Five versus more than five years of tamoxifen for lymph node-negative breast cancer: updated findings from the National Surgical Adjuvant Breast and Bowel Project B-14 randomized trial

BACKGROUND

Previously reported information from B-14, a National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized, placebo-controlled clinical trial, demonstrated that patients with estrogen receptor (ER)-positive breast cancer and negative axillary lymph nodes experienced a prolonged benefit from 5 years of tamoxifen therapy. When these women were rerandomized to receive either placebo or more prolonged tamoxifen therapy, they obtained no additional advantage from tamoxifen through 4 years of follow-up. Because the optimal duration of tamoxifen administration continues to be controversial and because there have been 3 more years of follow-up and a substantial increase in the number of events since our last report, an update of the B-14 study is appropriate.

METHODS

Patients (n = 1172) who had completed 5 years of tamoxifen therapy and who were disease free were rerandomized to receive placebo (n = 579) or tamoxifen (n = 593). Survival, disease-free survival (DFS), and relapse-free survival (RFS) were estimated by the Kaplan-Meier method; the differences between the treatment groups were assessed by the log-rank test. Relative risks of failure (with 95% confidence intervals) were determined by the Cox proportional hazards model. P values were two-sided.

RESULTS

Through 7 years after reassignment of tamoxifen-treated patients to either placebo or continued tamoxifen therapy, a slight advantage was observed in patients who discontinued tamoxifen relative to those who continued to receive it: DFS = 82% versus 78% (P =.03), RFS = 94% versus 92% (P =.13), and survival = 94% versus 91% (P =.07), respectively. The lack of benefit from additional tamoxifen therapy was independent of age or other characteristics.

CONCLUSION

Through 7 years of follow-up after rerandomization, there continues to be no additional benefit from tamoxifen administered beyond 5 years in women with ER-positive breast cancer and negative axillary lymph nodes.

Fifteen-year prognostic discriminants for invasive breast carcinoma: National Surgical Adjuvant Breast and Bowel Project Protocol-06

BACKGROUND

This report updated previous findings, at the 15-year mark, of the National Surgical Breast and Bowel Project (NSAPB) Protocol B-06 with respect to the treatment of invasive breast carcinoma and the effects of pathologic features and the effects of some clinical features on its natural history.

METHODS

Thirty-one pathologic and 6 clinical features that were observed in a pathologic subset of 1039 evaluable patients were assessed as to their value in predicting survival, in predicting ipsilateral breast tumor recurrence (IBTR), and in predicting the necessity for local breast irradiation after lumpectomy. The patients had been randomly assigned to treatment by lumpectomy without local irradiation or to treatment by lumpectomy with local irradiation of the breast. A traditional and another statistical method were used for this purpose.

RESULTS

Multivariate analyses revealed that the presence of IBTR, race, histologic tumor type, nodal status, nuclear grade, and blood vessel invasion affected survival independently. Treatment, patient age, nuclear grade, presence of intraductal carcinoma, and a lymphocytic tumor infiltrate were features that predicted IBTR by multivariate analyses. Irradiation reduced IBTR from 36% to 12% in the analyzed cohort. A test of interaction failed to reveal any pathologic or clinical feature that might have allowed for the omission of local irradiation of the breast after lumpectomy.

CONCLUSIONS

In addition to the influence of pathologic and clinical features on patient survival and IBTR, the site, histopathologic features, and time of occurrence of the latter allowed for insights into some important biologic considerations concerning invasive breast carcinoma.

Matrix-assisted laser desorption/ionization coupled with quadrupole/orthogonal acceleration time-of-flight mass spectrometry for protein discovery, identification, and structural analysis

The design and operation of a novel UV-MALDI ionization source on a commercial QqoaTOF mass spectrometer (Applied Biosystem/MDS Sciex QSTAR Pulsar) is described. Samples are loaded on a 96-well target plate, the movement of which is under software control and can be readily automated. Unlike conventional high-energy MALDI-TOF, the ions are produced with low energies (5-10 eV) in a region of relatively low vacuum (8 mTorr). Thus, they are cooled by extensive low-energy collisions before selection in the quadrupole mass analyzer (Q1), potentially giving a quasi-continuous ion beam ideally suited to the oaTOF used for mass analysis of the fragment ions, although ion yields from individual laser shots may vary widely. Ion dissociation is induced by collisions with argon in an rf-only quadrupole cell, giving typical low-energy CID spectra for protonated peptide ions. Ions separated in the oaTOF are registered by a four-anode detector and time-to-digital converter and accumulated in "bins" that are 625 ps wide. Peak shapes depend upon the number of ion counts in adjacent bins. As expected, the accuracy of mass measurement is shown to be dependent upon the number of ions recorded for a particular peak. With internal calibration, mass accuracy better than 10 ppm is attainable for peaks that contain sufficient ions to give well-defined Gaussian profiles. By virtue of its high resolution, capability for accurate mass measurements, and sensitivity in the low-femotomole range, this instrument is ideally suited to protein identification for proteomic applications by generation of peptide tags, manual sequence interpretation, identification of modifications such as phosphorylation, and protein structural elucidation. Unlike the multiply charged ions typical of electrospray ionization, the singly charged MALDI-generated peptide ions show a linear dependence of optimal collision energy upon molecular mass, which is advantageous for automated operation. It is shown that the novel pulsing technique of this instrument that increases the sensitivity for precursor ions scans is applicable to the identification of peptides labeled with isotope-coded affinity tags.

Disagreement about the occurrence of male-to-female intimate partner violence: a qualitative study

This work explored the reasons underlying inter-partner disagreement about the occurrence of intimate partner violence (IPV). Research indicates that partners often do not agree about episodes of conflict in their relationship. We conducted interviews with 48 women and men with and without histories of IPV to investigate this lack of agreement. Participant responses were analyzed and themes were identified about why men and women disagree about episodes of conflict. The main results indicate that participants think women and men remember differently; women remember more than men, both choose what they want to remember, and both remember that they were right in the conflict. This work contributes to understanding the disagreement that occurs between partners. Many of these findings have never been suggested by other IPV researchers. The broad-reaching implications of this study include improvement in the accuracy of measuring IPV.

Infiltrating T cells during liver graft-versus-host disease show a restricted T-cell repertoire

Data from animal models have shown that hepatic graft-versus-host disease (GVHD) may be mediated by donor T cells interacting with liver adhesion molecules, other minor histocompatibility antigens, or both. We hypothesized that T-cell infiltrates within a liver biopsy during clinical GVHD would show a restricted T-cell response because the T cells would be responding to a limited number of antigens. We studied the peripheral T-cell repertoire and the liver-infiltrating T-cell repertoire of a patient who developed skin GVHD and subsequent liver GVHD after a matched sibling bone marrow transplantation for acute myeloid leukemia. Spectratype analysis of peripheral blood at the time of liver GVHD revealed that the patient had reconstituted a complex peripheral T-cell repertoire as evidenced by the presence of complementarity-determining region 3 (CDR3) length heterogeneity in most of the T-cell families. The repertoire complexity was skewed in variable gene beta (VB) 5.3, VB4, VB7, VB8, and VB15. Spectratype analysis on the liver biopsy sample revealed a limited infiltrate with an oligoclonal expansion in VBs 4, 7, and 8. We evaluated the T-cell infiltrate in more detail by sequencing the relevant expansions noted by spectratype and developing probes for the predominant CDR3 sequences. These clonotype probes were hybridized to peripheral blood and liver samples from the patient, a T-cell line developed from the patient's peripheral blood at the time of the initial skin GVHD, the donor's blood and marrow, and control samples. The results showed that the T-cell infiltrate during liver GVHD is mediated by a limited number of T cells, and that those cells are mostly different from the ones expanded from the peripheral blood during an acute skin GVHD reaction. These data support the concept that liver GVHD is a response to tissue-specific minor histocompatibility antigens.

Tamoxifen and chemotherapy for axillary node-negative, estrogen receptor-negative breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-23

PURPOSE

Uncertainty about the relative worth of doxorubicin/cyclophosphamide (AC) and cyclophosphamide/methotrexate/fluorouracil (CMF), as well as doubt about the propriety of giving tamoxifen (TAM) with chemotherapy to patients with estrogen receptor-negative tumors and negative axillary nodes, prompted the National Surgical Adjuvant Breast and Bowel Project to initiate the B-23 study.

PATIENTS AND METHODS

Patients (n = 2,008) were randomly assigned to CMF plus placebo, CMF plus TAM, AC plus placebo, or AC plus TAM. Six cycles of CMF were given for 6 months; four cycles of AC were administered for 63 days. TAM was given daily for 5 years. Relapse-free survival (RFS), event-free survival (EFS), and survival (S) were determined by using life-table estimates. Tests for heterogeneity of outcome used log-rank statistics and Cox proportional hazards models to detect differences across all groups and according to chemotherapy and hormonal therapy status.

RESULTS

No significant difference in RFS, EFS, or S was observed among the four groups through 5 years (P =.96,.8, and.8, respectively), for those aged < or = 49 years (P =.97,.5, and.9, respectively), or for those aged > or = 50 years (P =.7,.6, and.6, respectively). A comparison between all CMF- and all AC-treated patients demonstrated no significant differences in RFS (87% at 5 years in both groups, P =.9), EFS (83% and 82%, P =.6), or S (89% and 90%, P =.4). There were no significant differences in RFS, EFS, or S between CMF and AC in patients aged < or = 49 or > or = 50 years. No significant difference in any outcome was observed when chemotherapy-treated patients who received placebo were compared with those given TAM. RFS in both groups was 87% (P =.6), 87% in patients aged < or = 49 (P =.9), and 88% and 87%, respectively (P =.4), in those aged > or = 50 years.

CONCLUSION

There was no significant difference in the outcome of patients who received AC or CMF. TAM with either regimen resulted in no significant advantage over that achieved from chemotherapy alone.

Associations of high myopia in childhood

PURPOSE

High myopia in early childhood is a recognised association of ocular and systemic disease. The aim of this study was to describe the types, pattern and frequency of these associations.

METHODS

All children presenting to two ophthalmology units over 3 years who were found to have high myopia were recruited. High myopia was defined as one or both eyes demonstrating 6 dioptres spherical equivalent or more of myopic refractive error on retinoscopy. We limited the age to less than 10 years old. A retrospective case review was undertaken of the 112 consecutive children who fulfilled the criteria above. The demographic data, source and indication for referral were recorded along with the ocular and systemic findings and diagnosis.

RESULTS

Only 9 (8%) of the children had 'simple high myopia' with no associated ocular or systemic associations. In 54% there was an underlying systemic association with or without further ocular problems (e.g. developmental delay, prematurity, Marfan, Stickler, Noonan, Down syndrome) and in the remaining 38% there were further ocular problems associated with the high myopia (e.g. lens subluxation, coloboma, retinal dystrophy, anisometropic amblyopia). A family history of high myopia did not preclude associated abnormality: in 4 cases the diagnosis of a systemic condition in the child led to the identification of the disease in at least one myopic relative. Asian (p < 0.001) and male (p < 0.05) patients were overrepresented in the series.

CONCLUSION

High myopia is strongly associated with systemic and ocular problems; it may be the reason for the child's initial medical referral and an important clue to an underlying systemic or ocular condition. Referrals infrequently originated from community optometrists despite prior attendance. We suggest that all children under 10 years of age with high myopia are referred to a paediatric ophthalmology clinic for review and we propose a structured clinical evaluation in the hospital eye clinic.

Prognosis and treatment of patients with breast tumors of one centimeter or less and negative axillary lymph nodes

BACKGROUND

Uncertainty about prognosis and treatment of axillary lymph node-negative patients with estrogen receptor (ER)-negative or ER-positive invasive breast tumors of 1 cm or less prompted the analysis of data from five National Surgical Adjuvant Breast and Bowel Project randomized clinical trials.

METHODS

Two hundred thirty-five patients with ER-negative tumors and 1024 patients with ER-positive tumors were identified in these trials. Patients with ER-negative tumors received surgery alone or surgery and chemotherapy. Patients with ER-positive tumors received surgery alone; surgery and tamoxifen; or surgery, tamoxifen, and chemotherapy. End points were relapse-free survival (RFS), event-free survival, and overall survival. A result was considered to be statistically significant with a P value of.05 or less; all statistical tests were two-sided.

RESULTS

The 8-year RFS of women with ER-negative tumors who received surgery alone or with chemotherapy was 81% and 90%, respectively (P = .06). Survival was similar in both groups (93% and 91%; P = .65). The 8-year RFS of women with ER-positive tumors was 86% after surgery alone, 93% when tamoxifen was added (P = .01), and 95% after the addition of tamoxifen and chemotherapy (P = .07 compared with tamoxifen). Survival in the three groups was 90%, 92% (P = .41), and 97%, respectively. The difference between the latter two groups was significant (P = .01). Regardless of ER status or treatment, overall mortality was 8%; one half of the deaths were related to breast cancer. Several covariates affected the risk of recurrence in ER-negative and ER-positive patients. Risk was greater in women with tumors of 1 cm than in those with tumors of less than 1 cm, in women aged 49 years or younger than in those aged 50 years or older, and in women with infiltrating ductal or lobular carcinoma than in those with other histologic tumor types.

CONCLUSIONS

Chemotherapy and/or tamoxifen should be considered for the treatment of women with ER-negative or ER-positive tumors of 1 cm or less and negative axillary lymph nodes.

Phase I dose-finding study of a new taxane, RPR 109881A, administered as a one-hour intravenous infusion days 1 and 8 to patients with advanced solid tumors

PURPOSE

To define the maximum-tolerated dose, recommended phase II dose (RD), dose-limiting toxicity (DLT), and pharmacokinetics of a novel taxane, RPR 109881A, administered on days 1 and 8 of a 21-day cycle.

PATIENTS AND METHODS

Twenty-nine patients were enrolled and treated according to a modified continual reassessment method from a starting dose of 7.5 mg/m(2) to 52.5 mg/m(2). Detailed pharmacokinetic analyses of blood and urine were performed on days 1 and 8 of the first cycle. Toxicity was monitored weekly.

RESULTS

DLT consisting of grade 3 or 4 diarrhea was seen in three of six patients at 52.5 mg/m(2). Grade 3 or 4 granulocytopenia was also seen in five of six patients treated at this dose (four of six in the first cycle). At the next lower dose level, 45 mg/m(2) toxicity was moderate, with only one of 12 patients experiencing severe diarrhea and grade 4 granulocytopenia with associated infection. Drug concentrations were consistent with a three-compartment open model. The total-body clearance suggests a linear dose-concentration relationship. RPR 109881A has a high clearance (mean, 42.6 L/h/m(2)), a large volume of distribution (mean, 952 L/m(2)), and a long terminal half-life (mean, 24 hours). There was no drug accumulation between days 1 and 8. One partial response was seen in a patient with renal cell carcinoma.

CONCLUSION

The RD of RPR 109881A given as a 1-hour infusion on days 1 and 8 of a 21-day cycle is 45 mg/m(2). At this dose the drug is well tolerated and should be further studied.

Phase II feasibility study of sequential couplets of Cisplatin/Topotecan followed by paclitaxel/cisplatin as primary treatment for advanced epithelial ovarian cancer: a National Cancer Institute of Canada Clinical Trials Group Study

PURPOSE

Despite the improved results in advanced ovarian cancer achieved with the addition of paclitaxel to frontline therapy, there remains room for improvement. One approach is to add new agents such as topotecan. Because myelosuppression limits the delivery of topotecan with paclitaxel/cisplatin in a three-drug combination, we explored giving sequential couplets of cisplatin/topotecan followed by paclitaxel/cisplatin.

PATIENTS AND METHODS

Forty-four patients with residual epithelial ovarian carcinoma after primary surgery were studied. Cisplatin 50 mg/m(2) on day 1 and topotecan 0.75 mg/m(2) on days 1 through 5 were administered at 21-day intervals for four cycles, followed by interval debulking surgery (if optimal debulking was not achieved with primary surgery), and then paclitaxel 135 mg/m(2) over 24 hours on day 1 and cisplatin 75 mg/m(2) on day 2 at 21-day intervals for four cycles.

RESULTS

Such sequential couplets are feasible. Myelotoxicity was the major toxic effect, but it was of short duration. The granulocyte nadir with topotecan/cisplatin occurred late (median, day 18), so retreatment on day 21 was not always possible. There was no unexpected nonhematologic toxicity. The regimen was active in this group of patients who had undergone largely suboptimal debulking surgery. In 34 patients with clinically measurable disease, the overall response rate was 78%, and 30 (77%) of the 39 patients with elevated CA 125 levels at baseline had normalization of CA 125 levels by the end of therapy.

CONCLUSION

Sequential couplets of cisplatin/topotecan followed by paclitaxel/cisplatin are feasible. The efficacy data in this suboptimal group of patients has encouraged us to proceed with a randomized study based on this approach.

In vivo histamine release from brain cortex: the effects of modulating cellular and extracellular sodium and calcium channels

The in vivo mechanisms underlying the actions of modulating Na(+)- and Ca(2+)-sensitive channels and its effect on basal histamine release in the cerebral cortex of freely-moving unanesthetized rats was investigated. Basal histamine release in the cerebral cortex was determined by in vivo microdialysis coupled with high-performance liquid chromatography (HPLC) fluorometry detection. Basal levels of histamine were 0.67+/-0.02 pmol/10 microl of dialysate. Diltiazem, a Ca(2+) channel antagonist, produced a dose-dependent decrease in dialysate basal histamine concentration. Elevated K(+) (100 mM) in the perfusion medium increased basal histamine to a maximum of 223% of the baseline value. Similarly, diltiazem (60 mM) reduced the K(+), veratridine (100 microg/ml) and ouabain (100 microM)-evoked increase in dialysate histamine. Basal histamine decreased by 48% when the perfusate contained 3 microM of voltage dependent Na(+) antagonist tetrodotoxin. The results of these studies indicate that the release of histamine in rat cerebral cortex can be induced by modulating Na(+) and Ca(2+) channels and that the L-type voltage-dependent sensitive Ca(2+) channels are involved in this release process.

Strong correlation between imaging response and survival among patients with primary central nervous system lymphoma: a secondary analysis of RTOG studies 83-15 and 88-06

PURPOSE

Primary central nervous system lymphoma (PCNSL) is the brain tumor with the most rapidly increasing incidence, yet little is known about its radiographic response to cranial irradiation. If traditionally used doses of radiotherapy ( approximately 60 Gy) are associated with low rates of complete response and poor survival, then an argument can be made to consider dose escalation of radiotherapy. Alternatively, if poor survival rates are associated with high rates of complete response, there would be no reason to subject patients to higher radiation doses with increased risks of treatment-related morbidity. The purpose of this analysis is to provide a detailed review of response following cranial irradiation. Based on these findings, recommendations are offered for future protocol design.

METHODS AND MATERIALS

Patients were treated on either RTOG 83-15 (whole brain irradiation to 40 Gy followed by a 20 Gy boost to the tumor plus 2-cm margin) or RTOG 88-06 (induction cyclophosphamide, doxorubicin, vincristine, dexamethasone [CHOD] followed by whole brain irradiation to 41.4 Gy and an 18 Gy tumor boost). Imaging surveillance (CT, MR) was required following surgery, prior to the initiation of RT and following completion of RT. Complete response referred to the absence of enhancement on follow-up scans in comparison to the pretherapy study. A tumor size reduction of at least 50% in the product of the largest cross-sectional diameter and its largest perpendicular diameter was scored as a partial response.

RESULTS

Seventy-nine patients had scans available for central review. Complete response was achieved in 83% and 85% of patients treated on RTOG 83-15 and 88-06, respectively. The rates of partial response (14%, 11%) and radiographic progression (3%, 4%) also were comparable between the studies. For survival analyses, data were aggregated from the two studies. The 4-year survival rates were 24% for complete responders versus 11% for other patients (p = 0.0006). In multivariate analysis, only complete radiographic response (p < 0.0007), and high Karnofsky performance status (KPS >/= 70) (p < 0.005) were independently associated with increased rates of 4-year survival.

CONCLUSION

A high rate of complete radiographic response was observed following moderate doses of cranial irradiation (alone or in combination with CHOD chemotherapy). Although complete responders had a statistically significant survival advantage at 4 years when compared with partial responders and nonresponders, the majority of patients who achieved complete response were dead of disease by 4 years following treatment. Based on this analysis of the RTOG database, there is no rationale for radiation dose escalation as a therapeutic strategy to combat PCNSL. Consequently, the radiotherapy component of the current RTOG Phase II trial (RTOG 93-10) now includes relatively low total doses of hyperfractionated irradiation for patients without residual disease (36 Gy/1.2 Gy, twice a day) as well as a more aggressive chemotherapy regimen.

Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury

OBJECTIVES

To evaluate the effect of prolonged infusion of 3% hypertonic saline (514 mEq/L) and sustained hypernatremia on refractory intracranial hypertension in pediatric traumatic brain injury patients.

DESIGN

A prospective study.

SETTING

A 24-bed Pediatric Intensive Care Unit (Level III) at Children's Hospital.

PATIENTS

We present ten children with increased intracranial pressure (ICP) resistant to conventional therapy (head elevation at 30 degrees, normothermia, sedation, paralysis and analgesia, osmolar therapy with mannitol, loop diuretic, external ventricular drainage in five patients), controlled hyperventilation (Pco2, 28-35 mm Hg), and barbiturate coma. We continuously monitored ICP, cerebral perfusion pressure (CPP), mean arterial pressure, central venous pressure, serum sodium concentrations, serum osmolarity, and serum creatinine.

INTERVENTIONS

A continuous infusion of 3% saline on a sliding scale was used to achieve a target serum sodium level that would maintain ICP <20 mm Hg once the conventional therapy and barbiturate coma as outlined above failed to control intracranial hypertension.

MEASUREMENTS AND MAIN RESULTS

The mean duration of treatment with 3% saline was 7.6 days (range, 4-18 days). The mean highest serum sodium was 170.7 mEq/L (range, 157-187 mEq/L). The mean highest serum osmolarity was 364.8 mosm/L (range, 330-431 mosm/L). The mean highest serum creatinine was 1.31 mg/dL (range, 0.4-5.0 mg/dL). There was a steady increase in serum sodium versus time zero that reached statistical significance at 24, 48, and 72 hrs (p < .01). There was a statistically significant decrease in ICP spike frequency at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in CPP versus time zero at 6, 12, 24, 48, and 72 hrs (p < .01). There was a statistically significant increase in serum osmolarity versus time zero at 12 hrs (p < .05) and at 24, 48, and 72 hrs (p < .01). Two patients developed acute renal failure and required continuous veno-venous hemodialysis; these were concurrent with an episode of sepsis and multisystem organ dysfunction. Both recovered full renal function with no electrolyte abnormalities at the time of discharge.

CONCLUSION

An increase in serum sodium concentration significantly decreases ICP and increases CPP. Hypertonic saline is an effective agent to increase serum sodium concentrations. Sustained hypernatremia and hyperosmolarity are safely tolerated in pediatric patients with traumatic brain injury. Controlled trials are needed before recommendation of widespread use.

Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients

OBJECTIVE

To determine the effects continuous infusions of hypertonic saline (3% NaCl) on intracranial pressure (ICP) control and describe the physiologic effects of hypertonic saline administered to closed head injury children.

DESIGN

Retrospective chart review.

SETTINGS

Pediatric intensive care unit of a children's hospital.

PATIENTS

Sixty-eight children with closed head injury.

INTERVENTIONS

Intravenous infusion of 3% hypertonic saline to increase serum sodium to levels necessary to reduce ICP < or =20 mm Hg.

MEASUREMENTS AND MAIN RESULTS

The patients enrolled had similar Injury Severity Scores. Treatment effectively lowered ICP in these patients and ICP was under good control a majority of the time. Only three patients (4%) died of uncontrolled elevation of ICP. No adverse effects of supraphysiologic hyperosmolarity such as renal failure, pulmonary edema, or central pontine demyelination, were noted.

CONCLUSIONS

Hypertonic saline administration to children with closed head injury appears to be a promising therapy for control of cerebral edema. Further controlled trials are required to determine the optimal duration of treatment before widespread use is advocated.