[Hospital anxiety and depression scale (HADS): Validation in a Greek general hospital sample]

The Hospital Anxiety and Depression Scale (HADS) has been translated and widely used in several countries to assess anxiety and depression in general hospital patients with good results. Material-Method The HADS was administered to 521 participants (275 controls and 246 inpatients and outpatients of Internal Medicine and Surgical Departments). The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were used as "gold standards" for depression and anxiety respectively. Results The HADS presented high internal consistency; Cronbach's α=0.884 (0.829 for anxiety and 0.840 for depression) and stability (test-retest Intraclass Correlation Coefficient 0.944). Factor analysis showed a two-factor structure. The HADS showed high concurrent validity; the correlations of the scale and its subscales with the BDI and the STAI were high (0.722-0.749).

CONCLUSIONS

The Greek version of HADS showed good psychometric properties and could prove as a good tool for clinicians to assess anxiety and depression in general hospital patients.

Performance status (PS): a simple predictor of short-term outcome of cancer patients with solid tumors admitted to the intensive care unit (ICU)

BACKGROUND

Admission of cancer patients with serious medical complications to the Intensive Care Unit (ICU) remains controversial. The aim of this study was to examine the 30-day all-cause mortality in cancer patients with solid tumors admitted to the ICU and to identify factors predicting 30-day mortality.

PATIENTS AND METHODS

A retrospective study was conducted in 69 consecutive cancer patients with solid tumors admitted to the ICU of a 400-bed general hospital in Greece, between October 2001 and October 2005. Demographics, ECOG performance status (PS) prior to hospitalization, stage of cancer, metastases, number of metastatic sites, prior chemotherapy, primary site of tumor, APACHE II score on ICU admission, development of ICU acquired infection, sepsis, multiple organ failure (MOF), need for mechanical ventilation (MV), length of ICU stay, hospital stay and 30-day mortality were examined.

RESULTS

The observed 30-day hospital mortality rate was 66.6% (n=46) with most deaths (n=32) occurring in the ICU. Univariate negative predictors of 30-day mortality were PS 3-4 (p=0.03), APACHE II score (p=0.001), MOF (p=0.001) and need for MV (p=0.001). Only PS 3-4 was an independent predictor in multivariate analysis (p=0.02).

CONCLUSION

ECOG PS 3-4 prior to hospitalization was found to be a simple negative predictor of short-term outcome of cancer patients with solid tumors admitted to the ICU.

Platelet-derived growth factor receptor alpha (PDGFRA) and C-Kit immunohistochemistry (IHC) in gastrointestinal stromal tumours (GISTs)

15156

Background: The vast majority of GISTs show activating mutations of the genes coding for c-kit (CD 117) and PDGFRA, two receptor tyrosine kinases (RTKs). The exact role of PDGFRA as this expressed immunohistochemically (IHC), has not been fully elucidated in the diagnosis and treatment of GISTs. The aim of this study was (1) to try to correlate the pathological features of patients (pts) with GISTs, with c-kit and PDGFRA as these expressed by IHC and 2) to correlate the c-kit and PDGFRA with the clinical outcome of the pts. We report here the first part of the study. Materials and Methods: Twenty one (21) pts with GISTs were studied 14 located in the stomach, 3 in small bowel, 3 in colon and 1 in the mesenterium. Criteria for positivity of c-kit were strong membranus, cytoplasmic and paranuclear staining and for PDGFRA dot-like or Golgi pattern of staining. Median age was 61 years while there was a male predominance. Results: C-kit was detected in 95% of cases while PDGFRA in 90.5%. All the GISTs that were positive for PDGFRA were also positive for c-kit. Conclusions: Preliminary results of the first part of the study show that an accurate diagnosis of GISTs can be achieved based on the conventional histological and IHC criteria without the need for mutational analysis.

No significant financial relationships to disclose.

Predictive value of EGFR mRNA levels assessed by quantitative RT-PCR in primary tumors of patients treated with cetuximab for metastatic colorectal cancer

4121

Background: The epidermal growth factor receptor (EGFR) protein is the nominal target of the monoclonal therapeutic antibody cetuximab. Yet, repeated failure of EGFR immunohistochemistry (IHC) in predicting treatment outcome has questioned its value in colorectal cancer (CRC). Therefore search for a valid molecular predictor of cetuximab efficacy is highly justified. Methods: 64 CRC patients were treated with standard chemotherapy plus cetuximab in the metastatic setting. RNA was isolated from fixed tumor tissue samples employing an experimental method based on magnetic beads from Siemens Medical Solutions Diagnostics, followed by kinetic one-step RT-PCR for EGFR, HER-2, HER-3, and HER-4 analysis. EGFR protein levels were also assessed by IHC in 62 of the patients, using the 31G7 clone of the mouse monoclonal antibody (Zymed). Slides scored 1+, 2+ and 3+ were considered EGFR protein positive. Results: After a median follow-up of 17 months, median survival was 15.1 months, while median time to disease progression (TTP) was 6.6 months. For the RT-PCR results an objective cut-off at the 2nd quartile (median) for the HER family was chosen. EGFR RNA levels above the median value, demonstrated predictive value in terms of a prolonged TTP (9.3 vs. 5.5 months, p=0.017). No difference was found in terms of survival (24.6 vs. 12.6 months, p=0.106). EGRF assessed by IHC and the rest of the HER family markers assessed by RT-PCR failed to predict TTP outcome or survival. Finally, no agreement was found between the IHC and RT-PCR methods when assessing EGFR. Conclusions: The results of this retrospective study show a predictive value of EGFR RNA levels assessed by RT-PCR on TTP, as opposed to EGFR protein levels. Prospective validation studies are needed to prove if this biomarker is the missing molecular predictor of response to cetuximab.

No significant financial relationships to disclose.

EGF105084, a phase II study of lapatinib for brain metastases in patients (pts) with HER2+ breast cancer following trastuzumab (H) based systemic therapy and cranial radiotherapy (RT)

1012

Background: CNS disease is a major problem among pts treated with H for stage IV HER2+ breast cancer with a reported incidence of 28–43%. This study was designed to characterize further the activity reported with lapatinib in an initial phase II trial in women with HER2+ disease metastatic to brain (Lin et al ASCO ‘06). Methods: Eligible pts had HER2+ breast cancer, prior H therapy and cranial RT, ECOG PS 0–2, and radiographic evidence of progressive brain metastases with at least one measurable (LD = 10mm) brain lesion. Pts received lapatinib 750 mg PO BID. Brain MRIs were obtained at 3.0 mm slices without gaps in the axial dimension. The primary endpoint was CNS response as defined by a = 50% volumetric (vol) reduction of CNS lesions in the absence of: new lesions, need for increased dose of steroids, progressive neurological signs/symptoms (NSS), or progressive extra-CNS disease. CNS disease progression was defined as either a = 40% vol increase from nadir, increase in steroid requirements, or progression of NSS. Results: The study exceeded its accrual goal of 220 pts in < 1 year; 238 pts were enrolled from Jan-Nov 06. Preliminary data from the initial 104 pts have undergone independent radiology review. 8 pts (7.7%) met vol criteria for partial response with a median absolute vol reduction of CNS disease of 3.6 cm3 (range 0.4 to 29.7 cm3). Exploratory analysis revealed that 17 of the initial 104 pts (16.3%) experienced a = 20% vol reduction of CNS disease with a median absolute vol reduction of 3.3cm3. The median time to vol progression in these 17 pts was 16 wks (range 12 -24 wks). Analysis of efficacy and tolerability based upon protocol defined criteria from all 238 pts will be presented. Conclusions: Preliminary data from this large multicenter trial provides evidence that lapatinib has activity based on vol reductions in pts with progressive HER2+ CNS disease following prior H-based systemic therapy and cranial RT. Definitive conclusions will be based on the entire database. Additional studies are warranted incorporating lapatinib in combination with other therapies and/or in a less refractory setting to optimize its use in HER2+ CNS disease.

[Table: see text]

Vasculopathy and arterial stenotic lesions in the antiphospholipid syndrome

The antiphospholipid (Hughes) syndrome (APS) is characterized by recurrent arterial or venous thromboembolism, or pregnancy loss, in association with antiphospholipid antibodies. These antibodies may be associated with premature or accelerated atherosclerosis and emerging evidence supports the concept of a vasculopathy in the APS that may lead to arterial stenotic lesions, possibly contributing to vascular occlusions and pregnancy morbidity.

State anxiety during watchful waiting for urinary lithiasis

OBJECTIVES

Guidelines on many disorders recommend a variable period of watchful waiting between diagnosis and indicated action. In this study, we assessed stress during the watchful waiting period for urinary lithiasis, a benign disorder treated with minimally invasive procedures, without the pitfall of the emotional burden of a terminal or debilitating disease or fear of impending major surgery and to assess the distress caused by waiting per se. Furthermore, we attempt to identify individual patients at risk of prolonged or debilitating psychological distress.

METHODS

A total of 112 lithiasis patients with stones < or =5 mm completed the study. State and trait anxiety were assessed both at baseline and after the end of watchful waiting using STAI, and then they were informed of the indicated action for their case.

RESULTS

During the 30 days of watchful waiting, patients experienced a significant increase in state anxiety scores, especially if they were male, had high state or trait anxiety scores at baseline, or if they had experienced more than one episode of colicky pain during the waiting period.

CONCLUSION

Clinicians should be more flexible when they face the above group of patients, as far as the duration of watchful waiting period is concerned, because a long waiting sets those patients under significant emotional burden.

Polyarticular septic arthritis

Septic arthritis can be polyarticular, and joints suspected of harbouring infection should be aspirated urgently

Paclitaxel and gemcitabine vs. paclitaxel and pegylated liposomal doxorubicin in advanced non–nasopharyngeal head and neck cancer. An efficacy and cost analysis randomized study conducted by the Hellenic Cooperative Oncology Group

BACKGROUND

The prognosis of patients with recurrent and/or metastatic head and neck cancer (HNC) is poor. Median survival of these patients following chemotherapy is in the range of 6 to 9 months. In the present randomized phase III trial we compared two new combinations containing new drugs with proven activity in phase II studies with patients with HNC.

PATIENTS AND METHODS

From November 1999 until November 2004, 166 eligible patients with HNC were enrolled in the study. They were treated with paclitaxel 175 mg/m(2) on day 1 and gemcitabine 1000 mg/m(2) on days 1 and 8 every 3 weeks (group A, 85 patients) or with paclitaxel, as in group A, and pegylated liposomal doxorubicin 40 mg/m(2) on day 1 every 4 weeks (group B, 81 patients).

RESULTS

There was no significant difference in response rate (20% versus 29%, P = 0.21), time to disease progression (median; 4.4 months versus 6.0 months, P = 0.09) and survival (median; 8.6 months versus 11.05 months, P = 0.25). Both regimens were generally well tolerated. The most frequently reported side effect, apart from alopecia, was neutropenia. Overall, there was no significant difference in severe toxicity between the two treatment arms.

CONCLUSIONS

The present study could not demonstrate a survival benefit with either regimen. Both treatments were well tolerated. Randomized studies comparing each of the two regimens with standard chemotherapy are warranted.

Evaluation of the prognostic and predictive value of p53 and Bcl-2 in breast cancer patients participating in a randomized study with dose-dense sequential adjuvant chemotherapy

PURPOSE

To assess the prognostic and predictive significance of p53 and Bcl-2 protein expression in high risk patients with breast cancer treated with dose-dense sequential chemotherapy.

PATIENTS AND METHODS

From June 1997 until November 2000, 595 patients were randomized to three cycles of epirubicin (E) 110 mg/m2 followed by three cycles of paclitaxel (P) 250 mg/m2 followed by three cycles of 'intensified' CMF (cyclophosphamide 840 mg/m2, methotrexate 47 mg/m2 and fluorouracil 840 mg/m2) or to four cycles of E, followed by four cycles of CMF. p53 and Bcl-2 expression was investigated by immunohistochemistry in 392 and 397 patients respectively.

RESULTS

Positive expression of p53 was detected in 104 (26.5%) patients and was significantly associated with negative hormonal status, worse histologic grade, higher incidence of disease relapse and higher rate of death. p53 positive expression was a significant negative predictor of overall survival (OS) (P = 0.002) and disease-free survival (DFS) (P = 0.001). Negative expression of Bcl-2 was detected in 203 (51%) patients and was significantly associated with negative hormonal status. Multivariate analysis revealed that, positive p53 expression, higher number of positive nodes and worse tumor grade were related to significantly poorer OS and DFS.

CONCLUSIONS

For both treatments, p53 positive expression was a significant negative prognostic factor for OS and DFS while Bcl-2 was not. No predictive ability of p53 status or Bcl-2 status for paclitaxel treatment was evident.

Expression of growth hormone-releasing hormone (GHRH) and splice variant of GHRH receptors in normal mouse tissues

Growth hormone-releasing hormone (GHRH) stimulates the production and release of growth hormone in the pituitary and induces cell proliferation in a variety of peripheral tissues and tumors. These extrapituitary effects of GHRH are in many cases mediated by a splice variant of GHRH receptor designated SV1 that differs from the pituitary GHRH receptor in a small portion of its amino-terminal region. While SV1 has been detected in several primary tumors and many cancer cell lines its expression in normal tissues remains unclear. In this study we report the results of an immunohistochemical analysis for SV1 and GHRH expression in normal mouse tissues. For the detection of SV1 immunoreactivity we used a polyclonal antiserum against segments 1-25 of the SV1 receptor protein. Mouse heart, colon, lungs, small intestine, stomach and kidneys exhibited increased SV1 immunoreactivity. These tissues were also positive for GHRH expression, however, tissues such as the endometrium were positive only for GHRH and not for SV1 expression. On the contrary, testis were positive for SV1 and not for GHRH expression. These results indicate that SV1 may play a role in normal physiology.

Novel germline mutations in the APC gene of Cypriot patients with familial and sporadic adenomatous polyposis

Familial adenomatous polyposis (FAP) is one of the two commonest familial syndromes that predispose to colorectal cancer. FAP is caused by mutations in the adenomatous polyposis coli (APC) tumour suppressor gene that has a high penetrance. The disease is characterized by the occurrence of hundreds to thousands of colorectal polyps, which if left untreated give rise to colorectal cancer. In Cyprus, there are no molecular data available as yet on families with FAP. This work presents the results of APC analysis in our population for the first time. The APC gene was analyzed in 33 DNA samples from 20 individuals belonging to four FAP families and 13 patients with sporadic polyposis. We identified three truncating mutations, four missense mutations and 11 polymorphisms. It is of interest that two of the three truncating mutations, 2307delA and Q1242X, are novel, which supports the existence of a unique genetic pool in the Cypriot population. This ethnic molecular study in addition to highlighting population heterogeneity also contributes to phenotype-genotype associations that are essential for the clinical management of FAP families in Cyprus.

Predictive markers for the treatment of colorectal cancer with cetuximab

13500

Background: Cetuximab is an anti-EGFR monoclonal antibody with activity in colorectal cancer. Patients most likely to benefit should be identified using molecular markers. Methods: A retrospective analysis was performed on patients treated with cetuximab who had paraffin embedded tissue available for testing. Tumor specimens were tested for EGFR (31G7, Zymed), PTEN (28H6, Novocastra) and pAkt 1/2/3 (Thr 308, Santa Cruz) expression by IHC. The EGFR gene status was investigated by FISH (Vysis). Results: Seventy-two patients were identified. EGFR expression was detected in 32/68 patients tested. PTEN was positive in all cases tested (64/64) and pAkt in 52 of 64 patients, in >70% of cells in 21/64 cases. Most patients were treated with cetuximab in various combinations, three patients received it as a single agent and 7 patients in more than one line of therapy. Median follow-up from diagnosis was 30.7 months and from Cetuximab initiation 6.9 months. Median survival from diagnosis has not been reached yet but from initiation of Cetuximab it is 13.6 months. 19 patients achieved a PR and 1 a CR. Most patients with PR were treated in first or second line however, 6 patients achieved a PR in 3rd line and 3 in subsequent lines. The patient with complete response, was treated in first line with CPT 11 and Cetuximab. TTP was 7.4 months for patients treated with Cetuximab in 1st line, 7.5 in 2nd line and 5.3 in 3rd line. Survival did not correlate significantly with any of the immunohistochemically assessed parameters. TTP correlated significantly with pAkt overexpression for patients treated in 3rd line (p=0.0065). The CR was seen in the only patient with EGFR amplification.The presence of skin toxicity did not correlate with response to therapy. Conclusions: Overexpression of pAkt may correlate with response to Cetuximab in colorectal cancer.

No significant financial relationships to disclose.

Mutations of the epidermal growth factor receptor tyrosine kinase domain and associations with clinicopathological features in non-small cell lung cancer patients

Somatic tyrosine kinase (TK) domain mutations of the epidermal growth factor receptor (EGFR) gene are associated with sensitivity of non-small cell lung cancer (NSCLC) to tyrosine kinase inhibitors (TKI's), however their incidence in distinct populations is not clarified. We sequenced exons 18-21 of the EGFR TK domain from 60 Greek and Czech patients, enrolled in an adjuvant chemotherapy trial following total resection for stages I-IIIa disease. Somatic mutations were found in 9/60 patients (15.0%), several being novel. EGFR mutations were more common in Stage I tumors (p = 0.023), they were also more common in women and never smokers; however, no other significant association of clinicopathological features with mutations was found. Median TTP and OS of patients with and without mutations were 13.2 and 40 months compared to 22.9 and 43.2 months, respectively. These differences were not statistically significant. K-ras (5/60, 8%) and EGFR mutations were found to be mutually exclusive. We identified a wide spectrum of somatic EGFR TK mutations reporting a relatively high incidence (15%) in NSCLC patients of Greek and Czech origin. As ethnicity seems to be a factor for the origin of these mutations, further studies in distinct populations are warranted.

Joint inflammation and cytokine inhibition in rheumatoid arthritis

The hallmark of rheumatoid arthritis (RA) is chronic synovial inflammation resulting in progressive joint damage. Cytokines are key mediators of inflammation and can be found in abundance both in the joint and blood of patients with active disease. They are responsible not only for the destructive synovitis but also for some of the systemic features. Research over the last 2 decades has highlighted the important role of cytokines such as tumour necrosis factor alpha (TNF-alpha) and interleukins (IL) 1, 6 and 15 in the pathogenesis of RA and these are potential therapeutic targets. Inhibitors of TNF-alpha and IL-1 are already licensed treatments for RA. Novel biologic agents targeting IL-6 and -15 are currently being developed and showed promise in early clinical trials. This article reviews the role of various cytokines in the pathogenesis of RA and the therapeutic effect of inhibiting these cytokines.

Donepezil improved memory in multiple sclerosis in a randomized clinical trial

OBJECTIVE

To determine the effect of donepezil in treating memory and cognitive dysfunction in multiple sclerosis (MS).

METHODS

This single-center double-blind placebo-controlled clinical trial evaluated 69 MS patients with cognitive impairment who were randomly assigned to receive a 24-week treatment course of either donepezil (10 mg daily) or placebo. Patients underwent neuropsychological assessment at baseline and after 24 weeks of treatment. The primary outcome was change in verbal learning and memory on the Selective Reminding Test (SRT). Secondary outcomes included other tests of cognitive function, patient-reported change in memory, and clinician-reported impression of cognitive change.

RESULTS

Donepezil-treated patients showed significant improvement in memory performance on the SRT compared to placebo (p = 0.043). The benefit of donepezil remained significant after controlling for various covariates including age, Expanded Disability Status Scale, baseline SRT score, reading ability, MS subtype, and sex. Donepezil-treated patients did not show significant improvements on other cognitive tests, but were more than twice as likely to report memory improvement than those in the placebo group (p = 0.006). The clinician also reported cognitive improvement in almost twice as many donepezil vs placebo patients (p = 0.036). No serious adverse events related to study medication occurred, although more donepezil (34.3%) than placebo (8.8%) subjects reported unusual/abnormal dreams (p = 0.010).

CONCLUSIONS

Donepezil improved memory in MS patients with initial cognitive impairment in a single center clinical trial. A larger multicenter investigation of donepezil in MS is warranted in order to more definitively assess the efficacy of this intervention.

Postoperative dose-dense sequential chemotherapy with epirubicin, followed by CMF with or without paclitaxel, in patients with high-risk operable breast cancer: a randomized phase III study conducted by the Hellenic Cooperative Oncology Group

PURPOSE

The aim of this study was to explore the effect of dose-dense sequential chemotherapy with or without paclitaxel primarily on disease-free survival (DFS) and secondarily on overall survival (OS) in patients with high-risk operable breast cancer.

PATIENTS AND METHODS

From June 1997 until November 2000, 604 patients with T1-3N1M0 or T3N0M0 tumors were randomized to three cycles of epirubicin 110 mg/m2 followed by three cycles of paclitaxel 250 mg/m2 followed by three cycles of 'intensified' CMF (cyclophosphamide 840 mg/m2, methotrexate 47 mg/m2 and fluorouracil 840 mg/m2) (group A), or to four cycles of epirubicin followed by four cycles of CMF, as in group A (group B). All cycles were given every 2 weeks with granulocyte colony-stimulating factor support.

RESULTS

A total of 595 patients were eligible. Median follow-up was 61.7 months for group A and 62 months for group B. The 3-year DFS was 80% in group A and 77% in group B. Survival rates were 93% and 90%, respectively. The effect of treatment on the hazard of death was different according to hormonal receptor status. More specifically, in patients with negative receptor status the hazard of death was significantly higher for group B (hazard ratio 2.42). Both regimens were well tolerated and severe acute side-effects were infrequent. No cases of severe cardiotoxicity or acute leukemia were recorded.

CONCLUSIONS

The present study failed to demonstrate a significant difference in DFS or OS between the two treatment groups. However, our study has shown clearly that high-dose paclitaxel can be safely incorporated to dose-dense sequential chemotherapy.