Oral uracil-tegafur (UFT) compared to classical cyclophosphamide/methotrexate/5-fluorouracil (CMF) as postoperative chemotherapy in patients with node-negative, high-risk breast cancer (BC): Results of the national surgical adjuvant study for breast cancer

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Background: Oral UFT and classical (c-) CMF provide similar response rates in patients (pts) with metastatic BC (CMF: 36.1%, UFT: 39.3%). In a postoperative setting, these regimens showed comparable effectiveness in terms of odds reductions in relapse-free survival (RFS) (CMF: 23.5%, UFT: 21.0%), but data fromrandomized controlled trials (RCT) is not sufficient. Methods: We conducted a RCT to study the efficacy and toxicity of 2-year oral UFT as compared with c-CMF in pts with Stage I - IIIA node-negative, pathologically high-risk BC in a postoperative setting. In the CMF arm, pts received 6 cycles of c-CMF (C: 100 mg po, days 1 to 14, M: 40 mg/m2 iv, days 1 and 8, F: 500 mg/m2 iv, days 1 and 8). In the UFT arm, pts received UFT at 300 mg/m2/day po for 2 years. Tamoxifen (20 mg/day) was administered for 5 years if ER or PgR was positive or unknown. The primary endpoint was RFS. Overall survival (OS), toxicity, and quality of life were secondary endpoints. The statistical hypothesis was non- inferiority of UFT in terms of RFS (95% CI of HR: <1.30). Results: From October 1996 through March 2001, a total of 733 pts were enrolled of whom 707 pts were analyzed. Patients’ characteristics were well balanced between the two arms. Median follow-up time was 6.1 years. At 5 years the RFS rate was 88.2% in the CMF arm and 87.7% in the UFT arm, and OS rates were 96.0% and 96.1%, respectively. Hazard ratios of the UFT arm to the CMF arm were 1.05 (95% CI: 0.69–1.57) for RFS and 0.88 (95% CI: 0.48–1.63) for OS. The toxicity profile differed between the groups. Major grade 3 or higher adverse events were as follows: leukopenia (CMF: 3.1%, UFT: 0.3%, p=0.006), neutropenia (CMF: 5.5%, UFT: 3.5%, p=0.27), elevation of total bilirubin (CMF: 0.3%, UFT: 5.5%, p=0.00001), elevation of GOT (CMF: 1.4%, UFT: 5.7%, p=0.004), elevation of GPT (CMF: 5.1%, UFT: 8.9%, p=0.08), nausea/vomiting (CMF: 2.8%, UFT: 1.1%, p=0.18) and diarrhea, (CMF: 0.3%, UFT: 2.0%, p=0.04). Conclusions: Our results suggest that UFT is a promising alternative to CMF as postoperative adjuvant chemotherapy in women with node-negative, high-risk breast cancer.

No significant financial relationships to disclose.

The synthetic TRH analogue taltirelin exerts modality-specific antinociceptive effects via distinct descending monoaminergic systems

BACKGROUND AND PURPOSE

Exogenously administered thyrotropin-releasing hormone (TRH) is known to exert potent but short-acting centrally-mediated antinociceptive effects. We sought to investigate the mechanisms underlying these effects using the synthetic TRH analogue taltirelin, focusing on the descending monoaminergic systems in mice.

EXPERIMENTAL APPROACH

The mice received systemic or local injections of taltirelin combined with either central noradrenaline (NA) or 5-hydroxytryptamine (5-HT) depletion by 6-hydroxydopamine (6-OHDA) or DL-p-chlorophenylalanine (PCPA), respectively, or blockade of their receptors. The degree of antinociception was determined using the tail flick and tail pressure tests.

KEY RESULTS

Subcutaneously (s.c.) administered taltirelin exhibited dose-dependent antinociceptive effects in the tail flick and tail pressure tests. These effects appeared to be primarily supraspinally mediated, since intracerebroventricularly (i.c.v.) but not intrathecally (i.t.) injected taltirelin generated similar effects. Depletion of central NA abolished only the analgesic effect of taltirelin (s.c. and i.c.v.) on mechanical nociception. By contrast, depletion of central 5-HT abolished only its analgesic effect on thermal nociception. Intraperitoneal (i.p.) and i.t. injection of the alpha2-adrenoceptor antagonist yohimbine respectively reduced the analgesic effect of taltirelin (s.c. and i.c.v.) on mechanical nociception. By contrast, the 5-HT1A receptor antagonist WAY-100635 (i.p. and i.t.) reduced the effect of taltirelin (s.c. and i.c.v.) on thermal nociception. Neither the 5-HT2 receptor antagonist ketanserin nor the opioid receptor antagonist naloxone altered the antinociceptive effect of taltirelin.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that taltirelin activates the descending noradrenergic and serotonergic pain inhibitory systems, respectively, to exert its analgesic effects on mechanical and thermal nociception.

A simple prediction algorithm for bacteraemia in patients with acute febrile illness

BACKGROUND

Existing prediction models for the risk of bacteraemia are complex and difficult to use. Physicians are likely to use a model only if it is simple and sensitive.

AIM

To develop a simple classification algorithm predicting the risk of bacteraemia.

DESIGN

Hospital-based study.

METHODS

We enrolled 526 adult consecutive patients with acute febrile illness (40 with bacteraemia) presenting to the emergency department at a community hospital in Okinawa, Japan. Recursive partitioning analysis was used to build the classification algorithm with V-fold cross-validation. We used two clinical scenarios: in the first, laboratory tests were not available; in the second, they were.

RESULTS

The two prediction algorithms generated three different risk groups for bacteraemia. In the first scenario, the important variables were chills, pulse, and physician diagnosis of a low-risk site. The low-risk group from this first algorithm included 68% of the total patients; sensitivity was 87.5% and the misclassification rate was 1.4% (5/358). In the second scenario, the important variables were chills, C-reactive protein, and physician diagnosis of a low-risk site. The low-risk group for the second algorithm included 62% of the total patients; sensitivity was 92.5% and misclassification rate 0.9% (3/328). The algorithms had negative predictive values of 98.6% (first scenario) and 99.1% (second).

DISCUSSION

This simple and sensitive prediction algorithm may be useful for identifying patients at low risk of bacteraemia. Prospective validation is needed in other settings.

Chronic obesity lymphoedematous mucinosis: three cases of pretibial mucinosis in obese patients with pitting oedema

Pretibial mucin deposition on the shins is known as pretibial myxoedema. We report three patients with pretibial mucinosis without thyroid disease. The patients were characterized clinically by morbid obesity and bilateral lower extremity pitting oedema with gradual and painless onset, and that did not involve the feet and ankles. Vesicles, semitranslucent papules or a woody plaque were found on the shins. Histologically, patients showed characteristic features of epidermal atrophy with effacement of the rete ridge pattern, separation of collagen bundles associated with oedema with stellate to linear fibroblasts, upward-running increased capillary and small vessels with haemosiderin deposition, and mucin deposition at the superficial papillary dermis and around the vessels. We propose that the present cases of 'chronic obesity lymphoedematous mucinosis' belong to the clinical entity of pretibial mucinosis.

Risk factors for acute myocardial infarction among Okinawans

PURPOSE

Okinawa is well known as the leading area for longevity and people in Okinawan islands are known to have the lowest risk of ischemic heart disease (IHD). Reasons for this particularly low IHD risk among Okinawans are unclear. Since most studies about IHD risk factors have been based on population in Western nations and their findings may not apply to Okinawans, a hospital-based case-control study was conducted at a community hospital in Okinawa.

METHODS

To assess the relative importance of risk factors for IHD among the people in Okinawa, 205 Okinawan patients who had acute myocardial infarction (AMI) and 205 age-and-gender matched control were analyzed.

RESULTS

The most important risk factor of AMI was current cigarette smoking. History of diabetes mellitus and hypertension were also independent risk factors. Of lipid profile, lower concentrations of serum high density lipoprotein (HDL) cholesterol and higher serum triglyceride (TG) were independent risk factors while, in contrary, serum low density lipoprotein cholesterol and uric acid were not associated with AMI.

CONCLUSIONS

To effectively prevent IHD among Okinawans, smoking cessation and treatment of hypertension, diabetes, and dyslipidemia (high TG and low HDL) are important. However, lowering LDL cholesterol may be not.

Nasal mask bilevel positive airway pressure ventilation for diaphragmatic paralysis after pediatric open-heart surgery

A 2-year-old boy underwent surgical repair of tetralogy of Fallot. Topical cooling of the heart with ice slush was used during the operation. Diaphragmatic paralysis occurred after the operation, inducing severe respiratory distress. To avoid repeated intubation and tracheostomy, the patient was placed on nasal mask bilevel positive airway pressure (BiPAP) ventilation. After ventilatory support with BiPAP for 40 days, the patient recovered spontaneously from the paralysis. No sedation was required during this time. This report illustrates the usefulness of BiPAP for a pediatric patient with diaphragmatic paralysis after cardiac surgery.

Visualization of pancreaticobiliary reflux in anomalous pancreaticobiliary junction by secretin-stimulated dynamic magnetic resonance cholangiopancreatography

PURPOSE

To assess the utility of secretin-stimulated dynamic MR cholangiopancreatography (MRCP) for the visualization of pancreaticobiliary reflux in patients with anomalous pancreaticobiliary junction (PBJ).

MATERIAL AND METHODS

Ten controls and seven patients diagnosed as having anomalous PBJ were prospectively examined by dynamic MRCP after secretin injection using a breath-hold, single-shot turbo spin-echo T2-weighted sequence. The optimal MRCP section was repeated 35 times at approx. 10-second interval after secretin injection; the acquisition time was 4 s per image. The signal intensity (SI) changes of the extrahepatic and intrahepatic bile ducts, presence or absence of intraluminal signal void, caliber change of the bile duct, duodenal filling, and peak time of the SI ratio of the extrahepatic bile duct after secretin injection were compared between the controls and patients.

RESULTS

In the controls, the extrahepatic and intrahepatic bile ducts showed neither enhancement nor caliber change over the observation period, providing no apparent peak time. Of the seven patients, the extrahepatic bile duct showed retrograde enhancement and sequential delay in occurrence of the peak time from its distal third to its proximal third (n = 6) with a signal void in its distal part (n =4); its caliber increased subsequently to pancreatic secretion (n = 5); the intrahepatic bile ducts showed a slight enhancement following SI increase of the proximal extrahepatic bile duct (n = 6); duodenal filling grade tended to be lower in the patients than volunteers (P<.005).

CONCLUSION

In patients with anomalous PBJ pancreaticobiliary reflux were demonstrated by dynamic secretin-stimulated MRCP.

Evaluation of end of life care in cancer patients at a teaching hospital in Japan

OBJECTIVES

To analyse the decision making for end of life care for patients with cancer at a teaching hospital in Japan at two periods 10 years apart.

DESIGN AND SETTING

Retrospective study conducted in a 550 bed community teaching hospital in Okinawa, Japan.

PATIENTS

There were 124 terminally ill cancer patients (45 women; 79 men; median age, 69 years) admitted either in 1989 and 1999 for end of life care with sufficient data to permit analysis.

MAIN MEASUREMENTS

Basic demographic data, notification to the patient that he or she had cancer, patient involvement in do not resuscitate (DNR) orders, and various medical interventions which were performed in the month prior to the patient's death were evaluated.

RESULTS

In 1989 none of the patients were notified of their diagnosis; in 1999 five patients were informed (p = 0.026). Of the 113 (91%) patients with a written DNR order, none were involved in consenting to the DNR order. In the month before death, patients in both groups received non-palliative treatments such as feeding tube placements (five in 1989; five in 1999), total parenteral nutrition (six in 1989; eight in 1999), and intravenous albumin infusion (four in 1989; five in 1999). Morphine use increased (30%) significantly in 1999 compared with the 1989 group.

CONCLUSIONS

The majority of patients dying of cancer were still not informed of their diagnosis and were seldom involved in DNR decision making at a teaching hospital in Japan. There was no change in the number of potentially futile interventions that were performed (6-13%) but morphine use increased. Modern ethical education is urgently needed in Japanese medical practice to improve decision making process in the end of life care.

[Early and late results of combined valvular and coronary artery surgery]

A total of 42 patients with combined valvular and coronary artery surgery were examined to analyze risk factors for cardiac related events and late deaths. There were aortic valve disease in 26 patients and mitral valve disease in 16. Preoperatively, 14 patients (33%) had cardiac dysfunction (ejection fraction < or = 40%) and 10 patients (24%) were in New York Heart Association (NYHA) functional class IV. There was no operative death with 96% of early graft patency. There was 8 late deaths during 5.6 years of mean follow up. Actuarial survival rate was 86% and 64% after 5 and 10 years, respectively. Cardiac dysfunction was a significant independent predictor for late death. Cardiac related events occurred in 9 patients. Freedom from cardiac related events was 78% and 59% after 5 and 10 years, respectively. Cardiac dysfunction and mitral valve surgery were significant independent predictors for cardiac related events. Late result of combined mitral and coronary artery surgery was unfavorable in patients with cardiac dysfunction.

[Management for type A acute dissection]

From March 1998 to May 2002, we experienced 46 patients with type A acute dissection (AAD). Fifteen patients managed initially with conservative treatment because of intramular hematoma (IH, n = 10), broad cerebral infarction (n = 3), others (n = 2). One who diagnosed IH at admission progressed to AAD and underwent surgery. However his diagnosis of IH at admission was proved to be misdiagnosis retrospectively. In 8 of the remaining 9 patients, hematoma disappeared during the follow-up of 6 months to 1 year. In patients with broad cerebral infarction, 2 died early after admission and 1 discharged with hemiplegia. Thirty-two patients underwent surgery and 1 with preoperative broad cerebral infarction died 36 days after surgery. In the remaining 31 patients, 30 patients discharged ambulatory.

Prostate cancer cell growth is modulated by adipocyte-cancer cell interaction

OBJECTIVE

To assess whether adipocytes (mesenchymal stromal cells thought to affect the proliferation and differentiation of epithelial cells) affect the behaviour of prostate cancer cells in vitro, as prostate cancer metastasizes to the bone, which is an adipocyte-rich environment.

MATERIALS AND METHODS

The human bone-metastatic prostate carcinoma cell line PC3 was cultured with or without adipocytes in a three-dimensional collagen gel matrix. Histological and immunohistochemical assays were used to evaluate the proliferation and differentiation of PC3 cells. The cytokine expression of this culture assembly was also examined by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

The proliferation and differentiation of cancer cells were clearly changed on co-culture with adipocytes compared with the control cultures. The mean (range) bromodeoxyuridine (BrdU) indices estimated (according to uptake) to evaluate the growth of the cultured cells were 36.3 (8.55)% in the co-culture and 26.95 (10.50) in the control (P < 0.02). PC3 cells in co-culture formed larger clusters than in the control, at 16.0 (11.0) vs 14.0 (10.0), respectively (P < 0.01). Cancer cells also showed pleomorphism, varying from cuboidal to spindle-shaped. The expressions of vascular endothelial and platelet-derived growth factor were greater in co-culture than in the control.

CONCLUSION

These findings suggest that adipocytes modulate the growth, morphology and cytokine expression of prostate cancer cells. This specific mesenchymal stromal cell type is important in the biological behaviour of prostate cancer cells.

Pupillary evaluation for differential diagnosis of coma

OBJECTIVES

To determine the usefulness of bedside evaluation of pupils in determining the aetiology of coma by adopting a probabilistic approach.

PATIENTS AND METHODS

One hundred and fifteen consecutive patients presenting with coma were enrolled in this prospective cohort during the 12 month study period in the emergency room of a community teaching hospital. Patients underwent structured clinical examinations and laboratory and imaging tests. Assignment of aetiology of coma was based on strict adherence to predetermined criteria and achieved by consensus of the two physician investigators. One year follow up was obtained in all patients.

RESULTS

Aetiology of coma was determined in 98% of the patients. It was metabolic in 69 patients (60%) and structural in 46 patients (40%). Metabolic causes included drug overdose, acute alcohol intoxication, hypoglycaemia, sepsis, and pneumonia. Structural causes included intracerebral haemorrhage, subarachnoid haemorrhage, cerebral infarction, subdural haematoma, and epidural haematoma. Multivariate logistic regression analysis showed light reflex loss (likelihood ratio for positive test result 3.59) and anisocoria (likelihood ratio for positive test result 9.0) as independent predictors of structural origin.

CONCLUSIONS

In this prospective study of patients presenting to the emergency room of a community based teaching hospital with coma, in about 60% the coma is of metabolic origins and in about 40% of structural origins. Light reflex loss and anisocoria suggest a structural aetiology.

Eclamptic encephalopathy: MRI, including diffusion-weighted images

Eclampsia is a rare condition peculiar to pregnant and puerperal women. We analyse imaging features in five patients with eclampsia, and determine whether diffusion-weighted imaging (DWI) could differentiate cytotoxic and vasogenic oedema in four of them. All were imaged within 4 days of the onset of symptoms. We found lesions with a prolonged T2 in the brain of all five patients, in the basal ganglia in four, pons in three and posterior cerebral white matter in two. Isotropic DWI revealed variable intensity in these regions. The ADC was decreased in one, and increased in all the others. The lesion with reduced ADC progressed to infarction.

Methicillin-resistant Staphylococcus aureus endocarditis following repair of tetralogy of Fallot

Infectious endocarditis following cardiac surgery, particularly that caused by methicillin-resistant Staphylococcus, aureus is a rare and highly lethal complication. We report a case of a 2-year-old girl who developed methicillin-resistant S. aureus endocarditis and mediastinitis following the intracardiac repair of tetralogy of Fallot using Dacron patches. The patient enveloped severe bacteremia accompanied by disseminated intravascular coagulation and progressive enlargement of vegetation. Despite this condition, the patient was successfully treated by repair using double autogenous pericardial patches. Aggressive removal of foreign material and replacement with autogenous tissue resulted in a favorable outcome.

Compassionate use of humanized anti-HER2/neu protein, trastuzumab for metastatic breast cancer in Japan

The HER-2/neu protein is thought to be a unique and useful target for antibody therapy of cancers overexpressing the HER-2/neu gene. The recombinant humanized anti-HER-2 monoclonal antibody, trastuzumab (Herceptin) was approved for clinical use in the US in 1998. In Japan, it was approved and later became available in June, 2001. We have treated 41 patients with metastatic breast cancer with trastuzumab purchased from the US. In this paper, the details of the patients we experienced are reviewed.

Evaluation of HER2 status: for the treatment of metastatic breast cancers by humanized anti-HER2 Monoclonal antibody (trastuzumab) (Pathological committee for optimal use of trastuzumab)

For the treatment of patients with metastatic breast cancer by humanized anti- human epidermal growth factor receptor type 2 (HER2) antibody (trastuzumab), it is important to evaluate HER2 status adequately. "A guideline for HER2 testing" and "HER2 atlas" produced by the "Pathological committee for optimal use of trastuzumab" are introduced in this report. Appropriate evaluations of biological markers are essential for targeting therapy.

Bladder cancer cell implantation in reconstructed bladder in vitro: a model of tumour recurrence

OBJECTIVE

To evaluate the involvement of umbrella cells in tumour adhesion and growth, by examining whether human urinary bladder carcinoma cells (HUBCC) can grow on reconstructed urinary bladder mucosa in vitro, as the implantation of tumour cells after resection is thought to be a cause of bladder tumour recurrence.

MATERIALS AND METHODS

Normal transitional epithelial cells isolated from porcine bladder were cultured on reconstructed lamina propria using fibroblasts in type I collagen gel. The urothelium thus reconstructed was artificially injured either by a scalpel or by dilute acid, after which transitional epithelial cells began to grow in a stratified fashion within a few days of culture. A HUBCC line (HT-1197) was seeded onto this impaired mucosa to determine whether the cells could become implanted. Cultured cells on the reconstructed mucosa were evaluated by histological observation of vertical paraffin sections.

RESULTS

The inoculated transitional epithelial cells grew in a stratified fashion and closely resembled urothelium in vivo. The superficial cells that were in contact with the medium solution differentiated into umbrella cells. HUBCC were unable to adhere to reconstructed mucosa which had not been injured, but these cells could adhere to and become implanted on the reconstructed mucosa after it had been injured either by a scalpel or by dilute acid. After acid injury, only the surface-covering cells were removed sporadically, while the lower epithelial cell layer remained intact. The bladder cancer cells adhered to and proliferated within these stripped regions.

CONCLUSION

These results suggest that the urothelium, especially umbrella cells, seems to be important in preventing the adhesion and growth of urinary bladder tumour cells.

[Emergent surgical treatment of type A acute aortic dissection in an elderly patient]

An 86-year-old man with severe chest pain and shock was transferred to our hospital. Computed tomography revealed type A aortic dissection with cardiac tamponade. He needed intubation and closed chest massage preoperatively. At operation, intrapericardial space was filled with clotted blood and rupture of the ascending aorta was confirmed. He underwent a successful emergency graft replacement of the ascending aorta. Postoperative course was uneventful except for mild hemianopsia due to cerebral infarction. He had recovered to be able to walk and is doing well.