seen in patients with glioblastoma.
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Foster C, Evans DGR, Eeles R, Eccles D, Ashley S, Brooks L, Davidson R, Mackay J, Morrison PJ, Watson M. Predictive testing for BRCA1/2: attributes, risk perception and management in a multi-centre clinical cohort. Br J Cancer 2002; 86:1209-16. [PMID: 11953874 PMCID: PMC2375339 DOI: 10.1038/sj.bjc.6600253] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2001] [Revised: 01/10/2002] [Accepted: 02/25/2002] [Indexed: 01/03/2023] Open
Abstract
The aim of this multi-centre UK study is to examine the attributes of a cohort offered predictive genetic testing for breast/ovarian cancer predisposition. Participants are adults unaffected with cancer from families with a known BRCA1/2 mutation. This is the first large multi-centre study of this population in the UK. The study evaluates mental health, perceived risk of developing cancer, preferred risk management options, and motivation for genetic testing. Participants were assessed when coming forward for genetic counselling prior to proceeding to genetic testing. Three hundred and twelve individuals, 76% of whom are female, from nine UK centres participated in the study. There are no gender differences in rates of psychiatric morbidity. Younger women (<50 years) are more worried about developing cancer than older women. Few women provide accurate figures for the population risk of breast (37%) or ovarian (6%) cancer but most think that they are at higher risk of developing breast (88%) and ovarian (69%) cancer than the average woman. Cancer related worry is not associated with perceived risk or uptake of risk management options except breast self-examination. The findings indicate that younger women may be particularly vulnerable at the time of the offer of a predictive genetic test.
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Jalali R, Loughrey C, Baumert B, Perks J, Warrington AP, Traish D, Ashley S, Brada M. High precision focused irradiation in the form of fractionated stereotactic conformal radiotherapy (SCRT) for benign meningiomas predominantly in the skull base location. Clin Oncol (R Coll Radiol) 2002; 14:103-9. [PMID: 12069116 DOI: 10.1053/clon.2001.0040] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To present early clinical results of stereotactic conformal radiotherapy (SCRT) in patients with benign predominantly skull base meningiomas. MATERIAL AND METHODS Between August 1994 and August 1999, 41 patients with benign residual or recurrent meningiomas were treated with SCRT. Thirty-three were histologically verified. All patients were immobilized in a GTC stereotactic relocatable frame, and underwent a post-contrast CT localization scan with additional MRI for fusion in 15 patients. Treatment was delivered on a 6 MV linear accelerator using three (12 patients), or 4 (29 patients) non-coplanar conformal fixed fields to doses of 50-55 Gy in 30-33 daily fractions. Tumours were relatively large with a median gross tumour volume (GTV) of 17.9 cm3 (range 2.5-183 cm3). RESULTS At a median follow-up of 21 months (range 6-62 months) none of 41 patients have recurred. The current imaging tumour control rate is 100% at 1 and 3 years. The actuarial survival at 2 years is 100% and 91% at 3 and 5 years. Following SCRT tumour decreased in size in 9 patients. SCRT was well tolerated. Five patients had improvement in vision, and six patients improvement in cranial nerve function. Two patients whose planning target volume (PTV) included the sella developed hypopituitarism during and at 18 months after SCRT. One patient with pre-existing hydrocephalus due to pineal region meningioma developed cognitive impairment 7 months after treatment. One patient with involvement of the optic nerve had visual deterioration at 18 months. CONCLUSIONS SCRT is a feasible high precision irradiation technique for residual and recurrent skull base meningiomas including both small and larger tumours with excellent early tumour control and low toxicity. Longer follow-up is necessary to demonstrate sustained tumour control and low morbidity of such high precision localized method of fractionated irradiation.
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Mendes R, O'Brien MER, Mitra A, Norton A, Gregory RK, Padhani AR, Bromelow KV, Winkley AR, Ashley S, Smith IE, Souberbielle BE. Clinical and immunological assessment of Mycobacterium vaccae (SRL172) with chemotherapy in patients with malignant mesothelioma. Br J Cancer 2002; 86:336-41. [PMID: 11875694 PMCID: PMC2375208 DOI: 10.1038/sj.bjc.6600063] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2001] [Revised: 11/08/2001] [Accepted: 11/13/2001] [Indexed: 11/13/2022] Open
Abstract
The objectives of this study were to determine the toxicity of intratumoural/intrapleural SRL172 in addition to intradermal SRL172 and standard chemotherapy (mitomycin-C, vinblastine and cisplatin) in patients with malignant mesothelioma. Patients received chemotherapy (mitomycin-C: 8 mg m(-2), vinblastine: 6 mg m(-2), cisplatin 50 mg m(-2)) on a 3-weekly basis for up to six courses. IP SRL172 injections were given 3-weekly prior to chemotherapy and escalated in groups of three patients from 1 microg to 1 mg bacilli in 10-fold increments. Patients were also given ID SRL172 at a dose of 1 mg bacilli 4-weekly. Patients were assessed for toxicity after each course of chemotherapy and for response by CT imaging. Immuno-haematological parameters were analyzed pre-treatment and 1 month after completion of treatment. There was no dose limiting toxicity with IP SRL172 although there was greater toxicity at the highest dose (n=13). There were six out of 16 partial responses (37.5%). Haemato-immunological parameters, measured in seven patients pre and post-therapy, revealed that response rate correlated with a decrease in platelet count and there was an increase in activation of natural killer cells and a decrease in the percentage of IL-4 producing T cells in all tested patients post-treatment. SRL172 can be given safely into tumour deposits and the pleural cavity in patients with malignant mesothelioma and we have established the dose for phase II testing.
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Jyothirmayi R, Saran FH, Jalali R, Perks J, Warrington AP, Traish D, Ashley S, Hines F, Brada M. Stereotactic radiotherapy for solitary brain metastases. Clin Oncol (R Coll Radiol) 2002; 13:228-34. [PMID: 11527300 DOI: 10.1053/clon.2001.9258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Surgery is considered to be the treatment of choice for patients with solitary brain metastases. We report a single-centre experience of stereotactic radiotherapy (SRT)/radiosurgery as an alternative to surgery and define prognostic parameters that provide for a more rational selection of patients for appropriate treatment. PATIENTS AND METHODS Between 1990 and 1997, 96 patients with 106 brain metastases received SRT to a dose of 20 Gy in two fractions (range 20-30 Gy in 24 fractions) either alone or in combination with whole brain radiotherapy. RESULTS After SRT, 51% of patients had improvement in neurological function. The median survival of the 96 patients was 9 months. The Radiation Therapy Oncology Group prognostic grouping for patients with multiple brain metastases (prognostic factors: age, performance status, systemic metastases, status of primary tumour) was applicable to this cohort, with median survivals of 15, 8 and 2 months for favourable, intermediate and poor prognostic groups respectively. CONCLUSION SRT is a non-invasive method of treatment of solitary brain metastases and the outcome is comparable with the results obtained after surgical excision. Prognosis is determined by factors defined for patients with multiple brain metastases, with performance status being the most important. SRT/radiosurgery should be reserved for patients with favourable prognostic factors, with a Karnofsky performance status >70, who have a reasonable chance of good quality prolonged survival. In future trials, radiosurgery should be compared in terms of survival, quality of life and health economics to whole brain radiotherapy and surgery.
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Ashley S. Reseizing the controls. Sci Am 2001; 285:23-4. [PMID: 11759582 DOI: 10.1038/scientificamerican1201-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Ashley S. Catching some sun. Sci Am 2001; 285:20. [PMID: 11570036 DOI: 10.1038/scientificamerican1001-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cosgrove C, Ashley S. Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Reg Anesth Pain Med 2001; 26:316-21. [PMID: 11464349 DOI: 10.1053/rapm.2001.23934] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine. METHODS In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics. RESULTS Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P <.01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P =.32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P =.25) at 6 months; 3 (38%) versus 4 (50%) (P =.61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months. CONCLUSIONS Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period.
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Barrett JA, Wells IP, Roobottom CA, Ashley S. Progression of peri-aortic fibrosis despite endovascular repair of an inflammatory aneurysm. Eur J Vasc Endovasc Surg 2001; 21:567-8. [PMID: 11397034 DOI: 10.1053/ejvs.2001.1357] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ashley S. Robotic bombers. Sci Am 2001; 284:24. [PMID: 11396332 DOI: 10.1038/scientificamerican0601-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Murray PV, O'Brien ME, Padhani AR, Powles R, Cunningham D, Jeanes A, Ashley S. Use of first line bronchoalveolar lavage in the immunosuppressed oncology patient. Bone Marrow Transplant 2001; 27:967-71. [PMID: 11436107 DOI: 10.1038/sj.bmt.1703020] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2000] [Accepted: 02/13/2001] [Indexed: 11/09/2022]
Abstract
Immunosuppressed oncology patients who develop pulmonary infiltrates during treatment have a mortality rate of the order of 55-90%. Early diagnosis and treatment is associated with increased survival. At present, diagnosis relies on invasive sampling of the respiratory tract using fibre-optic bronchoscopy. We have looked at a 30-month period, from June 1997 to December 1999, where 25 bronchoscopies were performed on patients from the Lymphoma and BMT units at The Royal Marsden Hospital for the further investigation of pulmonary infiltrates. Nine bronchoscopies (36%) yielded a positive result and seven (28%) led to a change in management. Analysis of the data showed that neither a positive result nor a change in management had any impact on overall survival. After reviewing the background literature on the investigation of pulmonary infiltrates in this group and discussion of the respective merits and limitations, we propose a management flowchart, with high-resolution computed tomography (HRCT) as the test arm in a future randomised trial of these patients.
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Jyothirmayi R, Saran FH, Jalali R, Perks J, Warrington AP, Traish D, Ashley S, Hines F, Brada M. Stereotactic Radiotherapy for Solitary Brain Metastases. Clin Oncol (R Coll Radiol) 2001. [DOI: 10.1007/s001740170080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Westburry C, Hines F, Hawkes E, Ashley S, Brada M. Advice on hair and scalp care during cranial radiotherapy: a prospective randomized trial. Cancer Radiother 2001. [DOI: 10.1016/s1278-3218(00)00083-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Harden SP, Neal AJ, Al-Nasiri N, Ashley S, Querci della Rovere G. Predicting axillary lymph node metastases in patients with T1infiltrating ductal carcinoma of the breast. Breast 2001; 10:155-9. [PMID: 14965577 DOI: 10.1054/brst.2000.0220] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Factors which can predict an increased risk of axillary metastases in cases of T1 breast cancer could help to identify those patients most likely to benefit from axillary surgery. This pragmatic study aimed to examine the ability of commonly reported tumour pathological features to predict axillary metastases. All cases of T1 infiltrating ductal carcinoma excised with ipsilateral axillary nodes over a 7 year period were reviewed retrospectively. Of the 639 cases, 197 (30.8%) had positive nodes. Axillary metastases were found with 66.3% of tumours showing vascular invasion but only 16.0% of those without vascular invasion. Following multivariate analysis, vascular invasion and tumour size were found to be independent predictors of positive nodes but tumour grade was not. The decision to perform axillary dissection in T1 breast cancer could be based on the presence of vascular invasion and the size of the primary tumour.
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Smith IE, O'Brien ME, Talbot DC, Nicolson MC, Mansi JL, Hickish TF, Norton A, Ashley S. Duration of chemotherapy in advanced non-small-cell lung cancer: a randomized trial of three versus six courses of mitomycin, vinblastine, and cisplatin. J Clin Oncol 2001; 19:1336-43. [PMID: 11230476 DOI: 10.1200/jco.2001.19.5.1336] [Citation(s) in RCA: 248] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE So far there are no published data on optimal duration of chemotherapy for advanced non-small-cell lung cancer (NSCLC); six or more courses are usually recommended. We have carried out a multicenter randomized trial comparing three versus six courses of chemotherapy. PATIENTS AND METHODS Patients with stage IIIb or IV NSCLC were randomized at start of treatment to receive either three or six courses of mitomycin 8 mg/m(2) (courses 1, 2, 4, and 6), vinblastine 6 mg/m(2), and cisplatin 50 mg/m(2) (MVP) every 21 days. Treatment was stopped early in both arms for progressive disease or unacceptable toxicity. Key end points were overall survival, duration of symptom relief, and quality-of-life assessment using the European Organization for Research and Treatment of Cancer (EORTC) core questionnaire QLQ-C30 with lung cancer-specific module QLQ-LC13. RESULTS Three hundred eight patients were randomized. Seventy-two percent of the 155 patients randomized to three courses completed treatment. In the 153 patients randomized to six courses, 73% completed three courses and 31% six courses. Median survival was 6 versus 7 months, respectively, and 1-year survival 22% versus 25% (P =.2). Median duration of symptom relief was 4.5 months (both arms), and 8% versus 18% had continuing symptom relief (P =.4). Quality-of-life parameters were the same or improved for patients randomized to only three courses, including significantly decreased fatigue (P =.03) and a trend toward decreased nausea and vomiting (P =.06). CONCLUSION Our findings show no evidence for additional clinical benefit by continuing MVP chemotherapy beyond three courses. This challenges current orthodoxy of six courses or more. Further trials addressing duration of chemotherapy are now warranted, particularly with newer chemotherapy schedules.
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Ashley S. The poetics of race in 1890s Ireland: an ethnography of the Aran Islands. PATTERNS OF PREJUDICE 2001; 35:5-18. [PMID: 18524041 DOI: 10.1080/003132201128811115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Murray PV, Soussi T, O'Brien ME, Smith IE, Brossault S, Norton A, Ashley S, Tavassoli M. Serum p53 antibodies: predictors of survival in small-cell lung cancer? Br J Cancer 2000; 83:1418-24. [PMID: 11076647 PMCID: PMC2363416 DOI: 10.1054/bjoc.2000.1475] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Serum p53 antibodies have been shown to be a poor prognostic marker in resected non-small-cell lung cancer (NSCLC), but studies in small-cell lung cancer (SCLC) have been contradictory. We have studied the incidence of p53 antibodies in a large SCLC cohort treated at one oncology centre and correlated the results with survival. 231 patients (63% male, median age 65), diagnosed and treated for SCLC between 1987 and 1994 at The Royal Marsden Hospital NHS Trust, had sera stored pretreatment. All samples were tested for p53 antibodies (p53-Ab) using a standardized ELISA technique with a selection of strongly ELISA positive, weakly ELISA positive and negative samples being confirmed with immunoprecipitation. 54 patients were positive for p53-Ab (23%). The presence of a high titre of p53-Ab (titre ratio >5) appears to be associated with a survival advantage with a relative risk of death of 1.71 (95% CI: 1.14-2.58) in those without the antibody (P = 0.02). This study, the largest homogeneous group so far looking at p53-Ab in SCLC, suggests that p53 antibody detection may have a role in predicting outcome in this type of cancer.
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McCarthy RJ, Neary W, Roobottom C, Tottle A, Ashley S. Short-term results of femoropopliteal subintimal angioplasty. Br J Surg 2000; 87:1361-5. [PMID: 11044162 DOI: 10.1046/j.1365-2168.2000.01633.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Subintimal angioplasty may be more successful than conventional (intraluminal) angioplasty for treatment of long femoropopliteal occlusions. This study assessed the clinical and haemodynamic outcome of subintimal angioplasty. METHODS All patients with femoropopliteal occlusions treated by subintimal angioplasty over a 3-year period at two centres were reviewed. Clinical assessment and colour duplex imaging were carried out. RESULTS Sixty-nine procedures were performed in 33 men and 33 women of median age 74 (range 47-92) years. Indications for treatment were intermittent claudication in 26 (38 per cent) and critical limb ischaemia in 43 (62 per cent). Median occlusion length was 10 (range 2-50) cm. Primary technical success was achieved in 51 occlusions (74 per cent). There were 11 complications (16 per cent); the majority were minor but surgical intervention was required in two patients (3 per cent). At 6 months the cumulative symptomatic and haemodynamic primary patency rates were 60 and 51 per cent respectively, analysed on an intention-to-treat basis. The symptomatic and haemodynamic patency rates for technically successful procedures were 80 and 77 per cent respectively. CONCLUSION In this series the short-term clinical success of subintimal angioplasty was poor because of a high incidence of reocclusion and restenosis, despite a relatively high initial technical success rate.
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De Boer RH, Allum WH, Ebbs SR, Gui GP, Johnston SR, Sacks NP, Walsh G, Ashley S, Smith IE. Multimodality therapy in inflammatory breast cancer: is there a place for surgery? Ann Oncol 2000; 11:1147-53. [PMID: 11061610 DOI: 10.1023/a:1008374931854] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In many centres surgery is used as part of a combined modality approach to the treatment of inflammatory breast cancer (IBC). Nevertheless, its value is controversial given the high risk of metastatic relapse and poor overall prognosis. We have reviewed patients with true IBC prospectively treated at the Royal Marsden Hospital in chemotherapy trials to assess further the role of surgery as part of combined modality treatment. PATIENTS AND METHODS Fifty-four patients who had responsive or stable disease to primary chemotherapy went on to have either radiotherapy alone (n = 35) or surgery plus radiotherapy (n = 19); the decision on surgery was based partly on clinician preference and partly on clinical response. RESULTS The 35 patients undergoing radiotherapy alone had a median progression-free survival (PFS) of 16 months and median overall survival (OS) of 35 months. Twenty-four patients (69%) have relapsed with a total of twelve (34%) relapsing locally. In comparison, the 19 patients receiving both surgery and radiotherapy had a PFS of 20 months, and a median OS of 35 months. Fifteen patients (79%) have relapsed, eight (42%) of these locally. None of these differences were statistically significant. CONCLUSIONS These results do not suggest a clinical advantage for surgery in addition to chemotherapy and radiotherapy for patients with IBC. They support the need for a prospective randomised trial to address this question.
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Abstract
BACKGROUND successful infra-popliteal bypass depends on precise, atraumatic technique in performing the distal anastomosis. The use of a tourniquet facilitates the distal anastomosis, reducing dissection, avoiding traumatising clamping of the vessels and providing an "uncluttered" operating field. Despite these advantages the technique is under-used. OBJECTIVES to review the use of tourniquets in arterial reconstruction, with particular reference to safety issues and complications. DESIGN, METHODS AND MATERIALS: a Medline search was performed (last search Feb. 2000), and keywords from relevant papers were used to perform subsequent searches. References were reviewed from each relevant paper. RESULTS no randomised controlled trials were found. The review details reported use of tourniquets in arterial reconstruction, including techniques, outcomes and potential complications. CONCLUSION the use of a tourniquet is a safe and effective technique to facilitate arterial reconstruction.
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Saso R, Kulkarni S, Mitchell P, Treleaven J, Swansbury GJ, Mehta J, Powles R, Ashley S, Kuan A, Powles T. Secondary myelodysplastic syndrome/acute myeloid leukaemia following mitoxantrone-based therapy for breast carcinoma. Br J Cancer 2000; 83:91-4. [PMID: 10883674 PMCID: PMC2374543 DOI: 10.1054/bjoc.2000.1196] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Of 1774 patients with breast cancer given mitoxantrone (MTZ) with methotrexate (n = 492) or with methotrexate and mitomycin C (n = 1282), nine developed MDS/AML after a median of 2.5 years. Median duration of survival from diagnosis of MDS/AML was 10 months and six patients died. The crude incidence of developing MDS/AML after MMM or MM chemotherapy was 15 per 100,000 patient years follow-up, while the actuarial risk was 1.1% and 1.6% at 5 and 10 years respectively. MTZ-based regimens carry a 10 x higher risk of subsequent MDS/AML compared to that seen in the general population.
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MESH Headings
- Acute Disease
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/genetics
- Breast Neoplasms/radiotherapy
- Combined Modality Therapy
- England/epidemiology
- Female
- Follow-Up Studies
- Genetic Predisposition to Disease
- Humans
- Incidence
- Leukemia, Myeloid/chemically induced
- Leukemia, Myeloid/epidemiology
- Leukemia, Myeloid/genetics
- Leukemia, Radiation-Induced/epidemiology
- Leukemia, Radiation-Induced/etiology
- Life Tables
- Methotrexate/administration & dosage
- Middle Aged
- Mitomycin/administration & dosage
- Mitoxantrone/administration & dosage
- Mitoxantrone/adverse effects
- Myelodysplastic Syndromes/chemically induced
- Myelodysplastic Syndromes/epidemiology
- Myelodysplastic Syndromes/etiology
- Neoplasms, Second Primary/chemically induced
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/genetics
- Prospective Studies
- Registries
- Risk
- Survival Analysis
- Tamoxifen/administration & dosage
- Translocation, Genetic
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de Boer RH, Saini A, Johnston SR, O'Brien ME, Ellis PA, Verrill MW, Prendiville JA, Walsh G, Ashley S, Smith IE. Continuous infusional combination chemotherapy in inflammatory breast cancer: a phase II study. Breast 2000; 9:149-55. [PMID: 14731839 DOI: 10.1054/brst.1999.0158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Despite the introduction of systemic chemotherapy, inflammatory breast cancer (IBC) remains a disease with a poor prognosis. We performed this phase II study to evaluate the efficacy of infusional chemotherapy as initial treatment in patients with IBC. Fifty-four patients with newly diagnosed IBC were offered infusional chemotherapy and 34 accepted. The schedule consisted of continuous infusional ECF (bolus epirubicin and cisplatin, substituted by carboplatin or cyclophosphamide in some patients) plus continuous 5-FU, given three weekly for six cycles. Following chemotherapy patients went on to have surgery and/or radiotherapy. The chemotherapy was well tolerated and resulted in an overall response rate of 79% with 35% of patients achieving a complete clinical response. The median response duration, time to progression and overall survival were 12 months (4-89+ months), 12 months (4-89+ months) and 23 months (7-89+ months), respectively. Patients had a 5 year disease free and overall survival of 11% and 29%, respectively. Infusional ECF is well tolerated and achieves a high clinical response rate in patients with IBC, but survival results do not appear to be superior to those achieved with conventional bolus chemotherapy schedules.
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Sardell S, Sharpe G, Ashley S, Guerrero D, Brada M. Evaluation of a nurse-led telephone clinic in the follow-up of patients with malignant glioma. Clin Oncol (R Coll Radiol) 2000; 12:36-41. [PMID: 10749018 DOI: 10.1053/clon.2000.9108] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this study was to evaluate nurse-led telephone follow-up (NTF) for patients with high-grade glioma as an alternative to conventional clinic follow-up (CCF) and to assess patient satisfaction with this approach. Patients who were completing primary therapy for high-grade glioma and were suitable for CCF were offered the alternative of nurse-led telephone follow-up. NTF was arranged by the nurse at mutually agreed times. Assessment was by open discussion and a semistructured questionnaire, together with the Barthel Activities of Daily Living Index. Formal medical assessment in the clinic was arranged at 4-month intervals or earlier if indicated. Twenty-two patients were asked to complete a satisfaction questionnaire. Between February 1996 and October 1997, 43 patients with high-grade glioma, one with primitive neuroectodermal tumour and one with oligoastrocytoma agreed to be monitored by NTF. Their median survival from diagnosis was 16 months (95% confidence interval 13-23 months). At the time of analysis, the median time of follow-up by the telephone clinic was 6 months (range 2-21), with symptomatic progressive disease the reason for discontinuation of NTF in all patients. Two-hundred and fifty-four telephone calls were made, of which 234 were routine and 20 non-routine, being initiated by the patients or their carers. NTF was considered as a sufficient replacement for CCF during the stable phase of the disease. There were 41 unscheduled clinic visits, of which 31 were at the time of progression and usually initiated at NTF. The majority of unplanned visits were due to a change in symptoms and would not have been avoided with CCF carried out at the same time intervals. Patient satisfaction was high, with a median satisfaction score of 9, (range 3.6-10 ) on a scale of 0-10. NTF provides an alternative approach to conventional hospital attendance and moves the emphasis away from cancer surveillance to a more patient centred supportive model. It can be carried out without apparent detriment to the patient and is associated with high satisfaction rating.
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Davidson A, Tait DM, Payne GS, Hopewell JW, Leach MO, Watson M, MacVicar AD, Britton JA, Ashley S. Magnetic resonance spectroscopy in the evaluation of neurotoxicity following cranial irradiation for childhood cancer. Br J Radiol 2000; 73:421-4. [PMID: 10844868 DOI: 10.1259/bjr.73.868.10844868] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In order to evaluate the role of proton MR spectroscopy (1H-MRS) in the diagnosis and assessment of long-term radiation-related neurotoxicity, 14 children who had received cranial irradiation for the treatment of childhood leukaemia (n = 6) or brain tumours (n = 8) underwent 1H-MRS, MRI and neuropsychological assessment. Short-term effects at 2 months following treatment were studied in a further three patients. MRI abnormalities were observed in nine patients. No statistically significant differences between patients and controls (n = 17) were seen in any of the calculated 1H-MRS metabolite ratios, in any of the three patient groups. On multivariate logistic regression analysis there was a correlation between the choline/water ratio and a low IQ. It is concluded that any systematic radiation-induced changes in the 1H MRS metabolites must be below the detection threshold of this study.
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Kote-Jarai Z, Powles TP, Ashley S, Easton DF, Assersohn L, Sodha N, Dowsett M, Gusterson B, Tidy A, Mitchell G, Eeles RA. BRCA1, BRCA2 and pedigree genetic analysis to determine genetic risk in the UK Royal Marsden Hospital tamoxifen prevention trial. Breast Cancer Res 2000. [PMCID: PMC3300843 DOI: 10.1186/bcr145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Westbury C, Hines F, Hawkes E, Ashley S, Brada M. Advice on hair and scalp care during cranial radiotherapy: a prospective randomized trial. Radiother Oncol 2000; 54:109-16. [PMID: 10699472 DOI: 10.1016/s0167-8140(99)00146-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The advice on hair washing during brain irradiation is aimed at minimizing radiation induced skin toxicity. We performed a prospective randomized trial to assess the effect of advice on scalp care on the local skin reaction in patients undergoing cranial radiotherapy. METHODS One hundred and nine patients undergoing cranial radiotherapy were randomized into two groups. Patients in group 1 were advised not to wash hair during treatment and patients in group 2 to maintain normal pattern of hair washing. They were assessed weekly over a period of 10 weeks from the start of treatment. Symptoms of pain and itching were recorded using a modified RTOG/EORTC acute skin reaction scoring system and skin reaction was assessed clinically using erythema/desquamation score. The frequency of hair washing and the distress of changing the practice of normal hygiene were recorded on a diary card. Skin reaction scores were compared as a summary measure using area under the curve per week (AUC/week) and median scores, and the differences between groups were assessed by means of the t-test. RESULTS One hundred and nine patients commencing cranial radiotherapy according to standard protocol were randomized into the trial (group 1, 55 patients; group 2, 54 patients). Patients asked to restrict hair washing, washed at a lower average frequency. There were no significant differences between scores of skin reaction in the two groups for each of the variables measured. CONCLUSIONS The practice of normal hair washing is not associated with increased severity of adverse skin reaction. As a request to change the pattern of normal hygiene may cause distress, the current advice should be to maintain normal hair washing during cranial radiotherapy.
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Gregory RK, Powles TJ, Salter J, Chang JC, Ashley S, Dowsett M. Prognostic relevance of cerbB2 expression following neoadjuvant chemotherapy in patients in a randomised trial of neoadjuvant versus adjuvant chemoendocrine therapy. Breast Cancer Res Treat 2000; 59:171-5. [PMID: 10817352 DOI: 10.1023/a:1006394317282] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Recent advances in the detection and treatment of breast cancer have led to an intensive search for new markers of both prognosis and chemoresponsiveness. The oncogene cerbB2 has proved to be one of the most promising markers currently under study, both as a predictor of chemoresponsiveness and as a marker of poor prognosis. In addition the increasing use of neoadjuvant chemotherapy has led to the loss of standard prognostic criteria. In order to study the potential role of cerbB2 expression as an indicator of chemoendocrine resistance and poor prognosis, both before and after chemotherapy, we obtained tumour sections from 283 women enrolled onto a neoadjuvant trial. In this trial patients were randomised to receive either primary surgery followed by adjuvant chemoendocrine treatment or neoadjuvant chemoendocrine therapy followed by surgery. CerbB2 status was determined immunohistochemically on all of these patients. Thirty-eight percent of the tumours were cerbB2 positive. There was no significant difference in expression between the adjuvant (41%) and neoadjuvant arms (35%). CerbB2 positive patients were much more likely to have shown non-response to chemoendocrine therapy (p < 0.001) and had a worse DES (p < 0.05). The best prognosis was seen in cerbB2 negative patients receiving neoadjuvant chemoendocrine therapy who showed a significantly better DFS (p < 0.05), than the cerbB2 negative patients receiving adjuvant therapy.
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139
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Assersohn L, Powles TJ, Ashley S, Nash AG, Neal AJ, Sacks N, Chang J, Querci della Rovere U, Naziri N. Local relapse in primary breast cancer patients with unexcised positive surgical margins after lumpectomy, radiotherapy and chemoendocrine therapy. Ann Oncol 1999; 10:1451-5. [PMID: 10643535 DOI: 10.1023/a:1008371318784] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inadequate surgical excision with residual involvement of resection margins by tumour after breast conservation results in increased local recurrence rates. To reduce this risk positive margins are, therefore, usually excised. Systemic treatment with tamoxifen or chemotherapy reduces local recurrence, along with radiotherapy. However, no studies to date have examined the correlation between chemoendocrine treatment, together with radiotherapy, and local relapse in patients with unexcised involved resection margins, having had breast conservation treatment. PATIENTS AND METHODS The histopathology reports were reviewed of 184 patients who were treated from June 1991 to August 1995 within our randomised study of neoadjuvant versus adjuvant chemoendocrine therapy with mitozantrone and methotrexate (2M) +/- mitomycin-C (3M) and tamoxifen, used concurrently with radiation following conservation surgical treatment. Histological resection margin was considered positive if ductal carcinoma in situ (DCIS) or invasive carcinoma was present microscopically less than 1 mm from the excision margin. RESULTS Although 38% of patients had unexcised microscopically involved margins, local relapse rate as first site of relapse was only 1.9% after a median follow up of 57 months. There was no difference in distant relapse (P = 0.2) and survival (P = 0.5) between the positive and negative margins groups. CONCLUSIONS The presence of positive unexcised margins does not have a significant effect on outcome in patients who are treated with chemoendocrine therapy together with radiotherapy. Further clinical trials are required.
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Shankar AG, Pinkerton CR, Atra A, Ashley S, Lewis I, Spooner D, Cannon S, Grimer R, Cotterill SJ, Craft AW. Local therapy and other factors influencing site of relapse in patients with localised Ewing's sarcoma. United Kingdom Children's Cancer Study Group (UKCCSG). Eur J Cancer 1999; 35:1698-704. [PMID: 10674016 DOI: 10.1016/s0959-8049(99)00144-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Relapse patterns have been documented in 191 children with localised Ewing's sarcoma treated with the United Kingdom Children's Cancer Group (UKCCSG) Ewing's Tumour regimen ET2. All received chemotherapy comprising ifosfamide, vincristine, doxorubicin and actinomycin D. Local treatment modality was excision and or radiotherapy depending on tumour site and response to primary chemotherapy. Although not strictly comparable, due to the clinical indications used for each modality, local relapse rates were very low and were similar, irrespective of the type of local treatment modality: radiotherapy (3/56), surgery (7/114) or a combination (0/20). Combined relapse (local + distant) rates were similarly low irrespective of the type of local therapy: radiotherapy (4/56), surgery (4/114) or a combination (0/20). Overall survival was lower in females (P = < 0.04), older children (P = < 0.002) and those with primaries at sites other than long bones (P = < 0.02). It is concluded that with effective intensive chemotherapy combined with either radiotherapy or surgery, local control in this study was excellent at sites other than the pelvis. Preventing distant relapse, predominantly to lung and bone, remains the major challenge.
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141
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Brada M, Burchell L, Ashley S, Traish D. The incidence of cerebrovascular accidents in patients with pituitary adenoma. Int J Radiat Oncol Biol Phys 1999; 45:693-8. [PMID: 10524424 DOI: 10.1016/s0360-3016(99)00159-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients with pituitary adenomas are effectively treated with a combination of surgery, radiotherapy, and medical therapy. Nevertheless, long-term studies suggest increased mortality that is independent of tumor control, with cerebrovascular accidents (CVA) as the major contributing cause. The purpose of this study was to define the frequency of CVAs in a cohort of patients with pituitary adenoma and identify potential predisposing factors. PATIENTS AND METHODS A cohort of 331 United Kingdom (UK) residents with pituitary adenoma treated at the Royal Marsden Hospital (RMH) between 1962 and 1986 was studied. The frequency of CVA was assessed from RMH and referring hospital records and clinicians, by postal questionnaire of referring hospitals and general practitioners, and by examination of all death certificates. The data were analyzed by actuarial methods, and risk factors were assessed by multivariate analysis. The data were compared to the incidence of CVA in the general population using a published UK population cohort. RESULTS Sixty-four of 331 patients developed CVA after primary treatment of pituitary adenoma. The actuarial incidence of CVA was 4% (95% CI: 2-7%) at 5 years, 11% (95% CI: 8-14%) at 10 years, and 21% (95% CI: 16-28%) at 20 years measured from the date of radiotherapy. The relative risk of CVA compared to the general population in the UK was 4.1. Age was an independent predictive factor for CVA. However, the relative risk in comparison to the general population was independent of age. The relative risk of developing CVA was higher in women compared to men, in patients undergoing debulking surgery compared to less radical procedures, and in patients diagnosed and treated in the 1980s compared to previous decades. The dose of radiotherapy was an additional independent prognostic factor on multivariate analysis. CONCLUSION Patients with pituitary adenoma treated with surgery and radiotherapy have a significantly increased risk of CVA compared to the general population. The factors which may contribute to the increased risk include the presence of pituitary adenoma and consequent endocrine disturbances and the treatment, particularly the extent of surgery and the dose of radiotherapy. When assessing the value of treatment strategies, it is therefore important to include not only intermediate endpoints of tumor and hormonal control, but also late toxicity, including the incidence of CVA and overall survival as the primary endpoint. The potential predisposing factors for CVA need further elucidation to develop treatment strategies with lower risk and consequently, reduced mortality.
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142
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Querci della Rovere G, Daniels I, Ahmad I, Singh P, Ashley S. Complications after level 1, 2 axillary dissection without division of pectoralis minor. Eur J Cancer 1999. [DOI: 10.1016/s0959-8049(99)81254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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143
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McKinna F, Gothard L, Ashley S, Ebbs S, Yarnold J. Selective avoidance of lymphatic radiotherapy in the conservative management of women with early breast cancer. Radiother Oncol 1999; 52:219-23. [PMID: 10580867 DOI: 10.1016/s0167-8140(99)00115-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Until recently, elective treatment of the lymphatic pathways in women with early invasive breast cancer was assumed to impact on quality of life rather than on overall survival. In a multidisciplinary breast clinic these considerations underpinned a policy of observation of the lymphatic pathways if axillary lymph nodes were not palpably enlarged and if recommendations for adjuvant systemic therapy did not depend on knowledge of pathological node status. This paper evaluates the long-term outcome of the observation policy in terms of lymphatic morbidity due to cancer recurrence. MATERIAL AND METHODS Seven hundred and fifty-nine patients with operable breast cancer and suitable for breast conserving surgery were seen between January 1984 and December 1994. Of these, 291 (38.3%) were recommended a policy of observation to the lymphatic pathways. The case records of these patients were reviewed to record regional relapse patterns and morbidity. RESULTS At a median follow up of 60 months, 32/291 (11%) patients suffered ipsilateral lymphatic relapse at some stage prior to death or last follow up, representing a 22% actuarial 10-year risk of lymphatic relapse. Metastases coincided with, or preceded, lymphatic relapse in 8/32 (25%) patients. Eighteen out of 32 (56%) patients suffered symptoms of lymphatic relapse prior to death or last follow up, despite subsequent surgery, radiotherapy and/or systemic therapies. The absolute risk of symptomatic ipsilateral lymphatic relapse in the observation group was 18/291 (6.2%), representing an actuarial 10-year risk of 17%. CONCLUSION A policy of observation on the axilla with deferred treatment of lymphatic relapse has benefited 273/291 (94%) patients, but at the expense of cancer-related regional morbidity in 18 (6%) patients. We conclude that the cancer-related morbidity suffered by a minority of patients and the strengthening evidence of an overall survival benefit conferred by elective local-regional therapy favours a policy of elective treatment of the lymphatic pathways in the routine setting.
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Helyer SJ, Moskovic E, Ashley S, Hastings L, Yarnold JR. A study testing the routine use of ultrasound measurements when selecting the electron energy for breast boost radiotherapy. Clin Oncol (R Coll Radiol) 1999; 11:164-8. [PMID: 10465469 DOI: 10.1053/clon.1999.9034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The determination of the depth of the tumour bed within the breast requiring an electron therapy boost dose is generally judged clinically and can be inconsistent between individual radiotherapists. High frequency ultrasound provides a reproducible, safe and quick method of measuring this depth. In order to improve current working practice at the Royal Marsden NHS Trust the routine use of ultrasound when planning breast boost radiotherapy was established. Fifty-three early stage postoperative breast cancer patients had both clinical and ultrasound assessments of boost depth performed. These measurements were converted into electron energy and compared. Measurements ranged from 0.8 cm to 4.9 cm and electron energy from 4 MeV to 15 MeV. As a direct result of the ultrasound measurements taken, 60% of patients had their electron energy changed from that chosen by the clinically assessed measurement. Overall, the energy was as likely to be increased as decreased. Breast size did not influence the need for change but patients with small breasts never required an increase in the energy from that chosen clinically. It was concluded that the use of ultrasound, once integrated into the planning process, can improve accuracy when selecting electron energy for patients receiving breast boost irradiation.
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McKinna F, Gothard L, Ashley S, Ebbs SR, Yarnold JR. Lymphatic relapse in women with early breast cancer: a difficult management problem. Eur J Cancer 1999; 35:1065-9. [PMID: 10533449 DOI: 10.1016/s0959-8049(99)00101-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The aim of this study was to review the ability to control symptoms of regional lymphatic relapse in women with early breast cancer. A retrospective study was made of 759 consecutive women presenting with stage 1 or 2 breast cancer treated by breast conserving surgery and radiotherapy between June 1984 and December 1994, 291 (38.3%) of whom were managed by a policy of observation on the lymphatic pathways. Patterns of lymphatic relapse, relapse management and morbidity caused by recurrent malignancy were reviewed from the case notes. The overall rate of relapse in the ipsilateral axilla and/or supraclavicular fossa was 76/759 (10%) at any time prior to death or last follow-up. 34 of 65 patients who relapsed in the axilla did so despite prior axillary surgery and/or radiotherapy. 41 of 76 patients with regional recurrence presented with symptoms, including lymphoedema, arm pain or sensory motor changes. These symptoms were poorly controlled by palliative surgery, radiotherapy or systemic therapy in 23 cases, including 12 who progressed to arm paralysis. Symptomatic control of patients with regional lymphatic relapse can be very difficult, even in women under regular surveillance in a multidisciplinary breast cancer clinic.
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146
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Nutting C, Brada M, Brazil L, Sibtain A, Saran F, Westbury C, Moore A, Thomas DG, Traish D, Ashley S. Radiotherapy in the treatment of benign meningioma of the skull base. J Neurosurg 1999; 90:823-7. [PMID: 10223446 DOI: 10.3171/jns.1999.90.5.0823] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study was undertaken to assess the long-term efficacy and toxicity of conventional fractionated external-beam radiation in the treatment of benign skull base meningioma. METHODS This is a retrospective study of 82 patients with histologically verified benign skull base meningioma treated by surgery followed by fractionated external-beam radiation at the Royal Marsden Hospital between 1962 and 1992. The 5- and 10-year progression-free survival (PFS) rates were 92% and 83%, respectively, with the site of disease being the only independent prognostic factor for tumor control according to multivariate analysis. The 10-year PFS rate for patients with sphenoid ridge meningiomas was 69% compared with 90% for those with tumors in the parasellar region. The overall 10-year survival rate was 71%, with performance status and patient age found to be significant independent prognostic factors. Six patients had worsening vision, which was due to cataract in five cases and retinopathy in one. There were no recorded cases of cranial nerve neuropathy. CONCLUSIONS The excellent long-term tumor control and length of survival with minimal toxicity associated with conventional external-beam radiation should serve as a baseline for evaluation of new treatment strategies such as radiosurgery and skull base surgery.
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147
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Midwinter MJ, Tytherleigh M, Ashley S. Estimation of mortality and morbidity risk in vascular surgery using POSSUM and the Portsmouth predictor equation. Br J Surg 1999; 86:471-4. [PMID: 10215816 DOI: 10.1046/j.1365-2168.1999.01112.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is a simple scoring system previously validated in general surgical patients which enables estimation of the risk of complications and death after operation. The Portsmouth predictor equation (P-POSSUM) is a modification that may result in more accurate prediction of death than POSSUM. The aim of this study was to test the validity of POSSUM and P-POSSUM in patients undergoing major arterial surgery in a specialist unit. METHODS Physiological and operative severity scores in 221 patients undergoing elective and emergency arterial surgery in a pure vascular practice under a single consultant were recorded prospectively. Observed morbidity and mortality rates were compared with the rates predicted by POSSUM and P-POSSUM using a linear method of analysis. RESULTS The POSSUM equation overestimated deaths with this analysis but the mortality rate estimated by P-POSSUM was not significantly different from the observed death rate. The risk of morbidity predicted by POSSUM was not significantly different from the observed complication rate. CONCLUSION The POSSUM methodology combined with the P-POSSUM adjustment for death allows satisfactory prediction of mortality and morbidity rates in patients undergoing vascular surgery.
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Kanis JA, McCloskey EV, Powles T, Paterson AH, Ashley S, Spector T. A high incidence of vertebral fracture in women with breast cancer. Br J Cancer 1999; 79:1179-81. [PMID: 10098755 PMCID: PMC2362233 DOI: 10.1038/sj.bjc.6690188] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Because treatment for breast cancer may adversely affect skeletal metabolism, we investigated vertebral fracture risk in women with non-metastatic breast cancer. The prevalence of vertebral fracture was similar in women at the time of first diagnosis to that in an age-matched sample of the general population. The incidence of vertebral fracture, however, was nearly five times greater than normal in women from the time of first diagnosis [odds ratio (OR), 4.7; 95% confidence interval (95% CI), 2.3-9.9], and 20-fold higher in women with soft-tissue metastases without evidence of skeletal metastases (OR, 22.7; 95% CI, 9.1-57.1). We conclude that vertebral fracture risk is markedly increased in women with breast cancer.
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de Boer RH, Smith IE, Pastorino U, O'Brien ME, Ramage F, Ashley S, Goldstraw P. Pre-operative chemotherapy in early stage resectable non-small-cell lung cancer: a randomized feasibility study justifying a multicentre phase III trial. Br J Cancer 1999; 79:1514-8. [PMID: 10188899 PMCID: PMC2362739 DOI: 10.1038/sj.bjc.6690241] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Surgical resection offers the best chance for cure for early stage non-small-cell lung cancer (NSCLC, stage I, II, IIIA), but the 5-year survival rates are only moderate, with systemic relapse being the major cause of death. Pre-operative (neo-adjuvant) chemotherapy has shown promise in small trials restricted to stage IIIA patients. We believe similar trials are now appropriate in all stages of operable lung cancer. A feasibility study was performed in 22 patients with early stage (IB, II, IIIA) resectable NSCLC; randomized to either three cycles of chemotherapy [mitomycin-C 8 mg m(-2), vinblastine 6 mg m(-2) and cisplatin 50 mg m(-2) (MVP)] followed by surgery (n = 11), or to surgery alone. Of 40 eligible patients, 22 agreed to participate (feasibility 55%) and all complied with the full treatment schedule. All symptomatic patients achieved either complete (50%) or partial (50%) relief of tumour-related symptoms with pre-operative chemotherapy. Fifty-five per cent achieved objective tumour response, and a further 27% minor tumour shrinkage; none had progressive disease. Partial pathological response was seen in 50%. No severe (WHO grade III-IV) toxicities occurred. No significant deterioration in quality of life was detected during chemotherapy. Pre-operative MVP chemotherapy is feasible in early stage NSCLC, and this study has now been initiated as a UK-wide Medical Research Council phase III trial.
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Prance SE, Wilson YG, Cosgrove CM, Walker AJ, Wilkins DC, Ashley S. Ruptured abdominal aortic aneurysms: selecting patients for surgery. Eur J Vasc Endovasc Surg 1999; 17:129-32. [PMID: 10063407 DOI: 10.1053/ejvs.1998.0718] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Mortality from ruptured abdominal aortic aneurysm (RAAA) remains high. Despite this, withholding surgery on poor-prognosis patients with RAAA may create a difficult dilemma for the surgeon. Hardman et al. identified five independent, preoperative risk factors associated with mortality and proposed a model for preoperative patient selection. The aim of this study was to test the validity of the same model in an independent series of RAAA patients. METHODS A consecutive series of patients undergoing surgery for RAAA was analysed retrospectively by case-note review. Thirty-day operative mortality and the presence of the five risk factors: age (> 76 years), creatinine (Cr) (> 190 mumol/l), haemoglobin (Hb) (< 9 g/dl), loss of consciousness and electrocardiographic (ECG) evidence of ischaemia were recorded for each patient. RESULTS Complete data sets existed for 69 patients (mean age: 73 years, range: 38-86 years, male to female ratio: 6:1). Operative mortality was 43%. The cumulative effect of 0, 1 and 2 risk factors on mortality was 18%, 28% and 48%, respectively. All patients with three or more risk factors died (eight patients). CONCLUSIONS These results lend support to the validity of the model. The potential to avoid surgery in patients with little or no chance of survival would spare unnecessary suffering, reduce operative mortality and enhance use of scarce resources.
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