Breast surgery after neoadjuvant treatment. Is it necessary?

The optimum management of women with advanced loco-regional breast cancer (T3-4, N1-2) is controversial. Neoadjuvant therapy in the form of chemotherapy and or radiotherapy is popular and results in an encouraging local response in over 70% of patients. However, should subsequent surgery (either mastectomy or breast conservation treatment) be undertaken in women who respond? We present a prospective evaluation of 15 patients with T3-4, N1-2 tumours (including 1 bilateral cancer) who underwent mastectomy after achieving a complete clinical response to neoadjuvant treatment. All patients had 6 cycles of chemotherapy and 10 also received 50 Gy radiotherapy. In addition to clinical examination, the response to neoadjuvant treatment was assessed by mammography (in all cases) and by magnetic resonance imaging (MR) (in eight patients). Careful histopathological assessment of the breast was undertaken to determine the extent of residual disease. In all patients histological malignancy was recognized within the breast. The size varied from 0.6 to 6.5 cm in maximum diameter with three grade I, eight grade II and five grade III tumours. Axillary lymph nodes were positive in seven patients. In conclusion, surgery is indicated for control of residual disease in locally advanced breast cancer regardless of the response to neoadjuvant treatment. Our preliminary observations suggest a potential role for breast MR in defining the extent of residual disease which may aid in the planning of surgery.

The role of radiotherapy in the management of cancer--an overview

Artificial X-rays were first produced in Germany in 1895 and used for cancer almost immediately. During the century since this remarkable discovery, radiation therapy has now become the most imporantant non-surgical modality in cancer: over 50% of all cancer patients now receive radiotherapy at some point during the illness. Radiation therapy has increasingly replaced surgical resection for primary control of a variety of solid tumours, particularly where surgical excision is accompanied by severe long-term tissue loss or psychological morbidity. Frequent examples include cancers of the breast, head and neck (especially larynx, naso- and other pharyngeal sites), and locally advanced cancer of the cervix. Combinations of surgery and radiotherapy are increasing used, for example in the preferred management of most cancers of the breast, by wide local surgical excision, breast preservation and postoperative radiotherapy. In rectal carcinoma as well, there is clear evidence of survival improvement in locally advanced cases when surgical excision is followed by routine pelvic irradiation. In other circumstances, radiation is routinely combined with chemotherapy, as for example in the standard management of small cell lung cancer. Anal carcinoma is also best treated by radical radiochemotherapy, avoiding surgical excision (with permanent colostomy) in the majority of patients. In both the developed and developing world, these are all common tumours, with the result that in 1990, almost half a million patients were treated with radiation therapy in the United States of America. Recent technical advances, both in imaging and therapy beam precision, have greatly improved the therapeutic ratio and accuracy of modern radiotherapy. Radiation therapy continues to progress on a rational scientific basis, with a secure clinical role for the foreseable future.

Financial ties as part of informed consent to postmarketing research. Attitudes of American doctors and patients

Postmarketing research, often called phase IV trials, is intended to familiarise doctors and patients with newly approved drugs. La Puma and colleagues, in Chicago, studied doctors' and patients' attitudes to whether doctors should receive payment for taking part in such research. We asked for commentaries on their findings from four ethical experts, who put the study in a British context, present the views of patients, and examine some methodological assumptions.

Hodgkin's disease, follicular non-Hodgkin's lymphoma and a high grade B cell non-Hodgkin's lymphoma in the same patient

We report an unusual patient with a 21 year history of lymphoma of three different histological varieties: a low grade follicular non-Hodgkin's lymphoma, mixed cellularity Hodgkin's disease and a high grade B cell monocytoid non-Hodgkin's lymphoma.

Cutaneous B-cell lymphoma with subsequent laryngeal involvement

Cutaneous lymphoma is uncommon and lymphomatous infiltration of the larynx, occurring either as primary disease or as a feature of multifocal disease, is rare. We report a case of cutaneous, high grade non-Hodgkin's lymphoma with isolated relapse in the larynx. The laryngeal deposit was identical to the original cutaneous lymphoma, demonstrated histologically and using the polymerase chain reaction. Complete remission of the primary lesion was attained with local radiotherapy, and a second complete remission with chemotherapy. To date, no case of primary cutaneous lymphoma with subsequent involvement of the larynx has been reported, but the association is worth documenting, since symptoms referable to the larynx are easily overlooked. They may indicate incipient embarrassment of the airway, thus requiring urgent investigation and treatment, which is generally highly effective.

Autologous bone marrow transplantation in multiple myeloma: a single centre experience of 23 patients

We report the complications and outcome of high-dose melphalan and TBI combined with ABMT used in the treatment of multiple myeloma at a single centre. Twenty-three patients, aged 65 years or less, who underwent the procedure are reviewed. All had chemosensitive disease. Response to ABMT assessed at 3 months showed 75% of evaluable patients to have further tumour cytoreduction of at least 50%, with 24% of patients who entered ABMT with residual disease eventually achieving CR. There was one toxic death. The overall survival is 60% and the progression-free survival is 49.8% at a median follow-up time of 17 months. Relapse or disease progression has occurred in 27% of patients, of whom half have died. No significant prognostic factors affecting survival were found although those patients with IgG myeloma had a better outcome. Patients transplanted in first plateau appeared to do significantly better if they had been resistant to their first-line chemotherapy but had then responded to further conventional chemotherapy (p = 0.029).

Randomized trial comparing weekly versus 3-week chemotherapy in small-cell lung cancer: a Cancer Research Campaign trial

PURPOSE

A randomized trial of chemotherapy, given on either a 1-week or a 3-week schedule, was performed in small-cell lung cancer (SCLC) patients. The aim was to determine if weekly scheduling produced survival superior to conventional treatment.

PATIENTS AND METHODS

Four hundred thirty-eight patients with SCLC with either limited disease (LD; 276 patients) or good-prognosis extensive disease (ED; 162 patients) were randomized. Weekly chemotherapy was 12 alternating cycles of ifosfamide/doxorubicin and cis-platin/etoposide (PE), while 3-week treatment was six alternating cycles of cyclophosphamide/doxorubicin/vincristine (CAV) and PE. Thoracic irradiation was administered 3 weeks after completion of chemotherapy to LD patients who attained a complete response (CR) or partial response (PR). Patients were well matched for clinical characteristics and prognostic factors.

RESULTS

Overall response was the same in both arms: 82.3% (39.4% CR) with weekly and 81.1% (36.9% CR) with 3-week treatment. The median survival (MS) durations were 10.8 and 10.6 months for weekly and 3-week chemotherapy, respectively. The 2-year survival rates were 11.8% and 11.7% in the weekly and 3-week arms, respectively. Received dose-intensity (DI) was 73.9% of projected for weekly treatment and 92.7% for 3-week treatment. Hematologic toxicity was the major dose-limiting toxicity for the weekly treatment.

CONCLUSION

This trial excludes at 90% power a benefit of greater than 10% for 2-year survival for weekly treatment. The received DI was reduced to a greater extent with weekly treatment, mainly due to hematologic toxicity.

Cancer of the head and neck

Cancers of the upper aerodigestive tract, collectively known as head and neck cancers, arise from a multiplicity of sites. In the West, excess tobacco and alcohol consumption are the most important of the known predisposing factors; elsewhere in the world, notably in India and China, the aetiology, pattern of primary sites, and clinical behaviour are different. Clinically these tumours pose exceptional problems in management, and skilled multidisciplinary teams are necessary in order to achieve the highest level of service and research. Historically, surgery and radiotherapy have been the most important treatment modalities; chemotherapy is now increasingly employed but not yet fully established. Successful rehabilitation of patients with head and neck cancers requires access to high quality speech therapists and other support staff with training in functional pharyngeal disorders. Current research efforts are largely directed towards defining the proper role of chemotherapy and assessing the possible advantage of unconventional radiation approaches. In recent years the roles of primary, reconstructive, and salvage surgery have also become better defined. Many patients are suitable for randomisation into ongoing prospective clinical trials which have been specifically designed to address these issues.

Fully informed consent can be needlessly cruel

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Radiation enhancement of laser palliation for advanced rectal and rectosigmoid cancer: a pilot study

Laser palliation for advanced rectal or rectosigmoid cancer requires repeat treatments every four to six weeks. Thirteen patients (seven men, six women) age range 65-91 (median 81) received additional external beam radiotherapy in an attempt to reduce the frequency of laser treatments required. After successful laser recanalisation, patients were treated with a dose of 30-55 Gy in 10-20 fractions. Bowel symptoms were well controlled for prolonged periods in 11 patients (85%) and further laser procedures were only required every 19 weeks median (range 6-53 weeks). The laser energy required after radiotherapy was only 800 J/month (median). Survival was 14 months (median, range 2.5-20 months) for the seven patients who have died. Seven patients received laser treatment only for three months or more (median 14 weeks, range 13-39). In this group control of symptoms required procedures every four weeks (median) before radiotherapy and 20 weeks (median) afterwards. The laser energy required before radiotherapy was 15,000 J/month and 2000 J/month afterwards (Wilcoxon rank sum test, p < 0.01 for both). Radiotherapy was well tolerated in all but one patient. Three patients developed strictures after radiotherapy but all were dealt with endoscopically. There were no complications solely due to endoscopic procedures. Additional radiotherapy enhances laser palliation for inoperable rectal or rectosigmoid cancer.

Interleukin-2-responsive wound-infiltrating lymphocytes in surgical adjuvant cancer immunotherapy

Wound-infiltrating lymphocytes (WIL) were assessed in murine models of localized sarcoma and carcinoma to evaluate the role of interleukin-2 (IL-2)-responsive lymphocytes in adjuvant immunotherapy. Following tumor resection, IL-2 or diluent was injected at the surgical site for 6 days. Surgical site tissues were harvested and digested in a triple enzyme mixture, and single cell suspensions were prepared. Thy 1.2+ lymphocytes were isolated by incubating cells with monoclonal anti-Thy 1.2 antibody-coated magnetic beads. Lymphocyte-bead complexes were extracted with a magnet and cultured in medium containing IL-2 (100 units/ml) for 1-3 weeks. Perioperative IL-2 immunotherapy led to a three- to four-fold increase in WIL yield. WIL from IL-2-treated mice also demonstrated enhanced cytolysis of the autologous tumor and bound to activated endothelial cells with greater avidity than did the controls. We conclude that perioperative IL-2 therapy augments the yield, as well as the cytolytic and adhesive properties, of wound-infiltrating lymphocytes.

Intratumoral interleukin-2 immunotherapy: activation of tumor-infiltrating and splenic lymphocytes in vivo

Direct intratumoral injection of interleukin-2 (IL-2) was evaluated in a murine model. Balb/c mice received 5 x 10(4) Line 1 alveolar carcinoma cells (L1C2) by subcutaneous injection. On the third day following tumor implantation, mice received injections of IL-2 (5 x 10(3)-5 x 10(4) units) or diluent twice daily, either by i.p. or intratumoral injection, 5 days/week for 3 weeks. Intratumoral injection of 5 x 10(4) units IL-2 significantly reduced tumor volume (P < 0.05 versus control), increased median survival time (P = 0.0001), and resulted in a 23.5% cure rate (P = 0.008). There were no long-term survivors in the other treatment groups. Both tumor-infiltrating lymphocytes (TIL) and splenic lymphocytes isolated directly from IL-2-treated mice demonstrated enhanced cytolytic activity compared to diluent-treated controls. To determine whether non-T-cell-mediated antitumor responses were active in our model, intratumoral immunotherapy was evaluated in athymic Balb/c nu/nu mice. In order to decrease the recruitment of lymphocyte precursors, nude mice were splenectomized and received cyclophosphamide prior to tumor injection and IL-2 therapy. Intratumoral IL-2 immunotherapy also significantly decreased tumor volume in these immunodeficient mice (P < 0.02), but did not lead to long-term survival. We conclude that both TIL and splenic lymphocytes are activated in vivo in response to intratumoral IL-2 immunotherapy, suggesting that intratumoral therapy with IL-2 activates both local and systemic antitumor responses.

Double hemibody irradiation (DHBI) in the management of relapsed and primary chemoresistant multiple myeloma

In view of increasing controversy regarding the role of double hemibody irradiation (DHBI) in the treatment of multiple myeloma, we have analysed the use of this technique at our institution over a 6-year period. Fifty-five patients with multiple myeloma were treated with both upper and lower hemibody irradiation between January 1985 and January 1991; 42 had relapsed post-plateau and 13 were chemoresistant to initial therapy. Fifteen patients received alpha IFN-2b maintenance therapy post-DHBI, at a dose of 3 Mu three times per week, as part of a randomized trial. Ninety-five per cent of patients experienced symptomatic improvement in bone pain post-DHBI, 21% of whom discontinued opiate analgesics altogether; 63% had a minor biochemical response and 38% had a partial biochemical response. The overall survival (OS) and progression free survivals (PFS) in all patients were 11 months and 8 months respectively. No significant difference was noted in either OS or PFS, according to whether patients were chemoresistant or had relapsed post-plateau. alpha IFN did not appear to prolong survival (OS or PFS) post-DHBI. Cytopenia was a significant problem, such that only 60% of patients had counts adequate enough to be eligible for alpha IFN. We conclude that DHBI is an effective treatment in patients with relapsed multiple myeloma and in those who are chemoresistant to initial therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiation enhancement of laser palliation for malignant dysphagia: a pilot study

Laser therapy offers rapid relief of dysphagia for patients with cancers of the oesophagus and gastric cardia but repeat treatments are required approximately every five weeks to maintain good swallowing. To try to prolong the treatment interval, 22 elderly patients were given additional external beam radiotherapy. Nine had squamous cell carcinoma and 13 adenocarcinoma: five had documented metastases. Six received 40 Gy and 16,30 Gy in 10-20 fractions. A 'check' endoscopy was performed three weeks after external beam radiotherapy. Dysphagia was graded from 0-4 (0 = normal; 4 = dysphagia for liquids). The median dysphagia grade improved from 3 to 1 after laser treatment. This improvement was maintained in the 30 Gy group but there was a noticeable deterioration in three of those who had received the higher radiation dose. A lifelong dysphagia grade of 2 or better was enjoyed by 14 of 16 patients in the 30 Gy group but only two of six in the 40 Gy group. The dysphagia controlled interval was 9 weeks (median) after check endoscopy and subsequent endoscopic procedures were required every 13 weeks to maintain good swallowing. There were no endoscopy related complications. Combined treatment is a promising approach for reducing the frequency of endoscopic treatments. The 30 Gy dose seems more appropriate and may prolong survival. A randomised study to test these conclusions is in progress.