Modern therapeutic approaches to postmastectomy brachial lymphedema

Over the past 10 years we have treated 36 patients affected by upper limb lymphedema, associated with mastectomy and axillary dissection, by either macrosurgical exeresis or microsurgical techniques. All cases had been unresponsive to prior drug or physical therapy (pressure and thermal therapy). Preoperative upper limb status was thoroughly examined by evaluating volume measurements, dynamic lymphoscintigraphy, venous Doppler fluximetry, ultrasonography, and nuclear magnetic resonance. Selected tests were repeated during follow-up to obtain more statistically significant results. Twenty-five of the 36 patients in our series presented a grade II lymphedema and underwent Degni-Cordeiro's microsurgical indirect lymphatico-venous shunt (L.V.S.) surgery. Fifteen of the 25 also received fasciotomies performed along the posterior aspect of the forearm. Three of the 36 patients presented grade II lymphedema and upper limb venous hypertension. These were treated with multiple fasciotomies alone. The remaining eight patients presented grade III lymphedemas. Seven underwent Kondoleon's partial superficial lymphangectomy, and one was treated with Servelle's total superficial lymphangectomy. Of the 36 patients who underwent surgery, only 27 were checked at 6 months; 22 were seen at 18 months. The remaining patients were followed up for too short of a period of time to be considered. Results were arranged into three groups. Classification criteria were: reduction of upper limb dimensions and the presence of the pre-existing symptoms (episodes of lymphangitis, pain, functional deficits. Results were considered good (class 3), fair (class 2), or poor (class 1). A positive clinical picture (class 2-3) was seen in 74% (20/27) at 6 months and in 59% (13/22) at 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

The teaching of clinical oncology in Italian medical schools. A survey among teachers and students

BACKGROUND

Oncologists, health care workers and health organizations consider well-performed teaching programs in clinical oncology a fundamental step in cancer control. The aim of our study was to assess the views of teachers and students on the present status of oncology teaching in Italian medical schools and on the most common shortcomings in cancer education.

MATERIALS AND METHODS

A survey was carried out among teachers and students of 17 Italian medical schools using two different questionnaires. Six hundred forty-seven students of Northern, Central and Southern Italy in the final two years (5th and 6th) of their medical curriculum and 87 professors of pathology, surgery, internal medicine and medical oncology completed the questionnaires.

RESULTS

Doctor/patient relationships and integration among disciplines were the most unsatisfactory aspects of oncology teaching, according to students. Biology, epidemiology, radiotherapy, and medical treatment were felt to be insufficiently treated, whilst diagnostic aspects, clinical management and surgery were rated sufficient. The median number of cancer patients to whom each student had access during his/her training was limited, averaging only 13 patients; however, a high degree of variability was noted. A larger number of patients was generally observed in smaller, less crowded medical schools, with notable exceptions. Although the majority of teachers had clinical practices related to their disciplines, only a small number of students underwent a period of clinical training. Traditional methods of teaching were preferred to innovative methods, while interaction among disciplines was uncommon.

CONCLUSIONS

This survey emphasizes the dualism between students' expectations and teachers' ideas about cancer teaching. Doctor/patient relationships and poor attention to practical clinical problems seem the most critical issues for clinical oncology training in Italian medical schools.

Factors influencing response to second-line treatment with teniposide (VM26) in patients with progressive small cell lung cancer (SCLC)

Twenty-eight patients with small cell lung cancer (SCLC), 12 with limited (LD) and 16 with extensive (ED) disease, 22 of them relapsed to first-line treatment and 6 not responsive, were treated with a single-agent second-line treatment consisting of teniposide (VM26) 60 mg/m2, i.v. on days 1 to 5, every three weeks, until progression. After a minimum of two courses, we observed no complete response, 7 (LD/ED = 4/3) partial responses (25%), 4 (LD/ED = 2/2) minor responses (14%), and 17 (LD/ED = 6/11) with no change (61%). Median duration of response (partial plus minor) was 3.5 months (range 1-8). Median duration of survival, from VM26 administration, was in LD 6 months (range 2.5-11), in ED 3 months (range 1.5-6) and in all patients 4 months (1.5-11). Correlating the 11 responses with major prognostic variables present in the patients, we observed that KPS > 70, few initial courses of PL/VP16 and response to first-line treatment were significant determinants for successful salvage treatment. This study suggests the need to consider detailed patient characteristics of exposure to previous treatment before prompting new drug phase II studies on SCLC.

Hyperthermic antiblastic perfusion in the treatment of local recurrence or "in-transit" metastases of limb melanoma

On the basis of personal experience and a review of the literature, the authors have evaluated the results obtained with hyperthermic antiblastic perfusion (HAP) for the treatment of stage II, III and IIIAB limb melanoma. The evaluation showed that today HAP may be considered a safe and effective treatment, with a major complication rate ranging between 1% and 4%. In terms of tumor response, locoregional control and survival, this treatment has provided better results than other regional chemotherapeutic modalities and undoubtedly better results than those obtained with conventional, even radical, surgery. The multiparametric analysis showed that, of the treatment-related prognostic factors, the minimum tumor temperature influenced the percentage of complete response (CR) to the greatest extent (P < 0.03), with a positive trend also with regard to the dosage of the antiblastic drug employed (P < 0.08). In turn, the complete response rate was a determinant as far as locoregional control (75.3%; P < 0.0009) and disease-free (51.4%; P < 0.009) and overall survival (63.2%; P < 0.009) rates were concerned. Of the tumor-related prognostic factors, the number of lesions (P < 0.0014), sex (P < 0.04), and the number of disease recurrences (P < 0.01) appear to influence overall survival.

Long-term zidovudine therapy in patients with AIDS and symptomatic and asymptomatic HIV infection

Zidovudine is the only anti-retroviral drug approved by the FDA for treatment of HIV infection. We have examined the clinical and laboratory efficacy of this drug for 4 years in a cohort of HIV-infected patients from Wisconsin. Overall, we have found that individuals with AIDS will have at least 1 year of symptom reduction while on the drug. Those with asymptomatic HIV infection tolerate the drug and none have progressed to AIDS in the 4 years of study. Zidovudine is an important component in the treatment of HIV infection.

Magnetic resonance imaging of central nervous system lesions in patients with lupus erythematosus. Correlation with clinical remission and antineurofilament and anticardiolipin antibody titers

Clinical, magnetic resonance imaging (MRI), and serologic studies were performed on 11 patients with diffuse central nervous system (CNS) systemic lupus erythematosus and 8 patients with focal CNS lupus. MRI of patients with diffuse clinical disease showed symmetrically distributed areas of increased signal intensity in the subcortical white matter; these resolved after treatment with high-dose methylprednisolone. These patients' sera contained elevated levels of antineurofilament antibodies. Patients with focal CNS lupus had areas of increased signal intensity and atrophic changes in regions corresponding to the major cerebral vessels. These MRI abnormalities did not improve after treatment with high-dose steroids. The sera of patients with focal CNS lupus had elevated levels of cardiolipin and lupus anticoagulant but normal levels of antineurofilament antibody. Our findings suggest that results of a combined clinical, MRI, and serologic evaluation of patients with CNS lupus may predict the response of patients to high-dose steroid therapy.

Contribution of upper airways to antigen-induced late airway obstructive responses in guinea pigs

The pathogenesis of the late asthmatic response has been of interest due to the fact that its development has been associated with airway obstruction, airway inflammation, and airway hyperresponsiveness: all features of chronic asthma. In order to study more precisely late responses, a number of animal models have been developed. Previous reports have described alterations in airway mechanics at both 3 to 6 and 17 h after antigen challenge in sensitized guinea pigs. In these experiments, however, animals were challenged through the nose with aerosolized antigen, and airway conductance was measured using whole body plethysmography while the animals breathed through the upper airways. In rats similarly challenged, the predominant immediate change in resistance occurs in the upper airways. The purpose of this study, therefore, was to evaluate the contribution made by both the upper and lower airways to late changes after allergen challenge in guinea pigs. Outbred female Hartley guinea pigs were actively or passively sensitized (IgG1 antibody response) to three different antigens and challenged either by direct tracheal insufflation (sheep gamma globulin [SGG] or oxazolone-human serum albumin [OX-HSA]) or by aerosolization (ovalbumin [OA]). Lung resistance (RL) and dynamic compliance (Cdyn) were measured in anesthetized guinea pigs through a tracheostomy tube, and specific airway conductance (SGaw) was measured in unanesthetized, nose-breathing guinea pigs using a whole body plethysmograph. Late responses were defined as a RL greater than the mean + 2 SD RL or as a decrease in SGaw from baseline greater than 2 SD from the placebo-challenged (bovine serum albumin) group.(ABSTRACT TRUNCATED AT 250 WORDS)

IgE antibody production in guinea pigs treated with cyclophosphamide

Guinea pig anaphylactic responses usually involve IgG1 antibodies. Although IgE antibody production has been accomplished, a reliable and sustained method for production has not been described. We have investigated a method of enhancing IgE antibody production in guinea pigs. The criteria for IgE production were homologous passive cutaneous anaphylaxis (PCA) antibody activity that passed an affinity column of rabbit anti-guinea pig IgG1, heat lability (56 degrees C for 3 hr), and a long sensitization period in skin (7 days). Hartley guinea pigs were primed and boosted monthly with 1 microgram Picryl-Ascaris plus 1 mg of alum i.p. Some Hartley guinea pigs also received cyclophosphamide (250 mg/kg) before the first boost. English short-hair guinea pigs (previously shown to be good IgE producers) were immunized similarly but received no cyclophosphamide. Hartley animals receiving no cyclophosphamide inconsistently made low titered IgE anti-hapten antibody (1:100). Fifteen of 15 Hartley animals that received cyclophosphamide had high titers (1:2000) of IgE anti-hapten antibody. English short-hair animals had moderate titers (1:400), and not all animals responded. Thus, cyclophosphamide converted IgE nonresponder Hartley guinea pigs to uniformly high responders. This method provides material to study the biologic properties of IgE in this species, and also provides a model to study the apparent suppression of IgE responses in Hartley guinea pigs.

IgE antibody production in guinea pigs treated with cyclophosphamide

Guinea pig anaphylactic responses usually involve IgG1 antibodies. Although IgE antibody production has been accomplished, a reliable and sustained method for production has not been described. We have investigated a method of enhancing IgE antibody production in guinea pigs. The criteria for IgE production were homologous passive cutaneous anaphylaxis (PCA) antibody activity that passed an affinity column of rabbit anti-guinea pig IgG1, heat lability (56 degrees C for 3 hr), and a long sensitization period in skin (7 days). Hartley guinea pigs were primed and boosted monthly with 1 microgram Picryl-Ascaris plus 1 mg of alum i.p. Some Hartley guinea pigs also received cyclophosphamide (250 mg/kg) before the first boost. English short-hair guinea pigs (previously shown to be good IgE producers) were immunized similarly but received no cyclophosphamide. Hartley animals receiving no cyclophosphamide inconsistently made low titered IgE anti-hapten antibody (1:100). Fifteen of 15 Hartley animals that received cyclophosphamide had high titers (1:2000) of IgE anti-hapten antibody. English short-hair animals had moderate titers (1:400), and not all animals responded. Thus, cyclophosphamide converted IgE nonresponder Hartley guinea pigs to uniformly high responders. This method provides material to study the biologic properties of IgE in this species, and also provides a model to study the apparent suppression of IgE responses in Hartley guinea pigs.